State Regulation of 

Residential Facilities

for Children with 

Mental Illness

Henry Ireys

Lori Achman

Ama Takyi

State Regulation of Residential Facilities for Children with Mental Illness iii

Acknowledgments

This report was prepared by Mathematica Policy Research, Inc. (MPR), for the Substance 

Abuse and Mental Health Services Administration (SAMHSA) of the U.S. Department of 

Health and Human Services (DHHS) under Contract No. 282-98-0021 (36). The authors of 

the report are Lori Achman, M.P.P., Henry T. Ireys, Ph.D., and Ama Takyi, M.A., of MPR. 

Judith L. Teich, M.S.W., of the Center for Mental Health Services (CMHS), SAMHSA, served 

as government project officer, and Jeffrey A. Buck, Ph.D., Associate Director for Organization 

and Financing, CMHS, served as advisor.

Disclaimer

Material for this report was prepared by MPR for SAMHSA, DHHS, under Contract Number 

282-98-0021, Task Order No. 36. The content of this publication does not necessarily reflect 

the views, opinions, or policies of CMHS, SAMHSA, or DHHS.

Public Domain Notice

All material appearing in this report is in the public domain and may be reproduced or copied 

without permission from SAMHSA or CMHS. Citation of the source is appreciated. However, 

this publication may not be reproduced or distributed for a fee without the specific, written 

authorization of the Office of Communications, SAMHSA, DHHS.

Electronic Access and Copies of Publication

This publication can be accessed electronically through the following Internet World Wide 

Web address: www.samhsa.hhs.gov/. For additional free copies of this document, please call 

SAMHSA’s National Mental Health Information Center at 1-800-789-2647 or 1-800-228-0427 

(TTD).

Recommended Citation

Ireys HT, Achman L, Takyi A. State Regulation of Residential Facilities for Children with 

Mental Illness. DHHS Pub. No. (SMA) 06-4167. Rockville, MD: Center for Mental Health 

Services, Substance Abuse and Mental Health Services Administration, 2006.

Originating Office

Office of the Associate Director for Organization and Financing, Center for Mental Health 

Services, Substance Abuse and Mental Health Services Administration, One Choke Cherry 

Road, 6-1065, Rockville, MD 20857.

DHHS Publication No. (SMA) 06-4167

Printed 2006

State Regulation of Residential Facilities for Children with Mental Illness iii

State Regulation of Residential Facilities for Children with Mental Illness 

Table of Contents

Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Residential Facilities in the Study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Major Findings on States’ Regulatory Methods . . . . . . . . . . . . . . . . . . . . . . . . 2

I. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

A. Organizations Providing Residential Care . . . . . . . . . . . . . . . . . . . . . . . . . 4

B. Characteristics of Residents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

C. Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

II. Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

A. Criteria for Including Residential Facilities . . . . . . . . . . . . . . . . . . . . . . . 9

B. Developing the Survey Questionnaire . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

C. Fielding the Survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

D. Assessing the Quality of Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

III. Number of Residential Facility Types, Associated Facilities, and Beds . . . . . 15

A. Number of Beds Associated with Facilities . . . . . . . . . . . . . . . . . . . . . . . 18

B. Ownership Arrangements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

C. Length of Stay . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

D. Secured Units . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

IV. Regulatory Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

A. Licensure and Certification . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

B. Complaint Reviews . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

C. Critical Incident Reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

D. Announced and Unannounced Visits . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

E. Regulations Governing Selected Facility Characteristics . . . . . . . . . . . . . 26

1. Required Resident-to-Staff Ratios . . . . . . . . . . . . . . . . . . . . . 28

2. Required Education Level of Facility Directors . . . . . . . . . . 28

F. Accreditation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
vi State Regulation of Residential Facilities for Children with Mental Illness 

V. Services and Sources of Financing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

A. Services Provided . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

B. Sources of Financing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

VI. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

Appendix A: Expert Advisory Panel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

Appendix B: Survey Questionnaire . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
List of Tables

I.1 Average Daily Census of Children Under 21 Years and Number 

of Beds in 24-hour Residential Care Organizations Funded and 

Operated by State Mental Health Agencies, 2002 . . . . . . . . . . . . . . . . . . . 5

II.1 Criteria for Identifying Residential Facilities for Children 

with Mental Illness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

II.2 Percent of Respondents Indicating Source of Information for 

Selected Survey Items . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

III.1 Types of Residential Facilities for Children with Mental Illness, 

Associated Facilities, and Average Number of Residents per 

Facility, by State, 2003 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

III.2 Residential Facilities for Children with Mental Illness and 

Associated Facilities and Beds, by Average Number of 

Residents, 2003 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

III.3 Ownership of Residential Facilities for Children with 

Mental Illness, 2003 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

III.4 Average Lengths of Stay in Residential Facilities for Children 

with Mental Illness, 2003 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

IV.1 Selected Agencies Licensing or Certifying Residential 

Facilities for Children with Mental Illness, 2003 . . . . . . . . . . . . . . . . . . . 22

IV.2 Number of Agencies Involved in Licensing or Certifying 

Residential Facilities for Children with Mental Illness, 2003 . . . . . . . . . . 22

IV.3 Procedures Required by States for Initial Licensure or 

Certification and Renewal of License or Certification of 

Residential Facilities for Children with Mental Illness, 2003 . . . . . . . . . . 23

IV.4 State Agencies Reviewing Complaints Against Residential 

Facilities for Children with Mental Illness, 2003 . . . . . . . . . . . . . . . . . . . 24

IV.5 Number of Agencies Involved in Reviewing Complaints 

Made Against Residential Facilities for Children with 

Mental Illness, 2003 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

IV.6 Adverse Events or Critical Incidents Required to be Reported 

by Facilities for Children with Mental Illness, 2003 . . . . . . . . . . . . . . . . 25

State Regulation of Residential Facilities for Children with Mental Illness vii
viii State Regulation of Residential Facilities for Children with Mental Illness 

IV.7 Agencies Involved in Conducting Unannounced or 

Announced Visits to Residential Facilities for Children 

with Mental Illness, 2003 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

IV.8 Residential Facilities Subject to State Requirements for 

Resident-to-Staff Ratios and Minimum Education Levels 

for Facility Directors, 2003 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

IV.9 Daytime Resident-to-Staff Minimum Ratios in Residential 

Facilities with Staffing Requirements, 2003 . . . . . . . . . . . . . . . . . . . . . . . 28

IV.10 Minimum Education Requirements for Facility Directors 

of Residential Facilities with Requirements, 2003 . . . . . . . . . . . . . . . . . . 29

V.1 Number and Percent of Residential Facilities for Children 

with Mental Illness Required to Provide Selected Services, 2003 . . . . . . . 32

V.2 Funding Sources for Services Received by Children with 

Mental Illness in Residential Facilities, 2003 . . . . . . . . . . . . . . . . . . . . . . 33
The specific purpose of this study was to 

conduct a national survey of State officials to 

identify methods that States use to monitor 

residential facilities for children with mental 

illness. Officials in departments of mental 

health, social services, health services, and 

child and family services responded to structured questions on facility characteristics 

and programs, licensing and oversight procedures, and sources of financing. The survey 

was fielded between November 2003 and 

March 2004. This report presents the results 

of the study.

Residential Facilities in the Study

To be included in the study, residential facilities for children with mental illness had to 

be licensed or certified by the State to provide some therapeutic services in addition to 

room and board. States vary widely in the 

types of residential facilities that they license 

or certify, the names of these facility types, 

and the number of associated facilities.

Because this study focuses on State regulations, facility type is the primary unit of 

analysis, but the study also provides information on the number of facilities in each 

type and the number of associated beds. 

Many States license multiple types of residential facilities for children with mental 

illness. For example, according to officials 

in one State, two types of facilities meeting 

study criteria were referred to as “residential 

care centers” and “group foster homes.” 

The first type included 44 facilities with a 

total of 1,464 associated beds; the second 

type included 120 facilities and 900 associated beds. 

The study data were derived from officials 

in 38 States who, in response to a structured 

survey, provided information on 71 types 

of facilities. The number of facilities associated with each type varied by State from 1 

to more than 800. The number of total beds 

associated with each facility type ranged 

from 6 to 7,160. Overall, the 71 types 

There is little national information on the policies and procedures 

used by States to regulate residential treatment facilities for children with mental illness. As a result, policymakers and program 

administrators face major difficulties in determining both the effectiveness of 

current policies and the potential need for new policies that are responsive to 

emerging trends in child mental health care. Based on a survey of State officials, this report provides the most accurate national data available concerning methods that States use to license and regulate residential facilities for 

children with mental illness. The information in this report can help Federal 

and State policymakers improve procedures for monitoring the quality of 

care provided in these facilities.

Executive Summary

State Regulation of Residential Facilities for Children with Mental Illness 
 State Regulation of Residential Facilities for Children with Mental Illness

n State departments of children and families, 

departments of health, and mental health 

agencies all had major roles in regulating 

residential facilities for children with mental illness. 

n To obtain initial licenses, more than 95 

percent of all facilities had to be inspected 

by State personnel and permit a review of 

staff qualifications; more than two-thirds 

were required to provide documentation 

of staff training and permit clinical record 

reviews. 

n To renew their license, more than 85 

percent of facilities had to be inspected 

by State personnel and permit a review of 

staff qualifications and training along with 

a review of clinical records; direct interviews with residents were required for less 

than two-thirds of the facilities.

n In 2002, State agencies made announced 

and unannounced visits to the majority of 

facilities for children with mental illness 

to assess living conditions, safety issues, 

and services provided; unannounced visits 

occurred less frequently than announced 

visits (65 percent of facilities compared 

with 92 percent).

n More than 60 percent of all facilities 

had to meet resident-to-staff ratios, and 

more than 80 percent had to meet minimum education requirements for facility 

directors.

n More than 90 percent of all facilities were 

required to report adverse events or critical incidents to the State, but the specific 

types of adverse events or incidents that 

had to be reported varied somewhat 

across facilities.

n Most residential facilities relied on several 

sources of funding, including Medicaid, 

State departments of children and family 

services, and State and local mental health 

agencies.

accounted for 3,628 facilities that, in total, 

had 50,507 beds as of September 30, 2003. 

These numbers exceeded counts based on 

the Survey of Mental Health Organizations 

(Manderscheid et al. 2004) and data from 

State mental health agencies (National 

Association of State Mental Health Program 

Directors 2005) because the study covered a 

wider range of residential settings under the 

auspices of various State agencies. 

Major Findings on States’ 

Regulatory Methods

The analysis of survey data led to two major 

findings. First, States differed in the mix 

of methods they used to regulate facilities. 

Typical methods included on-site inspections, documentation of staff qualifications 

and training, record reviews, resident interviews, critical-incident reports, standards for 

resident-to-staff ratios, and educational levels 

of facility directors. All States used at least 

several of these methods, but few States used 

all of them. 

Second, information provided by State 

officials indicated that the oversight and 

regulatory environment for residential 

facilities for children with mental illness 

was complex in many States because several 

agencies, each with a different mission and 

function, were involved in licensing the facilities, reviewing complaints, funding services, 

and making inspection visits. For 47 percent 

of all facility types covered by the survey, 

licenses or certifications were required from 

more than one agency. For 22 percent of 

facility types, complaints were reviewed 

by three or more agencies. Furthermore, in 

some States, agencies that provided major 

financial support may have had substantial 

reporting requirements but played a minor 

regulatory role.

Other findings included the following:
State Regulation of Residential Facilities for Children with Mental Illness 

I.

Although States have primary responsibility 

for regulating residential facilities for children 

with mental illness to ensure that the facilities meet basic safety, staffing, and service 

delivery standards, they vary widely in their 

specific regulatory practices. A few reports 

have addressed policy questions related to 

procedures for monitoring residential facilities in selected States (e.g., Colorado Office 

of the State Auditor 2002; Maryland Task 

Force 2002; Office of Inspector General 

2000), but few national data are available 

to help policymakers understand the policies 

and procedures that States use to regulate 

residential facilities for children with mental 

illness. As Pottick and colleagues note (2004, 

p. 324), “[D]eficiencies in knowledge are 

particularly troublesome in the residential 

treatment sector, where poor, displaced, and 

severely impaired youth are the majority.”

Several factors underscore the need for 

better information on this topic:

n In most States, residential care will remain 

part of the service system for the foreseeable future, and States need better information on methods for regulating residential facilities to ensure that the residential 

care component of the service system 

effectively addresses the needs of children 

with mental illness and their families.

n Many children in State custody are placed 

in residential settings because no foster 

or adoptive families are available. State 

officials are obligated both to ensure that 

these children receive effective services 

and to prevent the occurrence of critical incidents that could jeopardize their 

well-being.

n Residential facilities are costly and, in 

most States, mental health budgets are 

sharply limited. Policymakers need information on methods for regulating residential facilities to ensure that public dollars 

are spent effectively.

Introduction

Residential facilities for children with mental illness are owned 

by a wide variety of public and private entities and are operated 

under the auspices of various State agencies, including State 

departments of mental health, child welfare, and juvenile justice (Goldstrom 

et al. 2001; Pottick et al. 2004). The number of children living in these 

residential settings has increased during the last two decades in response 

to the closure of long-term psychiatric hospitals and inpatient institutions 

(Manderscheid et al. 2001). A total of 474 residential treatment centers for 

emotionally disturbed children were operated under the auspices of State 

mental health organizations in 2000, up from 261 centers in 1970; the number of beds in these centers more than doubled during this 30-year period, 

rising from 15,129 to 33,421 (Manderscheid et al. 2004). 
 State Regulation of Residential Facilities for Children with Mental Illness

Although most States have begun to build 

the legislative, regulatory, and programmatic 

foundations for transforming the mental 

health system for children (Arons et al. 

2004), many financial and systemic obstacles 

remain (Pottick et al. 2004). Children with 

mental illness continue to enter residential 

facilities, especially children whose families 

cannot find or do not have the resources 

to obtain the community services and supports needed to keep their children at home. 

As State child mental health service systems 

continue to evolve, policymakers and facility administrators need to know more about 

State practices related to licensing, monitoring, and regulating residential facilities.

Based on structured surveys designed for 

State officials in 50 States and the District 

of Columbia, the present study aimed to 

examine methods used by States to license, 

regulate, and monitor residential facilities 

for children with mental illness. The purposes of this report are to present the study’s 

findings on State methods for regulating 

these residential facilities and to provide 

information that will assist policymakers 

and facility administrators in understanding 

the potential role of residential treatment 

facilities in the evolving system of care for 

children with mental illness. (A companion report, State Regulation of Residential 

Facilities for Adults With Mental Illness, 

provides information about residential treatment facilities for adults.) This chapter summarizes existing information on the number 

of these facilities and the characteristics of 

their residents. The chapter reviews data 

on organizations providing residential care, 

including:

n The 2002 Survey of Mental Health 

Organizations and General Hospital 

Mental Health Services (SMHO)

n Reports from the Research Institute of 

the National Association of State Mental 

Health Program Directors (NASMHPD) 

based on 2002 data submitted by the 

States

n The 1998 Inventory of Mental Health 

Services in Juvenile Justice Facilities

The chapter also includes data on characteristics of residents from analyses of data 

from the 1997 Client/Patient Sample Survey 

(CPSS).

Chapter II provides an overview of the 

methods used to obtain data from the States 

and includes the criteria used to identify residential facilities for the survey. 

The subsequent three chapters present the study’s results in a series of tables, 

with major findings highlighted in the text. 

Specifically, these chapters cover the following topics:

n Number of residential facility types, associated facilities, and beds (Chapter III)

n Regulatory methods (Chapter IV)

n Services and sources of financing 

(Chapter V)

Chapter VI presents conclusions based on 

the findings. The Appendix includes the survey used to collect data from the States.

A. Organizations Providing 

Residential Care

The SMHO, conducted every two years 

by the Center for Mental Health Services 

(CMHS) at the Substance Abuse and Mental 

Health Services Administration (SAMHSA), 

is a count of specialty mental health organizations and psychiatric services of nonFederal general hospitals and a survey of a 

sample of these organizations that collects 

information on services, beds, staffing, 

expenditures, and sources of revenue. Recent 
State Regulation of Residential Facilities for Children with Mental Illness 

analyses of data from the SMHO indicate 

that, in 2000, State mental health agencies 

operated 474 residential treatment centers 

for emotionally disturbed children, with a 

total of 33,421 beds (Manderscheid et al. 

2004).

The SMHO focuses specifically on organizations that operate under the authority of 

mental health agencies and have the provision of clinical mental health services as their 

primary mission (J. Maedke, personal communication, April 2005). It does not include 

many other residential facilities that are operated by other State agencies, such as child 

welfare departments, or that serve as homes 

to children with mental illness who may need 

only supportive services, such as case management, vocational training, or medication 

management.

In addition to the SMHO, some information on the number of individuals in residential treatment beds operated and funded by 

State mental health authorities is available 

for selected States through the NASMHPD 

Research Institute’s State Profile Report

for 2002 (NASMHPD 2005). As Table I.1 

shows, States that submitted data reported 

widely different figures for the average daily 

Table I.1 Average Daily Census of Children Under 21 Years and Number of 

Beds in 24-hour Residential Care Organizations Funded and Operated by 

State Mental Health Agencies, 2002

State Average Daily Census of Clients Number of Beds

Alabama 51 56

California 1,771 —

Colorado 68 —

Connecticut 10 —

District of Columbia 119 108

Florida 860 —

Hawaii 1 0

Maryland 91 157

Massachusettsa 680 —

Minnesota 350 —

Missouri 51 65

Nebraska — 36

New Hampshire 3 37

New Jersey 438 —

New York 8 16

North Carolina 1,897 —

Oklahoma 2 16

Oregon 209 320

South Carolina 24 37

Texas 45 —

Utah 217 308

Vermont 225 —

Total 1,156

Source: NASMHPD 2005

Notes: Other States did not provide any information for these items or had no residential care organizations funded and operated by the States’ 

mental health organizations. Dashes (—) indicate the State did not respond to the specific item. Average daily census is for fiscal year 2002. 

Number of beds is as of the last day of fiscal year 2004. Twenty-four-hour residential care is defined as overnight mental health care in conjunction 

with (1) psychiatric treatment services in a setting other than a hospital, or (2) supervised living and other supportive services in a setting other 

than a hospital. Examples include halfway houses, community residences, and group homes.

a

 Children 19 years and under
State Regulation of Residential Facilities for Children with Mental Illness

number of children who were in residential 

settings owned or operated by State mental 

health agencies and the number of beds. 

The NASMHPD study defines residential 

beds as providing (1) overnight mental 

health care in conjunction with psychiatric 

treatment services in a setting other than a 

hospital, or (2) overnight mental health care 

in conjunction with supervised living and 

other supportive services in a setting other 

than a hospital (NASMHPD 2005).

State juvenile justice agencies typically 

play major roles in providing mental health 

treatment, rehabilitation, protection, and 

guidance to youth who commit crimes and 

who are neglected or abused. Juvenile court 

judges frequently place these children into 

residential treatment facilities that are operated by for-profit and not-for-profit entities 

under the jurisdiction of the States. These 

facilities include detention centers, shelters, 

group homes, and live-in treatment centers 

and camps. Detention centers house only 

children in the juvenile justice system, but 

the other types of settings also house children who enter through other agencies, such 

as psychiatric hospitals or community mental 

health centers. Group homes, some types 

of shelters, and other residential treatment 

centers used by juvenile justice authorities 

are likely to be included in the present study 

because they meet the study’s criteria; detention centers and certain types of camps are 

excluded because they do not.

Analyses of data from the 1998 Inventory 

of Mental Health Services in Juvenile Justice 

Facilities (Goldstrom et al. 2001) indicate 

that:

n On a given day in 1998, 673 residential 

treatment facilities (defined as long-term 

secure residences where treatment is the 

basis for placement) used for placement 

by juvenile justice authorities housed 

25,356 youth with mental illness. 

n For 257 facilities with funding data, 

58 percent received funding from the juvenile justice system, 40 percent from mental health agencies, and 51 percent from 

social service or child welfare systems.

n Among the 2,798 facilities surveyed 

(including detention centers, shelters, 

group homes, and camps), a total of 

1,039 provided mental health services 

to juveniles with mental illness in specially assigned residential arrangements in 

separate buildings or designated units. 

B. Characteristics of Residents

The 1997 CPSS provides information on 

characteristics of persons served by residential care programs (outpatient settings 

are excluded). The CPSS included 4,014 

youth representing a weighted estimate of 

1,314,938 children and adolescents who 

were admitted to inpatient or residential 

mental health settings in the United States 

in 1997 (Pottick et al. 2004). These settings 

included residential care programs of State 

and county mental hospitals, private psychiatric hospitals, non-Federal general hospitals, 

and residential treatment centers for youth 

that were originally identified in the 1994 

Inventory of Mental Health Organizations 

and General Hospital Mental Health Services 

(Milazzo-Sayre et al. 2001). Analyses of data 

from this survey indicate that:

n An estimated 65,949 children were admitted to residential settings in 1997.

n Seventy-six percent of these children were 

between the ages of 13 and 17.

n Sixty-one percent were male.

n Sixty-five percent were White, 21 percent 

were Black, and 12 percent were Hispanic.
State Regulation of Residential Facilities for Children with Mental Illness 

n Thirty-three percent had diagnoses related 

to disruptive behaviors, 14 percent had 

mood disorders, and 8 percent had anxiety 

disorders.

According to CPSS survey data, youth 

admitted to residential care were referred 

from a wide range of sources: 37 percent 

were referred from social service agencies, 

28 percent from the juvenile justice system, 

and 15 percent from psychiatric inpatient 

settings (Pottick et al. 2004). 

C. Summary

Previous studies provide a foundation for 

understanding the number and capacity of 

residential treatment settings for children 

with mental illness, but the gaps in available 

information are substantial. In particular, 

certain types of residential settings have not 

been included in existing surveys, such as settings that provide a minimum level of therapeutic services beyond room and board and 

that are not operated under the auspices of 

State mental health or juvenile justice agencies. Furthermore, existing studies do not 

address the methods States use to regulate or 

monitor these facilities.

The present study built on the existing 

foundation of data by gathering information 

on State regulatory methods. The types of 

facilities that States regulate include facilities 

that do not meet the criteria for inclusion in 

the SMHO and that have not been included 

in other surveys. As a result, this study 

reported on a larger number of facilities 

than had been included in previous studies. 

State Regulation of Residential Facilities for Children with Mental Illness 

II.

A. Criteria for Including Residential 

Facilities 

The study used a structured survey to gather 

information about State-regulated residential facilities that provided some therapeutic 

service beyond room and board for children 

with mental illness. In this report, “residential facility” refers to any entity that met the 

criteria listed in Table II.1.

These criteria were developed with guidance from the project’s expert advisory panel 

following a review of descriptions of State 

mental health systems and were designed to 

be broad enough to capture the wide range 

of State-regulated residential facilities that 

serve children. As a result, the study included facilities that (1) were regulated by any 

State agency, including mental health departments, departments of children and families, 

departments of health, and other agencies; 

(2) offered various sets of residential services; and (3) focused on diverse subgroups of 

children and adolescents with mental illness, 

including children with extreme behavior 

problems or children with multiple problems (e.g., mental illness and developmental 

disabilities).

Children with mental illness live in a 

wide variety of community settings—including detention centers, military-like camps 

for children with severe behavioral disorders, individual foster care homes, 

short-stay crisis residences, and their own 

homes—but this study was not designed 

to gather information on these settings. 

Specifically, the study’s criteria were 

designed to exclude facilities for children 

who were homeless or who had physical disabilities alone, psychiatric hospitals 

or inpatient facilities of general hospitals, 

nursing homes, facilities where children 

stay for short periods (e.g., detention centers, community shelters), residential substance abuse treatment programs (unless 

the program was specifically for children 

dually diagnosed with a mental disorder 

I

n the absence of national data on policies and procedures that States 

use to regulate and monitor residential facilities for children with 

mental illness, this study required a systematic approach to gathering relevant information from State officials. To accomplish its goals, the 

study was organized around the following steps:

n Determining the criteria for including residential facilities in the present 

study

n Developing the survey questionnaire

n Fielding the survey

n Assessing the quality of the data

Methods
10 State Regulation of Residential Facilities for Children with Mental Illness

and a substance abuse disorder), and individual foster care homes.

Some States have developed innovative family-based residential arrangements 

for children with mental illness that would 

not meet the criteria listed in Table II.1, 

but that are nonetheless critical to building 

community-­based service systems. For example, some States support children with mental 

illness in special foster care placements with 

individual families who receive extra training and compensation. These residential 

arrangements may play a critical role in a 

State’s overall system of care but would not 

fall under the purview of the present study. 

Furthermore, some States are beginning to 

develop innovative short-term residential 

options for children with mental illness and 

their families (e.g., short-stay residential 

settings for the entire family as part of a 

crisis-­diversion or crisis-intervention service). 

These arrangements were not included in the 

study because, in most cases, they involved 

few children and would require a somewhat 

different set of regulatory practices than the 

more traditional types of residential facilities 

now in place in most States.

As others have noted (e.g., Fleishman 

2004), the lack of standard definitions of 

key terms such as “psychiatric residential 

facility,” “residential treatment center,” 

and “group home” have stymied efforts to 

develop a national statistical portrait of residential settings for individuals with mental 

illness. States have adopted widely discrepant 

terms for essentially similar institutional entities and, conversely, operate facilities with 

similar names that provide markedly different sets of services and living environments. 

For example, residential settings with fewer 

than 16 children are called therapeutic group 

homes in Maryland and Hawaii, type I residential facilities in Ohio, level 1 residential 

treatment facilities in West Virginia, residential treatment facilities for youth in Alaska, 

and supervised independent living programs 

in South Carolina. Important differences 

may exist between these institutions in terms 

of their specific target population and services provided, but knowledge of the official 

name of these facilities offers little insight 

into the nature of their differences. The 

diversity of names has impeded the development of standard categories of facilities for 

Table II.1 Criteria for Identifying Residential Facilities for Children with 

Mental Illness

To be included in this study, facilities had to:

Specialize in the treatment of children with serious emotional or behavioral disorders, including children 

who were dually diagnosed (mental illness and substance abuse or mental illness and developmental 

disability), as long as mental illness was the primary problem.

Be an establishment that furnished (in single or several facilities) food, shelter, and some treatment or 

services to three or more persons unrelated to the proprietor.

Provide staffing 24 hours per day, seven days per week.

Operate under some State authority, such as a State office granting pertinent licenses or a State mental 

health authority.

Include at least 50 percent of residents whose need for placement was based on mental illness. 

Include children with average stays of 30 days or longer.

Provide at least some on-site therapeutic services beyond housing (e.g., group therapy, individual therapy, 

medication management, and so forth) either by staff or under contract.

•

•

•

•

•

•

•
State Regulation of Residential Facilities for Children with Mental Illness 11

which national statistics could be developed 

(Fleishman 2004).

B. Developing the Survey 

Questionnaire

The goal of the questionnaire was to gather 

descriptive information on specific aspects of 

residential facilities for children with mental illness and the methods that States used 

to regulate them as of September 2003. As 

a first step, an Internet search of relevant 

Websites was conducted to obtain information on the specific rules and regulations 

promulgated by 10 different-sized States in 

different regions for residential facilities for 

children with mental illness. This task made 

it clear that States relied on different regulatory practices for different types of licensed 

facilities. Accordingly, a survey method was 

developed that allowed State officials to 

respond separately for each type of facility.

The review of information available on 

the Internet also was used to develop specific 

items in the following five topic areas:

n Program characteristics (including questions on number of residents, beds, average length of stay, and staffing ratios)

n Licensing, certification, and accreditation (including a chart to determine 

which State agencies provided licensing, 

certifi­cation, and accreditation for each 

program type) 

n Program services (including questions 

about whether the residential programs 

were obligated to provide specific services)

n Program monitoring and oversight (including questions about which State agency 

conducted site visits and responded to 

critical incidents)

n Financing (including questions about 

funding sources and per diem rates) 

The initial draft of the questionnaire was 

sent to a selected group of mental health 

experts for their comments, and changes 

were made as needed. The survey was tested 

in three States and, on the basis of respondent feedback, minor modifications were 

made to ensure that questions were as concise as possible. Appendix B includes the 

final version of the questionnaire. 

C. Fielding the Survey

The survey implementation phase of the 

project involved the following tasks:

n Web searches were conducted for all 

States to identify (1) a preliminary list 

of program types that met the study’s 

criteria, and (2) State officials who 

potentially could serve as primary contacts (e.g., the director of child services 

in the mental health department).

n These officials, or a person who was in 

the same position if the initial contact had 

left, were contacted by mail and telephone 

to verify the list of program types, amend 

the types as needed, and ask the person to 

serve as the primary contact. (An average 

of four to five telephone calls or emails per 

State were made before establishing a primary contact and, after a contact person 

was identified, an average of three to four 

telephone or email contacts were needed 

to verify the list of program types. On 

average, four hours were needed per State 

to conduct initial Web searches, identify 

the contact person, and compile a final list 

of program types.)

n Each person who agreed to be a primary 

contact received a formal letter from the 

project officer at SAMHSA detailing the 

purpose of the study and thanking the 

contact person for supporting the project.
12 State Regulation of Residential Facilities for Children with Mental Illness

n The contact person was sent one or more 

questionnaires, depending on the number 

of program types in the State. (The specific 

name of the program type was included 

on a cover page and strategically embedded in the questionnaire to ensure that 

respondents knew to which program type 

the questions applied. A comprehensive 

instruction guide assisted respondents in 

completing the survey.)

Depending on the preference of the contact person, surveys were mailed, faxed, or 

emailed. Respondents could elect to return 

the completed questionnaire by mail, fax, or 

email or to complete the questionnaire in a 

telephone conversation with an interviewer. 

Surveys sent by email were based on an 

Excel spreadsheet so that respondents could 

reply to the questions on the screen, save 

the survey, and return it in the spreadsheet 

format. In all cases, the material included a 

second cover letter from the project officer 

at SAMHSA, the list of criteria that defined 

the types of programs of interest to the study, 

and specific instructions regarding the survey. 

The first questionnaire was mailed in 

October 2003, and the last completed one 

was received in March 2004. Most of the 

questionnaires were sent out and returned 

by email; most were completed and returned 

within two to three weeks, although several 

months were needed to obtain a completed 

questionnaire from some States. Although a 

primary contact was available in each State, 

several individuals typically were involved 

in responding to the questionnaire because, 

in most States, no one person was familiar 

with all topics covered in the questionnaire. 

For example, one individual was familiar 

with service requirements while another was 

familiar with financing. After a survey was 

received, it was reviewed, and follow-up 

telephone calls or emails were made to clarify 

ambiguous responses or fill in missing data, 

if possible. When all questions were resolved, 

a questionnaire was considered complete, 

and a thank-you card was mailed to the 

respondent. 

By the end of March 2004, a total of 

89 questionnaires had been mailed to 42 

of the 51 States (including the District of 

Columbia); 38 States returned at least one 

useable questionnaire. Of the remaining 

13 States,

n Nine States did not respond to our request 

to participate in the survey (repeated calls 

and emails to the contact person went 

unanswered, or no primary contact could 

be located, or State officials indicated that 

rules were under revision).

n One State indicated that it did not have 

the resources to complete the questionnaires and instead, provided a brief explanation of the housing options for children 

with mental illness.

n Three States had programs that did not 

fit the study’s criteria (e.g., the State used 

only foster home, out-of-State placements, 

or hospital settings). 

Overall, of the 50 States and the District 

of Columbia, useable information was provided by 41 States (80 percent) including the 

38 States completing at least one questionnaire and the three States indicating that they 

did not license facilities that met our criteria.

Of the 89 questionnaires sent out, 76 were 

received by the end of the survey period. 

Several reasons contributed to the fact that 

13 questionnaires were not returned: after 

receiving the questionnaire, some respondents 

indicated that they did not have the time to 

complete it; after reading the instructions, 

some respondents indicated that the program 

type on which the questionnaire focused did 
State Regulation of Residential Facilities for Children with Mental Illness 13

not fit the study criteria; some respondents 

did not return a questionnaire and would not 

return calls or respond to emails.

Of the 76 questionnaires received, 5 were 

excluded because of missing responses for 

almost all questions or because close inspection indicated that the program type did not 

fit the study criteria. Information from the 

questionnaires was entered into a standard 

SAS database. Several rounds of detailed 

data verification with State officials occurred 

between July and October 2004.

D. Assessing the Quality of Data

The quantitative information presented in 

this report is drawn entirely from information that staff in State agencies provided in 

response to the survey questionnaire. Pilot 

testing of the questionnaire, extensive conversations with selected State and Federal 

officials, and comments from members of 

the expert advisory panel showed that States 

vary widely in whether they have access to 

statistical information pertinent to the questions in the survey. Consequently, for seven 

items, the questionnaire asked respondents 

to indicate whether their responses were 

premised on experience-based estimates or 

reviews of specific records or statistical data. 

Depending on the item, between 13 and 62 

percent of respondents indicated that they 

used estimates (see Table II.2). 

Because of the uncertainty in some of the 

answers provided by some respondents, a 

final data check was conducted by downloading information from completed questionnaires into two-page templates. These 

templates were sent back to the appropriate 

contact person for final verification and 

a request for any missing information on 

facility characteristics. Several States suggested minor changes. In some States, officials 

indicated that they could not provide the 

data on facility characteristics owing to the 

Table II.2 Percent of Respondents Indicating Source of Information for Selected 

Survey Items

Percent of Respondents Who

Survey Item

Were Unable 

to Answer 

Question

Used an 

Estimate

Used Record 

Reviews

Answered but Did Not Indicate 

Whether Response Was Based 

on Record Review or Estimate

A1. Number of facilities 0.0 12.7 84.5 2.8

A3. Average number of residents 1.4 62.0 32.4 4.2

A7. Average length of stay 21.1 49.3 26.8 2.8

A14a. Percent of facilities with 

secure units, if the program was 

allowed secure units

6.3 34.4 59.4 0.0

D1a. Percent of facilities with an 

unannounced visit, if the State 

conducted unannounced visits

8.7 50.0 37.0 4.3

D2a. Percent of facilities with 

an announced visit, if the State 

conducted announced visits

4.6 52.3 43.1 0.0

E3. Medicaid per diem, if State 

had a Medicaid per diem 10.2 44.1 44.1 1.7

Source: Surveys submitted by 38 States
14 State Regulation of Residential Facilities for Children with Mental Illness

impracticality (i.e., too time-consuming) or 

impossibility (i.e., the relevant data were not 

available) of collecting the information.

The quality of the information presented 

in this report depended on the extent and 

accuracy of the information available to 

respondents. Based on extensive efforts to 

check questionable data through telephone 

calls and emails to State officials and given 

that States approved the final data used for 

the analyses, the report reflects the most 

accurate national data available on characteristics of the facilities that met the study’s 

criteria and the methods that States used to 

regulate residential facilities for children with 

mental illness as of September 2003. 
State Regulation of Residential Facilities for Children with Mental Illness 15

III.

n Connecticut operated 3 facility types:

Permanency Diagnostic Centers, a type 

of facility that included 2 facilities, 

each with an average of 12 children 

and a total of 26 beds

Residential Treatment Centers, a type 

of facility that included 21 facilities, 

each with an average of 47 children 

and a total of 1,002 beds

Subacute Facilities, a type of facility 

that included 4 facilities, each with an 

average of 12 children and a total of 

47 beds

n Wisconsin operated 2 facility types:

Residential Care Centers, a type of 

facility that included 44 facilities, each 

with an average of 33 children and a 

total of 1,464 beds

Group Foster Homes, a type of facility 

that included 120 facilities, each with 

an average of 7 children and a total of 

900 beds

—

—

—

—

—

n Utah operated 1 type of facility:

Residential Treatment Facilities for 

Children, a type of facility that included 41 facilities, each with an average 

of 17 children and a total of 843 beds

Overall, the 71 facility types accounted 

for 3,628 separate residential facilities, which 

had 50,507 beds as of September 30, 2003. 

Twenty-three of the 71 facility types (32 

percent of all facility types) had 8 or fewer 

associated facilities, and 7 types (11 percent) 

had more than 100 associated facilities. 

The remainder of this chapter presents 

information about the characteristics of 

residential facilities for children with mental 

illness by describing: 

n The number of beds associated with 

residential facilities, 

n Ownership arrangements, 

n Average lengths of stay, and 

n Number of secured (i.e., locked) units.

—

The survey yielded information on 71 types of residential facilities 

in 38 States. There was considerable variation in the number of 

facilities associated with each facility type, the average number 

of residents in a single facility within each type, and the total number of 

beds in operation in all facilities within a facility type (see Table III.1). Three 

States illustrate the variation as of September 2003:

Number of Residential 

Facility Types, 

Associated Facilities, 

and Beds
16 State Regulation of Residential Facilities for Children with Mental Illness

Table III.1 Types of Residential Facilities for Children with Mental Illness, 

Associated Facilities, and Average Number of Residents per Facility, 

by State, 2003

State Facility Type

Number of 

Associated 

Facilities

Average 

Number of 

Residents 

per Facility

Total 

Number 

of Beds

Alaska Residential treatment facilities for youth 36 9 396

Residential psychiatric treatment centers 5 23 116

Group homes for youth 8 5 64

Arizona Juvenile group homes 90 9 849

California Community treatment facilities 5 27 137

Connecticut Permanency diagnostic centers 2 12 26

Residential treatment centers 21 47 1,002

Subacute facilities 4 12 47

Delaware Residential treatment centers 6 9 62

Preadolescent therapeutic group homes 1 5 6

Florida Therapeutic group care 12 12 163

Residential treatment centers 14 23 385

Hawaii Community-based mental illness residential facilities 16 6 115

Therapeutic group homes 14 5 76

Illinois Individual care grants 25 12 310

Indiana Child-caring institutions (long-term care) 78 65 2,500

Private secure facilities (long-term care) 17 15 170

Kansas Level V—residential care facilities for children 17 33 660

Level VI—residential care facilities for children 8 26 233

Kentucky Psychiatric residential treatment facilities for adolescents 21 8 184

Maine Residential child care facilities with mental health program 116 6 780

Residential facilities with secure containment rules 7 3 48

Maryland Therapeutic group homes—children 23 7 161

Massachusetts Clinically intensive residential treatment 2 9 24

Intensive residential treatment facilities for adolescents 5 13 73

Behavior-intensive residential treatment 2 14 30

Community residential facilities 24 8 184

Michigan Child-caring institutions 225 32 7,160

Minnesota Rule 5 child treatment centers 32 40 929

Mississippi Therapeutic group homes—children 22 10 220

Residential treatment—dually diagnosed youth 3 19 56

Missouri Residential treatment services—children 146 25 3,592

Family-focused mental illness residential services—children 12 N/A N/A

Montana Group homes—children 47 6 304

Residential treatment facilities for children 3 58 238

Nebraska Residential treatment centers—children 21 12 368

Treatment group homes—children 19 8 226
State Regulation of Residential Facilities for Children with Mental Illness 17

State Facility Type

Number of 

Associated 

Facilities

Average 

Number of 

Residents 

per Facility

Total 

Number 

of Beds

Nevada Residential treatment facilities for children 2 37 75

New Hampshire Child care institutions 40 22 887

New Jersey Psychiatric community residences for youth 21 8 160

New Mexico Residential treatment facilities for youth 68 10 796

Group homes for youth 4 22 86

New York Community-based mental illness treatment facilities 

for children

26 8 208

Residential treatment facilities for children 19 28 539

North Carolina Residential treatment facilities for children 817 4 3,465

Therapeutic/foster care camps for children 11 62 681

Ohio Type I residential facilities 170 5 930

Oregon Assessment and evaluation psychiatric residential 

treatment facilities for children

4 13 54

Subacute treatment facilities for children 2 22 28

Pennsylvania Residential treatment facilities for children 70 30 2,162

South Carolina State-operated residential treatment facilities 2 26 31

Privately operated residential treatment facilities 8 45 284

High-management group homes 42 20 810

Moderate-management group homes 20 18 363

Supervised independent living facilities 11 10 130

South Dakota Licensed mental illness group care centers 14 25 354

Residential treatment centers 13 38 499

Texas Residential treatment centers 85 41 3,487

Therapeutic foster care group homes 661 9 5,868

Utah Residential treatment facilities for children 41 17 843

Virginia Children’s group homes 99 6 594

Children’s residential treatment facilities 22 49 1,347

Washington Children’s long-term inpatient facilities 5 19 96

West Virginia Psychiatric residential treatment facilities 6 20 121

Level I residential treatment facilities 12 9 108

Level II residential treatment facilities 19 16 304

Level III residential treatment facilities 8 31 252

Shelters 20 10 195

Wisconsin Residential care centers for children and youth 44 33 1,464

Group foster homes 120 7 900

Wyoming Residential treatment facilities 13 34 492

Source: Surveys submitted by 38 States. 

Note: The 71 facility types listed in this table were reported by State officials to have had a total of 3,628 associated facilities and 50,507 beds as of 

September 30, 2003.

Table III.1 (cont.)
18 State Regulation of Residential Facilities for Children with Mental Illness

A. Number of Beds Associated 

with Facilities

Overall, the 71 facility types accounted for 

3,628 separate residential facilities. As Table 

III.2 shows, the 3,628 facilities covered in 

the present study included 50,507 beds as 

of September 30, 2003. Occupancy rates 

varied from 50 to 100 percent across facility 

types, with 12 facility types occupied at less 

than 80 percent. Information on occupancy 

rates was unavailable for 16 facility types 

(23 percent).

Information on the average number of 

children residing in facilities was reported 

for 70 of the 71 facility types. The average number of residents ranged from 3 to 

65 as of September 30, 2003. Most facilities were small in terms of the number of 

residents. About one-third of the 71 facility 

types (23 facility types) had fewer than 10 

children on average in each facility; these 

23 facility types accounted for 65 percent 

of all facilities and 31 percent of all beds. 

Eleven percent of all facility types (8 facility 

types) had 40 or more residents on average, 

accounting for 7 percent of associated facilities and 21 percent of beds. 

Given that Medicaid defines institutions 

for mental diseases (IMDs) as residential settings with more than 16 residents, facilities 

were grouped into those with an average of 

3 to 16 residents and those with an average of 17 or more residents. As Table III.2 

shows, 37 (52.1 percent) of the 71 facility 

types included in the study housed an average of 3 to 16 residents in each facility. The 

37 facility types accounted for 2,588 associated facilities (71.3 percent of all associated 

facilities) and 18,598 beds (36.8 percent of 

all beds).

A total of 33 facility types (46.5 percent) 

had an average of 17 or more residents in 

each facility (see Table III.2). The 33 facility 

types accounted for 1,028 associated facilities 

(28.3 percent of all associated facilities) and 

31,909 beds (63.2 percent of all beds). One 

facility type could not be classified because 

the number of average residents in the facilities within the type was not available (see 

Table III.2).

Overall, the facility types that housed, 

on average, between 3 and 16 residents 

accounted for a larger proportion of the 

facilities but a smaller proportion of beds as 

compared with the facility types that housed, 

Table III.2 Residential Facilities for Children with Mental Illness and 

Associated Facilities and Beds, by Average Number of Residents, 2003

Facilities with 3 to 16 

Residents on Average

Facilities with 17 or More 

Residents on Average

Average Number of 

Residents Not Available

Survey 

Results Total Number Percent Number Percent Number Percent

Results for 

all facilities

Facility 

types

71 37 52.1 33 46.5 1* 1.4

Facilities 3,628 2,588 71.3 1,028 28.3 12 .3

Beds 50,507 18,598 36.8 31,909 63.2 — —

Source: Surveys submitted by 38 States

*The respondent for this facility type could not provide the number of beds in the associated facilities.
State Regulation of Residential Facilities for Children with Mental Illness 19

on average, 17 or more residents. Simply 

put, the number of smaller facilities exceeded 

the number of larger ones, but the latter 

accounted for proportionally more beds. It is 

useful to keep this observation in mind when 

examining the results of the study.

B. Ownership Arrangements

The ownership of residential facilities for 

children with mental illness varied widely 

across States and, in some cases, within facility types. To examine the ownership issue, 

the questionnaire asked respondents to indicate what percent of the facilities within a 

particular facility type operated under selected ownership arrangements. For example, 

within a particular facility type, 75 percent of 

the associated facilities might be operated by 

not-for-profit organizations and 25 percent 

by for-profit organizations. Facility types 

were classified by the dominant ownership 

arrangement, whereby dominant was defined 

as an arrangement that covered 75 percent or 

more of facilities within a facility type. Thus, 

in the example, the facility type would have 

been classified as predominantly owned by 

not-for-profit organizations.

As Table III.3 indicates, facilities in about 

two-thirds of the 71 facility types (47 types 

or 66.2 percent) were wholly or predominantly owned by not-for-profit organizations; 

these types accounted for 51.9 percent of 

the facilities and 42.0 percent of the beds. 

Facilities in most of the other facility types 

operated under varied ownership arrangements (i.e., no one type of organization 

owned 75 percent of the facilities within 

a facility type). Specifically, facilities in 

17 facility types had varied arrangements, 

accounting for 31.6 percent of the facilities 

and 33.2 percent of the beds.

C. Length of Stay 

Length of stay is an important variable 

because of concerns that long lengths of stay 

are associated with greater difficulties in 

returning to family and community after discharge. However, data on length of stay were 

unavailable for more than one-fifth of the 71 

facility types, accounting for 39.1 percent of 

Table III.3 Ownership of Residential Facilities for Children with Mental Illness, 

2003

Facility Type Facilities Beds

Number Percent Number Percent Number Percent

Wholly or predominantly 

operated by not-forprofits

47 66.2 1,884 51.9 21,235 42.0

Wholly or predominantly 

operated by for-profits

4 5.6 299 8.2 3,155 6.3

Wholly or predominantly 

operated by government

2 2.8 72 2.0 2,193 4.3

Wholly or predominantly 

operated by other type 

of entity

1 1.4 225 6.2 7,160 14.2

Varied ownership 17 23.9 1,148 31.6 16,764 33.2

Total 71 100.0 3,628 100.0 50,507 100.0

Source: Surveys submitted by 38 States

Note: “Varied ownership” indicates that no given type of organization operated 75 percent or more of these 17 types of residential facilities.
20 State Regulation of Residential Facilities for Children with Mental Illness

all facilities and almost half (46.3 percent) 

of all beds in residential facilities for children 

with mental illness (see Table III.4).

In 18 facility types (25.4 percent), average lengths of stay ranged between 1 and 6 

months, but these facility types accounted 

for only about 10 percent of facilities and 

10 percent of beds. In about one-third of 

all facility types (accounting for about the 

same proportion of facilities and beds), 

length of stay ranged between 7 and 12 

months. In less than 20 percent of facility 

types (accounting for 12.9 percent of facilities and 7.8 percent of beds), children stayed 

for longer than a year on average. Analyses 

of facility types by size indicated that longer 

lengths of stay were more common in facilities averaging 3 to 16 residents, as compared 

with facilities averaging 17 or more residents 

(data not shown). 

Few States indicated that they regulated 

lengths of stay for the facility types included 

in the study. Maximum lengths of stay were 

mandated for children in facilities in only 

10 of the 71 facility types (14 percent of 

facility types, accounting for 11 percent of 

all facilities). 

D. Secured Units 

Twenty-six types of facilities (37 percent of 

all facility types) were allowed by State law 

to have secured or locked units, but State 

officials indicated that only some facilities 

within these types actually had locked units. 

In some cases, facilities within these types 

did not have such units even though State 

law allowed them. Specifically, in half of the 

facility types allowed to have secured units, 

50 percent or less of the associated facilities actually had such units. The questionnaire did not ask State officials to report 

on the number of beds in locked units in 

facilities that were allowed to have such 

arrangements.

With respect to this issue, size of facility 

matters: more than 80 percent of facilities 

that averaged more than 16 residents were 

allowed to have locked units, as compared 

with less than 10 percent of facilities that 

averaged between 3 and 16 residents. 

Table III.4 Average Lengths of Stay in Residential Facilities for Children with 

Mental Illness, 2003

Average Length of Stay

Facility Type Facilities Beds

Number Percent Number Percent Number Percent

1–6 months 18 25.4 377 10.4 5,415 10.7

7–12 months 24 33.8 1,365 37.6 17,792 35.2

13 or more months 14 19.7 468 12.9 3,929 7.8

Data unavailable 15 21.1 1,418 39.1 23,371 46.3

Total 71 100.0 3,628 100.0 50,507 100.0

Source: Surveys submitted by 38 States
State Regulation of Residential Facilities for Children with Mental Illness 21

IV.

A. Licensure and Certification 

Analyses of data from State officials indicated that, depending on the particular State, 

several agencies licensed or certified residential facilities for children with mental illness. 

These agencies included:

n State departments of children and families 

(including welfare agencies)

n State and local mental health agencies

n State departments of health or departments of health and human services

n Various other State agencies, such as the 

Medicaid agency, the office for child care 

services, social service agencies, and the 

department of protective and regulatory 

services

As Table IV.1 shows, State departments of 

children and families were involved in licensing or certifying residential treatment facilities for children with mental illness. These 

departments licensed or certified 30 of the 

71 facility types (42.3 percent) in the study, 

accounting for 19.4 percent of all facilities 

and 27.1 percent of all beds. State departments of health and State mental health 

agencies also played a major role in licensing 

or certifying residential facilities for children 

with mental illness, each certifying about 

one-third of the facility types in the study. 

Five facility types were licensed or certified 

by departments of health and human services, but these 5 types accounted for 25.3 percent of all facilities (Table IV.1), indicating 

that these departments were involved with 

facility types that had a large number of 

associated facilities. Similarly, 7 facility types 

were licensed or regulated by other departments and agencies (such as Medicaid agencies or departments of protective services), 

but these 7 types accounted for 34.5 percent 

of all beds, meaning that these departments 

were involved with facility types that served 

large numbers of residents.

Licensing patterns were influenced by 

facility size. For example, State mental 

States have available a variety of methods to regulate residential 

facilities for children with mental illness, including licensure 

and certification, visits to facilities, review of complaints, and 

enforcement of important regulations. This chapter presents findings related 

to the States’ regulatory methods. Specifically, it provides information on:

n Licensure and certification 

n Complaint reviews

n Critical incident reporting

n Announced and unannounced visits

n Regulations governing selected facility characteristics

n Accreditation

Regulatory Methods
22 State Regulation of Residential Facilities for Children with Mental Illness

health agencies licensed 21 percent of facilities that had between 3 and 16 residents on 

average and 17 percent of facilities that had 

17 or more residents on average. In contrast, 

departments of social service licensed 1 percent of facilities that had between 3 and 16 

residents on average and 56 percent of facilities that had 17 or more residents on average 

(data not shown). 

For many facility types, more than one 

department or agency played a licensing or 

certifying role (which explains why the percentages in Table IV.1 add up to more than 

100). Table IV.2 shows the number of facility 

types (and associated facilities and beds) that 

were subject to licensing or certification by 

more than one agency. As the table shows, 

30 of the 71 facility types (42.3 percent) 

had to respond to two licensing agencies 

or departments, and 3 facility types had to 

respond to 3 or more licensing agencies. 

Additional analyses indicated the common combinations of agencies responsible 

for licensing or certifying residential facilities 

for children with mental illness. The facilities 

had to obtain licensure or certification from:

Table IV.2 Number of Agencies Involved in Licensing or Certifying Residential 

Facilities for Children with Mental Illness, 2003

Number of Agencies 

Involved

Facility Type Facilities Beds

Number Percent Number Percent Number Percent

Total 71 100.0 3,628 100.0 50,507 100.0

One 38 53.5 2,564 70.7 31,786 62.9

Two 30 42.3 813 22.4 11,287 22.4

Three or more 3 4.2 251 6.9 7,434 14.7

Source: Surveys submitted by 38 States

Table IV.1 Selected Agencies Licensing or Certifying Residential Facilities for 

Children with Mental Illness, 2003

Agency

Facility Type Facilities Beds

Number Percent Number Percent Number Percent

Total 71 3,628 50,507

Department of children and 

families 30 42.3 704 19.4 13,687 27.1

Department of health 24 33.8 599 16.5 12,781 25.3

State mental health agency 23 32.4 739 20.4 9,294 18.4

Department of social 

services 14 19.7 625 17.2 15,999 31.7

Department of health and 

human services 5 7.0 918 25.3 5,575 11..0

Local mental health agency 2 2.8 193 5.3 1,091 2.2

Department of human 

services 2 2.8 123 3.4 828 1.6

Other departments and 

agencies 7 9.9 1042 28.7 17,407 34.5

Source: Surveys submitted by 38 States
State Regulation of Residential Facilities for Children with Mental Illness 23

n Departments of children and families 

and departments of health in the case 

of 12 facility types

n State mental health agencies and 

departments of health in the case of 

6 facility types

n Departments of social service and 

departments of health in the case of 

4 facility types

n State mental health agencies and 

departments of social services in the 

case of 4 facility types 

n State mental health agencies and 

departments of children and families 

in the case of 3 facility types

In their licensing role, States typically 

required facilities to complete certain 

procedures for both initial licensure and 

certification and renewal: on-site inspections, review of documentation of staff 

qualifications and training, review of a 

sample of residents’ clinical records, and 

interviews with residents. As shown in 

Table IV.3:

n Virtually all facility types (97.2 percent) 

had to have on-site inspection for initial 

licensure or certification, and almost 

all (90.1 percent) had to have such an 

inspection for licensure renewal.

n Most facility types had to submit documentation of staff qualifications for 

initial licensure and certification (91.6 

percent) as well as for licensure renewal 

(87.3 percent).

n Documentation of staff training was 

required for 80.3 percent of facility types 

at the time of initial licensure and for 85.9 

percent at the time of licensure renewal.

n Record reviews had to occur at the time 

of initial licensure for 67.6 percent of 

facility types and at the time of licensure 

renewal for 85.9 percent of facility types.

n Resident interviews were required for 

far fewer facilities than the other proTable IV.3 Procedures Required by States for Initial Licensure or Certification 

and Renewal of License or Certification of Residential Facilities for Children 

with Mental Illness, 2003

Procedures

Percent of

Licensure or 

Certification Facility Type Facilities Beds

On-site inspection

Initial 97.2 98.8 98.9

Renewal 90.1 73.5 85.1

Documentation of 

staff qualifications

Initial 91.6 96.6 95.8

Renewal 87.3 72.4 83.3

Documentation of 

staff training

Initial 80.3 87.4 88.1

Renewal 85.9 67.4 78.1

Record review

Initial 67.6 64.1 63.7

Renewal 85.9 68.4 79.7

Resident interviews

Initial 38.0 14.2 19.1

Renewal 62.0 26.1 35.8

Source: Surveys submitted by 38 States

Note: Some States permitted provisional licensure or certification, which allowed facilities to begin operations before obtaining an initial license. 

This meant, for example, that some facilities had records for review at the time of initial licensure or certification.
24 State Regulation of Residential Facilities for Children with Mental Illness

cedures used in licensing and certification, with only 38.0 percent of facility 

types (accounting for 14.2 percent of all 

facilities) required to conduct interviews at 

initial licensure and 62.0 percent (26.1 percent of all facilities) at licensure renewal.

States rarely revoked licenses or certification. In 2003, respondents in 7 States 

indicated that licenses or certifications were 

revoked for 26 residential facilities for children with mental illness, less than 1 percent 

of all facilities. 

B. Complaint Reviews

Just as several agencies provided licensure 

and certification for residential facilities 

for children with mental illness, several agencies reviewed complaints filed against these 

facilities. As Table IV.4 shows, State departments of children and families reviewed 36 

of the 71 facility types, accounting for 27.1 

percent of the facilities and 31.0 percent 

of the beds. State mental health agencies 

also played a role in the complaint review 

process; these agencies reviewed complaints 

for 46.5 percent of all facility types, which 

accounted for 28.9 percent of facilities and 

34.5 percent of beds. In comparison, departments of health reviewed fewer facility types 

(21.1 percent), but such facilities accounted 

for 36.3 percent of facilities and 29.6 percent of beds. A variety of other departments 

and agencies (such as the Medicaid agency, 

department of justice, office of child care 

services, State commission on quality of 

care, behavioral health managed care organizations, protection and advocacy offices, 

and an office of children’s affairs) also were 

involved to a substantial extent in reviewing 

complaints against residential facilities for 

children with mental illness. Of the 71 facility types, survey responses indicated that 20 

(28.2 percent) were subject to review by one 

of these other entities, accounting for a substantial proportion of facilities (40.4 percent) 

and beds (46.5 percent). 

Table IV.4 State Agencies Reviewing Complaints Against Residential Facilities 

for Children with Mental Illness, 2003

Agency

Facility Type Facilities Beds

Number Percent Number Percent Number Percent

Total 71 3,628 50,507

Department of children 

and families

36 50.7 983 27.1 15,641 31.0

State mental health agency 33 46.5 1,049 28.9 17,441 34.5

Department of social 

services

17 23.9 779 21.5 16,435 32.5

Department of health 15 21.1 1,316 36.3 14,942 29.6

Local mental health agency 7 9.9 673 18.6 12,937 25.6

Department of health 

and human services

3 4.2 90 2.5 1,429 2.8

Department of 

human services

2 2.8 123 3.4 828 1.6

Other departments 

and agencies

20 28.2 1,466 40.4 23,482 46.5

Source: Surveys submitted by 38 States
State Regulation of Residential Facilities for Children with Mental Illness 25

For facilities in many facility types, more 

than one department or agency reviewed 

complaints against them (which explains why 

the percentages in Table IV.4 add up to more 

than 100). Table IV.5 presents the number 

of facility types (and associated facilities 

and beds) that were subject to complaint 

review by more than one agency. As the table 

shows, 2 agencies or departments reviewed 

23 of the 71 facility types (32.4 percent) with 

complaints against them (accounting for 13.7 

percent of facilities), and 3 or more agencies 

reviewed 16 facility types (22.5 percent) with 

complaints against them (accounting for 21.3 

percent of facilities). 

C. Critical Incident Reporting

All of the States in the study required all 

facilities to report adverse events or critical 

incidents to the State, but the specific types 

of adverse events or incidents that had to be 

reported varied somewhat across facilities. 

Of the 71 facility types included in the study, 

more than 90 percent were required to report 

deaths, suicides, and incidents or allegations 

of abuse or neglect (see Table IV.6). Suicide 

attempts had to be reported by 77.5 percent of facility types (accounting for about 

two-thirds of all facilities), and 63.4 percent 

of facility types (accounting for about 40 

percent of all facilities) had to report hospitalizations of residents. State laws require 

Table IV.5 Number of Agencies Involved in Reviewing Complaints Made Against 

Residential Facilities for Children with Mental Illness, 2003

Number of Agencies 

Involved

Facility Type Facilities Beds

Number Percent Number Percent Number Percent

Total 71 100 3,628 100.0 50,507 100.0

One 32 45.1 2,357 65.0 29,961 59.3

Two 23 32.4 497 13.7 7,022 13.9

Three 10 14.1 193 5.3 2,126 4.2

Four 5 7.0 356 9.8 4,238 8.4

Five 1 1.4 225 6.2 7,160 14.2

Source: Surveys submitted by 38 States

Table IV.6 Adverse Events or Critical Incidents Required to be Reported by 

Facilities for Children with Mental Illness, 2003

Adverse Event/

Critical Incident

Facility Type Facilities Beds

Number Percent Number Percent Number Percent

Total 71 3,628 50,507

Death 69 97.2 3,571 98.4 49,268 97.6

Allegation of abuse 

or neglect

67 94.4 3,529 97.3 48,522 96.1

Suicide 66 93.0 3,508 96.7 48,567 96.2

Suicide attempt 55 77.5 2,456 67.7 41,844 82.9

Hospitalization of resident 45 63.4 1,436 39.6 26,947 53.4

Source: Surveys submitted by 38 States
26 State Regulation of Residential Facilities for Children with Mental Illness

facilities to report other critical incidents as 

well, including runaways (required for 15.5 

percent of facility types and 4.6 percent of 

all facilities), criminal activities or assaults 

(required for 15.5 percent of facility types 

and 3.3 percent of facilities), serious injuries (14.1 percent of facility types and 8.2 

percent of facilities), and use of restraints or 

seclusion (11.3 percent of facility types and 

7.3 percent of facilities). Less than 5 percent 

of facility types are required to report fires, 

medication errors, and sexual incidents. 

D. Announced and Unannounced 

Visits

State agencies typically visited residential 

facilities for children with mental illness to 

assess living conditions, safety issues, and 

services provided. Visits could have been 

announced or unannounced. According to 

survey respondents, most States relied on 

both methods.

Analyses showed that, in 2002, States 

made announced visits to at least some of 

the associated facilities in 65 of the 71 types 

of residential facilities included in the study 

(91.5 percent). If respondents indicated that 

States made visits to at least some associated 

facilities within a particular facility type, 

they were asked what percent of associated 

facilities were visited in 2002. In some cases, 

States visited 100 percent of the associated 

facilities within a facility type; in other cases, 

States visited only 1 percent of the associated facilities. For 2 types of facilities, States 

did not know whether announced visits 

occurred. 

States were somewhat less likely to make 

unannounced visits as compared with 

announced visits. In 2002, States made 

unannounced visits to at least some of the 

associated facilities in 46 of the 71 types of 

residential facilities included in the study 

(64.8 percent). In some cases, States made 

unannounced visits to 100 percent of the 

associated facilities within a facility type; in 

other cases, States made unannounced visits 

to only 5 percent of the associated facilities. 

For 3 types of facilities, respondents did not 

know whether unannounced visits occurred.

The same State departments and agencies that were responsible for reviewing 

complaints against residential facilities for 

children with mental illness made most of 

the announced or unannounced visits. As 

Table IV.7 shows, departments of children 

and families and State mental health agencies 

each conducted some type of visit to slightly 

more than one-third of facility types in 2002. 

Again, more than one government entity 

made visits to residential facilities (which 

explains why the percentages in Table IV.7 

add up to more than 100).

E. Regulations Governing Selected 

Facility Characteristics

Analyses of data from State officials 

indicated that States varied in the extent to 

which laws or regulations governed operational requirements for residential facilities 

for children with mental illness. Two requirements frequently included in laws covering 

residential facilities involved resident-to-staff 

ratios and minimum education requirements 

for facility directors. The survey first asked 

respondents to indicate whether a State law 

or regulation required minimum residentto-staff ratios or a minimum level of education for facility directors; if there was such a 

requirement, the survey asked respondents to 

indicate its specific nature.

More than three-quarters (77.5 percent) 

of all facility types and 61.3 percent of all 

facilities were subject to required resident-
State Regulation of Residential Facilities for Children with Mental Illness 27

to-staff ratios, which means that about 40 

percent of all facilities were not required 

to maintain any specific ratios (Table IV.8). 

Slightly more than two-thirds (67.6 percent) 

of facility types and more than 80 percent 

of facilities were subject to minimum education requirements for facility directors 

(Table IV.8). Additional analyses on size of 

facility type indicated that facilities with an 

average of 3 to 16 residents were substantially less likely to be subject to either requirement (data not shown).

Survey data provided information on 

minimum requirements rather than on actual 

resident-to-staff ratios or education levels 

of facility directors. A separate study would 

be needed to determine whether residential 

facilities for children with serious mental illness met or exceeded the requirements.

For those States with requirements governing resident-to-staff ratios and directors’ 

education levels, information on the specifics 

of the requirements is presented in the following sections. 

Table IV.8 Residential Facilities Subject to State Requirements for Residentto-Staff Ratios and Minimum Education Levels for Facility Directors, 2003

Requirement

Facility Type Facilities Beds

Number Percent Number Percent Number Percent

Total 71 3,628 50,507

Resident-to-staff ratios 55 77.5 2,223 61.3 35,691 70.7

Minimum education level 

for facility directors

48 67.6 2,977 82.1 42,571 84.3

Source: Surveys submitted by 38 States

Table IV.7 Agencies Involved in Conducting Unannounced or Announced Visits 

to Residential Facilities for Children with Mental Illness, 2003

Agency

Facility Type Facilities Beds

Number Percent Number Percent Number Percent

Total 71 3,628 50,507

Department of children 

and families

27 38.0 645 17.8 13,049 25.8

State mental health agency 26 36.6 771 21.3 9,559 18.9

Department of health 16 22.5 1,303 35.9 14,726 29.2

Department of social 

services

12 16.9 610 16.8 16,074 31.8

Department of human 

services

2 2.8 123 3.4 828 1.6

Department of health 

and human services

1 1.4 40 1.1 887 1.8

Local mental health agency 1 1.4 23 0.6 161 0.3

Other departments 

and agencies

14 19.7 1,231 33.9 22,129 43.8

Source: Surveys submitted by 38 States

Note: Percentages add to more than 100 because States may require facilities to report more than one type of event.
28 State Regulation of Residential Facilities for Children with Mental Illness

1. Required Resident-to-Staff Ratios

As Table IV.9 shows, of the 55 facility types 

required to have a particular daytime resident-to-staff ratio, the required minimum 

ratio fell between

n 2 and 4 residents per staff member for 

15 facility types (27.3 percent)

n 5 and 8 residents per staff member for 

26 facility types (47.3 percent)

n 9 and 20 residents per staff member for 

10 facility types (18.2 percent)

Specific minimum staffing requirements 

varied by facility size (data not shown). 

Facilities averaging 3 to 16 residents were 

subject to State laws that impose lower ratios 

(i.e., fewer residents per staff member), while 

facilities averaging 17 or more residents were 

subject to laws that impose higher ratios 

(i.e., more residents per staff member). Also, 

survey responses indicated that nighttime 

ratios were slightly higher (i.e., a single staff 

member was responsible for more residents) 

across most facility types.

2. Required Education Level of Facility 

Directors 

As Table IV.10 shows, of the 48 facility types 

with minimum requirements for the education level of facility directors, the specific 

requirement was

n Less than a bachelor’s degree for 2 facility 

types (4.2 percent of all facilities with such 

a requirement, accounting for 30.3 percent 

of all facilities and 16.3 percent of all 

beds).

n A bachelor’s degree for 19 facility types 

(39.6 percent of all facilities, accounting 

for 22.4 percent of all facilities and 36.6 

percent of all beds).

n A master’s degree for 15 facility types 

(31.3 percent of all facilities, accounting 

for 32.2 percent of all facilities and 22.6 

percent of all beds).

n A combination of education and experience for 10 facility types (20.8 percent 

of all facilities, accounting for 12.0 

percent of all facilities and 22.3 perTable IV.9 Daytime Resident-to-Staff Minimum Ratios in Residential Facilities 

with Staffing Requirements, 2003

Ratios

Facility Type Facilities Beds

Number Percent Number Percent Number Percent

Total 55 100.0 2,223 100.0 35,691 100.0

2–4 residents per staff 

member

15 27.3 1,030 46.3 6,203 17.4

5–8 residents per staff 

member

26 47.3 756 34.0 17,089 47.9

9–20 residents per staff 

member

10 18.2 386 17.4 11,389 31.9

Not applicable* 2 3.6 24 1.1 334 0.9

Not available** 2 3.6 27 1.2 676 1.9

Source: Surveys submitted by 38 States

Note: The table includes only facility types that had State requirements for resident-to-staff ratios.

* The item was not applicable for two facility types because the State imposed a staffing requirement that did not correspond to a specific resident-tostaff ratio (e.g., one staff person per living unit).

** Data on specific resident-to-staff ratios were not available for two facility types. 
State Regulation of Residential Facilities for Children with Mental Illness 29

cent of all beds). For example, in West 

Virginia’s psychiatric residential treatment facilities, the facility director must 

hold a master’s degree and demonstrate 

two years of experience or hold a bachelor’s degree and demonstrate five years 

of experience.

n Specific experience for 2 facility types 

(4.2 percent of all facilities, accounting 

for 3.2 percent of all facilities and 2.1 

percent of all beds).

State requirements for minimum education levels for facility directors varied 

somewhat by size of facilities (data not 

shown). For example, facility types with 

a minimum requirement of less than a 

bachelor’s degree for facility directors 

were more likely to include larger facilities 

(with an average of 17 or more residents), 

as compared with smaller ones (with an 

average of 3 to 16 residents). 

F. Accreditation

In addition to requiring licensure or certification, a few states require residential 

facilities for children with mental illness 

to be accredited by one of the national 

accrediting organizations. According to 

State officials, slightly more than 6 percent 

of the residential facilities included in the 

survey were required to obtain accreditation from at least one national accrediting 

organization. These organizations included 

the Joint Commission on Accreditation 

of Healthcare Organizations, the Council 

on Accreditation for Children and Family 

Services, the Commission on Accreditation 

of Rehabilitation Facilities, and the National 

Committee for Quality Assurance.

Table IV.10 Minimum Education Requirements for Facility Directors of Residential 

Facilities with Requirements, 2003

Of Those with a Requirement, Number and Percentage Requiring

Education Requirements

Facility Type Facilities Beds

Number Percent Number Percent Number Percent

Total 48 100.0 2,977 100.0 42,571 100.0

Less than a bachelor’s 

degree

2 4.2 902 30.3 6,952 16.3

Bachelor’s degree 19 39.6 666 22.4 15,577 36.6

Master’s degree 15 31.3 957 32.2 9,634 22.6

Combination of education 

and experience

10 20.8 358 12.0 9,505 22.3

Experience requirement 

only

2 4.2 94 3.2 903 2.1

Source: Surveys submitted by 38 States

Note: The table includes only facility types that had minimum education requirements for facility directors.

State Regulation of Residential Facilities for Children with Mental Illness 31

V.

A. Services Provided

As Table V.1 shows, respondents indicated 

that State law required 90.1 percent of all 

facility types in the study (accounting for 

88.2 percent of all associated facilities) to 

provide individual counseling and 85.9 percent to provide group counseling. Family 

counseling was required in 71.8 percent 

of facility types and financial management 

counseling in 28.2 percent of facility types. 

The majority of facility types also provided 

medication-related services: 81.7 percent 

were required to manage medications for 

residents and 73.2 percent to dispense 

medications.

Between 76 and 82 percent of facility 

types were required to provide education 

services and assistance with or training in 

activities of daily living (ADLs). A smaller 

percentage of facility types were required 

to provide vocational training (45.1 percent) or occupational therapy (31.0 percent). States required case management to 

be provided to residents in 81.7 percent of 

facility types and client advocacy in 49.3 

percent.

As shown in Table V.1, the percentage of 

facility types required to provide discharge 

services also varied by specific service. Most 

facility types (88.7 percent) were required 

to develop a comprehensive discharge plan, 

and about half (49.3 percent) were required 

to provide medications or a medication 

plan at discharge. About a quarter of facility types (22.5 percent) were required to 

conduct discharge interviews or satisfaction 

surveys. A small proportion of facility types 

(7 percent) were required to provide followup home visits after discharge.

B. Sources of Financing 

Most facilities relied on several sources of 

funding (Table V.2). The three most important sources of funding were:

n State Medicaid programs, which provided 

funds for children in 87.3 percent of 

Children with mental illness who are placed in residential settings 

typically require a broad range of services, from counseling to 

medication management. Analyses of survey data showed that 

most residential facilities provided some type of counseling services, but 

facilities varied substantially in the package of services they were required to 

provide. This chapter presents data on services that facilities were required 

to provide to children both during their stay and upon discharge. In practice, 

facilities might provide more (or less) than they were required to provide. 

The chapter also discusses findings on sources of financing. 

Services and Sources 

of Financing
32 State Regulation of Residential Facilities for Children with Mental Illness

facility types (accounting for 84.1 percent 

of facilities and 80.9 percent of beds)

n State departments of child and family 

services, which provided funds for children 

in 67.6 percent of facility types (accounting for 65.9 percent of facilities and 76.5 

percent of beds) 

n State and local mental health agencies, 

which provided funds for children in 57.8 

percent of facility types (accounting for 

81.3 percent of facilities and 74.8 percent 

of beds)

Table V.1 Number and Percent of Residential Facilities for Children 

with Mental Illness Required to Provide Selected Services, 2003

Agency

Facility Type Facilities Beds

Number Percent Number Percent Number Percent

Counseling Services

Individual counseling 64 90.1 3,201 88.2 39,787 78.8

Group counseling 61 85.9 2,353 64.9 36,557 72.4

Family counseling 51 71.8 1,976 54.5 26,809 53.1

Financial management 

counseling

20 28.2 1,108 30.5 13,452 26.6

Medication Services

Medication management 58 81.7 3,030 83.5 39,592 78.4

Dispensing of medication 52 73.2 2,324 64.1 37,517 74.3

Education and Training 

Services

Education 58 81.7 3,025 83.4 41,252 81.7

Assistance with ADLs 56 78.9 2,051 56.5 30,253 59.9

Training in ADLs 54 76.1 2,654 73.2 31,656 62.7

Vocational training 32 45.1 1,317 36.3 19,259 38.1

Occupational therapy 22 31.0 1,204 33.2 16,070 31.8

Case Management/

Advocacy

Case management 58 81.7 3,005 82.8 43,670 86.5

Client advocacy 35 49.3 1,383 38.1 20,599 40.8

Discharge Services

Comprehensive discharge plan

63 88.7 3,361 92.6 46,962 93.0

Discharge medications 

or medication plan

35 49.3 806 22.2 13,230 26.2

Discharge interview or 

satisfaction survey

16 22.5 291 8.0 4,958 9.8

Follow-up visit at home/

other residence

5 7.0 16 0.4 249 0.5

Total 71 3,628 50,507

Source: Surveys submitted by 38 States

Note: ADLs are activities of daily living.
State Regulation of Residential Facilities for Children with Mental Illness 33

Other third-party payments, Supplemental Security Income (SSI) payments, 

and family out-of-pocket payments were 

sources of funding for between 34 and 

47 percent of facility types. Department 

of education, juvenile justice authorities, 

State welfare payments, Social Security 

Disability Income (SSDI) payments, and 

private grants were sources of funding 

for between 21 and 28 percent of facility types. Federal grants, State payments 

supplementing SSI payments, and the 

Department of Defense were sources of 

financial support for relatively few facility 

types (Table V.2). 

Overall, 53 types of facilities (or 74.6 

percent of facility types, accounting for 

45 percent of facilities) reported using a 

Medicaid per diem rate ranging from $40 

to $540. Of the 53 facility types that used 

Medicaid per diem rates, 29 (54.7 percent) 

had a rate of $200 or less.

Table V.2 Funding Sources for Services Received by Children with Mental Illness 

in Residential Facilities, 2003

Funding Source

Facility Type Facilities Beds

Number Percent Number Percent Number Percent

Medicaid 62 87.3 3,050 84.1 40,877 80.9

Department of child and 

family services

48 67.6 2,392 65.9 38,656 76.5

State or local mental health 

agency

41 57.8 2,950 81.3 37,752 74.8

Other third-party payments 33 46.5 1,877 51.7 35,078 69.5

SSI payments 26 36.6 1,585 43.7 27,383 54.2

Out-of-pocket family 

payments

24 33.8 1,929 53.2 30,931 61.2

Department of education 20 28.2 555 15.3 12,531 24.8

Juvenile justice 18 25.4 1,761 48.5 24,996 49.5

State welfare payments 18 25.4 878 24.2 19,426 38.5

SSDI payments 18 25.4 551 15.2 11,136 22.1

Private grants 15 21.1 1,091 30.1 15,845 31.4

Federal grants 8 11.3 323 8.9 4,902 9.7

State supplemental 

payments

4 5.6 168 4.6 3,182 6.3

Department of Defense 2 2.8 73 2.0 892 1.8

Total 71 3,628 50,507

Source: Surveys submitted by 38 States

Note: SSI is Supplemental Security Income; SSDI is Social Security Disability Income.

State Regulation of Residential Facilities for Children with Mental Illness 35

VI.

n Requirements for announced and 

unannounced visits

n Mandated staff-to-client ratios

n Requirements for minimum residentto-staff ratios and minimum levels of 

education for facility directors 

n Specifications for critical-incident 

reporting

n Specific licensing practices

n Mandated complaint-review procedures

n Accreditation from designated State or 

national organizations

States also differed widely in the types of 

residential facilities that they indicated they 

regulated. Some States, for example, had 

regulations for a facility type that included 

small facilities staffed to provide homes for 

children with mental illness who were in 

State custody and who may have needed 

help in developing social skills; children 

may have stayed in these settings for a year 

or longer. Other States had regulations for 

larger congregate settings that focused on 

short-term rehabilitation (i.e., three months 

or less) and that offered a full set of counseling and therapeutic activities. The types 

of facilities that States regulated are different along numerous dimensions, such 

as mission, administrative structure, size, 

ownership arrangements, typical length of 

stay, services provided, and mix of funding 

sources. States also referred to facilities by 

different names, making it difficult to identify the extent to which facilities in different 

States were similar. 

The findings further demonstrated that 

the organizations that operated facilities for 

children with mental illness typically faced 

a complex regulatory environment. A wide 

variety of State agencies with different missions and functions, ranging from State 

mental health authorities to departments of 

health to departments of child welfare, oversaw these residential facilities. Furthermore, 

in most States, several agencies were typically involved in licensing, regulating, and 

reviewing complaints against residential 

facilities. For 47 percent of all facility types 

covered by the survey (accounting for 29 

percent of all facilities), licenses or certifications were required from more than one 

agency, and for 22 percent of facility types 

(accounting for 21 percent of all facilities), 

three or more agencies were involved in 

Findings from this study provide information on methods that 

States used to regulate residential facilities for children with mental illness and underscore the substantial variation across States 

in their use of regulatory methods in 2003. Analyses of data from State 

officials indicated that States relied on at least several regulatory methods, 

but no State used all of the possible methods. These methods included a wide 

range of specifications and requirements, such as:

Conclusions
36 State Regulation of Residential Facilities for Children with Mental Illness

reviewing complaints. In addition, facilities may have had administrative reporting 

requirements from their multiple funding 

sources.

At the State level, the study showed that 

some States lacked ready access to important 

data about residential facilities for children 

with mental illness. For example, respondents 

were unable to provide information on the 

average length of stay for 21 percent of facility types, accounting for 39 percent of facilities and 46 percent of beds. For several key 

items, respondents indicated that they were 

relying on administrative estimates rather 

than specific records or documents to report 

on certain types of descriptive data, such 

as average number of residents per facility, 

frequency of announced visits, or Medicaid 

per diems. 

Although the present study was not 

designed to provide a national count of 

residential facilities for children with mental 

illness, its results on the number of facilities and beds can be compared with data 

from other studies, such as studies based on 

SMHO data. These comparisons show that 

different studies have yielded different counts 

of residential beds for children with mental 

illness because the studies used different criteria and methods for identifying residential 

settings. For example, the present study 

began from a regulatory perspective and 

focused on the types of facilities that States 

regulated, regardless of what organizations 

operated these facilities. The criteria for the 

present study included facilities that provided 

some therapeutic services beyond room and 

board, but not necessarily a broad set of clinical psychiatric or psychological services. The 

SMHO, in contrast, focuses specifically on 

mental health organizations operated under 

the auspices of State mental health agencies, and gathers information on the number 

of those organizations that provide major 

clinical services in a residential venue. 

Analyses based on data from the SMHO 

indicate that there were 474 residential 

treatment centers for emotionally disturbed 

children in 2000 and that these centers 

had a total of 33,421 beds in operation 

(Manderscheid et al. 2004). The numbers 

from the present study are substantially 

higher than these figures because the present study included a larger range of facilities 

compared with the SMHO. Specifically, the 

SMHO was developed to provide counts of 

residential treatment centers for emotionally 

disturbed children that operated under the 

auspices of State mental health agencies and 

that met the following criteria (Manderscheid 

and Henderson 2004, p. 371):

n It must provide 24-hour residential 

services.

n It is an organization, not licensed as a 

psychiatric hospital, the primary purpose 

of which is the provision of individually 

planned programs of mental health treatment services in conjunction with residential care for its patients/clients.

n It has a clinical program within the organization that is directed by a psychiatrist, 

psychologist, social worker, or psychiatric 

nurse who has a master’s degree or a 

doctorate degree.

n It serves children and youth primarily 

under the age of 18.

n The primary reason for the admission of 

50 percent of more of the children and 

youth is mental illness that can be classified by DSM-IV/ICD-9-CM codes other 

than codes for mental retardation, drugrelated disorders, or alcoholism.

In contrast to the SMHO, the present 

study was designed specifically to examine 
State Regulation of Residential Facilities for Children with Mental Illness 37

methods that States used to regulate residential facilities that met the criteria listed in 

Table II.1. These criteria led to the inclusion 

of a wide range of facilities, including facilities that would not be counted in the SMHO. 

For example, South Carolina had regulations governing five different types of residential facilities that met study criteria. In 

one of these types, referred to as supervised 

independent living programs, facilities were 

licensed only by the State’s department of 

social services. These facilities housed on 

average 10 adolescents ages 16 to 21 for an 

average of one year and provided education, 

financial management training, occupational 

therapy, and vocational training, in addition 

to individual and group counseling. Sources 

of financial support included the State’s 

Medicaid program and local family and 

child service agencies, but no mental health 

agency. 

As noted above, the SMHO included residential treatment centers for emotionally disturbed children that operated under the auspices of State mental health agencies and that 

had as their primary purpose the provision 

of individually planned programs of mental 

health treatment services in conjunction with 

residential care. Because South Carolina’s 

supervised independent living programs were 

not operated under the auspices of the State’s 

mental health agency and appear to focus 

on providing education and rehabilitative 

services, rather than primarily clinical mental 

health services, they may not be included in 

the SMHO. 

Overall, the criteria used to generate the 

list of organizations counted in the SMHO 

would be expected to lead to a count of the 

number of residential treatment centers for 

emotionally disturbed children that would 

be substantially lower than the number of 

facilities covered by the present study. The 

present study cast a wider net than the 

SMHO because its purpose was to conduct a 

regulatory analysis, rather than to enumerate 

and describe clinical services offered by residential facilities under the auspices of State 

mental health organizations. 

It is also useful to compare results from 

the present study (Table III.1) with data 

from NASMHPD’s State profiles (Table I.1). 

These comparisons show that for all but one 

State with data in both studies, the number of beds identified in the present study 

exceeded the number of beds identified in 

NASMHPD’s State profiles. For example, in 

the present study, the total number of beds 

in all State-regulated facilities was reported 

to be 594, 887, and 747 in Nebraska, New 

Hampshire, and New York, respectively. In 

the NASMHPD report, the total bed count 

was 36, 37, and 16 for Nebraska, New 

Hampshire, and New York, respectively. The 

difference is likely to result from the fact that 

the present study included a greater number 

of facilities (and therefore a greater number 

of associated beds) because it incorporated 

facilities beyond those that were funded 

and operated by State mental health agencies. (Oregon is an exception to the pattern, 

and the reasons for this finding may involve 

reporting error, the differences in the time 

period between the studies, or some other 

factors.)

As noted in Chapter I, a previous study 

indicated that 25,356 youths resided in 673 

juvenile justice residential treatment facilities 

in 1998 (Goldstrom et al. 2001). That study 

included some facilities that were excluded in 

the present study, such as detention centers, 

and the present study included facilities that 

were not placements for individuals in the 

juvenile justice system.
38 State Regulation of Residential Facilities for Children with Mental Illness

In addition to extending previous studies of residential settings for children with 

mental illness, this study’s findings also 

relate directly to the recommendation in the 

report from the President’s New Freedom 

Commission on Mental Health (2003) that 

each State develop a comprehensive State 

mental health plan. As a continuation of the 

Commission’s efforts, SAMHSA, in partnership with key Federal agencies, recently 

issued Transforming Mental Health Care 

in America. The Federal Action Agenda: 

First Steps (SAMHSA 2005). One of 

the five principles outlined in the Action 

Agenda is to “ensure innovation, flexibility, and accountability at all levels of 

government.” The action steps related to 

this principle include the initiation of State 

Mental Health Transformation Grants (first 

awarded in September 2005) and the provision of technical assistance to help States 

develop their comprehensive State mental 

health plans. Incorporating a comprehensive set of methods for regulating residential 

treatment facilities should help States minimize redundant and potentially conflicting 

administrative burdens on such facilities, 

leverage resources across multiple agencies, 

and foster a coherent continuum of child 

mental health services. 
References

MD: Center for Mental Health Services, 

Substance Abuse and Mental Health 

Services Administration.

Manderscheid, Ronald, Joanne Atay, María 

Hernández-Cartagena, Pamela Edmond, 

Alisa Male, Albert Parker, and Hongwei 

Zhang. 2001. “Highlights of Organized 

Mental Health Services in 1998 and 

Major National and State Trends.” In 

Mental Health, United States, 2000, 

ed. R. W. Manderscheid and M. J. 

Henderson. DHHS Pub. No. (SMA) 01-

3537. Washington, DC: Superintendent 

of Documents, U.S. Government Printing 

Office.

Manderscheid, Ronald, Joanne Atay, Alisa 

Male, Beatrice Backlow, Christine Forest, 

Linda Ingram, James Maedke, Jeffrey 

Sussman, and Adrien Ndikumwami. 

2004. “Highlights of Organized Mental 

Health Services in 2000 and Major 

National and State Trends.” In Mental 

Health, United States, 2002, ed. R. W. 

Manderscheid and. M. J. Henderson. 

DHHS Pub, No. (SMA) 3938. Rockville, 

MD: Substance Abuse and Mental 

Health Services Administration, Center 

for Mental Health Services. 

Manderscheid, Ronald, and Marilyn J. 

Henderson, eds. 2004. Mental Health, 

United States, 2002, DHHS Pub. No. 

(SMA) 3938. Rockville, MD: Substance 

Abuse and Mental Health Services 

Administration, Center for Mental 

Health Services. 

Arons, B., Ted Searle, Anita Sweetman, 

Michael English, Ann MatthewsYounes, Joyce Berry, Mel Haas, Paolo 

del Vecchio, and Dale Kaufman. 2004. 

“SAMHSA’s Center for Mental Health 

Services: A Decade of Achievement, 

1992–2002.” In Mental Health, United 

States, 2002, ed. R. W. Manderscheid 

and M. J. Henderson, Chapter 1. DHHS 

Pub. No. (SMA) 3938. Rockville, MD: 

Substance Abuse and Mental Health 

Services Administration.

Colorado Office of the State Auditor. 2002, 

January. Residential Treatment Center 

Rate Setting and Monitoring. Denver: 

Colorado Office of the State Auditor.

Fleishman, M. 2004. “The Problem: How 

Many Patients Live in Residential Care 

Facilities?” Psychiatric Services 55(6): 

620–622.

Goldstrom, I., F. Jaiquan, M. Henderson, 

A. Male, and R. Manderscheid. 2001. 

“The Availability of Mental Health 

Services to Young People in Juvenile 

Justice Facilities: A National Survey.” 

In Mental Health, United States, 2000, 

ed. R. W. Manderscheid and M. J. 

Henderson. DHHS Pub. No. (SMA) 01-

3537. Washington, DC: Superintendent 

of Documents, U.S. Government Printing 

Office.

Ireys H, Achman L, Takyi A. 2006. “State 

Regulation of Residential Facilities for 

Adults with Mental Illness.” DHHS 

Pub. No. (SMA) 06-4166. Rockville, 

State Regulation of Residential Facilities for Children with Mental Illness 39
40 State Regulation of Residential Facilities for Children with Mental Illness

Maryland Task Force to Study the Licensing 

and Monitoring of Community-Based 

Homes for Children. 2002, September. 

Final Report to the Governor. Baltimore: 

Governor’s Office for Children, Youth, 

and Families.

Milazzo-Sayre, L., M. Henderson, R. 

Manderscheid, M. Bokossa, C. Evans, 

and A. Male. 2001. “Persons Treated in 

Specialty Mental Health Care Programs, 

United States, 1997.” In Mental Health, 

United States, 2000, ed. R. W. 

Manderscheid and M. J. Henderson. 

DHHS Pub. No. (SMA) 01-3537. 

Washington, DC: Superintendent of 

Documents, U.S. Government Printing 

Office.

National Association of State Mental 

Health Program Directors (NASMHPD). 

2005. The NASMHPD Research 

Institute’s State Mental Health Agency 

Profiling System. Available at http://

www.nri-inc.org/defprofiles.cfm. 

Accessed May 2005.

New Freedom Commission on Mental 

Health. 2003. Achieving the Promise: 

Transforming Mental Health Care in 

America. Final Report. DHHS Pub. 

No. SMA-03-3832. Rockville, MD: 

Substance Abuse and Mental Health 

Services Administration, Center for 

Mental Health Services.

Office of the Inspector General (OIG), 

U.S. Department of Health and Human 

Services. 2000, May. State Oversight 

of Residential Facilities for Children. 

Washington, DC: OIG.

Pottick, Kathleen, Lynn Warner, 

Mareasa Isaacs, Marilyn Henderson, 

Laura Milazzo-Sayre, and Ronald 

Manderscheid. 2004. “Children and 

Adolescents Admitted to Specialty 

Mental Health Care Programs in the 

United States, 1986 and 1997.” In 

Mental Health, United States, 2002, 

ed. R. W. Manderscheid and M. J. 

Henderson, Chapter 20. DHHS Pub. 

No. (SMA) 3938. Rockville, MD: 

Substance Abuse and Mental Health 

Services Administration, Center for 

Mental Health Services.

Substance Abuse and Mental Health 

Services Administration. 2005. 

Transforming Mental Health Care in 

America. The Federal Action Agenda: 

First Steps. Washington, DC: U.S. 

Department of Health and Human 

Services. 
State Regulation of Residential Facilities for Children with Mental Illness 41

Appendix A

Expert Advisory Panel

The authors are grateful to the members of the expert advisory 

panel who provided thoughtful input into study questions, survey methods, and criteria for the residential facilities included 

in the study; members of this panel are listed in Appendix A. The authors 

would like to extend particular thanks to Joy Midman, Sandra Newman, 

and Tom Harmon for their careful review of an early draft of the survey 

instrument and for guidance at strategic stages of the study. Jeff Horton of 

North Carolina, Brenda Harvey of Maine, and Alfred Nichols of California 

also provided useful feedback during the pilot test of the survey. James 

Maedke and Nancy Darrow of Social and Scientific Systems, Inc., provided 

assistance in understanding definitions of mental health organizations used 

in the Survey of Mental Health Organizations. 

At MPR, Debra Draper played an important leadership role in the first phase of the 

project. Jesse Gregory and Kathy Bencio 

spent many hours contacting State officials 

as part of the survey effort. Myles Maxfield 

gave us insightful comments on an early 

draft of the report, and Sharon Clark 

provided unmatched secretarial assistance 

in producing the report. The authors 

extend special thanks to the individuals 

in the various States who took time to

complete the survey.
42 State Regulation of Residential Facilities for Children with Mental Illness

Expert Advisory Panel List of Participants

Panel Members

Karen Saltus Armstrong

Senior Public Health Advisor

Protection & Advocacy for 

Individuals with Mental Illness 

(PAIMI) Program 

Substance Abuse and Mental Health 

Services Administration (SAMHSA)

Collete Croze

Consultant 

Technical Assistance Collaborative 

(TAC) Housing Center

Joe Dziobek

President/CEO

Fellowship Health Resources, Inc.

Steve Fields

Director

Progress Foundation

Brian Fitzmaurice

Director of Community Assistance 

Programs

U.S. Department of Housing and 

Urban Development (HUD)

Tom Harmon

Commission Staff

New York Commission on the Quality 

of Care for the Mentally Ill

Jeff Horton

Chief of Mental Health Licensure and 

Certification

North Carolina Division of Facilities

Bonnie Kirkland

Special Secretary

Maryland Governor’s Office for 

Children, Youth, and Families

Martha Knisley

Director

DC Department of Mental Health

Joy Midman

Executive Director

National Association for Children’s 

Behavioral Health

Sandra Newman

Director

Institute for Policy Studies

Johns Hopkins University

Fran Randolph

Acting Branch Chief

Homeless Programs Branch

Substance Abuse and Mental Health 

Services Administration (SAMHSA)

John Rio

Program Director

Corporation for Supportive Housing

Sam Tsemberis

Executive Director

Pathways to Housing

Deborah Wilkerson

Director of Research and Quality 

Improvement

Commission on Accreditation of 

Rehabilitation Facilities (CARF)

SAMHSA Project Staff

Jeffrey Buck

Associate Director 

Office of Organization and Financing

Judith Teich

Office of Organization and Financing

William Wallace

Office of Organization and Financing

Mathematica Policy Research, Inc. Staff

Debra Draper

Senior Researcher

Myles Maxfield

Senior Fellow

Henry Ireys

Senior Researcher

Deborah Bukoski

Survey Researcher

Lori Achman

Research Analyst

Ama Takyi

Research Assistant
State Regulation of Residential Facilities for Children with Mental Illness 43

Appendix B

Survey Questionnaire
44 State Regulation of Residential Facilities for Children with Mental Illness 

OMB Number: 0930-0251

Expiration Date: 10/31/2004

Case ID:

Agency Name:

Address:

City, State, Zip:

Respondent Name:

Respondent Title:

Respondent Email:

INTRODUCTION:

or

SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES ADMINISTRATION

FACILITY TYPE HERE

NATIONAL SURVEY OF ADMINISTRATION AND FINANCING OF GROUP 

HOMES AND RESIDENTIAL FACILITIES FOR PERSONS WITH MENTAL 

ILLNESS

Thank you for agreeing to complete this questionnaire. Your participation is critical to the success of this 

important project. Instructions for completing and returning the questionnaire are included in a separate 

document. If you have any questions, please do not hesitate to contact:

DEPARTMENT OF HEALTH AND HUMAN SERVICES

600 Maryland Avenue, S.W., Suite 550

Washington, DC 20024-2512

Lori Achman

Research Analyst, Mathematica Policy Research

600 Maryland Avenue, S.W., Suite 550

Washington, DC 20024-2512

Henry Ireys

Senior Researcher, Mathematica Policy Research

hireys@mathematica-mpr.com lachman@mathematica-mpr.com

Tel: 202.554.7536

Fax: 202.863.1763

Tel: 202.264.2464

Fax: 202.863.1763

Public reporting burden for this collection of information

is estimated to average 1 hour per response, including

the time for reviewing instructions, searching existing

data sources, gathering and maintaining the data

needed, and completing and reviewing the collection of

information. Send comments regarding this burden

estimate or any other aspect of this collection of

information, including suggestions for reducing this

burden to SAMHSA Reports Clearance Officer;

Paperwork Reduction Project (0930-0251); Room 16-

105, Parklawn Building; 5600 Fishers Lane, Rockville,

MD 20857. An agency may not conduct or sponsor, and 

a person is not required to respond to, a collection of

information unless it displays a currently valid OMB

control number. The OMB contro l number for this

project is 0930-0251.
State Regulation of Residential Facilities for Children with Mental Illness 45

Helpful Hints to Complete Your Survey

Remember to save often!

Use the arrow keys to the left of the Section Tabs at the bottom of the page to navigate left to

right to see the sections (tabs).

Click on the Section Tabs at the bottom of the screen to get to that section. You can skip around

between sections and instructions if needed.

Follow any skips you see after questions. They may be in one of two formats:

(after a choice) GO TO Q3_a

(at the end of a section) GO TO SECTION C

There are 4 types of questions: Fill-in; Yes/No; Select One; Check All That Apply.

Below are examples of each and how to answer them.

Yes/No:

In this type of question you will move the mouse (which appears as a hand) 

over the circle next to the response you’d like, and click. Once you do that, 

the circle will be filled in. If you’d like to change your answer, simply click on the other choice.

Fill-In:

ENTER NUMBER OF HOURS PER YEAR:

In this type of question, you may be entering a number – such as a percent or you may

be typing text for an Other (specify) answer.

Select One:

This type of question is similar to Yes/No. Rather than an arrow appearing 

over the choices, a hand will appear. As with the Yes/No questions, 

While there are many types of facilities in your state, this survey is only asking about [FILL TYPE] .

Yes

No

Associate Degree

Some College

Bachelor's Degree

Master's Degree

Doctorate/Ph.D.

M.D.

Special Certifications

OTHER (SPECIFY):

High School Diploma

SELECT ONE
46 State Regulation of Residential Facilities for Children with Mental Illness 

you may only choose one (by clicking on the circle beside your choice).

You may change your answer by clicking on a different answer.

Check All That Apply:

For this type of question, you will also see a hand when you move the mouse 

over the choices. To select the choices you’d like, click your mouse 

over the box next to your desired answer. Repeat for all your choices.

To change any answer, click again in the box already filled in. It will become blank again.

Assessing Data Quality

We recognize that some items may require you to estimate a number. For a limited number of 

items, we are asking you to indicate whether your answers are based on an estimate or on actual 

figures in an existing report or database. This will help SAMHSA evaluate the precision and 

accuracy of the data. Whenever possible, please use actual figures.

Physician

Psychologist

Nurse

OTHER (SPECIFY):

CHECK ALL THAT APPLY

Social Worker
State Regulation of Residential Facilities for Children with Mental Illness 47

A1.

ENTER NUMBER:

A2.

 TOTAL NUMBER OF BEDS:

A2_a.

ENTER PERCENT:

A3.

ENTER AVERAGE NUMBER OF RESIDENTS:

A4.

 GO TO A4_a

 GO TO A5

A4_a.

ENTER NUMBER OF BEDS:

A5. What is the usual age range of residents in these facilities?

ENTER AGE RANGE:

A6.

 GO TO A6_a

 GO TO A7

A6_a. What is the maximum length of stay for residents of these facilities?

ENTER NUMBER:

Of these beds, what percent were occupied as of September 30, 2003?

What was the average number of residents in a single facility of this type as of September 30, 2003?

Is there a law or regulation in the state that limits the number of beds in a single facility of this type?

What is the maximum number of beds allowed by law or regulation for a single facility of this 

type?

Is there a state law or regulation that specifies the maximum length of stay for residents in these facilities?

 A. FACILITY CHARACTERISTICS

We would like to start by asking some questions about the characteristics of [FILL TYPE] in your State.

How many of these facilities were licensed in your state as of September 30, 2003?

What were the total number of beds in operation in all of these facilities as of September 30, 2003?

Please indicate whether this figue is an 

estimate or is the result of record review.

Please indicate whether this figue is an 

estimate or is the result of record review.

Days Weeks Months Years

SELECT ONE

Yes

No

Yes

No

Estimate Record Review

Estimate Record Review
48 State Regulation of Residential Facilities for Children with Mental Illness 

A7. What is the average length of stay for residents of these facilities?

ENTER NUMBER:

A8. Is there a state law or regulation requiring minimum patient-to-staff ratios for these facilities?

 GO TO A8_a

 GO TO A9

A8_a. What are the minimum patient-to-staff ratios during daytime hours?

ENTER NUMBER OF PATIENTS PER STAFF MEMBER:

A8_b. What are the minimum patient-to-staff ratios during evening hours?

ENTER NUMBER OF PATIENTS PER STAFF MEMBER:

A8_c. What are the minimum patient-to-staff ratios during overnight hours?

ENTER NUMBER OF PATIENTS PER STAFF MEMBER:

A9. What percentage of these facilities are operated by...

0% MUST EQUAL 100%

A10.

at these facilities?

 GO TO A10_a

 GO TO A11

NOTE: A direct care worker is defined as an individual who provides active direct care, treatment, 

rehabilitation or habilitation services to clients.

Is there a state law or regulation requiring clinical supervision of direct care workers

State or Local Governmental Units

Not-for-Profit Organizations

For-Profit/Proprietary Organization

TOTAL

OTHER (SPECIFY):

Please indicate whether this figue is an 

estimate or is the result of record review.

Not Applicable

Not Applicable

Not Applicable

Days Weeks Months Years

SELECT ONE

Yes

No

Yes

No

Estimate Record Review
State Regulation of Residential Facilities for Children with Mental Illness 49

A10_a.

ENTER NUMBER OF HOURS PER MONTH:

A10_b.

A11.

 GO TO A11_a

 GO TO A12

A11_a. What is the minimum education required for facility directors?

A12.

 GO TO A12_a

 GO TO A13

A12_a.

ENTER NUMBER OF HOURS PER YEAR:

What is the minimum number of hours per month that direct care workers must be clinically 

supervised?

What is the minimum number of hours required per year?

Are facilities required to provide in-service or continuing education for direct care staff?

What type of individual is allowed to provide this clinical supervision?

Is there a state law or regulation that requires a minimum amount of education for facility directors?

Associate Degree

Some College

Bachelor's Degree

Master's Degree

Doctorate/Ph.D.

M.D.

Special Certifications

OTHER (SPECIFY):

High School Diploma

SELECT ONE

Physician

Psychologist

Nurse

OTHER (SPECIFY):

CHECK ALL THAT APPLY

Social Worker

Yes

No

Yes

No
50 State Regulation of Residential Facilities for Children with Mental Illness 

A12_b.

confidentiality issues; first aid training) be covered for all or most direct care staff?

 GO TO LIST BELOW

 GO TO A13

A13.

A14. Are these facilities allowed to have locked units?

 GO TO A14_a

 GO TO PART B

A14_a. What percent of these facilities have locked units?

GO TO PART B: LICENSING, CERTIFICATION, & ACCREDITING

Does state law or regulation require that specific topics (e.g., training on 

Please List Topics:

What agency or entity has the authority to hire and terminate facility directors?

Please indicate whether this figue is an 

estimate or is the result of record review

ENTER PERCENT OF FACILITIES

WITH LOCKED UNITS:

State Mental Health Agency

Local Mental Health Agency

Department of Health

Children and Family Services Agency

Social Services Agency

Board of Directors of Private Entities

No One

OTHER (SPECIFY):

CHECK ALL THAT APPLY

Senior Management in Private Entities

Yes

No

Yes

No

Estimate Records Review
State Regulation of Residential Facilities for Children with Mental Illness 51

Is this license...?

CHECK ALL THAT APPLY

Duration of Licensure 

Period (in years)

Duration of Licensure 

Period (in years)

Duration of Licensure 

Period (in years)

Duration of Licensure 

Period (in years)

 B. LICENSING, CERTIFICATION, AND ACCREDITATION

Duration of Licensure 

Period (in years)

Duration of Licensure 

Period (in years)

B1. LICENSURE

What is the duration of 

the licensure period?

The next questions are about licensure, certification, and accreditation requirements for [FILL TYPE] .

Which of the following agencies/departments license 

these facilities in your state?

CHECK ALL THAT APPLY

Required to Operate

Required to Receive Public Funding

Optional

State Mental Health Agency

Local (i.e., city or county) Mental Health Agency Required to Operate

Required to Receive Public Funding

Optional

Required to Operate

Required to Receive Public Funding

Optional

Department of Social Services

Required to Operate

Required to Receive Public Funding

Optional

Department of Children and Families

Department of Health Required to Operate

Required to Receive Public Funding

Optional

OTHER (SPECIFY): Required to Operate

Required to Receive Public Funding

Optional
52 State Regulation of Residential Facilities for Children with Mental Illness 

Is this certification...?

CHECK ALL THAT APPLY

B2. CERTIFICATION

CHECK ALL THAT APPLY

What is the duration of 

the certification 

period?

Duration of Certification 

Period (in years)

Which of the following agencies/departments certify 

these facilities in your state?

Duration of Certification 

Period (in years)

Duration of Certification 

Period (in years)

Duration of Certification 

Period (in years)

Duration of Certification 

Period (in years)

Duration of Certification 

Period (in years)

Required to Operate

Required to Receive Public Funding

Optional

State Mental Health Agency

Local Mental Health Agency Required to Operate

Required to Receive Public Funding

Optional

Required to Operate

Required to Receive Public Funding

Optional

Department of Social Services

Required to Operate

Required to Receive Public Funding

Optional

Department of Children and Families

Department of Health Required to Operate

Required to Receive Public Funding

Optional

OTHER (SPECIFY): Required to Operate

Required to Receive Public Funding

Optional
State Regulation of Residential Facilities for Children with Mental Illness 53

Is this Accreditation...?

CHECK ALL THAT APPLY

What is the duration of 

the accreditation 

period?

Duration of Accreditation 

Period (in years)

Duration of Accreditation 

Period (in years)

Duration of Accreditation 

Period (in years)

Duration of Accreditation 

Period (in years)

CHECK ALL THAT APPLY

 Organizations (JCAHO)

B3. ACCREDITATION

Which of the following entities accredit these facilities 

in your state?

 (CARF)

 (CACFS)

Duration of Accreditation 

Period (in years)

Required to Operate

Required to Receive Public Funding

Optional

Utilization Review Accreditation Commission (URAC)

Commission on Accreditation of Rehabilitation Facilities Required to Operate

Required to Receive Public Funding

Optional

Required to Operate

Required to Receive Public Funding

Optional

Joint Commission on Accreditation of Healthcare

Required to Operate

Required to Receive Public Funding

Optional

Council on Accreditation for Children and Family Services

OTHER (SPECIFY): Required to Operate

Required to Receive Public Funding

Optional
54 State Regulation of Residential Facilities for Children with Mental Illness 

On-Site State 

Inspection/

Visit

Record

Review

Resident

Interviews

B6.

 GO TO B6_a, then B6_b

 GO TO C1

B6_a. How many?

ENTER NUMBER:

B6_b. What were the reasons?

GO TO PART C: FACILITY PROGRAMS & TREATMENT SERVICES

License Renewal

Certification

Submission of 

Documentation

of Staff Training

Submission of 

Documentation of 

Staff

Qualifications

Re-Certification

Were any licenses for these facilities in your state revoked or suspended in 2002?

CHECK ALL THAT APPLY

Initial Licensure

B4. Is there a provisional license process for first-time applicants?

B5. What is required for initial licensure, license renewal, certification, and re-certification?

OTHER (SPECIFY)

Client Neglect

Unsafe conditions

Failure to report critical events

Lack of qualified staff

Fraud

OTHER (SPECIFY):

CHECK ALL THAT APPLY

Yes

No

Yes

No
State Regulation of Residential Facilities for Children with Mental Illness 55

C1.

 GO TO C1_a then C1_b

 GO TO C2

C1_a.

ENTER NUMBER:

C1_b.

C2.

 C. FACILITY PROGRAMS AND TREATMENT SERVICES

How often must the individualized treatment/service plans be updated?

In this section we'd like you to answer some questions about the services provided to residents and 

requirements governing service provision in [FILL TYPE] .

Is the client or parent/guardian required to provide written acknowledgement of the 

individualized treatment plan?

Which of the following services does the state require these facilities to provide, either by staff or 

through contractual arrangements?

Are these facilities required to develop individualized treatment/service plans for residents?

Days Weeks Months Years

PLEASE SPECIFY

Individual Counseling

Group Counseling

Family Counseling

Assistance with Activities of Daily Living

Financial Management Counseling

Vocational Training

Training in Activities of Daily Living

Education

Client Advocacy

Case Management

Dispensing of Medication

Medication Management

OTHER (SPECIFY):

OTHER (SPECIFY):

OTHER (SPECIFY):

CHECK ALL THAT APPLY

Occupational Therapy

Yes

No

Yes

No
56 State Regulation of Residential Facilities for Children with Mental Illness 

C3.

 GO TO C3_a

 GO TO C4

C3_a.

ENTER NUMBER:

C4.

GO TO PART D: FACILITY MONITORING & OVERSIGHT

Are these facilities required to provide any of the following services upon discharging residents?

Are these facilities required to provide a minimum number of service/treatment hours to residents?

What is the minimim number of service/treatment hours required per resident?

PLEASE SPECIFY

Days Weeks Months Years

CHECK ALL THAT APPLY

Comprehensive Discharge Plan

Followup Visit at Home/Other Residence

Followup Treatment or Aftercare Plan Post Discharge

Discharge Interview or Satisfaction Survey

OTHER (SPECIFY):

Discharge Medications or Specific Medication Plan

Yes

No
State Regulation of Residential Facilities for Children with Mental Illness 57

D1.

 GO TO D1_a then D1_b and D1_c

 GO TO D2

D1_a.

ENTER PERCENT: %

D1_b.

D1_c.

ENTER NUMBER:

D2.

 GO TO D2_a then D2_b and D2_c

 GO TO D3

D2_a.

ENTER PERCENT: %

The following questions involve procedures for monitoring and overseeing [FILL TYPE] .

D. FACILITY MONITORING AND OVERSIGHT

What percent of these facilities did the state make unannounced visits to in 2002?

Did the state make unannounced visits to any of these facilities in 2002?

What agency or agencies conducted these site visits?

What is the minimum required frequency of these visits per facility?

Did the state make announced visits to any of these facilities in 2002?

What percent of these facilities did the state make announced visits to in 2002?

Please indicate whether this figue is an estimate or 

is the result of record review

Please indicate whether this figue is an estimate or 

is the result of record review

Days Weeks Months Years

PLEASE SPECIFY

CHECK ALL THAT APPLY

State Mental Health Agency

Local (i.e., city or county) Mental Health Agency

Department of Social Services

Department of Children and Families

Department of Health

OTHER (SPECIFY):

No Frequency Rate Required

Yes

No

Yes

No

Estimate

Estimate Records Review

Records Review
58 State Regulation of Residential Facilities for Children with Mental Illness 

D2_b.

D2_c.

ENTER NUMBER:

D3.

D4.

 GO TO D4_a

 GO TO D5

D4_a. What types of adverse events or incidents must be reported?

Are these facilities required to report adverse events or incidents to the state?

What agency (or agencies) reviews complaints and/or grievances about these facilities?

What agency or agencies conducted these site visits?

What is the minimum required frequency of these visits per facility?

Days Weeks Months Years

PLEASE SPECIFY

CHECK ALL THAT APPLY

Deaths

Suicides

Suicide Attempts

Hospitalization of a Resident

Allegations of Abuse or Neglect

Other Critical Incidents:

CHECK ALL THAT APPLY

State Mental Health Agency

Local (i.e., city or county) Mental Health Agency

Department of Social Services

Department of Children and Families

Department of Health

OTHER (SPECIFY):

CHECK ALL THAT APPLY

State Mental Health Agency

Local (i.e., city or county) Mental Health Agency

Department of Social Services

Department of Children and Families

Department of Health

OTHER (SPECIFY):

No Frequency Rate Required

Yes

No
State Regulation of Residential Facilities for Children with Mental Illness 59

D5.

 GO TO D5_a



D5_a.

GO TO PART E: FINANCING

Is there a court order in effect that is influencing any monitoring or oversight procedures for these 

facilities?

GO TO PART E

Please describe the nature of any court orders in place.

Yes

No
60 State Regulation of Residential Facilities for Children with Mental Illness 

These questions involve financing of services in [FILL TYPE] .

E1.

E. FINANCING

Private 3rd Party Payments

Self Pay

OTHER (SPECIFY):

SSI Payments

For a typical facility, where does financial support come from? Check all the apply.

Medicaid

State/Local Mental Health Agency Funds

State/Local Family/Child Service Agency Funds

State Welfare Agency

OTHER (SPECIFY):

Juvenile Justice

OTHER (SPECIFY):

SSDI Payments

State Supplemental Payments (SSP)

Federal Grants

Department of Education

Department of Defense

Private Grants
State Regulation of Residential Facilities for Children with Mental Illness 61

E2.

 GO TO E2_a

 GO TO E3

E2_a.

ENTER THE RANGE: to

E3.

OR

Please indicate whether this figue is an 

estimate or is the result of record review.

MAIL IT TO [RESEARCHER] AT 600 MARYLAND AVE., SW STE. 550, WASHINGTON, DC 20024

PLEASE EMAIL IT TO [RESEARCHER] AT [EMAIL] .

THANK YOU FOR TAKING THE TIME TO COMPLETE THIS SURVEY.

For a typical facility of this type, what is the Medicaid per diem for treatment services?

ENTER AVERAGE DAILY RATE:

What is the range?

For these facilities, are there different per diem rates for treatment services applied to different groups of 

Medicaid patients (for example, a group of residents with more severe problems might be charged a 

higher rate)?

Yes

No

Estimate Record Review




DHHS Publication Number (SMA) 06-4167

Printed 2006