U.S. Department of Health and Human Services
Office of Inspector General 
HHS Should Improve Internal
Coordination Regarding
Unaccompanied Children 
Christi A. Grimm 
Inspector General 
May 2022, OEI-BL-20-00670  U.S. Department of Health and Human Services 
Office of Inspector General
Report in Brief
May 2022, OEI-BL-20-00670 
Why OIG Did This Review HHS Should Improve Internal Coordination
HHS frequently addresses issues 
Regarding Unaccompanied Children  
that transcend a single program.  
To achieve its mission, HHS needs 
What OIG Found    
to collaborate effectively across its 
Key Takeaway 
internal agencies.  In March 2020, citing the risk of 
CDC did not coordinate with  COVID-19, CDC invoked authorities 
In previous work, OIG identified 
ORR on development or  under Title 42 of the United States 
instances in which limited or 
implementation of a public  Code to suspend entry of certain 
ineffective internal coordination 
health order that significantly  persons into the United States at or 
hampered the Departments
affected unaccompanied  near the border with Canada or 
efforts to effectively serve 
children.  Mexico. Under CDCs Title 42 order 
beneficiaries.  Accordingly, OIG 
directing this suspension, most
initiated this review to assess 
unaccompanied children were expelled to their home countries upon
coordination within HHS regarding 
attempting to enter the United States.  Before the Title 42 order, these 
a Centers for Disease Control and 
children generally would have been referred to ORR, which provides 
Prevention (CDC) public health 
temporary care for unaccompanied children until they are released to a 
order that significantly affected 
operations of the Office of  sponsor or otherwise leave ORR custody.  Therefore, after the Title 42 
Refugee Resettlement (ORR), a  order, the number of children entering ORRs care dropped substantially. 
program office within the 
Despite the Title 42 orders impact on ORR, OIG found that CDC did not 
Administration for Children and 
inform the Assistant Secretary for Children and Families, the ORR 
Families (ACF).  Specifically, in 
Director, or ORR career staff in advance about the Title 42 order. Instead, 
March 2020, CDC issued a Title 42 
ORR staff first learned of the forthcoming order through a draft 
order under which most noncitizen 
children entering the United States  Department of Homeland Security document received 2 days before CDC 
without a parent (unaccompanied  issued the Title 42 order.  This lack of communication was due, in part, to 
children) were expelled to their the fact that CDC career staff who typically coordinate with ORR staff 
home countries.  This Title 42  regarding migration-related health issues were not involved in 
order affected ORR because  developing or managing the Title 42 order. 
previously such children would 
have been referred to ORR for  OIG also found a lack of communication during the Title 42 orders 
care.  ongoing implementation. Approximately 2,000 children were excepted 
from the order and referred to ORRs care between April and September 
Coordination across HHS  2020.  However, ORR staff reported that they had not been informed 
operating divisions regarding 
about criteria for these exceptions and did not know why certain children
overlapping programs or initiatives 
had been referred to ORR during this period.  Incomplete information
is a best practice for effective 
about the factors driving referrals can complicate efforts to predict ORRs 
governance. Our retrospective 
facility capacity and programmatic needs. 
analysis of the Title 42 orders 
development and initial  Finally, OIG found that CDC did not inform ORR about a timeline or 
implementation in 2020 serves to 
process for lifting the Title 42 order, despite the likelihood that this 
identify steps that HHS can take to 
action would lead to a significant increase in the number of children
improve internal coordination in
referred to ORR and the need for ORR to rapidly increase capacity.  This 
the future and better ensure that 
may have been, in part, because the Title 42 order continued to be 
ORR has the information necessary 
managed through the Office of the CDC Director, without involvement 
to effectively care for
from career staff who typically coordinate with ORR.  Additionally, CDC 
unaccompanied children.  How OIG Did This Review  reported to OIG in November 2020 that it considered a variety of factors
This review focuses primarily on to determine, every 30 days, whether the Title 42 order would remain in 
events that occurred from March  effect; however, CDC did not provide to OIG any targets or benchmarks 
through November 2020.    associated with these criteria.  Without specific metrics that would trigger 
a decision to lift the Title 42 order, CDC had limited ability to advise ORR 
Our findings are based on  about a possible timeline for rescission. 
interviews with officials and staff 
within CDC and ACF; written  What OIG Recommends and How the Agency Responded 
responses to questions  Past OIG work noted that poor internal communication had impeded 
submitted to CDC, ACF, and  ORRs ability to provide prompt and appropriate care for unaccompanied 
others within HHS; and internal  children in 2018.  OIGs findings in this review demonstrate a similar lack 
HHS documents, such as emails  of internal communication regarding unaccompanied children from
and memoranda.  We also  March through November 2020, during the development and early 
reviewed relevant public  implementation of CDCs Title 42 order. As a best practice, HHS can, and 
documents.   should, take action to improve communication among its own internal 
offices and operating divisions regarding decisions affecting 
We conducted a qualitative
unaccompanied children. To excel in its mission, ORR must have timely 
analysis of these materials to 
access to all relevant information about HHS decision making that affects 
establish the timeline and 
unaccompanied children.  
content of coordination between 
CDC and ORR; the context for  Given these findings, as well as OIGs prior findings regarding poor 
that coordination; and factors  internal communication about unaccompanied children, OIG 
that assisted or challenged  recommends that HHS: (1) take steps to improve internal coordination 
effective coordination to protect and communication about unaccompanied children and (2) ensure that 
the well-being of  CDC coordinates with ORR when making future decisions that could 
unaccompanied children and to  affect the number of unaccompanied children placed in ORRs care, 
address the impact of the Title  including any Title 42 order.  
42 order on ORR operations.   
ACF and CDC concurred with both of our recommendations.  ACF stated 
that it has already taken significant steps to implement the 
recommendations and affirmed that it will continue these efforts to 
support effective operation of the Unaccompanied Children Program.  
CDC also provided examples of recent coordination and stated that it will 
continue to improve internal coordination and communication efforts.  TABLE OF CONTENTS 
BACKGROUND................................................................................................................................................ 1 
FINDINGS......................................................................................................................................................... 7 
CDC did not inform ORR in advance about the Title 42 order................................................................................ 7 
Some children were excepted from the Title 42 order and referred to ORR, but ORR was not informed 
about the criteria for these exceptions, which complicated programmatic and capacity planning ......... 9 
CDC did not inform ORR about a timeline or criteria for lifting the Title 42 order ......................................... 9 
CONCLUSION AND RECOMMENDATIONS............................................................................................11 
Take steps to improve internal coordination and communication about unaccompanied children ......11 
Ensure that CDC coordinates with ORR when making future decisions that could affect the number of 
unaccompanied children placed in ORRs care, including any Title 42 order ..................................................12 
AGENCY COMMENTS AND OIG RESPONSE ......................................................................................... 13 
APPENDICES.................................................................................................................................................. 14 
Appendix A: Factors That CDC Considered When Determining Whether the Title 42 Order Should 
Remain in Effect (as Reported to OIG in November 2020)..................................................................................... 14 
Appendix B: Agency Comments: Administration for Children and Families ....................................................15 
Appendix C: Agency Comments: Centers for Disease Control and Prevention ..............................................18 
ACKNOWLEDGMENTS AND CONTACT ................................................................................................ 20 
Acknowledgments .................................................................................................................................................................. 20 
Contact........................................................................................................................................................................................ 20 
ABOUT THE OFFICE OF INSPECTOR GENERAL. .................................................................................... 21 
ENDNOTES ................................................................................................................................................... 22  BACKGROUND 
OBJECTIVE 
To assess coordination within the Department of Health and Human Services (HHS) 
during the development and early implementation of a March 2020 public health 
order affecting unaccompanied noncitizen children. 
The Office of Inspector General (OIG) initiated this review to assess coordination 
within HHS regarding a Centers for Disease Control and Prevention (CDC) public 
health order affecting noncitizen children who had crossed the United States border 
without a parent or guardian (unaccompanied children).  This population is typically
served by the HHS Office of Refugee Resettlement (ORR) within the Administration 
for Children and Families (ACF).  Effective internal communication about policies 
affecting unaccompanied children is vital to ORRs ability to effectively plan for facility 
capacity and programmatic needs. 
Specifically, in March 2020, in response to the COVID-19 pandemic, CDC invoked 
public health authorities under Title 42 of the United States Code to issue Order 
Suspending Introduction of Certain Persons From Countries Where a Communicable 
Disease Exists (hereafter, Title 42 order).  Under the Title 42 order, numerous 
individuals seeking to enter the United States were expelled, including thousands of 
unaccompanied children. Prior to the Title 42 order, these children generally would 
have been placed in ORRs custody. 
Our review focused on the orders development and early implementation, from 
March through November 2020. Since the period of OIGs review, substantial 
changes in agency leadership and policy have occurred. Our retrospective analysis 
serves to identify steps that HHS can take to improve internal coordination in the 
future and better ensure that ORR has the information necessary to effectively care 
for unaccompanied children. 
ORR Care of Unaccompanied Children 
ORR is a program office of ACF within HHS.  ORR operates the Unaccompanied
Children Program to provide care to minors (under 18 years of age) who have no 
lawful immigration status in the United States and do not have a parent or legal 
guardian available in the United States to provide care and physical custody.1 Most 
children referred to ORR are apprehended by immigration authorities while crossing 
the border; some are apprehended within the U.S. interior.  In rare cases, children are 
referred to ORR after being separated from their parents or legal guardians by 
HHS Should Improve Internal Coordination Regarding Unaccompanied Children
OEI-BL-20-00670   Background | 1  immigration authorities within the Department of Homeland Security (DHS) after 
entering the country.   
Under the Trafficking Victims Protection Reauthorization Act of 2008, an 
unaccompanied child must be transferred to ORR within 72 hours barring exceptional 
circumstances.2  Federal law requires the safe and timely placement of children in the 
least restrictive setting that is in the best interest of the child.3  To that end, ORR 
funds and oversees a network of approximately 200 facilities that provide temporary 
care for children until they are released to a sponsor or otherwise leave ORR custody.  
Nearly all ORR facilities are licensed under the laws of their respective States and 
provide housing, food, medical care, mental health services, educational services, and
recreational activities.4 
A child remains in ORR custody until one of the following occurs: an appropriate 
sponsor (usually a parent or close relative) is located in the United States who can 
care for the child, the child turns 18 years of age, or the childs immigration status is 
resolved. ORR releases a child to a sponsor only after conducting a sponsor 
assessment, in accordance with Federal law and ORR policy, to confirm that the 
sponsor can safely care for the child. 
ORR Capacity Planning for Care of Unaccompanied Children 
Capacity planningaccurately predicting the number of children that ORR should be
prepared to serve at any given timeposes an ongoing challenge for ORR.  
Numerous factors affect the number of children in ORRs care.  These factors include 
fluctuating migration trends, immigration policies and enforcement practices 
(typically determined by DHS and the Department of Justice), and ORRs ability to
locate and discharge children to appropriate sponsors.    
As a result of these factors, ORR periodically experiences surges in the number of 
children receiving care. During such an influx, ORR may expand its care provider 
network or place children into temporary emergency care facilities, including influx 
care facilities and emergency intake sites.  ORR can either activate or deactivate these 
facilities depending on the number of children requiring care.5 Influx care facilities 
provide temporary shelter and minimum required services and may be exempt from 
State or local licensing.6  Emergency intake sites are unlicensed and intended to meet 
the immediate shelter needs of unaccompanied children, implementing standards for 
care for children in an emergency response setting.7 
Effective capacity planning is critical to ensure that unaccompanied children can 
promptly be placed in a suitable ORR facility and begin receiving the care and services 
to which they are entitled under Federal law.  If ORR does not have sufficient capacity, 
children may be detained for longer than 72 hours in DHS detention facilities.  
Conversely, if excess capacity is unnecessarily maintained, Federal funds may be used 
ineffectively. To balance these risks, ORR uses both internal information as well as 
information from interagency partners to predict and plan for its capacity needs. 
HHS Should Improve Internal Coordination Regarding Unaccompanied Children
OEI-BL-20-00670   Background | 2  CDC Actions Affecting Unaccompanied Children 
HHS Statutory and Regulatory Authorities for Control of 
Communicable Diseases 
Section 362 of the Public Health Service Act (42 U.S.C.  265) authorizes the Secretary 
of HHS to prohibit the introduction of persons or property from foreign countries to 
prevent the entry and spread of any communicable disease into the United States8, 9 
Federal regulations issued in 2017 permit the CDC Directorwho has been delegated 
the authority to carry out these functions10to suspend introduction into the United 
States of animals or products that pose a threat to public health and to quarantine or 
isolate persons in accordance with certain principles and procedures.  As part of its 
response to the COVID-19 pandemic, CDC issued an interim final rule, effective March 
20, 2020, designating a procedure for the CDC Director to suspend the introduction 
of persons from designated countries or places, if required, in the interest of public 
health. CDC subsequently finalized this interim rule, effective October 13, 2020.11, 12 
Title 42 Order Suspending Entry of Certain Persons Into the 
United States 
Effective March 20, 2020, citing the COVID-19 pandemic, CDC invoked public health 
authorities under Title 42 of the United States Code to issue Order Suspending 
Introduction of Certain Persons From Countries Where a Communicable Disease 
Exists.13  The Title 42 order suspends entry of individuals into the United States at or 
near the border with Canada or Mexico if entry would result in their being placed in a 
congregate setting in a land or coastal port of entry or border patrol station at or near
the U.S. borders (i.e., immigrant processing and detention facilities operated by DHS, 
including facilities used to process and detain unaccompanied children).14 These 
include individuals seeking to enter the United States who lack proper travel 
documents, whose entry is otherwise contrary to law, or who are apprehended at or 
near the border seeking to unlawfully enter the United States between ports of entry.  
The Title 42 order exempts U.S. citizens, lawful permanent residents, and those with 
valid travel documents or subject to the visa waiver program, among others.  The 
order states that CDC requested that DHS implement this Order because CDC does 
not have the capability, resources, or personnel needed to do so.15 
The Title 42 order was implemented for an initial period of 30 days, extended in April 
2020 for an additional 30 days, and extended again in May 2020 for an indefinite 
period.16, 17, 18  The May extension stated, CDC shall review the latest information 
regarding the status of the COVID-19 pandemic and associated public health risks every 
thirty days to ensure that the Order remains necessary to protect the public health.   
Effective October 13, 2020, immediately after the final rule took effect, CDC issued a 
new order replacing the extended March 20, 2020, order.19 The October 13, 2020, 
Title 42 order was substantially the same as the prior Title 42 order and, like the May 
HHS Should Improve Internal Coordination Regarding Unaccompanied Children
OEI-BL-20-00670   Background | 3  extension, stated that CDC would conduct a review every 30 days to determine 
whether the order remains necessary to protect the public health. 
Impact of the Title 42 Order on Unaccompanied Children Entering ORR Care 
As a result of the Title 42 order, numerous individuals seeking to enter the United 
States were expelled, including thousands of unaccompanied children.  Prior to the 
Title 42 order, these children generally would have been processed through DHS 
facilities and then transferred to ORRs care.  Accordingly, after implementation of the
Title 42 order, the number of unaccompanied children entering ORR care dropped 
substantially.  At the end of August 2020, when the Title 42 order had been in effect 
for approximately 5 months, ORR was operating at just 3 percent of its total bed 
capacity, with more than 10,000 vacant beds.20 
Relevant Events Occurring After the Period of OIGs Review 
OIGs review addresses coordination within HHS regarding the development and early 
implementation of the Title 42 order, from March through November 2020.  Since 
that time, court rulings and Federal actions have affected the orders implementation:  
  On November 18, 2020, the United States District Court for the District of 
Columbia issued a preliminary injunction to prevent the expulsion of 
unaccompanied children.21 
  On January 29, 2021, the United States Court of Appeals for the District of 
Columbia Circuit granted a motion to stay pending appeal the lower courts 
preliminary injunction of the Title 42 order, enabling DHS to resume expelling
unaccompanied children under the authority of CDCs Title 42 order.22 
  On February 2, 2021, President Biden issued an Executive Order directing that 
HHS, in consultation with DHS, review the Title 42 order and the CDC final rule 
to determine whether termination, rescission, or modification of these 
actions is necessary and appropriate.23 
  On February 11, 2021, CDC issued a notice stating that CDC has decided to 
exercise its discretion to temporarily except from expulsion unaccompanied 
noncitizen children encountered in the United States pending the outcome of 
its forthcoming public health reassessment of the Order.24 
  On July 16, 2021, CDC issued an order fully excepting unaccompanied children 
from the Title 42 order.25 
  On August 2, 2021, CDC issued a new Title 42 order that replaces and 
supersedes the October 13, 2020, Title 42 order.26  The August 2, 2021, Title 42
order continues the suspension of the right to introduce covered noncitizens 
into the United States along the U.S. land and adjacent coastal borders while 
also continuing the exception for unaccompanied children.  CDC stated that it 
HHS Should Improve Internal Coordination Regarding Unaccompanied Children
OEI-BL-20-00670   Background | 4  would reassess the circumstances necessitating the Order at least every 60 
days. 
  Effective March 11, 2022, CDC terminated the Title 42 order with respect to 
unaccompanied noncitizen children.27  In April 2022, CDC announced that it 
would terminate the Title 42 order for other noncitizens effective May 23, 2022.28 
Prior OIG Work 
In 2018, OIG initiated a large, multifaceted review of the health and safety of 
unaccompanied children in ORR care, including how both internal and interagency 
communication affected ORRs ability to provide prompt and appropriate care and 
placement. Key findings from this body of work include: 
  In September 2019, OIG found that in general, ORR facilities met a range of 
background check and qualification requirements.  However, some facilities 
did not have evidence of the required Federal Bureau of Investigation 
fingerprint or Child Protective Services check results and did not always ensure 
that the out-of-State Child Protective Services checks were completed.29 
  In January 2019, OIG found that the total number of children separated from 
their parents or legal guardians and placed in ORR care as a result of DHS 
practices to increase immigration enforcement was unknown but likely 
significantly more than the 2,737 identified by HHS at the time of our review.30 
  In September 2019, OIG found that ORR facilities struggled to address the 
mental health needs of children who had experienced intense trauma and had 
difficulty accessing specialized treatment for children who needed it.31 
  In March 2020, OIG found that communication and management challenges 
impeded HHSs response to the zero-tolerance policy. As a result, HHS was 
unable to provide prompt and appropriate care for an increasing number of 
immigrant children who were separated from their families under the policy.32 
  In June 2020, OIG found that ORRs incident reporting system for incidents of 
serious harm was not effectively capturing data to assist in its efforts to ensure 
the safety of minors in HHS custody.33 
Methodology 
Scope 
This review assessed coordination within HHS regarding CDCs Order Suspending 
Introduction of Certain Persons From Countries Where a Communicable Disease 
Exists. In particular, we assessed coordination between CDC and ORR in advance of 
the Title 42 orders issuance and during its initial implementation.  Our review 
examined events that occurred from March through November 2020.  We did not 
HHS Should Improve Internal Coordination Regarding Unaccompanied Children
OEI-BL-20-00670   Background | 5  assess the substance of the Title 42 policy itself; we focused exclusively on 
communication and coordination within HHS regarding aspects of the policy that 
affected unaccompanied children. 
Data Sources and Analysis 
This review is based on interviews with officials and staff within CDC and ORR; written 
responses to questions submitted to CDC, ACF, and the HHS Office of the General 
Counsel; and internal HHS documents such as emails and memoranda.  We 
conducted a qualitative analysis of these materials to establish the timeline and 
content of coordination between CDC and ORR, the context for that coordination, and 
factors that assisted or challenged effective coordination. 
Interviews and Written Responses 
We interviewed knowledgeable officials and staff within CDC and ORR between 
September and November 2020. At CDC, we separately interviewed the Chief of Staff 
and a career official within the Division of Global Migration and Quarantine.  At ORR, 
we conducted a panel interview of ORR staff holding management and operational 
responsibilities affected by the Title 42 order, including staff in ORRs Division of 
Unaccompanied Childrens Services and ORRs Division of Policy and Procedures.  
We requested and received answers to questions in writing submitted to CDC, ACF, 
and the HHS Office of the General Counsel.  We also requested and received data
from ORR about the number of children referred to ORR prior to and after the Title 42
order went into effect. 
Documents 
We requested documents from CDC, ACF, and the HHS Office of the General Counsel 
to support, provide context for, and expand upon interview responses.  These 
documents included emails, memoranda, and other materials to document the 
frequency and nature of internal HHS coordination about the Title 42 order.  We also 
reviewed public documents related to the Title 42 order to the extent that they 
pertained to the issues under review. 
Limitations 
We did not interview certain officials involved in decisions related to the Title 42 order 
who had left Federal service prior to our data collection.  We gathered as much 
information as possible from other staff with knowledge of events surrounding the 
Title 42 order and from the documentary record.  We note that significant changes in 
agency leadership and policy have occurred since the period of our review.    
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. 
HHS Should Improve Internal Coordination Regarding Unaccompanied Children
OEI-BL-20-00670   Background | 6  FINDINGS 
CDC did not inform ORR in advance about the Title 42 order   
ACF and ORR leadership and ORR career staff reported that CDC did not inform them 
in advance about the Title 42 order, despite the orders impact on the number of 
children who would enter ORRs care.  Staff-level communication channels exist 
between ORR and CDC to address issues affecting unaccompanied children; however,
the Title 42 order was initiated through an interagency process that did not include 
CDC career staff, which contributed to the lack of communication. 
ORR staff first learned of the Title 42 order through a draft DHS 
document received 2 days before CDC issued the order 
CDC did not inform the Assistant Secretary for Children and Families, the ORR 
Director, or ORR career staff in advance about the Title 42 order.  ORR staff recalled 
that they first became aware of the Title 42 order through a draft DHS document that 
only referenced the forthcoming order. That draft DHS document was circulated to 
ACF on March 18, 20202 days before CDC would issue the Title 42 order.   
ACF leadership consulted ORR staff and elevated their concerns and 
perspectives within HHS 
Upon receiving the DHS document, which described its planned implementation of 
CDCs forthcoming Title 42 order, ACF leadership requested feedback from ORR staff 
about DHSs plans. ORR staff raised several operational concerns and emphasized 
that DHS should not separate children from their parents as a result of the Title 42 
order; ACF leadership elevated these concerns to HHS leadership in preparation for 
interagency discussions. (OIG reviewed ORR referral data for the 6 months before 
and after March 2020 and did not observe any increase in separations following 
issuance of the Title 42 order.) 
Additionally, ACF leadership consulted ORR staff regarding a DHS request that ORR 
use influx facilities to provide temporary care for children who were subject to 
expulsion under the Title 42 order but whom DHS could not immediately remove 
from the United States.  ORR staff expressed to ACF leadership that an influx facility is
not appropriate for all children (for example, young children or children with special 
needs) and that licensed shelters could better serve this purpose.  (Ultimately, this
subset of children remained in the care of DHS.) 34, 35 
HHS Should Improve Internal Coordination Regarding Unaccompanied Children
OEI-BL-20-00670   Findings | 7  CDC staff who typically coordinate with ORR staff were not 
involved in the Title 42 order, contributing to the lack of internal 
communication 
The Title 42 order and its subsequent extensions were signed by the CDC Director.  
However, CDC reported to OIG that CDC did not issue the Order unilaterally, 
characterizing the order as an interagency decision led from the White House, 
developed in coordination with HHS and DHS.  Specifically, an interagency group 
including representatives from the White House, National Security Council, and DHS, 
engaged with HHS to discuss potential regulations and subsequent orders that CDC 
could issue related to COVID-19 and DHS operations at the northern and southern 
borders. In response to the interagency request, an HHS official noted in internal 
correspondence from early March 2020 that HHS is willing to put together a 
justification for DHSs exercise of [HHS] authorities related to the turning back of 
aliens for security reasons driven by public health concerns.  This justification 
ultimately took the form of the Title 42 order issued by CDC on March 20, 2020.  
Within CDC, the Division of Global Migration and Quarantine (DGMQ) typically plays a 
leading role in CDCs efforts to prevent the introduction, transmission, and spread of 
communicable disease into the United States from other countries.  However, DGMQ 
did not develop or implement the Title 42 order.  A career DGMQ official requested
that DGMQ be recused from involvement in the Title 42 order, because the official 
believed that the order was inconsistent with a CDC guiding principle articulated in 
2017 Federal regulations: HHS/CDC will seek to use the least restrictive means 
necessary to prevent the spread of communicable disease.36 The official reported to 
OIG that CDCs Office of the Director respected this request.  CDC confirmed that 
within the agency, coordination of the Title 42 order was handled within the Office of 
the CDC Director, with engagement with senior officials at HHS and DHS; CDC career 
staff had no role.  
The lack of DGMQ staffs involvement contributed to the lack of communication 
between CDC and ORR about the Title 42 order.  Staff-level communication channels 
do exist between ORR (within ACF) and DGMQ (within CDC) to address operational 
issues. ORR staff indicated that those previously established channels have been used
regularly and effectively throughout the COVID-19 pandemic; for example, they noted 
that CDC and ORR staff communicate about infection control guidance for ORR care 
provider facilities and share draft guidance for informal review.  However, with the 
Title 42 order removed from DGMQs purview, information related to the Title 42 
order was not communicated through those channels. 
HHS Should Improve Internal Coordination Regarding Unaccompanied Children
OEI-BL-20-00670   Findings | 8  Some children were excepted from the Title 42 order and 
referred to ORR, but ORR was not informed about the criteria 
for these exceptions, which complicated programmatic and 
capacity planning 
According to ORR referral data, between April and September 2020, a total of 1,971 
children were excepted from the Title 42 order and referred to ORRs care.  ORR staff 
reported that they did not know what criteria were used to determine which children 
would receive these exceptions.      
The Title 42 order does not require coordination with ORR about exceptions for 
unaccompanied children. Decisions about which children to except from the Title 42 
order and refer to ORR were made by DHS officials charged with implementing the 
order on CDCs behalf.37  CDC officials whom OIG interviewed in October and 
November 2020 reported that they were not aware of any consultation with DHS 
about these exceptions. 
Incomplete information about the factors driving referralssuch as the exceptions to
the Title 42 ordercomplicates efforts to predict ORR facility capacity and 
programmatic needs. ORR staff explained that the total number of children for whom 
it can provide care at any given time depends in part on the flow of kids and any 
grouping of kids infected [with COVID-19], and what those demographics of 
individual children are.  As an example of the difficulties faced during this period, 
ORR staff noted that on some occasions, they had received groups of 50 to 60 
COVID-19-exposed children at one time, posing challenges for placement.   
CDC did not inform ORR about a timeline or criteria for lifting 
the Title 42 order 
ORR staff whom OIG interviewed in October 2020 reported no communications with 
CDC about the orders multiple extensions or about the timeline or criteria for 
rescinding it, despite the likelihood that lifting the Title 42 order would lead to a
significant increase in the number of children requiring ORRs care.   
Both the May 2020 extension and the October 2020 reissuance of the Title 42 order 
state that CDC will, every 30 days, review information about the COVID-19 pandemic 
to ensure that the Title 42 order remains necessary to protect the public health.  
However, ORR staff reported that they did not know what metrics CDC had 
established for this review and that they were not informed of progress on those 
metrics or a likely timeline for lifting the Title 42 order.  ORR staff explained to OIG 
that ideally, they would prefer a 60-day notice before the Title 42 order was rescinded 
to ensure that ORR facilities would be sufficiently prepared. 
CDC reported to OIG in November 2020 that it considered a variety of factors when 
conducting its 30-day review to determine whether the Title 42 order would remain in 
HHS Should Improve Internal Coordination Regarding Unaccompanied Children
OEI-BL-20-00670   Findings | 9  effect. These included, for example, the total number of COVID-19 infections, active 
infections, deaths, and tests in Canada, Mexico, the United States, and other relevant 
countries; modeling released by public health authorities and major public health 
institutions in Canada, Mexico, the United States, and other relevant countries; and 
DHS enforcement data, such as the number of border encounters, apprehensions, and 
expulsions pursuant to the Title 42 order.  (See Appendix A for a complete list of 
criteria that CDC reported considering in its determinations that the Title 42 order 
remained necessary to protect the public health.)  However, CDC did not provide any 
targets or benchmarks associated with these criteria that would determine when a 
threat to public safety no longer exists and the Title 42 order can be lifted.  
With no specific metrics that would trigger a decision to lift the Title 42 order, CDC 
had limited ability to predict the timing of that decision, and therefore also had 
limited ability to provide ORR with a likely timeline that ORR could consider in its 
programmatic and capacity planning.  Additionally, the Title 42 order continued to be 
managed through the Office of the CDC Director, without involvement from career 
staff who typically coordinate with ORR and might otherwise have engaged further 
with ORR staff to address their planning needs as they related to the Title 42 order.  
As a result of these two factors, ORR staff were left without insight into CDCs plans.  
When interviewed in October 2020, ORR staff expressed significant concerns about 
ORRs ability to adapt to capacity demands if the Title 42 order were to be lifted 
without sufficient prior notice. 
HHS Should Improve Internal Coordination Regarding Unaccompanied Children
OEI-BL-20-00670   Findings | 10  CONCLUSION AND RECOMMENDATIONS 
HHS frequently faces complex issues that transcend a single HHS program.  To 
achieve its mission, HHS needs to collaborate effectively across its internal offices and 
operating divisions. Providing care for unaccompanied children exemplifies the type 
of challenge that demands effective coordination.  HHS can best protect 
unaccompanied childrens interests when it works across program lines to leverage 
the Departments expertise and infrastructure on their behalf.  
OIG found a lack of internal coordination during the development and early 
implementation of the Title 42 order. In particular, CDC did not inform ACF or ORR in 
advance about the Title 42 order or the timing or circumstances of its eventual 
rescission, despite the impact of those actions on unaccompanied children and ORR 
operations.  However, OIG also noted effective communication between ACF 
leadership and ORR staff; upon learning of the Title 42 order through DHSs 
implementation plans, ACF leadership both consulted with ORR staff and elevated 
their concerns within the Department. 
Past OIG work noted that poor internal communication had impeded ORRs ability to 
ensure sufficient capacity to provide prompt and appropriate care for unaccompanied 
children and that risks to the well-being of unaccompanied children had not been 
prioritized in decisions affecting their care.   To excel in its mission, ORR must have 
timely access to all relevant information about HHS decision making that affects 
unaccompanied children. HHS can, and should, take action to improve 
communication among its internal offices and operating divisions with regard to this
highly vulnerable population.  We recommend that HHS: 
Take steps to improve internal coordination and communication 
about unaccompanied children 
ORR faces significant challenges inherent to its complex mission.  ORR can best meet 
those challenges when it has timely information about HHS decisions that affect 
unaccompanied children placed in ORRs care.  OIG has previously recommended that 
HHS ensure that unaccompanied childrens interests are prioritized and represented 
in decisions affecting their care and placement.  Improving internal coordination 
about unaccompanied children will help HHS accomplish this aim by supporting 
ORRs ability to carry out effective capacity and programmatic planning for this 
population. 
HHS should therefore take steps to ensure that, in the future, any information 
potentially affecting this population is promptly shared with ORR.  For example, HHS
should assess whether its reporting structures and formal communication channels 
enable prompt and effective sharing of such information across operating divisions 
HHS Should Improve Internal Coordination Regarding Unaccompanied Children
OEI-BL-20-00670   Conclusion and Recommendations | 11  and make any necessary changes to improve communication and protect childrens
interests. Further, HHS must be alert to communication gaps that may arise when 
policies are developed or implemented under atypical circumstances, as occurred 
when the CDC recused DGMQ from involvement in the Title 42 order.   
Ensure that CDC coordinates with ORR when making future 
decisions that could affect the number of unaccompanied 
children placed in ORRs care, including any Title 42 order   
This review highlights a lack of internal coordination related to the Title 42 order 
during its development and early implementation, from March through November 
2020. In July 2021after the period of OIGs reviewCDC issued an order fully 
excepting unaccompanied children from expulsion under the Title 42 order.  The July
2021 order explained that at this time, there is appropriate infrastructure in place to 
protect the children, caregivers, and local communities from elevated risk of COVID-
19 transmission as a result of the introduction of [unaccompanied children] but also 
warned that [t]his situation could change based on an increased influx of 
[unaccompanied children], changes in COVID-19 infection dynamics among 
[unaccompanied children], or unforeseen reductions in housing capacity.  On March 
11, 2022, CDC terminated the Title 42 order with respect to unaccompanied children 
but also stated that nothing in this termination will prevent CDC from issuing a new 
order, based on new findings, as dictated by public health needs.  Effective 
coordination between CDC and ORR will be necessary to ensure that ORR has all 
relevant information to facilitate capacity and programmatic planning for care of 
unaccompanied children. 
HHS Should Improve Internal Coordination Regarding Unaccompanied Children
OEI-BL-20-00670   Conclusion and Recommendations | 12  AGENCY COMMENTS AND OIG RESPONSE 
ACF and CDC concurred with both of our recommendations.  ACF stated that it has 
already taken significant steps to implement the recommendations and affirmed that 
it will continue these efforts to support effective operation of the Unaccompanied 
Children Program. CDC also provided examples of recent coordination and stated 
that it will continue to improve internal coordination and communication efforts. 
Regarding our first recommendation, ACF described steps taken to improve 
coordination between ORR and CDC. For example, ORR staff now meet weekly with 
the CDC Southern Border Migrant Health Workgroup to address ORR operational 
issues. In addition, ORR and CDC leadership meet weekly to ensure coordination of 
activities.  CDC similarly cited recent examples of coordination with ORR to provide 
public health technical assistance and stated that it defers to HHS regarding how best
to address Departmentwide communication gaps, policy development, and 
implementation. 
Regarding our second recommendation, ACF stated that since January 2021 (after the
period of OIGs review), weekly meetings between ORR and CDC have included 
discussion of topics related to the Title 42 order.  CDC likewise described recent 
coordination regarding Title 42. CDC further stated, The COVID-19 pandemic is 
occurring at the same time as a global and ongoing child refugee crisis.  It is HHSs 
collective goal to protect the health and wellbeing of these children as part of the 
overall U.S. [G]overnment response. 
For the full text of ACFs comments, see Appendix B.  For the full text of CDCs 
comments, see Appendix C. 
HHS Should Improve Internal Coordination Regarding Unaccompanied Children
OEI-BL-20-00670   Agency Comments and OIG Response | 13  APPENDICES 
Appendix A: Factors That CDC Considered When Determining
Whether the Title 42 Order Should Remain in Effect (as
Reported to OIG in November 2020) 
In November 2020, CDC reported to OIG that the decision made each month as to 
whether the Title 42 order should remain in effect was based on the following factors:  
 total number of COVID-19 infections in Canada, Mexico, the United States,
and other relevant countries (i.e., other South or Central American countries,
Schengen Area countries);
 total number of COVID-19-related deaths in Canada, Mexico, the United
States, and other relevant countries;
 total number of active COVID-19 infections in Canada, Mexico, the United
States, and other relevant countries;
 total number of COVID-19 tests administered and positivity rates in Canada,
Mexico, the United States, and other relevant countries;
 hospital utilization data from Canada, Mexico, the United States, and other
relevant countries;
 shortcomings in epidemiologic surveillance data;
 significant outbreaks in Canada, Mexico, and the United States, particularly
those occurring in areas close to United States borders;
 major public health measures in Canada, Mexico, the United States, and other
relevant countries, such as mask mandates or lockdown orders;
 modeling released by public health authorities and major public health
institutions in Canada, Mexico, the United States, and other relevant countries;
 mortality and fatality rates among DHS personnel; and
 DHS enforcement data, such as the number of border encounters,
apprehensions, and expulsions pursuant to the order.
HHS Should Improve Internal Coordination Regarding Unaccompanied Children
OEI-BL-20-00670   Appendix A | 14  Appendix B: Agency Comments: Administration for Children and 
Families 
Office of the Assistant Secretary | 330 C Street, S.W., Suite 4034 
Washington, D.C. 20201 | www.acf.hhs.gov 
March 25, 2022 
Ms. Christi A. Grimm 
Principle Deputy Inspector General  
U.S. Department of Health and Human Services 
330 Independence Avenue, SW. 
Washington, DC    20201 
Dear Ms. Grimm: 
I am writing to provide the Administration for Children and Families (ACF) response to the 
Office of Inspector Generals (OIG) report titled, HHS Should Improve Internal Coordination 
Regarding Unaccompanied Children, (OEI-BL-20-00670), which contains recommendations for 
the Office of Refugee Resettlement.  We appreciate the opportunity to review and comment on 
the report.  Below you will find our general comments on the report findings and our specific 
response to each recommendation. 
As described below, ACF concurs with all of the OIG recommendations, and has already 
taken significant steps to implement the recommended improvements. 
ACF Response to Recommendations 
Recommendation 1:  Take steps to improve internal coordination and communication 
about unaccompanied children. 
ACF Response:  ACF concurs with this recommendation. 
Since January 2021, ACFs Office of Refugee Resettlement (ORR) and the Centers for 
Disease Control and Prevention (CDC) have been in close, frequent contact at both the 
leadership and staff level regarding the health and safety of unaccompanied children in the 
care and custody of ORR during the coronavirus disease (COVID-19) pandemic. 
Coordination and communication between ORR and the CDC has been critical in ensuring 
ORR has information and resources available to effectively implement safeguards to protect 
unaccompanied children, staff at ORR-funded programs, and their respective communities 
from the risk of COVID-19. 
ORR consults with CDC to ensure COVID-19 guidance issued to ORR-funded care 
providers is consistent with the latest CDC guidelines and is adapted to best serve ORRs 
specific population in both congregate and foster care settings.  Since January 2021, ORR 
and CDC have taken steps to strengthen existing lines of communication and to establish 
new ones.  For example, ORR Division of Health for Unaccompanied Children (DHUC) and 
the CDCs Southwest Border Migrant Health Workgroup (SBMHW), previously the 
HHS Should Improve Internal Coordination Regarding Unaccompanied Children OEI-
BL-20-00670       Appendix B | 15 Page 2  Inspector General Christi A. Grimm 
Southwest Border Migrant Health Task Force, continue to maintain weekly staff-level 
communications with CDC career staff to address ORR operational issues.  These weekly 
discussions focus on prevention and control efforts for COVID-19, and other communicable 
diseases, and have yielded essential protocols, policy, and field guidance to keep 
unaccompanied children safe, including at Emergency Intake Sites (EIS).  The COVID-19 
guidelines issued by ORR in close consultation and collaboration with CDC include: 
 Field Guidance #2 COVID-19 Verbal Screening and Temperature Check for
Staff and Visitors
 Field Guidance #3 Temperature Checks and Reporting
 Field Guidance #4 COVID-19 Discharge Guidance
 Field Guidance #6 COVID-19 Intake Procedures for Unaccompanied Children
Newly Admitted into ORR Custody
 Field Guidance #17 COVID-19 Vaccination of Unaccompanied Children (UC) in
ORR Care
Appendix B - Children Who Received COVID-19 Vaccine Outside the US
o
Discharge Letter for Sponsors
o
In addition to the weekly staff-level meetings, ORRs DHUC and CDCs SBMHW 
leadership meet once per week to facilitate and ensure coordination of efforts and activities 
within each organizations work units.  This has allowed for closer coordination between 
DHUC and CDC SBMHW subject matter experts, who meet routinely to discuss specific 
cases that require closer subject matter review and analysis.  This has also opened a direct 
line of communication between DHUC and CDC SBMHW staff and medical staff and 
leadership at active EIS facilities.  DHUC and CDC SBMHW staff participate on weekly 
calls with EIS facility medical leadership to ensure any site-specific issues or complex 
problems or cases are directly elevated to DHUC and CDC leadership.  These weekly calls 
with EIS medical leadership have been critical to facilitating communication of site-specific 
issues and coordination of a prompt response from DHUC and CDC SBMHW.  
ORR will continue to closely monitor the COVID-19 situation and coordinate efforts with 
the CDC SBMHW. 
Recommendation 2:  Ensure that CDC coordinates with ORR when making future 
decisions that could affect the number of unaccompanied children placed in ORRs care, 
including any Title 42 order. 
ACF Response:  ACF concurs with this recommendation. 
Generally speaking, in addition to historical migration trends and patterns, ORRs largest 
predictor for advanced planning of UC Program needs is current Department of Homeland 
Security (DHS) referral levels.  While ORR works very closely with DHS stakeholders to 
monitor and predict referral levels to ensure ORR has the bed capacity and resources necessary 
to safely receive referrals of UC, who DHS is required by law to transfer to ORR within 72 
HHS Should Improve Internal Coordination Regarding Unaccompanied Children OEI-
BL-20-00670       Appendix B | 16 Page 3  Inspector General Christi A. Grimm 
hours, there are several other factors that contribute to the challenges of planning and preparing 
for the UC Programs needs and bed capacity.  Among these factors are the emergence and 
effects of communicable diseases.  While the COVID-19 pandemic was unprecedented, 
interagency collaboration between ORR and CDC in the last 2 years have promoted greater 
efficiencies in information and resource sharing that leveraged the expertise and strengths of 
each agency and will only benefit future collaboration efforts to response and preparedness.  To 
date, COVID-19 continues to be a major driver of ORR bed capacity unavailability due to safety 
protocols.  For example, and as recommended by the CDC in order to help prevent the spread of 
COVID-19 at each program, care providers have moved bed capacity offline to ensure proper 
social distancing and other safety measures that prioritize the health and well-being of children. 
Additional capacity constraints derive from adherence to COVID-19 quarantine and medical 
isolation provisions and unpredictable staffing challenges.  Though these challenges remain and 
the extent of which vary from program to program, ORR and CDC have built a strong 
collaborative partnership at both career and leadership levels working to safely implement and 
adapt CDC protocols and guidance to bring back online beds that were negatively impacted by 
COVID-19.  ORR and CDC continue to leverage these communication channels to share 
information in order to ensure children are placed in a safe, child-friendly environment and do 
not remain in DHS custody, whose facilities are not staffed or equipped to care for children. 
ORR and CDC continue to meet weekly at both the staff and leadership levels to discuss 
overall COVID-19 trends and cases among unaccompanied children, and to coordinate and 
resolve issues.  These discussions include topics related to the Title 42 order with ORR 
equities.  Since CDC first excepted unaccompanied children from the Title 42 order in 
January 2021, through its decision to terminate the Title 42 order with respect to 
unaccompanied children on March 12, 2022, ORR and CDC have continued to leverage 
communication channels to discuss any potential changes to Title 42 or CDC guidance that 
further impact the UC program.  These efforts ensure ORR has all CDC information 
available and necessary to effectively plan for UC Program needs as far in advance as 
possible, and ensure children continue to be promptly and safely placed in a ORR care 
within 72 hours. 
Again, I appreciate the opportunity to review and comment on this report.  Please direct any 
follow-up inquiries to our OIG liaison Scott Logan within ACFs Office of Legislative Affairs 
and Budget, at (202) 401-4529. 
Sincerely, 
Jennifer M. Cannistra, 
Acting Assistant Secretary 
  for Children and Families 
HHS Should Improve Internal Coordination Regarding Unaccompanied Children OEI-
BL-20-00670       Appendix B | 17 Appendix C: Agency Comments: Centers for Disease Control and 
Prevention 
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES  Public Health Service 
Centers for Disease Control 
and Prevention (CDC) 
Atlanta GA 30333 
MEMORANDUM 
To:  Christi A. Grimm 
Principal Deputy Performing Duties of the Inspector General 
From:  Rochelle P. Walensky, MD, MPH 
Director, Centers for Disease Control and Prevention (CDC) 
Date:  March 7, 2022 
Subject:  Office of the Inspector General (OIG) Draft Report, "HHS Should Improve Internal 
Coordination Regarding Unaccompanied Children" OEI-BL-20-00670 
OIG's work on this n:vit:w and draft rt:port asst:sst:s wordination within tht: Dt:partmt:nt of 
Health and Human Services (HHS) during the development and early implementation of a March 
2020 public health order affecting unaccompanied noncitizen children. Based on these findings, 
OIG issued two recommendations. 
CDC appreciates the opportunity to review and comment prior to release of the final report and 
submits the following in response to the OIG's recommendations. 
OIG Recommendation 1: 
OIG recommends that HHS take steps to improve internal coordination and communication 
about unaccompanied children 
CDC Response: 
CDC concurs with the recommendation. 
CDC agrees effective internal communication about policies affecting unaccompanied children is 
vital to effectively plan for facility capacity and programmatic needs.  CDC has a long-standing 
partnership and history of close coordination with the Administration for Children and Families 
(ACF), Office of Refugee Resettlement (ORR).  CDC will continue to improve internal 
coordination and communication efforts. 
CDC defers to HHS for specific recommendations regarding how best to address department 
wide communication gaps, policy development, and implementation. 
In a more recent example of effective coordination between CDC and ACF, CDC's Southwest 
Border team supports ORR by providing public health technical assistance and expertise on 
communicable disease control, COVID-19 mitigation efforts, outbreak response, and children's 
vaccination and safety and wellness.  CDC coordinates closely with ORR (staff and contractors) 
and Public Health Service officers to provide technical assistance.  CDC does this work in 
coordination and partnership with multiple federal partners including ORR, the Department of 
HHS Should Improve Internal Coordination Regarding Unaccompanied Children
OEI-BL-20-00670   Appendix C | 18  Inspector General 
Page2 
Homeland Security and Customs and Border Protection, and as part of the larger U.S. 
government activities. 
OIG Recommendation 2: 
OIG recommends that CDC coordinates with ORR when making future decisions that could 
affect the number of unaccompanied children placed in ORR's care, including any Title 42 order. 
CDC Response: 
CDC concurs with the recommendation. 
Recognizing the backdrop of this work was at the time of a pandemic when certain planning and 
processes that were prudent did not exist, these processes are being established. CDC, in 
coordination with other HHS components, is currently building this critical capacity through 
planning, lessons learned, and future exercises. 
With more recent examples during the pandemic, the agencies have been in close communication 
regarding Title 42, and ACF has provided input on the draft orders.  Since January 2021, CDC 
and ORR senior staff have been meeting regularly with other HHS components to resolve issues 
as they arise.  This close collaboration - which is happening at the senior level of both 
organizations - has further strengthened the relationship and coordination between the two 
agencies.  The COVID-19 pandemic is occurring at the same time as a global and ongoing child 
refugee crisis. It is HHS's collective goal to protect the health and wellbeing of these children as 
part of the overall U.S. government response. 
Rochelle P. Walensky, :MD, MPH 
Director, CDC 
HHS Should Improve Internal Coordination Regarding Unaccompanied Children
OEI-BL-20-00670   Appendix C | 19  ACKNOWLEDGMENTS AND CONTACT 
Acknowledgments 
Louise Schoggen served as the team leader for this study.  Others in the Office of 
Evaluation and Inspections who conducted the study include Bahar Adili and Louis 
Day. Office of Evaluation and Inspections staff who provided support include 
Christine Moritz and Mike Novello. 
We would also like to acknowledge the contributions of other Office of Inspector 
General staff, including Sara Bodnar, Laura Canfield, Sarai Infante, and Peter 
Taschenberger.   
This report was prepared under the direction of David Tawes, Regional Inspector 
General for Evaluation and Inspections in the Baltimore regional office; 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 
HHS Should Improve Internal Coordination Regarding Unaccompanied Children
OEI-BL-20-00670   Acknowledgments and Contact | 20  ABOUT THE OFFICE OF INSPECTOR GENERAL 
The mission of the Office of Inspector General (OIG), as mandated by Public Law
95-452, as amended, is to protect the integrity of the Department of Health and 
Human Services (HHS) programs, as well as the health and welfare of beneficiaries 
served by those programs.  This statutory mission is carried out through a nationwide 
network of audits, investigations, and inspections conducted by the following 
operating components: 
The Office of Audit Services (OAS) provides auditing services for HHS, 
either by conducting audits with its own audit resources or by overseeing audit work 
done by others. Audits examine the performance of HHS programs and/or its 
grantees and contractors in carrying out their respective responsibilities and are 
intended to provide independent assessments of HHS programs and operations.  
These audits help reduce waste, abuse, and mismanagement and promote economy 
and efficiency throughout HHS. 
The Office of Evaluation and Inspections (OEI) conducts national 
evaluations to provide HHS, Congress, and the public with timely, useful, and reliable
information on significant issues.  These evaluations focus on preventing fraud, waste, 
or abuse and promoting economy, efficiency, and effectiveness of departmental 
programs. To promote impact, OEI reports also present practical recommendations 
for improving program operations. 
The Office of Investigations (OI) conducts criminal, civil, and administrative 
investigations of fraud and misconduct related to HHS programs, operations, and 
beneficiaries. With investigators working in all 50 States and the District of Columbia, 
OI utilizes its resources by actively coordinating with the Department of Justice and 
other Federal, State, and local law enforcement authorities.  The investigative efforts
of OI often lead to criminal convictions, administrative sanctions, and/or civil 
monetary penalties. 
The Office of Counsel to the Inspector General (OCIG) provides 
general legal services to OIG, rendering advice and opinions on HHS programs and 
operations and providing all legal support for OIGs internal operations.  OCIG 
represents OIG in all civil and administrative fraud and abuse cases involving HHS 
programs, including False Claims Act, program exclusion, and civil monetary penalty 
cases. In connection with these cases, OCIG also negotiates and monitors corporate 
integrity agreements. OCIG renders advisory opinions, issues compliance program 
guidance, publishes fraud alerts, and provides other guidance to the health care 
industry concerning the anti-kickback statute and other OIG enforcement authorities. 
HHS Should Improve Internal Coordination Regarding Unaccompanied Children
OEI-BL-20-00670   About OIG | 21  ENDNOTES 
1 6 U.S.C.  279(g)(2). 
2 8 U.S.C.  1232(b)(3). 
3 8 U.S.C.  1232(c)(2)(A). 
4 Exceptions include influx care facilities and emergency intake sites; see Endnote 5.  In addition, the State of Texas announced 
in summer 2021 that it intended to discontinue the licenses of any facility providing care to unaccompanied children under 
agreement with HHS.  As a result, ORR issued a request for information to explore the possibility of providing Federal licenses
to ORR-funded facilities where States decline to license or otherwise exempt these facilities from needing licenses.  See: 86 Fed. 
Reg. 49549 (published on Sept. 3, 2021), Notice, Federal Licensing of Office of Refugee Resettlement Facilities Request for 
Information. 
5 ORR may activate and open an influx care facility when the net bed capacity of ORRs State-licensed shelters and transitional 
foster care programs is at or exceeds 85 percent for a period of 3 days.  (See: Office of Refugee Resettlement, ORR Guide: 
Children Entering the United States Unaccompanied,  7 Policies for Influx Care Facilities.)  In the event of a severe shortage of 
licensed facilities and influx facilities, ORR may open one or more emergency intake sites.  According to ORR field guidance, a 
severe shortage occurs when ORR is unable to accept referrals of children for placement in [S]tate-licensed facilities and influx 
care facilities that result or would result in unaccompanied children remaining in DHS custody for over 72 hours without a 
placement designation due to shortages of available [non-emergency intake site] ORR bed capacity. (See: Office of Refugee
Resettlement, ORR Field Guidance No. 13, Emergency Intake Sites (EIS) Instructions and Standards.)  Emergency intake sites 
were first established during a significant influx that began in spring 2021, after the period of OIGs review. 
6 Office of Refugee Resettlement, ORR Guide: Children Entering the United States Unaccompanied,  7 Policies for Influx Care 
Facilities. 
7 Office of Refugee Resettlement, ORR Field Guidance No. 13, Emergency Intake Sites (EIS) Instructions and Standards. 
8 42 U.S.C.  265. 
9 The statute assigns this authority to the Surgeon General of the Public Health Service; however, Reorganization Plan No. 3 of 
1966 transferred all statutory powers and functions of the Surgeon General and other officers of the Public Health Service and 
of all agencies of or in the Public Health Service to the Secretary of Health, Education, and Welfare, now the Secretary of Health 
and Human Services, who retains that authority today.  See 31 Fed. Reg. 8855 (June 25, 1966) and 20 U.S.C. Sec. 3508(b). 
10 Sections 361 through 369 of the Public Health Service Act (42 U.S.C.  264272) have been delegated from the HHS 
Secretary to the CDC Director. 
11 85 Fed. Reg. 16559 (published on Mar. 24, 2020, and effective on Mar. 20, 2020), Control of Communicable Diseases; Foreign 
Quarantine: Suspension of Introduction of Persons Into United States From Designated Foreign Countries or Places for Public 
Health Purposes. 
12 42 C.F.R. Part 71 (85 Fed. Reg. 56424 (published on Sept. 11, 2020, and effective on Oct. 13, 2020)), Control of Communicable 
Diseases; Foreign Quarantine: Suspension of the Right To Introduce and Prohibition of Introduction of Persons Into United 
States From Designated Foreign Countries or Places for Public Health Purposes.  There were several changes between the 
interim final rule and this final rule, including the use of the term quarantinable communicable disease in place of 
communicable disease and the addition of the requirement that the CDC Director include in the CDC order a statement of 
the serious danger posed by the introduction of the quarantinable communicable disease. 
HHS Should Improve Internal Coordination Regarding Unaccompanied Children
OEI-BL-20-00670   Endnotes | 22  13 85 Fed. Reg. 17060 (published on Mar. 26, 2020, and effective on Mar. 20, 2020), Notice of Order Under Sections 362 and 
365 of the Public Health Service Act Suspending Introduction of Certain Persons From Countries Where a Communicable 
Disease Exists. Additionally, CDC published an earlier notice informing the public of the Title 42 order.  See: 85 Fed. Reg. 16567 
(published on Mar. 24, 2020, and effective on Mar. 20, 2020), Order Suspending Introduction of Persons From a Country Where 
a Communicable Disease Exists. 
14 The initial March 2020 Order specifies a land Port of Entry (POE) or Border Patrol station (85 Fed. Reg. at 17061); however,
the extension issued in May 2020 amended the initial Title 42 Order to add the modifier coastal so that the Order expressly 
applied to land and coastal Ports of Entry and Border Patrol stations (85 Fed. Reg. at 31507). 
15 85 Fed. Reg. 17060 (published on Mar. 26, 2020, and effective on Mar. 20, 2020), Notice of Order Under Sections 362 and 
365 of the Public Health Service Act Suspending Introduction of Certain Persons From Countries Where a Communicable 
Disease Exists. 
16 Ibid. 
17 85 Fed. Reg. 22424 (published on Apr. 22, 2020, and effective on Apr. 20, 2020), Extension of Order Under Sections 362 and 
365 of the Public Health Service Act; Order Suspending Introduction of Certain Persons From Countries Where a 
Communicable Disease Exists. 
18 85 Fed. Reg. 31503 (published on May 26, 2020, and effective on May 21, 2020), Amendment and Extension of Order Under 
Sections 362 and 365 of the Public Health Service Act; Order Suspending Introduction of Certain Persons From Countries 
Where a Communicable Disease Exists. 
19 85 Fed. Reg. 65806 (published on Oct. 16, 2020, and effective on Oct. 13, 2020), Order Suspending the Right To Introduce 
Certain Persons From Countries Where a Quarantinable Communicable Disease Exists.  CDC has stated that this version of the 
order is substantially the same as the initial Title 42 order (85 Fed. Reg. at 65807).  
20 Flores v. Barr, No. CV 85-4544-DMG, In ChambersOrder Re Plaintiffs Motion to Enforce Settlement as to Title 42 Class 
Members [920], Sept. 4, 2020.  ORR reported to OIG that due to COVID-19 restrictions, its operational capacity was 30 to 40 
percent below its total bed capacity in August 2020.  OIG notes the small percentage of total bed capacity in use as of August 
2020 to illustrate the sudden and significant drop in the number of children in ORRs care compared to the level for which the 
program had previously been prepared to serve. 
21 P.J.E.S. v. Wolf, No. 20-2245, Memorandum Opinion, Nov. 18, 2020 (adopting the Magistrate Judges Report and 
Recommendation, Sept. 25, 2020). 
22 P.J.E.S. v. Mayorkas, No. 20-5357, Order, Jan. 29, 2021. 
23 Executive Order 14010 of February 2, 2021, Creating a Comprehensive Regional Framework To Address the Causes of
Migration, To Manage Migration Throughout North and Central America, and To Provide Safe and Orderly Processing of 
Asylum Seekers at the United States Border, 86 Fed. Reg. 8267 (Feb. 5, 2021). 
24 86 Fed. Reg. 9942 (published on Feb. 17, 2021, and effective on or about Jan. 30, 2021), Notice of Temporary Exception from 
Expulsion of Unaccompanied Noncitizen Children Encountered in the United States Pending Forthcoming Public Health
Determination. 
25 86 Fed. Reg. 38717 (published on July 22, 2021, and effective on July 16, 2021), Public Health Determination Regarding an 
Exception for Unaccompanied Noncitizen Children From the Order Suspending the Right To Introduce Certain Persons From 
Countries Where a Quarantinable Communicable Disease Exists.  This July 16, 2021, order supersedes the February 2021 notice 
that provided for a temporary exception from expulsion for unaccompanied children. 
26 86 Fed. Reg. 42828 (published on Aug. 5, 2021, and effective on Aug. 2, 2021), Public Health Reassessment and Order 
Suspending the Right To Introduce Certain Persons From Countries Where a Quarantinable Communicable Disease Exists. 
27 87 Fed. Reg. 15243 (published on Mar. 17, 2022, and implemented on Mar. 11, 2022). 
HHS Should Improve Internal Coordination Regarding Unaccompanied Children
OEI-BL-20-00670   Endnotes | 23  28 At the time of this reports publication, there is active litigation that could affect the Title 42 order. 
29 HHS-OIG, Unaccompanied Alien Children Care Provider Facilities Generally Conducted Required Background Checks but Faced 
Challenges in Hiring, Screening, and Retaining Employees, A-12-19-20001, September 2019. Available at 
https://oig.hhs.gov/oas/reports/region12/121920001.pdf. 
30 HHS-OIG, Separated Children Placed in Office of Refugee Resettlement Care, OEI-BL-18-00511, January 2019.  Available at 
https://oig.hhs.gov/oei/reports/oei-BL-18-00511.pdf. Following OIGs report, HHS identified an additional 1,556 children that 
were separated and referred to ORR after July 1, 2017.  An interagency task force is currently reviewing records from January 
20, 2017, through January 20, 2021, to determine whether additional family separations occurred. 
31 HHS-OIG, Care Provider Facilities Described Challenges Addressing Mental Health Needs of Children in HHS Custody, OEI-09-
18-00431, September 2019.  Available at https://oig.hhs.gov/oei/reports/oei-09-18-00431.pdf. 
32 HHS-OIG, Communication and Management Challenges Impeded HHS's Response to the Zero-Tolerance Policy, OEI-BL-18-
00510, March 2020.  Available at https://oig.hhs.gov/oei/reports/oei-BL-18-00510.pdf. 
33 HHS-OIG, The Office of Refugee Resettlements Incident Reporting System Is Not Effectively Capturing Data To Assist Its Efforts 
To Ensure the Safety of Minors in HHS Custody, OEI-09-18-00430, June 2020.  Available at https://oig.hhs.gov/oei/reports/oei-
09-18-00430.pdf. 
34 HHS reported to OIG that day-to-day responsibility for these children was delegated to DHS through the Title 42 order; the 
order does not explicitly discuss care of children but states that the CDC Director requested that DHS implement the order.
After a court-appointed independent monitor raised concerns about the care provided to these children, a district court 
ordered DHS to stop placing minors at hotels, with the exception that DHS may, as necessary and in good faith to alleviate 
bottlenecks in the intake process, implement brief stays of not more than 72 hours before transferring minors to ORR-funded 
licensed facilities.  After granting a series of temporary stay orders, the district courts ruling ultimately went into effect on 
October 4, 2020, and was affirmed on appeal by the 9th Circuit in June 2021.  See: Flores v. Barr, No. CV-85-4544-DMG, In 
ChambersOrder Re Plaintiffs Motion to Enforce Settlement as to Title 42 Class Members [920], Sept. 4, 2020; Flores v. Barr, 
No. CV-85-4544-DMG, In ChambersOrder Re Defendants Ex Parte Application to Stay [985], Sept. 21, 2020; Flores v. Barr, 
No. 20-55951, Order, Oct. 4, 2020; Flores v. Garland, Nos. 20-55951 and 20-56052, Opinion, June 30, 2021.  
35 Court documents in related litigation note a small number of cases in which children were placed in ORR custody prior to 
expulsion under the Title 42 order; in one case a child was transferred from an ORR facility to a hotel prior to expulsion.  See: 
Flores v. Barr, No. CV 85-4544-DMG, In ChambersOrder Re Plaintiffs Motion to Enforce Settlement as to Title 42 Class 
Members [920], Sept. 4, 2020. 
36 82 Fed. Reg. 6890 (published on Jan. 19, 2017, and effective on Feb. 21, 2017), Control of Communicable Diseases. 
37 The Title 42 Order states that DHS shall consult with CDC concerning how these types of case-by-case, individualized 
exceptions shall be made to help ensure consistency with current CDC guidance and public health assessments. 
HHS Should Improve Internal Coordination Regarding Unaccompanied Children
OEI-BL-20-00670   Endnotes | 24