U.S. Department of Health and Human Services

Office of Inspector General

Communication and 

Management 

Challenges Impeded 

HHS’s Response to 

the Zero-Tolerance 

Policy

Christi A. Grimm

Principal Deputy 

Inspector General

OEI-BL-18-00510

March 2020

oig.hhs.gov
Why OIG Did This Review

Within HHS, the Unaccompanied Alien 

Children (UAC) Program serves minors 

who have no lawful immigration status 

in the United States and do not have a 

parent or legal guardian available in 

the United States to provide care and 

physical custody. A network of more 

than 100 HHS-funded care provider 

facilities furnish housing, food, 

medical care, mental health services, 

educational services, and recreational 

activities for such children until HHS 

can identify an appropriate sponsor 

(typically a parent or close relative) to 

take custody. 

In 2017 and 2018, DOJ and DHS took 

steps to increase enforcement of 

immigration laws, culminating in the 

spring 2018 implementation of a zerotolerance policy for some immigration 

offenses. Under that policy, large 

numbers of families entering the 

United States without authorization

were separated by DHS. Typically, 

adults were held in Federal detention 

while their children were placed in 

HHS custody and provided care 

through the UAC Program. 

On June 26, 2018, a Federal district 

court halted further family separations 

(subject to some exceptions) and 

ordered the Federal Government to 

quickly reunify separated families who 

met certain criteria. 

Given the impact of the zerotolerance policy on vulnerable 

children and families, OIG conducted 

this review to examine challenges that 

HHS and care provider facilities faced

in responding to the policy and 

carrying out the court-ordered 

reunification effort. We also sought to 

identify actions that HHS can take to 

improve program operations.

Communication and Management Challenges Impeded 

HHS’s Response to the Zero-Tolerance Policy

What OIG Found 

Interagency communication failures and 

poor internal management decisions left 

HHS unprepared for the zero-tolerance 

policy. Specifically, interagency channels 

for coordinating immigration policy

across Federal departments were not 

used to notify HHS of the zero-tolerance 

policy in advance. Meanwhile, key senior 

HHS officials did not act on staff’s 

repeated warnings that family separations 

were occurring and might increase. 

HHS’s lack of planning for the possibility 

of larger-scale family separation left the 

Department unable to provide prompt 

and appropriate care for separated 

children when the zero-tolerance policy

was implemented. Without sufficient bed 

capacity, HHS could not always place 

separated children in care provider 

facilities within 72 hours (as required by 

law), leaving hundreds inappropriately 

detained in Department of Homeland 

Security (DHS) custody. Care provider 

facilities facing an unexpected increase in 

young, separated children encountered numerous challenges to meeting their 

unique needs. Further, because no procedures or systems had been established to 

track separated families across HHS and DHS for later reunification, HHS struggled 

to identify separated children. HHS also experienced challenges coordinating the 

reunification effort under overlapping court-imposed requirements.

Additionally, OIG found that care provider facilities faced significant operational 

challenges at every stage of the reunification process. Facilities encountered 

difficulties locating and communicating with parents in DHS or Department of 

Justice (DOJ) custody as well as determining whether parents and children could be 

safely reunified. Facilities also reported that guidance and directives from HHS 

related to separated children were poorly communicated.

HHS has taken steps to improve tracking of separated children, but the procedures 

rely on manual processes that are vulnerable to error. HHS also continues to 

experience difficulties obtaining information from DHS about parents’ criminal 

backgrounds, impeding HHS’s ability to provide appropriate care and identify 

sponsors to whom children can be safely released.

Report in Brief

March 2020

OEI-BL-18-00510

U.S. Department of Health and Human Services

Office of Inspector General

Key Takeaways

• Poor interagency 

communication and internal 

management decisions that 

failed to protect children’s 

interests left HHS unprepared 

for the zero-tolerance policy

• This lack of preparation 

impeded HHS’s ability to 

identify, care for, and reunify 

separated children

• Care provider facilities faced 

significant operational 

challenges at every stage of 

reunification, causing 

additional stress to children

• HHS has taken steps to 

improve tracking and 

placement of separated 

children, but vulnerabilities 

remain
How OIG Did This Review

This report synthesizes information 

from interviews with, and written 

responses from, senior HHS officials 

and HHS staff (see page 10 for 

definitions of these terms); interviews 

with staff at 45 care provider facilities; 

case reviews for a purposive sample of 

separated children; and more than 

5,000 documents obtained through 

requests to the Department, from 

facility staff, and from interview 

respondents. We reviewed 

documents internal to HHS as well as 

interagency correspondence and 

records that involved HHS senior 

officials and staff. 

We analyzed interview and 

documentary data to identify 

significant challenges that HHS and 

facilities faced in responding to the 

zero-tolerance policy and reunifying 

separated children, as well as factors 

that contributed to those challenges. 

Regarding factors affecting HHS, we 

identified themes across multiple 

respondents and sought to 

corroborate their statements with 

other interviewees and 

documentation. Regarding challenges 

faced by facilities, we sought to 

identify the most significant challenges 

reported by facility staff and Federal 

field specialists. Each of the key 

challenges we discuss was reported by 

the majority of facilities in our review. 

We also reviewed internal HHS 

documents as well as public materials 

such as court filings to establish 

specific facts (e.g., dates and topics of 

meetings); to confirm timelines (e.g., 

dates of guidance communications); 

and, when possible, to verify interview 

responses (e.g., by identifying emails 

or memos consistent with 

interviewees’ statements). 

Report in Brief continued

Report No. OEI-BL-18-00510

What OIG Recommends

HHS confronted significant challenges to its ability to respond effectively to the 

zero-tolerance policy and reunify children separated from their parents by 

immigration authorities. HHS was not responsible for separating families, but HHS’s 

inadequate communication, management, and planning made the situation worse 

for many separated children. OIG’s review focused on challenges related to the 

zero-tolerance policy, but many issues we identified speak to broader management 

concerns. To address these challenges and improve program operations, OIG 

recommends the following:

HHS should take steps to ensure that children’s interests are prioritized and 

represented in decisions affecting the UAC Program, both internally and when 

engaging with interagency partners. As the UAC Program is called to adapt to 

changes in policy and immigration trends beyond its control, HHS leadership must 

ensure that the Department centers children’s interests in its internal decisionmaking as well as in the information and recommendations it provides to 

interagency partners. Internally, HHS leadership should ensure that potential risks 

to children are explicitly assessed, ensure that staff are permitted to document 

concerns about children’s well-being, and communicate to officials and staff at all 

levels that concerns about potential harm to children in HHS custody should be 

expressed and will be taken seriously.

HHS should modify or pursue formal agreements with DHS and DOJ to ensure

that it is receiving information that supports its operation of and ability to 

provide care for children in the UAC Program. These agreements should include 

specific mechanisms and timeframes to enable effective interagency notification 

about changes to immigration policy and enforcement initiatives that may 

foreseeably affect HHS’s responsibilities. Additionally, the agreement with DHS

should ensure that DHS is fully responsive to HHS’s informational needs, including 

information about parents’ locations in detention and their criminal histories, so that 

HHS and its facilities can provide optimal care and release children to suitable 

sponsors. HHS should also explore with DHS options for data system improvements 

to enable more efficient and accurate information-sharing to support the UAC 

Program mission. With respect to DOJ, the agreement should ensure HHS access to 

information about parents in U.S. Marshals’ custody. 

HHS should improve communication to care provider facilities regarding 

interim guidance, operational directives, and other instructions that are not 

immediately available in published policy documents. Given the ongoing 

potential for changes in policy affecting the UAC Program, HHS will likely have 

future need to communicate information to its network of facilities quickly, 

accurately, and in such a manner that facility staff can easily determine what 

guidance is active.

HHS should further improve its ability to identify and track separated children

by reducing reliance on manual processes. HHS should streamline its procedures 

for tracking separated children to reduce reliance on manual, multistep processes 

that are inherently vulnerable to error. In particular, HHS should identify and resolve

barriers to automating exchange of separation information between DHS and HHS.

Full report can be found at oig.hhs.gov/oei/reports/oei-BL-18-00510.asp.
TABLE OF CONTENTS

BACKGROUND 1

Methodology 9

FINDINGS

Part I: Factors That Affected HHS’s Ability To Respond to the Zero-Tolerance Policy and 

Manage the Reunification Effort

13

Interagency channels intended to facilitate coordination were not used to notify HHS 

of the zero-tolerance policy in advance

14

Key senior HHS officials failed to act on repeated warnings from staff; as a result, HHS 

did not plan for family separation

15

The lack of planning for zero-tolerance hindered HHS’s ability to provide prompt and 

appropriate care for separated children

20

The lack of planning also contributed to data limitations, complicating efforts to 

identify separated children

22

HHS experienced challenges coordinating the reunification effort under overlapping 

court-imposed requirements

23

Part II: Factors That Affected Care Provider Facilities’ Ability To Reunify Separated Children

With Their Parents

24

Care provider facilities experienced difficulties in locating and communicating with 

parents of separated children

25

Care provider facilities encountered challenges to determining whether parents and 

children could be safely reunified 

27

Care provider facilities described coordination problems that impeded efforts to 

reunify separated children with their parents

30

Care provider facilities reported that guidance and directives from ORR were poorly 

communicated and caused confusion

32

Part III: Factors Affecting HHS’s Ongoing Efforts To Improve Tracking and Placement of 

Separated Children

36

Despite efforts to improve tracking of separated children, current procedures rely on 

manual processes that are vulnerable to error

37

HHS does not consistently receive complete information from DHS about parents’ 

criminal backgrounds

38
CONCLUSION AND RECOMMENDATIONS

HHS should take steps to ensure that children’s interests are prioritized and represented in 

decisions affecting the UAC Program, both internally and when engaging with interagency

partners

39

HHS should modify or pursue formal agreements with DHS and DOJ to ensure that it is 

receiving information that supports its operation of and ability to provide care for children in 

the UAC Program 

40

HHS should improve communication to care provider facilities regarding interim guidance, 

operational directives, and other instructions that are not immediately available in published 

policy documents

42

HHS should further improve its ability to identify and track separated children by reducing 

reliance on manual processes 

42

AGENCY COMMENTS AND OIG RESPONSE 43

APPENDICES

A: Timeline of Key Events 45

B: Previous Related Office of Inspector General Work 47

C: Lines of Authority Over the Unaccompanied Alien Children Program During the Period of 

Review

48

D: Care Provider Facilities Visited by OIG 49

E: Detailed Methodology 53

F: Timeline of Key Guidance to Care Provider Facilities Regarding Separated Children 58

G: Agency Comments 61

ACKNOWLEDGMENTS 65
Communication and Management Challenges Impeded HHS’s Response to the Zero-Tolerance Policy 1

OEI-BL-18-00510

BACKGROUND

In 2017 and 2018, the Department of Justice (DOJ) and Department of 

Homeland Security (DHS) took steps to increase enforcement of 

immigration laws, culminating in the spring 2018 implementation of a “zerotolerance” policy for certain immigration offenses. Under that policy, large 

numbers of families entering the United States without authorization were 

separated by DHS. Typically, adults were held in Federal detention while 

their children were transferred to the care of the Office of Refugee 

Resettlement (ORR) within the Department of Health and Human Services 

(HHS or Department). A June 20, 2018, Executive Order curtailed the policy 

but did not address reunification of families already separated. On June 26, 

2018, a Federal district court issued a preliminary injunction prohibiting

family separations (subject to some exceptions) and ordered the Federal 

Government to quickly reunify separated families who met certain criteria. 

Given the impact of the zero-tolerance policy on vulnerable children and 

families, the Office of Inspector General (OIG) conducted this review to 

examine challenges that HHS and care provider facilities faced and identify 

opportunities for program improvement. 

Objectives

1. To identify challenges that the Department of Health and Human 

Services (HHS) faced in responding to the zero-tolerance policy

2. To identify challenges that HHS and care provider facilities faced 

in reunifying separated children with their parents as directed by 

a Federal district court

Background ORR Care of Unaccompanied Alien Children (UAC)

ORR, a program office of the Administration for Children and Families (ACF)

within HHS, manages the UAC Program. Children referred to the UAC

Program are minors who have no lawful immigration status in the United 

States and do not have a parent or legal guardian available in the United 

States to provide care and physical custody.1 In Federal fiscal year 2018, the 

UAC Program received appropriations of $1.6 billion and cared for at least 

49,100 children.2,3

The UAC Program serves children who arrive in the United States 

unaccompanied, as well as children who are separated from their parents or 

legal guardians by immigration authorities within DHS after entering the 

country (separated children). By law, DHS must transfer unaccompanied 

children to ORR within 72 hours from the determination that the child is a 

UAC unless there are exceptional circumstances.4 A child remains in ORR 
Communication and Management Challenges Impeded HHS’s Response to the Zero-Tolerance Policy 2

OEI-BL-18-00510

custody until an appropriate sponsor (usually a parent or close relative) is 

located in the United States who can assume custody, the child turns 

18 years old and ages out of the UAC Program, or the child’s immigration 

status is resolved.5 

Federal law requires the safe and timely placement of children in the least 

restrictive setting that is in the best interest of the child.6To that end, ORR 

funds a network of more than 100 care provider facilities (facilities) that 

furnish temporary care for children until they are released to a sponsor or 

otherwise leave ORR custody. These facilities, generally, are State-licensed 

and must meet ORR requirements.7Facilities provide housing, food, 

medical care, mental health services, educational services, and recreational 

activities. 

ORR Identification and Assessment of Sponsors

ORR is responsible for identifying a suitable sponsor in the United States 

who can care for the child when he or she leaves ORR custody. Most 

sponsors are a parent or close relative of the child. 8, 9 When ORR cannot 

identify a suitable, safe sponsor, children will remain in a facility or may be 

placed in long-term foster care, including community-based foster care or a 

group home. Children who turn 18 years old while in ORR care are typically 

transferred to DHS custody. 

The process for releasing a child in ORR’s care to a sponsor includes:

Identifying a sponsor. Staff at the facility where the child resides interview 

the child, parents, legal guardians, or other family members (including those 

in their home country) to identify potential sponsors in the United States.

Sponsor submission of application for release. The potential sponsor must 

complete and submit a variety of documents, including a Sponsor Care 

Agreement and documentation to verify identity, address, and relationship 

to the child. 

Background checks. ORR requires a background check of potential sponsors 

and adult members of a sponsor’s household. These may include a public 

records check, sex offender registry check, State child abuse and neglect 

registry check, immigration status check, and a Federal Bureau of 

Investigation (FBI) criminal history check (based on fingerprints).10 ORR 

conducts additional checks (such as a State-based criminal history and local 

police checks) on a case-by-case basis.

Home study. Facility staff review each child’s case to determine whether to 

recommend a home study of the potential sponsor. Federal law requires a 

home study when the child is a victim of trafficking or physical or sexual 

abuse, when the child has a disability, or when the proposed sponsor 

presents a risk to the child.11
Communication and Management Challenges Impeded HHS’s Response to the Zero-Tolerance Policy 3

OEI-BL-18-00510

Release decision. Facility staff consider all relevant information and make a 

recommendation to ORR regarding the child’s release to a potential 

sponsor. ORR staff then make one of the following determinations: 

• approve the release, 

• approve with post-release services, 

• require a home study before making a decision, 

• deny the release, or 

• remand for further information.

ORR and Facility Staff Roles and Responsibilities

ORR and facility staff are responsible for ensuring quality of care for children 

in ORR custody as they await release to a sponsor or judicial resolution of 

their immigration status. Key staff include:

Federal Field Specialists. Federal field specialists are ORR employees who 

serve as local ORR liaisons to one or more facilities within a region. They 

are responsible for providing guidance and technical assistance to facilities 

and approving or denying children’s transfer between ORR facilities and 

release to sponsors.

Program Directors. Program directors are senior facility staff who manage 

facility employees and oversee facility operations. 

Medical Coordinators. Medical coordinators are facility staff who arrange 

care from external providers, coordinate other services related to children’s 

medical and mental health care, and manage medication. 

Mental Health Clinicians. Mental health clinicians are facility staff who are 

responsible for providing in-house mental health care for children in the 

facility. 

Case Managers. Case managers are facility staff who coordinate 

assessments of children, individual service plans, and efforts to release 

children to sponsors. 

Youth Care Workers. Youth care workers are facility staff who provide 

around-the-clock monitoring of children. Youth care workers have direct 

and frequent contact with children and are the staff primarily responsible for 

their supervision.

Coordination Between HHS and DHS

Federal law and two Memoranda of Agreement (MOAs) between HHS and 

DHS formally delineate each agency’s responsibilities with respect to 

children eligible for the UAC Program: 

• Federal laws broadly describe the Agencies’ roles as they relate to 

notification, transfer, placement, sponsor assessment, and 

postrelease activities.12 

• An MOA signed in February 2016 establishes a framework for 

interagency coordination on establishing procedures and shared 
Communication and Management Challenges Impeded HHS’s Response to the Zero-Tolerance Policy 4

OEI-BL-18-00510

goals. Under the 2016 MOA, the Agencies also agree to develop a 

Joint Concept of Operations.13 

• A second MOA, signed in April 2018, sets out expectations and 

general processes for sharing information between DHS and ORR at 

the time of a child’s referral, while the child is in ORR care, while 

vetting potential sponsors for the child, and upon the child’s release 

from ORR care.

14 Among other provisions, the MOA stipulated that 

ORR will provide DHS with biographic information and fingerprints 

of potential sponsors and all adult members of their households, 

which DHS will use to ascertain criminal and immigration history for 

these individuals. (ORR subsequently modified its policy to require 

fingerprints only for certain categories of sponsors.)15 The 2016 

MOA also remains in effect and is not superseded by the 2018 MOA. 

Federal law, the 2016 MOA, and the 2018 MOA do not specifically define or 

address separated children as distinct from children who arrive in the United 

States without a parent or legal guardian. Additionally, although the 2018 

MOA specifies that DHS will provide HHS with a variety of biographic, 

immigration, and criminal history about children at the time of transfer, the 

agreement does not extend to identifying information about, or criminal 

histories of, family members apprehended with children.

On July 31, 2018 (after issuance of the zero-tolerance policy and the 

subsequent Executive Order and court order limiting further family 

separations), HHS and DHS finalized the Joint Concept of Operations

described in the 2016 MOA. The Joint Concept of Operations provides field 

guidance and standardization of interagency policies, procedures, and 

guidelines related to UAC. For example, it states that the referring DHS 

agency—Customs and Border Protection (CBP) or Immigration and Customs 

Enforcement (ICE)—should review and verify children’s medical and 

disability information, criminal records, languages spoken, other family with 

whom the child was traveling, and those family members’ contact 

information. If a child has been separated from a parent or legal guardian, 

the referring DHS agency is directed to enter that information into ORR’s 

online case management system, known as the UAC Portal.

Federal Policies and Practices Resulting in Family Separation

In recent years, DOJ and DHS have taken a variety of actions to increase 

enforcement of immigration laws. (See Exhibit 1. Also, see Appendix A for a 

detailed list of events relevant to family separation and reunification.) On 

April 11, 2017, the Attorney General issued a memorandum instructing 

Federal prosecutors to prioritize prosecution of certain immigration 

offenses, including offenses under 8 U.S.C. § 1325(a), which addresses 

attempts by an individual who is not a U.S. citizen to enter the country at an 

unauthorized time or place.16 From July through November 2017, the El 

Paso sector of CBP conducted a prosecution initiative that resulted in 

increased family separations; CBP has stated that 283 parents were referred 

March 2017

DHS Secretary states publicly 

that DHS might separate families 

who enter the United States 

without authorization; weeks 

later, he announces DHS will not 

pursue the policy.

April 2017

Attorney General issues 

memorandum prioritizing 

prosecution of immigration 

offenses.

July 2017

El Paso sector of CBP 

implements policies resulting in 

increased family separations.

February 2018

Ms. L v. ICE lawsuit is filed.

April 2018

Attorney General issues 

memorandum instituting zerotolerance policy at DOJ.

May 2018

DHS adopts zero-tolerance; the 

Attorney General publicly 

announces the policy’s 

implementation at DOJ and DHS.

June 2018

President Trump issues Executive 

Order directing DHS to detain 

alien families together.

June 2018

Court orders Federal 

Government to cease most 

family separations and reunite 

eligible families.

July 2018

HHS identifies 2,654 separated 

children under Ms. L v. ICE.

December 2018

After multiple revisions, HHS 

reports a new total of 2,737 

separated children under Ms. L v. 

ICE. (See Endnote 28.)

March 2019

Court expands the Ms. L class to 

include parents who entered the 

United States on or after July 1, 

2017, with children from whom 

they were separated.

October 2019

HHS identifies an additional 

1,556 separated children under 

the expanded Ms. L class.

Source: OIG analysis of memoranda, court 

filings, and other public documents, 2019.

Exhibit 1. Family Separation

and Reunification: Key Events
Communication and Management Challenges Impeded HHS’s Response to the Zero-Tolerance Policy 5

OEI-BL-18-00510

for prosecution under this initiative, but the number of children separated 

from those parents and referred to ORR has not been reported.

17

 On April 

6, 2018, the Attorney General issued a memorandum directing U.S. 

Attorney’s Offices along the Southwest border to immediately adopt a 

“zero-tolerance policy” for all offenses referred for prosecution under 8 

U.S.C. § 1325(a).18 On May 5, 2018, DHS also adopted the zero-tolerance 

policy.19 On May 7, 2018, the Attorney General announced the joint DOJ 

and DHS implementation of the zero-tolerance policy, stating that DHS 

would now refer all illegal Southwest border crossings to DOJ for 

prosecution, and that DOJ would accept those cases.20

Under the zero-tolerance policy, similar to the more limited El Paso sector 

initiative that preceded it, when a child and parent were apprehended 

together by immigration authorities, DHS separated the family and the 

parent was placed in Federal custody to await prosecution for illegal entry. 

With the detained parent unavailable to care for his or her child, the child 

was treated as unaccompanied and transferred to ORR. This represented a 

significant departure from previous practices: historically, separations were 

rare and occurred only when the parent posed a danger to the child or was 

medically unable to care for the child.

On June 20, 2018, the President issued Executive Order 13841, which 

directed DHS to detain alien families together whenever “appropriate and 

consistent with the law and available resources.” The Executive Order did 

not address reunification of families already separated.21 

Judicial Actions Affecting Family Separation and Reunification

Federal policies and practices resulting in family separation have led to 

multiple lawsuits. Court orders in these lawsuits have curtailed the 

separation and deportation of families apprehended by immigration 

authorities and have required the Government to reunify separated parents 

and children, subject to certain conditions and deadlines. 

Most prominent—and with the most substantive consequences for the 

Federal Government—is the class action lawsuit Ms. L v. ICE. A June 26, 

2018, preliminary injunction order in this case reshaped policy and 

requirements around family separations in two important ways. First, the 

court preliminarily enjoined DHS from continuing to separate families, 

subject to certain exceptions, ruling that the Government likely violated

plaintiffs’ Fifth Amendment due process rights to family integrity.

22, 23

 

Second, for those Ms. L v. ICE class members who were separated from their 

children and the children were still in ORR custody as of the date of the 

ruling, the court ordered the Federal Government to reunify class members 

with their minor children within 14 days for children younger than 5 years

old and 30 days for those aged 5 to 17 years.

24

 On March 8, 2019, the court 

expanded the Ms. L v. ICE class definition to include parents who were 

separated from their children, and whose children were referred to and 

discharged from ORR custody, from July 1, 2017, through June 25, 2018.25 
Communication and Management Challenges Impeded HHS’s Response to the Zero-Tolerance Policy 6

OEI-BL-18-00510

Several other lawsuits have been filed on behalf of separated parents or 

children in various courts around the country. Actions in these lawsuits have 

sometimes also affected children of Ms. L class members. For example, in 

N.T.C. v. ICE, a Federal court in New York ordered that separated children in 

ORR care in New York State may not be moved to a different State unless 

the Government provided 48 hours’ advance notice to the child and his or 

her attorneys.26 

Efforts To Identify and Reunify Separated Children

In June 2018, HHS and DHS did not routinely collect and share the 

information necessary to identify, track, or connect families separated by 

DHS. Compliance with the Ms. L v. ICE court order of June 26, 2018, 

therefore required both HHS and DHS to undertake a significant new effort 

to rapidly identify children in ORR care who had been separated from their 

parents and reunify them. To facilitate this effort, the HHS Secretary 

(Secretary) directed the Office of the Assistant Secretary for Preparedness 

and Response (ASPR), a staff division within the Office of the Secretary with 

experience in crisis response and data management, to lead the 

reunification effort for HHS. (See Exhibit 2 for a summary of Federal entities’ 

roles in the court-ordered reunification effort.)

• ASPR: Leads HHS medical and public health 

preparedness for and response to disasters and 

public health emergencies. Established Incident 

Management Team (IMT) to lead the reunification 

effort. 

• U.S. Public Health Service: Responds to public 

health needs. U.S. Public Health Service 

Commissioned Corps officers were deployed 

across the country to assist with the reunification 

effort. 

• ORR: As a program office within ACF, manages 

the UAC Program to ensure care and safe 

placement of children; provides guidance to care 

provider facilities. Worked with ASPR, including 

contributing staff to the IMT, to coordinate 

reunification effort. 

o Care provider facilities: As ORR-funded 

grantees or contractors, provide care for 

children in ORR custody. Managed 

individual separated children's cases, 

including locating and contacting parents 

and facilitating reunification. 

HHS

• CBP: Provides border security at and between 

ports of entry; apprehends, processes, and 

temporarily detains individuals who enter the 

United States without authorization, including 

children; may refer adults entering the United 

States without authorization for criminal 

prosecution. Provided HHS with data to assist in 

identifying separated children under Ms. L. 

• ICE: Enforces immigration law; is responsible for 

detention and removal of non-citizens; transfers 

children to ORR. Provided HHS with data to assist 

in identifying separated children under Ms. L; 

oversaw ICE detention centers that served as 

reunification sites. 

DHS 

• U.S. Marshals Service: Takes custody of 

individuals referred by CBP for prosecution by U.S. 

Attorneys’ Offices in Federal court and remanded 

by a judge; transports them and houses them in 

Federal, State, or local jails pending outcome of 

criminal proceedings. Individuals prosecuted for 

illegal entry usually are referred back to ICE until 

they are removed or receive immigration relief. 

DOJ 

Source: OIG analysis, 2019.

Exhibit 2. Key Federal Entities Involved in the Court-Ordered Reunification Effort
Communication and Management Challenges Impeded HHS’s Response to the Zero-Tolerance Policy 7

OEI-BL-18-00510

Interagency Plan for Reunification Under Ms. L v. ICE

HHS coordinated closely with DHS and DOJ to develop a joint plan outlining 

the Agencies’ response to the court order in Ms. L v. ICE. The plan, dated

July 18, 2018, describes processes to reunify Ms. L class members with their 

children.27 These steps include conducting background checks of the 

parent, confirming parentage, assessing parental fitness and child safety 

(including a home study if warranted), conducting a parent interview, and 

reunification with the parent if eligible. According to the plan, examples of 

criteria that would preclude reunification with the parent from whom the 

child was separated include:

• the parent is in the custody of the U.S. Marshals Service or in a State 

jail; 

• the parent is being treated for a communicable disease; 

• the child has already been reunified with the other parent; or 

• the parent has a criminal record and may pose a safety risk to the 

child. 

Reunification was not pursued if the parent declined to be reunified with the 

child, as evidenced by signing a voluntary Letter of Designation consenting 

to the child’s placement with a sponsor. 

This reunification process was a more streamlined version of ORR’s standard 

procedure for vetting a sponsor. For example, in summer 2018, ORR’s 

standard process required a prospective sponsor to submit a Sponsor Care 

Plan and required an FBI fingerprint background check on all adults who 

would reside in a household with the child being released from ORR care. 

However, for Ms. L v. ICE class members, the court ruled that those 

procedures were designed for children who had entered the United States 

unaccompanied and were unnecessarily onerous when applied to parents 

and children who were apprehended together but separated by 

Government officials.

28

If ORR determined that a child subject to the Ms. L v. ICE reunification order 

could not be reunified with the parent from whom he or she was separated 

(e.g., due to parental unfitness or danger to the child), ORR followed its 

usual sponsorship procedures for unaccompanied children. For all 

placements, ORR prioritizes parents and close relatives when selecting 

sponsors.

Role of the Incident Management Team

Within HHS, ASPR created an IMT to directly oversee the reunification 

mission. The IMT utilized the Secretary’s Operation Center, a command 

center that can operate 24 hours per day, 365 days per year, and is 

designed for operations with complex communication and data analysis 

needs. At its peak, the IMT included more than 60 staff in Washington, DC,

and more than 250 field staff, including approximately 140 contractors. 
Communication and Management Challenges Impeded HHS’s Response to the Zero-Tolerance Policy 8

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The IMT worked closely with interagency partners to identify separated 

families, develop the interagency reunification plan described above, and to 

establish logistical processes for reunification. An interagency data team 

was tasked with analyzing multiple data sources to identify separated 

children covered by the court order. The IMT then collaborated with DHS, 

DOJ, and the Department of State to reunify children with parents in ICE 

custody (subject to an HHS determination that reunification would not pose 

a danger to the child), with DHS and HHS transporting separated parents 

and children, respectively, to selected ICE detention centers that served as 

reunification sites. At the reunification sites, HHS transferred custody of 

separated children to ICE, which then facilitated physical reunification of the 

family. The IMT developed separate processes to reunify children with 

parents who had been released into the interior of the United States, as well 

as those who were no longer in the United States—a particularly complex 

endeavor that required coordination across Federal agencies and with the 

consulates and embassies of children’s home countries, as well as with legal 

counsel for the Ms. L class.

Status of the Reunification Effort

As of January 2020, HHS and DHS reported to the Ms. L court that 2,168

children had been reunited with the parent from whom they had been 

separated, and that an additional 626 children had been discharged under 

other circumstances, such as being released to a sponsor or after turning 18 

(which typically results in transfer to DHS custody). HHS reported that only

one separated child of a Ms. L class member (as the class was originally 

defined in June 2018) still remained in ORR care; that child’s parent is 

presently not in the United States, and efforts are being made to establish 

whether the parent wishes for the child to be reunified and repatriated or 

placed with a qualified sponsor in the United States. An additional 

20 children originally identified as possible children of potential Ms. L class 

members remain in ORR care, but HHS has determined that their parents 

are not in fact class members (e.g., because of criminal history or because 

the parent chose to decline reunification so that their child may remain in 

the United States with a sponsor). Together, these children represent all 

2,815 potential children of possible Ms. L class members who were in ORR 

care as of June 26, 2018, the date of the original court order requiring 

reunification for this population.29 Prior court filings noted that 2,737 

children in this group were confirmed to have been separated; for 

transparency, HHS has continued to report the status of all 2,815 identified 

to the court as potential children of class members, including those later 

determined not to have been separated from a parent. 

As a result of the recent expansion of the Ms. L class to encompass parents 

who entered the United States on or after July 1, 2017, HHS recently 

identified 1,556 additional separated children under the expanded class 

criteria. These children were discharged from HHS care (e.g., to sponsors) 
Communication and Management Challenges Impeded HHS’s Response to the Zero-Tolerance Policy 9

OEI-BL-18-00510

prior to June 26, 2018. Efforts to contact their parents are ongoing, under 

the leadership of a court-appointed Steering Committee.

Related HHS OIG Work

In January 2019, OIG found that the total number of separated children 

placed in ORR care as a result of DHS practices to increase immigration 

enforcement (including but not limited to the subset of separated children 

covered by the Ms. L v. ICE litigation) was unknown but likely significantly

more than the 2,737 separated children of Ms. L v. ICE class members who 

were identified by HHS as of the time of our review.

30 Additionally, OIG 

found that some separations have continued since the court order. 

Subsequent court filings by the Government have confirmed both findings.

In September 2019, OIG found that facilities struggled to address the mental 

health needs of children who had experienced intense trauma, including 

separated children, and had difficulty accessing specialized treatment for 

children who needed it. Facilities also reported that challenges employing 

mental health clinicians resulted in high caseloads and limited their 

effectiveness in addressing children’s needs. 

In another September 2019 review, OIG found that facilities generally met a 

range of background checks and qualification requirements designed to 

keep individuals who may pose a risk to the safety and well-being of 

children from having direct access to children. However, some facilities did 

not have evidence of the required FBI fingerprint or Child Protective 

Services check results and did not always ensure that out-of-State Child 

Protective Services checks were conducted.

OIG is currently conducting additional reviews of the safety of children and 

facility security in ORR’s UAC Program. See Appendix B for a complete list 

of previous OIG work related to the UAC Program. 

Scope

To identify opportunities for program improvement, this review focused on 

challenges that affected HHS’s response to the zero-tolerance policy, 

including challenges HHS and facilities encountered in reunifying separated 

children with their parents. 

The heightened enforcement of immigration laws beginning in 2017 and

culminating in the spring 2018 zero-tolerance policy, which was then 

curtailed by Executive Order and enjoined by the courts, involved DOJ, DHS, 

and HHS. Although this work focuses on HHS, given the involvement of 

these departments, the inspectors general at each agency and the 

Government Accountability Office have kept one another apprised of our 

planning efforts, the status of our ongoing work, and the impending release 

of our reports. 

Methodology
Communication and Management Challenges Impeded HHS’s Response to the Zero-Tolerance Policy 10

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Overview

To identify challenges that HHS and care provider facilities faced in

responding to the zero-tolerance policy and reunifying separated children

with their parents, we interviewed numerous senior HHS officials and HHS 

staff and conducted site visits to 45 facilities. We also reviewed both

internal HHS documents and publicly available information to confirm and 

expand upon information provided in interviews. We analyzed these data 

to establish facts, confirm timelines, and identify internal and external 

factors that affected the Department’s response to the zero-tolerance 

policy.

Data Sources

This report synthesizes information from a wide array of sources, including 

extensive interviews with, and written responses from, senior HHS officials 

and HHS staff in the Office of the Secretary, the Office of the Assistant 

Secretary for Financial Resources (ASFR), ASPR, ACF, and ORR; interviews 

with staff at 45 care provider facilities; case reviews for a purposive sample 

of separated children; and thousands of documents obtained through 

requests to the Department, from facility staff during site visits, and from 

interview respondents.

Interviews. OIG conducted numerous interviews with senior HHS officials in 

the Office of the Secretary, ASFR, ASPR, ACF, and ORR. We submitted 

written questions to, and received written responses from, the Secretary and 

Deputy Secretary. Additionally, we interviewed HHS staff in ASPR, ACF 

Office of Legislation and Budget, and ORR.

In this report, “senior official” means a Presidential appointee under the 

Executive Schedule, a non-career appointee to the Senior Executive Service

(SES), or a non-career Schedule C appointee. “Staff” means career 

employees at or below the SES level, including career U.S. Public Health 

Service Commissioned Corps Officers. Throughout the report, certain 

individuals are referred to by their titles at the time of the events being 

described. Please note that the individuals who held the positions of 

Counselor to the Secretary for Human Services Policy (within the Office of 

the Secretary), Acting Assistant Secretary for ACF, ORR Director, and ORR 

Deputy Director during the periods those roles are discussed—primarily, 

2017 through mid-2018—are no longer in those positions as of the date of 

this report. See Appendix C for further detail on these positions as they 

relate to the UAC Program and to the Office of the Secretary.

Site visits. OIG conducted site visits to 45 ORR-funded care provider 

facilities in operation across the country. All site visits lasted 2 to 3 days and 

occurred in August or September 2018, with the majority taking place in 

August, shortly after the court-established deadline for reunifying separated 

children with their parents. The 45 sites were selected purposively to 

achieve wide coverage of facilities participating in the UAC Program and to 
Communication and Management Challenges Impeded HHS’s Response to the Zero-Tolerance Policy 11

OEI-BL-18-00510

include a variety of facility types, sizes, populations in care, and geographic 

locations. Combined, the 45 sites that we visited included facilities that 

cared for 72 percent of the children in ORR custody at the time of our 

review. See Appendix D for information about the 45 facilities we visited 

and the children in their care.

During our site visits, we interviewed program directors and case managers 

knowledgeable about the facility’s experiences with the reunification of 

separated children. At the time of OIG’s site visits, we had obtained from 

HHS child-specific data about separated children who were covered by the 

Ms. L v. ICE lawsuit and who had been placed in 35 of the 45 facilities in our 

review. For each of those 35 sites, we purposively selected up to 5 

separated children. Our case selection prioritized children who had not yet 

been reunified at the time of our site visits and sought to illustrate a range 

of ages and circumstances. We reviewed their cases onsite with their case 

manager to better understand factors affecting their reunification.31 

Documents. OIG conducted an extensive review of HHS documents related 

to family separation, the zero-tolerance policy, and the reunification of 

separated children with their parents, as well as documents reflecting 

interactions between HHS and other Federal agencies regarding 

immigration policy more broadly. In total, OIG reviewed more than 5,000 

documents encompassing memoranda, letters, emails, spreadsheets, 

meeting agendas, meeting summaries, and other records created or 

received by HHS employees related to these matters, primarily from early 

2017 through mid-2018. We reviewed documents internal to HHS, 

communications between HHS and care provider facilities, and interagency 

correspondence and records that involved HHS senior officials and staff. 

Consistent with OIG’s statutory role, we reviewed both privileged 

documents (e.g., legal opinions, interagency deliberative correspondence, 

and draft memoranda) as well as non-privileged documents (e.g., 

correspondence about operational matters, guidance transmittals to 

facilities, and final memoranda). 

OIG reviewed HHS’s procedures for identifying and collecting documents 

responsive to OIG’s request and confirmed that they were sufficient to 

identify potentially relevant material. 

Analysis 

We conducted qualitative analysis of interview and documentary data to 

identify critical facts, dates, and activities related to HHS’s awareness of, 

communication about, and response to the zero-tolerance policy and the 

reunification of separated children. We also conducted qualitative analysis 

to identify significant challenges that HHS and facilities faced and key 

factors that contributed to those challenges.

Regarding information from facilities, we sought to identify the most 

significant challenges affecting facilities’ reunification efforts as reported by 
Communication and Management Challenges Impeded HHS’s Response to the Zero-Tolerance Policy 12

OEI-BL-18-00510

facility management, case managers, and Federal field specialists. Each of 

the key challenges affecting facilities that we discuss in this report (locating 

and communicating with parents, confirming whether reunification could 

safely occur, transporting children to be reunified, and unclear guidance

from ORR) was reported by more than half of facilities in our review. 

Throughout the review we sought to verify interview responses with 

documentary evidence wherever possible. See Appendix E for a detailed 

methodology. 

Limitations

We were not able to independently verify all information provided by HHS 

or facility staff. However, wherever possible, we compared interviewees’ 

statements to facts we could determine from our review of correspondence, 

memos, and numerous other documents; as appropriate, we also requested 

documentation from interviewees to support their statements. We 

confirmed certain information about DHS IT systems directly with DHS staff.

The facilities we visited and the case files we reviewed were purposively 

selected and may not represent all facilities’ experiences. Likewise, the 

exhibits included in this report were selected to illustrate how various factors 

affected children’s reunification cases; they do not necessarily represent the 

experiences of all facilities or all separated children. 

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.
Communication and Management Challenges Impeded HHS’s Response to the Zero-Tolerance Policy 13

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FINDINGS, PART I

Factors That Affected

HHS’s Ability To 

Respond to the ZeroTolerance Policy and 

Manage the 

Reunification Effort

Key Takeaway

Poor interagency communication and 

management decisions that failed to protect 

children’s interests left HHS unprepared for the 

zero-tolerance policy, adversely affecting both 

the Department’s immediate response to the 

policy as well as later efforts to identify and 

reunify separated children as directed by a 

Federal district court. 
Communication and Management Challenges Impeded HHS’s Response to the Zero-Tolerance Policy 14

OEI-BL-18-00510

FINDINGS

On the basis of interviews with and written responses from senior HHS 

officials, as well as a review of correspondence and interagency meeting

records, OIG found no evidence that HHS was notified in advance by either

DOJ or DHS that the zero-tolerance policy would be implemented. In fact, 

senior HHS officials generally reported that they first learned of the spring 

2018 implementation of zero-tolerance when it was reported by the media. 

This lack of communication occurred despite a variety of channels that exist 

to facilitate high-level interagency coordination and engagement on 

immigration issues. These include direct communication between Agency 

executives; interagency principals and deputies meetings or calls on 

immigration; and interagency Policy Coordination Committee (PCC)32 and 

sub-PCC meetings. These meetings usually include officials representing 

DOJ and DHS as well as other Federal agencies. Additionally, the 2016 MOA 

between HHS and DHS states, “Each Party will make all reasonable efforts to 

notify the other about upcoming changes in UAC policy and procedures 

that may impact the other agency's policies or operations (absent exigent 

circumstances).”33 However, the MOA does not specify the mechanism or 

timeline by which such notification should occur. 

The Counselor to the Secretary for Human Services Policy and the ORR 

Director, both of whom typically represented HHS at PCC meetings on 

immigration, did not recall being informed of plans for the zero-tolerance 

policy prior to its implementation. The Counselor to the Secretary for 

Human Services Policy recalled discussion of family separation in 

interagency forums in early 2017. However, after the DHS Secretary publicly 

announced in March 2017 that DHS would not pursue such a policy, she 

understood the idea to have been dismissed. OIG reviewed PCC-related 

records and likewise found no reference to the zero-tolerance policy until 

mid-April 2018, more than a week after the Attorney General instituted the 

policy at DOJ. DHS’s intention to immediately begin implementing the 

policy was also noted; however, there was no mention of coordination with 

HHS or how zero-tolerance would affect the UAC Program. 

Further, senior HHS officials indicated that even when they did become 

aware of the Attorney General’s memorandum implementing the zerotolerance policy at DOJ in April 2018, they did not initially understand how it 

would be carried out by DHS or its implications for HHS. The Acting 

Assistant Secretary for ACF noted that because DHS may detain families and 

children together for up to 20 days, it was not immediately clear that 

increased prosecution of adults in family units—as the policy was initially 

framed during interagency meetings—would necessarily result in family 

separation, with children transferred to ORR care. The Counselor to the 

Secretary for Human Services Policy indicated a similar understanding. 

Interagency 

channels intended 

to facilitate 

coordination were 

not used to notify 

HHS of the 

zero-tolerance 

policy in advance
Communication and Management Challenges Impeded HHS’s Response to the Zero-Tolerance Policy 15

OEI-BL-18-00510

However, the Attorney General’s May 7, 2018, public announcement of the 

zero-tolerance policy clarified that family separation would indeed occur.

Key senior HHS 

officials failed to 

act on repeated 

warnings from 

staff; as a result, 

HHS did not plan 

for family 

separation

For months before the zero-tolerance policy was announced, the Counselor 

to the Secretary for Human Services Policy, the Acting Assistant Secretary 

for ACF, and the ORR Director disregarded specific, repeated warnings from 

ORR staff regarding the possibility that DHS would implement family 

separation. Beginning in mid-2017, ORR staff saw indications that atypically 

large numbers of separated children were entering ORR care. In early 2018, 

ORR staff received information suggesting that DHS might implement a 

policy resulting in larger-scale family separation. ORR staff believed that the 

UAC Program lacked the bed capacity to accommodate a large increase in 

separated children and were also concerned about the trauma such a policy 

would inflict on children. At several points before the zero-tolerance policy 

was implemented, ORR staff shared these concerns with the ORR Director, 

the Acting Assistant Secretary for ACF, and the Counselor to the Secretary 

for Human Services Policy. 

OIG found no evidence that these three senior HHS officials took action to 

protect children’s interests in response to the information and concerns 

raised by ORR staff. For example, we found no evidence that senior HHS 

officials directed ORR to plan for a possible increase in separated children, 

pressed the topic in PCC meetings or other interagency forums, or elevated 

the matter to the Deputy Secretary or Secretary to pursue at higher levels.

By statute, HHS through its Office of Refugee Resettlement is responsible 

for ensuring that an unaccompanied child’s interests are considered in 

decisions and actions affecting his or her care and custody.34

ORR staff reported raising information and concerns about 

separation to key senior officials on multiple occasions in 2017 

and 2018

In late 2017, ORR staff raised concerns about a significant increase in 

the number of separated children. In summer 2017, ORR staff noticed an 

increase in the number of separated children entering ORR care; such 

separations were historically rare.35 By August 2017, the proportion of 

separated children compared to other children entering the UAC Program 

had risen to 3.6 percent of all intakes, a more than tenfold increase from the

0.3 percent of intakes that ORR staff had observed in late 2016. Although 

separated children represented a small proportion of those in ORR care, the 

UAC Program faced challenges in serving this atypical and high-need

population, especially the infants and very young children who required

placement at a limited number of specially licensed facilities. 

As a result of these difficulties, in November 2017, ORR’s then-Deputy 

Director for Children’s Programs—a senior ORR career employee 

responsible for managing the UAC Program36—alerted the ORR Director to 

“I said ORR was seeing 

much higher levels of 

separation, and that 

those separations were 

impacting particularly 

babies and young 

children. I said this so 

many times that I was 

called a broken record.”

-(Former) ORR Deputy 

Director for Children’s 

Programs
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OEI-BL-18-00510

challenges with infant placements due primarily to separations, noting, “We 

had a shortage last night of beds for babies.” Approximately 1 week later,

the Deputy Director contacted senior officials in CBP and ICE to express 

concern about the increase in separated children and consequent 

operational burden on the UAC Program.

37

 The CBP and ICE officials 

acknowledged the communication but did not directly respond to the issue 

of family separation. 

The Deputy Director also reported to OIG that he elevated information and 

concerns about family separation to the ORR Director, the Acting Assistant 

Secretary for ACF, and the Counselor to the Secretary for Human Services 

Policy. Specifically, he reported that in meetings with those individuals at 

several points in 2017 and early 2018, he stated that the UAC Program 

would not have sufficient bed capacity if DHS implemented larger-scale 

family separations and expressed that separation would harm children and 

was inconsistent with the UAC Program's responsibility to protect children’s 

interests. Other ACF and ORR staff who were present at these discussions

corroborated the Deputy Director’s statements. Additionally, two other ORR 

employees reported that they also had raised concerns to the ORR Director 

and the Acting Assistant Secretary for ACF regarding the impact of 

separation on children’s well-being. The Deputy Director explained to OIG 

that in repeatedly raising his concerns, he hoped that senior HHS officials 

would “fight against” any DHS family separation policy and “enlist the 

Secretary” in doing so.

In interviews with OIG, the Counselor to the Secretary for Human Services 

Policy and the Acting Assistant Secretary for ACF did not recall having 

received information about increasing numbers of separated children in 

2017, nor did they recall discussions of child welfare concerns related to 

separation. The ORR Director confirmed that he was informed of the 

increase in separated children in 2017 and was copied on the November 

2017 outreach to CBP and ICE about that issue. 

ORR staff continued to raise concerns about family separation as 

additional warning signs emerged. In January 2018, the ORR Deputy 

Director for Children’s Programs learned from DHS staff that DHS had 

developed, and planned to submit to the Office of Management and 

Budget, a projection of the number of children who would be referred to 

ORR under an enforcement policy that would increase the prosecution of 

adults in family units and refer their children to ORR. In addition to his preexisting concerns about the impact of separations on children’s well-being, 

he believed that the number of beds DHS had predicted would be required

under a such a policy was unrealistically low. He conveyed that assessment 

directly to DHS staff and engaged the ORR Director as well as ACF’s Office 

of Legislation and Budget in an attempt to address the issue internally. 

Additionally, he verbally informed the Acting Assistant Secretary for ACF 

“I told them it was 

going to traumatize 

children to separate 

them unnecessarily. 

I said that to anyone I 

could.”

-ORR staff member
Communication and Management Challenges Impeded HHS’s Response to the Zero-Tolerance Policy 17

OEI-BL-18-00510

and the Counselor to the Secretary for Human Services Policy of these 

events during their weekly meetings on UAC Program matters. 

Key senior HHS officials failed to act on information from ORR staff

Based on our review of available documents, interviews with senior HHS 

officials and HHS staff, and written responses from the Deputy Secretary 

and Secretary, OIG found no evidence that the Counselor to the Secretary 

for Human Services Policy, the Acting Assistant Secretary for ACF, or the 

ORR Director took or directed proactive steps to prepare the UAC Program 

for a future situation in which DHS routinely separated families, as ORR staff 

warned was likely and as ultimately did occur under the zero-tolerance 

policy. We also found no evidence that these senior HHS officials

attempted to raise ORR staff’s information and concerns about family 

separation in the PCC or similar interagency forums to seek clarity about 

what might occur. Finally, we found no evidence that these senior officials 

elevated these issues to the Deputy Secretary or Secretary. 

Key factors that contributed to this failure to act include concurrent pressure 

to finalize an MOA with DHS regarding the UAC Program, senior HHS 

officials’ doubts that DHS would implement larger-scale family separations, 

senior HHS officials’ reluctance to advocate for the HHS mission in 

immigration policy discussions, and a lack of awareness about challenges 

that separated children pose for the UAC Program. 

Key senior HHS officials were focused on finalizing an MOA with DHS. 

In early 2018, senior HHS officials within the Office of the Secretary, ACF, 

and ORR were heavily involved in finalizing an MOA between HHS and DHS 

regarding the UAC Program under which both agencies accepted new 

information-sharing responsibilities. The Counselor to the Secretary for 

Human Services Policy described finalizing and implementing the MOA as 

“the core issue for HHS” during spring 2018. 

Among other changes, the MOA stipulated that HHS would obtain 

fingerprints from potential sponsors and their household members and 

provide that biographic data to ICE within DHS. ICE would then provide 

HHS with a summary of criminal and immigration history about those 

individuals, to the extent it was available to ICE. 

HHS also anticipated that ICE would use this biographic information to take 

enforcement actions against potential sponsors, which would ultimately 

deter sponsors from coming forward. That, in turn, was expected to 

increase the length of time children remained in ORR care before discharge, 

requiring substantially greater overall bed capacity. The Acting Assistant 

Secretary for ACF acknowledged to OIG that the MOA was expected to 

increase the length of time that children remained in ORR care, but 

maintained that the MOA was also of value to HHS’s ability to evaluate 

potential sponsors. (The new fingerprinting provisions were later largely 

withdrawn by ORR after it was determined that the requirements had 

“If conversations 

occurred referring to 

separated children, it 

did not have the 

context of meaning it 

was children separated 

from parents...I either 

missed it in reporting or 

it was not reported up 

to me.”

-(Former) Counselor to 

the Secretary for 

Human Services Policy
Communication and Management Challenges Impeded HHS’s Response to the Zero-Tolerance Policy 18

OEI-BL-18-00510

extended children’s stay in ORR custody without significantly improving 

their safety.)38

Key senior HHS officials were unconvinced that DHS would implement 

larger-scale family separations. As previously noted, the zero-tolerance 

policy was not addressed at high-level interagency immigration policy 

meetings attended by the Counselor to the Secretary for Human Services

Policy and the ORR Director until its implementation was underway. The 

ORR Director stated that he expected DHS would notify HHS of any 

forthcoming policy change, but that DHS had not done so. The Deputy 

Director for Children’s Programs reported that, in response to the 

information and concerns he conveyed in late 2017 and early 2018, the 

Counselor to the Secretary for Human Services Policy and the ORR Director 

reiterated to him on multiple occasions that DHS was not implementing a 

family separation policy. 

Key senior HHS officials were reluctant to intercede in immigration law

enforcement policies. ACF’s mission includes “providing Federal 

leadership...for the compassionate and effective delivery of human services”;

additionally, by statute, the ORR Director is responsible for “ensuring that 

the interests of the child are considered in decisions and actions relating to 

the care and custody of an unaccompanied alien child.”39 In some cases, 

HHS’s responsibilities intersect with DHS’s and DOJ’s law enforcement 

priorities—such as when enforcement initiatives affect the number of 

children in ORR care. 

However, some senior HHS officials expressed reluctance to advocate for

the HHS mission in interagency forums where such policy conflicts could 

potentially be addressed. The Counselor to the Secretary for Human 

Services Policy acknowledged tension between HHS and law enforcement

agencies stemming from their differing statutory responsibilities, noting that 

HHS suggestions regarding immigration policy were sometimes interpreted 

as obstructing law enforcement efforts. She explained to OIG that 

interagency meetings on immigration were primarily focused on 

enforcement issues and that in her view, HHS was a “minor participant.” 

The Acting Assistant Secretary for ACF stated that HHS should not seek to 

affect immigration policy regardless of its impact on the UAC Program; 

rather, HHS should adapt to whatever policies are put in place. 

Additionally, senior HHS officials did not necessarily share ORR staff’s alarm 

about family separation. Some senior HHS officials expressed to OIG that 

trauma to children caused by separation should be weighed against the 

benefit of preventing families from attempting the potentially dangerous 

journey to the United States in the first place. For example, the Acting 

Assistant Secretary for ACF stated that he had believed the zero-tolerance 

policy would have a deterrent effect, resulting in fewer children entering 

ORR care. The Counselor to the Secretary for Human Services Policy stated 

that “it is not great for children to be separated from their parents,” but “I 

“...we didn’t know what 

was going on. I just 

sort of expected lines of 

communication with 

DHS that, if there was a 

formal policy change, 

we would hear about it 

from DHS.”

-(Former) ORR Director

“Our participation in 

immigration policy is 

very limited and welldefined. Our job is to 

have a bed available 

for the next child that is 

brought to us by ICE or 

CBP. That is what our 

role is and what we 

focus on. Our role is 

limited to that.”

-(Former) Acting 

Assistant Secretary for 

ACF
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OEI-BL-18-00510

do not know what the moral right thing to do is in this situation,” noting 

that children are also placed at risk when their parents bring them to the 

United States without authorization.

Ultimately, HHS took a supportive public stance toward the zero-tolerance 

policy once enacted. In late May 2018, after the policy had been in effect for 

several weeks, HHS issued a fact sheet stating: “Anyone who crosses the 

border illegally is subject to Federal criminal prosecution.... If parents do 

not wish to be separated from their children, they should not violate the 

laws of the United States or endanger minors through criminal smuggling.”

Key senior HHS officials did not understand the magnitude and nature 

of challenges that separated children posed for the UAC Program. The 

UAC Program was established to provide care for minors who arrive in the 

United States unaccompanied; its processes and facilities were not designed 

to accommodate large numbers of children who were brought to the 

United States by a parent or guardian and then unexpectedly separated 

from that adult. As more separated children began entering ORR care, ORR 

staff became aware of significant needs and challenges associated with such 

cases. In addition to their general concerns about these children’s 

wellbeing, ORR staff reported, and contemporaneous emails describe, 

practical and logistical concerns such as problems locating parents of 

separated children to ensure appropriate placement; the possibility that

parents might be deported without their children; and difficulties ensuring

sufficient bed capacity, especially for very young children. 

Nonetheless, the ORR Director reported to OIG that “a child that comes into 

ORR’s care as a separated child is treated the same as any child referred to 

the program. By definition, all children are experiencing some sort of 

separation.” Similarly, the Acting Assistant Secretary for ACF stated that in 

his view, separated children are not “materially different” from other 

children entering ORR care. He also stated that absent the Ms. L v. ICE court 

order and deadlines, separated children would not have posed difficulties 

for ORR. Given this perspective, he and other senior HHS officials may have 

discounted the importance of warnings from ORR staff. 

Key senior HHS officials’ failure to act hindered ORR staff’s ability to 

plan for family separation

In the absence of any directive from the ORR Director or his superiors to 

plan for the possibility of increased separations, the UAC Program was left 

in the position of reacting to changes as they occurred rather than taking 

proactive measures that might mitigate risk to children. ORR staff noted 

that typically, procedures operationalize policy; ORR staff could not, on their 

own, develop and promulgate formal plans and procedures that appeared 

to contradict official policy on family separation. Without centralized 

leadership and coordination on the issue, ORR staff began independently 

monitoring intakes of separated children—through informal methods that 

“A real lesson for me is 

that I need to ask more 

questions. I think, sure, 

in retrospect, I could 

have probed more. It is 

hard to know what to 

ask when you do not 

know what you do not 

know.”

-(Former) Acting 

Assistant Secretary for 

ACF
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OEI-BL-18-00510

were unconnected to the UAC Portal—and sought to coordinate with DHS 

offices at the local level.

Communication about family separation was impeded by an 

organizational culture that discouraged putting potentially 

controversial information in writing 

Some ORR staff described an organizational culture that discouraged 

putting potentially controversial information in writing, including but not 

limited to information about separated children. Although such cautions 

may sometimes be reasonable—for example, to warn HHS personnel 

against creating an inaccurate factual record—ORR staff reported more 

pervasive warnings to limit documentation related to sensitive topics. For 

example, ORR staff recalled receiving repeated, general reminders to be 

cautious about putting information in writing, as well as being instructed to 

provide verbal-only briefings and offer verbal-only comments on certain 

matters. Some ORR staff also reported that they were criticized for 

documenting certain topics. For example, one ORR employee recalled that 

immediately after sending an email that included concerns about family 

separation, a superior within ORR verbally advised the employee that those 

concerns should not have been put in an email. 

Collectively, these repeated reminders to limit written information may have 

had a chilling effect on frank discussion about the possibility that largerscale family separation would occur, impeding the UAC Program’s ability to 

prepare. The lack of documentation may also have contributed to senior 

HHS officials’ ability to dismiss staffs’ concerns about capacity and children’s 

well-being rather than squarely address them. Additionally, the lack of 

written records on these topics hampers subsequent efforts to determine 

what occurred and how HHS could better respond to similar challenges in 

the future.

The lack of 

planning for 

zero-tolerance 

hindered HHS’s 

ability to provide 

prompt and 

appropriate care 

for separated 

children

In the absence of comprehensive, coordinated planning for the possibility of

larger-scale family separations, ORR was unprepared for the surge in 

separated children—and particularly very young children—after zerotolerance was formally implemented in May 2018. Insufficient bed capacity 

led to delays in placing children in ORR facilities, including delays past the 

72-hour legal limit for such transfers to occur. Additionally, facilities 

struggled to meet the significant and unique needs of this especially 

vulnerable population.

Insufficient bed capacity delayed children’s transfers from DHS to 

HHS care

After the zero-tolerance policy was announced on May 7, 2018, the number 

of separated children grew sharply. This drove overall intakes higher at a 

time when ORR was already receiving significantly more children than had 
Communication and Management Challenges Impeded HHS’s Response to the Zero-Tolerance Policy 21

OEI-BL-18-00510

entered care the prior year. From January through April 2018, new referrals 

to ORR hovered between 3,000 and 4,000 per month. However, in May 

2018, new intakes rose to 6,127. Similarly, the proportion of children ages 

0 to 12 rose from approximately 14 percent of all intakes in March and April 

2018 to 24 percent in May 2018. 

ORR struggled to adapt to the sudden increase in children, and especially 

the increase in young children. In an internal email from May 10, 2018, 

shortly after DHS formally adopted the zero-tolerance policy, ORR staff 

cited the large numbers of young, separated children referred that day and

expressed concern about whether the UAC Program would have sufficient 

capacity moving forward. Ultimately, it did not: a September 2018 review by 

the DHS-OIG found that during the period that zero-tolerance was in effect, 

more than 800 children inappropriately remained in CBP custody for more 

than 72 hours before being transferred to HHS.40 (DHS is generally required 

by law to transfer children to HHS within 72 hours of determining that they 

are unaccompanied.) The review also found that CBP officials attributed 

these delays to HHS’s inability to promptly accept referrals. By the time the

Ms. L v. ICE court ordered the Government to cease most family separations, 

the UAC Program was caring for approximately 12,000 children in total; 

nearly 1 in 4 of those children was in ORR care because he or she had been 

separated from a parent.

To address the need to rapidly expand capacity, on June 14, 2018, ORR 

opened an emergency influx care facility in Tornillo, TX. Such shelters are 

exempt from some licensing requirements and are generally more 

expensive to operate compared to standard shelter facilities. In December 

2018, OIG found two significant vulnerabilities at the Tornillo shelter—

limited background checks of staff and an insufficient number of staff 

clinicians to provide adequate mental health care—that could compromise 

children’s health and safety. In January 2019, HHS announced that the influx 

shelter at Tornillo would be closed.

Care provider facilities struggled to meet separated children’s needs

without advance notice or preparation

As reported in a previous OIG review, facilities described a variety of 

challenges to meeting separated children’s needs in the immediate wake of 

zero-tolerance implementation. Faced with an unexpected and dramatic 

increase in young, separated children, staff reported feeling challenged to 

care for children who presented different needs from the unaccompanied 

teenagers they typically served. One program director noted that prior to 

the zero-tolerance policy, they had no children younger than 10 years old; 

after its implementation, they received 70 such children within the space of 1 

month.

Facilities also reported that addressing the unique mental health needs of 

separated children was particularly challenging. According to program 

“[Thirty-three percent] 

of all referrals 

yesterday were age 12 

or under—most of 

these were separations. 

I’m very concerned 

about having sufficient 

tender age capacity if 

this is the trend moving 

forward.”

- May 10, 2018, email 

from ORR staff 

member to her 

supervisor 

“The abruptness of the 

‘no tolerance’ policy 

made this challenging... 

[We] were now 

bombarded with kids 

who had these needs 

related to being very 

recently separated... 

now [we] had to 

dedicate staff to learn 

about how to provide 

services to an entirely 

different kind of client.”

- Facility program 

director 
Communication and Management Challenges Impeded HHS’s Response to the Zero-Tolerance Policy 22

OEI-BL-18-00510

directors and mental health clinicians, separated children exhibited more 

fear, feelings of abandonment, and post-traumatic stress than did children 

who were not separated. Separated children experienced heightened 

feelings of anxiety and loss as a result of their unexpected separation from 

their parents after their arrival in the United States. For example, some 

separated children expressed acute grief that caused them to cry 

inconsolably.41

The lack of 

planning also 

contributed to 

data limitations, 

complicating 

efforts to identify 

separated children 

The lack of effective interagency information-sharing about separated 

families significantly impeded the Department’s ability to identify separated 

children eligible to be reunified under Ms. L v. ICE. At the time of the ourt 

order, HHS was unable to produce an accurate list of separated children 

who had entered ORR’s care. ORR had been informally monitoring intake 

of separated children since late 2016, but this tracking was designed for 

monitoring purposes rather than the retrospective accounting and reporting

eventually required by the court, and staff could not rely on its accuracy. An 

ASPR official and ASPR staff closely involved in the effort to identify 

separated children reported that DHS had likewise not maintained reliable 

data about this population, noting that what DHS provided to HHS for use 

in the reunification effort was inconsistent and decentralized. A recent 

DHS-OIG report confirmed that DHS lacked information technology (IT) 

systems to reliably track separated families during the time that the zerotolerance policy was in effect, leading to “widespread errors” in DHS data 

about these families.42

Because HHS and DHS did not systematically collect, share, and track 

information about separated children across both agencies, the effort to 

identify separated children ultimately required analysis of more than 60 HHS 

and DHS datasets and a manual review of more than 12,000 case files. 

Senior HHS officials, including the Secretary, worked alongside hundreds of 

HHS staff to review children’s files to identify indicators of separation. Court 

filings described the effort as “a fact-intensive and time consuming analysis 

that involves the reconciliation of data from multiple sources and the 

exercise of programmatic judgment to interpret the data.”43 Due, in part, to 

these complications, HHS was still identifying separated children of Ms. L 

class members in December 2018, more than 5 months after the court 

order. 

A March 2019 ruling expanded the Ms. L v. ICE class to include parents who 

entered the United States on or after July 1, 2017, and were then separated 

from their children, who were placed in ORR care and released (e.g., to a 

sponsor) before the June 26, 2018, original order. HHS has identified 1,556 

such children. 

“I am working with 

[DHS staff] to figure 

this out, but in short, 

no, we do not have any 

linkages from parents 

to UAC, save for a 

handful...We have a list 

of parent alien 

numbers but no way to 

link them to children.” 

- June 23, 2018, email 

from ASPR staff 

member to senior DHS 

official
Communication and Management Challenges Impeded HHS’s Response to the Zero-Tolerance Policy 23

OEI-BL-18-00510

HHS experienced 

challenges 

coordinating the 

reunification 

effort under 

overlapping 

court-imposed 

requirements 

ORR staff reported that court orders in multiple lawsuits required ORR to 

adopt new procedures and create multiple pathways for children’s 

reunification with their parents, depending upon which lawsuits applied to 

their cases. For example, although ORR initially followed its standard 

process for vetting sponsors—including parents from whom a child had 

been separated—the Ms. L v. ICE court ultimately ruled that some aspects of 

that process were unduly burdensome when applied to families included in

the class. As a result, ORR needed to change, on multiple occasions, its 

procedures related to reunifying or otherwise placing separated children

with sponsors. This sometimes led to confusion about what process should 

be followed for a given child. Similarly, children covered by the N.T.C. v. ICE 

lawsuit could not be transferred out of New York State—including for 

reunification under Ms. L v. ICE—without 48 hours prior notice to the child 

and their legal counsel, requiring ORR to incorporate that notice into their 

release procedures for those children.

ORR staff also reported difficulties in reuniting children and parents who 

were affected by multiple lawsuits. In those cases, children sometimes had 

multiple groups of attorneys representing their interests; their parents might 

also have separate legal representation. ORR staff stated that necessary 

coordination among these groups sometimes caused confusion, delaying 

children’s release from ORR care. In October 2018, when approximately 130 

children were yet to be reunified as directed by the June 2018 Ms. L v. ICE

court order, ASPR staff noted that “the limiting factors right now are not 

operational—they are legal reasons as to why they are not reunified. It’s 

about the confluence of different lawsuits.” 

Officials and staff also cited the reunification deadlines imposed by the June 

2018 Ms. L v. ICE court order as a significant operational challenge. 

Specifically, the court required children of class members to be reunified 

with their parents within 14 days for children younger than 5 years old and 

30 days for children aged 5 to 17 years. The ORR Director noted that staff 

worked 18- to 20-hour days, with some staff working 45 days straight, to 

meet the court-ordered reunification timeframes. These deadlines also led 

ORR to make extremely short-turnaround directives to facilities caring for 

separated children. 

“So what happened was 

you had to obtain 

notification from the 

attorney, sometimes 

multiple groups of 

attorneys, before you 

could release the kid. 

That became confusing. 

The release had more 

layers. It was confusing 

as all get-out.”

- ORR staff member
Communication and Management Challenges Impeded HHS’s Response to the Zero-Tolerance Policy 24

OEI-BL-18-00510

FINDINGS, PART II

Factors That Affected

Care Provider Facilities’ 

Ability To Reunify 

Separated Children With 

Their Parents

Key Takeaway

Care provider facilities faced significant 

operational challenges at every stage of the 

reunification process, complicated by poorly

communicated guidance from ORR. 
Communication and Management Challenges Impeded HHS’s Response to the Zero-Tolerance Policy 25

OEI-BL-18-00510

FINDINGS

Facilities, working closely with ORR Federal field specialists, played a critical 

role in reunifying separated children with their parents. Facilities commonly

indicated that they encountered difficulties when trying to locate parents in 

DHS or DOJ custody, a necessary first step to establishing communication 

and eventually reunifying the family. Locating parents who were no longer 

in the United States presented different challenges.

Care provider facilities reported difficulties locating and 

communicating with parents in DHS detention centers

Facilities reported difficulty obtaining accurate, real-time data on parents’ 

locations; specifically, some facility staff noted that the online ICE parent 

locator tool they were instructed to consult was often inaccurate or out of 

date. Facility staff explained that it was especially difficult to locate parents 

during the first days after a child was separated and referred to ORR care, 

because little information was available while the parent was initially being 

processed by DHS. The problem was particularly acute for younger 

children, because they were often not able to provide full names, birth 

dates, or phone numbers of parents or relatives inside or outside the United 

States. 

As a result, facility staff found that the most effective—but timeconsuming—way to locate parents in DHS detention was to call detention 

centers directly to ask whether they had custody of a given parent. One 

program director noted that their staff had successfully located parents of 

separated children this way in the past, when such children were rare, but 

that the task was much more difficult when faced with the large number of

separated children who entered ORR care in May and June 2018. Several 

facilities reported to OIG that in some cases, no one at the DHS detention 

center would answer their calls. In one case, the Associate Director of a 

facility reported that a DHS detention center blocked her phone number 

because she had called so many times attempting to get information about 

parents of separated children. When ORR staff gathered information from 

facilities about their initial efforts to establish contact with parents in 

detention, they found that, of 371 attempts on a given day, 159 had been

unsuccessful; the most common reason given was that the detention center 

did not answer the phone. 

A program director estimated that overall, it took an average of 2 weeks to 

locate parents and then an additional 3 to 7 days to arrange a phone call 

between the parent and child, a necessary first step before reunification 

could be pursued. A case manager indicated that these delays sometimes 

led children to lose trust in facility staff. 

Some facility staff noted that these problems were most severe near the

Care provider 

facilities

experienced 

difficulties in 

locating and 

communicating 

with parents of 

separated children

“...the facility called 

[the DHS detention 

center] every day 

seeking the parents of 

an 11-year-old child. 

They could not reach 

anyone. The child cried 

every day.”

- Facility program 

director 

“Sometimes it’s easier 

to find a parent in a 

rural village in 

Guatemala than to find 

them in detention.”

- ORR staff member
Communication and Management Challenges Impeded HHS’s Response to the Zero-Tolerance Policy 26

OEI-BL-18-00510

beginning of the reunification effort. ORR took several steps to address the 

problem, including providing direct assistance from Federal field specialists

and compiling and distributing spreadsheets with contact names and 

numbers at DHS detention centers. Some facilities reported that these 

measures improved their ability to locate parents in DHS detention.

Care provider facilities described difficulties in locating parents 

detained by the U.S. Marshals Service

In some cases, parents of separated children were in custody of the U.S. 

Marshals Service (within DOJ) rather than in DHS detention. Facility staff 

reported that U.S. Marshals Service staff told them it did not have the same 

obligations as DHS to share information about parents with ORR. As of 

April 2019, ORR staff reported that the UAC Program continued to 

experience significant difficulties obtaining information about parents who 

were in U.S. Marshals Service custody. Several court filings in Ms. L have

included the statement that “defendants also have reached out to 

representatives for the Bureau of Prisons and the U.S. Marshals Service to 

ensure that those entities are included in discussions regarding...processes 

and procedures” related to children in ORR care. However, it is not clear 

what, if any, specific actions have been taken.

44

 

Some parents were repatriated before ORR could locate and 

establish contact with them

In some cases, parents were repatriated (returned to their home country 

through deportation or voluntary departure) before facility staff were able 

to locate and contact them. Facilities reported that locating repatriated 

parents was difficult because they sometimes had no information about 

parents’ whereabouts until the parent contacted the ORR facility. In a 

March 2019 court filing, the Government stated that it had identified 471 

original Ms. L v. ICE class members who had been repatriated without their 

children, and without being given the opportunity to elect or waive 

reunification. Exhibit 3 illustrates how difficulties facilities faced in obtaining 

current information about parents’ locations affected one child’s 

reunification case.

Exhibit 3. How difficulties obtaining information about parents’ locations affected one child’s 

reunification

“B” is 4 years old and was separated from her father. Her case manager sent an inquiry to ICE about 

her father’s location but did not receive a response. B’s referral information from CBP did not include a 

phone number for her mother. The case manager eventually obtained a phone number for another 

relative, who was able to connect B to her mother, after which the facility arranged regular phone calls. 

Approximately 1 month after B arrived at the facility, they learned from B’s mother that B’s father had

been repatriated. B’s parents have requested that B also be repatriated to her home country through 

voluntary departure, which requires a court order. At the time of our site visit, B had been in ORR care 

for approximately 120 days.

“Not knowing what 

happened to their 

parents haunted the 

children. We couldn’t 

tell them whether they 

would ultimately be 

reunited. It was 

challenging. We 

weren’t notified initially 

about how to connect 

parents with their kids. 

The kids had lots of 

questions, but we had 

no answers for them.” 

- Facility lead mental 

health clinician
Communication and Management Challenges Impeded HHS’s Response to the Zero-Tolerance Policy 27

OEI-BL-18-00510

Care provider 

facilities 

encountered 

challenges to 

determining 

whether parents 

and children 

could be safely 

reunified

To ensure children’s safety, facilities sought to confirm parentage and 

collect necessary information from and about parents (and alternate 

sponsors when appropriate). However, communication difficulties, 

problems obtaining documentation, and issues related to fingerprint-based 

background checks impeded their efforts and delayed children’s release 

from ORR care.

Care provider facilities encountered challenges to confirming the 

relationship between parent and child

In accordance with ORR policy and procedures to ensure children’s safety—

and because the Ms. L v. ICE court order limited class membership to 

parents—facility staff and Federal field specialists reported that they sought 

to confirm parental relationships by reviewing birth certificates, conducting 

DNA tests (under certain circumstances), and consulting with consulates 

about the authenticity of documents. However, these efforts were 

sometimes hampered by lack of documentation or information from the 

child. Unlike unaccompanied children, who often arrive prepared to provide 

ORR with information about relatives, children separated from parents by 

immigration officials were less likely to have this information, and very 

young children could not communicate basic facts needed to confirm 

relationships.

Facilities reported that documentation to verify the parent-child 

relationship was not always available. Several facilities discussed cases in 

which parents did not have birth certificates to verify their relationship to 

the child. In other instances, facilities had to consult with embassies or 

consulates of children’s home countries to authenticate documentation 

provided by the parents. Facilities reported that they sometimes needed to 

locate another relative in the child’s home country to obtain the necessary 

documentation or to confirm the parent-child relationship (e.g., verifying 

facts relayed by the parent or child).

Facilities reported that confirming the parent-child relationship was 

more challenging for young children. Very young children were less able 

(or in the case of preverbal children, unable) to confirm the identity of their

parents. To address this, ORR initially instructed its facilities to conduct DNA 

testing for children younger than 5 years old and their parents; this 

guidance changed after the Ms. L v. ICE court deemed routine DNA testing 

unnecessary for those parents covered by the June 2018 court order. 

Care provider facilities had difficulty obtaining necessary 

information about parents’ backgrounds

ORR’s process requires that facility staff complete an assessment for each 

potential sponsor to gather information necessary to ensure the child’s 

safety upon release; these assessments were also conducted for parents 

separated from their children and potentially eligible for reunification under 

Ms. L v. ICE. In addition, sponsors—including parents—were, until March 

“She was 5 [years old] 

so that was harder 

too... Where they lived, 

who with, where they 

were going; she was 

unable to provide us 

with that info.”

- Facility case manager 
Communication and Management Challenges Impeded HHS’s Response to the Zero-Tolerance Policy 28

OEI-BL-18-00510

2019, required to undergo a fingerprint-based background check.45 

Facilities reported challenges to completing these tasks for parents of 

separated children, which extended the time that children were in ORR care.

Care provider facility staff experienced challenges in completing 

assessments for parents in detention. Facility staff reported two main 

challenges to completing assessments for parents in detention: limited time 

to speak with parents and lack of access to necessary documents. 

Completing the necessary assessment typically requires 1 to 3 hours on the 

phone with the potential sponsor (in these cases, the detained parent). 

Facilities reported that it was difficult to schedule calls with detained parents 

and, once scheduled, each call was restricted by the detention center to 10 

to 15 minutes. This restriction limited the amount of information gathered 

during each call and required multiple calls to complete the assessment. 

Getting necessary documentation was also challenging. Facilities reported 

that parents in detention did not always have the right documentation and 

needed case managers to help them obtain the documents. 

HHS and facilities took various measures to complete sponsor assessments 

more quickly. In late June 2018, the ASPR-led IMT deployed U.S. Public 

Health Service personnel to some detention centers to assist with 

assessments. Additionally, facilities reported that staff at some DHS 

detention centers assisted with completing sponsor assessments; however, 

some facilities reported that assessments conducted by DHS staff were not 

usable or took too long to complete due to the high volume of separated 

parents in custody. Based on guidance documents provided to OIG, ORR 

does not appear to have provided instructions to facilities about DHS staff 

conducting parent assessments or how facilities should coordinate with DHS 

detention centers in that regard. 

In mid-July 2018, in response to a court order in Ms. L v. ICE directing HHS 

to streamline its process for vetting parents who are Ms. L class members, 

ORR directed facilities to cease gathering additional information, including 

the sponsor assessment, from such parents. Instead, for parents covered by 

Ms. L, ORR instructed care provider facilities to rely on any identification 

documents that the parent had available, background check information 

gathered by ICE, and any information that ORR or the facility had already 

gathered at that point.

Children’s releases were delayed by long wait times for ORR to process 

fingerprint-based background checks. On June 7, 2018, ORR

implemented a provision of the April 2018 MOA between DHS and HHS by

instituting a new policy requiring fingerprints from not only all potential 

sponsors, including parents, but also all adult members of their 

households.46 The implementation of the new fingerprinting policy 

coincided with a peak period for processing separated children’s cases as a 

result of the zero-tolerance policy, leading to significant delays in receiving 

background check results. 

“ICE would only allow 

parents 10-minute 

phone calls and parents 

would want to talk to 

their children as long as 

possible, so this would 

not leave much time for 

case managers to talk 

to parents and 

complete the 

assessment.” 

- Facility program 

director 
Communication and Management Challenges Impeded HHS’s Response to the Zero-Tolerance Policy 29

OEI-BL-18-00510

On July 10, 2018, the Ms. L court ruled that parents in the class should not be 

subject to the same level of background check as other sponsors, noting in 

particular that background checks of household members were 

unnecessary.47 However, fingerprint-related backlogs continued to delay 

discharges for all children in ORR care throughout the summer, increasing 

the total number of children in ORR care at the same time shelters were 

attempting to carry out the time-sensitive and challenging reunification 

effort. Overall, by November 2018, the average length of stay for a child in 

ORR care was 93 days, compared to an average of 64 days for fiscal year 

2018.48 Care provider facilities reported that longer lengths of stay resulted 

in deteriorating mental health for some children and increased demands on 

staff. 

After the period of OIG’s site visits, senior ACF officials reported that HHS 

had increased the resources and technology available for processing 

fingerprints and stated that, as of November 2018, the backlog had been 

eliminated. Additionally, between December 2018 and June 2019, ORR 

implemented a series of policy changes that significantly reduced the 

number of individuals required to obtain fingerprints as part of the 

sponsorship process.49

Care provider facilities had greater difficulty resolving cases with ”red 

flags.” Facilities reported that it was challenging to resolve cases that were 

red-flagged due to safety concerns for the child. Examples of red flags 

included cases in which parentage was uncertain, as well as cases in which 

there were allegations that the parent had abused or could be a danger to 

the child. For all red-flag cases, facility staff provided information to ORR 

staff so that they could decide whether the child could be safely reunified 

with their parent. Due to the complex circumstances of red-flagged cases, 

facilities reported that these children remained in ORR care for longer 

periods while ORR made a final decision on how to resolve each case. 

Exhibit 4 on the following page illustrates how red flags affected two 

children’s reunification cases.
Communication and Management Challenges Impeded HHS’s Response to the Zero-Tolerance Policy 30

OEI-BL-18-00510

Under Ms. L v. ICE, the Government was required to reunify parents in the 

original class with their children by July 10, 2018 (for children younger than 5

years old) or July 26, 2018 (for children aged 5 years and older). To 

accomplish this, the IMT worked with DHS to develop a process whereby

DHS would transport parents to a limited number of DHS detention centers, 

and HHS would then direct facilities to bring separated children to those 

same detention centers to be reunified with their parents. Facilities 

described a variety of coordination problems that impeded this process,

including issues with transporting children and long waits to be processed 

at some DHS centers serving as reunification sites. Reunification with 

parents who were no longer in the United States presented special

challenges because of the need for coordination with the court system.

Facilities encountered challenges in transporting children to 

reunification sites

Facilities described several obstacles to efficient transportation of separated 

children to reunification sites. For example, facility staff stated that they 

received short notice from ORR’s transportation contractor about flight 

arrangements; they sometimes were informed late in the evening, which 

necessitated waking children up and transporting them that same night. In 

one case, a final approved list of children to be reunified and their flight 

arrangements was provided to a facility at 1 a.m. for airport dropoff times as 

early as 6 a.m. the same morning. Some of the children on the list had 

been placed in foster homes, and so the facility was unable to gather all the 

minors in time; as a result, three children who had been cleared for 

“P” is 13 years old. P’s father would like to be reunified with his son and is in a DHS detention center 

waiting for a court date. DHS informed facility staff that P’s father had a suspected criminal

disqualification (one type of red flag) preventing reunification. However, the case manager reports that 

DHS never disclosed the exact charges. In the meantime, facility staff attempted to vet three potential 

sponsors. Two sponsors were denied, and one withdrew. Facility staff requested a lawyer for P to 

counsel him on his options (e.g., voluntary departure or long-term foster care in the United States) if he 

is not able to reunify with his father. At the time of our site visit, P had been in ORR care for 

approximately 90 days.

“J” is 12 years old. J was ready for potential reunification with his father. However, the process was 

interrupted after ICE identified red flags purportedly stemming from J’s father’s gang-related 

background. The case manager said that the facility’s Federal field specialist became involved to gather 

more information about the red flags. ORR sent a series of emails to DHS in an attempt to identify the 

right person to speak with regarding the red flags. In the end, no gang-related background was found

and J’s father’s background check was cleared. At the time of our site visit, J had been in ORR care for 

approximately 90 days and was scheduled to be reunified with his father the following day.

Exhibit 4. How red flags affected two children’s reunifications

Care provider 

facilities described 

coordination 

problems that 

impeded efforts to 

reunify separated 

children with their 

parents
Communication and Management Challenges Impeded HHS’s Response to the Zero-Tolerance Policy 31

OEI-BL-18-00510

reunification missed their flight. Additionally, facility staff reported that the 

lack of time to prepare children for reunification sometimes caused the 

children distress. 

Facilities also reported instances in which children were transported to the 

reunification site as directed, but the parent was not there. In other cases, 

children were transported to detention centers for reunification but could 

not reunify with their parents for various reasons and had to be transported 

back to an ORR shelter. Additionally, facilities described two cases in which

minors were released to ICE for reunification, in accordance with the 

established process, but ended up being detained at the DHS location by

themselves without being reunited with their parents.

Facilities reported long wait times at some DHS detention centers 

serving as reunification sites

Some facilities reported that separated children experienced long wait 

times—from 8 hours to multiple days at or near DHS detention centers—

before being reunified with their parents. Facility staff stayed with children

during this time, sometimes waiting in vans in detention center parking lots. 

In some cases, staff needed to find hotel rooms and follow safeguards for 

overnight stays (e.g., ensuring that female staff were available to stay with 

girls and male staff with boys). Facilities also began sending staff and 

children with food and blankets to accommodate them during the long 

wait. Facilities reported having staff sleep in shifts so that someone was 

always supervising the children and so that the children would not lose their 

place in line to be processed at the DHS detention center. ORR facilities 

reported that these long waits led to significant stress for children and 

caseworkers. 

OIG also independently reviewed emails sent from facilities to ORR, as well 

as internal emails sent among ORR and ASPR staff, describing these issues. 

For example, on July 15, 2018, shortly before 10 p.m., a facility contacted 

HHS to report the significant delays they were experiencing at the Port 

Isabel detention center. In the email, facility staff explained that the 37 

children they had brought to the site had been waiting for 8 hours with no 

progress and noted that vans of children from other facilities were waiting 

as well. On July 19, 2018, staff from a different facility contacted HHS to 

report that the DHS official at the El Paso detention center had informed 

them that no more reunifications could take place that day, leaving 

approximately 20 children waiting and in need of overnight 

accommodations. The following day, facility staff contacted HHS again, 

stating that the El Paso detention center had announced they would soon 

be ceasing reunifications for that day, this time with approximately 50 

children still waiting. Exhibit 5 illustrates how coordination problems

affected one child’s reunification.

“[The] computer system 

at the detention center 

said R’s father was 

there, but he was not 

reunified with his dad. 

R was in the detention 

center for 3 weeks 

without a family 

member. [The ORR 

facility] believes his dad 

is not in the detention 

center because R never 

saw his father during 

the 3 weeks. R is now 

back at [the ORR 

facility] and [we are] 

working to unite him 

with a sponsor.” 

- Facility program 

director 
Communication and Management Challenges Impeded HHS’s Response to the Zero-Tolerance Policy 32

OEI-BL-18-00510

Exhibit 5. How coordination problems affected one child’s reunification

Lack of coordination of parents’ and children’s immigration court 

cases delayed some children’s reunification

Facilities also reported delays in reunification because immigration court 

dates (which are determined by DOJ) were not coordinated for parents and 

their children as a family unit. Instead, some parents were deported while

their children remained in ORR care awaiting their own court hearings. In 

cases where the deported parent wanted the child to return to the home 

country, ORR facilities reported that children remained in their care for 

several months pending the court date to approve the child’s repatriation. 

Care provider 

facilities reported 

that guidance and 

directives from ORR 

were poorly 

communicated and 

caused confusion

Facilities receive guidance and policy from ORR through a variety of 

mechanisms. When ORR needed to frequently update facilities with rapidly 

changing guidance about separated children in response to court orders, it 

relied primarily on emails. The resulting high volume of changing

instructions from a variety of sources contributed to confusion among 

facility staff. Further, facility staff reported that ORR guidance they received 

regarding separated children was not sufficiently detailed. Facility staff 

reported that these issues sometimes impeded their efforts to reunify 

children with their parents. 

ORR staff reported that because the reunification effort was led by the IMT, 

in collaboration with other Federal agencies and under the requirements of 

the Ms. L court, facility staff did not have full visibility into the reunification 

effort and the reasons for atypical processes and changing guidance. ORR 

staff acknowledged that the program relies on email to convey certain types 

of guidance but believed the confusion facility staff expressed was a result 

of unusual circumstances rather than indicative of a pervasive 

communication problem. However, OIG notes that if ORR continues to

provide critical instructions to facilities by email, such confusion is likely to 

recur in any future situations requiring rapidly changing guidance. 

“D” is 11 years old. He was separated from his father, who was in ICE custody. Approximately 45 days 

after arriving at the facility, the case manager requested D’s transfer for reunification. Two weeks later, 

D was on a manifest list to be transported to the DHS facility where D and his father would be 

reunified. The case manager and D arrived at the DHS facility after midnight and waited 6 hours before 

they were able to enter the facility. D’s father was not yet at the facility and arrived 2 hours later. The 

case manager said the required transfer of custody paperwork took additional hours to complete. On 

the date that D and his father were reunified, D had been in ORR care for approximately 60 days.
Communication and Management Challenges Impeded HHS’s Response to the Zero-Tolerance Policy 33

OEI-BL-18-00510

ORR relies on email to provide certain guidance and operational 

directives to its care provider facilities; these instructions are not 

archived in a central, searchable location

ORR provides guidance, including policies and operational directives, to its 

network of care facilities through the following channels:

• The ORR Guide: Children Entering the United States Unaccompanied

(Guide) is publicly available on the ACF website and includes a 

change log to help users determine when policies have been 

altered.

• The UAC Manual of Procedures (Manual) is accessible only to ORR 

staff, contractors, and grantees and provides additional guidance.

• ORR headquarters staff send emails to all Federal field specialists 

with instructions to convey certain guidance and operational 

directives to facilities.

• ORR headquarters staff send emails to facilities to directly convey 

certain guidance and operational directives.

Formal ORR policies are centrally maintained and accessible in the Guide

and the Manual. ORR provides other types of guidance by email. 

Specifically, ORR staff reported that they use email to provide time-sensitive 

policy updates before they are published in the Guide, as well as to provide 

guidance that ORR views as temporary and which will therefore not be 

included in the Guide or the Manual as formal policy. Guidance that ORR 

conveys by email is not catalogued or accessible in a central and searchable 

location.

Although communicating by email allows for rapid updates, it can also 

create confusion about what guidance is active. To confirm the most 

current set of instructions, facility staff must locate the most recent email 

they have received on a topic, which may have come from a central UAC 

policy account, any of several ORR employees’ individual accounts, or the 

facility’s Federal field specialist. 

Guidance about separated children changed rapidly, and care provider 

facility staff were often unsure which instructions to follow. As the 

number of separated children entering ORR care grew, and particularly after 

the June 2018 court order in Ms. L, ORR frequently emailed facilities to 

provide new or changed procedures required by court orders or other 

needs of the reunification effort. Because these were temporary and 

situation-specific instructions that would not be memorialized in the Guide

or Manual, they were provided only by email, supplemented by conference 

calls. As with emailed guidance in general, these instructions were not 

archived in a central, searchable location. Below are examples of the 

changing guidance that facilities received about reunifying separated 

children:

“We did not have one 

central repository for all 

directives... It would 

just be archived in 

emails.”

- ORR staff member 
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OEI-BL-18-00510

• On June 14, 2018, ORR directed facilities to conduct a specialized

parent assessment for all separation cases; 12 days later, ORR 

discontinued that requirement. 

• On July 2, 2018, ORR instructed facilities to use DNA tests to confirm 

parentage for separated children younger than 5 years old; on July 

9, ORR instructed facilities to also conduct DNA testing for 

separated children aged 5 to 17 years. On July 10, ORR instructed 

facilities to discontinue DNA testing, following a Ms. L v. ICE court 

order determining that routine DNA testing of parents was 

unnecessarily burdensome. 

• On July 9, 2018, ORR provided guidance to facilities that birth 

certificates for separated children should be authenticated by the 

home country consulate. ORR retracted that guidance July 10. On 

July 13, ORR distributed a guidance document with information 

about the reunification process and requirements, but the document 

did not specifically address authentication of birth certificates. On 

July 14, ORR reinstated guidance to authenticate separated 

children’s birth certificates. 

(See Appendix F for a detailed description of guidance that ORR provided to 

facilities regarding separated children.)

Facility staff reported that the constantly changing guidance and 

consequent confusion delayed reunification efforts. A program director 

stated that “the guidance changed frequently and in a manner that made it 

difficult to comply without inefficiencies.” A case manager explained that 

the facility staff “would begin to plan to reunify with family members, but 

the policy changed and they couldn’t.” Another case manager described 

cases as becoming stagnant through the uncertainty and “back and forth” 

of changing guidance.

Additionally, the high volume of messages originating from multiple sources 

within ORR led to confusion about what guidance was active. Facilities 

frequently emailed ORR staff with questions about what guidance to follow. 

Responding to those many questions constituted an additional, timeconsuming task for ORR staff who were already working long hours to 

coordinate the reunification effort. Additionally, emails containing timesensitive guidance were sometimes sent to incorrect or outdated addresses 

at facilities, creating opportunities for miscommunication or delays in 

providing important information. A facility program director stated that that 

reunification of children was sometimes delayed because the facility was 

wondering which guidance to follow. 

The timelines and directives associated with the court-ordered reunification 

undoubtedly exacerbated problems associated with guidance provided by 

email. However, OIG notes that these vulnerabilities are likely to recur in 

any future situation calling for rapid or changing instructions to facilities, 

“One time there were 

three or four policy 

changes via email in 

one day...it’s hard to 

keep up.”

- Facility program 

director 
Communication and Management Challenges Impeded HHS’s Response to the Zero-Tolerance Policy 35

OEI-BL-18-00510

including future litigation or future DHS or DOJ policy changes that affect 

ORR operations. 

Care provider facilities reported that ORR guidance about separated 

children was not sufficiently detailed 

Facilities and ORR field staff reported that guidance from ORR Headquarters 

staff was vague and did not address the full range of children’s situations. 

For example, a Federal field specialist stated that ORR provided insufficient 

guidance regarding separated children whose parents were in DHS custody 

and wished the child to be placed with someone else (e.g., a sponsor 

residing in the United States). Facility staff told OIG that they were 

continuing to attempt to identify and vet potential sponsors for such 

children, but that a child could not be discharged until ORR advised facility 

staff that the child could be legally released to someone other than the 

parent with whom he or she had entered the United States. Similarly, a case 

manager described a lack of guidance for cases in which the child’s parent 

had been deported and the child did not wish to voluntarily depart to be 

reunified with the parent. Facility staff also recounted instances in which 

they attempted to get clarification about ORR guidance from their Federal 

field specialist or other ORR staff, but the individuals they contacted could 

not answer their questions. Some staff indicated that they believed ORR did 

not understand the difficulties being imposed on facilities, leading to stress 

and frustration among facility staff attempting to comply with ORR 

guidance and directives.

“The facility relies 

heavily on ORR 

guidance. Without

clear, consistent, and 

specific guidance 

during the enforcement 

of the zero-tolerance 

policy, the facility’s 

resources were greatly 

strained and challenges 

were added to an 

already delicate 

system.”

- Facility program 

director 
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OEI-BL-18-00510

FINDINGS, PART III

Factors Affecting HHS’s 

Ongoing Efforts To 

Improve Tracking and 

Placement of Separated 

Children

Key Takeaway

HHS has taken steps to improve tracking of 

separated children, but the procedures include 

manual processes that are vulnerable to error; 

additionally, ORR continues to experience 

difficulties obtaining specific information from 

DHS about parents’ criminal backgrounds, 

impeding ORR’s ability to provide appropriate 

care and placement.
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OEI-BL-18-00510

FINDINGS

In the wake of Ms. L v. ICE, ORR made several changes to its procedures for 

identifying and tracking separated children. Notably, ORR added an 

indicator to children’s records in the UAC Portal to record that a child was 

separated before his or her referral to ORR. This indicator can then be used 

to create a list of all separated children at any given time. 

However, ORR staff explained that a lack of coordination between the UAC 

Portal and CBP’s IT system prevents this indicator from operating as ideally 

intended. Currently, most referral data are automatically transmitted from 

CBP’s IT system to the UAC Portal, eliminating the need to manually reenter basic information. However, data about separation are not 

automatically transmitted: when a child is flagged as separated in CBP’s 

system, the “separated” indicator in the UAC Portal is not triggered. 

Based on emails that OIG reviewed, CBP attempted to enable automatic 

transfer of separation data from the CBP system to the UAC Portal in 

October 2018. However, they were informed by ACF IT staff that no 

changes could be made to the UAC Portal and that separation information 

would have to be entered manually. Some CBP staff have the ability to log 

into the UAC Portal directly to manually trigger the “separated” indicator, 

but according to ORR staff, they are not typically doing so. 

As a result, identification and tracking of separated children currently relies 

on multiple manual steps. CBP staff may enter narrative information 

relevant to a child’s separated status in any of several possible sections of 

the referral form, including a Notes section and a Parent/Relative section. In 

some cases, the narrative information is not included in the form but is 

emailed to ORR separately. ORR intake staff must then review any narrative 

information provided about the child—either on the referral form or by 

email—and mark the separation indicator as appropriate. If adequate

narrative information has not been conveyed at the time of referral, the

ORR intake staff may not know that a child was separated.

To facilitate centralized tracking of separated children, ORR now maintains a 

consolidated spreadsheet of separated children referred to ORR. ORR staff 

reported that to create this spreadsheet, they use the “separated” indicator 

to pull relevant records from the UAC Portal and then manually reconcile 

this information with another spreadsheet maintained by intake staff as well 

as another list provided by CBP and confirmatory information from ICE. The 

consolidated spreadsheet is updated weekly. This represents a significant 

improvement over the informal systems ORR used in the past but still relies 

on manual processes that are inherently vulnerable to error, raising 

questions about the accuracy of current data on separated children.

Despite efforts to 

improve tracking 

of separated 

children, current 

procedures rely 

on manual 

processes that are 

vulnerable to 

error
Communication and Management Challenges Impeded HHS’s Response to the Zero-Tolerance Policy 38

OEI-BL-18-00510

HHS does not 

consistently 

receive complete 

information from 

DHS about 

parents’ criminal 

backgrounds

In a prior review, OIG reported that, as of November 2018, ORR was 

receiving limited information from DHS about the reasons for family 

separations. A tracking spreadsheet that OIG reviewed containing data on 

separated children who were referred to ORR from July 1 through 

November 9, 2018, included numerous instances in which the reason given 

for separation was “criminal history” with minimal or no further information 

about the nature of the criminal history.50 When a proposed sponsor 

(including a parent) has a criminal history, ORR policy is to evaluate the 

severity and type of crime and the length of time that has passed since the 

criminal act, along with any mitigating factors. To that end, ORR officials 

stated that when DHS provided insufficiently detailed explanations for a 

child’s separation, ORR staff would contact DHS for followup information. 

However, the spreadsheet we reviewed indicated that DHS did not always 

respond to these requests for followup information. 

According to a September 2019 court filing, DHS separated 955 children 

from an accompanying parent between June 27, 2018, and July 20, 2019.51 

In an earlier court filing, the Government stated that “DHS will communicate 

the basis for separation to HHS, and will, as soon as practicable, provide 

HHS with available and appropriate information about the reason for the 

separation (taking into account any restrictions on the sharing of such 

information). DHS and HHS have designated points of contact to assist HHS 

in obtaining information about the reasons for the separation.”

52

However, as of April 2019, ORR staff reported that they continue to face 

challenges in obtaining information from DHS regarding parents of 

separated children, including complete information about parents’ criminal 

histories; further, they reported that in some cases, key identifying 

information such as the parent’s name or alien registration number is also 

omitted. Staff reported that they still sometimes have difficulty locating 

parents in DHS custody, describing efforts to improve this function as “a 

work in progress.” Staff noted that the information they receive for newly

referred children varies across CBP sectors, with some sectors more 

receptive than others to ORR’s requests for followup information. ORR staff 

explained that complete and accurate information about criminal history is 

critical to their ability to provide appropriate case management and to 

determine what placement will best serve the child, regardless of whether 

that child is ultimately reunified with a parent or placed with a different 

sponsor. 

 
Communication and Management Challenges Impeded HHS’s Response to the Zero-Tolerance Policy 39

OEI-BL-18-00510

CONCLUSION AND RECOMMENDATIONS

Poor interagency communication and internal management decisions that 

failed to prioritize and protect children’s interests left HHS unprepared for 

the zero-tolerance policy. HHS was not responsible for separating families, 

but HHS’s inadequate communication, management, and planning made 

the situation worse for many separated children. For example, insufficient 

bed capacity left hundreds of children in CBP detention centers for 

extended periods before transfer to ORR’s care provider facilities, delaying 

their receipt of age-appropriate care and case management. Additionally, 

data limitations impeded HHS’s ability to quickly and accurately identify 

separated children, complicating efforts to promptly reunify separated 

children with their parents. Further, with no way to link children’s and 

parents’ information, facilities were unable to provide many children with 

timely information about or contact with their parents. Facilities also faced 

numerous operational challenges in carrying out their role in the courtordered reunification effort under short timeframes and with unclear 

Federal guidance. ORR has made recent changes to improve its tracking of 

newly separated children, but it relies on multistep, largely manual 

processes that are inherently vulnerable to error.

OIG’s review focused on factors affecting HHS’s response to the zerotolerance policy and the reunification of separated children as directed by 

the Ms. L v. ICE court. However, many of the problems we identified speak 

to broader communication and management concerns. For example, we 

noted management decisions that did not appropriately weigh risk to 

children, poor coordination between HHS and other Federal agencies, and 

inadequate information-sharing across HHS and DHS. Additionally, 

vulnerabilities in ORR’s methods of providing guidance to facilities, if left 

unaddressed, will hamper ORR’s ability to carry out its child welfare mission. 

In a quickly changing policy landscape, clear lines of communication—both 

across Federal agencies and within HHS—are vital to the Department’s 

ability to adapt and respond effectively to new developments.

To address these management challenges and improve UAC Program 

operations, OIG recommends the following:

HHS should take steps to ensure that children’s interests are 

prioritized and represented in decisions affecting the UAC 

Program, both internally and when engaging with interagency 

partners

HHS is charged with ensuring that children’s interests are considered in 

decisions and actions related to the care and custody of unaccompanied 

children. As the UAC Program is called to adapt to changes in immigration 

policy, enforcement, and trends beyond its control, HHS leadership across 
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OEI-BL-18-00510

the Office of the Secretary, ACF, and ORR must ensure that HHS centers 

children’s interests in its internal decision-making as well as in its 

interactions with interagency partners. To do so, HHS leadership should:

• direct ACF and ORR leadership to ensure that potential risks to 

children are explicitly assessed and considered in decisions about 

policies affecting unaccompanied children, including by proactively 

representing these children’s interests in interagency policy 

discussions;

• direct ACF and ORR leadership to ensure that staff are not 

prevented from documenting concerns about children’s well-being;

and

• clearly communicate to ACF and ORR leadership and staff that they 

are empowered and expected to elevate information, perspectives, 

and recommendations necessary to protect children’s interests and 

that concerns about potential harm to children in HHS custody will 

be taken seriously.

These directives should be provided through both written and oral 

communication to support an organizational culture that aligns with the 

Agency’s mission.

Regarding internal communication about separated children specifically, we 

recommend that ORR use its “separated” indicator in the UAC Portal to add 

information about separated children to regular reports provided to senior 

ACF officials about ORR operations. This indicator would provide ACF 

officials with greater awareness and information about ongoing separations 

and put them in a better position to address any concerns, such as the flow 

of information between DHS and HHS about separated children and their 

parents or legal guardians. 

HHS should modify or pursue formal agreements with DHS and 

DOJ to ensure that it is receiving information that supports its 

operation of and ability to provide care for children in the UAC 

Program

HHS has active agreements with DHS regarding the UAC Program generally, 

but these documents do not fully address the coordination challenges that 

OIG identified, as evidenced by the lack of communication in advance of the 

zero-tolerance policy and the difficulties that ORR and facilities

encountered—and still encounter—in obtaining information about parents 

of separated children. Meanwhile, HHS has no formal agreement with DOJ 

regarding locating children’s family members in DOJ custody.

53

 Therefore, 

we recommend that HHS work with DHS and DOJ to address the following 

concerns:

• Formal agreements (such as an MOA or its functional equivalent) 

with both agencies should include specific mechanisms and 

timeframes to enable effective interagency notification about 
Communication and Management Challenges Impeded HHS’s Response to the Zero-Tolerance Policy 41

OEI-BL-18-00510

any changes to immigration policy or enforcement initiatives that 

may foreseeably affect ORR’s responsibilities. Notice should be 

sufficiently in advance of the policy or initiative to allow ORR to 

prepare for the changes and minimize adverse impact on children. 

• Formal agreements with both agencies should include

commitments to ensure that DHS, DOJ, and their subagencies 

are fully responsive to ORR’s informational needs so that ORR 

and facilities can provide optimal care for vulnerable children. ORR 

should receive complete, timely, and accurate information about

parents’ locations, parents’ criminal history, and other background 

information (subject to legal constraints on law enforcement 

sensitive information). Communication with parents (e.g., about 

their own background, relatives in the United States, and children’s 

medical history) is also vital to enable ORR and facility staff to

provide care and make appropriate placement decisions.

With regard to DHS, current operational guidance documents 

support the sharing of certain information between DHS and HHS at 

the time of referral, but HHS should pursue agreements that require

DHS to improve the completeness and accuracy of the information 

provided to ORR. It is important that ORR and facilities are able to 

identify parents or guardians who remain in DHS custody and link 

that information to children in ORR care; determine parents’ or 

guardians’ locations in DHS custody; and receive sufficiently detailed 

information about parents’ or guardians’ criminal histories. 

Additionally, HHS should work with DHS to improve systems and 

procedures for collecting and sharing data, with the goal of ensuring 

that HHS receives complete, accurate, timely, and secure 

information about children referred to its care.

With regard to DOJ, no current agreement requires DOJ to 

coordinate with ORR or provide information about parents’ 

locations, which has led to ongoing difficulties locating parents in 

U.S. Marshals’ custody. An MOA or other formal agreement should 

be pursued to improve ORR’s access to this information.

• Consistent with OIG’s recommendation above, formal agreements 

with both agencies should protect the interests of children who 

are or will be in HHS custody. HHS should ensure that interagency 

agreements affecting the UAC Program are consistent with its 

humanitarian mission. 

OIG recognizes that effective collaboration requires effort and 

responsiveness from all parties and that HHS cannot compel other Federal 

agencies to modify or enter into agreements. Nonetheless, HHS has a 

responsibility to diligently pursue interagency agreements and informationsharing to the extent that they can support the HHS mission and serve the 

interests of children in HHS custody. OIG notes that greater interagency 
Communication and Management Challenges Impeded HHS’s Response to the Zero-Tolerance Policy 42

OEI-BL-18-00510

coordination around separated children has been occurring in the context 

of Ms. L v. ICE and other litigation. HHS should take steps to continue and 

formalize this increased coordination after the litigation resolves. 

HHS should improve communication to care provider facilities 

regarding interim guidance, operational directives, and other 

instructions that are not immediately available in published 

policy documents 

ORR was placed in the difficult position of needing to frequently send

updated information and guidance to its facility network about separated 

children. Given the ongoing potential for changes in policy and other 

emerging issues that affect the UAC Program, it is likely that ORR will have 

future need to communicate information to its network of facilities quickly, 

accurately, and in such a manner that both ORR and facility staff can easily 

determine what directives should be followed at any given time. To that 

end, we recommend that ORR ensure that any instructions they expect 

facilities to follow—including temporary, interim, and operational 

guidance—are archived and available in a searchable location with clear 

issuance and effective dates. In addition to improving facilities’ access to 

critical guidance, such a system would also reduce the need for ORR 

Headquarters staff to respond to requests for information and clarification 

from facilities.

HHS should further improve its ability to identify and track 

separated children by reducing reliance on manual processes

In the wake of the zero-tolerance policy and the court-ordered reunification

effort, ORR made several changes to its systems and procedures for 

identifying and tracking separated children. OIG recognizes these 

significant improvements. However, information about children’s separated 

status is still conveyed through manual, multistep processes that are 

inherently vulnerable to error. ORR should streamline its procedures to 

reduce reliance on these manual processes. As part of this effort, ORR

should identify and resolve barriers to automating exchange of the 

“separated” data element between the CBP IT system and the UAC Portal.
Communication and Management Challenges Impeded HHS’s Response to the Zero-Tolerance Policy 43

OEI-BL-18-00510

AGENCY COMMENTS AND OIG RESPONSE

ACF concurred with all of our recommendations.

In response to our first recommendation, ACF generally concurred but 

noted limitations to HHS’s statutory authority regarding the formulation and 

implementation of immigration law enforcement policy. ACF indicated that 

it is committed to ensuring that children’s interests are prioritized while in 

ORR’s care and custody and acknowledged its statutory obligation to 

consider children’s interests when making certain decisions. ACF did not 

describe actions it would take to address the specific steps OIG 

recommended to ensure that children’s interests are prioritized. We 

encourage HHS to issue internal directives and related communications as 

we recommended to support an organizational culture that aligns with the 

Agency’s mission. 

In response to our second recommendation, ACF generally concurred but 

stated that its ability to modify or enter into agreements is dependent on a 

variety of factors, including the actions of other Federal agencies. We 

recognize that HHS cannot unilaterally implement interagency agreements

but recommend that HHS pursue, to the best of its ability, agreements that 

support UAC Program operations and are consistent with the interests of 

children in the Department’s custody. 

ACF also stated that interagency agreements are not legally enforceable. 

However, as ACF affirmed, interagency agreements are nonetheless a useful

tool to define each parties’ expectations and clarify consensus practices. We 

note that MOAs can include mechanisms to address parties’ failure to 

adhere to the agreement. 

ACF also described two planned actions that address interagency 

coordination. First, ORR will engage with DHS regarding updates to the 

Unaccompanied Alien Children Joint Concept of Operations. Second, ORR 

will establish annual meetings of ORR and grantee leadership along with 

interagency partners to discuss field operations, policy and procedure 

formulation, and best practices.

ACF concurred with our third recommendation and described steps taken 

and planned to improve communication with care provider facilities. 

Specifically, ORR has made training and other resources available to 

facilities, and ORR’s UAC separations team will support the UAC policy team 

in developing procedures regarding communication of new guidance, 

directives, and instructions to facilities. Additionally, ORR is working with 

other HHS components to implement an October 2019 Executive Order that, 

among other provisions, requires each agency to establish a searchable 

database of all guidance documents in effect.
Communication and Management Challenges Impeded HHS’s Response to the Zero-Tolerance Policy 44

OEI-BL-18-00510

ACF concurred with our fourth recommendation and described steps taken 

and planned to improve its ability to identify and track separated children. 

ACF stated that ORR is undertaking a modernization of the UAC Portal that 

will reduce reliance on manual processes to track separated children.

Please see Appendix G for the full text of ACF’s comments.
Communication and Management Challenges Impeded HHS’s Response to the Zero-Tolerance Policy 45

OEI-BL-18-00510

APPENDIX A: Timeline of Key Events

January 25, 2017

President Trump issues “Executive Order: Border Security and Immigration 

Enforcement Improvements,” directing the DHS Secretary to issue guidance ending 

“catch and release” policies and calling for a more stringent detention and removal 

policy.

February 9, 2017 Jeff Sessions is sworn in as U.S. Attorney General.

February 10, 2017 Tom Price is sworn in as Secretary of HHS.

February 20, 2017

DHS Secretary John Kelly issues memorandum titled, “Implementing the 

President’s Border Security and Immigration Enforcement Improvements Policies,” 

which calls for an end to policies known as “catch and release.”

March 7, 2017 DHS Secretary Kelly publicly confirms the possibility of separating families as a 

deterrence policy.

March 29, 2017 DHS Secretary Kelly publicly states that DHS will not pursue a policy of family 

separation.

April 11, 2017

Attorney General Sessions issues a memorandum titled, “Renewed Commitment to 

Criminal Immigration Enforcement,” which directs Federal prosecutors to prioritize 

prosecution of certain immigration offenses.

July 2017 El Paso sector of CBP begins prosecution initiative resulting in family separations.

July 31, 2017 Former DHS Secretary Kelly becomes White House Chief of Staff; Elaine Duke is 

designated Acting Secretary of DHS.

September 29, 2017 HHS Secretary Price resigns; Don J. Wright is designated Acting Secretary of HHS.

October 6, 2017 Eric D. Hargan is sworn in as Deputy Secretary of HHS.

October 10, 2017 Eric D. Hargan is designated Acting Secretary of HHS.

December 6, 2017 Kirstjen Nielsen is sworn in as Secretary of DHS.

January 29, 2018 Alex M. Azar II is sworn in as Secretary of HHS.

February 26, 2018 Ms. L v. ICE lawsuit is filed.

April 6, 2018

President Trump issues memorandum “Ending ‘Catch and Release’ at the Border of 

the United States and Directing Other Enhancements to Immigration 

Enforcement.”

April 6, 2018

Attorney General Sessions issues memorandum “Zero-Tolerance Policy for 

Offenses under 8 U.S.C. § 1325(a),” directing prosecutors to accept all referrals of 

improper entry offenses from DHS for criminal prosecution.
Communication and Management Challenges Impeded HHS’s Response to the Zero-Tolerance Policy 46

OEI-BL-18-00510

April 13, 2018 HHS and DHS sign MOA establishing new information-sharing responsibilities, 

effective 30 days from the date of signature.

May 7, 2018 Attorney General Sessions announces DOJ and DHS implementation of the zerotolerance policy in a public speech.

June 7, 2018 ORR revises policy on fingerprint-based background check requirements, 

implementing a key provision of the April 2018 MOA.

June 20, 2018

President Trump issues “Executive Order: Affording Congress an Opportunity To 

Address Family Separation,” which directs DHS to detain families together 

whenever possible.

June 26, 2018

A Federal district court rules in Ms. L v. ICE that the Federal Government must 

cease separations (with some exceptions) and must reunify parents with their 

minor children who are in ORR care on that date.

July 10, 2018 Court-ordered deadline for reunification of Ms. L v. ICE class members with their 

children younger than 5 years old.

July 26, 2018 Court-ordered deadline for reunification of Ms. L v. ICE class members with their 

children aged 5 to 17 years.

November 7, 2018 Attorney General Sessions resigns; Matthew Whitaker is designated Acting 

Attorney General.

February 14, 2019 William Barr is sworn in as Attorney General.

April 7, 2019 DHS Secretary Kirstjen Nielsen resigns; Kevin McAleenan is designated Acting 

Secretary of DHS.

March 8, 2019 The Ms. L v. ICE court expands the class definition to include parents who entered 

the United States on or after July 1, 2017.

Source: OIG analysis of public and internal HHS documents, 2019.
Communication and Management Challenges Impeded HHS’s Response to the Zero-Tolerance Policy 47

OEI-BL-18-00510

APPENDIX B: Previous Related Office of Inspector 

General Work 

Additional information on OIG’s work on this topic, including reports prior to 2018, can be found on our 

Unaccompanied Children webpage. Below is a list of recent OIG reports on unaccompanied children.

Title Report Number Date Issued

Care Provider Facilities Described Challenges Addressing Mental Health 

Needs of Children in HHS Custody

OEI-09-18-00431 September 2019

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

Southwest Key Programs Did Not Always Comply With Health and 

Safety Requirements for the Unaccompanied Alien Children Program

A-06-17-07005 August 2019

Southwest Key Did Not Have Adequate Controls in Place To Secure 

Personally Identifiable Information Under the Unaccompanied Alien 

Children Program

A-18-18-06001 August 2019

The Children’s Village, Inc., an Administration for Children and 

Families Grantee, Did Not Always Comply With Applicable Federal 

and State Policies and Requirements

A-02-16-02013 April 2019

Lincoln Hall Boys’ Haven, an Administration for Children and Families 

Grantee, Did Not Always Comply with Applicable Federal and State 

Policies and Requirements

A-02-16-02007 February 2019

Separated Children Placed in Office of Refugee Resettlement Care OEI-BL-18-00511 January 2019

BCFS Health and Human Services Did Not Always Comply With 

Federal and State Requirements Related to the Health and Safety of 

Unaccompanied Alien Children

A-06-17-07007 December 2018

The Tornillo Influx Care Facility: Concerns About Staff Background 

Checks and Number of Clinicians on Staff

A-12-19-20000 November 2018

Florence Crittenton Services of Orange County, Inc., Did Not Always 

Claim Expenditures in Accordance With Federal Requirements

A-09-17-01002 October 2018

Heartland Human Care Services, Inc., Generally Met Safety Standards, 

but Claimed Unallowable Rental Costs

A-05-16-00038 September 2018

Florence Crittenton Services of Orange County, Inc., Did Not Always 

Meet Applicable Safety Standards Related to Unaccompanied Alien 

Children 

A-09-16-01005 June 2018

BCFS Health and Human Services Did Not Always Comply With 

Federal Requirements Related to Less-Than-Arm's-Length Leases

A-06-16-07007 February 2018
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APPENDIX C: Lines of Authority Over the 

Unaccompanied Alien Children Program

During the Period of Review

Source: OIG Analysis, 2019.
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APPENDIX D: Care Provider Facilities Visited 

by OIG

During August and September 2018, OIG staff conducted site visits to 45 facilities across 

10 States. 

Number and Type of Facilities Visited 

28 Shelter

Most common type of residential care facility; provides housing, 

food, medical care, mental health and educational services, and 

recreational activities. 

9 Staff Secure

Provides close supervision to children who exhibit disruptive 

behavior, are a flight risk, or display gang affiliation. This includes 

the only therapeutic staff secure facility that ORR funded at the 

time of our site visit, which provides a combination of close 

supervision and intensive support and clinical services (e.g., indepth counseling).

2 Secure Provides care for children who pose a danger to self or others, or 

who have been charged with a crime.

2

Residential 

Treatment Center

Provides children who need more intensive mental health 

treatment with subacute therapeutic care through a structured 

24-hour-a-day program and services that are highly customized 

to individual needs. 

2 Influx Provides children with temporary emergency shelter and services; 

used when ORR experiences an influx of children.

2

Transitional 

Foster Care

Provides short-term foster care for children younger than 13

years old, siblings, pregnant and parenting teens, or those with 

special needs; services provided in the community.

Source: OIG analysis of ORR and facility data, 2019.
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Facilities Visited

The table below lists and describes the 45 facilities that OIG visited.

Facility Name Facility Type Number of 

Children in Care*

Licensed To Care for 

Younger Children**

Cared for Separated 

Children***

Arizona (4)

SWK Campbell Shelter 126 ● ●

SWK Casa Phoenix Shelter 385 ●

SWK Estrella Shelter 295 ● ●

SWK Hacienda del Sol Shelter 139 ● ●

California (3)

BCFS Fairfield Staff Secure 11

SWK Pleasant Hill Shelter 26 ●

Yolo County Secure 19

Florida (1)

Homestead Influx 1,347 ●

Illinois (4)

Heartland CRC IRC Shelter 193 ● ●

Heartland 

Casa Guadalupe Shelter 47 ● ●

Heartland IYC Staff Secure 6

Heartland SCIY Shelter 5 ●

Maryland (1) 

Board of Child Care Shelter 42 ● ●

New York (7)

Abbott House Shelter 51 ● ●

Cayuga Centers Transitional Foster 

Care 609 ● ●

Children’s Village Shelter 167 ●

Children’s Village Staff Secure 26

MercyFirst Residential 

Treatment Center 9

●

Leake and Watts/

Rising Ground Shelter 47 ●

Lincoln Hall Shelter 184 ●

Oregon (1)

Morrison Paso Staff Secure 11

(Continued on next page)
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Facility Name Facility Type Number of 

Children in Care*

Licensed to Care for 

Younger Children**

Cared for Separated 

Children***

Texas (20)

BCFS Baytown Shelter 216 ● ●

BCFS Harlingen Shelter 576 ● ●

BCFS Raymondville Shelter 50 ● ●

BCFS 

San Antonio Shelter 110 ● ●

BCFS 

San Antonio Staff Secure 26

BCFS 

San Antonio

Transitional Foster 

Care 119 ● ●

BCFS Tornillo Influx 665 ●

Shiloh Treatment 

Center

Residential 

Treatment Center 23 ●

SWK Antigua Shelter 276 ●

SWK Casa Houston Shelter 71 ●

SWK Montezuma Shelter 209 ●

SWK Casa Padre Shelter 1,398 ●

SWK Casa Quetzal Shelter 246 ●

SWK Casita del Valle Shelter 84 ● ●

SWK Combes Shelter 73 ● ●

SWK Mesa Staff Secure 7

SWK El Presidente Shelter 372 ● ●

SWK Nueva 

Esperanza Shelter 290 ●

SWK Processing 

Center Staff Secure 16

SWK Rio Grande Shelter 225 ●

Virginia (2)

Shenandoah Valley 

Juvenile Center Secure 20 ●

Youth for Tomorrow Shelter 111 ●

Washington (2)

Friends of Youth Staff Secure 11 ●

Selma Carson Staff Secure 14 ●

Source: OIG analysis of ORR and ASPR data, 2019. 

* Data on the number of children in care as of August 30, 2018. 

** Younger children include those who were 9 years old or younger. 

*** We obtained from ORR and ASPR data on separated children that were part of the Ms. L v. ICE lawsuit.  Our 

analysis identified that 37 of the 45 facilities had children covered by the lawsuit.
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Children’s Demographics at Facilities Visited

Source: OIG analysis of ORR and facility data, 2019. 

* According to ORR data, on August 30, 2018, a total of 12,409 children were in ORR care. Of those, 8,953 children 

were at the facilities that OIG visited; the percentages of boys and girls are based on this number. The percentages 

on age range and country of origin are based on data collected directly from the facilities that we visited. We 

reviewed age and country of origin data that facilities provided to OIG. Because some facilities provided data for a 

point-in-time (i.e., specific date) while other facilities provided data over a specific timeframe (i.e., 3-month period), 

the total number of children between these two data points differs. Age range is based on data from 5,835 

children; country of origin is based on data from 7,081 children. Because of rounding, the total percentage for 

country of origin does not add up to 100 percent.
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APPENDIX E: Detailed Methodology

To identify challenges that HHS and care provider facilities faced in

responding to the zero-tolerance policy and reunifying separated children

with their parents, we interviewed numerous senior HHS officials and HHS 

staff and conducted site visits to 45 facilities. Additionally, we reviewed 

both internal HHS documents and publicly available information to confirm 

and expand upon information provided in interviews. We analyzed these 

data to establish facts, confirm timelines, and identify internal and external 

factors that affected the Department’s response to the zero-tolerance 

policy.

Overview of Data Sources

This report synthesizes information from a wide array of sources, including

extensive interviews with, and written responses from, senior HHS officials 

and HHS staff in the Office of the Secretary, ASFR, ASPR, ACF, and ORR; 

interviews with staff at 45 care provider facilities; case reviews for a 

purposive sample of separated children; and thousands of documents 

obtained through requests to the Department, from facility staff, and from 

interview respondents. These data sources are described in detail below.

Interviews With Senior HHS Officials and HHS Staff

Our work draws on numerous interviews with senior HHS officials and HHS 

headquarters and regional staff. In this report, “senior official” means a 

Presidential appointee under the Executive Schedule, a non-career 

appointee to the Senior Executive Service (SES), or a non-career Schedule C 

appointee. “Staff” means career employees at or below the SES level, 

including career U.S. Public Health Service Commissioned Corps Officers. 

We selected respondents to include offices and individuals who played key 

leadership or operational roles before and during the zero-tolerance 

policy’s implementation and during the subsequent court-ordered 

reunification. Specifically: 

• We interviewed seven senior officials in the HHS Office of the 

Secretary, ASFR, ASPR, ACF, and ORR between September 2018 and 

August 2019. Some officials were interviewed more than once. 

• We submitted questions in writing to the Secretary and Deputy 

Secretary, who provided written responses.

• We interviewed 16 staff in ASPR, ACF, and ORR Headquarters 

between September 2018 and August 2019. These interviewees 

included ACF staff with expertise in budget formulation; ORR staff 

with expertise in policy, data, intakes, and other matters relevant to 

our review; and ASPR staff in both leadership and support positions 

assigned to the reunification mission. Some staff were interviewed 
Communication and Management Challenges Impeded HHS’s Response to the Zero-Tolerance Policy 54

OEI-BL-18-00510

individually, while others were interviewed as a group. Some staff 

were interviewed more than once.

• We interviewed 28 ORR Federal field specialists (field staff) who are 

responsible for providing guidance and technical assistance to 

facilities and approving or denying children’s transfer and release.

Throughout the report, certain individuals are referred to by their titles at 

the time of the events being described. Please note that the individuals who 

held the positions of ORR Director, Acting Assistant Secretary for ACF, 

Counselor to the Secretary for Human Services Policy, and ORR Deputy 

Director during the periods those roles are discussed are no longer in those 

positions as of the date of this report.

Site Visits to Care Provider Facilities

OIG conducted site visits to 45 ORR-funded facilities in operation across the 

country. All site visits lasted 2 to 3 days and occurred in August or 

September 2018, with the majority taking place in August. Site visits 

included more than 100 interviews with facility leadership and staff as well as 

case reviews of selected separated children.

Site selection. The 45 sites were selected purposively to achieve wide 

coverage of facilities participating in the UAC Program and to include a 

variety of facility types, sizes, populations in care, and geographic locations. 

Combined, the 45 sites that we visited included facilities that cared for 

72 percent of the children in ORR custody at the time of our review. Of the 

facilities we visited, approximately two-thirds (28) were shelter facilities, the 

most common type of facility in ORR’s network. We also visited every

residential treatment center (2), staff-secure (9), secure (2), and influx (2)

facility in ORR’s network at that time. Additionally, at least 37 facilities that 

we visited cared for at least one separated child whom HHS had identified, 

as of August 2018, as a possible child of a potential Ms. L v. ICE class 

member. Other facilities may also have cared for separated children who 

were not part of this litigation or who were identified under Ms. L v. ICE after 

the time of our review. See Appendix B for information about the 45 

facilities we visited and the children in their care. 

Site visit protocol. Multidisciplinary teams of OIG staff conducted each site 

visit. Each team consisted of at least one evaluator, auditor, investigator, 

and lawyer. These teams were trained in advance regarding their 

responsibilities specific to this fieldwork. 

This report is focused on challenges that HHS and facilities faced in their 

efforts to reunify separated children. To that end, at each of the 45 facilities, 

we interviewed facility leadership, including the program director, as well as

case managers involved in the reunification effort.

54

 We interviewed these 

key personnel in private by using standardized interview protocols. 
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Additionally, at most facilities, we reviewed the cases of up to five separated 

children selected purposively to represent a range of ages and situations 

affecting their cases. Specifically, at the time of OIG’s site visits, we had 

obtained from HHS child-specific data about separated children who were 

covered by the Ms. L v. ICE lawsuit and who had been placed in 35 of the 45 

facilities in our review. For each of those 35 sites, we purposively selected 

up to 5 separated children and reviewed their cases onsite with their case 

manager to better understand factors affecting their reunification, including

factors contributing to delays in reunification.55 In total, we interviewed 80 

case managers and completed 89 case reviews for analysis.

Criteria used to select children for case review included:

1. Children who had not yet been reunified. When the facility housed 

separated children who had not yet been reunified, we selected 

from among those children’s files first.

2. Age. We sought to represent children of different ages; children in 

our case review ranged in age from 1 to 17 years.

3. Reasons they had not been reunified. We sought to represent a 

range of factors affecting children’s ability to be reunified, such as a 

parent having been deported, a parent having a red flag on their 

file, difficulty locating the parent, parent declining reunification, etc.

Because our case selections prioritized separated children who remained in 

ORR care at the time of our site visits—which occurred after the Ms. L v. ICE

deadline to reunify separated children—they are not representative of the 

universe of separated children. The five case examples provided in our 

report are intended to illustrate the complexity of some separated children’s 

situations and the many factors that could impede reunification.

Document Review

OIG conducted an extensive review of HHS documents related to family 

separation, the zero-tolerance policy, and the reunification of separated 

children with their parents, as well as documents reflecting interactions 

between HHS and other Federal agencies regarding immigration policy 

more broadly. In total, OIG reviewed more than 5,000 documents 

encompassing memoranda, letters, emails, spreadsheets, meeting agendas, 

meeting summaries, and other records created or received by HHS 

employees related to these matters, primarily from early 2017 through mid2018. We reviewed documents internal to HHS as well as interagency 

correspondence and records that involved HHS senior officials and staff. 

Consistent with OIG’s statutory role, we reviewed both privileged 

documents (e.g., legal opinions, interagency deliberative correspondence, 

and draft memoranda) as well as non-privileged documents (e.g., 

correspondence about operational matters, guidance transmittals to 

facilities, and certain final memoranda). 
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OIG requested and received documents from the following sources:

• documents provided by interview respondents, including facility 

staff, to corroborate or expand upon interview responses;

• documents provided by HHS containing guidance and operational 

directives that ORR transmitted to facilities regarding separated 

children;

• documents originally compiled by HHS staff to prepare senior

officials for congressional testimony related to the zero-tolerance 

policy; and

• documents retrieved by HHS staff from senior officials’ and staff 

members’ computers and paper files through a broader 

Departmental effort to identify all documents relevant to family 

separation as well as other ORR issues. 

Regarding the Department’s efforts to identify and retrieve all documents 

relevant to family separation, staff within the Office of the General Counsel, 

with contractor support, constructed an extensive database of documents to 

respond to requests from OIG, Congress, and outside litigants. The full 

database covered issues related to family separation as well as other ORR 

topics beyond the scope of OIG’s review. OIG reviewed HHS’s procedures 

for identifying and collecting documents responsive to OIG’s request and 

confirmed that they were sufficient to identify potentially relevant material. 

For example, the Department collected all emails and documents on 

computers and shared drives for HHS senior officials and staff with extensive 

involvement in ORR; additionally, the Department used automated 

processes with topic-specific search terms to retrieve potentially relevant 

documents from the computers and shared drives of senior HHS officials 

with portfolios encompassing ORR as well as other program offices within 

ACF and other HHS operating divisions. From this larger database, OIG 

identified documents by using search terms and dates pertinent to our 

objectives. Artificial intelligence software was employed to identify the most 

relevant documents for review. 

Analysis 

We conducted qualitative review and analysis of interview data to identify 

significant challenges that HHS and facilities faced in responding to the 

zero-tolerance policy and reunifying separated children, as well as key 

factors that contributed to those challenges. Regarding factors affecting 

HHS, we identified key themes across multiple respondents and sought to 

corroborate key statements with other interviewees. Regarding challenges 

faced by facilities, we sought to identify the most significant challenges 

reported by facility management, case managers, and Federal field 

specialists. Each of the key challenges we discuss (locating and

communicating with parents, confirming whether reunification could safely 
Communication and Management Challenges Impeded HHS’s Response to the Zero-Tolerance Policy 57

OEI-BL-18-00510

occur, transporting children to be reunified, and unclear guidance from 

ORR) was reported by the majority of facilities in our review. 

Additionally, we conducted content-based review of internal HHS 

documents as well as public materials such as court filings to establish

specific facts (e.g., dates and topics of meetings); to confirm timelines (e.g., 

dates of guidance communications); and, when possible, to verify interview 

responses (e.g., by identifying emails or memos consistent with 

interviewees’ statements).

Limitations

We were not able to independently verify all information provided by HHS 

or facility staff. Whenever possible, we compared interviewees’ statements 

to facts we could determine from the extensive documentary record; as 

appropriate, we also requested documentation from interviewees to 

support their statements. We confirmed certain information about DHS IT 

systems directly with DHS staff.

The facilities we visited and the case files we reviewed were purposively 

selected and do not necessarily represent the experiences of all facilities or 

all separated children. Likewise, the exhibits included in this report were 

selected to illustrate how various factors affected children’s reunification 

cases; they do not necessarily represent the experiences of all facilities or all 

separated children. 
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APPENDIX F: Timeline of Key Guidance to Care 

Provider Facilities About Separated Children

April 6, 2018

Attorney General issues memorandum “Zero-Tolerance for Offenses under 8 U.S.C. 

§ 1325(a),” directing prosecutors to accept all referrals of improper entry offenses 

from DHS for criminal prosecution.

April 11, 2018

ORR issues guidance for reunifying separated children with parents (including 

those in DHS custody but expected to be released, and those in removal 

proceedings) or placing such children with an alternative sponsor. Guidance 

stipulates that Federal field specialists will confirm familial relationships, verify 

criminal history background check, and gather other information before initiating 

procedures to release the child to the parent upon the parent’s release from 

detention. For children who will not be reunified with their parent, the Federal 

field specialist will seek to contact the parent in detention to gather information 

about alternate sponsors.

April 21, 2018

ORR instructs facilities to file a Significant Incident Report (SIR) for any future cases 

of children identified as separated from biological parents that DHS had not 

previously reported as separated when transferring the child to ORR.

May 7, 2018 Attorney General makes public speech announcing that the zero-tolerance policy 

has been implemented at both DOJ and DHS.

May 9, 2018

ORR discontinues the process established in April 2018 for reunifying separated 

children with parents in ICE custody. Facilities are instructed that in cases in which

the child does not have a sponsor, they should wait for the immigration judge to 

issue a voluntary departure order for returning to their country of origin. 

May 14, 2018

ORR issues guidance to facilities on establishing swift contact between separated 

children and parents in detention, noting that all ORR responsibilities for screening 

children and adults remain in place. Case managers and clinicians are to notify 

their Federal field specialist immediately if a parent requests to return to their 

country of origin with their child. ORR issues guidance on the transfer of 

separated children to DHS in cases when a parent or legal guardian requests 

reunification with the child for repatriation. The Federal field specialist can 

approve the transfer after meeting all safety requirements, including confirming 

the parent-child relationship and that the parent does not pose a risk to the child.

June 4, 2018

ORR expands SIR guidance to require that facilities submit a SIR for any child 

separated from a parent if that separation was not already reported, and for any 

child who was previously reported as separated but the facility has determined was 

not actually separated.
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June 20, 2018

President Trump issues “Executive Order: Affording Congress an Opportunity to 

Address Family Separation,” which directs DHS to detain families together 

wherever possible.

June 26, 2018

A Federal district court rules in Ms. L v. ICE that the Federal Government must 

cease separations (with some exceptions) and must reunify parents with their 

minor children in ORR care.

June 28, 2018

ORR instructs facilities to compile a list of separated children and to log efforts to 

establish contact between separated children and their parents, noting that the 

Federal field specialist can provide a list of detention centers and contact numbers 

needed to locate and establish contact with a parent in detention.

July 2, 2018 ORR instructs facilities to conduct DNA testing on all separated children aged 0 to 

4 years to determine parentage.

July 3, 2018

ORR informs facilities of a new requirement that parents whose separated children 

have an identified alternative sponsor must sign a “Letter of Designation for Care 

of a Minor” before ORR will release the child to the sponsor.

July 9, 2018

ORR instructs facilities that all birth certificates must be authenticated by the 

consulate. Additionally, separated children aged 5 to 17 years and their parents 

must now be DNA tested.

July 10, 2018 Ms. L v. ICE court deadline to reunify children younger than age 5 with their 

parents

July 10, 2018 ORR issues guidance that birth certificates no longer need to be authenticated. 

Further, parents of separated children will no longer be DNA tested.

July 13, 2018

ORR instructs facilities to only reunify children with parents in ICE detention and to 

await guidance on reunifying children with potential sponsors or parents who are 

in the United States. ORR provides to facilities a document with guidance on 

reunification of separated children subject to the Ms. L v. ICE litigation, including

requirements for reunification, the limited circumstances under which DNA testing 

will be completed, and how the process differs from the standard ORR process 

(e.g., Ms. L v. ICE class members need not sign sponsor care agreements or attend 

a legal orientation program).

July 14, 2018

ORR provides guidance to facilities that all separated children must have 

authenticated birth certificates before release. ORR also instructs facilities to 

temporarily stop reunifying separated children cleared for release to parents in 

DHS custody. Later that day, ORR instructs facilities to resume reunification efforts 

for separated children cleared for release to ICE custody if they have a verified 

birth certificate and meet other requirements. ORR also provides guidance and 

forms for the transfer of custody to DHS for the purpose for reunification.
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July 15, 2018

ORR provides guidance on transferring separated children to ICE detention centers 

and adds protocols for discharge to parents already released from ICE custody. 

The guidance instructs facilities to complete release requests and manifests with 

information on transport logistics, medical clearance, and verification of birth 

certificates. ORR also authorizes full payments for transport of children to 

detention centers for reunification or to released parents for reunification.

July 18, 2018

ORR updates guidance on transferring separated children to ICE detention centers 

to include notification to the child’s legal service provider or attorney about the 

date and time of the child’s departure.

July 26, 2018 Ms. L v. ICE court deadline to reunify all children of class members with their 

parents

Source: OIG analysis of public and internal HHS documents, 2019.
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APPENDIX G: Agency Comments
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-Tolerance Policy 62

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-Tolerance Policy 63

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-Tolerance Policy 64

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ACKNOWLEDGMENTS

Louise Schoggen served as team leader for this study. Other Office of 

Evaluation and Inspections staff who conducted the study and were primary 

contributors include Bahar Adili, Heather Barton, Louis Day, Seta 

Hovagimian, Michael Kvassay, Zunara Naeem, and Brianna So. Key advisors 

included Laura Canfield, Blaine Collins, Abigail Cummings, Lonie Kim, Carla 

Lewis, Diana Merelman, and Peter Taschenberger, with support from 

Lyndsay Patty. 

We would also like to acknowledge other significant contributors without 

which this effort would not have been successful. Staff from each Office of 

Inspector General component contributed, including the Office of Audit 

Services, the Office of Counsel, the Office of Evaluation and Inspections, the 

Office of Investigations, the Office of Management and Policy, and the 

Immediate Office of the Inspector General. Contributions included planning 

and conducting fieldwork, data and administrative support, and report 

production and distribution. 

This report was prepared under the direction of Dave Tawes, Regional 

Inspector General for Evaluation and Inspections. 

To obtain additional information concerning this report or to obtain copies, 

contact the Office of Public Affairs at Public.Affairs@oig.hhs.gov.
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 assessments 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 OIG’s 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.

Office of Audit 

Services

Office of Evaluation 

and Inspections

Office of 

Investigations

Office of Counsel to 

the Inspector 

General
ENDNOTES

1 6 U.S.C. § 279(g)(2).

2 HHS, ACF, Justification of Estimates for Appropriations Committees, Fiscal Year 2020, pg. 6. 

Accessed at 

https://www.acf.hhs.gov/sites/default/files/olab/acf_congressional_budget_justification_2020.

pdf on June 20, 2019.

3 ACF, Fact Sheet: Unaccompanied Children Program, December 2018. Accessed at 

https://www.acf.hhs.gov/sites/default/files/orr/unaccompanied_alien_children_program_fact_s

heet_december_2018.pdf on April 26, 2019. DHS referred 49,100 children to ORR, although 

additional children may have been referred by other agencies.

4 8 U.S.C. § 1232(b)(3).

5

In fiscal year 2018, 42 percent of children released to sponsors were released to a parent. 

Ms. L v. ICE, No. 18-0428. (S.D. Cal. Feb. 1, 2019) (Declaration of Jonathan White). 

6 8 U.S.C. § 1232(c)(2)(A).

7

Influx care facilities are subject to different requirements than other types of shelters.

Specifically, an influx care facility provides temporary emergency shelter and services for 

children during an influx or emergency. Because of the temporary and emergency nature of 

influx care facilities, they may not be licensed or they may be exempt from licensing 

requirements. In addition, influx care facilities may be opened on federally owned or leased 

properties, in which case the facility is not subject to State or local licensing standards. 

8 Overall, in fiscal year 2018, 86 percent of children discharged were released to an individual 

sponsor. Of those, 42 percent were discharged to a parent, and another 47 percent were 

discharged to a close relative. Ms. L v. ICE, No. 18-0428. (S.D. Cal. Feb. 1, 2019) (Declaration of 

Jonathan White).

9 Flores v. Reno, No. 85-4544 (C.D. Cal. Jan. 17, 1997), Stipulated Settlement Agreement, 

setting out an order of priority for sponsors with whom children should be placed. The first 

preference is for placement with a parent, followed by a child’s legal guardian, then other 

adult relatives. 

10 The specific background checks required have varied over time, as ORR adjusted policies 

to balance timely release with safety concerns. For example, before June 2018, ORR required 

all potential sponsors who were not parents or legal guardians of the child to submit 

fingerprints for processing by the FBI. Parents or legal guardians (who comprise a large 

percentage of sponsors) and adult household members were required to submit fingerprints 

only in particular circumstances, such as when there was documented risk to the safety of the 

child. In June 2018, ORR changed its background check policies to require fingerprint-based 

FBI criminal history checks of all potential sponsors and their adult household members in all 

circumstances; additionally, fingerprints and other identifying information would be shared 

with ICE, which was not prohibited from using this information for immigration enforcement 

purposes. In December 2018, ORR changed its policy to eliminate the requirement of 

fingerprint checks for adult household members, except in limited instances. In March 

2019, it further modified its policy, removing the required fingerprint checks for parents and 

legal guardians, except in limited circumstances. In June 2019, ORR again modified the 

policy, so that immediate relatives—a sibling or grandparent or other close relatives who 

previously served as the child’s primary caregiver—are not required to submit fingerprints in 

most situations. See, generally, Office of Refugee Resettlement, ORR Guide: Children Entering 

the United States Unaccompanied, § 2.5. Accessed at 

https://www.acf.hhs.gov/orr/resource/children-entering-the-united-states-unaccompanied

on November 23, 2019. As of February 2019, Federal appropriations law prohibited DHS 

from using any data submitted by ORR for immigration enforcement purposes, except in 

limited circumstances. This prohibition is also contained in the fiscal year 2020 DHS 

appropriation and appears to be time-limited. See section 224 of the Consolidated 
Appropriations Act, 2019, P.L. No. 116-6 (Feb. 15, 2019) and section 216 of Consolidated 

Appropriations Act, 2020, P.L. No. 116-93 (Dec. 20. 2019). Additionally, beginning in July 2019, 

Federal appropriations law prohibited ORR from reversing the changes to the fingerprint 

policies made in December 2018, March 2019, and June 2019, unless the Secretary provides a 

written justification to Congress and the HHS Inspector General demonstrating that such 

changes are necessary to prevent UACs from being placed in danger. The HHS Inspector 

General must provide an assessment the Secretary and Congress that such changes are 

necessary. See section 403 of the Emergency Supplemental Appropriations for Humanitarian 

Assistance and Security at the Southern Border Act, 2019, P.L. No. 116-26 (July 1, 2019) and 

section 231 of Further Consolidated Appropriations Act, 2020, P.L. No. 116-94 (Dec. 20, 2019).

11 8 U.S.C. § 1232(c)(3)(B).

12 Homeland Security Act of 2002, P.L. No. 107-296 §462 (Nov. 25, 2002); William Wilberforce 

Trafficking Victims Protection Reauthorization Act of 2008, P.L. No. 110-457 §235 (Dec. 23, 

2008).

13 Memorandum of Agreement Between the Department of Homeland Security and the 

Department of Health and Human Services Regarding Unaccompanied Alien Children, Feb. 

22, 2016.

14 Memorandum of Agreement Among the Office of Refugee Resettlement of the U.S. 

Department of Health and Human Services and U.S. Immigration and Customs Enforcement 

and U.S. Customs and Border Protection of the U.S. Department of Homeland Security 

Regarding Consultation and Information Sharing in Unaccompanied Alien Children Matters, 

April 13, 2018.

15 See Endnote 10.

16 Memorandum for All Federal Prosecutors. Renewed Commitment to Criminal Immigration 

Enforcement. Office of the Attorney General, April 11, 2017. Accessed at 

https://www.justice.gov/opa/press-release/file/956841/download on November 18, 2018.

17 Letter from CBP Commissioner McAleenan to Senator Wyden, January 18, 2019. Accessed at 

https://www.finance.senate.gov/imo/media/doc/2018-01-19%20CBP%20Response.pdf on 

April 15, 2019. 

18 Memorandum for Federal Prosecutors Along the Southwest Border. Zero-Tolerance for 

Offenses Under 8 U.S.C. § 1325(a). Office of the Attorney General, April 6, 2018. Accessed at 

https://www.justice.gov/opa/press-release/file/1049751/download on November 18, 2018,

19 DHS OIG, DHS Lacked Technology Needed To Successfully Account for Separated Migrant 

Families, OIG-20-06, November 2019. Available at 

https://www.oig.dhs.gov/sites/default/files/assets/2019-11/OIG-20-06-Nov19.pdf.

20 DOJ Office of Public Affairs, Attorney General Sessions Delivers Remarks Discussing the 

Immigration Enforcement Actions of the Trump Administration, May 7, 2018. Accessed at 

https://www.justice.gov/opa/speech/attorney-general-sessions-delivers-remarks-discussingimmigration-enforcement-actions on November 18, 2018.

21 Exec. Order 13841, 83 Fed. Reg. 29435, dated June 20, 2018; published on June 25, 2018.

22 A preliminary injunction is a temporary order prohibiting a party from specified actions; it 

is intended to maintain the status quo until the issues at trial are resolved.

23 Ms. L v. ICE, No. 18-0428 (S.D. Cal. June 26, 2018) (Order Granting Plaintiffs’ Motion for 

Classwide Preliminary Injunction).

24 Parents are excluded from the class if they have a criminal history or communicable 

disease or are in the interior of the country. Also, the court’s order does not apply to parents 

for whom there is a determination that the parent is unfit or presents a danger to the child. 

Parents may also decline reunification. Id.

25 Ms. L v. ICE, No. 18-0428 (S.D. Cal. March 8, 2019) (Order Granting Plaintiffs’ Motion to 

Modify Class Definition).

26 N.T.C. v. ICE, No. 18-06428 (S.D. N.Y. July 17, 2018) (Order). The court extended the 

temporary restraining order and transferred the case to the Southern District of California, 

where Ms. L. v. ICE was being litigated, in recognition of the strong policy favoring the 
litigation of related claims in the same forum. N.T.C. v. ICE, No. 18-06428 (S.D.N.Y. July 19, 

2018) (Memorandum Opinion and Order). The plaintiffs voluntarily dismissed the action on 

December 21, 2018. N.T.C. v. ICE, No. 18-01626 (S.D. Cal. Dec. 21, 2018) (Notice of Voluntary 

Dismissal).

27 HHS, DHS, DOJ, The Tri-Department Plan for Stage II of Family Reunification, July 18, 2018. 

Accessed at https://www.hhs.gov/sites/default/files/UAC-Tri-Department-Process.pdf on 

November 18, 2018.

28 Ms. L v. ICE, No. 18-0428 (S.D. Cal. July 10, 2018) (Order Following Status Conference).

29 HHS had previously reported 2,816 possible children of potential class members; however, 

in March 2019, ORR determined that two of those children entered ORR care in July 2018, 

after the date of the original court order, leaving 2,814 possible children of potential class 

members. (Both children have been discharged from ORR care.) In January 2020, HHS 

reported to the court that it had identified another potentially separated child of a class 

member, but that after further review, had determined the child was not actually separated 

from a parent. In the interest of transparency HHS nonetheless included the child in its 

reporting to the court, bringing the total number of possible children of potential class 

members to 2,815.

30 As of December 2018, HHS had identified 2,816 possible children of potential Ms. L v. ICE

class members but had also determined that 79 of those children had not, in fact, been 

separated by DHS, leaving a total of 2,737 separated children who had been in ORR custody 

as of the June 26, 2018, court order. Thus, the total number of separated children who had 

been in ORR care as of the Ms. L v. ICE court order was 2,737. (See Exhibit 1.) 

31 At least 2 additional sites among the 45 OIG visited had also cared for separated children, 

but OIG’s site visits to those facilities took place before the date we received data about 

separated children, and so reunification case reviews were not conducted at those sites. 

32 The PCC is a committee of the National Security Council, Border and Transportation 

Security Directorate, Office of Management and Budget, and Domestic Policy Council.

33 Memorandum of Agreement between the Department of Homeland Security and the 

Department of Health and Human Services Regarding Unaccompanied Alien Children, Feb. 

22, 2016.

34 6 USC § 279(b)(1)(B)

35 No statute dictates the circumstances under which families must be separated upon 

apprehension by immigration authorities, and no historical records of the number or cause of 

family separations exist. ORR staff we interviewed stated that historically, ORR had received 

small numbers of separated children, because families were separated only in rare instances 

such as the parent experiencing a medical problem that precluded caring for their child. See 

also: 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. DHS 

OIG also reports that separations of families rarely occurred. DHS OIG, DHS Lacked 

Technology Needed to Successfully Account for Separated Migrant Families, OIG-20-06, 

November 2019. Available at https://www.oig.dhs.gov/sites/default/files/assets/2019-11/OIG20-06-Nov19.pdf.

36 OIG’s general policy is not to identify career staff by name or title in our public reports. 

However, the individual who held the position of ORR Deputy Director for Children’s Services 

until March 15, 2018, has provided extensive public testimony as to his role in the events 

discussed in this report. For that reason, and with that individual’s permission, OIG is making 

an exception to our policy to provide readers with greater clarity about patterns of 

communication within HHS in 2017 and early 2018 about family separation.

37 The Acting Assistant Secretary for ACF and the Counselor to the Secretary for Human 

Services Policy reported to OIG that it was not unusual for experienced ORR staff to 

communicate directly with senior CBP and ICE officials. 

38 See Endnote 10.

39 6 U.S.C. § 279(b)(1)(B).
40 DHS OIG determined that 18.4 percent of separated children had remained in DHS custody 

for 5 or more days before transfer to ORR care. DHS OIG, Special Review—Initial 

Observations Regarding Family Separation Issues Under the Zero Tolerance Policy, OIG-18-84, 

September 2018. Available at https://www.oig.dhs.gov/sites/default/files/assets/2018-10/OIG18-84-Sep18.pdf.

41 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.

42 See: DHS OIG, DHS Lacked Technology Needed To Successfully Account for Separated 

Migrant Families, OIG-20-06, November 2019. Available at 

https://www.oig.dhs.gov/sites/default/files/assets/2019-11/OIG-20-06-Nov19.pdf.

43 Ms. L v. ICE, No. 18-0428. (S.D. Cal. Feb. 1, 2019) (Declaration of Jallyn Sualog).

44 For example, please see Ms. L v. ICE, No. 18-0428 (S.D. Cal. Apr 12, 2019) (Joint Status 

Report); Ms. L v. ICE, No. 18-0428 (S.D. Cal. June 6, 2019) (Joint Status Report); Ms. L v. ICE, 

No. 18-0428 (S.D. Cal. Sep 11, 2019) (Joint Status Report).

45 See Endnote 10. 

46 See Endnote 10.

47 Ms. L v. ICE, No. 18-0428 (S.D. Cal. July 10, 2018) (Order Following Status Conference).

48 As described in a previous OIG report, facilities attributed longer stays for children to 

ORR’s new sponsor screening requirements. Facilities reported that it became more difficult 

to identify sponsors willing to accept children after the new fingerprinting requirements were 

implemented, which delayed placing children with sponsors, adding further stress and 

uncertainty. See: 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.

49 See Endnote 10.

50 On July 30, 2019, Plaintiffs in Ms. L v. ICE filed a motion to enforce the preliminary 

injunction, in which they asked the court to clarify the standard for ongoing separations (i.e., 

the bases on which families may be separated for criminal history or parental fitness) to 

ensure that children may not be separated from their parents absent an objective reason to 

believe the parent is unfit or a danger. As of the date of this report, the court has not yet 

ruled on the motion.

51 Ms. L v. ICE, No. 18-0428. (S.D. Cal. Sep. 10, 2019) (Defendants’ Opposition to Plaintiffs’ 

Motion to Enforce Preliminary Injunction).

52 Ms. L v. ICE, No. 18-0428. (S.D. Cal. Feb. 2, 2019) (Joint Status Report).

53 A 2016 MOU between HHS and DOJ addresses procedures for referral and investigation of 

incidents of possible sexual abuse of children in facilities. The MOU does not address issues 

related to locating parents in DOJ custody. HHS and DOJ, Interagency Memorandum of 

Understanding Between the Department of Health and Human Services and the Department of 

Justice Regarding Procedures for Referral and Investigation of Incidents of Possible Sexual 

Abuse of Unaccompanied Alien Children in Federal Grantee or Contract Facilities.

54 As part of the larger review, OIG teams also interviewed the lead mental health clinician, 

other mental health clinicians who had regular interaction with children, facility medical 

coordinators, and youth care workers.

55 See Endnote 29.