U.S.  Department of Health and  Human Services  
 
Office of Inspector General  
 
 
 
.
 
 
Operational Challenges  Within  
ORR and  the ORR  Emergency 
Intake Site  at  Fort Bliss  Hindered  
Case Management for  Children  
 
 
Christi A. Grimm  
Inspector  General  
September 2022, OEI-07-21-00251  
  U  .S. Department of Health and Human Services  
Office of Inspector General  
Report  in Brief  
September  2022, OEI-07-21-00251  
Operational Challenges  Within ORR  and  the 
Why OIG  Did This Review  
ORR  Emergency  Intake Site at  Fort  Bliss  
In 2021, the United States saw  
a  substantial increase  in the  
Hindered  Case Management  for Children  
number of unaccompanied  
children  who  arrived at  the  
What OIG Found  
southern border and were referred 
to the care of HHSs Office of   To  provide  care  to  the  historically  high  
Refugee Resettlement (ORR).  The  Key Takeaway   number  of  unaccompanied  children  who  
number of such children  increased  arrived  at  the  southern  border  in  early  
From  its  opening  in March 
from 1,929 children  in October  2021,  ORR  opened  emergency  intake  
2021 through  June  2021,  
2020 to 20,339 children  in April  sites  (EISs),  including  the  ORR  EIS  at  Fort  
operational  challenges  
2021.   At the same time, ORRs   Bliss.   From  the  opening  of  the  ORR  EIS  
within ORR  and  at  the  ORR 
capacity to care for children  was   at  Fort  Bliss  in  March  2021  through  
emergency  intake  site  at  
diminished due to COVID-19- June  2021,  operational  challenges  within 
Fort  Bliss  hindered case 
related staffing shortages and the   ORR and  at  this  EIS  hindered case 
loss of bed space due to   management,  which may  
management, which  raises  concerns  
recommended public  health  have adversely  affected 
related to  childrens  safe and timely  
mitigation strategies.  To  unaccompanied childrens  
release  from ORR care.   ORR and  facility 
accommodate these children,  safety  and well -being.   
staff reported  that  the facilitys  rushed 
ORRa program office of HHSs 
opening  impeded  ORRs ability to bring  
Administration  for  Children  and  
in  experienced case managers  and  provide them  with  adequate and  timely  
Families (ACF)  that operates  the  
training.   This  created a  situation  where some children  waited weeks  
Unaccompanied Children  
between  updates  from  their  case  managers,  which staff  at  the  facility  
Programopened 14 temporary  
reported as  causing  many  children  to  experience distress,  anxiety,  and in 
emergency  intake  sites (EISs),  
including the  ORR EIS at Fort Bliss,   some  cases,  panic  attacks.  
Texas.      
Additionally,  case management  for  childrens  safe and timely  release 
Members of Congress, child   from the  ORR  EIS  at  Fort  Bliss faced  challenges as  a  result  of  ORR-wide 
welfare  advocates, and staff  at  
approaches that  hindered  case  management  across all  ORR facilities.   
ORR facilities raised  concerns  
Specifically,  ORR  issued guidance to  expedite childrens  release, and this  
about inadequate case  
guidance removed several  safeguards  from  ORRs  process  for  screening 
management at the ORR EIS at 
potential  sponsors.   Sponsors are  parents,  guardians,  or  relatives  or  other  
Fort Bliss and its adverse effect on  
individuals  designated  by  an  unaccompanied  childs  parents  to  assume  
childrens well-being and their safe  
care  for  the  child.   Although the  purpose  of  the  guidance  was  to  reduce  
and timely release to sponsors.    
delays, the removal  of these safeguards  may  have  also  increased 
How OIG Did This Review   childrens  risk  of release to  unsafe sponsors.   In  addition,  deficiencies  with  
ORRs case  management  systemthe Unaccompanied Children  Portal 
This review analyzed information  
contributed to  case management  delays  and potentially  increased 
from interviews with 66 ORR  and  
facility staff.  It also analyzed  HHS   childrens risk  of  release  to unsafe  sponsors.    
documents related to case  
management  at ORR facilities.   Finally,  staff reported  acts  of  potential  retaliation  and  whistleblower  
Finally, OIG visited the ORR EIS at   chilling.  This  may  have  created  an  environment  in which  staff  at  the  ORR  
Fort Bliss  in June 2021.   EIS  at  Fort  Bliss  and ORR  headquarters  felt  discouraged from  raising 
concerns  about  case  management  and  child  safety  to  supervisors.  
 
   
What OIG  Recommends and How the Agency Responded  
The  Office of Inspector  General  recommends  thatto help  ensure  that  
children  receive quality  case management  services  that  prioritize their  
safety  and well-being,  including  during  an  influxACF:  (1)  develop  and 
implement  a  plan  that  supports  ORR  and  its  contractors  in securing  
qualified case managers  during an  influx  to  help  ensure childrens  safe 
and timely  release to  sponsors;  (2)  provide  case  managers  with  timely  
and comprehensive training and support  to  help  ensure childrens  safe 
and timely  release to  sponsors;  (3)  create  an  emergency  policy  
development  protocol  that  provides  for  adequate input  from  staff with  
expertise in  child welfare when  ORR develops  field guidance during an  
influx;  (4)  ensure that  ORR  addresses  challenges  regarding usability  and 
search  capabilities  within  its case  management  system,  the  UC  Portal;  and 
(5)  ensure  that  ORRs employees and employees  of ORRs  contractors  
and recipients  are  informed  about  Federal  whistleblower  protections.   
ACF  concurred  with  all of  our  recommendations.        
   
TABLE OF  CONTENTS  
 
   
BACKGROUND ................................................................................................................................................  1  
FINDINGS ........................................................................................................................................................ 11  
ORRs rapid  staffing  of the ORR EIS  at Fort Bliss left inexperienced and untrained case managers 
unprepared to provide case management for childrens safe and timely release to sponsors ................ 11  
In the early months of operation of the ORR EIS  at Fort  Bliss, some case managers infrequent  
communication with children and their sponsors caused children to experience distress, anxiety, and  
in some cases,  panic attacks ............................................................................................................................................... 13  
ORR issued field guidance that removed certain steps of the sponsor screening process across ORR  
facilities, potentially increasing childrens risk of release to unsafe sponsors ................................................. 15  
Deficiencies with ORRs online case management system contributed to case management delays and  
potentially increased childrens risk of release to  unsafe sponsors ..................................................................... 17  
Alleged acts of retaliation and whistleblower chilling may have created an environment in which staff  
at the ORR EIS at  Fort Bliss and ORR  headquarters felt that  they were discouraged from raising issues 
about case management and child safety ..................................................................................................................... 20  
CONCLUSION AND RECOMMENDATIONS ..........................................................................................  23  
Develop and implement a plan that supports ORR and its contractors in securing qualified case 
managers during an influx to help ensure childrens safe and timely release to sponsors ........................ 24  
Provide case managers with timely and comprehensive training and support to help ensure childrens 
safe and timely release to sponsors ................................................................................................................................. 24  
Create an emergency policy development protocol that provides for adequate input from staff with 
expertise in child welfare when ORR  develops field guidance during an influx  ............................................. 25  
Ensure that  ORR addresses challenges regarding usability and search capabilities within its case 
management system, the UC Portal  ................................................................................................................................ 25  
Ensure that  ORRs employees and employees of ORR contractors and recipients are informed about  
Federal whistleblower protections  ................................................................................................................................... 25  
AGENCY COMMENTS AND OIG RESPONSE  ......................................................................................... 27  
APPENDICES .................................................................................................................................................  29  
Appendix A: Services Provided by ORR Facility Types .............................................................................................. 29  
Appendix B: Timeline of EIS Op enings and Field Guidance No. 13.....................................................................3 0 
Appendix C: Related OIG Work . ........................................................................................................................................ 31  
Appendix D: Agency Comments.................. .................................................................................................................... .34  
   
ACKNOWLEDGMENTS AND CONTACT ................................................................................................ 48 
     
Acknowledgments ..................................................................................................................................................................48 
     
Contact........................................................................................................................................................................................48 
     
ABOUT THE OFFICE OF INSPECTOR GENERAL.................................................................................... 49 
     
ENDNOTES ................................................................................................................................................... 50 
 
 
   
BACKGROUND  
Objective  
To examine operational  challenges within ORR  and at the ORR  emergency 
intake site (EIS)  at  Fort Bliss that hindered case management  for childrens safe 
and timely release  from  March through June 2021.  
 
The Office of Refugee Resettlement (ORR), a  program office of the Administration for 
Children and Families (ACF) within the Department of Health and Human Services 
(HHS), manages the Unaccompanied Children (UC) Program.  The UC Program serves 
children who arrive in the United States unaccompanied.   Although the number of  
unaccompanied children arriving at  the southern border varies from season to season 
and year to  year, in  fiscal year (FY) 2021 a  historically high number of unaccompanied  
children began arriving at the southern border of the United States.  The  number of  
unaccompanied children referred to ORR custody nearly doubled from FY  2019 to  
FY  2021.  The UC Program received 69,488 referrals for unaccompanied children from 
the Department of Homeland Security (DHS) in FY  2019, and 122,731 referrals for  
unaccompanied children in FY  2021.1, 2    
 
The  2021 surge of unaccompanied children at the U.S. border presented  several  
urgent challenges that ORR  needed to  address to  house and care for unaccompanied  
children referred from DHS.  These challenges were exacerbated by the fact that, in 
early 2021, ORRs capacity to care for children in its regular network of  care provider 
facilities  (facilities)  was diminished due to COVID-19-related  staffing shortages and   
a decrease in  bed space  in response  to physical  distancing protocols  and other  public 
health mitigation strategies.  3  
 
Operational Challenges Within ORR and the  ORR Emergency Intake Site at Fort Bliss Hindered Case Management for Children    
OEI-07-21-00251   Background |  1     
Exhibit 1. Referrals of  unaccompanied children to ORR,  by fiscal year  
140,000 
120,000 
100,000 
80,000 
60,000 
40,000 
20,000 
0 
FY 2012 FY 2013 FY 2014 FY 2015 FY 2016 FY 2017 FY 2018 FY 2019 FY 2020 FY 2021 
Source:  ORR data on annual  referrals of unaccompanied  children from DHS, 2022.  
Unaccompanied  Children Program  
Unaccompanied children are minors who have no lawful immigration status in the  
United States and do not have a parent or legal guardian available in the United  
States to provide care and physical custody.4   The majority of  unaccompanied  
children have been apprehended by immigration authorities at or near the United  
States border  without a  parent or legal guardian.   Children in  custody of  any Federal  
department or agency, including DHS,  must be transferred to ORR within 72 hours 
from the determination that the child is unaccompanied unless there are exceptional  
circumstances.5   Federal  law requires ORR to make safe and timely placements for 
children in the least restrictive setting that is in the best interest of the child.6   To that  
end, ORR  funds a network of facilities that furnish temporary care for children until  
they are released to a sponsor or otherwise leave ORR custody.  A child remains in 
ORR custody until an appropriate sponsor in the United States who can assume 
custody is identified, the child turns 18 years old and ages out  of the UC Program, or 
the childs immigration status is resolved.  Childrens sponsors can include parents,  
guardians, and  relatives, and other individuals designated by the childs parents.7  
Office of  Refugee Resettlement  care provider network  
ORR enters into grants, cooperative agreements,  and contracts with  several types of  
facilities, in a variety of settings, to form  a  care provider network that provides  
placements for the children in its  care.8   These facilities must provide services for 
children,  including housing, food, medical care, mental health services, educational  
services, and recreational activities.  Most  facilities are licensed or accredited under 
the laws of their respective States,  and  they must meet ORR requirements.  In FY  2021, 
ORR provided funding to approximately 200 facilities and programs in 22 States.   
Operational Challenges Within ORR and the  ORR Emergency Intake Site at Fort Bliss Hindered Case Management for Children    
OEI-07-21-00251   Background |  2     
ORRs bed management strategy aims to accommodate the substantial fluctuations in 
the number of unaccompanied children that arrive at the U.S. southern border 
throughout the year.9    ORR maintains standard beds that are available year-round  
at licensed care facilities.  Additionally, ORR can add or reduce temporary beds as 
needed at unlicensed  influx  care facilities, which are opened on a temporary basis 
when ORR experiences an influx of children.  The COVID-19 pandemic had a  
significant  impact on ORRs care provider network capacity, which was reduced by up 
to 40 percent.  This reduction was primarily caused by staffing shortages and loss of  
bed space attributable to  physical distancing protocols and  other public health 
mitigation strategies  set by the Centers for Disease Control  and Prevention to  
mitigate the spread of COVID-19.  Although ORR  has worked  to build up its licensed  
bed capacity andas of  June  2022funds more than 17,000  licensed beds (the 
highest in the UC Programs history), additional capacity was needed in early 2021 to  
manage the historic increase in  the number of  unaccompanied children referred from 
DHS  and to  implement COVID-19 mitigation strategies.10   
Exhibit  2. Children  in ORR care, October 2020June 2021 
25,000 
20,000 
15,000 
10,000 
5,000 
0 
Oct.  Nov.  Dec.  Jan.  Feb.  Mar.  Apr.  May  Jun.  Jul.  Aug.  Sep. 
2020  2020  2020  2021  2021  2021  2021  2021  2021  2021  2021  2021 
Source:  ORR data on unaccompanied children in ORR care, 2022.  
In  response to the number of unaccompanied children referred from DHS  in spring  
2021, ORR reopened one influx  care facility and, in collaboration  with the Federal  
Emergency Management  Agency  and  the Department  of Defense, opened a new type 
of facility: the EIS.11   In 2021, ORR  opened a total  of 14 EISs  along the U.S. southern 
border and in the U.S. interior; facility  operations ranged from a period  of weeks to  
more than 1 year.   For a  comparison of services offered at  EISs, influx  care facilities,  
and licensed shelters, see Appendix A.  
 
 
Operational Challenges Within ORR and the  ORR Emergency Intake Site at Fort Bliss Hindered Case Management for Children    
OEI-07-21-00251   Background |  3     
Emergency Intake Sites  
ORR established  EISs  as  unlicensed, short-term facilities  intended to be open for less 
than 6 months  and  to receive timely  referrals from DHS,  which  was experiencing  
overcrowding in border facilities due to the unprecedented influx of migrants.12   ORR 
opened  EISs  in FY  2021  due to  a severe shortage of beds in ORRs licensed care 
provider network and  influx  care facilities.   ORR defines a  severe shortage as  when 
ORR does not have enough licensed beds available, which would result in children 
remaining in DHS custody for more than 72 hours.13   EISs were initially established as 
temporary stopgap facilities from which children would be referred to licensed care 
facilities as soon as beds became available.   
On April 30, 2021more than a  month after ORR  opened its first EISsORR  issued  
field guidance outlining  instructions and standards for operations at EISs.14   Prior  to 
this guidance,  ORR had  not published  comprehensive instructions or standards for 
EISs on its  website.15   For a detailed timeline of EIS opening dates and relevant  field  
guidance issuance, see Appendix B.  
As of  June 2022, ORR does not currently operate any EISs.  ORR closed 12 of the 14 
EISs  by January  2022, and converted the remaining two  facilities (the ORR  EIS at Fort  
Bliss and the Pecos EIS)  from EISs to influx care facilities in May and June 2022,  
respectively.   This conversion means that the ORR facilities at Fort Bliss and Pecos 
must meet minimum standards of care for licensed facilities; for a comparison of  
services offered at  EISs, influx  care facilities, and  licensed shelters, see Appendix A.  
Concerns about  EISs.   EISs have been the subject of media reports and complaints 
from members of Congress, child  welfare  advocates, and staff at the facilities.  Many 
of the reports and complaints included concerns about the safety and well-being of  
children in EIS facilities and the delays that some children experienced in receiving  
services.16, 17, 18    
ORR EIS at Fort Bliss.   ORR opened its EIS on the Fort Bliss military base  in  El Paso, 
Texas,  on March 30, 2021.  The  facility  reached a capacity to care for up to  10,000 
children 1317  years  of age  in May 2021, andas of  June 2022has beds for 2,000 
children.   Children are housed at the facility in warehouse-sized tents with cot-style 
bunkbeds, consistent with temporary shelters used during emergency responses and  
disaster relief efforts.19, 20   Operations at  the ORR EIS  at Fort Bliss are overseen  by 
facility leadership, including:  
Incident commanders. Incident commanders are Federal employees temporarily 
assigned  to  work at  EIS facilities by ORR to  oversee facility  operations and  
custodial care of the children.21,  22  
Federal field  specialists. Federal field  specialists and Federal field specialist  
supervisors are ORR employees who  serve as local ORR liaisons to one or more 
facilities within a region.  They are responsible for providing guidance and  
technical assistance to facilities.  
Operational Challenges Within ORR and the  ORR Emergency Intake Site at Fort Bliss Hindered Case Management for Children    
OEI-07-21-00251   Background |  4     
Contract leadership.  Leaders from various contractors also  work closely with ORR  
to oversee facility operations and ensure that children receive appropriate 
services.  
Throughout this report, we refer to the ORR facility at  Fort Bliss as the ORR EIS at  Fort  
Bliss.   The facility operated as an EIS for the duration of  our review period (March 
June 2021)  and was converted to an influx care facility on May 30, 2022.  
Case management  for  childrens  safe and  timely release  
Through its case management process  for childrens safe and timely release, ORR  is  
responsible for identifying a suitable sponsor in the  United States who can care for 
the child when he or she leaves ORR  custody.  By law, ORR must establish the safety 
and suitability of potential sponsors.23   Thorough sponsor screening processes help 
protect  children from  being  at risk of  harm after their release.24   Efficient processes 
are also  important because in  previous Office of Inspector General (OIG)  work,  staff at  
care provider facilities reported  that  childrens mental health often deteriorated  with  
longer  lengths  of stay in ORR care.25   ORR policy assigns the  responsibility  of  
screening  sponsors to case managers.26   
When ORR cannot identify a suitable, safe sponsor, children will remain in a facility or 
may be placed in long-term foster care, including community-based foster care or a  
group home.  Children who turn 18 years old while in ORR care are typically 
transferred to DHS custody.  As laid  out in ORR  policy,  the process for releasing a  
child in ORRs care to a sponsor includes:  
Identifying a sponsor.   Staff at the facility where the child resides interview the 
child, parents, legal guardians, or other family members (including those in their 
home country) to identify potential sponsors in the United States.  
Sponsor submission of application for release.   The potential sponsor must  
complete and submit  the Family Reunification Packet, which consists of  
documents a potential sponsor must complete before a release decision can be 
made, as well as  documentation needed  to verify  the sponsors identity, address, 
and relationship to the child.27  
Background checks.   ORR requires a background check of potential sponsors and  
adult members of a sponsors household.   Depending on the sponsors 
relationship to the child  and other factors, these may include a public records 
check, sex offender registry check, State child abuse and neglect registry check, 
and a Federal Bureau of  Investigation criminal history check.   
Release decision.   Facility staff consider  all collected  information and make  a 
recommendation to ORR regarding  the childs release to a  potential sponsor.   
ORR staff then make one of the following determinations:  
   approve the release,  
   approve with post-release services,  
Operational Challenges Within ORR and the  ORR Emergency Intake Site at Fort Bliss Hindered Case Management for Children    
OEI-07-21-00251   Background |  5     
   require a home study before making  a decision,  
   deny the release, or  
   send back for further review.  
ORR and  facility staff roles  related to  case management  for 
childrens safe and  timely release  
Sponsor screening processes are carried out by a variety of staff  at all types of ORR  
facilities.  Key staff include:  
Case managers. Case managers are facility staff  who are responsible for 
assessing children and their potential sponsors, providing regular case updates to  
children, making transfer and release recommendations  based on collected  
information, and coordinating children's release.    
Case  management team members. Other members of the case management  
team are facility staff,  including case aides, data aides, and case management  
quality control staff.  These staff members assist in preparing, tracking, and  
reviewing childrens cases.  
Federal field  specialists.   Federal field  specialists and Federal field specialist  
supervisors are ORR employees who are responsible for approving or denying  
childrens transfer between ORR  facilities and release to sponsors.  
Youth care workers. Youth care workers are facility staff who provide around-the-
clock monitoring of children and are responsible for bringing children to and  
from case management meetings.  
Mental health staff.   Mental health staff  are facility staff  who  are responsible for 
providing in-house mental health care for children.  
Case coordinators.  Although case coordinators are not involved in sponsor 
screening at EISs, they review all assessment information for  unaccompanied  
children  and  childrens sponsors  to make  a recommendation for release at other 
ORR facilities.    
ORRs online case management  system  
The Unaccompanied Children (UC) Portal  is ORRs online case management system 
and is used throughout the sponsor screening process.  Every child who enters ORR  
care is logged in the system.28   Case managers use the UC Portal to manage all  
activities related to  a  childs sponsorship case.  The system contains detailed  
information about  a child's interactions with case managers, documentation used to  
verify a sponsors identity, address(es), and relationship with a child, release 
paperwork, and other documents related to  a childs case.  The system tracks the child  
from intake to discharge to a sponsor.   
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OEI-07-21-00251   Background |  6     
Since April  2021, ORR has been making incremental improvements to  the UC Portal.  
According to ORR, these improvements prioritize child safety, efficiency of the case 
management process, the overall user experience, and system security and stability.  
Case management  at EISs  
Because EISs  were established as temporary stopgap facilities, they  were not  initially  
intended  to  provide the full range of services offered at ORRs licensed facilities (e.g.,  
case management  for  childrens safe and timely release).29   However, the rapid  
increase of  unaccompanied children referred to ORR care from  February through April  
2021combined with physical  distancing  protocols  recommended to reduce the 
spread of COVID-19caused a  severe shortage of beds in ORRs licensed  care 
provider network.   This meant that  many children could not be  transferred from  EISs  
to licensed ORR facilities  and needed to be  released directly from EISs  to sponsors.   As 
a result, ORR and its contractors had to  establish services for childrens safe and  
timely release  from EISs.  ORR quickly staffed case management at  EISs  with hundreds  
of individuals who could  pass background checks and were able and willing to work in  
a mass care setting during the COVID-19 pandemic.30  
On April 30, 2021, ORR issued field guidance stating that  EISs  should begin providing  
case management services for childrens safe and timely release to sponsors either at  
the time of  an EIS stand-up or as soon as reasonable under the circumstances.31   
According to the guidance, case management services at EIS facilities should be 
primarily focused on releasing children without unnecessary delay to sponsors who  
are able to provide for their care.  Once established, case management services at  EISs  
were  carried out by contractors, subcontractors, and Federal employees, including  
teams from United States Citizenship and Immigration Services and volunteers from 
across the Federal  Government.32   In June 2021, ORR reported that all  EISs  in  
operation had implemented some case management services.33   
Concerns about case management at the ORR EIS at Fort Bliss.  Members of  
Congress, child  welfare  advocates, and staff at the facility reported concerns about  
the inadequate case management at  the ORR EIS at  Fort Bliss and  its adverse effect  
on childrens well-being and their safe and timely release to  sponsors.34   Among these 
reports were multiple letters to OIG from the Government Accountability Projecta 
whistleblower and advocacy organizationin which several Federal employees who  
had  volunteered for temporary  assignments  at the ORR EIS at Fort Bliss shared  
concerns about case management and child safety.35   The reports described  
overwhelming noise levels; extreme weather such as dust storms and high 
temperatures; and unsanitary conditions.36   These reports also  alleged that  ORR staff,  
ORR contractors, ORR subcontractors, and other Federal employees (whom we refer 
to collectively as staff) at  the facility were ill-prepared to provide adequate case 
management services, which adversely affected  childrens mental health as well  as the 
quality of case management that the children received.  Some reports  alleged that  
staff at the ORR EIS at  Fort Bliss were discouraged from raising issues about case 
Operational Challenges Within ORR and the  ORR Emergency Intake Site at Fort Bliss Hindered Case Management for Children    
OEI-07-21-00251   Background |  7     
management and child safety, leading to concerns about the potential violation of  
whistleblower protection laws.37    
Methodology  
This review  analyzed data from interviews OIG conducted with ORR staff  and facility 
staff (i.e., ORR contractors, ORR subcontractors, and Federal volunteers) virtually and  
during OIGs June 2930, 2021, visit to the ORR EIS at  Fort Bliss.  OIG took  several  
steps to protect the identities of the individuals we interviewed, including removing  
names and other identifying information from interview excerpts.  In cases where it  
was necessary to include  sensitive and potentially identifying  information about the 
interviewees role or experience, OIG obtained their verbal and written consent.   
The review also analyzed internal and public HHS  documents.  This review  reports on 
the most salient themes regarding case management practices that may have  
adversely affected  childrens safety and well-being during our March 30June 30, 
2021, review period.   For more information on past OIG work regarding the UC  
Program, see Appendix C.  
Data Collection   
Interviews.   We conducted interviews with a sample of 66 individuals  who were 
directly or indirectly involved in case management at the ORR EIS at Fort Bliss  during  
our review period.  OIG conducted interviews from June 11, 2021, through  December  
17, 2021. Approximately half of all  interviews were conducted during OIGs site visit  
June 29June 30, 2021, and  approximately half  were conducted virtually before and  
after the site visit.  These 66 interviewees included case managers and  case 
management team members; youth care workers; Federal field specialists and their 
supervisors; incident commanders; and ORR leadership.  In this report, ORR leadership 
refers  to Presidential appointees under the Executive Schedule and career employees 
with supervisory functions who oversee the UC Program.   
The majority of staff  that OIG interviewed while onsite at the  ORR EIS at  Fort Bliss  
were members of the case management team.  OIG randomly selected 41 case  
managers and case management team members for interview and purposively 
selected other staff, including members of the youth care, administrative, and mental  
health teams, based on job titles of relevance to  case management processes at the  
facility.  We  were able to interview 25 case managers and case management team 
members for a response rate of 61 percent.  For a detailed breakdown of  interviewees  
roles at the facility and  in ORR, see Exhibit  3.  
 
 
 
 
 
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OEI-07-21-00251   Background |  8     
Exhibit 3. ORR and  Facility Staff Interviewed   
Staff Role   Number Interviewed  
ORR  Staff  
Federal field specialists/Federal  field specialist  supervisors   8  
ORR  leadership   4  
Contractor  Officer  Representative   1  
UC  Portal technical expert   1  
Facility  Staff*  
Case managers  and case management  team  members   28  
Youth  care  team   8  
Mental health team   5  
Administrative  team   5  
Incident  commanders   4  
Contract  leadership    2  
Total Staff Interviewed   66  
*Facility staff include ORR contractors, ORR  subcontractors, and Federal volunteers.  
 Source:  OIG interview data, 2022.  
 
Documents.   We reviewed HHS documents related to case management at ORR  
facilities, standards of care at  EISs, and the surge in arrivals of  unaccompanied  
children that began in January 2021 (e.g., ORR policies and procedures, ORR training  
materials, ORR Juvenile Coordinator Interim Reports, and ORR field guidance).  We 
also reviewed a letter that Federal  field specialist supervisors presented  to  ORR 
leadership  in which they raised concerns about the development of field guidance, 
EISs rushed  opening, case management, and child welfare.  
 
Data Analysis  
We performed qualitative analysis of the interview data collected from 66 ORR and  
facility staff  members, which involved multiple steps carried out by OIG staff.  We  
used qualitative analysis software to  organize interview  responses and categorize the 
themes that emerged related to  operational challenges that hindered case  
management.   
We examined results to identify significant challenges reported by ORR  and facility 
staff.  We  identified the most significant challenges impeding case management, as 
reported by ORR and facility staff.  As such, the report does not reflect every 
challenge that facility staff mentioned during interviews.  We considered a challenge 
significant  if it was identified by the majority of staff  across relevant roles, with one 
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OEI-07-21-00251   Background |  9     
exception: concerns raised by staff regarding alleged acts of retaliation and  
whistleblower chilling.  Due to the nature and importance of these allegations, the 
team decided  that any information related to  this issue  warranted  inclusion in the 
report.  OIG values the critical role that whistleblowers play in disclosing  fraud, waste  
and abuse and protecting of public health and safety.  OIG investigates complaints of  
whistleblower retaliation as appropriate within its jurisdictional boundaries.  
We also reviewed  available internal  and public HHS documentsincluding ORR 
training materials, ORR  Juvenile Coordinator Interim Reports, and ORR field  
guidanceto establish facts, confirm timelines, and, when possible, verify interview  
responses.  
Limitations  
This review reflects the perspectives of staff  who  were present onsite or had  
knowledge  of case management processes at the ORR EIS  at Fort Bliss during our 
March 30June 30, 2021, review period.  Our review is limited  to operational  
challenges that hindered case management  during the first  4 months of operations at  
the ORR EIS  at Fort Bliss, as reported by interviewees.    
Comprehensive field guidancewhich ORR  issues to address emergency or short-
term policy goalswas not issued  to outline EIS standards until a month into  our 
review period.  We did not analyze informal guidance that may have been distributed  
to EISs prior to the April 30, 2021,  field guidance.  
Standards   
We conducted this study in accordance with the Quality Standards for Inspection  and  
Evaluation  issued by the Council  of the Inspectors General on Integrity and Efficiency.   
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FINDINGS  
ORRs  rapid  staffing  of  the  ORR  EIS at  Fort  Bliss  left  
inexperienced  and  untrained  case managers  unprepared  to  
provide case management  for childrens  safe and  timely release 
to sponsors  
Following the rapid opening of the ORR EIS at  Fort Bliss on March 30, 2021, and the  
arrival of thousands of  unaccompanied children at the facility, ORR faced difficulties 
related to  case management for the safe and timely release of children to sponsors as 
required by ORR guidance.38   Specifically, ORR  faced difficulties in securing  
experienced case managers and providing adequate training  for inexperienced case 
managers.  To provide  case management, ORR employed nearly 300 case managers 
within a month of opening its EIS at  Fort Bliss.  
To meet  the need for case  management staff,  positions were  
often filled with inexperienced case managers  who lacked  
knowledge about child-welfare best practices  and the  
Unaccompanied Children Program  
Many of the case managers who were rapidly placed at the facility to meet the 
demand for case management reportedly lacked  relevant knowledge and  experience, 
which left them unprepared to navigate ORRs process for the safe and timely release 
of children to sponsors.  Interviewees reported that it  was difficult to  find  staff  
qualified to  conduct ORRs complex  sponsor screening process, which requires 
coordination among care provider staff, ORR staff, and other Federal agencies.  As a  
result, case management positions were filled with Federal volunteers and contract  
staff  from a  diverse variety of professional backgrounds.  ORR leaders, incident  
commanders, and Federal field specialist supervisors told OIG that  many of these case 
managers lacked relevant experience.  
Staffing the case management program with experienced individuals is important for 
ensuring that case management is conducted in accordance with ORR policy and with 
consideration for childrens safety and well-being.  One ORR leader reported concern 
about the impact of rapid hiring practices on the vulnerable children in ORRs care.   
The population that  we are supporting is an at-risk population, he said.  They are  
children; they are inherently vulnerable.  There are unfortunately bad actors out in the 
world that specifically target programs that support and provide services to children 
so that they can victimize and abuse children.  For this reason, he explained, bringing  
on inexperienced case management staff rapidly is something that should never 
occur.  
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Contractors at EIS facilities were expected to  hire large numbers of case 
managers in an  extremely short period of time.  Unfortunately, this appears to  
have been done at the expense of hiring individuals  [with] the knowledge, 
skills, or  abilities  to serve as skilled case managers in the UC Program.  
 
  Letter from Federal  field specialist supervisors to  ORR leadership, July 23,  2021  
When  inexperienced case managers conduct case management with limited or no  
knowledge of  child-welfare best practices, childrens risk of release to unsafe sponsors 
may increase.  Federal field specialist supervisors reported that some inexperienced  
case managers showed a disregard for long-established  child-welfare best practices.   
In some cases, release recommendations made by these inexperienced case managers 
reportedly failed to consider childrens significant history of abuse and neglect or 
whether  sex offenders resided in the potential  sponsors household.  ORR  leaders 
reportedly received numerous complaints about the quality and thoroughness of  
some  case managers work.    
In the early months of operation of the ORR EIS at Fort  Bliss, ORR  
did not  provide inexperienced case management  staff with  
adequate training  to help ensure childrens safe and timely  
release to sponsors  
In the absence of adequate training  during the early months of operation of the ORR  
EIS at Fort Bliss, inexperienced case managers at the facility were left  ill-prepared to  
help ensure that children were released to safe sponsors.  ORR policy guidance 
includes training requirements for all ORR staff  who have contact with children, but  
according to staff  familiar with operations at the facility, ORR initially waived these 
requirements for 60 days.39   This meant that hundreds of case managers who were 
hired at the facility in March and April may not have received training on a variety of  
topics prior to assuming case management duties and  interacting with children.   
We were thrown in with  no formal training.  We relied on each   
other and shared what  we  had learned.  They  spoke to us like we  
knew how to process cases when, in reality, it was trial and error.  
  Case manager  
Although ORR and its contractors began offering in-person training modules in late  
April, some staff reported that the trainings they received were irrelevant, outdated, or 
not applicable to case management at the ORR EIS at  Fort Bliss.  Specifically, they 
reported receiving little or no training on topics related to case management duties,  
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such as managing a caseload  or working with personally identifiable information.   
Staff described an environment in which case managers relied on their peers and  
learned from their mistakes.  
This lack of training for inexperienced case managers at the ORR EIS at  Fort Bliss may  
have caused unnecessary delays in uniting children with their sponsors.  Staff reported  
that when case managers were not adequately trained, they were unprepared to  
conduct case management in a particularly challenging environment.  According to an 
incident commander, several  cases submitted by case managers at the facility were 
sent back by Federal field specialists tasked with approving childrens release.  Cases 
were sent back for further review after Federal field specialists observed deficiencies 
including incomplete sponsor screenings and insufficient evidence to support the safe 
release of a  child to a sponsor.  
In the early months  of  operation of  the ORR  EIS  at  Fort  Bliss, 
some case managers  infrequent  communication  with  children 
and  their sponsors  caused  children to  experience distress,  
anxiety,  and  in some cases,  panic attacks   
Staff who were  onsite during the facilitys early months of operation reported that  
children experienced distress related to infrequent communication from  case 
managers.   ORR guidance for licensed facilities highlights the importance of regular 
updates, stating that that case managers should provide children with weekly updates 
on the status of their cases.40   ORR did not publish guidance on how  often case 
managers at unlicensed  EISs  should meet with children until  late  May.  In the 
meantime, hundreds of children who  began arriving at the ORR EIS at  Fort Bliss on 
March 30 reportedly spent weeks without receiving updates from case managers.  A  
case management team member reported that, near the end of  May, she became 
aware of a  list of 700 children who had not been seen by a case manager for 
approximately 60 days.  Similarly, a youth care worker recalled compiling  a list  of  
nearly 100 children who  had been at the facility for more than 30 days and who  
reported infrequent communication with their case managers.  The youth care worker 
stated that, in many cases, these children had not been contacted by any case 
management staff after their initial intake interview.   
Kids would say, I havent talked  to my case  manager in 48 days.  
They had a sense that they had been forgotten.  Even if someone  
was working the  case, it wasnt communicated to  the kids in any  
systematic  way.  One girl kept saying she didnt know what was going on,  
and one day  she broke down and said  she couldnt take it anymore.  
  Youth care worker  
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This lack  of  communication contributed to what  another interviewee called a  
pervasive sense of despair among  children at the facility,  who reportedly experienced  
distress, anxiety, and in some cases, panic attacks.  Interviewees shared childrens 
fears  of  being  forgotten by case management staff, which led  to uncertainty about  
when they would be released from the facility and reunited with their family or other 
sponsors.  In one extreme case of a child in distress, a youth care worker described  
witnessing a young girl  begin to hit  and cut herself in front of a group of  children 
after learning that her mother had not yet been contacted by a case manager as part  
of the sponsor screening process.  Following this episode, the girl was restrained by 
security guards and other staff and  transferred to a psychiatric facility.  According to  
the youth care worker, staff were told that her mothers commentthat she hadnt  
been contacted by the case managerwas what prompted this reaction.  41  
Facility staff  attributed the initial lack  of communication with children to a variety of  
factors.  One factor leading to infrequent communication with children was that case  
managers often had large caseloads due to staffing shortages, high rates of turnover,  
and the large number of children onsite.  Some case managers told OIG that they 
managed caseloads of as many as 30  to 35 children during spring 2021, which 
contributed to delays in providing children with updates.42   At the time of  our onsite  
interviews in late June 2021, case managers reported managing fewer than five  cases 
as the number of children at the facility was lower.  
I started early in  the month of May.  It was overwhelming at the  
beginning.   At one point, I was up to 35 kids. I had no time to  
process the kids I was seeing. I was not the only one in that boat.  
There were so many kids who had not been seen 30 [or more] days.  
  Case manager  
Additionally, confusion surrounding  case assignment in the facilitys early months left  
case managers unsure about which children were assigned to their caseloads, which 
some staff said caused childrens cases to fall  through the cracks.  Another factor 
was case managers inability to locate children onsite in a timely manner.  Site 
leadership described the facilitys initial process of locating children as chaotic and  
haphazard, recalling how youth care workers would  walk through the massive tents 
shouting childrens names using bullhorns.  One case manager reported that the  
process  of locating a child to meet  with a  case manager  often took 3 hours.   
Facility staff stated that quality control measures implemented in June  
2021 resulted in more frequent communication between case managers,  
children, and sponsors.   Several  interviewees offered that  ORR and facility 
leaderships efforts to track and set goals for case managers communication with 
children resulted in more frequent interactions between case managers, children, and  
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sponsors.  According to  facility leadership,  the facilitys data team began analyzing  
metrics related to case assignment  and case management communication.  Facility 
leadership also implemented a tracking system that required guards to scan childrens 
bracelets when they entered or exited any part of  the facility.  This enabled youth care  
workers to  locate children for case management meetings more quickly.  
ORR issued  guidance standards specific to  EISs  in late May 2021, which states that  
case managers at  EISs  should update unaccompanied children  on  the status of their 
case throughout the process and no less than every 10 to 12 days.43   By late June, 
case managers at the ORR EIS at  Fort Bliss had  met the facilitys goal  of  ensuring that  
every child at the facility met with their case manager every 7 days.  ORR leadership 
reported that this improvement was helpful for the mental health of children at the 
facility.  
ORR  issued  field  guidance that  removed  certain steps  of  the 
sponsor  screening  process  across  ORR  facilities,  potentially 
increasing  childrens  risk  of  release to  unsafe sponsors  
In early 2021, in response to a surge in  arrivals of unaccompanied children  (see Exhibit  
2), ORR issued field guidance to modify case management and sponsor screening  
processes for children in ORRs care.  ORR field guidance is issued to address 
emergency or short-term policy goals and is used to modify or supplement ORRs 
standard policies and procedures.  ORR and facility leadership expressed  concerns 
with the way in which this field guidance was developed and its effect  on childrens 
safety.  
According to Federal field specialist  supervisors,  some  ORR field  
guidance  issued from March  2021  through  June 2021  was  
developed without adequate input  from  ORR staff  with  expertise  
in child welfare  
During the 2021 surge  in arrivals of unaccompanied children (see Exhibit 2), ORR 
leadership quickly developed and issued field guidance without adequate input from 
ORR child-welfare experts.  Months after the field guidance was implemented, a  
group of  11 ORR staff that included  all but  one of the Federal field specialist  
supervisors presented ORR leadership  with a  letter in which they raised concerns 
about the development of field guidance.  According to this letter  and staff interviews, 
the rapid development and implementation of this  field guidance meant that ORRs 
child-welfare experts were not given the chance to review the policies and ensure that 
they prioritized childrens safety.   
ORR leaders presented differing perspectives on the amount of planning  and review  
that took place  prior to  the implementation of this field guidance.  One  ORR leader 
reported that their team was excluded from the review process, while another ORR  
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leader reported discussing the policies development with a  variety of ORR and field  
staff.   Additionally, ORR  stated that field guidance was reviewed extensively by field  
staff.   Nonetheless, all ORR policy should be planned and reviewed  with careful  
consideration for ORRs responsibility to facilitate childrens safe release to sponsors.  
This should also  include  field guidance created to rapidly implement procedural  
changes.  
It should be emphasized that [the field guidance issued within  the  
past 3  to 4 months] were developed without significant voice  
from ORRs own UC child-welfare subject matter  experts.  
 
  Letter from Federal  field specialist supervisors to  ORR leadership, July 23,  2021  
ORR field guidance issued from March  2021  through  June  2021  
eliminated multiple aspects of the sponsor  screening process  
According to ORR  leadership and staff, field guidance issued from March  2021 
through June 2021 removed basic safety measures from the sponsor screening  
process in an effort to expedite childrens release from care.  Although ORR must  
ensure that  children do not experience unnecessary delays in release, it must also  
ensure that  children are safely released to thoroughly vetted sponsors.   
One field guidance issued on March 22, 2021, greatly reduced the  information  
collected by case managers  to examine childrens mental health, social history, and  
the quality of childrens relationships  with their potential sponsors,  for children being  
released to  a parent or legal guardian.44, 45   This field guidance also removed  a  level of  
third-party review of the sponsor screening process designed to help ensure that  
children are safely released to their sponsors.46   Finally, it removed  background checks  
and  identity verification for other adult household members and alternate adult  
caregivers in cases involving  a sponsor who  is the childs parent or legal  guardian.  
This change applied only to cases where the child was determined not to  be 
especially vulnerable, subject to a required home study, or to be at additional risk for 
abuse or neglect.  Another field guidance issued on March 31, 2021, reduced the  
background checks and identity verification  required in cases in which children are 
released to siblings, grandparents, cousins, or other close relatives.47    
Some ORR leaders and other staff reported concerns that these policies prioritized  
quick discharge over safety by eliminating critical safeguards from the sponsor 
screening process.  One ORR leader stated,  what you're going to hear from staff is 
they're concerned that all of the focus seems to be entirely on this throughput notion 
[releasing children to sponsors quickly], but there's a lack  of recognition about the 
very real situations that children find  themselves in when they crossed the border 
unaccompanied.  Similarly, the letter written by Federal field specialist supervisors 
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alleged that  these changes have weakened ORRs ability to vet sponsors and protect   
children  from risks such as trafficking and exploitation.   
Case management staff are encouraged to strive to do  the absolute   
minimum vetting of sponsors  to effectuate the quickest releases.   
As a result, there are safety issues  that are likely being overlooked.  
 
  Letter from Federal  field specialist supervisors to  ORR leadership, July 23,  2021  
Other ORR leaders did not share the concern that these policies presented a risk to  
childrens safety and instead believed that they served to expedite  childrens release 
from ORR facilities  to sponsors who  are parents or other close relatives.  One ORR  
leader stated that these policies only removed components of the sponsor screening  
process for children being released to parents and other close relatives, who ORR  
considers to be at lower risk of presenting safety concerns to unaccompanied  
children.  These ORR  leaders spoke of the challenges of balancing a thorough sponsor 
screening process with a release process that efficiently reunites children with safe  
sponsors during an influx.  
Deficiencies  with  ORRs  online case management  system  
contributed  to  case management  delays  and  potentially 
increased  childrens  risk  of  release to  unsafe sponsors  
Staff at  the facility reported that usability issues, including crashes, timeouts, and  
missing data, diminished the utility of ORRs online case management system, the  UC 
Portal,  as a case management tool.  Additionally, staff reported that limitations in the  
UC Portals search capabilities made it inefficient  and ineffective for use in the sponsor 
screening process.  Because the UC Portal is an essential tool used in the process to  
determine the suitability of potential sponsors, these deficiencies may have put  
childrens safety at risk.  
Timeouts, crashes,  and missing data limited case managers 
ability  to  reliably enter and  access information in the UC Portal  
Case management staff  at the ORR EIS at  Fort Bliss reported that frequent  timeouts 
made it difficult for them to input information related to childrens cases into the UC  
Portal.  Many case managers stated that the UC Portal  frequently signed users out at  
unexpected  intervals throughout the day, regardless of how active they had been in 
the Portal or how recently they had opted to remain signed in when prompted by the 
system.  These timeouts reportedly occurred approximately 10 times each workday.  
When users were signed out unexpectedly, all unsaved information that  they had  
entered into  a childs case file was erased.  This meant that case managers were 
forced to re-enter case information multiple times, rather than using this time to  
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advance childrens cases.   According to ORR,  improvements made to the UC Portal  
after our review period  have since reduced the frequency with which users are 
unexpectedly signed out.  
Case management staff  also reported that the UC Portal occasionally crashed and  
remained offline for extended periods of time.  One Federal field specialist reported  
that crashes and other Portal  issues caused delays in documenting case information 
at the ORR EIS  at  Fort Bliss from March  through June.  When these crashes occurred, 
case managers experienced delays in documenting and uploading important  
information related to childrens cases.  As a result of these frequent crashes, many 
case managers resorted  to using less-secure case management tools,  including  
spreadsheets and handwritten notes.  One case manager stated, I prefer to have 
everything handwritten, so I bought myself a notebook and tabs.  I learned that I 
needed to write everything down because the Portal kicks me out every few minutes. . 
. . Everyone has their own method.  
The UC Portal frequently times out and kicks out users  while they are in it.  
The Portal has been down in the past for months at a time.  
 
  Federal field specialist  
Case management staff  reported that some of childrens medical  and release 
information was missing from the UC Portal, which also contributed to delays in 
childrens release to sponsors.  Staff  reported that case managers were not always 
able to  access information through the UC Portal that could be used to determine 
childrens whereabouts, such as  medical quarantine and release information.  As a  
result, these case managers were unaware when issues with transportation or COVID-
19 quarantine requirements prevented children from departing the facility as 
scheduled.48   In these cases, the Portal  inaccurately listed children as released from 
ORR care although they remained in the facility.  According to one case manager, as 
many as 500 children at  a time would be displayed in the Portal as having been 
released when they were still present at the facility.  Without  this crucial information 
about childrens whereabouts, case managers were unaware that they needed to take  
additional steps to  help ensure childrens timely release to sponsors.  
Deficiencies in the UC Portals search  capabilities impeded case 
managers  ability to reliably determine whether potential 
sponsors  were sponsoring  other children, an indicator of possible  
trafficking    
According to case management staff, search functions in the UC Portal used to  
identify whether a sponsor had previously sponsored or attempted to sponsor a child  
did not always provide accurate results.  The process of confirming a sponsors history 
of attempted and actual sponsorship is a crucial and required step to ensuring that  
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children are released to safe adults who can provide for their care, as it provides case 
managers with information collected about a potential sponsor during previous 
screening.  This step is necessary to help ensure that children do not  fall victim to  
trafficking  and other forms of exploitation, as could  be the case when one adult  
attempts to  sponsor several unrelated children.  The UC Portals reported inability to  
link these records may have increased childrens risk of release to unsafe sponsors.   
Case managers reported issues when searching  the UC Portals for a sponsors name  
or address.  When searching for a sponsor by name, case managers found that only 
records that exactly matched the spelling and capitalization of the entered name were 
produced.  For example, a search for sponsor Juana Gomez would not  produce 
results for former sponsors juana gomez, JUANA GOMEZ,  Juana M. Gomez, or 
Juana Gomez-Ramos.    
Similarly, searches for addresses yielded only records that exactly matched the 
entered address.  A search for 101 Main Street  Apartment C would not produce  
results for former addresses 101 Main St Apt  C,  101 Main Street Unit C, 101 Main 
Street #C,  or 101 main street apt c.  
Staff  reported  finding  cases 
Exhibit 4. Visual representation of a name and  
in which many  children were 
address search in the UC Portal  
released to the same address.  
 
 
Because the UC Portal  lacked  
the ability to link  nearly-
identical records and includes 
all historic sponsorship 
records for attempted and  
actual sponsors, search 
results were  not always  
reliable for use in quickly  
identifying potentially  unsafe 
sponsors.  As one  case 
manager  stated, The system 
doesnt trigger a notification 
that one person may be 
sponsoring 15 kids at the 
same apartment complex, or 
in the same unit.  
 
Source:  OIG analysis  of interview  data and onsite  UC Portal demonstration, 2022.  
ORR shared a summary of improvements it made to the UC Portal after our review  
period, some of  which were related to search capabilities.  
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Alleged  acts  of  retaliation and  whistleblower  chilling may have 
created  an environment  in which  staff  at  the ORR  EIS  at  Fort  Bliss  and  
ORR  headquarters  felt  that  they  were discouraged  from  raising  issues  
about  case management  and  child  safety   
OIG received information that staff at the ORR EIS at  Fort Bliss and ORR headquarters 
faced potential retaliation after raising issues about case management and child  
safety, which caused hesitation among other staff who wished to share concerns.  OIG  
also received reports that staff were removed from their roles at the facility and ORR  
headquarters after raising concerns to supervisors.  Several other reports disclosed  
actions that  may have created fear of retaliation among staff.    
Some  staff who raised concerns about case management and  
childrens safety allegedly experienced potential retaliation by  
ORR and  field leadership in  the form  of reassignment  or dismissal   
Two staff reported experiencing potential retaliatory actions from their supervisors 
after raising  concerns about case management and childrens safety.49   One individual 
was a staff  member of ORR leadership.  This staff member was allegedly demoted and  
transferred  after raising  concerns to supervisors about the safety of children at EISs 
and the removal  of certain safety checks in the sponsor screening process.  The 
second individual who reportedly experienced alleged retaliatory actions was a  
Federal employee from a non-HHS agency temporarily assigned  to work  on the case 
management team at the ORR EIS at Fort Bliss.  This employee reported  having  sent  
an email to the facility suggestion boxthe established method for reporting  
concerns to facility leadershipthat listed concerns about the lack of case  
management updates for children.  After sending the email, the employee reported  
being  dismissed from the temporary assignment  by an HHS  contractor.50    
I think [staff] have learned that  if  you ask questions. . .  
you're going to be pushed aside.  Either your role is going to   
be diminished or you're going to  be  pushed  out of ORR.  
  ORR leader  
In addition to the two interviewees who reported experiencing alleged retaliation 
firsthand, several interviewees reported having secondhand knowledge  of staff  who  
were allegedly dismissed or reassigned after reporting concerns.  Three such 
examples involved staff  who reportedly raised issues about case management and  
childrens safety:  
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   OIG received a report alleging that a staff member was reassigned after raising  
concerns about case management oversight at facilities including the ORR EIS  
at Fort Bliss.  
   OIG  received a report alleging that a staff member was iced  out of the ORR  
EIS at Fort Bliss after raising concerns about childrens safety at the facility.  
   OIG received a report alleging that a staff member was removed from a  
temporary assignment  at the facility after not following the chain of command.  
According to the report, the staff member had intervened in a childs case to  
prevent unnecessary delays in the childs reunification with a  sponsor.   
ORR and  facility staff who  were aware of alleged  retaliation  
reported hesitation raising  concerns  about case management and  
childrens safety  
Some staff reported that they were hesitant to raise concerns about case 
management and childrens safety due to the fear of retaliation by ORR  and facility 
leadership.   In some cases, the reported actions of ORR and  facility leadership may 
have risen to the level  of whistleblower chilling.  Whistleblower chilling  occurs when  
leadership of an organization create a culture of  fear of retaliation amongst staff, 
effectively  scaring staff  into withholding any complaints or reports of wrongdoing.51   
Whistleblower chilling obstructs the mission of HHS-OIG to investigate allegations of  
fraud, waste, and abuse.  One staff member told OIG, Im under the impression that  
there have  been some [dismissals] that appear to be retaliatory when people voice 
grievances or concerns.  It has crossed my mind more than once when sending an 
email.  Another staff member reported hearing that employees at the facility had  
received  messages threatening dismissal if  they continued raising issues.   
The worst part of the [ORR EIS at Fort Bliss] was the  utter   
lack of transparency. . . .  They did everything possible to  
discourage people  from discussing what was  going on.  
  Facility staff member  
Other facility staff reported that they felt generally discouraged from raising concerns.  
One staff member stated that as the field people on the ground, we feel like [facility 
leadership] dont want us to say anything bad. . . If you have an issue  and say it, you 
hear, Dont  be confrontational with the contractor.  Dont say that.  You learn quickly 
they dont want [you] to  talk about these issues.  Another staff member stated that if  
you don't go along with [leadership], its like, I'm not going  to work with you. In 
addition,  2  staff members working at ORR EIS at  Fort Bliss reported that  they 
alongside about 100 other staff memberswere told during their first  day onsite  not  
to send anything to the facility suggestion box during their first  10 days.   According to 
Operational Challenges Within ORR and the  ORR Emergency Intake Site at Fort Bliss Hindered Case Management for Children    
OEI-07-21-00251   Findings |  21     
one Incident Commander, this instruction may have been given to staff to prevent  
them from suggesting process improvements before they fully understood operations 
at the facility.  However, if  staff  are hesitant to share feedback, ORR and facility  
leadership may not be able to ensure that children in ORR care receive services that  
adhere to ORR standards and child-welfare best practices.   
As a result of these concerns, OIG provided  ACF  leadership and staff  with materials 
and  training  intended  to educate them  on the appropriate handling of protected  
disclosures and whistleblower rights available to Federal employees.  OIG issued an 
informational memo to ACF  on November  1,  2021, that noted whistleblower 
protection concerns in unaccompanied children  operations.   Following this memo, 
HHS and ACF have coordinated with the HHS-OIG Whistleblower Protection 
Coordinator to provide ACF staff with whistleblower protection training.  In March  
2022, ACF hosted an optional  Whistleblower 101 training presented by the  
Whistleblower Protection Coordinator for over 300 ACF employees.   ACF held a  
Whistleblower 102 training for ACF managers and supervisors in July 2022.  
 
   
Operational Challenges Within ORR and the  ORR Emergency Intake Site at Fort Bliss Hindered Case Management for Children    
OEI-07-21-00251   Findings |  22     
CONCLUSION AND  RECOMMENDATIONS    
From its opening in March 2021 through June 2021, operational  challenges within 
ORR and at  the ORR EIS  at Fort Bliss hindered case management services provided to  
unaccompanied children at the facility.  These  challenges  reportedly contributed to  
uncertainty  and distress for  children  and potentially impeded  their safe release to  
sponsors.  In response to the  unprecedented increase in unaccompanied children 
arriving at the U.S. southern border in early 2021  and reduced bed capacity caused by 
COVID-19-related challenges, ORR  created  EIS  facilities.  These facilities  were quickly 
established  to accommodate  referrals for children from  DHS  within 72 hours.    
The historic  increase of  unaccompanied children referred to ORR care meant that  
many children needed case management services for safe and timely release  directly 
from EISs to  sponsors.  As a result, some case management positions at the ORR EIS  
at Fort Bliss were rapidly filled with case managers who lacked relevant skills and  
experience.  Additionally, ORR did not provide these inexperienced case managers  at  
the ORR EIS  at  Fort Bliss with adequate training to prepare them to help ensure 
childrens safe and timely release to  sponsors.  
Case management at the ORR EIS at Fort Bliss also faced challenges due to  ORR-wide  
approaches that may have adversely affected  children and staff  at  all ORR  facilities.  In 
an effort to  manage thousands of childrens cases  during the  2021 surge in arrivals, 
ORR rapidly issued field  guidance that removed certain safeguards from the sponsor 
screening process across ORR facilities, and the rapid  removal of these safeguards 
may have increased childrens risk of release to  unsafe sponsors.  In addition, 
deficiencies with ORRs case management system, the UC Portal, may have also put  
childrens safety at risk by impeding case managers ability to reliably identify unsafe 
placements across the country.  Finally, reported acts of potential retaliation and  
whistleblower chilling may have affected  staffs willingness to share feedback and  
limited ORRs ability to ensure that children at all ORR facilities received  services that  
adhere to ORR standards and child-welfare best practices.  
ORR has taken steps to address some of the  challenges  that hindered case 
management at the ORR EIS at Fort Bliss  (which, as of  May 2022,  is classified as an  
influx care facility).  Several interviewees mentioned quality control efforts that  
significantly improved the frequency of case managers communication with children 
and their sponsors.  Additionally,  ORR shared a summary of  actions taken after our 
review period to address challenges related to case management at the ORR EIS at  
Fort Bliss.  Among these actions were efforts to streamline the hiring of qualified case 
managers; a new case management training approach; quality control efforts 
intended to  improve communication between case managers, children, and sponsors;  
and updates to the UC Portal  intended to increase usability and search functionality.  
 
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OEI-07-21-00251   Conclusion and Recommendations | 23     
During the past decade, there has been substantial variation in the number of  
unaccompanied children that are referred to ORR care during  an  influx.  This variation 
demonstrates the need  for ORR  facilities to be adequately prepared to provide quality 
services when numbers of children in ORR care rapidly increase.  ACF will  need to take  
steps to ensure that children at ORR facilitiesincluding  facilities  established in 
response to influxes, like  the ORR EIS at Fort Blissreceive quality case management  
services that  appropriately balance childrens safety and well-being  with  their timely 
release to  sponsors.   
We recommend  that  ACF:  
Develop  and  implement  a  plan that  supports  ORR  and  its  
contractors  in  securing  qualified case managers  during  an influx  
to  help  ensure childrens  safe and  timely release to  sponsors   
To respond  to  surges  in arrivals of unaccompanied children, ORR must have processes 
in place to  quickly establish  case management services in order to  safely release 
children from its care.  ACF should  require all facilities in its care provider network 
including those opened  in response to  an  influxto hire qualified staff, when 
possible, to  conduct case management.  To accomplish this, ACF could  proactively 
identify contractors with case management experience in preparation for staffing  
facilities opened in response to an influx.  
Provide case managers with  timely and comprehensive training  
and  support  to  help  ensure childrens  safe and  timely release to  
sponsors  
ACF should  ensure that  all case managers are trained in ORR  procedures and  child-
welfare best practices  before providing services to children.  Additionally, case 
managers should receive additional  training as needed on a  continuous basis.  ACF  
should also  ensure that  newly hired case managers receive ongoing support and  
oversight as they adapt to the challenging role of conducting ORRs sponsor 
screening process for the safe and timely release of children.   This training and  
support  could also  include resources that are specific to emergency processes and  
new ORR field guidance.   
Operational Challenges Within ORR and the  ORR Emergency Intake Site at Fort Bliss Hindered Case Management for Children    
OEI-07-21-00251   Conclusion and Recommendations | 24     
Create an emergency policy development  protocol  that  
provides  for  adequate input  from  staff  with  expertise in child  
welfare  when ORR  develops  field  guidance during  an influx  
To  help  ensure that field guidance  developed in response to surges in arrivals of  
unaccompanied children  fully considers  childrens safety, ORR  should  create an 
emergency policy development  protocol.   This protocol should establish a process for 
the review and implementation of guidance developed rapidly in response to an 
influx.  This protocol  should  also establish  an emergency policy team that would be 
activated during an influx  to provide multiple perspectives on the potential impact  of  
policy changes  on childrens safe and timely release.  This advisory team should  
include  a wide spectrum of  representatives, such  as policy staff, Federal field staff, 
facility  staff, and external  child-welfare experts.   
In a March 2020 report, Communication and  Management Challenges Impeded HHS's 
Response to the Zero-Tolerance Policy,  OIG recommended that ACF take steps to  
ensure that  unaccompanied childrens interests are prioritized and represented in 
decisions affecting the UC Program.   Based on the findings in this review, we reiterate 
this unimplemented recommendation.  ACFs actions to protect childrens safety 
should include ensuring  that potential risks to unaccompanied children are explicitly 
assessed and considered in  decisions about policies affecting unaccompanied  
children.  Without  such  risk assessments, policies intended to  help children may have 
unintended or unforeseen consequences that result in greater harm.  
Ensure that  ORR addresses  challenges  regarding  usability and  
search  capabilities  within its  case management system, the UC 
Portal  
As ORR works to  improve the UC Portal,  it  must ensure that it supports case managers 
in facilitating the safe release of children to sponsors.  Specifically, ORR  should  
address the timeouts, crashes, and missing data that currently impede case managers  
from reliably entering and accessing information in the UC Portal.  Additionally, ORR 
should ensure that an address or name search in the UC Portal  enables case managers 
to review  all relevant  sponsor records, regardless of  minor variations in spelling, 
format, and  capitalization  of the information entered.   
Ensure that  ORRs  employees  and  employees  of  ORR  
contractors  and  recipients  are informed  about  Federal 
whistleblower protections   
ORR employees should participate in training aimed at ensuring that staff are not  
discouraged from, or retaliated against for, reporting concerns about childrens safety 
Operational Challenges Within ORR and the  ORR Emergency Intake Site at Fort Bliss Hindered Case Management for Children    
OEI-07-21-00251   Conclusion and Recommendations | 25     
and the quality of services they receive at ORR  facilities.  As a  component of this 
training, we recommend that ACF mandate Whistleblower 101 training  for all  
employees, to be provided  in coordination with  OIGs Whistleblower Protection 
Coordinator.  The training should be mandatory for all ORR  leadership and provided  
annually.  ACF should also consider offering this training to  other ORR  employees on 
an annual basis.  Additionally, ACF should  inform and  stress to its contractors and  
recipients that their employees are also covered by whistleblower protections, and it  
is their responsibility to  convey those protections to their subcontractors  and  sub-
recipients.52   
 
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OEI-07-21-00251   Conclusion and Recommendations | 26     
AGENCY  COMMENTS  AND  OIG  RESPONSE    
ACF concurred with all  of our recommendations.  ACF provided additional context  
regarding the historic challenges that ORR faced during the period of review, and  
detailed the significant steps that it has since taken to enhance services for 
unaccompanied  children.  
In response to our first recommendationfor ACF to develop and implement a plan 
that supports ORR and its contractors in securing qualified case managers during an 
influx to help ensure childrens safe and timely release to sponsorsACF described  
steps taken to secure experienced case managers who can be mobilized within its 
provider network during periods of  influx.  ACF stated that, as of July 2022, ORRs 
contractor has recruited and onboarded  more than 400 experienced case managers 
who  can deploy to ORR programs nationwide.   We  appreciate ACFs continued efforts 
to secure additional case managers.  We  urge  ACF to continue these efforts so that  
ORR and its contractors have a sufficient pool of  qualified case managers to deploy 
during future influxes.  
In response to our second recommendationfor ACF  to provide case managers with 
timely and comprehensive training and support to help ensure childrens safe and  
timely release to sponsorsACF described the development and delivery of new  
training for case managers, and affirmed its continued investment in expanding and  
strengthening the UC Programs training infrastructure.  ACF stated that in September 
2021, ORR awarded a 5-year contract to update the UC Program training  
infrastructure.  ACF noted that the updated training will employ performance 
standards for planning, delivery, and evaluation, and support ORRs longstanding  
training needseven during influx periods.   We  urge ACF to  ensure that  essential  
components of this updated training  are  provided to case managers before they 
begin providing services to children.    
In response  to our third  recommendationfor ACF to create an emergency policy 
development protocol that provides for adequate input from staff  with expertise in 
child welfare when ORR  develops field guidance during an influxACF stated that 
ORR created an emergency policy development protocol  to evaluate field guidance 
developed during the 2021 influx.  ACF  also detailed the process by which ORRs new  
Policy Evaluation Workgroupcomposed of staff from several UC Program 
divisionsperforms in-depth reviews of the UC Program and collects feedback on 
field guidance review.  ACF noted that information and analyses from these reviews 
are documented in a decision memo before the workgroup makes a recommendation 
to rescind, extend, modify, or permanently adopt  field guidance into ORR  policy.  The 
ORR Director and ACF leadership review and approve decision memos, as needed.   
ACF  also noted that the workgroup relied on critical insights from child welfare 
advocates, whose input was solicited throughout the evaluation process and included  
Operational Challenges Within ORR and the  ORR Emergency Intake Site at Fort Bliss Hindered Case Management for Children    
OEI-07-21-00251   Conclusion and Recommendations | 27     
direct input on field guidance.   We  appreciate ACF taking this action and encourage 
this workgroup to remain active  throughout future influxes and policy changes.  
In response to our fourth recommendationfor ACF  to ensure that ORR  addresses 
challenges regarding usability and search capabilities within its case management  
system, the UC PortalACF described its collaborative efforts to improve the UC  
Portal through multiple feature and function upgrades released every 2 weeks.  ACF  
outlined specific upgrades that were recently made to help users find sponsor records  
more efficiently and accurately, as well as reduce the frequency of system timeouts.  
We  urge ACF to continue developing and releasing upgrades to the UC  Portal  to  
address crashes and missing data  and to improve search capabilities.  
In response to our fifth recommendationfor ACF to ensure that ORRs employees 
and employees of ORR  contractors and recipients are informed about  Federal  
whistleblower protectionsACF pledged to amend ORRs template cooperative 
agreement to more specifically explain whistleblower policy and training  as well as 
HHS-OIG reporting and  protections, as appropriate.53   Additionally, ACF described the 
optional training series it conducted in conjunction with HHS-OIG  from  March 
through  July 2022, as well as a mandatory course for supervisors and managers.   We  
appreciate ACFs collaboration with HHS-OIG on this matter, and encourage ACF to  
mandate Whistleblower 101 training for all employeesnot just supervisors and  
managers.   
For the full text of  ACFs comments, see  Appendix D.  
Operational Challenges Within ORR and the  ORR Emergency Intake Site at Fort Bliss Hindered Case Management for Children    
OEI-07-21-00251   Conclusion and Recommendations | 28     
APPENDICES  
Appendix A:  Services  Provided  by ORR  Facility Types  
Standard  ORR   Influx  Care   Emergency  Intake  
 
Facility   Facility   Site  
Case Management  
Recommended as  
Services  for  Safe and  Required   Required  
of April 30,  2021*  
Timely  Release  
Recommended as  
Routine Health  Care   Required   Required  
of April 30,  2021*  
Recommended as  
Educational Services   Required   Required  
of April 30,  2021*  
Recommended as  
Recreation  and Leisure   Required   Required  
of April 30,  2021*  
Not  Addressed in  
Routine Counseling   Required   Required  
Field Guidance**   
Not  Addressed in  
Acculturation  Services   Required   Required  
Field Guidance**    
Sanitation  and Hygiene   Required   Required   Required  
Adequate Supervision   Required   Required   Required  
Legal Services   Required   Required   Required  
Emergency  Health  Care   Required   Required   Required  
Source:  OIG analysis  of ORR Policy  Guide,  Children Entering the United States Unaccompanied, Sections 3, 7,  and ORR  
Field  Guidance 13,  Emergency Intake Sites (EIS) Instructions and Standards  
*  Our  use of the term  recommended  reflects  the terminology  in  the ORR  Field Guidance 
issued  on April  30,  2021,  which states  that  as  soon as  possible  and  to  the  extent  practicable,  
EISs  should  seek  to  provide  the  following  services:  case management  services  for  safe and 
timely  release;  a reasonable  access  to  privacy;  an  in-person presentation by  a  legal service  
provider;  educational  services;  and  daily  recreational/leisure  time.  
 
Comprehensive field guidancewhich  ORR issues to  address emergency or  short-term  policy  
goalsoutlining  EIS  standards  was  not  issued  until  a  month after  children began  arriving  at  
the  ORR  EIS  at  Fort  Bliss.   We  did  not  analyze  informal  guidance  that  may  have  been 
distributed  to  EISs  prior  to  the  April  30,  2021,  field  guidance.  
 
**  This  topic  was  not  addressed  in ORR  Field  Guidance  13.   We  note  that  the  guidance  states  
that  EISs  should,  to  the  extent  practicable,  ramp  up  services  to  meet  minimum  standards  of  an  
influx  care  facility.  
Operational Challenges Within ORR and the  ORR Emergency Intake Site at Fort Bliss Hindered Case Management for Children    
OEI-07-21-00251   Appendix A | 29     
Appendix B:  Timeline of  EIS  Openings  and  Field  Guidance 
No.  13 
 
Source:  EIS opening  dates provided by  ORR; ORR field  guidance,  ORR Field Guidance  13, Emergency Intake Sites (EIS) 
Instructions and Standards, April 30, 2021.  Accessed at  https://www.acf.hhs.gov/orr/policy-guidance/uc-program-field-
guidance  on  May 16, 2022.  
Operational Challenges Within ORR and the  ORR Emergency Intake Site at Fort Bliss Hindered Case Management for Children    
OEI-07-21-00251   Appendix B | 30    Appendix C: Related OIG Work  
Information on OIGs  work on this topic  can be found on our Unaccompanied  
Children webpage.  Below is a list of OIG reports  on unaccompanied  children.  
Title   Report Number   Date Issued  
Office of  Refugee Resettlements Influx Care 
Facility and Emergency Intake Sites  Did Not 
A-06-21-07002  June 2022  
Adequately  Safeguard Unaccompanied  
Children From COVID-19   
HHS Should Improve Internal Coordination 
OEI-BL-20-00670   May 2022  
Regarding Unaccompanied Children  
Office of  Refugee Resettlement Generally  
Ensured That Selected Care Provider Facilities  
for Its Unaccompanied Children  Program   A-04-20-02025  February 2022  
Complied With Federal  Emergency  
Preparedness Requirements  
Characteristics of Separated Children in ORR's 
OEI-BL-20-00680   November 2021  
Care: June 27, 2018November 15, 2020 
 
OIG Toolkit:  Insights from OIGs Work on the 
Office of  Refugee Resettlements Efforts To   OEI-09-21-00220   May 2021  
Care for Unaccompanied Children 
The Office of Refugee Resettlement Did Not  
Award and Manage the Homestead Influx Care 
A-12-20-20001  December 2020  
Facility Contracts in Accordance With Federal  
Requirements 
 
Office of  Refugee Resettlement Ensured That  
Selected Care Providers  Were Prepared to   A-04-20-02031  November 2020  
Respond to the COVID-19 Pandemic 
 
Youth For TomorrowNew Life Center,  Inc., an 
Administration for Children and Families  
A-03-16-00250  September 2020  
Grantee,  Did Not Comply With All Applicable 
Federal Policies and Requirements 
 
Southwest Key  Programs Failed to Protect 
Federal Funds  Intended for the Care and   A-06-17-07004  September 2020  
Placement of Unaccompanied Alien Children 
 
Unaccompanied Alien Children Program  Care 
Provider Facilities Do  Not Include All Required   OEI 05-19-00210   June 2020  
Security Measures in Their Checklists 
 
Operational Challenges Within ORR and the ORR Emergency  Intake Site at Fort Bliss Hindered Case Management for Children  
OEI-07-21-00251   Appendix C |  31   The Office of Refugee Resettlement's Incident  
Reporting System Is Not  Effectively Capturing  
OEI-09-18-00430   June 2020  
Data To Assist Its Efforts To Ensure the Safety of  
 
Minors in HHS Custody 
Communication and  Management Challenges  
Impeded HHS's Response to the Zero- OEI-BL-18-00510   March 2020  
Tolerance Policy 
 
Care Provider Facilities Described Challenges  
Addressing Mental Health Needs of Children in  OEI-09-18-00431   September 2019  
HHS Custody 
 
Unaccompanied Alien Children Care Provider  
Facilities Generally  Conducted Required  
A-12-19-20001  September 2019  
Background Checks but  Faced Challenges in 
Hiring, Screening, and Retaining Employees 
 
Southwest Key  Did Not  Have Adequate 
Controls in Place To Secure Personally  
A-18-18-06001  August 2019  
Identifiable Information Under the 
 
Unaccompanied Alien Children Program 
Southwest Key  Programs Did Not Always  
Comply With Health and  Safety Requirements  
A-06-17-07005  August 2019  
For The Unaccompanied  Alien Children 
Program 
 
The Children's Village Inc., An Administration 
for Children and Families Grantee, Did  Not  
A-02-16-02013  April 2019  
Always Comply With Applicable Federal and  
State Policies and Requirements 
 
Lincoln Hall Boys Haven, an Administration for  
Children and Families Grantee, Did Not Always  
A-02-16-02007  February 2019  
Comply With Applicable Federal and State 
Policies and Requirements 
 
Separated Children Placed in Office of Refugee 
OEI-BL-18-00511   January 2019  
Resettlement Care 
 
BCFS  Health and  Human Services Did  Not  
Always Comply With Federal Regulations  
A-06-17-07007  December 2018  
Related to the Health and Safety of  
Unaccompanied Alien Children 
 
The Tornillo Influx Care Facility: Concerns About  
Staff  Background Checks and Number of   A-12-19-20000  November 2018  
Clinicians on Staff 
 
Florence Crittenton Services of Orange County,  
Inc., Did Not Always Claim Expenditures in  A-09-17-01002  October 2018  
Accordance With Federal Requirements 
 
Operational Challenges Within ORR and the ORR Emergency  Intake Site at Fort Bliss Hindered Case Management for Children  
OEI-07-21-00251   Appendix C |  32   Heartland Human Care Services,  Inc. Generally  
Met Safety Standards, but Claimed Unallowable  A-05-16-00038  September 2018  
Rental Costs 
 
Florence Crittenton Services of Orange County,  
Inc., Did Not Always  Meet Applicable Safety  
A-09-16-01005  June 2018  
Standards Related to Unaccompanied Alien  
Children 
 
BCFS  Health and  Human Services Did  Not  
Always Comply With Federal Requirements   A-06-16-07007  February 2018  
 
Related to Less-Than-Arm's-Length Leases 
Office of  Refugee Resettlement  
Unaccompanied Alien Children Grantee  A-04-16-03566  December 2017  
ReviewHis House 
 
HHSs Office of Refugee Resettlement  
Improved Coordination and Outreach to  
OEI-09-16-00260   July 2017  
Promote the Safety  and Well-Being of  
Unaccompanied Alien Children 
 
Division of Unaccompanied Childrens Services:  
OEI-07-06-00290   March 2008  
 
Efforts to Serve Children 
Operational Challenges Within ORR and the ORR Emergency  Intake Site at Fort Bliss Hindered Case Management for Children  
OEI-07-21-00251   Appendix C |  33      
Appendix D: Agency Comments 
August  10, 2022  
Ms. Christi A. Grimm  
Principle Deputy Inspector General   
U.S.  Department  of  Health and  Human  Services  
330  Independence  Avenue,  SW.  
Washington,  DC     20201  
Dear Ms. Grimm:  
The U.S. Department of Health and Human Services (HHS) Administration for Children and 
Families (ACF) thanks the HHS Office of Inspector General (OIG) for the opportunity to 
comment  on the report  titled,  Operational Challenges Within ORR and the ORR Emergency  
Intake Site at Fort Bliss Hindered Case Management for Children,  which  contains  
recommendations  for ACF and the Office of Refugee Resettlement (ORR).  Your report reviews 
one of the most challenging periods in ORRs history amid a historic  number  of unaccompanied 
children  placed in ORR care, the largest and fastest expansion of emergency capacity, and at the  
height of the  Coronavirus Disease 2019  (COVID-19)  pandemic.  As ORR  worked quickly to 
respond to this unprecedented emergency, and with limited resources, it  prioritized the safety and 
wellbeing of children at every step.   The  ORR  Emergency Intake Site (EIS) at Fort Bliss was 
activated due to the urgent and compelling need to safely receive timely referrals of 
unaccompanied children  from the Department of Homeland Security (DHS) who experienced 
severe overcrowding in border facilities due to the  influx.  Overcrowding in DHS border 
facilities   which are not designed nor equipped to safely care  for children   coupled with the 
threat of the COVID-19  pandemic  created a situation in which there was significantly increased 
risk of serious harm to children while in DHS custody (i.e., death or serious illness/injury).  At 
the time of  ORR EIS at  Fort Bliss  standup on March 30, 2021, ORRs total available  bed 
capacity  across its standard care provider network  was reduced by up to 40 percent due to 
COVID-19 mitigation measures  and staffing shortages,  while over 4,000 unaccompanied 
children  were in DHS custody awaiting placement  and transfer to an ORR  program.  
Given the exigency of the circumstances, the ORR EIS at Fort Bliss service delivery evolution  
was significant.  From its initial activation  in March 2021, through  and beyond OIGs review  
period  that ended  in June 2021, a snapshot of all the improvements that were made included:  
  The ORR  EIS  at Fort  Bliss went from an initial length of stay (measured from admission 
at the ORR EIS at Fort Bliss to an  unaccompanied children  transfer or discharge  from 
ORR custody from the site) of approximately 41 days at the end of March  2021  to 16 
days  at the end of June, and 13 days  at the end of July  2021, demonstrating ORRs clear 
commitment to enhancing and improving the case management  process. 
  In June 2021, the ORR EIS at Fort Bliss  began twice daily  onsite  coordination briefings 
(morning and evening) that convened all case management leadership from team leads, 
Operational Challenges Within ORR and the ORR Emergency  Intake Site at Fort Bliss Hindered Case Management for Children  
OEI-07-21-00251   Appendix D |  34  Ms. Christi A. Grimm  
Page  2  
representatives from behavioral and mental health teams, representatives from the  
contractual vendor leadership including transportation, dormitories, and medical services, 
to ensure ongoing, consistent communication and to clearly articulate strategy and 
priorities for each day.  
  In June 2021, the ORR  EIS  at Fort Bliss  contractor, in collaboration with ORR federal 
staff, launched a partnership with Casey Family Programs and the Annie E. Casey 
Foundation intended to more quickly identify true Category 4 children and to develop a 
Family Finding and Engagement playbook, a practical guide for  case managers in 
identifying, locating, and engaging family and supportive adults.  This playbook was 
shared with  all case managers and mental health clinicians at other EISs  to standardize 
sponsor identification best practices. 
  In June 2021,  ORR mobilized an  established case  management contractor to provide 
technical assistance staff to improve the safe  release of children at the ORR EIS at Fort 
Bliss.   The case management contractor, with experience providing case  management 
services at other ORR programs, deployed  staff highly proficient in ORR release policies 
and procedures to support case management operations as a co-contractor at  the  ORR EIS 
at Fort Bliss.  Technical assistance staff offered targeted, case-specific  expertise for all 
levels of unaccompanied children's  cases  with a particular focus on remand status cases 
when field staff needed additional instruction or information from case managers.  The 
contractor  provided group and  individual training to facilitate case progress. 
  In June 2021, the  case management contractor  established a Quality Control/Quality 
Review Strike Team and a Remand Strike Team to ensure that case  recommendations 
submitted by case managers were complete with sufficient information necessary for 
ORRs Federal Field Specialist (FFS)  to review  and make  an informed release decision 
that prioritized safety and best interest of the child. Implementation of this remand 
review process improved the number of total remands from a high of over 60 remands a 
day to an average of 5  to 9  remands  in July 2021. 
ORR has consistently expressed  publicly  that EIS are a temporary solution and a short-term 
placement option for unaccompanied children  to address significant capacity challenges,  with 
child welfare and safety being the primary focus.   Due to the continually high referrals from 
DHS, as well as the ongoing need for bed capacity that can accommodate COVID-positive  
unaccompanied children, ORR determined that extending the use of the ORR EIS at Fort Bliss  
was necessary to ensure  unaccompanied children  were timely transferred from DHS to HHS  
custody within timelines required by statute.   ORR  worked with the  operator of the ORR EIS at  
Fort Bliss towards meeting all Flores Settlement Agreement  (FSA)  Exhibit 1 service standards 
and congressionally mandated staffing ratios  for unlicensed facilities. Since  OIGs review  
period concluded,  the ORR EIS at Fort Bliss  has  enhanced services  for unaccompanied children, 
including expanding educational and recreational activities, offering  weekly individual and 
group counseling sessions in addition to emergency mental health services, and implementing  
critical aspects of the full initial medical exam as required by  the FSA.  On May 30, 2022, ORR  
finalized the facilitys transition to the ORR influx care  facility (ICF) at Fort Bliss to reflect the  
heightened service standards available  to all children at the site.  
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To date, the ORR  ICF at Fort Bliss continues to support ORRs operations by ensuring ORR has 
the bed capacity to receive  referrals from DHS in a timely manner  during the ongoing influx, as 
required by law, and  by providing child-friendly programming  with services and resources 
tailored to children who immediately receive individualized services, including appropriate 
medical  and dental care, individualized case management, structured educational services 
appropriate to a  childs  level of development and communication skills, recreational activities, 
individualized and group counseling sessions, access to religious services, and legal services. 
The ORR  ICF  at Fort Bliss  continues to meet ORR  UC Program Policy  Guide  Section 7 Policies 
for  Influx Care Facilities  and FSA  Exhibit 1 standards.  For example, children placed at  the ORR  
ICF at  Fort Bliss are expected to be released to a sponsor within 30 days. As of  July 24, 2022, 
the ORR ICF  at Fort Bliss  average length of stay is 14  days  for children unified with vetted 
sponsors.  
Below please find our  comments on the report findings and our specific  response to each 
recommendation.   As  described  below,  ACF concurs with  all recommendations and  has  
already taken steps to implement OIG recommendations.  
ACF Response to  Recommendations  
Recommendation 1:  Develop and implement a plan that supports ORR and its contractors 
in securing qualified case managers during an  influx  to  help  ensure childrens safe  and  
timely release to sponsors.  
ACF Response:  ACF  concurs with this recommendation.  
Measurable improvements in case management resulting from enhanced contractor support  
at the ORR EIS at Fort  Bliss led ORR field staff to recommend  establishing a similar  
support model for all ORR programs  nationwide.  In  direct response, ORR established  a  
national case management contract to guarantee experienced  case managers were secured  
and could  be mobilized  within its provider network  during periods of influx.   The  case  
management contract requires remote or onsite  operational readiness to  provide case  
management support services, complete sponsor assessments and sponsor identify  
verification, as well  as ensure safe  and timely  unifications and  post-release services for 
unaccompanied children.   Included in the contract is a requirement for a  cadre of qualified case  
management staff who will provide case management services, support recruitment of qualified 
case managers, screening, credentialing, training, and data tracking systems. Qualified case  
management staff is defined as possessing 2-5 years of experience in case  management and child  
care, and education experience in social work and/or social services. ORR also included the  
following contractor requirements:    
  (a) maintain a robust personnel credentialing and vetting process; 
  (b) comply with all personnel policies found in ORR  Policy Section 4.3 Personnel; 
  (c) ensure all qualified case management staff receive training in ORR policies and 
procedures, including case management processes;  completion of the Family 
Reunification Packet;  ORR interim guidance and operations; ORR field guidance; 
standards to prevent, detect, and respond to sexual abuse and sexual harassment;  behavior 
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OEI-07-21-00251   Appendix D  | 36   Ms. Christi A. Grimm  
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management and de-escalation strategies;  cultural competence;  child welfare best 
practices;  and ORRs UC Portal;  
  (d) provide targeted technical assistance  (TA) services to those programs ORR 
recognizes could benefit from additional case management support. TA staff will support 
case management operations as a co-contractor at a given site and provide  a hands on 
support structure. 
As of July 2022, ORRs contractor has recruited and onboarded 373 experienced case managers 
and 32 case manager supervisors who  can deploy to ORR programs across the United States in 
need of case management support  and onsite TA. Additionally, between April 2022 and July 
2022, ORR received 21 federal detailee volunteers based on contractor outreach who meet the  
cooperative  agreement definition of qualified case managers, making ORRs total 426  as of July 
2022. While the total number of federal detailee  volunteers can fluctuate  day-to-day  based on 
deployment periods, it  continues to serve as a valuable case management resource  pool to 
supplement the case management contract. Overall, this national case management contract has 
already made an immediate impact on the quality and continuity of case management operations 
by limiting disruptions to services during weekends and holidays.1   It is clear that by leveraging 
such a flexible, national case management model, children in ORRs care are safely and 
efficiently receiving services while avoiding unnecessary delays in the process.  
ORR received over 122,000 referrals of unaccompanied children  from DHS in fiscal year 2021. 
This historic referral influx strained not only ORRs network bed capacity but also its ability to 
quickly recruit and staff  programs across the country, due mainly to the staffing challenges 
brought forth by the COVID-19 pandemic. ORR understands the critical role case managers 
play in ensuring the safe  and timely release of children from ORR care, especially during periods 
of influx where bed capacity is an essential resource. ORR prioritized expanding case  
management staff capacity and could not increase  capacity  as quickly as needed given the 
historic level of referrals and hiring challenges resulting from the COVID-19 pandemic.  
ORRs employs a holistic  approach to case management that is  grounded in child welfare best 
practices.  ORR makes clear in its cooperative agreement language with grantees that case  
managers are the backbone to efficient and effective case management processes that prioritize  
the safety and wellbeing of every child.   A requirement of all grantees is for programs to staff 
lead case managers who are responsible for coordinating the programs case management and 
safe and timely release services, train new case managers, and supervise the work of other  case  
managers.  ORRs minimum qualification standards for lead case managers includes a masters 
degree in  the behavioral sciences, human services,  or social services fields or a bachelors degree  
and at least 3 years of progressive employment experience that demonstrates supervisory and 
case management experience.   These lead case manager positions require  ORR review and 
approval in order to ensure qualified lead case managers are hired.   Additionally, ORRs 
1  During  the 2022  extended  Fourth  of  July  holiday  weekend,  ORR  mobilized  44  case managers  to  provide temporary  
case management support from  Saturday  July  2  through  Monday  July  4,  at both  standard  programs  and  influx  care 
facilities.  Furthermore,  26  of  the mobilized  staff  continued  to  provide case management support to  their  assigned  
program  beyond  the holiday  weekend  in  order  to  address  additional case management issues  and  areas  of  
improvement that were identified  over  the support period.   
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minimum qualifications for case managers requires a bachelor's degree in the behavioral 
sciences, human services,  or social services field,  and it is strongly encouraged that case  
managers hired by grantees have child welfare and/or case management experience.  ORR  
Project Officers work very closely with grantees to review qualified candidates in order to ensure  
that qualified case managers are identified and hired and collaborate on overcoming any barriers 
to securing and hiring qualified case managers.   
When it comes to contracts, ORR extends the same child welfare principles found in its 
cooperative  agreements.  ORR requires contractors to recruit and employ case managers based 
on the appropriate level of need to ensure staff must be able to contact sponsors outside of 
traditional working hours and work around sponsors schedule.   This approach to maximize  
communication opportunities and channels with potential sponsors to ensure the childs best 
interests are prioritized during their stay in ORR care.  ORR also requires contractors to staff 
experienced case managers who have  at least 2-5 years of  experience in recording case  
management activities and child  care  experience, an associate degree, degree in social work or 
social services, with demonstrated ability to gather, document, and verify information. 
Contractors are also required to staff lead case managers with at least 1 year of experience with 
ORR  program case management and a minimum of 2 years of experience in staff management 
and supervisory duties.  Additionally, ORR requires contractors to recruit supervisory case  
managers who have  a minimum of 3 years of experience with ORR program case management 
and a minimum of 5 years of experience in staff management and supervisory duties.  ORR  
considers this structured approach as a model to support case management services and leverage  
experienced case managers in a collaborative  environment and ensure  children receive their 
services in a timely fashion and prevent any unnecessary delays in case management services.  
Recommendation 2:   Provide  case managers with timely and  comprehensive training and  
support  to  help  ensure  childrens safe and timely release  to sponsors.  
ACF Response:  ACF  concurs with this recommendation.  
ORR has deployed  a two-pronged approach to address ORR training  needs  to  enhance the  
comprehensiveness of training and support offered.   First, ORR has taken significant steps  
to  immediately  respond  to  critical  operational feedback gathered from various sources, 
including  field staff, contractors, federal volunteers,  and  other stakeholders, during the 2021  
influx to focus on training  needs across the ORR network.  In response  to  earlier noticeable  
gaps in training support, ORR supported the  development and delivery of a  robust training 
curriculum, particularly for case managers, which  provide  training modules in effective  case  
processing and procedures, which began in June 2021.  Second, in September 2021 ORR  
invested in a long-term training initiative for federal, grantee, and contractor staff that would 
establish a strong ORR training infrastructure for the  Unaccompanied Children  (UC)  program, 
adaptive to ORRs current and future training needs.  
Early in  the ORR EIS at  Fort Bliss activation period, ORR field staff recognized the need to 
implement training support, particularly for case  managers, to ensure the efficiency of case  
processing and the safety and wellbeing of children in ORR care.  In coordination with its case  
management contractor, ORR developed a responsive training approach in June 2021 that not 
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only provides  introductory case management training to all federal detailees during their first 
week on-the-ground, but also supports ongoing training in areas of deficiencies or questions 
identified by ORR federal and field staff  called weekly refresher or deep-dive trainings and 
technical assistance solutions in real time.  These trainings also include a self-test component for 
case managers to determine knowledge  retention and resulted in more engagement with case  
managers during training sessions and increased retention of core competencies.  ORR is 
working strategically to ensure case management training needs are identified across the ORR  
network and are delivered appropriately to further develop ORR programs case management 
proficiency and mastery of case processing.   
For a  list of ORRs Training and Technical Assistance Case Management trainings that have  
already been developed, please see  Appendix A.  
Broadly speaking, ORR continues to invest in expanding and strengthening the UC  programs 
training infrastructure for federal staff, grantees, and contractors.  In September 2021, ORR  
awarded a new training and technical assistance contract with a 5-year period of performance to 
update the UC  program training infrastructure.  Feedback and lessons learned from ORR staff, 
grantees, and contractors were provided through interviews and leveraged to provide ORR with a 
collaborative needs assessment on how the  UC  programs current operations and specific  
services could be enhanced and refined to more  effectively meet the needs and support the 
performance of ORR care provider programs across the network. This includes training needs 
for case management services. The overall training foundation will employ performance  
standards for effective assessment, planning, delivery, and evaluation of training and technical 
assistance needs.   These long-term investments in a foundational ORR training infrastructure  are  
ongoing and aim to flexibly support ORRs longstanding training needs regardless of operations 
during influx periods.   
Recommendation 3:   Create  an  emergency  policy  development protocol that  provides for  
adequate input from staff with  expertise in  child  welfare when ORR develops field  guidance  
during  an influx.  
ACF Response:   ACF  concurs with this recommendation.  
ORR developed an  emergency policy development protocol to guide its comprehensive 
evaluations of field guidance developed during the 2021 influx.   ORRs Policy Evaluation 
Workgroup, officially formed in September 2021, performed in-depth reviews of the UC  
program,  including safe and timely release, unification efforts, and  the  needs of unaccompanied 
children  while in ORR care through qualitative and quantitative data analytics.  Direct 
engagement with the  unaccompanied children  care provider network in October 2021  offered an 
opportunity to highlight  challenges and benefits resulting from rapid policy implementation and 
to link quantitative case  data to qualitative narratives and perspectives from field staff.   
The Policy Evaluation workgroup membership consisted of staff from different UC  program 
divisions, including Policy, Health, and Operations,  with representatives ranging from Project 
Officers to FFS  supervisors.  Additionally, the weekly workgroup relied on critical insights from 
child welfare advocates to inform the workgroups recommendations, including from the United 
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States  Committee for Refugees and Immigrants, United States Conference  of Catholic Bishops, 
the Young Center for Immigrant Childrens Rights, Casey Family Programs, Migration Policy 
Institute, Kids in Need of Defense, Vera  Institute  of Justice, and Lutheran Immigration and 
Refugee Service.  Their input was solicited throughout the evaluation and re-evaluation process 
in Fall 2021 and Spring 2022 and included direct input on pros and cons associated with a 
particular field guidance  and whether to revise, rescind, or leave such policy untouched in light  
of child welfare best practices.  
In order to continue to evaluate the many systemic and programmatic  factors impacting the 
initial outcomes of  field guidance implementation, the workgroup also conducted a qualitative 
survey released to all engagement groups (with 216 responses), facilitated 18 targeted focus 
groups with a total of 97 participants, and gathered quantitative data from sources such as the UC  
Portal, the ORR National Call Center, and ACFs Office on Trafficking in Persons (OTIP). 
Furthermore, the evaluations centered its metrics on child welfare and safety.  Many of the 
questions asked by child welfare experts during the evaluation process included how field 
guidance  1) impacted an unaccompanied childs  length of care, 2) considered child safety 
concerns in implementation, and 3) facilitated the  ability for staff to express safety concerns 
around release procedures and background check requirement modifications.  Leveraging child 
welfare expertise during  the evaluation process was essential to ensuring that the safety and best 
interest of children was prioritized in the implementation and review of all  field guidance, and 
ORR continues to maintain that focus in all its evaluations.  
The protocol to develop and evaluate field guidance is still in-use and ORR continues to leverage  
subject matter experts within ORR and external stakeholders including advocate groups with 
child welfare and immigrant expertise.   To summarize, the process begins with identifying field 
guidance in need of evaluation.  Through focus groups and surveys first, feedback is collected 
and reviewed on the implementation of field guidance, including areas that need strengthening. 
The workgroup utilizes data team metrics as a key component to define and measure success or 
improvement of implementation.  To ensure a wide spectrum of representatives participate and 
are allowed to weigh in when reviewing a particular field guidance, the workgroup meets 
multiple times (and, at the start, met weekly) to discuss focus group, survey, and data findings. 
Feedback on field guidance review is not limited to members of the workgroup only.  Members 
are encouraged to meet with additional staff outside the workgroup should they determine  
additional insight is essential for a holistic child welfare review.  All relevant and essential 
information and analyses considered  are documented in a decision memo, which includes 
specific callouts of pros, cons, and implementation roadblocks.  The  federal staff  workgroup 
collectively reviews the  memorandum and agrees on a recommendation to document whether to 
rescind, extend, modify, or permanently adopt the field guidance into ORR policy.  All decisions 
memos are reviewed and approved by the ORR Director and ACF leadership, as needed.  
Recommendation 4:   Ensure that ORR addresses challenges regarding usability and search 
capabilities within its case management system, the UC Portal.  
ACF Response:   ACF  concurs with this recommendation. 
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ORR, led by the UC Portal Technology Team, has sought bi-weekly releases of UC Portal 
enhancements to ensure that children in ORR care are receiving case management services 
without unnecessary technological delays.  
ORR worked with the United States Digital Service for nearly a year to implement 
improvements to the UC Portal and  continues to deliver iterative improvements to the UC Portal 
with a user-centered, agile process. Recent  improvements increased usability and search 
functionality to speed up processes, reduce errors, built in checks to prevent improper discharges, 
and made it easier to identify possibly problematic sponsors. Continued usability strategy is 
two-fold: improve upon the current code base while also iteratively replacing each component of  
the UC Portal with a completely new and modernized code base over time.  Every two weeks 
since  April 2021,  the UC Portal technology team releases multiple feature and function upgrades 
to production ranging from user experience improvements through the redesign of processes in 
the Portal, to adding features and functions required by ORR Policy.  
Among the many improvements ORR has made to the UC Portal since April 2021, ORR has 
made significant improvements to the search capability.  Since January 2022, all users can now 
search for a sponsors full name regardless of minor variations in spelling, format, or 
capitalization of the information entered by the user. Previously, when searching for information 
on a potential sponsor in the UC Portal database, users would  use very broad search terms (e.g., 
first name only, last name only, part of an address) in order to capture  a wider range of results. 
This was a functionality issue that made it  cumbersome for users to search for an individual with 
more precise search terms. The search capability improvement allows users to now search for a  
full name (first and last  names together), date of birth, or address.  Users can now enter an 
individuals full name into the search function and the top results will match that individuals 
information, removing the need for users to enter  broader search terms to retrieve results. 
Searching by full name, date of birth, or full address yields  better results: helping uses find 
sponsors quickly, efficiently, and with greater  accuracy.  These search improvements have been 
made to all search functions in the UC Portal: the quick search box on the top right corner of 
database  and the search box located in the Sponsor Information section of  an unaccompanied 
childs record. Additionally, the search capability improvements also have  allowed UC Portal 
users to identify duplicate sponsor profiles and flagging those for the UC Portal team.  This 
improvement also allows users to avoid creating duplicate sponsor profiles unintentionally.  
Another improvement to the UC Portal is the integration of a tool called SmartyStreets, which 
validates, enriches, and standardizes addresses. This improvement, integrated in October 2021,  
helps reduce the frequency of case managers entering duplicate sponsor records due to variation 
in addresses and makes it easier for case managers to find the sponsor they are searching for  
across multiple sponsor records. The new functionality will prompt the user if they try to enter 
an address that has an invalid number. The notification will ask the user to double-check the 
address and correct the mistake, if necessary.  
Beginning in April 2021,  ORR has also made system stability enhancements to better sense user 
inactivity when logged into the UC Portal. Previously, users would experience timeouts or be  
logged out of the database unexpectedly, which would cause disruption when entering 
information into the UC Portal. ORR redefined what the system considers activity to include, for 
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Page  9  
example, typing in a text box, clicking a radio button, and interacting with a date picker.  The  UC 
Portals 60-minute timeout clock now senses these actions as activity, removing unexpected 
logouts that would cause  a loss of information or documentation and a disruption to the case  
management process. Other system stability enhancements, beginning in April 2021,  include  
enhanced resilience of the UC Portal platform by migrating from a single cloud-based sever to 
Amazon Relational Database Service. Also added is a technical performance monitoring tool in 
April 2021 to assist in identifying and quickly addressing system outages before they occur. 
ORR continues to work on improving the UC Portal database  with end-users in mind to ensure  
efficient and effective  case management processing.  
Recommendation 5:  Ensure that ORRs employees and employees of ORRs contractors and 
grant recipients are informed about Federal whistleblower protections.  
ACF Response:  ACF  concurs with this recommendation. 
All ORR contracts (i.e., for EIS or ICF) must include whistleblower protection provisions as 
prescribed by the Federal Acquisition Regulation (FAR) 3.908-9 or FAR 12.301(b)(3) for  
commercial contracts. Commercial contracts require the inclusion of FAR 52.212-4(r),  which 
requires compliance with laws unique to Government contracts. The contractor agrees to comply 
with 31 U.S.C. 1352 relating to limitations on the use of appropriated funds to influence certain 
Federal contracts; 18 U.S.C. 431 related to officials not to benefit; 40 U.S.C. chapter 37, 
Contract Work Hours and Safety Standards; 41 U.S.C. chapter 87, Kickbacks; 41 U.S.C. 4712 
and 10 U.S.C. 2409 relating to whistleblower protections; 49 U.S.C. 40118, Fly American; and 
41 U.S.C. chapter 21 relating to the procurement integrity. Non-commercial contracts require  
the inclusion of FAR 52.203-17 Contractor Employee Whistleblower Rights and Requirement to 
Inform Employees of Whistleblower Rights,  which requires the contractor to inform its 
employees in writing the whistleblower rights and protections under 41 U.S.C. 4712.  The  
contractor is also required to include this  information on whistleblower rights and protections in 
all subcontracts on the date of subcontract award to ensure all subcontractors are  aware of their 
whistleblower rights and protections.   
Whistleblower protections are a key mechanism for ensuring the safety and wellbeing of all  
children in ORR care. Cooperative  agreements with care providers  set the  value framework for  
care provider  grantees to ensure that children and staff concerns are  always heard and valued, 
and that grantees are responsible for  the establishment of an environment and culture that 
prioritizes processes and procedures for individuals to elevate and report any child welfare  
concerns without concern for retaliation.  For example, ORRs cooperative  agreement requires 
grantees to create and implement a Code of Conduct that reflects the professional and ethical 
standards of their own agency and state licensing agency in addition to those of a reputable  
professional organization, such as the National Association of Social Workers, Child Welfare  
League of America, or the American Public Human Services Association.  The Code of Conduct 
must specifically address the employees obligations with respect to interactions and 
interventions with unaccompanied children, staff, and external stakeholders. The Code of 
Conduct must ensure that all board members, contractors, sub-contractors, grantees, sub-
grantees, and volunteers comply with the code.  
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Additionally, the grantee  must train all persons subject to its Code of Conduct and have  a  
whistleblower policy that provides staff an opportunity to report suspicious unethical, 
inappropriate, or illegal activities without negative consequence. The grantee must include proof 
in the personnel files that the employee has received training in, agrees to abide by, and 
understands the Code of Conduct. ORR will amend the  template  cooperative  agreement to 
include language that more specifically explains that the whistleblower policy and training 
should cover and provide more specific information on HHS OIG reporting and protections, as 
appropriate.  
With respect to federal employees, supervisors, managers, and supervisory commission corps 
staff who oversee  General Schedule employees are required to complete training on 
whistleblower protections and how to respond to complaints alleging a violation of 
whistleblower protections. Completion of this annual training ensures that managers and 
supervisors are well informed of the rights and protections afforded to whistleblowers, and how 
to address any complaints alleging retaliation. Further, and as noted in your report, beginning in 
March 2022, ACF  conducted a series of webinars in conjunction with the HHS OIG  on 
interacting with various components of the HHS OIG. This webinar series included two sessions 
on whistleblower protections: Whistleblower 101, which targeted the entire  ACF community and 
contractors, and Whistleblower 102, which targeted Managers and Supervisors. This series, 
which concluded in July 2022 during National Whistleblower Week, culminated with an HHS 
OIG panel presentation that included representatives from several  HHS OIG components, 
including the HHS OIG Office of Counsel to the Inspector General, who recapped the earlier 
presentations and provided key whistleblower takeaways.   The ACF sponsored OIG webinar  
training materials are  located on ACF Connect and are available to all ACF employees anytime. 
The mandatory course, 2022 Supervisors and Managers: What You Need to Know about 
Whistleblower Protection, Prohibited Personnel Practices, and Retaliation, is available on the  
HHS Website under HHS Mandatory Employee  Training.   
Again, I appreciate the opportunity to review and comment on this report. Thank you  and your  
team for sharing our commitment to keeping the unaccompanied children in our care safe. 
Please direct any follow-up inquiries to our OIG liaison, Scott  Logan, Office of Legislative  
Affairs and Budget, at (202) 401-4529.  
Sincerely,  
January Contreras,  
Assistant Secretary  
  for Children and Families  
Appendix  
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Appendix A. ORRs Training and Technical Assistance Case Management Trainings.  
Course Title   Description  
Behavior Management   This course discusses behavior management strategies, per 
ORR Policy, 3.3.13, and meets child welfare best practice  
standards. This course emphasizes the importance of 
communication and the utilization of de-escalation techniques.  
Case Management Learning  This course provides case managers an opportunity to engage  
Circles: Sponsor Engagement   in peer exchange to promote strategies for sponsor engagement 
in support of safe  and timely release.  
Case Management Overview   This course reviews the key participants involved in an 
unaccompanied child's case and identifies sponsor categories, 
how to flag a sponsor for any high-risk indicators.   Other 
topics covered include how to complete the Family 
Reunification Application,  identify proof of address, and 
register a potential sponsor for the Legal Orientation Program 
for Custodians.   The course concludes with overview of the 
release process and resources.   
Case Practicum: Admissions   Part 2 of Case Management Intensive course reviews ORR  
admission requirements and activities, such as assessments.  
Case Practicum: Discharges   Part 4 of Case Management Intensive course reviews  ORRs 
discharge process and covers topics including home studies, 
post release services, and discharge  activities.  
Case Practicum: Resources   Part 1 of Case Management Intensive course covers all the 
available ORR resources for case managers,  such as ORR  
online Policy Guide, ORRs Manual of Procedures (MAP), 
ORR issued Field Guidance, and other user manuals.  
Case Practicum: Sponsors   Part 3 of Case Management Intensive course focuses  on 
activities involving sponsors,  such as searching for a sponsor 
and completing the Family Reunification Packet.    
Category 3   Family  This course reviews the policies, procedures, and best practices 
Conferences   related to Category 3 sponsors and how to conduct effective  
family conferences, particularly in relation to Category 3 cases.  
Category 3   Sponsor  This course reviews the policies, procedures, and best practices 
Assessment   related to working with Category 3 sponsors.  
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Category 4   This course reviews the policies, procedures, and best practices 
related to unaccompanied children  without an identified 
sponsor.  
Child Development   This course covers child development. Among the topics 
discussed is identifying normal benchmarks and how to notice  
warning signs of an issue with a particular  child.  
Child Welfare Best Practices   This course provides an overview of  child welfare best 
practices framed within the context of ORR's child welfare  
mission.  
Cultural Competence   This course discusses the topics of culture, race, tolerance, and 
how to develop an inclusive environment that honors everyone. 
The course  explores ways programs can be inclusive and 
culturally competent.   
Duchitanga (Unaccompanied  This course reviews the latest update to sponsor fingerprint  
Children  Portal   Fingerprint)   procedures and how to properly document in ORRs UC Portal 
database.  
Family Conferences   This course provides practical tips on the utilization of family 
conferencing, including the purpose of holding family 
conferences, and how best to facilitate.  
Home Studies   This course reviews criteria for  unaccompanied children's  
cases that are required to undergo a home study.  Among the 
topics covered are how to create a home study referral on the  
UC Portal, and how to track the progress of an accepted home  
study referral.   
Introduction to  A guide on the UC  Portal that shows how data is processed 
Unaccompanied Children   from admittance to discharge. A basic introduction explaining 
Portal   the tabs and the case management features.  
OTIP Eligibility   This course provides an overview of human trafficking, 
including how to screen unaccompanied  children  for  
trafficking indicators, how to report trafficking concerns, the  
mission of  OTIP, how to refer to OTIP, and the benefits and 
services available to eligible children.   
Policies, Procedures,  This course provides a general overview of  ORR, including a 
Operations, and Care and   review of ORRs Policy Guide, MAP, and related resources; 
Custody   describes the roles of the  unaccompanied children program  
team; describes the levels of care within the ORR network; 
reviews the procedures for transfer between care  providers; 
reviews the admission and discharge processes.  
Operational Challenges Within ORR and the ORR Emergency  Intake Site at Fort Bliss Hindered Case Management for Children  
OEI-07-21-00251   Appendix D |  45   Ms. Christi A. Grimm  
Page  13  
Prior Sponsorships   This course provides an overview of how to search for a  
potential sponsors previous sponsorship attempts, how to 
document completion of  the search, and how to mitigate  any 
potential concerns or red flags.  
Privacy and Information  This course reviews the unaccompanied children program 
Sharing   policies and procedures related to privacy of information,  and 
how to handle requests for unaccompanied childrens  case  
information.  
Professionalism   This course provides an overview of the ORR Code of 
Conduct; reviews professional boundaries, confidentiality, 
conflicts of interest, prohibition on giving legal advice, and 
reporting non-compliant or unprofessional conduct.  
Proof of Address   This course reviews acceptable forms of proof of  address with 
examples.   
Release Request   This course provides an in-depth workshop of the  ORR release  
request requirements, including review of sample  release  
requests and writing practice.  
Reporting and Boundaries    This course reviews ORRs Zero Tolerance Policy and 
Prevention of Sexual Abuse   accompanying policies,  including reporting methods, 
definitions, reporting requirements, responses and follow up, 
and a review of the latest policy updates.  
Response to Remands   This course defines case  remands, provides examples of  
common case remand reasons,  and describes how  to proceed 
after receiving a remand.  
Separations / Migrant  This course describes the process and accompanying 
Protection Protocols   procedures for  working on unaccompanied children program 
cases impacted by family separation or Migrant Protection 
Protocols.  
Significant Incident Report  This course provides and overview and scenarios of Significant 
Best Practices   Incident Reports (SIR), including the purpose of SIRs, how to 
compete an SIR addendum, best practices for reporting and 
writing SIRs.  
Significant Incident Report  This course provides a demonstration and walkthrough for how 
Demonstration   to access and create SIRs in the UC Portal.  
Sponsor Fingerprint   This course reviews the process and procedures associated 
with completing sponsor fingerprints.   
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OEI-07-21-00251   Appendix D  |  46   Ms. Christi A. Grimm  
Page  14  
Sponsors   This course describes sponsor screening activities,  ranging 
from identifying a sponsor to completing a safe  release  
recommendation.  
Trauma-Informed Care   This course provides a basic introduction to trauma-informed 
care systems, definitions, and applications. The  course  
explores various trauma-informed topics and secondary 
trauma, and how programs can help make their facilities better 
able to serve vulnerable populations.  
UC Portal Sponsorship  This course reviews the most recent updates to the sponsor 
Assessment   assessment process procedures and how to effectively 
document in the UC Portal.  
Safe Release  of  This course describes procedures for sponsor assessment, 
Unaccompanied Children   vetting, fraud identification, and safe  release.  
Operational Challenges Within ORR and the ORR Emergency  Intake Site at Fort Bliss Hindered Case Management for Children  
OEI-07-21-00251   Appendix D  |  47    
ACKNOWLEDGMENTS  AND CONTACT  
Acknowledgments  
Dana Squires served as the team leader for this study, and Caroline Filbrun served as 
the lead analyst.  Others in the Office of Evaluation and Inspections who conducted  
the study include Natalie Aflalo, Haley Lubeck, and Mollee Sultani.  Office of  
Evaluation and Inspections headquarters staff who provided support include Kaliane 
Davidson, Althea Hosein, Christine Moritz, and Kelly Waldhoff.  
We would also like to acknowledge the contributions of other Office of Inspector 
General staff, including Jessica Swanstrom.  
This report was prepared under the direction of  Brian Whitley, Regional Inspector 
General for Evaluation and Inspections in the Kansas City regional  office, and Dana  
Squires and Abbi Warmker, Deputy Regional Inspectors General.  
Contact  
To obtain additional information concerning this report, contact the Office of Public  
Affairs at Public.Affairs@oig.hhs.gov.  OIG reports and other information can be found  
on the OIG website at  oig.hhs.gov.  
Office of Inspector General  
U.S. Department of Health and Human Services  
330 Independence Avenue, SW  
Washington, DC 20201  
 
Operational Challenges Within ORR and the  ORR Emergency Intake Site at Fort Bliss Hindered Case Management for Children    
OEI-07-21-00251   Acknowledgments and Contact | 48     
ABOUT THE  OFFICE  OF INSPECTOR  GENERAL  
The mission of the Office of Inspector General (OIG), as mandated by Public Law  
95-452, as amended, is to protect the integrity of the Department of Health and  
Human Services (HHS) programs, as well  as the health and welfare of beneficiaries 
served by those programs.  This statutory mission is carried out through a nationwide  
network of audits, investigations, and inspections conducted by the following  
operating components:  
The Office of  Audit Services (OAS)  provides auditing services for HHS, 
either by conducting audits with its own audit resources or by overseeing audit work  
done by others.  Audits examine the performance of HHS programs and/or its 
grantees and contractors in carrying out their respective responsibilities and are 
intended to  provide independent assessments of HHS programs and operations.   
These audits help reduce waste, abuse, and mismanagement and promote economy 
and efficiency throughout HHS.  
The Office of Evaluation and Inspections  (OEI)  conducts national  
evaluations to provide HHS, Congress, and the public with timely, useful, and reliable  
information on significant issues.  These evaluations focus on preventing fraud, waste, 
or abuse and promoting economy, efficiency, and effectiveness of departmental  
programs.  To promote impact, OEI reports also  present practical recommendations 
for improving program operations.  
The Office of Investigations  (OI)  conducts criminal, civil, and administrative 
investigations of fraud and misconduct related to HHS programs, operations, and  
beneficiaries.  With investigators working in all 50 States and the District  of  Columbia, 
OI utilizes its resources by actively coordinating  with the Department of  Justice and  
other Federal, State, and local law enforcement authorities.  The investigative efforts 
of OI  often lead to criminal convictions, administrative sanctions, and/or civil  
monetary penalties.  
The Office of Counsel to the Inspector General (OCIG)  provides 
general legal services to  OIG, rendering advice and opinions on HHS programs and  
operations and providing all  legal support for OIGs internal operations.  OCIG 
represents OIG in all civil and administrative fraud and abuse cases involving HHS  
programs, including False Claims Act, program exclusion, and civil monetary penalty 
cases.  In connection with these cases, OCIG also  negotiates and monitors corporate 
integrity agreements.  OCIG renders advisory opinions, issues compliance program 
guidance, publishes fraud alerts, and provides other guidance to the health care 
industry concerning the anti-kickback statute and other OIG enforcement authorities. 
Operational Challenges Within ORR and the  ORR Emergency Intake Site at Fort Bliss Hindered Case Management for Children    
OEI-07-21-00251   About OIG | 49     
ENDNOTES         
 
1  ORR,  Factsheets  and Data: Referrals.  Accessed at   https://www.acf.hhs.gov/orr/about/ucs/facts-and-data  on January 12,  
2022.  
2  In FY 2020, the number of referrals  decreased to 15,381 because of a U.S. public health order responding to the COVID-19 
pandemic that was implemented in March 2020.  The order suspended  entry of certain non-citizens at or  near the U.S.  
borders,  resulting in the expulsion of most unaccompanied  children upon attempting to enter the United States.  Following a  
court injunction and a February 2021 policy change, referrals of unaccompanied children  to HHS began to increase.   
3  CDC issued guidance,  COVID-19 Interim Guidance to Reduce the Risk of COVID-19 Spread at  ACF, ORR,  Temporary Influx 
Care Facilities,  and EIS, on March 30, 2021.   According to this guidance, all  ORR facilities  should adopt and strictly implement  
mitigation measures,  including universal and proper  wearing of masks,  physical distancing, frequent handwashing, cleaning 
and disinfection, improved ventilation, increased testing, and vaccination.   This guidance  defines physical distancing as  
keeping a safe space between yourself and  other people who are not from your household.  When physical distancing is a  
challengesuch as at ORR facilitiesCDC recommended cohorting (i.e., identifying a group and keeping them distanced 
from other groups).  Given the number of  children, staff, volunteers, and contractors at each ORR facility, CDC advised that 
mixing of staff  and cohorts should be minimized as much as possible.  
4  8 USC  1232(g).  
5  8 USC  1232(b)(3).  
6  8 USC  1232(c)(2).  
7  ORR,  Children Entering the United States Unaccompanied:  Section 2.1  (ORRs Policy Guide), May 11, 2015.  Accessed at  
https://www.acf.hhs.gov/orr/policy-guidance/children-entering-united-states-unaccompanied-section-2  on January 25,  2022.  
8  Facility types in ORRs licensed care provider network include shelters, foster care or group homes, staff secure or secure  
facilities, and residential treatment centers.  
9  CBP, U.S. Border Patrol Total Monthly UC Encounters by Sector (FY 2010FY 2020).  Accessed at 
https://www.cbp.gov/sites/default/files/assets/documents/2021-
Aug/U.S.%20Border%20Patrol%20Total%20Monthly%20UC%20Encounters%20by%20Sector%20%28FY%202010%20-
%20FY%202020%29%20%28508%29a_0.pdf  on January 25,  2022.   
10  Flores v. Barr, No. CV 85-4544-DMG-AGR, ORR, ORR Juvenile Coordinator Interim Report (Document 1104-2:  42935), April 
9, 2021.  Accessed on July 19,  2021.  
11  ORR worked closely with  the  Federal Emergency Management Agency  and other  Federal partners to establish EIS facilities  
and engage service providers.  Services were  provided by a combination of  the American Red Cross, Federal staff, including 
teams from the HHS Office of the Assistant Secretary for Preparedness and  Response and the U.S. Public Health Service  
Commissioned  Corps, and various contractors.   Flores v. Barr, No. CV 85-4544-DMG-AGR, ORR Juvenile Coordinator Interim  
Report (Document 1104-2:  42930), April 9, 2021.  Accessed on April 7, 2022.  
12  ORR,  Field Guidance 13, Emergency Intake Sites (EIS) Instructions and Standards,  April 30, 2021.  Accessed at 
https://www.acf.hhs.gov/orr/policy-guidance/uc-program-field-guidance  on November 23, 2021.  
13  DHS is required to transfer unaccompanied  children to HHS within 72 hours, except in the case of  exceptional  
circumstances.  8 U.S.C.  1232(b)(3).  
14  ORR,  Field Guidance 13, Emergency Intake Sites (EIS) Instructions and Standards,  April 30, 2021.  Accessed at 
https://www.acf.hhs.gov/orr/policy-guidance/uc-program-field-guidance  on November 23, 2021.  
 
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OEI-07-21-00251   Endnotes | 50   
   
 
15  ORR, Unaccompanied Childrens Program Field Guidance.  Accessed at  https://www.acf.hhs.gov/orr/policy-guidance/uc-
program-field-guidance  on April 7, 2021.  
16  Camilo Montoya-Galvez,  CBS News, Migrant children endure despair and isolation inside  tent city in the  Texas desert, 
June 22, 2021.   Accessed at https://www.cbsnews.com/news/immigration-migrant-children-fort-bliss-tent-city-texas/  on 
November 17,  2021.  
17  Government Accountability Project, New, Detailed Whistleblower Evidence  Further Documenting Abuses of  
Unaccompanied Immigrant Children Warehoused by the Federal Government at Fort Bliss and Other Emergency Intake Sites,  
September 8, 2021.  Accessed at https://whistleblower.org/press-release/press-release-new-detailed-whistleblower-evidence-
further-documenting-abuses-of-unaccompanied-immigrant-children-warehoused-by-the-federal-government-at-fort-bliss-
and-other-emergency-intake-sites/  on November 17, 2021.  
18  Letter to ORR Director Cindy Huang from Senators Merkley, Blumenthal, Booker, Padilla,  Feinstein, Hirono, Whitehouse,  
Wyden, Warren, Casey, and Sanders;  October  13, 2021.  Accessed at 
https://www.merkley.senate.gov/imo/media/doc/Letter%20to%20ORR%20re_%20Anomaly%20Request%20FINAL.pdf  on 
November 17,  2021.  
19  According to  a January 2022 article in the  El  Paso Times, the ORR EIS at Fort Bliss  had capacity to care for  2,500  children.   
Previous reports from April and May 2021 listed total capacity at 2,000 beds and 10,000 beds,  respectively.   Accessed at  
https://www.elpasotimes.com/story/news/2022/01/11/migrant-children-still-housed-emergency-shelters-el-paso-
pecos/9157540002/  on June 14, 2022.  
20  ORR reported  that it worked  closely with the Federal Emergency  Management Agency to ensure  that each EIS adhered to 
emergency response setting requirements.  
21  Four incident commanders led operations at the ORR EIS at Fort Bliss during spring and summer 2021.  
22  ORR,  Field Guidance 13, Emergency Intake Sites (EIS) Instructions and Standards, April 30, 2021.  Accessed at 
https://www.acf.hhs.gov/orr/policy-guidance/uc-program-field-guidance  on November 23, 2021.  
23  8 U.S.C.  1232 (c)(3).    
24  In 2014, ORR released several children to unrelated sponsors who were  associates of traffickers.  The children were forced  
to work physically demanding jobs at an Ohio egg farm for  up to 12 hours  a day.   Documents reviewed  by the United States  
Senate Permanent Subcommittee on Investigations confirm  that the failure  to adequately  verify a sponsors alleged  
relationship  with an unaccompanied  child has led to unsafe  placements.  United States Senate, Permanent Subcommittee on 
Investigations, Committee on Homeland Security and Governmental Affairs,  Protecting Unaccompanied Alien Children From  
Trafficking and Other Abuses: The Role of the  Office of Refugee Resettlement, February 10, 2016.  
25  OIG,  Care Provider Facilities Described Challenges Addressing Mental Health Needs of Children in HHS Custody, September 
2019.  Accessed at https://oig.hhs.gov/oei/reports/oei-09-18-00431.pdf  on April 23, 2021.  
26  ORR Policy Guide,  Key Participants in the Release Process: Section 2.3,  January 30, 2015.  Accessed at 
https://www.acf.hhs.gov/orr/policy-guidance/children-entering-united-states-unaccompanied-section-2  on January 25,  2022.  
27   The Family Reunification Packet consists of  documents a potential sponsor must complete before a  release decision can be  
made, including an Authorization for Release  of Information, a Family Reunification Application, and a Sponsor Care  
Agreement.   To view the  Family Reunification  Packet, see  https://www.acf.hhs.gov/orr/policy-guidance/unaccompanied-
children-program.  
28  ACF,  UAC Portal User Manual, September 2017.    
29  ORR,  Field Guidance 13, Emergency Intake Sites (EIS) Instructions and Standards, April 30, 2021.   Accessed at  
https://www.acf.hhs.gov/orr/policy-guidance/uc-program-field-guidance  on November 23, 2021.  
30  ORR Policy Guide,  Employee  Background Investigations: Section 4.3.3,  February 5, 2018.  Accessed at  
https://www.acf.hhs.gov/orr/policy-guidance/children-entering-united-states-unaccompanied-section-2  on January 25,  2022.  
 
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OEI-07-21-00251   Endnotes | 51   
   
 
31  ORR,  Field Guidance 13, Emergency Intake Sites (EIS) Instructions and Standards, April 30, 2021.  Accessed at 
https://www.acf.hhs.gov/orr/policy-guidance/uc-program-field-guidance  on November 23, 2021.  
32  Office of Personnel Management, Detail Opportunity, March 25, 2021.  Accessed at https://www.chcoc.gov/content/detail-
opportunity-information-departmentagency-leadership  on February 23, 2022.  
33  Flores v. Barr, No. CV 85-4544-DMG-AGR, ORR, ORR Juvenile Coordinator Interim Report (Document 1124-2:  42123),  June  
4, 2021.  Accessed on July 19,  2021.  
34  Priscilla Alvarez, CNN,  Texas emergency shelter is mostly warehousing thousands of migrant children,  according to 
eyewitnesses,  March  24, 2021.  Accessed at https://www.cnn.com/2021/05/24/politics/fort-bliss-migrant-children-
shelter/index.html  on February 23, 2022.  
35  Government Accountability Project, More Whistleblowers Call Attention to Mistreatment of Immigrant Children, July  
2021.  Accessed at https://whistleblower.org/in-the-news/whistleblower-network-news-more-whistleblowers-call-attention-
to-mistreatment-of-immigrant-children/  on December  23, 2021.  
36  Letters to the U.S.  House of Representatives, U.S. Senate, U.S. Office of Special Counsel, and HHS-OIG from the Government 
Accountability  Project on July 7, 2021, and July 28, 2021.  Accessed at https://whistleblower.org/wp-
content/uploads/2021/07/070721-Fort-Bliss-Whistleblowers-Disclosure.pdf  and https://whistleblower.org/wp-
content/uploads/2021/07/072821-2nd-Fort-Bliss-Whistleblower-Disclosure-FINAL.pdf  on February 17, 2022.    
37  The Whistleblower Protection Act, 5 U.S.C.  2302, and the HHS Whistleblower retaliation  regulation, 45 CFR 73-735-1303,  
prohibit any employee  who has authority to take, direct others to take, recommend, or approve any personnel action from  
using that authority to take or threaten to take any action against any employee in reprisal for making  a complaint or  
providing  information pursuant to 45 CFR 73-735-1301 (Mandatory Reporting of Criminal  Violations) and 45 CFR 73-735-
1302 (Mandatory Reporting of Misconduct).  
38  ORR has policies and procedures in place to  ensure  that unaccompanied alien children in  ORR care are released in  a safe,  
efficient, and timely manner.   Additionally, ORR issued Field Guidance 13 on April 30, 2021, which requires EIS facilities  (e.g.,  
the ORR EIS at Fort Bliss)  to establish case  management services for the safe and timely release of children  as soon as  
possible after opening.   
39  According to section 4.3.6 of  ORRs Policy Guide,  Children Entering the United States Unaccompanied, care provider  
facilities must provide training to all staff, contractors, and volunteer employees who may have contact with unaccompanied  
children.  New  employees, including case managers, must complete training before gaining access to children and youth.    
40   Section 2.3.2 of ORRs Policy Guide states that the Case Manager provides weekly status updates (monthly for children in 
LTFC) to the unaccompanied child on the child's case and provision of services, preferably  in person.  
41  According to a CBS News article from June 2021, similar incidents of self-harm and panic attacks occurred at the ORR EIS at 
Fort Bliss.  Accessed at  https://www.cbsnews.com/news/immigration-migrant-children-fort-bliss-tent-city-texas/  on June 22,  
2022.  
42  ORR Field Guidance 13, issued on April 30, 2022, noted that EISs should maintain a  minimum ratio of one case manager to 
every eight children.  The guidance does not specify what size each  case managers case  load should be.   
43   ACF, Standard Operating Procedures: Case Management Procedures for Emergency Intake Sites (EIS), May 2021.    
44  ORR field guidance, ORR Field Guidance 10, Expedited Release for Eligible  Category 1 Cases,  March 22, 2021.  Accessed at 
https://www.acf.hhs.gov/orr/policy-guidance/uc-program-field-guidance  on May 17, 2022.  
45  OIG compared ORRs standard UC Assessment and Sponsor Assessment tools with ORRs modified UC Assessment and  
Sponsor tools, which are used in expedited release cases authorized under  ORR Field Guidance 10.  The Mental Health  
section of the standard UC assessment contains a mental health assessment, including questions relating to the child's  
mental health, behavioral concerns and substance abuse; the Mental Health section in the modified UC Assessment is limited  
to asking the child if the child  has any mental health concerns.  It does not ask the child specific  questions relating to their  
mental health, behavioral concerns, or substance  abuse.  Similarly, the Proof of Relationship section in the standard Sponsor  
 
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OEI-07-21-00251   Endnotes | 52   
   
 
Assessment seeks to establish the sponsor's relationship to the child and  confirm that the relationship  was verified; the  
modified Sponsor Assessment does not contain an analogous section.  Finally, the standard Sponsor Assessment contains  
questions about how much the potential sponsor knows about the childs journey and could provide context into their  
relationship; the same section in the modified Sponsor Assessment only asks if  the child owes any debt.  
46  ORR Field Guidance 10 removed third-party review of eligible cases by case coordinators.  Prior to this guidance, case  
coordinators concurrently reviewed all assessment information on an unaccompanied child and sponsor to make a  
recommendation for release.  Once case managers and case  coordinators agreed on a particular recommendation for release,  
the Federal field specialists made a final release decision.   
47  ORR,  Field Guidance 11, Temporary Waivers of Background Check Requirements for Category 2 Adult Household Members  
and Adult Caregivers, March 31, 2021.  Accessed at  https://www.acf.hhs.gov/orr/policy-guidance/uc-program-field-guidance  
on May 17, 2022.  
48  According to ORR, children who are  infectious with communicable diseases of public health concern, which have potential 
to cause outbreaks, will not be released from ORR care until they are non-infectious.  ORR, Children Entering the United  
States Unaccompanied: Section 3.4.8,  May  11, 2015.  Accessed at https://www.acf.hhs.gov/orr/policy-guidance/children-
entering-united-states-unaccompanied-section-3#3.4.8  on January 21, 2022.  
49  According to the Whistleblower Protection Act, 5 U.S.C.  2302, Federal employees with supervisory responsibilities are  
prohibited from taking action against any employee in  reprisal for making a protected disclosure.  Protected disclosures  
include complaints that the employee believes evidence  gross mismanagement or violations of law, rule, or regulation.   
Prohibited personnel actions against employees may include  dismissal, reassignment, and/or other changes to duties.  
50  The two interviewees  who reported experiencing retaliation have not filed complaints with HHS-OIG.  One has filed a 
complaint with the Office of Special Counsel  and the other falls outside of  HHS-OIGs jurisdiction because that  individual is  
not an HHS employee.  
51  For whistleblower chilling to  be considered an adverse action, it must be accompanied by a personnel action or threat  of a 
personnel action.   Chacon v. Department of Health and Human Services, NY-1221-14-0372-W-1  27 (2017); see Covarrubias v.  
Social  Security Administration, 113 M.S.P.R. 583,  15 n.  4 (2010);  Shivaee v. Department of the Navy, 74 M.S.P.R.  383,  388 
(1997).  
52  Federal law mandates that all Federal contractors, subcontractors, grantees, subgrantees, or personal services contractors  
must inform their employees  in writing of the rights and remedies provided  under 41 U.S.C.  4712.  Accessed at 
https://oig.hhs.gov/documents/fraud/367/NDAA-Notice-HHS-Contractors.pdf  on August 16, 2022.  
53  HHS, Notice to HHS Contractors, Subcontractors, Grantees,  Subgrantees or Personal Services Contractors.   Accessed at  
https://oig.hhs.gov/documents/fraud/367/NDAA-Notice-HHS-Contractors.pdf  on August 16, 2022.  
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OEI-07-21-00251   Endnotes | 53