residential facilities

State and Federal Oversight Gaps May Increase Risk to Youth Well-Being

Statement of Kay E. Brown, Director

Education, Workforce, and Income Security Issues

April 24, 2008

The Honorable George Miller

Chairman

Committee on Education and Labor

House of Representatives

Mr. Chairman and Members of the Committee:

Thank you for inviting me here today to discuss our ongoing work
reviewing how state and federal agencies protect the well-being of youth
in residential facilities who are receiving services for their
behavioral or emotional challenges. Nationwide, federal funding to
states supported more than 200,000 youth in government or private
facilities in 2004. In addition, an unknown number of youth are placed
in facilities by parents or others. These facilities include boarding
schools and academies, boot camps, and wilderness camps. Overall,
residential facilities play an important role in serving youth who
cannot be safely served in their communities while living at home, due
to risk of running away or harm to themselves or others. However, recent
federal reviews highlighted youth fatalities in residential facilities
due to neglect or maltreatment, and ongoing federal investigations
continue to document incidents of abuse and neglect in some facilities
for youth that in some cases have been severe enough to result in
hospitalization or death.

As you know, states are primarily responsible for ensuring the
well-being of youth in facilities and other settings, and do so by
setting their own standards of care certain facilities must meet to
obtain and maintain an operating license. Federal agencies also set
requirements for youth well-being that states agree to uphold in
exchange for receiving federal program funds, such as those administered
by the Department of Health and Human Services (HHS) to support state
systems of care for child welfare, mental health, and substance abuse;
the Department of Justice (DOJ), for state juvenile justice systems; and
the Department of Education (Education), for state education systems.
Further, if patterns of maltreatment are identified and found to violate
the civil rights of youth in certain facilities that are operated or
substantially sponsored by state and local governments, the federal
Civil Rights of Institutionalized Persons Act (CRIPA) authorizes the
Attorney General of the United States to conduct investigations and
bring actions against state and local governments. However, under the
current regulatory framework, federal oversight authority does not
extend to private facilities that serve only youth placed and funded by
parents or other private entities. In some states, safeguarding youth in
these facilities is the primary responsibility of parents and facility
staff.

My remarks today will focus on the following issues with regard to youth
well-being in residential facilities in terms of

\(1\) what is known about the incidents that adversely affect the
well-being of youth in residential facilities,

\(2\) the extent that state oversight ensures the well-being of youth in
residential facilities, and

\(3\) the factors that affect the ability of federal agencies to hold
states accountable for youth well-being in residential facilities.

This testimony was developed using multiple methodologies, and was
limited to residential facilities we defined as those that require
youth---ages 12 through 17---to reside at the facility and that provide
program services[^1] for youth with behavioral and emotional challenges.
We surveyed three stateagencies---child welfare, health and mental
health, and juvenile justice[^2] ---about residential facilities that
were government operated, privately operated that received government
funds, and privately operated with no government funding. To further our
understanding, we visited four states---California, Florida, Maryland,
and Utah---and interviewed relevant officials. These states were
selected based on the diversity of their state licensing and monitoring
policies for residential programs, reports of child maltreatment, and
geographic location. We also obtained data from HHS's National Child
Abuse and Neglect Data System (NCANDS); reviewed federal statutes,
regulations, and guidance; and interviewed HHS, DOJ, and Education
officials, as well as national association representatives and other
experts on residential facilities for youth. The scope of our work did
not include the quality of services provided at residential facilities.
We performed our work between November 2006 and March 2008, in
accordance with generally accepted government auditing standards.

In summary,

-   Youth maltreatment and death occurred in government and private
    residential facilities across the nation, according to states we
    surveyed; however, data limitations hinder efforts to quantify the
    full extent of the problem. State-reported data collected by HHS in
    2005 showed 1,503 incidents of maltreatment by facility staff in 34
    states, including physical abuse, neglect or deprivation of
    necessities, and sexual abuse. Moreover, 28 states responding to our
    survey reported at least one death in residential facilities in
    2006, with accidents and suicides among the most common types of
    fatalities. These reported data, however, did not capture
    information from all facilities. Many states lack authority under
    state law to collect data on exclusively private facilities, and
    data that states did report were often incomplete. As a result, the
    number of adverse incidents was likely more numerous and widespread
    than reported.

-   All states have processes in place to license and monitor certain
    residential facilities, but states reported oversight gaps that may
    place youth in some facilities at higher risk for maltreatment and
    death. Most notably, state agencies exempted some types of
    government and private facilities from licensing requirements
    altogether, primarily juvenile justice facilities and private
    schools and academies. In addition, licensing standards do not
    always address suicide and other common risks to youth well-being.
    Although monitoring is key to ensuring facility compliance with
    standards, agencies in states we visited reported an inability to
    conduct yearly on-site reviews of conditions at each facility,
    because of fluctuating levels of staff resources committed by the
    state. Similarly, although information sharing can strengthen
    oversight for facilities shared by multiple agencies, many state
    agencies reported that they did not routinely share information with
    other state agencies about negative findings or when facility
    licenses were suspended or revoked.

-   HHS, DOJ, and Education all have processes to hold states
    accountable for the well-being of youth, but federal efforts are
    hindered by the scope of the agencies' oversight authority and
    monitoring practices. Most notably, these agencies do not have the
    authority to hold states accountable for youth well-being in private
    residential facilities unless they serve youth in state programs
    that receive federal funds. For facilities under federal purview,
    federal requirements did not always address the primary risks to
    youth well-being, such as suicide, and requirements were
    inconsistent among programs. In monitoring state compliance, federal
    agencies did not always include residential facilities in their
    oversight reviews.

**Youth Maltreatment Occurred in Facilities Across the Nation, but Data
Are Limited and Not Used to Target Federal Civil Rights Investigations**

Nearly all states (49) responding to our survey reported investigating
complaints of youth maltreatment in residential facilities in 2006,
including facilities operated by government as well as private entities,
and located in both urban or rural areas. The types of maltreatment
reported by states included physical abuse, neglect or deprivation of
necessities, and sexual abuse that sometimes resulted in hospitalization
or death. State reported data to NCANDS from 2005 showed that 34 states
reported 1,503 incidents of youth maltreatment by facility staff. Of
these incidents, neglect or deprivation of necessities was the most
frequent cause of youth maltreatment, followed by physical abuse, as
shown in figure 1.

Figure 1: Percentage of State-Reported Incidents of Youth Maltreatment
by Residential Facility Staff, Fiscal Year 2005

![](media/image2.png){width="5.902777777777778in"
height="1.7493055555555554in"}

^a^"Other" incidents of youth maltreatment states reported to NCANDS
include medical neglect and psychological or emotional maltreatment.

Of the states we surveyed, 28 reported that at least one youth had died
in a residential facility in 2006. These deaths were primarily due to
accidents and suicide, but also due to homicide and application of
seclusion and restraint (see fig. 2).

Figure 2: Number of States That Reported Specific Causes of Youth
Fatalities in Residential Facilities, 2006

![](media/image3.png){width="5.877777777777778in"
height="2.890972222222222in"}

Notes:

The survey question was as follows: Of the total youth deaths that you
reported, how many died from each of the following causes: (a) suicide,
(b) homicide, (c) application of seclusion and restraint techniques, (d)
medically related accident, (e) accident that occurred while in a
runaway or absence without leave status, (f) other accidental cause, and
(g) other causes?

Other causes of youth fatalities in residential facilities include
natural causes, choking, and internal bleeding.

Overall, officials from the states we visited said that the number of
maltreatment incidents and deaths was greater than reported due to
barriers in collecting and maintaining data. When available,
comprehensive reporting of incident data can be used by state and
federal agencies to assess the extent of maltreatment in residential
facilities, inform risk assessments, target oversight resources, and
develop policies to address trends. However, the lack of authority under
state law hinders many states from collecting data on certain
facilities---such as exclusively private facilities\--and expanding
oversight to cover them. In addition, states that have such authority
reported difficulties sustaining data collection in times of budget
shortages. National data in NCANDS for 2005---derived from state
reports---suffered from these same limitations, as well as others.
First, some states did not report data for residential facilities to
NCANDS,[^3] so the data may have understated the number of maltreatments
and fatalities. Second, many states (37) did not consistently identify
whether the individual maltreating youth was facility staff, a parent,
or other individual. Last, NCANDS only tracked fatalities resulting from
maltreatment, not suicide or accidents that may be an indicator of
neglect or other problem that needs resolution.

In the states we visited, youth maltreatment in facilities was
attributed to several factors---such as a lack of experienced staff,
insufficient staff training, or lack of appropriate
supervision---particularly in smaller facilities. For example, county
officials in one state told us that adverse incidents were most likely
to occur in contractor operated six-bed group homes---frequently used by
state probation and child welfare agencies---where the state
reimbursement rate is generally not high enough to hire skilled
personnel and provide staff with ongoing training, support, and
oversight.

However, while in most facilities youth maltreatment may occur
infrequently as a result of isolated circumstances, investigations of
government and private facilities serving youth conducted under DOJ's
Civil Rights Division (Division) have found a pattern or practice of
civil rights violations in some facilities, including physical and
sexual abuse, medical neglect, and inadequate education. At the end of
fiscal year 2006, the latest year for which data were available, federal
investigators reported active cases involving over 175 facilities in 34
states.[^4] Annual reports from DOJ over the past several years have
documented their findings of youth maltreatment in certain juvenile
justice or mental health facilities:

[Physical and sexual abuse occurred without management
intervention.]{.underline} In one facility, staff hit youth and slammed
them to the ground. Staff hog-tied and shackled youth to poles in public
places, and girls were forced to eat their own vomit if they threw up
while exercising in the hot sun. Staff routinely broke and wired shut
the jaws of youth who showed disrespect in another facility. In some
facilities, staff engaged in sexual acts with boys. Youth-on-youth
violence occurred on an almost daily basis in some facilities, at times
resulting in injuries that required hospitalization. Youth were sexually
assaulted and threatened with sexual assault by other youth in some
facilities, all without effective intervention from management.

[Severe neglect resulted in poor education, suffering, and
death.]{.underline} In a 1-year period at one facility, three boys
committed suicide. In one suicide, staff lacked the appropriate tool to
cut the noose from a victim's neck and also did not have oxygen in the
tank they brought to help resuscitate him. The dental clinic at one
facility was full of mouse droppings, dead roaches, and cobwebs;
medications in the cabinet had expired over 10 years ago. In a
state-operated mental health facility used by adolescents, older
psychotropic medications, with serious side effects, were administered
to sedate patients. One adolescent received 22 such psychotropic
sedatives over a 2-month period. In another facility, youth were not
provided with special education services as required by federal law.

The Special Litigation Section of DOJ's Civil Rights Division receives
more credible allegations of violations of youth rights than it can
investigate. During fiscal year 2006 alone, the Division received
approximately 5,000 citizen letters; hundreds of telephone complaints,
and 135 inquiries from Congress and the White House. Division officials
stated that with additional sources of information, they could better
target their scarce investigative resources. Officials said that
receiving more detailed information from NCANDS on the incidents of
maltreatment and death occurring in specific facilities would be
helpful, as would the results of federal agency monitoring reviews of
states that highlight findings related to residential facilities. Except
in one instance,[^5] officials said that no federal agencies---including
HHS, Education, and DOJ's Office of Juvenile Justice and Delinquency
Prevention (OJJDP)\--were coordinating with the Division to provide
pertinent oversight results.

**Gaps in State Oversight of Residential Facilities May Place Well-being
of Some Youth at Risk**

All states have processes in place to license and monitor certain
residential facilities, but our survey identified several gaps that
allow some of the common causes of youth maltreatment and death to go
unaddressed. These gaps include the fact that some types of government
and private facilities are exempt from licensing requirements, licensing
standards do not always address the primary causes of youth maltreatment
and death, and state agencies inconsistently monitor and enforce
facility compliance and share their monitoring results.

[Certain Facilities Are Exempt from State Licensing
Requirements]{.underline}

Licensing all facilities in a state, government or private facilities,
can help ensure that residential facilities meet relevant state
standards. Among state-operated facilities, however, more than half (28)
of juvenile justice agencies reported exempting facilities from
licensing.[^6] In addition, many state agencies reported that certain
types of private facilities were also exempt from licensing, regardless
of whether they received some government funding or were exclusively
private. Private residential schools and academies---a category that
includes boarding schools and training or reform schools---were exempted
more often from licensing than other types of private facilities,
according to survey respondents. Conversely, treatment facilities were
the type most commonly required to have a license. Agencies in 6 states
reported they exempted faith-based facilities from licensure.[^7] In
addition, many agencies reported not knowing the licensing status of
certain types of private facilities or reported that they did not have
certain types of facilities in their state.[^8] Some states are
considering laws that would expand their licensing authority for private
facilities.

One reason that private residential facilities may be exempt from
licensing requirements is that state agencies do not have the necessary
statutory or regulatory authority. Regarding residential schools and
academies, for example, all agencies in 15 of the 33 states that
responded to all three agency surveys reported that they did not have
either the authority or the regulatory responsibility to license these
facilities.[^9]

The lack of licensing for all facilities serving youth has several
consequences, in that there are no commonly accepted definitions of
facility types. Within individual states, facility operators may bypass
state licensing requirements by self-identifying their business as a
type that is exempt from state licensing. In Texas, for example, a
residential program self-identified as a private boarding school is not
regulated by the state licensing agency, but the same facility would
require a license if it self-identified as a residential treatment
center or therapeutic camp. Inconsistent licensing practices across
states can have implications as well. For example, a 2007 directory
showed that Utah, which only recently implemented licensing requirements
covering wilderness camps, was home to over 25 percent of registered
wilderness programs in the United States.

Facility licensing is also important because parents and others
considering placing youth in private facilities at their own expense do
not always have the information they need to screen facilities and make
an informed decision. In our testimony on private facilities last
October,[^10] we described cases in which program leaders told parents
their programs could provide services that they were not qualified to
offer, claimed to have credentials in therapy or medicine that they did
not have, and led parents to trust them with youth who had serious
mental disabilities. One national association for programs serving youth
with behavioral and emotional difficulties testified before Congress
that state licensing was important because the field does not currently
have the capacity to certify facility integrity.

Some states are considering laws that would expand their licensing
authority for private facilities, while some use other methods to
provide protections for youth. For example, Florida, among other states,
include requirements addressing youth well-being in contracts facilities
must sign to serve youth under state care. Florida officials estimated
that 85 percent of residential facilities in the state's juvenile
justice system are private facilities under contract with the state. The
agency uses the contract provisions to help ensure that facilities
provide youth with needed services in compliance with agency regulations
as well as state statutes.

Accreditation is another method used by some states in lieu of, or to
augment, state licensing requirements. For example, Ohio and Wyoming
require specific health-related facilities to obtain accreditation
instead of licensure as a condition to serving youth under state care.
Of the states responding to our survey, a greater number of health and
mental health agencies reported requiring facilities to be accredited by
private organizations, due in part to conditions of participation for
certain federal programs.[^11] The accreditation process may require
providers to meet higher standards than those required by state
licensing bodies; however, accreditation does not necessarily ensure the
safety and well-being of youth. Officials from an accrediting
organization told us that they do not always inform the state if a
facility's accreditation status has been suspended or limited. In
general, fewer states reported requiring accreditation than not across
the three agencies we surveyed.

[State Licensing Standards Do Not Address Some Primary Risks to Youth
Well-being]{.underline}

Our survey results showed that the licensing standards that states have
in place for certain government and private residential facilities
address many, but not all, of the most common risks to youth well-being
that states had identified in our survey. The extent that state
licensing standards cover the various aspects of youth well-being is
important to safeguard youth from harm. Almost all states reported that
when they required licensing, they required facilities to meet standards
related to the safety of the physical plant, proper use of seclusion and
restraint techniques, reporting of adverse incidents, and qualification
requirements and background checks for staff.[^12] These standards can
help reduce the risk of harm due to accidental causes and staff
maltreatment. However, other requirements addressing risks to youth are
less often included as a part of licensing. For example, while states
reported that almost all juvenile justice facilities are required to
have written suicide prevention plans, about a third of state child
welfare and health and mental health agencies reported that they do not
have similar requirements for government facilities. In addition, most
of the agencies in our survey did not require private facilities to have
written suicide prevention plans.

[State Practices Inconsistent in Monitoring and Enforcing Facility
Compliance]{.underline}

State agencies reported monitoring youth well-being in residential
facilities, but survey results showed that certain aspects of youth
well-being were not included in all monitoring activities, as shown in
figure 3. Periodic on-site reviews to monitor and enforce facility
compliance helps ensure that licensing standards are taken seriously and
that risks to youth well-being are quickly addressed. Among six
different aspects of youth well-being we asked about in our survey, the
quality of educational programming and use of psychotropic medications
were most likely to be reviewed at only some or none of the facilities
monitored by child welfare, health and mental health, and juvenile
justice agencies. Conversely, staffing issues were most often included
in all monitoring reviews of government and private facilities.

Fig. 3: Aspects of Well-Being Monitored by State Agencies in Private
Residential

Facilities That Served Youth and Received Government Funding

![](media/image4.png){width="5.664583333333334in"
height="3.8722222222222222in"}

Note: The survey question was as follows: In 2006, did your agency
routinely monitor or follow-up, or authorize for monitoring or
follow-up, any of the following issues---in the absence of a
complaint---at private residential facilities that received government
funding providing targeted services for youth? Response options for this
question were: (a) yes, monitored for all; (b) yes, monitored for some,
(c) no, did not monitor, (d) no such facility in the state, (e) don't
know, (f) no response.

In addition, three of the four states we visited reported that they were
unable to meet their goals for conducting annual monitoring visits at
residential facilities due to a lack of resources. States reported that
visiting facilities was necessary at least once a year, if not more
often, to ensure that conditions for youth had not changed due to
changes in personnel, ownership, or funding. However, the number of
facilities visited each year depended on the fluctuating levels of
resources committed by the state. In Maryland, agency officials said
that state resources were redirected, as necessary, to meet state goals
for monitoring residential facilities for youth. In Florida and Utah,
however, agency officials said that imbalances between the current
workload and staff resources constrained the state's capacity to conduct
efficient, effective, and timely monitoring of residential facilities. A
facility operator in California said that on-site monitoring had been as
infrequent as once every 5 years.

State agencies reported taking actions against facilities with
identified problems in the last 3 years, but few reported suspending or
revoking a facility's operating license. Options used include increased
monitoring or requiring corrective action plans. Maryland state
officials said that they may be less likely to close facilities when
they fall below state standards if there is a shortage of facilities in
the state and closing the facility would limit the state's ability to
serve the youth who would be displaced by a closing. In addition, these
officials noted that shutting down a facility is extremely disruptive to
the youth who are placed there.

[State Agencies Reported a Lack of Coordination to Share Oversight
Results]{.underline}

Many state agencies reported that they did not routinely share
information with others regarding negative findings from their
monitoring reviews. State agency coordination to share monitoring
results can strengthen oversight in situations where facilities are used
by multiple agencies and can help ensure that youth are not placed in
facilities that another agency has already identified as having
problems. However, one or more state agencies reported that they did not
routinely share reports of adverse incidents (17) or when facility
licenses had been suspended or revoked (12).

Improving coordination among agencies across states is also important
because almost all states reported in our survey that they placed some
youth in out-of-state residential facilities. For example, child welfare
agencies in the top 5 states reported placing over 3,500 youth in at
least 26 states. Out-of-state placement can be difficult to manage, but
may be used when the demand for services exceeds the state's capacity,
particularly for cases requiring highly specialized services\--such as
therapeutic treatment for youth who committed arson, or who were
involved in gangs. State agencies or parents may also place youth in
other states where family members reside. Interstate coordination is
important is to ensure that agencies sending youth for placement in
other states are able to screen out facilities that have had negative
findings uncovered during monitoring reviews or have outstanding
allegations of maltreatment. Information sharing about adverse
conditions in facilities may be particularly important in cases where
state licenses cannot serve to help in making appropriate placement
decisions. Four of the top 5 states that received the greatest number of
out-of-state placements---according to child welfare agencies we
surveyed---exempted one or more types of facilities from state licensing
requirements.

**Federal Agencies Challenged to Address Weaknesses in State Oversight
of Residential Facilities**

HHS, DOJ, and Education hold states accountable for youth well-being in
certain residential facilities, but their scope of authority is limited,
and gaps in agency oversight practices result in inconsistent
protections for youth. Most notably, these agencies can hold states
accountable for conditions in facilities that serve youth through
programs supported by federal funds[^13]---whether government or
private---but cannot hold states accountable for conditions in
facilities that are exclusively private. When federal agencies do have
oversight authority under certain federal programs, however, they do not
always hold states accountable for addressing some of the primary risks
to youth well-being. For example, in comparing requirements across HHS,
Justice, and Education, only HHS reported requiring states to address
abuse and neglect prevention under certain federal programs. (See table
1.)

Table 1: Federal Program Requirements for States that Address Certain
Risks to Youth Well-being in Residential Facilities

  -------------------------------------------------------------------------
  Agency and        Abuse and    Suicide      Use of         Education
  program area      neglect      prevention   seclusion and  quality
                    prevention                restraint      
  ----------------- ------------ ------------ -------------- --------------
  **HHS**                                                    

  Child welfare     Yes          No           No             Yes

  Medicaid          Yes          Yes          Yes^1^         No

  Substance abuse   Yes          No           No             No
  and mental health                                          

  **DOJ**                                                    

  Juvenile justice  No           No           No             No
  and delinquency                                            
  prevention                                                 

  **Education**                                              

  Elementary and    No           No           No             Yes^2^
  secondary                                                  
  education                                                  

  Special education No           No           No             Yes^2^
  and                                                        
  rehabilitative                                             
  services                                                   
  -------------------------------------------------------------------------

Source: Analysis of HHS, DOJ, and Education documents.

^1^Applies only to psychiatric residential treatment facilities**.**
^2^Applies only to public agencies and children placed by public
agencies in private facilities.

Federal program requirements are limited even for risks such as suicide,
a problem documented by several federal agencies. For example, the
Centers for Disease Control and Prevention (CDC)---which is part of
HHS---have identified suicide as the third leading cause of death in
2004 among all U.S. youth, and suicide was one of the leading causes of
death among youth in residential facilities, as reported by states in
this study. In addition, a study commissioned by the Department of
Justice recommends increased mental health screening for suicide
prevention among incarcerated youth.[^14] DOJ officials we spoke with
generally agreed with the need to focus on suicide prevention in
residential facilities, and suggested that additional federal
requirements in this area would be helpful. DOJ and HHS have Web sites
that list resources states can use for this purpose, but HHS officials
said that states are more responsive to a requirement or more specific
agency guidance.

Similarly, federal programs also do not generally require that states
ensure the proper use of seclusion and restraint practices, which have
come under intense scrutiny in recent years. Researchers and clinicians
have chronicled the inherent physical and psychological risks in each
use of these types of interventions\-\--including death, disabling
physical injuries, and significant trauma. Currently, federal seclusion
and restraint requirements cover youth placed in psychiatric residential
treatment facilities that receive Medicaid payments. However,
requirements do not extend to other types of facilities, and federal
officials told us that these techniques continue to be used in ways that
sometimes cause injury and death. HHS is preparing a draft notice of
proposed rulemaking concerning the use of seclusion and restraint in
non-medical community-based children's facilities.[^15]

Federal agencies have several means of oversight for youth well-being,
but perhaps one of the most rigorous is unannounced site visits to the
youth's place of residence. According to the federal and state officials
we spoke with, only an on-site visit to the facility can reveal whether
services in the administrative reports are provided under conditions
that ensure youth well-being. For example, DOJ officials observed that
students in one of the facilities they visited received their
educational instruction while in cages, and reported that it would have
been difficult to detect this practice in an administrative review.

Among the federal agencies we reviewed, all included visits to states to
ensure compliance with federal requirements, but agencies did not always
include visits to residential facilities. DOJ officials target juvenile
justice facilities, such as correctional facilities and detention
centers, during on-site reviews, but HHS officials do not necessarily
include residential facilities in their oversight reviews of state child
welfare systems. HHS selects a sample of child case files for site
visits, and because most children are in foster home settings,
residential facilities are usually not included.

Similarly, while federal programs contain provisions agencies can use to
enforce state compliance with federal requirements, these provisions
vary in their rigor and use, and only Justice has levied financial
penalties.[^16] To date, HHS and Education have required state
corrective action plans as a method of enforcement, but officials said
that they may also assess financial penalties in the future.

**Concluding Remarks**

As the results of our work show, protecting youth in residential
facilities---many of whom are troubled and vulnerable to harm from
themselves or from others---requires particular vigilance on the part of
parents and responsible government agencies. However, abuse, neglect,
and civil rights violations documented in all types of residential
facilities---government and private, licensed and unlicensed---show that
the current federal-state oversight structure is inadequate to protect
youth from maltreatment. Comprehensive results of our work will be
included in a report to be released next month. This report will provide
some options for action that states, federal agencies, and Congress may
consider in any restructuring effort. We anticipate our report will also
include recommendations for action that federal agencies can implement
now under the existing regulatory structure.

Mr. Chairman, this completes my prepared statement. I would be happy to
respond to any questions you or other Members of the committee may have.

**Appendix I: GAO Contacts and Acknowledgments**

> For further information regarding this testimony, please contact me at
> (202) 512-7215. Individuals making key contributions to this testimony
> include Lacinda Ayers, Carolyn Boyce, Art Merriam, and Mark Ward.

[^1]: Our review included facilities that provided services under one or
    more of the following types of programs: juvenile justice, youth
    offender, juvenile delinquency, and incorrigibility programs;
    treatment programs for youth with behavioral, emotional, mental
    health, and substance abuse issues; homes for pregnant teens;
    schools for discipline or character education; and therapeutic group
    homes, such as a home that specializes in supporting and treating
    youth with severe emotional disorders.

[^2]: In this report, we use the term *states* to refer collectively to
    the 50 states plus the District of Columbia and Puerto Rico. We did
    not survey state education agencies because they generally do not
    license residential facilities for youth.

[^3]: ^3^In fiscal year 2005, 10 states did not submit reports showing
    the number of fatalities in residential facilities\--2 states did
    not submit a report, 7 states did not track facility incident data
    in a format that could be shared with NCANDS, and 1 state involved
    in litigation did not report facility data.

[^4]: For additional information see U.S. Department of Justice
    *Department of Justice Activities Under the Civil Rights for
    Institutionalized Persons Act, Fiscal Year 2006*, U.S. Department of
    Justice (Washington, D.C.: 2007).

[^5]: According to DOJ officials, the Civil Rights Division has been
    granted access to HHS's Centers for Medicare and Medicaid Services
    (CMS) database that contains the annual survey results for CMS
    oversight of residential facilities.

[^6]: The survey question was as follows: Which, if any, of the
    following types of government operated facilities providing
    residential targeted (child welfare, health mental health, juvenile
    justice) services for youth are currently exempt from licensing or
    monitoring in your state by statute or state regulations---state
    operated facilities? Response options were (a) exempt from licensing
    by our agency, (b) exempt from routine monitoring by our agency, (c)
    exempt from both, (d) not exempt from either, (e) no such facility
    in state (f), don't know, and (g) no response.

[^7]: These six states are Arizona, Arkansas, Iowa, Maine, Missouri, and
    South Carolina. In addition, licensing officials we interviewed in
    Florida stated that faith-based facilities had the option of being
    licensed by the state or by a faith-based licensing authority. The
    survey question was as follows: Which, if any, of the following
    types of private facilities providing residential targeted services
    for youth are currently exempt from licensing or routine monitoring
    in your state by statute or state regulation: Faith-based
    facilities? (a) exempt from licensure by our agency, (b) exempt from
    routine monitoring by our agency, (c) exempt from both, (d) not
    exempt from either, (e) no such facility in state, (f) don't know,
    and (g) no response.

[^8]: Across agencies, states most often responded that they did not
    have private boot camps, ranches, and wilderness camps. Among state
    juvenile justice agencies, for example, 25 reported having no
    private boot camps in their state that received government funding,
    22 reported having no ranches, and 17 reported having no wilderness
    camps. Somewhat fewer states reported not having exclusively private
    boot camps (19), ranches (17), and wilderness camps (14).

[^9]: Two of the 15 states---Massachusetts and Utah---have a central
    agency that is responsible for licensing residential facilities.
    While we did not receive all three surveys from Texas, it also
    exempts residential schools and academies from licensing.

[^10]: GAO, [Residential Treatment Programs: Concerns regarding Abuse
    and Death in Certain Programs for Troubled Youth]{.underline}
    GAO-08-146T (Washington, D.C.: October 10, 2007)

[^11]: For example, HHS's Medicaid program, a federal-state health
    insurance program for low-income and other specific populations,
    requires that providers of certain health or mental health services
    obtain accreditation from an approved accrediting organization to
    certify that the facility meets standards for safety, quality of
    care, treatment, and services.

[^12]: Note: the survey question was as follows: When your agency
    develops or opens a government-operated residential facility that
    provides targeted services to youth, is the facility required to
    meet state standards in any of the following areas? (a) pass
    inspection of physical plant, (b) provide evidence of safe child
    care practices, (c) have written procedures for reporting physical
    or sexual abuse or neglect of youth, (d) meet all staff
    qualifications requirements, including training, (e) perform staff
    background checks, (f) meet specified staff-to-child ratios (g)
    provide evidence of appropriate educational programming, (h) have
    procedures in place for use of approved seclusion and restraint
    techniques, and (i) have written suicide prevention plans. A similar
    question was asked for asked for private facilities.

[^13]: This derives from Congress' powers under Article I, Section 8 of
    the U.S. Constitution and provisions of federal law establishing
    conditions for state grants. Congress, as part of its spending
    power, can attach conditions to states' receipt of federal funds.

[^14]: National Center on Institutions and Alternatives. Juvenile
    Suicide in Confinement: A National Survey. February 2004.

[^15]: This draft notice has been submitted for departmental review and
    clearance. This rule is being promulgated in response to the
    Children's Health Act of 2000 (Pub. L. No. 106-310, tit. XXXII,
    §3208) (amending Title V of the Public Health Service Act)), which
    requires that public or private non-medical, community-based
    facilities for children receiving support in any form from any
    program supported, in whole or part, with funds appropriated under
    the Children's Health Act, shall protect and promote the rights of
    each resident of a facility, including the right to be free from any
    restraint or involuntary seclusion imposed for purposes of
    discipline or convenience. The statute requires HHS to define in
    regulation the types of facilities covered by this provision's
    requirements.

[^16]: Federal funding was reduced by \$1,552,200 among 8 states and
    territories in 2007.