U.S. Department of  Health  and  Human Services  
Office of Inspector General  
ACF Should Improve Oversight 
of Head Start To Better  
Protect Childrens Safety  
 
Suzanne Murrin  
Deputy  Inspector General  for  Evaluation and  Inspections  
September  2022, OEI-BL-19-00560   U.S.  Department of Health and  Human Services  
 
Office  of  Inspector  General  
Report in Brief  
September  2022,  OEI-BL-19-00560  
Why OIG Did This Review   ACF Should Improve Oversight of Head Start  
The Office of Head Start (OHS)part  
To Better Protect Childrens Safety   
of the  Department of Health and  
Human Services  Administration for  
Children and Families (ACF)  What OIG Found  
oversees Head Start grant recipients   Approximately one in four  Head   Key Takeaway  
to ensure their compliance with  Start grant recipients received an  
ACF is not aware of all incidents in  
program standards, including 
adverse finding  from ACF  for child  
which children in the care of a  
standards addressing childrens  
abuse, lack of supervision, or  
Head Start  center are abused, left  
safety.   The Office of Inspector  
unauthorized release  between  
General (OIG)  initiated this review to   unsupervised, or released to an 
October 2015 and May 2020.   These 
determine the extent to which   unauthorized person, impeding  
recipients received adverse findings   adverse findings encompassed   ACFs efforts  to protect childrens  
from ACF  for violating  program   1,029 individual incidents.     safety.    
standards that prohibit child abuse,  
Additionally,  Head Start grant  
leaving a child unsupervised  (lack of  
supervision), or releasing a child to an   recipients did not promptly self-report all incidents of  child  abuse, lack of  
unauthorized person  (unauthorized   supervision, and unauthorized release  as required.  Of  recipients with one or  
release); assess ACFs oversight of   more adverse findings  from  ACF  in these three categories, 24 percent also  
how recipients identify, address, and  received  an adverse finding for failure to promptly report these incidents.  
prevent such incidents; and identify  
Further, using data from  2  States  for 2017 through 2019, OIG identified 130  
opportunities to better protect  
additional incidents that occurred  in  Head Start centers  but  of which ACF  
children.   
was not aware.  ACF  noted that  recipients  are not required to report  
incidents in which the victim is not a child  funded  by Head Start, even if the  
How OIG Did This Review  
incident  occurs in  a blended  classroom  that includes  Head Start enrollees.  
We reviewed data from ACF  
monitoring of Head Start grant  
Head Start grant recipients  most often addressed incidents of  child  abuse,  
recipients to identify adverse findings  
lack of supervision, and unauthorized release  at Head Start centers  through 
for child abuse, lack of  supervision,  
a combination of disciplinary action, administrative improvements, and  
unauthorized release, and failure to  
report significant incidents.  We also   training.   Additionally,  ACF uses monitoring data to target  recipients for  
reviewed narratives from ACF   training  and technical assistance  on  these issues.   Some  OHS regional offices  
monitoring reports to determine the   have also  developed data systems and procedures to  better track and  
number and nature of incidents   respond to  incidents that threaten childrens safety.  
associated with each adverse finding.   
Additionally, we obtained data from   What OIG Recommends and How the Agency Responded  
child care licensing agencies and 
To ensure that ACF is  aware of and can appropriately respond to  all  
child protective services agencies in  
incidents  in which  children  in the care of a Head Start  center  are abused, left  
Florida and Texas to determine  
unsupervised, or released to an unauthorized person, we recommend that  
whether ACF was aware of all  
ACF (1) improve  Head Start grant recipients  self-reporting of  incidents of 
incidents that those State agencies  
had identified.  Finally, we  child abuse, lack of supervision, and unauthorized release through better  
interviewed OHS staff and reviewed   guidance and stronger consequences for failure  to report; (2)  extend the 
internal and public documents to   reporting requirement to include incidents in  blended  classrooms in  which 
better understand ACFs processes   the victim is not a  Head  Start-funded child; (3)  improve  data-sharing with 
and criteria for monitoring, incident  
States about  incidents in Head Start centers; and (4)  disseminate  information  
response, and adverse finding 
about  innovative practices that OHS regional offices  have developed to  
determinations related to child  
better identify  and prevent  incidents  that threaten childrens safety.   ACF 
abuse, lack of supervision, and  
concurred with all four of our recommendations.  
unauthorized release.  
   
TABLE OF CONTENTS  
 
 
BACKGROUND ................................................................................................................................................  1  
FINDINGS ......................................................................................................................................................... 8  
Approximately one in four Head Start grant recipients received an adverse finding from ACF for child  
abuse, lack of supervision, or unauthorized release between October 2015  and May  2020  ......................  8  
Head Start grant recipients did not promptly report all incidents of child abuse, lack of supervision,  
and unauthorized release as required  ............................................................................................................................ 11  
Head Start grant recipients most often addressed incidents of  child abuse, lack  of  supervision, or  
unauthorized release through a combination of disciplinary  action,  administrative improvements, and  
training ........................................................................................................................................................................................ 15  
ACF uses monitoring data to target training and technical assistance regarding childrens safety in 
Head Start centers .................................................................................................................................................................. 17  
CONCLUSION  AND RECOMMENDATIONS ...........................................................................................  19  
Improve Head Start grant recipients self-reporting of incidents of  child abuse, lack of supervision,  
and unauthorized release through better guidance and stronger  consequences for  failure to report  19  
Extend the reporting  requirement to include incidents of child abuse, lack  of supervision,  and  
unauthorized release in blended classrooms in which the victim is not a Head Start-funded child ...... 20  
Improve data-sharing with States about incidents  of child abuse, lack of supervision, and  
unauthorized release in Head Start centers .................................................................................................................. 20  
Disseminate information about innovative practices that OHS regional offices have developed to  
better identify and prevent incidents that threaten childrens safety ................................................................. 21  
AGENCY COMMENTS AND OIG RESPONSE  ........................................................................................  22  
DETAILED METHODOLOGY ......................................................................................................................  23  
APPENDICES.................................................................................................................................................  29  
Appendix A:  Head Start Program Standards Included in OIGs  Review ............................................................ 29  
Appendix B:  Agency Comments ....................................................................................................................................... 33  
ACKNOWLEDGMENTS AND CONTACT  ................................................................................................  39  
Acknowledgments .................................................................................................................................................................. 39  
Contact ........................................................................................................................................................................................ 39  
ABOUT THE OFFICE  OF INSPECTOR GENERAL ....................................................................................  40  
ENDNOTES  .................................................................................................................................................... 41  
   
BACKGROUND  
OBJECTIVES  
1.   To  determine the extent to which  Head Start grant recipients received  
adverse findings from ACF for violating  program  standards  that prohibit  
child abuse,  leaving a  child  unsupervised, and releasing  a child to an  
unauthorized person  
2.   To assess ACF oversight  of  how  Head Start grant  recipients  identify, address,  
and prevent  incidents  of  child abuse, leaving  a child unsupervised, and  
releasing a child to an unauthorized person  
 
Head Start grant  recipients  (recipients)  are funded by the Department of  Health and  
Human Services (HHS) to provide early  childhood  education and social services to  
infants  and young children.  To ensure the well-being of children receiving Head Start  
services,  all recipients  must meet Federal  requirements  for quality  and safety.  The 
Office of Head Start (OHS) within the HHS Administration for Children and  Families  
(ACF)  monitors  recipients  to ensure their compliance with all  program  standards.   
OHS also provides training and technical assistance to  support  recipients  compliance.   
OIG initiated this review to  assess ACF oversight of recipients to  prevent, identify, and  
respond to incidents  of  child abuse, leaving a child unsupervised  (lack of supervision),  
and  releasing  a  child to an unauthorized person  (unauthorized release).    
Head Start: Program Overview  
Head Start is a nationwide grant program to provide early childhood education and  
social services to  children, birth to age  five, whose families meet income or other  
eligibility requirements.  With a  fiscal  year (FY)  2022  budget of $11  billion,  ACF  awards 
funds to approximately  1,600  recipients, including public agencies, for-profit  
organizations,  nonprofit  organizations, school systems, and Tribal governments.   
Head Start programs served approximately 861,000  children in FY 2021.1  
Recipients typically provide services in child  care centers or school settings.   Some  
recipients  are  very large,  operating  multiple  facilities,  while other  recipients  operate  
only one facility.   Some recipients operate blended classrooms, i.e., classrooms that  
include children funded through Head Start as  well as children funded through other  
sources, such as State programs.   Additionally, some  recipients serve  families through  
a home visiting and family child care model.   In this report, we use the term Head  
Start center  to refer to any location or program serving children enrolled in Head  
Start.   In total, recipients  operate approximately  20,000  individual Head  Start centers.  
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Head Start  Program  Standards Addressing  Child  Safety  
Recipients must comply  with Federal regulations  containing detailed standards for  
Head Start program governance, operations, and  financial and  administrative  
requirements.2   These  standards  also  require that recipients  establish  and enforce a  
system of health and safety practices that ensure children  are kept safe at all times.   In 
this review, we focus on the following subset of  standards  that  affect childrens safety:  
   Standards that prohibit child abuse, including physical abuse;  corporal  
punishment;  other prohibited disciplinary practices such as binding or tying;  
emotional abuse;  and verbal abuse;3  
   Standards that prohibit leaving any  child  alone or  unsupervised;4  
   Standards that prohibit release of a  child to an unauthorized person.5     
The Head Start program standards also require recipients to report to  ACF  
immediately or  as soon  as practicable  any significant incident that affects  Head Start 
program participants health and safety, including any incident regarding staff or  
volunteer compliance with laws addressing child abuse and neglect.   Recipients must  
also comply  with State, Tribal,  and local reporting  laws regarding child abuse and  
neglect.6 
Please see Appendix A for a  complete list of regulatory  citations for all  Head Start 
program  standards included in our review.  
Oversight of Head Start  Grant Recipients  
ACF oversees recipients to ensure that they meet  all grant requirements.   Many  
recipients operate multiple centers; however,  ACF  awards  grant funding and provides  
oversight to grant recipients, not individual centers.      
Federal law requires that  each recipient  receive a full review immediately after  
completion of the recipients first year and at least  once during each  3-year  period.7   
In addition to  these  Federal  monitoring  reviews,  staff in  12  OHS  regional offices  
maintain ongoing contact with  recipients throughout the grant cycle to gather  
information,  assess performance,  and facilitate training and technical assistance.  
Federal  Monitoring  
All recipients  undergo  multiple  types of regularly  scheduled  Federal  monitoring 
reviews.   These  reviews address operations  across all of a recipients program sites,  
but do not necessarily include an onsite visit to each individual Head Start center  
operated by the recipient.   Recipients may also  be subject to additional  reviews  
initiated  as needed  to address performance issues brought to  ACFs attention outside 
of the scheduled review  cycle or  to ensure that  previously identified performance 
concerns  have been corrected.   Typically,  some  reviews are conducted through phone 
calls  and document reviews,  while others  are conducted onsite.  However,  ACF  
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suspended all in-person reviews in March 2020 as a result of the COVID-19 pandemic.   
ACF  resumed  onsite reviews  in January 2022.  
Adverse  Findings  
ACF  uses  data collected during monitoring reviews to determine whether  recipients 
comply with all Head Start program standards.  Monitoring  reviews may result in  the 
following adverse findings  issued to the recipient:  
   Deficiency findings  indicate that a  recipient  exhibits systemic or substantial 
noncompliance with significant State or Federal requirements.8   Examples  
include failure to adhere to  program  standards regarding threats to  childrens  
health or safety or the misuse of Head Start funds.   
   Noncompliance findings  indicate that a  recipient  is out of compliance  with  a  
Federal or State requirement, but not to a level that constitutes  a deficiency.9     
Correction of Adverse Findings  
After  receiving  an adverse finding,  the  recipient works  with the appropriate OHS  
regional office  to identify appropriate steps to correct the finding.  Recipients with 
either a deficiency  or noncompliance finding must correct these findings  within the 
time period designated by ACF (typically  30  to 120 days, depending  on the nature of  
the finding; however, ACF may require a shorter timeline, including immediate 
correction of a deficiency, under certain circumstances).   If the finding is a  deficiency,  
the recipient  may  also  be required to  submit to ACF  a Quality  Improvement Plan.10      
ACF conducts  followup reviews to confirm  that  recipients have completed  all actions  
necessary to  correct adverse findings.   If  a noncompliance is not corrected in the 
allotted time, it is reclassified as a deficiency.11    
Designation  Renewal System  
In 2011,  ACF  established  the Designation Renewal System  (DRS)  to  improve the 
quality of  Head Start program  services  by increasing competition for grant funding.   
Recipients are typically funded for a  5-year project period.  Under the DRS,  at the  
conclusion of the project  period,  a recipient  is  non-competitively renewed for funding  
if it  does  not  meet  any  of seven conditions specified in regulation.  These conditions  
include measures  that reflect poor  classroom quality,  problems with financial  
management,  significant noncompliance with Head Start standards, and other factors  
that signal concerns about the recipients performance.12   A recipient that meets  any  
of the seven conditions  must participate in open competition for funding  renewal,  a  
process also  known as  recompetition.  
When the DRS  was  initially  implemented,  one of  the seven  conditions  that triggered 
recompetition  was receipt of  a  single deficiency  finding at any point in the project  
period.  In late 2020, that condition was revised,  and a  recipient  is now required to  
compete for renewal if it receives  two  or more  deficiencies during the project period  
(or if it  meets any  of the remaining six conditions  that trigger  recompetition).  
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Suspension or  Termination of Funding   
Regulations at 45 CFR   1304  detail reasons for which ACF may suspend  or terminate 
a recipients funding, which include failure to timely correct one or more deficiency  
findings.13   Typically, a recipient receives notice prior to suspension or termination;  
however,  ACF may issue an emergency suspension without advance notice for  certain  
reasons, including harm to participants health and safety.   Termination decisions are  
subject to appeal through the Departmental Appeals Board.   Recipients may also  
submit written materials  or request a meeting  with ACF about  why the recipient  
believes  financial assistance should not be suspended.  
Training and Technical  Assistance  
ACF  provides training and technical assistance to  recipients to support delivery of  
quality services and compliance with program standards.  At the national level, OHS  
and the ACF Office of  Child Care jointly operate four  training and technical  assistance 
centers, each with a specific focus (e.g., program management and  fiscal operations,  
early  childhood health and wellness, etc.).  Additionally, OHS  regional offices  work  
with training and technical assistance  contractors  to provide direct  assistance to  
individual recipients.   
State  Oversight  of Head  Start  Programs  
Most Head Start grant recipients  are licensed  child care providers  in their respective 
States  and are  subject to  State child care licensure standards as well as Head Start 
program  standards.  Some  Head Start programs  are  therefore  monitored by State-
level agencies  to ensure compliance with State standards.  Additionally, State Child  
Protective Services  (CPS)  agencies receive and investigate reports of  child  abuse and  
neglect in child care settings, including Head Start centers.   
Head Start  State Collaboration Offices  
As directed by the Head  Start Act, ACF has established Head  Start State Collaboration  
Offices.14   The purpose of  these offices is to  facilitate  ongoing collaboration  between 
the Office of Head Start  and  State and local entities  to support activities related to the 
delivery of  Head Start services, such as  building early childhood systems and  
improving  access to  comprehensive services for  children from  low-income  families.  
Related OIG Work  
OIG regularly conducts  audits of Head Start grant  recipients  and periodically conducts  
broader reviews of programmatic issues.   In 2016, OIG recommended improvements  
to the  DRS to more effectively identify lower-performing recipients that should  
participate in open competition for  funding  renewal.  In 2011, OIG reviewed  
24  recipients  (selected in collaboration with ACF because the recipients  were 
considered  most  at risk for noncompliance  with health and safety standards)  and  
found that none  complied fully with  health and safety requirements.   
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Methodology  
Data Sources  
This review combined data from the following sources:   
Federal Monitoring Data.  We reviewed OHS data on  recipients monitoring review  
results from October 1, 2015, through May 11, 2020  (i.e., from the beginning  of  fiscal 
year 2016when  the current  Head Start performance standards  went  into effectto  
the start of this studys data  collection).   These data included  identifying information  
for each recipient; the dates of each review;  regulatory  citations for  each adverse 
finding;  the status of  each  finding (e.g. active, corrected, etc.); and narrative fields  
detailing the reasons for  the review  results  and  corrective actions taken.  
Program Information Report  (PIR) Data.  We used  publicly available PIR data for the 
2018-2019 program year (the most recent  available at the time of analysis)  to obtain a  
list of recipients and  identify their  location, program type,  and other characteristics.   
OHS Center List.   We requested from  OHS the  names and addresses  of  each  individual 
Head Start center  operated by recipients.    
State Data.   We requested the following data from  the appropriate State agencies in 
Texas and Florida:   
   State  CPS Data. 15   We  requested all substantiated  abuse and neglect  reports  
for children in the care of a child care facility for  calendar years 2017 through 
2019.   
   State  Child Care  Monitoring Data. 16   We requested child care monitoring data  
for all licensed  child care  facilities for  calendar years 2017 through  2019.    
We requested  State  data  for calendar  years  2017 through 2019 because this range 
provided a  3-year  subset of the broader period of Federal  monitoring data in our  
review.    
Interviews  With  Selected OHS  Staff.   We conducted  a  panel  interview with OHS  central  
office  staff and  five panel  interviews with staff from selected OHS  regional  offices  
(Regions  1, 4, 6,  11,  and 12).   We  also  submitted questions in writing to  OHS  and 
received  written responses. 
OHS Procedural and Training Documents.   We  requested  from OHS  documentation on  
written policies, procedures, and training materials related to identifying and  
addressing incidents  of child abuse,  lack of supervision, or  unauthorized release; 
reporting requirements;  and determining whether a violation will be classified as a  
deficiency or  a noncompliance.    
OHS  Administrative Action  Records.   We requested from OHS  documentation about  
recipients that  were subject to suspension, termination, and/or recompetition for  
renewal of funding  under  the DRS  from October  1, 2015, through January 6, 2022.   
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We requested administrative actions for this date  range  to ensure that we captured all  
actions taken during the period of monitoring data  we reviewed  (October 1,  2015,  
through May  11,  2020) as well as actions taken more recently, given that  the 
administrative processes  involved may take months or years to  complete.  
Data Analysis  
Analysis To  Determine  the Extent of  Adverse Findings  
To  determine  the extent to which recipients  received adverse findings from ACF for  
violating  Head Start  standards  related to  child abuse,  lack of supervision,  or  
unauthorized release, we  analyzed  Federal  monitoring data to  identify  recipients that  
received  noncompliance or  deficiency  findings for  violating these standards, as well as  
findings for failure to report such incidents,  from October 1,  2015,  through May 11,  
2020.   (Please see Appendix  A  for a list of all Head Start program standards  included  
in our review.)   We also  reviewed  narratives from  monitoring reports  to  determine the 
number and type of individual incidents associated with each adverse finding.   We 
analyzed these data to  determine the number and percentage of recipients with 
adverse findings for  child abuse,  lack of supervision, unauthorized release,  and failure  
to report, as  well as the  total  number of each type  of  incident  within those categories.  
Analysis To  Assess  ACF Oversight  
To better understand ACF oversight processes and procedures, we analyzed interview  
and written responses from OHS  regional and central office  staff.  We also reviewed  
policy, procedural, and guidance documents to identify processes  and criteria for  
monitoring, incident response, and adverse finding determinations.  
To determine the extent to which all incidents are reported to ACF,  we matched child  
care licensing and CPS data from Texas and Florida with  Federal  monitoring data. For  
each incident observed in State  data,  we determined whether the incident was also  
reflected in Federal  monitoring data.  We provided to OHS a list of incidents we  
identified that had not been previously reported to ACF.  
To  determine which  corrective actions  recipients took,  we  analyzed  OHS  monitoring  
data to  identify  actions taken by recipients to resolve adverse findings for  child abuse,  
lack of supervision,  or unauthorized release.   We  then  calculated the percentage of  
incidents addressed through different types of actions: disciplinary actions  against 
staff, administrative improvements,  and staff training.   We also reviewed data on 
recompetition, suspension, and termination to determine the extent to which 
recipients were subject to these ACF  administrative actions.  
Limitations  
The number of incidents  of child abuse,  lack of supervision, or unauthorized release  
that occurred in Head  Start centers in Texas  and Florida may be higher than the 
number OIG identified.   OIG linked State and  ACF  data by  geocoding child care  center  
addresses.  If a  center that appeared in the State data had a matching address in the 
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ACF  data,  and  was confirmed by  our  manual review of the center name and other  
information,  we identified it as a Head Start center.   This method could have failed  to  
identify a Head Start center  in the State data  if, for example,  the addresses were 
slightly different, outdated, or the State used post  office box addresses.    
Additionally, we did not independently verify the evidence that ACF collected  from  
recipients to confirm that they had  completed all corrective actions timely.  
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  
Approximately one in four Head Start  grant  recipients  received  
an adverse finding  from ACF  for  child abuse,  lack of supervision,  
or  unauthorized release  between October 2015 and  May 2020  
From our review of  Federal  monitoring data,  we found that  438 out  of  1,611  recipients  
received  one or more adverse findings  (noncompliance or deficiency)  from ACF  for 
child  abuse,  lack of supervision, or  unauthorized release  between October 2015 and  
May 2020.   ACF issues  an adverse finding when it  determines  that a recipient  has  
violated  one or more Head Start program standards.   One adverse finding  may be 
associated with multiple incidents,  which may have occurred at one or more centers  
that the recipient operates.   For example, an adverse finding  for lack of supervision  
could be based  on a monitoring report describing  children left  unsupervised on 
multiple dates.17   Our review of  monitoring report  narratives associated with these 
adverse findings  identified  1,029 individual incidents.    
Exhibit  1: During the period of review,  
27 percent of Head Start grant  
recipients received an adverse  finding  
for child abuse, lack of supervision, or 
unauthorized release.  
 
Source:  OIG analysis of Federal Head Start  
monitoring data,  2022  
Among Head Start grant recipients with  one  or  more  adverse 
findings  in  these three categories,  the  most common citation was  
for lack  of supervision  
Among recipients  with  one or more  adverse findings  for child  abuse,  lack of  
supervision, or  unauthorized  release, the most common citation  was  for  lack of  
supervision.   Six percent of recipients  received  adverse findings  from ACF  in more 
than one of these three categories.  
   
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Nineteen percent of Head Start grant recipients were cited for lack of 
supervision  
Nearly  one in five recipients received an adverse finding for lack of supervision 
between October  2015 and May 2020.   Our review of monitoring report narratives  
associated with these findings identified  533  individual incidents in which a child was  
left unsupervised.   
Exhibit  2: Examples of  incidents  involving lack of supervision  
[A] 4-year-old  child left the [school] building  and was unsupervised for approximately  
5  to 10 minutes, during which time the child ran into the  street.  
[The] contracted bus driver left the child unattended on the bus for an undetermined  
period of time during very  cold weather.  The parent discovered discoloration on the  
childs feet later that day.  An examination by  a physician the following day indicated  
evidence of frostbite.  
Source:  OIG analysis of Federal Head Start monitoring reports, 2022  
The  most frequent type of  supervision incident,  with  358 incidents,  involved  children 
left alone on the grounds of  a Head Start facility,  such as in a  classroom, in  a  
bathroom, or  on  a  playground.  We also identified 95  incidents  of children left alone 
outside  a facility, such as  in a parking lot or on a nearby  street.  Finally,  we identified  
80  incidents of  children left alone on a bus.   
Twelve percent of  Head Start grant  recipients  were cited for  child abuse  
Between October  2015 and May 2020,  12 percent of recipients received an adverse 
finding  for  child abuse.   Our review of monitoring report narratives associated with 
these findings identified 454 separate incidents  (i.e., unique child-date combinations)  
of  abuse.   A single  incident of child  abuse  sometimes included  multiple  forms of  
abuse  (for example, both physical and verbal  abuse).    
Exhibit  3: Examples of  incidents  involving child abuse  
[T]he Head Start Director... observed the teacher dragging the  child across the floor on  
three separate occasions and placing the  childs cot in the office and turning off the  
light.  When the child got off his cot, the teacher roughly pushed him into one of the  
childrens  cubbies and  stood in front of the cubby to prevent him from getting out.  
[P]arents came forward to report concerns of the teacher and teacher  assistant using  
verbal abuse by calling the children demeaning  nicknames, including  chanchopig, in 
Spanishand mustache girl....  [C]hildren described a stick that was used to scare  and  
hit them and the  children expressed fear of the staff returning.  
Source:  OIG analysis of Federal Head  Start monitoring reports, 2022  
   
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Of the 454 incidents of child abuse described in Federal monitoring reports:   
   374 incidents included physical abuse or  corporal punishment,  defined as  
hitting, spanking, shaking, slapping, twisting, pulling, squeezing, or biting  a  
child;  
   102 incidents included emotional or verbal abuse,  defined as  any  form of 
public or private humiliation;  rejecting, terrorizing, extended ignoring, or  
corrupting a  child;  or  using profane, sarcastic, threatening, or derogatory  
language or remarks  about a child or a  childs family;  
   54 incidents included prohibited disciplinary practices,  defined as  using  
isolation; binding or tying; taping a childs mouth; using or withholding food  
as a punishment or reward; using toilet learning or training methods that  
punish, demean, or humiliate a child; or using physical activity or outdoor time 
as a punishment or reward;  and  
   8 incidents included sexual abuse.  
Two  percent of Head Start grant  recipients  were cited for  unauthorized release  
Few recipients had adverse findings for unauthorized release.   We identified  
42  incidents  between October 2015 and  May 2020  in which a  child  was released to an 
unauthorized  person.   Of these, 25  incidents  involved children released from a bus to  
an unauthorized  person  and 17 involved  children  released from a  Head Start facility to  
an unauthorized  person.  
Exhibit  4:  Examples of  incidents involving unauthorized release  
A Head Start  child was released to  an unauthorized adult... and the location of the  
child was undetermined for approximately 1.5 hours.  
[A] 4-year-old  child.... was  dropped off at the wrong bus stop and not released to an 
authorized  adult.  The  child  was then left unsupervised  for approximately 7 minutes.  
Source:  OIG analysis of Federal Head  Start monitoring reports, 2022.  
Most  adverse  findings  for child abuse,  lack  of supervision,  or  
unauthorized  release  were classified as  deficiencies,  which carry  
greater  consequences  than  findings  of  noncompliance  
Of all adverse findings for  child  abuse,  lack of  supervision, and unauthorized release 
during the period of OIGs review,  65  percent  were cited as deficiencies and  
35  percent were  cited  as noncompliances.  ACF provided internal documents that  
describe its criteria  for determining whether  these types of  citations  will be  classified  
as a deficiency or a  noncompliance.   These criteria  include  the severity of  an abuse 
incident;  the number of minutes a child was left alone;  whether an unauthorized  
release involved  a known or  unknown individual;  the number of incidents involved;  
and other factors.  Although both types of adverse findings must be corrected,  
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recipients who receive a  deficiency finding may be required to complete a Quality  
Improvement Plan and will be terminated if they fail to correct the deficiency.   
Additionally, unlike a noncompliance, a deficiency finding may contribute  to a  
recipient being required  to recompete for funding renewal.   If a noncompliance is not  
corrected in the allotted  time, it is reclassified as a deficiency.18  
During the  period of  review,  most  Head  Start grant recipients  did  
not  have repeated  adverse findings for  child abuse,  lack  of  
supervision, or  unauthorized  release   
Between  October 2015  and  May 2020,  110 recipients  received adverse findings for  
child  abuse,  lack of supervision, or unauthorized  release  in  2 or more  fiscal years.  This  
represents  25 percent of  recipients that  were ever  cited  for violating these  Head Start 
standards  during the period of review and  7  percent of all recipients.   In addition,  
18  recipients  were cited for  any  of these 3  categories of violations  during 3  or more  
fiscal  years during the period of review.  
Head Start  grant recipients did not  promptly  report all incidents  
of  child abuse, lack of supervision,  and  unauthorized release  as  
required   
Recipients are required to report  to ACF immediately or as soon  as practicable...any  
significant incidents  affecting the health and safety of program participants.19   
Additionally, all staff  at Head Start centers are  considered mandated reporters,  
i.e.,  they are legally obligated to report suspected  child abuse or neglect to the  
appropriate State agency.20   We found that despite these requirements,  recipients did  
not promptly  report  all incidents  of  child abuse, lack of supervision,  and unauthorized  
release.  
Of  Head Start  grant  recipients  with  one  or  more  adverse findings  
for child abuse, lack  of  supervision,  or  unauthorized release, 
24  percent  also  received an  adverse finding  for  failure to  
promptly  report these  incidents  
We found that  nearly  one quarter of  recipients  that were  cited  for  child  abuse,  lack of 
supervision, or  unauthorized release were also cited  for failure to  properly  report  
these incidents.   Recipients  are in violation of  Head Start program standards  if they do  
not report an incident as  soon as practicable or  if they  fail to report the incident  at all.   
From our review of monitoring report narratives associated  with these adverse 
findings, we identified  202  individual incidents  that were not promptly  reported  to the  
proper authorities  as required.   Of these, 78  percent had not been appropriately  
reported to ACF, and 22  percent had not been appropriately reported to State or local  
authorities.  Many  of these incidents violated the Head Start standards because the 
recipient did not report the incident as soon as practicable,  which OHS central office 
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staff explained is generally interpreted as 3 to 5 days.  However, in nearly  one-third of  
cases, the  recipient failed  to report the incident at  all.  
Exhibit  5:  Examples of  incidents of failure to report  
[A]n incident occurred in which a  child was injured and required  stitches due to a lack of  
proper supervision in the bathroom. The Regional Office was not notified of the incident  
by the grantee but was informed of the incident by an anonymous complaint.  
A parent reported  allegations of a teacher restraining a 4-year-old  child...  The Head  
Start Director was  informed of the allegation,  but expressed that  she was  unaware  of the  
need to report the incident  since the child was not injured.  
Source: OIG analysis of Federal Head Start monitoring reports, 2022.  
ACF  staff explained that they learn of most  incidents  of  child abuse, lack of  
supervision, and unauthorized release  through recipient  self-reporting.  However,  
incidents  are also reported through other sources, enabling ACF to identify recipients 
failure to self-report.   For example,  ACF operates a hotline that  parents  and 
community members  can  use to alert ACF to possible child  abuse or other safety  
concerns.   ACF  staff stated that they  also learn of  nonreported incidents  during  
monitoring reviews  and  through media reports regarding allegations of  abuse.   In 
reviewing narratives associated with adverse findings for reporting  failures, we found  
that  some  incidents  were discovered  when ACF became aware of State child care  
licensing  violations  or CPS  reports  involving Head  Start recipients,  although the ACF  
staff we interviewed  did not  characterize this as a  routine source of information.  
OIG  identified  130 additional incidents  of  child abuse,  lack  of  
supervision, and  unauthorized  release  in Head Start centers  in 
2  States  that  were  never  reported to ACF  
Federal monitoring data  reflect  only the  incidents  of which ACF is aware.  To  
determine whether  additional incidents  occurred that were never reported  to ACF,  
OIG reviewed data from  Texas and Florida  State agencies that oversee child care 
settings, including Head Start centers.   Specifically,  we obtained  data on  child care 
licensing  violations and substantiated reports  of abuse and neglect from these two  
States child  care licensing and CPS  agencies, respectively.   We then reviewed these  
State records  to identify  incidents  of  child abuse,  lack of  supervision, or  unauthorized  
release  that occurred in Head Start centers  from January  1, 2017,  through December  
31, 2019,  and then reviewed Federal monitoring  data to determine whether  these 
incidents  were  also  present in the Federal data.   For any incident that did not appear  
in the Federal data,  we consulted ACF to confirm  whether ACF  was aware of the 
incident.  
From  our analysis,  at least  130 incidents  of  child  abuse,  lack of supervision, or  
unauthorized release  occurred  in Head Start  centers in  Florida and Texas  that were 
never  reported to ACF.  In Florida, we  identified 41  incidents; of these,  16  involved  
child  abuse,  23  involved  lack of  supervision,  and 2  involved  unauthorized release.   In 
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Texas, we identified 89 incidents; of these,  82  involved  child  abuse,  6  involved  lack of 
supervision,21  and 1  involved  unauthorized release.   OIGs figures represent the 
minimum  number of incidents in these two States of which ACF  was unaware; the true 
number may be higher.   Specifically,  because of  challenges  identifying Head Start 
centers in the State records through address matching, and our exclusion of all Texas  
licensing violations involving supervision,22  it  is likely that we did not identify every  
incident in a Head  Start  center in these two States.    
Without knowledge of these incidents, ACF may have been limited in its ability to  
ensure the safety and quality of  care that  children received in Head Start  centers.   The 
incidents  we identified in State data  that recipients had  not reported to ACF  included  
physical and sexual abuse;  severe and humiliating punishments;  and injury resulting  
from lack of supervision.  Furthermore,  we identified 22  recipients who received  
multiple State  citations  or reports but  for which  the Federal monitoring data  had no  
record of any related performance issues.    
Head Start grant recipients are not required to report  to ACF incidents  in  which 
the victim is not  a child funded by  Head Start  
OIG shared  with ACF  information  about the  incidents  we identified, and ACF  reported  
that it is determining the appropriate followup actions.  ACF staff also  noted that  
some Head  Start centers operate blended classrooms,  which  include children funded  
through Head Start as well as children funded through other  sources.   ACF staff 
explained that recipients  are not required to report to ACF  significant health and  
safety  incidents that affect only  children who are not funded by Head Start.  This is  
true even if the incident  occurs in a blended  classroom that  also  includes Head  Start  
enrollees.23    
ACF does not  routinely  communicate with State agencies about incidents  in  
Head Start centers involving  child abuse, lack  of supervision, or unauthorized  
release   
OHS  central  office  staff  reported  that  ACF  does not routinely  communicate with  State  
child care licensing  or CPS  agencies  about  incidents of  child  abuse, lack of 
supervision,  and unauthorized release in Head Start centers.   Four of the five OHS  
regional offices  that OIG interviewed similarly reported no  routine communication  
with these State agencies.  One OHS  regional office reported more frequent  
communication, noting that its office obtains  information about  maltreatment and 
neglect  incidents directly from State agencies, when necessary,  by working  with  its  
Head Start State Collaboration Office Director.    
   
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Head  Start grant recipients  failure  to  report child abuse,  lack  of  
supervision, and  unauthorized  release  may  reflect  confusion 
about  reporting  requirements  as  well as  weaker  consequences  for 
violating these requirements  
Head Start grant recipients may not fully understand the reporting requirements  
The Head Start standards require that recipients report to ACF immediately or as  
soon as practicable  any  significant incidents  affecting Head Start participants health 
and safety.  ACF  central office  staff explained to OIG that  generally,  this requirement  
is  interpreted to mean that an incident should be reported  within  3 to 5 days of  its  
occurrence.   In 2015, ACF issued written guidance to recipients stating that  incidents  
of unsupervised  children should be reported to the regional office within 3  days of  
the incident.24   However, ACF has not issued  written guidance to recipients  to similarly  
clarify  the  reporting timeframe  for incidents in which a child  was abused or released  
to an unauthorized person.  Similarly, ACF has not  issued written guidance to  
recipients providing details or examples of the types of  incidents  they  should  report.25    
In some cases, recipients  with adverse findings  for  failure to report  told ACF that they  
had misunderstood the requirements, including confusion  about  the reporting  
timeframe and the types  of  incidents  that must be reported.   Additionally, some  
monitoring narratives described recipients that reported incidents to appropriate 
State or local authorities but failed to report the same incidents to ACF.  Other  
narratives noted that the recipient attributed its  failure to report to the fact that it  had 
already taken steps internally to address the incident.   
Exhibit  6:  Examples of  explanations that recipients provided to ACF to explain  
their failure to report  incidents as required  
Failure To Report a Child  Left Unsupervised: The grantee informed  the Program  
Specialist it was waiting to  collect all supporting documents before reporting.  
Failure To Report Child Abuse: [T]he  Head Start Director reported she was not  aware  
that she needed to make a  report to the Office of Head Start.  
Failure To Report  Unauthorized Release of a Child: The grantee stated they did not  
believe this was an incident that required reporting.  
Source:  OIG analysis of Federal Head Start monitoring reports, 2022.  
Consequences for  failing to report an  incident  are  usually  less severe than  the  
consequences for the  incident itself  
Of  all adverse findings for  failure to report  during  the period of OIGs review,  
87  percent  were classified  as noncompliances  and 13 percent  were classified  as 
deficiencies.   Failure-to-report  violations were often cited as a noncompliance even 
when the originating incident was itself  cited as a  deficiency.   ACF  informed  OIG that 
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it  does  not have written criteria for classifying a  failure-to-report  finding  as a  
deficiency  or a  noncompliance.  ACF also stated  that failure to report is typically  
classified as  a noncompliance  but that  such citations may be elevated to a  deficiency  
on a  case-by-case basis,  based on the severity of  the incident or length of  time it took  
the recipient  to report the incident.    
Until late 2020, under the DRS,  a single deficiency finding within a recipients 5-year  
project period  would force the recipient  to  recompete for grant renewal.  ACF staff  
suggested  that the  DRS  may  discourage  recipients from  reporting, because the 
recompetition process is onerous and  could result in the recipient failing to be 
renewed.  Staff noted that in late 2020,  the DRS  criteria were altered such that two  
deficiencies  (rather than just one) trigger  recompetition and expressed that this  
change might improve reporting.   
However,  under  the current  DRS  criteria,  and given typically lesser  consequences for  
failure to report,  recipients  still have an incentive to  withhold information  about  
significant  incidents.   Recompetition  for funding renewal  is triggered by two  
deficiencies.   If a  recipient does not report an  incident  of (for example) leaving a child  
unsupervised,  it may never come to ACFs attention, and the recipient will avoid  the 
possibility of  receiving  a deficiency  for that incident.   On the  other hand, if  ACF learns  
of the incident  through other means, the recipient  may  receive a deficiency  finding  for 
the supervision incidentbut will  likely  receive only  a noncompliance  finding  for 
failure to report.   In this scenario,  the recipient is  not significantly worse  off  than if  it  
had properly  reported the incident to begin with,  because the additional 
noncompliance  finding  for failure to report does  not  trigger  recompetition.    
Head Start grant recipients most  often addressed  incidents  of  
child abuse, lack of supervision,  or unauthorized  release  
through a combination of disciplinary action, administrative  
improvements,  and training  
Following an adverse finding  for child  abuse,  lack of supervision, or  unauthorized  
release, the recipient  works with the appropriate OHS  regional office  to determine the 
necessary steps to correct the finding.  This may include developing a  corrective 
action plan or quality improvement plan, depending on the finding.26   ACF staff 
reported to OIG that corrective actions should  not be limited to staff termination but  
should also  address the root cause of  the  incident to reduce the likelihood  of  similar  
incidents in the future.    
For 81 percent of all incidents  of  child  abuse,  lack of supervision, or  unauthorized  
release  in our review, recipients took disciplinary action against the staff member(s)  
involved, including written warnings, administrative leave, suspension,  or terminating  
employment.  Staff  were terminated or resigned in response to  75 percent of  
incidents  of child  abuse, 41  percent of incidents of  lack of  supervision,  and 52  percent  
of incidents of unauthorized release.  ACF staff noted that recipients are responsible 
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for developing their own human resources  and  standards of  conduct policies,  
including determining when termination or other personnel actions are appropriate.  
Recipients also  commonly implemented administrative improvements and  staff  
training as part of their corrective actions to  address  incidents  of child  abuse,  lack of 
supervision, or unauthorized release.   For example, recipients reported revising their  
operating procedures by  creating  clearer and more prescriptive supervision and  
standards of conduct policies.  Recipients also responded to incidents by increasing  
classroom monitoring through in-person visits or  video cameras, as  well as  by  making  
facility improvements, such as installing alarms and physical barriers to  prevent  
children from leaving the facility  without supervision.   Finally, recipients reported  
providing staff training on current and new policies, including instituting mandatory  
trainings.    
 
Exhibit  7:  Examples of  corrective  actions  that Head Start grant recipients took  to  
address  incidents of  child abuse  and  lack of supervision  
Incident: Child  Abuse   Incident:  Leaving a Child  Unsupervised  
A  child was lying on the floor while the   A child  exited  the  center without shoes.   
teacher dragged him by one arm down   The child walked through the parking lot  
the hallway.   and onto the  sidewalk where he was  
picked up and returned  to the center by a  
 
passerby in a car.   The child had a history  
of leaving unsupervised.  
 
Removed teacher  from service on  day of   Provided intensive guidance and retraining  for 
incident, terminated 1 day later   teachers involved  
Conducted announced and unannounced visits   Updated the  Child Health History form to  
by supervisors, education staff, and mental  include more information on  each childs  
health providers    behaviors  
Installed video cameras   Installed alarms on classroom  doors   
Implemented  new  child supports  such as   Seated Family  Advocates at main doors   
social-emotional skill building activities,  fidget  
Installed whiteboards in each classroom to be  
manipulatives,  soft seats to help strengthen 
updated when each child arrives/departs  
core and focus, and motion bottles for self-
soothing   Directed center management  to monitor  
classrooms monthly,  conduct  teacher-coach  
Implemented  new  staff supports  such as  
classroom observations twice monthly,  and 
coaching on child communication strategies  
conduct unannounced classroom observations  
Held training for staff on standards of  conduct,   twice annually;  arranged for  State licensing 
child abuse and neglect, Right Response   consultant to make  unannounced site visits  
Toolkit, Child-Adult Relationship Enhancement,  
Created  Active Supervision and Accountability  
mental health, and dealing with challenging 
checklists  used  by staff  
behaviors  
 
Created training video library  for  staff  
Source:  OIG analysis of Federal Head Start monitoring data, 2022.  
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ACF conducts followup reviews to ensure that recipients complete their corrective 
actions  within the specified timeframe.  In the case of  an  adverse finding  for  child  
abuse,  lack of supervision, or unauthorized  release, a recipient typically must correct  
the finding within 30 to 120 days.27   ACF reported that its followup reviews include 
reviewing  documentation  of  corrective actions  (e.g.,  policies and procedures, training  
logs); when necessary,  ACF may  also conduct  site visits and interviews.   From our  
review of monitoring data,  OIG did not identify  any  adverse  findings  for  child  abuse,  
lack of supervision,  or unauthorized release  that  recipients  had failed to correct 
through ACFs corrective action process.28  
ACF requires a  recipient to recompete  for funding renewal  if it receives two or more  
deficiency findings, even if the deficiencies  are corrected.   Recompetition is a  
demanding process that  requires the recipient to  demonstrate that it remains the  
best-qualified entity to provide Head Start services.   From October 1,  2015, through 
January 6, 2022, ACF required  459 recipients to  recompete for funding renewal.   Of 
the  302  recipients with at least  one  deficiency  finding  for child  abuse,  lack of 
supervision, or unauthorized release  during the period of OIGs review, 68 percent  
had recompeted  for funding  renewal  as of  January 6, 2022.  
In contrast, ACF has rarely used its suspension and  termination authorities.  From  
October  1, 2015, through January 6,  2022, ACF suspended six recipients and  
terminated seven recipients for any reason.29     
ACF  uses monitoring data to  target  training and technical  
assistance  regarding  childrens safety in Head Start centers  
ACF provides recipients  with training and technical assistance to support  compliance 
with Head Start standards.   Both OHS  central office  and regional office  staff reported 
using monitoring data to identify training needs, including training about  child abuse,  
supervision,  and  safe  release  of  children.   For example, staff from one OHS  regional 
office  explained that,  based on the  health and safety incidents  they observed among  
recipients in their region, the  office had  developed a training program involving  
monthly  check-ins  with  recipients  to discuss challenges  related to childrens safety  
and identify systemic improvements to better protect children.   Another OHS  regional 
office  described initiating Statewide trainings  on child maltreatment after noticing an 
uptick in incidents.   ACF also uses monitoring data to  prioritize  technical  assistance  
for  recipients  with adverse findings.  
Some  OHS regional  offices  have developed  data systems  and  
procedures  to  better track  and  respond  to  incidents  of  child 
abuse, lack  of  supervision, and  unauthorized  release  
ACF does not  centrally  track individual incidents  of  child  abuse,  lack of  supervision, or  
unauthorized  release.   Instead, ACF  tracks  violations  of  Head Start standards  at the  
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finding  level:   during a review,  a  recipient  receives  a  single adverse  finding  for each  
standard it is found to have  violated.   A single  adverse  finding  may  be based on one 
or many individual incidents  related to the same standard.    
Information about individual incidents  associated with an adverse finding  is included  
in the  monitoring report  narrative.   In reviewing narratives  associated with adverse  
findings for  child  abuse,  lack of  supervision,  and  unauthorized  release,  we found that  
most  findings  were based on  a single incident.   Overall,  the number of  incidents  
involved in a single adverse  finding ranged from 1 to  21  incidents.   We also noted  
variation in  narratives  format and level of detail.    
Exhibit  8: Example of a Head Start  monitoring  report  narrative  describing 
multiple  incidents  
[T]here  were four maltreatment incidents between June 2018 and October 2018...  
Incident One: On June 12, 2018, a teacher grabbed  a 21-month-old child by the arm and  
shoved him against the wall, injuring the toddler.  Incident Two: On June 12, 2018, a  
teacher grabbed  a 23-month-old child by the  arm while she was  cleaning up  after painting. 
There was water on the sink and floor, causing the child to slip when she was grabbed by  
the teacher.   The  child hit her head on the sink, causing an injury.  Incident Three: On June  
28, 2018, a teacher slapped  a 21-month-old child in the face  after repeatedly  asking the  
child to stop hitting others... Incident Four: On October 2, 2018, a student teacher observed  
a teacher firmly grab  a child's wrist... and told him to wash his hands. When the child was  
washing his hands and appeared to be playing in the  water, the teacher grabbed his arm, 
swung him around, and swatted him on the behind. The child began crying.  
Source:  OIG analysis of Federal Head Start monitoring data, 2022.  
Staff from three  OHS  regional offices  indicated that the current  monitoring data  
meets their  oversight needs  without tracking  individual  incidents.  However, two of  
the five OHS  regional offices  we interviewed reported that they had developed  
supplementary  internal data systems to track individual incidents within their region.   
Staff reported that these  supplementary tracking systems  helped  them  examine 
trends in the nature and  number of  significant  incidents  and develop actions to  
support recipients  efforts to ensure childrens safety.    
Some OHS  regional offices  also  reported that they had created additional procedures  
to better address  these types of  incidents  within their region.   For example, one 
regional office  established  a dedicated team that meets  weekly to discuss  significant  
incidents.  Another  regional office  developed a  standardized  list of questions to  
gather  information about incidents; staff reported that  this  tool  aided  them  in  
collecting  consistent  data  about  incidents that threaten childrens safety.    
 
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CONCLUSION AND  RECOMMENDATIONS  
All Head Start grant recipients are required to adhere to Head Start standards,  which 
include  standards that prohibit child abuse, leaving a child unsupervised,  and  
releasing a child to an unauthorized person.   To identify violations of these standards,  
ACF relies primarily on recipients self-reporting  of significant  incidents.  However,  
OIG found that recipients do not always report these incidents to ACF as required.  In 
some cases, ACF only learns  that a child  in a Head Start center  was abused,  left  
unsupervised, or released to an unauthorized person long after the incident occurs.   
In other  cases, ACF never learns of an incident at all.  Our review identified at least  
130  incidents  of  child  abuse, lack of supervision, and unauthorized release  over  
3  years in just  2  States  that had never been reported to ACF.  
Accurate information about  incidents that threaten childrens safety  is critical for  
effective oversight.   ACF  reported that it uses monitoring data to identify training 
needs and target technical assistance to  Head Start grant recipients to better  prevent  
child  abuse,  lack of supervision, and unauthorized release.   ACF also reported that  
when it does learn of an  incident  of this nature, it  works  closely with  the recipient to  
identify and carry out a  comprehensive set of  corrective actions intended  to address 
the root cause of  the incident.   However,  given OIGs findings,  ACFs ability to  
effectively implement these approaches is limited by its lack of  complete and timely  
information.  
To better  protect childrens safety  in  Head Start centers, we recommend that ACF:  
Improve Head  Start  grant  recipients  self-reporting of  incidents  
of child abuse, lack of supervision, and unauthorized release  
through better  guidance and stronger  consequences for  failure  
to report  
ACF should provide recipients with  more  detailed  guidance about  the requirement to  
report  significant incidents that threaten childrens health and safety, which includes  
incidents of  child  abuse, lack  of supervision, and  unauthorized release.   In particular,  
ACF should more clearly  specify the reporting  timeframe  and provide examples of the 
types of incidents that must be reported.   ACF should then provide additional training  
and technical assistance to ensure that recipients clearly understand the requirement.   
Head Start programs  may  also  benefit from  regularly  recurring training on these  
important  requirements.    
ACF should  also impose stronger consequences for  failure to report.  Currently, 
citations  for failure to report are typically classified as a  noncompliance  rather than as  
a deficiency.  ACF should establish specific  criteria for circumstances under which it  
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will classify failure to report  as  a deficiency, just as it has established similar criteria for  
citations  involving  child  abuse,  lack of supervision, and unauthorized  release.   For  
example,  ACF  should consider  classifying  failure to report  as a deficiency  when 
multiple incidents were not reported or  when the unreported incident itself results in 
a deficiency  finding.   Given that  a recipient must recompete for funding if it receives  
two deficiencies,  this  change  could encourage recipients to  report  incidents  rather  
than risk an additional  deficiency  finding  by  withholding  information that ACF  could  
later discover.  
Extend the reporting requirement to include incidents of  child  
abuse, lack of supervision, and unauthorized release  in blended  
classrooms in which the victim is not a Head  Start-funded child  
Some  recipients operate blended  classrooms  that  serve children funded by  Head Start 
together  with  children  funded through other sources.  Currently, a recipient is not  
required to report an otherwise reportable incident if the victim is not a Head  Start-
funded childeven though  an incident  of  child  abuse, lack of supervision, or  
unauthorized release clearly reflects a danger to  Head  Start-funded children in the 
same blended classroom.   ACFs oversight approach  relies in part on information 
about  the number  and nature  of  incidents  that have occurred at Head  Start centers  
operated by each recipient.   Without complete information about  all incidents, ACF 
may erroneously believe that a problem is more limited in scope than is in fact the 
caseor may be unaware that a safety problem exists at all.    
To protect  childrens safety, ACF  should  take the necessary steps  (such as issuing new  
program guidance  or revising regulations, depending on its  assessment of its 
authorities)  to  seek full transparency regarding  incidents of child abuse, lack of  
supervision, and unauthorized release  that occur in any Head  Start center,  regardless  
of  whether the individual victim is a Head Start enrollee.   This additional reporting  
would better inform ACFs determinations about  whether and what training, technical  
assistance, or other  actions are necessary to prevent future incidents and ensure the 
recipients compliance with these critical Head  Start standards.  
Improve  data-sharing with States  about  incidents  of  child abuse,  
lack of supervision,  and  unauthorized release  in Head Start  
centers  
OIG was able to identify incidents  of  child  abuse, lack  of supervision, and  
unauthorized release of which ACF was not aware by reviewing  data from  child care  
licensing and  CPS  agencies in two States.  This suggests that State data  could be a  
useful source of information to help ACF identify incidents that recipients fail to self-
report.   As noted above,  such information is critical to support effective ACF oversight  
of recipients.  
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To improve its access to information about  childrens safety,  ACF should develop 
data-sharing agreements with States  regarding incidents  of  child abuse,  lack of  
supervision, and unauthorized release at  Head Start centers.   ACF  should consider  
leveraging the Head Start  State Collaboration Offices  for this purpose.   OIG notes that 
information-sharing need not include child victims personally identifying information;  
the Head Start center location, date, and general  nature of the incident is sufficient to  
enable ACF  to  follow  up with the recipient.   Additionally,  many States make child care  
licensing reports publicly available online;  ACF should explore methods to  
systematically  retrieve and search these materials  as they pertain to Head Start  
centers.    
Disseminate  information about  innovative practices  that  OHS  
regional  offices  have developed  to better identify and prevent  
incidents  that threaten childrens safety   
We found that some OHS  regional offices  have implemented  innovative methods  to  
track and respond to  incidents of  child  abuse, lack of supervision, and unauthorized  
release  in  Head Start  centers in their regions.  For  example, some OHS  regional offices  
reported practices such as creating a supplemental data system to better track  
incidents at the child level and establishing a dedicated response team that meets  
routinely  to discuss incidents  in  Head Start centers within the region.   ACF should  
foster information-sharing across OHS  regional offices  so that  these and other  
innovative practices  can be shared and exchanged.    
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AGENCY  COMMENTS AND OIG  RESPONSE  
ACF concurred  with all four of our recommendations.  ACF stated that it will take both 
immediate and long-term steps to improve child safety in the Head  Start  program.   
ACF provided examples  of  how  it  will improve oversight and monitoring of Head Start  
grant recipients to better address incidents of child safety.      
Regarding our first recommendation, ACF described  steps to improve recipients 
reporting  of  incidents of  child abuse, lack of supervision, and unauthorized  release.   
For example,  ACF stated that in August 2022,  the agency  provided  recipients with  
letters of guidance and  webinars  about  Head Start reporting requirements.  In 
addition, ACF stated that  it  will provide ongoing training and technical assistance 
resources for these requirements.  
Regarding our second recommendation, ACF  agreed that its current protocol leaves  
OHS unaware of  important  safety information.   ACF stated that it does not currently  
have authority to fully implement  OIGs  recommendation but will explore options to  
extend its reporting requirements.   ACF also stated that while exploring those options,  
it  will take immediate steps to increase training and guidance to  clarify  reporting 
requirements  as they apply to  blended classrooms, such as providing guidance that  
the reporting requirement applies  to incidents involving Head Start  staff, contractors,  
and volunteers in all Head Start and Early Head Start settings, including blended  
classrooms.    
Regarding our third recommendation, ACF stated that it  will take a tiered approach to  
improving data-sharing with States.  As a first step, ACF will examine publicly available  
State child care licensing  reports in the 20222023 program year.  ACF  will also  
explore additional ways to get information  from States  about  child safety  incidents,  
including creating data-sharing plans  with States.   
Regarding our fourth recommendation, ACF described  steps to disseminate 
information about  innovative child safety  practices across Head Start regional offices.  
For example, ACF stated  that program managers  from the regional offices  currently  
meet on a weekly basis to  collaborate and  share information.  ACF  also stated that it 
will consider more formal structures for sharing innovations across regional offices, 
such as  analyzing  trends and  technical  assistance activities.   
OIG appreciates ACFs  commitment to protect  children from incidents  of child abuse,  
lack of supervision,  and unauthorized release  while in the care of  a Head Start center.    
For  the  full text of ACFs  comments,  see  Appendix B.  
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DETAILED  METHODOLOGY  
To  determine the extent to which Head Start grant recipients received  adverse 
findings from ACF for violating program standards that prohibit child abuse, leaving a  
child unsupervised, and releasing a child to an unauthorized person, and to assess 
ACF oversight of recipients compliance with these standards,  we used mixed methods  
to analyze Federal monitoring data, State monitoring data,  Federal administrative  
action data,  interviews, written responses, and documents.    
Data Sources  
This review combined data from the following sources:   
Federal Monitoring Data.  We reviewed OHS data  on  recipients monitoring review  
results from October 1, 2015, through May 11, 2020  (i.e., from the beginning of fiscal  
year 2016the year the current  Head  Start performance standards  went into effect 
to the start of this studys data collection).   These data  included  identifying  
information for each recipient (e.g.,  name, address, etc.); the dates of each review;  
regulatory  citations for  each adverse finding  identified during  the  review;  the level of  
adverse finding (deficiency or noncompliance); the status of each finding (new,  active,  
corrected,  or  not corrected); and narrative fields detailing  the  incidents and reasons 
for the review  results and corrective actions taken by the recipient.  
Program Information Report  (PIR) Data.   Recipients report PIR data annually.  We used  
PIR data for the 2018-2019 program  year (the  most recent  available at the  time of  
analysis) to obtain a list  of recipients and each recipients location, program type,  
number of  children the recipient is funded to serve,  and ACF regional affiliation.   We 
identified 6 recipients  with adverse findings during the period of review who were not  
on the 2018-2019  PIR recipient list; we removed these  6 recipients  from our analysis.  
OHS Center List.   We requested from  OHS the  names and addresses  of each  Head  
Start center  operated  by recipients.    
State Data.   To  gain further insight into the extent to which ACF reliably receives  
information about all  incidents  of  child abuse, lack of supervision, and unauthorized  
release, OIG reviewed data from  two  States  agencies that oversee child care settings,  
including Head  Start centers.   We purposively selected two States, Texas and Florida,  
based on representation of multiple types of Head Start programs, multiple ACF  
administrative regions  (OHS  regional offices  4 and 6), urban and rural populations,  
and ability to provide  data.  We requested the following from each State:   
   State  CPS Data.   From the  two  selected States, we  requested all substantiated  
abuse and neglect reports for children in the care of a child care facility  for  
calendar  years 2017 through 2019.   These data  included the child care facilitys  
name and address, the date of the report,  and descriptive information about  
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the abuse or neglect incident.  We did not request or receive identifying  
information about individual children.  
   State  Child Care Monitoring Data.   From the two selected States,  we requested  
child care monitoring data for all licensed  child care facilities for  calendar years  
2017 through 2019.   These data included the child care facilitys name and  
address, the date of the States review, the licensing violation, and descriptive 
information about the violation.  We did not request or receive identifying  
information about individual children.  
We requested State data  for calendar  years  2017 through 2019 because this range 
provided a  3-year subset of the broader period of Federal monitoring data in our  
review, ensuring that we would be able to identify incidents in the State data that  
were reported to ACF either before or  after they  were reported to the State. 
Interviews with Selected  OHS Staff.   We conducted  a  panel  interview with OHS  central  
office  staff and  five panel  interviews with staff from selected OHS  regional  offices  
(Regions  1, 4, 6,  11,  and 12).   We purposively selected these five OHS regional offices  
to capture variation in key regional and programmatic features  (e.g.,  geographic  
location, program types)  and to ensure we met with regional offices responsible for  
the largest number of  children potentially  at risk  of harm (e.g.,  overall number of  
children served  and overall number of incidents  of  child  abuse, lack  of supervision,  
and unauthorized release).  Specifically,  Regions 4  (serving Kentucky, Tennessee,  
North Carolina, South Carolina, Georgia, Alabama, Mississippi, and Florida)  and 6  
(serving New Mexico, Oklahoma, Arkansas, Louisiana, and Texas) serve large numbers 
of  children  and had the highest number of  incidents  during the period of review.   
Region  1 (serving Maine, New Hampshire, Vermont, Massachusetts, Rhode Island, and  
Connecticut) was  among  the smallest regions,  serving a  smaller  number of  children.   
Regions 11 and 12  oversee  Head Start programs  nationwide that serve children and  
families in  American Indian and Alaska Native  communities  and migrant and seasonal  
communities, respectively.   We  also submitted questions in writing to OHS and 
received written responses. 
OHS Procedural and Training Documents.   We  requested from OHS  documentation on  
written policies, procedures, and training materials related to identifying and  
addressing incidents of child abuse, lack of supervision, and unauthorized release; 
reporting requirements;  and determining whether a violation will be classified as a  
deficiency or  a noncompliance.  
OHS  Administrative Action  Records.   We requested from OHS  documentation about  
recipients that  were subject to suspension, termination, and/or recompetition for  
renewal of funding  under  the DRS  from October  1, 2015, through January 6, 2022.    
   
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Data Analysis  
Identifying and  Categorizing  Head Start Grant  Recipients  
We analyzed  PIR data to  obtain a list of Head Start recipients.   To do so,  we defined a  
recipient  as an organization operating in a unique State that oversees one or more 
individual Head Start center(s) and received one or more grants  directly  from  ACF to 
provide Head  Start services.   We removed all recipients with no funded enrollment for  
the 2018-2019 enrollment year.  Through this process, we identified 1,611 unique 
recipients; collectively, these recipients operate approximately 20,000  Head Start 
centers.  We  also used PIR data fields to identify the type(s) of Head Start programs  
each recipient operated (i.e., Head Start;  Early Head Start;  AI/AN  Head Start;  and 
Migrant and  Seasonal Head Start)30  and the recipients ACF regional affiliation 
(1  through 12).    
Analysis of Monitoring  Data  
We identified regulatory citations in both the 2009 and 2016 Head  Start program  
standards that are related to  child abuse,  lack of supervision, unauthorized release,  or 
failure to report significant incidents.   (Although the current  standards went into  
effect  in 2016,  ACF sometimes cited to the 2009 version  of the standards during the 
early part  of our review period; the 2009 and 2016 standards are not substantively  
different  with regard to  the types of incidents included in our review.)   Please see 
Appendix A for a  detailed  list of  all  Head Start program  standards included in our  
review  and how they align with these categories.  
To  determine the extent to which recipients  received adverse findings from ACF for  
violating these  Head Start standards,  we analyzed  Federal  monitoring data  for 
October 1,  2015,  through May 11, 2020.  This dataset lists all adverse findings  
associated with each recipient.  We  identified  and summed  the number of  unique 
adverse findings (noncompliance or deficiency) for  each of the four citation categories  
in our review  (i.e.,  child abuse,  lack of supervision, unauthorized  release, and failure to  
report).   To  confirm the accuracy of the citation, we also  reviewed the monitoring  
report narrative associated with each adverse finding.   Then,  we calculated  the 
number and percentage of  adverse findings in each  of the four  citation categories, as 
well as the number and percentage of recipients with such findings.  We also analyzed  
review dates  to identify recipients with child abuse, lack of supervision,  or 
unauthorized release  findings in separate fiscal years.  
To  further  categorize  these violations,  we  conducted  qualitative analysis of each 
report narrative  to identify and classify  each child  abuse, lack of supervision,  
unauthorized release,  and failure-to-report incident by its subcategory.  The incidents  
were categorized as follows:  
   physical abuse  and/or corporal  punishment, emotional and/or verbal  abuse,  
other prohibited disciplinary practices,  or sexual abuse;  
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   child left unsupervised  on the grounds of the Head Start facility, outside the  
Head Start facility, or  on  a bus;  
   release of a  child to an unauthorized person  from the facility or  from a bus;  
and  
   failure to report an incident  to ACF or to State  or  local authorities as required,  
including  not reporting the incident as soon as practicable or not reporting  
the incident at all.     
Then, we identified the number of individual incidents associated  with the finding.   
We defined an incident as a unique child-date combination.  For example,  a child  
left unsupervised on four  separate dates was treated as four  incidents,  and three 
children subjected to  child abuse on the same date was treated as three incidents.   
We summed  these counts  to identify the number  and percentage of incidents related  
to  each category  (e.g.,  child abuse)  and subcategory  (e.g., physical abuse and/or  
corporal punishment), as well as the number and  percentage of recipients  with such 
incidents.    
To  determine the status  of adverse findings,  we manually  matched  each citations  
record  with its followup record  where necessary  (due to a change in ACF process  
partway through the dataset, some records  included  followup  action  information  in  
the same entry  as the original citation, whereas  others had separate followup records).   
We determined the number of adverse findings listed  as "new or  active  
(i.e.,  currently in the corrective action process);  corrected;  or  not corrected.   We 
also calculated the number and percentage of individual incidents associated with 
adverse findings of each status.    
To describe corrective actions that recipients took  to address incidents of  child  abuse,  
lack of supervision,  or unauthorized release,  we conducted qualitative analysis of each 
report narrative to identify and  categorize actions  as follows:   
   disciplinary actions against  staff,  including written warnings; administrative 
leave; suspension;  and termination of staff;  
   administrative improvements, including  revised policies and procedures;  
updated monitoring procedures (e.g., in-person or video classroom  
monitoring); and  facility improvements (e.g., installation of alarms, installation  
of  physical barriers to  prevent  children  from leaving the facility  without  
supervision); and  
   staff training.  
We calculated the percentage  of incidents  addressed through each category of  
corrective action.   We also  calculated the percentage  of incidents  for  which the 
involved staff member  was terminated or resigned.    
   
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Analysis of Data on ACF Administrative Actions   
To determine the extent to which ACF used administrative authorities,  we requested  
and reviewed data on  recipients  termination,  suspension, and  recompetition  from  
October  1, 2015 through January 6,  2022.   We requested administrative actions for  
this date range to ensure that we captured all actions taken during the period of  
monitoring data  we reviewed (October  1, 2015 through May  11,  2020) as  well as  
actions taken more recently, given that the administrative processes involved may  
take months or years to  complete.  
We summed the number of recipients that  were terminated, suspended,  and/or  
required to recompete for  funding renewal  under the DRS.   We also compared our list  
of recipients  with deficiency  findings for  child  abuse, lack  of supervision, or  
unauthorized release to the recompetition list to  calculate  the percentage of such 
recipients  who had been required to recompete.       
Analysis of State Data  
To determine whether all  incidents  of  child  abuse, lack  of  supervision, and  
unauthorized release are reported  to  ACF, we requested data on child care licensing  
violations and substantiated CPS  reports from Texas and Florida  for calendar years 
2017 through 2019.   To  match the State and Federal monitoring data,  we identified  
Head Start centers by geocoding addresses in both the State data  and  the  OHS  
Center List  (which contains  all center names  and addresses, as well as their associated 
recipient organizations).   We further  confirmed  all matches through manual review of  
the center names.    
Next, we  identified  incidents  in these State datasets that described  child  abuse, lack of 
supervision,  or unauthorized release.   To do so, we reviewed the  citation descriptions  
and narrative fields to identify  those that reflect actions  that are prohibited under the 
Head Start standards included in our review (child abuse,  lack of supervision, or  
unauthorized  release).  We collected additional  procedural and regulatory information 
from the State agencies  where needed to make accurate determinations.  
We then manually compared the date and description of each incident in the State 
data to all incidents associated  with the recipient in the Federal  monitoring  data.  We  
summed the number of incidents of each type (child  abuse, lack  of supervision,  
unauthorized release)  that were present in a State dataset but were not present in the 
Federal monitoring data,  as well as the number of  recipients with such incidents. We  
provided to OHS a list of  incidents we identified that had not been previously  
reported to ACF.  
   
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Interviews and Written Responses  
We conducted  a thematic  qualitative analysis  of  interview responses from  our panel  
interviews with staff from OHS  central office  and five OHS  regional offices.   We also 
analyzed  OHS  written responses to questions.      
Document Review  
We reviewed policy, procedural, and guidance documents to identify processes and  
criteria for monitoring, incident response, and adverse finding determinations.   
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APPENDICES  
Appendix A:   Head Start Program Standards  Included in 
OIGs  Review  
This table lists Head Start program standards that ACF  cited  in  one or more  adverse findings  
involving  child abuse, leaving a child unsupervised, or releasing a  child to an unauthorized  
person  from October  1, 2015, through May 11, 2020.   The current  Head Start program  standards  
went into effect in  September 2016; however, ACF sometimes cited to the 2009 version of the 
standards during the early part of our review  period.  
Type of Violation   Head Start Program Standard   Head Start Program  Standard Text  
Regulatory  Citation  
  45 CFR    1304.52(i)(1)(iv)   [S]taff, consultants, and volunteers...  will use  
Child  Abuse    (October 2009)   positive methods of child guidance and will not  
engage in corporal punishment, emotional or  
physical abuse, or humiliation. In addition, they  
will not employ methods of discipline that involve  
isolation, the use of food as punishment or  
reward, or the denial of basic needs  
45 CFR    1302.90(c)(1)(ii)(A-I)   Ensure  staff, consultants, contractors, and  
(September 2016)   volunteers do not maltreat  or endanger the health  
or safety of children, including, at a minimum, that  
staff must not:  
(A) Use corporal punishment; 
(B) Use isolation to discipline a child;  
(C) Bind or tie  a child to restrict movement or tape  
a childs mouth;  
(D) Use or withhold food as a punishment or  
reward;  
(E) Use  toilet learning/training methods that  
punish, demean, or humiliate a child;  
(F) Use any form of emotional abuse, including  
public or private humiliation, rejecting, terrorizing,  
extended ignoring, or corrupting a child;  
(G) Physically abuse a child;  
(H) Use  any form of verbal  abuse, including  
profane, sarcastic language, threats, or derogatory  
remarks about the child or childs family; or  
(I) Use physical activity or outdoor time as  a  
punishment or reward  
   
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Type of Violation   Head Start Program Standard   Head Start Program  Standard Text  
Regulatory  Citation  
  45 CFR   1304.52(i)(1)(iii)   No child will be left alone or unsupervised while  
Child Left   (October 2009)   under their  [i.e., staff, consultants, and volunteers] 
Unsupervised1   care  
  45 CFR   1306.35(b)(2)(iv)    Children are supervised at all times. Providers  
  (October 2009)     must have  systems for assuring the safety of any  
child not within view for any period (e.g. the  
provider needs to use the bathroom or an infant is  
napping in one room while  toddlers play in  
another room)  
45 CFR   1310.10(g)   Each agency must  ensure that children are only  
(October 2009)   released to a parent or legal guardian, or other  
individual identified in writing by the parent or  
legal guardian.  This regulation applies when  
children are not transported and are picked up 
from the classroom, as well  as when they are 
dropped off by a vehicle.  Agencies must maintain 
lists of the persons, including alternates in  case of  
emergency, and up-to-date child rosters must be  
maintained at all times to  ensure that no child is  
left behind,  either at the classroom or on the  
vehicle at the  end of the route    
45 CFR   1302.90(c)(1)(v)   Ensure no  child is left  alone or unsupervised by  
(September 2016)   staff, consultants, contractors, or volunteers while  
under their care  
45 CFR   1302.47(b)(5)(iii)   All staff and  consultants must follow appropriate  
(September 2016)   practices to keep children safe during all activities,  
including... [a]ppropriate  indoor and outdoor  
supervision of children at all times  
45 CFR 1303.72(a)(3)   A program must ensure... [u]p-to-date child  
(September 2016)   rosters  and lists of the adults each child is  
authorized to be released to, including  alternates  
in case of emergency, are  maintained and no child  
is left behind, either at the  classroom or on the  
vehicle at the  end of the route  
45 CFR   1302.47(a)-(b)(4)(i)(I)2   All staff with regular child contact  have... training  
(September 2016)   in... [a]ppropriate precautions in transporting  
children  
45 CFR   1303.72(a)(4)   A program must ensure...  [w]ith the exception of  
(September 2016)   transportation services to  children  served under  a  
home-based option, there is at least one bus  
monitor on board at all times, with additional bus  
monitors provided as necessary  
1 
 ACF cited 45 CFR  1310.10(g)  and 45 CFR  1303.72(a)(3) in adverse findings for both child supervision and unauthorized 
release  incidents.  
2  ACF cited  45 CFR   1302.47(a)-(b)(4)(i)(I)  in an adverse finding for leaving a  child alone and unsupervised in a vehicle.   
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Type of Violation   Head Start Program Standard   Head Start Program  Standard Text  
Regulatory  Citation  
  45 CFR   1310.10(g)   Each agency must  ensure that children are only  
Child  Released  To an   (October 2009)   released to a parent or legal guardian, or other  
Unauthorized  Person3   individual identified in writing by the parent or  
legal guardian.  This regulation applies when  
children are not transported and are picked up 
from the classroom, as well  as when they are  
dropped off by a vehicle.  Agencies must maintain 
lists of the persons, including alternates in  case of  
emergency, and up-to-date child rosters must be  
maintained at all times to  ensure that no child is  
left behind,  either at the classroom or on the  
vehicle at the end of the route   
45 CFR   1302.47(b)(5)(iv)    All staff and consultants follow appropriate  
(September 2016)   practices to keep children safe  during all activities,  
  including... [o]nly releasing  children to an  
authorized adult  
 
45 CFR   1302.47(b)(7)(v)   Programs establish, follow,  and practice, as  
(September 2016)   appropriate, procedures for... [m]aintaining  
procedures and systems to  ensure children  are 
only released to an authorized adult  
45 CFR   1303.72(a)(3)   A program must ensure... [u]p-to-date child  
(September 2016)   rosters  and lists of the adults each child is  
authorized to be released to, including  alternates  
in case of emergency, are  maintained and no child  
is left behind, either at the  classroom or on the  
vehicle at the  end of the route  
3 
 ACF cited 45 CFR  1310.10(g)  and 45 CFR  1303.72(a)(3) in adverse findings for both child supervision and unauthorized  
release  incidents.    
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Type of Violation   Head Start Program Standard   Head Start Program  Standard Text  
Regulatory  Citation  
  45 CFR    1302.47(b)(5)(i)   All staff and consultants follow appropriate practices  
Failure to Report  a  (September 2016)   to keep  children safe  during all activities,  
Significant  Incident   including...[r]eporting of suspected or known child  
Affecting Childrens   abuse and neglect, including that staff comply with  
Health and Safety   applicable federal, state, local, and tribal laws  
45 CFR    1302.102(d)(1)(ii)(A)   A program must submit... [r]eports, as appropriate,  
(September 2016)   to the responsible HHS official immediately or as  
soon as practicable, related to any significant  
incidents  affecting the health and safety of program  
participants, circumstances  affecting the financial  
viability of the program, breaches of personally  
identifiable information, or program involvement in 
legal proceedings, any matter for which notification 
or  a report to state, tribal, or local authorities is  
required by applicable law,  including at a minimum:  
(A) Any reports regarding  agency staff or volunteer  
compliance with federal, state, tribal, or local laws  
addressing  child abuse and  neglect or laws  
governing sex offenders   
   
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OEI-BL-19-00560    Appendix A |  32    Appendix B:  Agency Comments 
Office of the Assistant Secretary | 330 C Street, S.W., Suite 4034 
Washington, D.C. 20201 | www.acf.hhs.gov 
September 9, 2022 
Ms. Suzanne Murrin 
Deputy Inspector General 
U.S. Department of Health and Human Services 
330 Independence Avenue, SW 
Washington, DC  20201 
Dear Ms. Murrin: 
The Administration for Children and Families (ACF) appreciates the opportunity to respond to 
the Office of Inspector Generals (OIG) draft report titled ACF Should Improve Oversight of 
Head Start To Better Protect Children's Safety (OEI-BL-19-00560).  Protecting the health and 
safety of children is central to ACFs mission across programs.  
ACF places the utmost priority on child health and safety and appreciates OIGs work to 
identify actions that will improve the Head Start program and better ensure childrens well-
being.  Program rules are designed to support child safety, and the Office of Head Start 
(OHS) expects that any incident will be carefully assessed by the grant recipient and 
appropriate actions will be taken swiftly.  At the same time, ACF is committed to 
continuous quality improvement to enhance oversight of Head Start programs and support 
grant recipients in preventing incidents that jeopardize childrens safety.  
We appreciate OIG utilizing OHS robust data set in its report in order to identify areas we 
can build on our rigorous process and make additional improvement to our system.  ACF is 
committed to implementing the recommendations proposed by OIG as soon as possible and 
identifying additional opportunities to improve OHS approach to protecting young children 
enrolled in Head Start. 
All child safety incidents are unacceptable.  During the 5 year period covered in the report (2015 
to 2020), Head Starts 1,600 grant recipients operated more than 20,000 centers and 
cumulatively served 5 million children.  The OIG report identified 1,029 incidents involving lack 
of supervision, release to an unauthorized adult, and child abuse (defined broadly to include child 
abuse, corporal punishment, derogatory language, or discipline practices prohibited in Head 
Start).  OIG finds that during the 5 year time period reviewed, 27 percent of Head Start grant 
recipients had an adverse finding in one of these categories.  In alignment with these findings, 
further analysis by OHS shows that fewer than one in 1,000 children were involved in an 
incident involving lack of supervision, release to an unauthorized adult, or inappropriate 
discipline or child abuse.  In addition, less than 5 percent of Head Start centers experienced an 
incident involving lack of supervision, release to an unauthorized adult, or inappropriate 
discipline or child abuse.  In response to the incidents referenced in the report, local programs 
took contemporaneous, immediate, and appropriate actions in the vast majority of cases.  
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OEI-BL-19-00560  Appendix B | 33   Deputy Inspector General Murrin  Page 2 
OHS supports and oversees Head Start grantees that adhere to Head Start program 
standards, which set a high bar for quality early childhood programs and are research-based, 
as mandated by Congress in the Head Start Act.  Head Start Program Performance Standards 
are comprehensive and include standards with regard to health, safety, and adult-child 
interactions.  Head Start staff, contractors, and volunteers are required to abide by a code of 
conduct informed by child development experts that includes using positive, developmentally 
appropriate strategies to support childrens well-being and prohibits inappropriate discipline or 
harsh language.  All grant recipients must follow these standards and undergo a rigorous 
federal monitoring process every 3 years.  Grantees found to be out of compliance with the 
Head Start Program Performance Standards must take corrective action.  Serious infractions 
result in a finding(s) of deficiency, and multiple deficiencies require grant recipients to 
participate in a competitive grant process in order to retain funding.  
OHS proactively works with grant recipients through technical assistance efforts and provides 
resources to support the mitigation of health and safety incidents.  The OIG report found that 
only 7 percent of Head Start grant recipients had adverse child safety findings for multiple years. 
OHS believes this finding reflects the need to continue to strengthen and build on existing 
technical assistance and training to prevent incidents from occurring and addressing them 
immediately if they do. 
Since the time period covered by the report concluded, specifically in November 2021, OHS 
launched a new tool that supports Head Start in preventing and reporting child abuse and 
adhering to the Head Start standards of conduct, called iLookOut.  The iLookOut tool is an 
interactive, online professional development course for mandated reporters of child abuse.  OHS 
offers iLookOut training specifically for early childhood staff and providers to promote a deeper 
understanding of how to protect children from abuse.  This includes people who work as staff, 
consultants, and contractors or volunteer in Head Start programs, child care centers, and other 
early childhood education settings.  This evidence-based, online course covers a variety of topics 
critical to keeping children safe from abuse.  Additionally, OHS is scheduled to release iLookOut 
in Spanish in November 2022. 
Grant recipients also have access to technical assistance resources such as podcasts, webinars, 
and toolkits to support their understanding of how to reduce incidents of lack of supervision, 
inappropriate discipline, and unauthorized release.  OHS will continue to update and make 
resources more accessible to grant recipients and their staff.  For example, OHS has tools to 
provide practical support to programs in complying with the Head Start Program Performance 
Standards related to child supervision, and OHS and its national technical assistance centers 
work closely with programs to implement a culture of safety and environments where every 
program staff member understands their role and responsibilities in preventing childhood 
injuries.  
However, the OIG report makes clear OHS must take additional immediate and long-term steps 
to improve child safety.  The following are ACFs responses to the reports four 
recommendations to OHS. 
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OEI-BL-19-00560  Appendix B | 34   Deputy Inspector General Murrin  Page 3 
OIG Recommendation 1:  Improve Head Start grant recipients self-reporting of child 
abuse, lack of supervision, and unauthorized release incidents through better guidance and 
stronger consequences for failure to report. 
ACF Response:  ACF concurs with this recommendation. 
Currently, ACF requires Early Head Start and Head Start grant recipients, under 45 CFR 
1302.102(d)(ii)(A), to report immediately or as soon as practicable, any significant incidents 
affecting the safety of program participants and staff or volunteer violations of federal, state, 
tribal, or local laws addressing child abuse and neglect or governing sex offenders.  Most Head 
Start grant recipients report as required.  Seventy-six percent of grant recipients cited for 
violations of Head Start health and safety standards during the timeframe of the study 
reported incidents in a timely manner.  
Consequences for violation of the reporting requirement vary based on the severity of the 
incident affecting the program participant or the failure of the grant recipient to report 
immediately or as soon as practicable.  In most cases, grant recipients who fail to report 
health and safety incidents within 7 to 10 days of an incident are determined to have a 
noncompliance, and the grant recipient must correct the violation within 120 days.  If a 
health and safety incident is more severe, or the grant recipient fails to report for a longer 
period of time, OHS issues a deficiency determination, which typically must be corrected 
sooner and could lead to re-competition or termination of the grant.  
OHS has recently taken the following additional steps to further improve self-reporting of 
incidents by grant recipients: 
 In August 2022, OHS issued a Dear Colleague Letter to align with the beginning of the
typical program year outlining Early Head Start and Head Start reporting requirements,
examples of what to report, and emphasizing the importance of mandated reporting and
child safety.
 In August 2022, OHS provided a health and safety webinar for programs to reinforce
additional reporting guidance and online professional development tools, including the
Head Start Health Services Competencies and modules that address safety practices.
 In September 2022, OHS will issue an Information Memorandum on the current Early
Head Start and Head Start reporting requirements that will further define when child
safety incidents must be reported and to whom, including examples of what types of
incidents to report.
In addition, OHS will: 
 Develop more robust strategies to communicate the consequences for grant recipients of
not reporting, or not reporting immediately, significant incidents affecting the health and
safety of children to OHS;
 Clearly communicate the criteria for when delays in reporting are classified as an area of
non-compliance or deficiency, while also preserving some discretion based on the severity
of the incident and context;
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OEI-BL-19-00560  Appendix B | 35   Deputy Inspector General Murrin  Page 4 
 Provide regular training on reporting requirements, especially targeting new Head Start
program directors;
 Include more information and guidance on reporting requirements in OHS annual
monitoring information memorandum and webinar; and
 Highlight Training and Technical Assistance (TTA) resources and information available
to Early Head Start and Head Start grant recipients regarding reporting and preventing
child health and safety on the Early Childhood Knowledge & Learning Center website.
OIG Recommendation 2:  Extend the reporting requirement to include child abuse, lack of 
supervision, and unauthorized release incidents in blended classrooms in which the victim is 
not a Head Start-funded child. 
ACF Response:  ACF concurs with this recommendation. 
Head Start staff are already mandated under state, local, or tribal law to report all suspected 
child abuse to state or tribal officials.  However, if the behavior involves a child who is not a 
Head Start program participant, they are not required to report the incident to OHS, but to 
the appropriate state or tribal agency.  Conversely, most incidents involving lack of 
supervision or unauthorized release of a child are typically not reported to state or tribal 
child welfare officials because, while they violate Head Start Performance Standards and 
should be reported to OHS, they may not meet a state or tribal reporting requirement.  ACF 
agrees with OIG that this current protocol means OHS is left unaware of important 
information about the safety of children in Head Start programs and changes to procedures 
are warranted.  Though ACF does not currently have authority to fully implement this 
recommendation, ACF agrees with the need to explore options to extend its requirement 
about grantees reporting to OHS incidents that compromise the safety of any child in their 
care. 
While exploring additional options, ACF will take immediate steps to increase training and 
guidance, including to:   
 Provide guidance that the requirement to report applies to incidents involving Head Start
staff, contractors, and volunteers in all Head Start and Early Head Start settings including
blended classrooms;
 Enhance efforts to encourage Head Start to utilize the iLookOut tool to train Head Start
staff;
 Provide additional guidance to all Early Head Start and Head Start recipients on
mandated reporting;
 Identify OHS legal authority in this area and identify available ways to improve guidance
on mandated reporting involving children in blended classrooms;
 Increase OHS TTA related to mandated reporting to local authorities; and
 Create Early Head Start and Head Start resources to mitigate safety incidents, to be
available on ACF websites for use by early childhood education agencies, including those
operating blended classrooms.
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OEI-BL-19-00560  Appendix B | 36   Deputy Inspector General Murrin  Page 5 
OIG Recommendation 3:  Improve data-sharing with states about incidents of child abuse, 
lack of supervision, and unauthorized release in Head Start centers. 
ACF Response:  ACF concurs with this recommendation. 
OHS will take a tiered approach to addressing this recommendation.  As an immediate first step, 
OHS will incorporate a review of publicly available state child care licensing reports as part of 
its monitoring reviews in the 2022 to 2023 program year.  OHS will review publicly available 
licensing findings from the grant period to inform Head Start monitoring reviews and to 
determine if there were any incidents of child safety reported to the state licensing agencies that 
were not reported to OHS.   
Simultaneously, OHS will explore additional methods for obtaining data on incidents reported 
via state licensing and other child protective services, such as through data sharing plans with 
states, partnerships with other ACF program offices, and through Head Start State Collaboration 
Offices.  Finally, OHS will consider ways to clarify requirements related to concurrently 
reporting information to both the state and federal government.  
OIG Recommendation 4:  Disseminate information about innovative practices that OHS 
regional offices have developed to better identify and prevent incidents that threaten 
childrens safety. 
ACF Response:  ACF concurs with this recommendation. 
OHS regional offices are critical to the effective implementation and monitoring of Early Head 
Start and Head Start programs across the country.  Historically, OHS regional offices have 
shared knowledge, skills, and abilities across the 12 OHS regions.  OHS regional program 
managers (RPMs) meet weekly to share ideas, trends, and concerns.  RPMs also meet in person 
at least quarterly to share innovations.  Regional offices are consulted on the development and 
innovation of strategies to mitigate child health and safety risks, and many of those strategies are 
the cornerstones of the OHS monitoring system.  Sharing innovations is an intrigal part of the 
OHS structure, and ideas generated are disseminated through multiple channels.  
ACF will consider more formal structures for collecting and disseminating information across 
regions including new innovations and strategies to identify and prevent incidents that threaten 
childrens safety.  Examples of structures and resources being considered, include: 
 Analyzing regional TTA Activity reports in the areas of child health and safety, sharing
trends and innovative practices, and summarizing by region planned yearly regional
professional development related to child incidents and reporting;
 Documenting the innovative strategies of the five OHS regional offices interviewed by
OIG for its report;
 Documenting additional strategies from the remaining seven OHS regional offices not
interviewed by OIG for its report; and
 Using regional innovations to improve the identification of child health and safety issues
across regions.
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OEI-BL-19-00560  Appendix B | 37   Deputy Inspector General Murrin  Page 6 
ACF is proud to be the home of Head Start, which over the course of its 57-year history has 
upheld rigorous national standards and reporting requirements to promote the well-being of the 
children participating in Early Head Start and Head Start-funded programs.  We appreciate OIG 
for the review of this critical national program and for identifying areas that should be 
strengthened.   
Again, thank you for the opportunity to review and comment on this draft report.  Please direct 
any follow-up inquiries to Scott Logan, Office of Legislative Affairs and Budget, Administration 
for Children and Families, (202) 401-4529. 
Sincerely, 
January Contreras  
Assistant Secretary 
Administration for Children and Families 
U.S. Department of Health and Human Services 
ACF Should Improve Oversight of Head Start To Better Protect Childrens Safety 
OEI-BL-19-00560  Appendix B | 38   
ACKNOWLEDGMENTS AND CONTACT  
Acknowledgments  
Jennifer  Hutnich  served as the team leader for this study.  Others in the Office of  
Evaluation and Inspections who  conducted the study include Suriya Karim, Tori 
Lawson, and Anne Leong.   Office of  Management  and Policy staff  who provided  
support include Jason Lee.   Office  of  Evaluation and Inspections headquarters staff  
who provided support include Kevin Manley and  Christine Moritz.   
This report was prepared under the direction of  Dave  Tawes,  Regional Inspector  
General for  Evaluation and Inspections in the Baltimore  regional office, and  Louise  
Schoggen, Assistant Regional  Inspector  General  and  Heather Barton, Deputy Regional  
Inspector 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  
 
ACF Should Improve Oversight of Head Start  To Better Protect Childrens Safety    
OEI-BL-19-00560    Acknowledgments and Contact |  39     
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  
recipients 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. 
ACF Should Improve Oversight of Head Start  To Better Protect Childrens Safety    
OEI-BL-19-00560    About OIG | 40     
ENDNOTES  
 
1  Recipients operate one or  more of the following program types: (1) Head Start programs, which serve children  
ages 3 to 5; (2) Early Head Start programs, which serve infants  and toddlers up to age 3, as well as pregnant  
women; (3) Migrant  and Seasonal Head  Start programs, which  serve children  and  families in the migrant  and  
seasonal worker community; and (4) American Indian-Alaska Native Head Start programs, which serve children  
and families in the American Indian and Alaska Native  communities.  
2  The Head Start program standards  were revised and reissued in 2016; provisions  related to child abuse, lack of  
supervision, and  unauthorized release did not  substantively change. We cite the 2016 standards in this report, 
because they were in  effect  during our study period. For the complete  current Head Start program standards,  see  
45 CFR Chapter XIII.  
3  45 CFR    1302.47(b)(5)(v);  45 CFR    1302.90(c)(1)(ii).  
4  45 CFR    1302.47(b)(5)(iii);  45 CFR    1302.90(c)(1)(v).  
5  45 CFR    1302.47(b)(5)(iv).  
6  45 CFR  1302.102(d)(1)(ii); 45 CFR   1302.47 (c).  
7  42 U.S.C.  9836a(c)(1).  
8  42 U.S.C.  9832(2).  
9  45 CFR  1304.2(a).  
10  42 U.S.C.  9836a(d)(2)(A).  
11  42 U.S.C.  9832(2)(C).  
12  The seven DRS conditions  are as follows:  (1) Two or more deficiencies, defined as a systemic or substantial 
material failure of an agency in an area of performance; (2) Score below a competitive threshold in one or more  
Classroom Assessment Scoring System (CLASS) domains; (3) Two or more audit findings of material weakness or  
questioned  costs  associated with Head Start funds, or  a going concern  finding  (i.e., a determination that the  
grantee is  at risk of financial failure); (4) Failure to establish and take steps to achieve school readiness goals; (5)  
License revocation; (6) Suspension by OHS; and (7) Debarment by  another federal or state  agency or  
disqualification from the Child and Adult  Care Food Program.  See 45  CFR    1304.11.  
13  The complete list of reasons ACF may terminate Head Start funding to a recipient  is as follows: (i) The grantee is  
no longer financially viable;  (ii) The grantee has lost the  requisite legal status or permits; (iii) The grantee has failed  
to timely  correct one or more deficiencies  as defined in the Act; (iv) The grantee has failed to comply with  
eligibility requirements; (v) The grantee has failed to  comply with the Head Start grants administration or fiscal  
requirements set forth in 45 CFR part 1303; (vi) The grantee has failed to comply with requirements in the Act;  (vii) 
The grantee is debarred from receiving federal grants or contracts; or (viii) The grantee has failed to abide by any  
other terms and conditions  of its award of financial  assistance, or any other  applicable  laws, regulations, or other  
applicable federal or state requirements or policies.  See 45 CFR    1304.5.  
14  42 U.S.C.   9837b.  
15  We requested  data from the Florida Department of Children and FamiliesOffice of Child Welfare and the 
Texas  Department of Family  and Protective Services.   In this report, we  refer to these generally as  CPS agencies  
and CPS  data.  
16  We requested  data from the Florida Department of Children and FamiliesOffice  of Child Care Regulation and  
the Texas Health and Human Services  CommissionChild Care Regulation/Regulatory Services  Division.   In this  
report, we  refer to these generally  as  child  care licensing agencies and  child care monitoring  data.    
 
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OEI-BL-19-00560    Endnotes  | 41     
 
17  We defined an incident as a unique child-date  combination.   For example, a child subjected to  child abuse  on 
two separate dates was treated as  two incidents, and  three children subjected to  child abuse  on the same date 
was treated as three incidents.  
18  42 U.S.C.  9832(2)(C).  
19  45 CFR    1302.102(d).  
20  ACF,  Information Memorandum:  Mandated Reporting of Child Abuse and Neglect,  ACF-IM-HS-15-04, September  
18, 2015. 
21  In addition to 6 incidents of children left unsupervised  that were reported to the Texas CPS agency but were  not  
reported to ACF, our review of Texas child care licensing  data  also  identified 102  licensing violations related to  
child supervision  that were  not in the ACF monitoring  database.  However, the Texas licensing violation data  did  
not clearly distinguish between incidents involving  children who  are left completely  unsupervisedincidents  
included in this reportand other types of supervision events (e.g., child/caregiver ratio, room capacity  
limitations) that are not addressed in this report.  Therefore, we did not include them in the total number of  
incidents not reported to ACF.  
22  See Endnote 20.  
23  ACF was not able to provide a list of recipients or centers that operate blended classrooms.  OIG was therefore  
unable  to determine whether any of the incidents that  we identified in State data, but which were not present  in  
Federal data, had occurred in blended classrooms and thus could have involved a child who was not funded  
through Head Start.  
24  ACF,  Supervision and Transitions, Information Memorandum ACF-IM-HS-15-05, Sep. 18, 2015.   Accessed at  
https://eclkc.ohs.acf.hhs.gov/policy/im/acf-im-hs-15-05  on May 12, 2022.  
25  In January 2018, the Acting Director of the Office of Head Start wrote a letter to recipients  cautioning against  
over-reporting of practices, and/or behaviors that need improvement but do not  harm or endanger children,  
versus reportable practices or behaviors that harm or endanger  children.  The letter does not describe or give  
examples of incidents that  do or do not warrant reporting, instead directing that recipients work  with  
management, governing bodies, Health Advisory  Committees, mental health consultants, and local or state  
licensing  agencies  to identify reportable incidents.  
26  Deficiencies with corrective action periods over 90 days must submit  a quality improvement plan (QIP) to ACF  
for approval.  (See  42  U.S.C.   9836a(e)(2).)  However, ACF staff reported that QIPs  are rarely used because, in  
practice, ACF requires  most  of the types of incidents included in this report to be  corrected within 30 to 45 days.    
27   42 U.S.C.  9836a(e)(1)(B) and (e)(2)(A)(ii). The Head Start Act requires all deficiencies to be corrected within  
one year, but ACF may require some deficiencies to be corrected immediately or within 90 days depending on the 
nature and magnitude of the deficiency and whether it  threatens the health and safety of staff or program  
participants.   In practice, ACF staff reported that the  corrective action period for the incidents included in this  
report usually range between 30 to 120 days.    
28  All adverse findings  for child abuse, lack of supervision, and unauthorized release  in our review had either been  
corrected or were still listed as new  or active  in ACFs database; ACF informed OIG that a new or active  
status indicates that the finding is  still in the corrective action process.  One adverse finding was excluded from  
our corrective status analysis because of anomalous data; specifically, the primary record showed the status  as  
not corrected,  but multiple incomplete followup records with missing data were listed for the same recipient.    
29  This number does not include terminations for which the termination was reversed by the Departmental  
Appeals Board or the appeal was in progress at the time of our data collection.  
30  See Endnote 1 for information on the different  types  of Head Start programs.  
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OEI-BL-19-00560    Endnotes  | 42