United States Government Accountability Office

GAO Testimony 

Before the Committee on Education and 

Labor, House of Representatives

RESIDENTIAL FACILITIES

State and Federal Oversight 

Gaps May Increase Risk to 

Youth Well-Being 

Statement of Kay E. Brown, Director 

Education, Workforce, and Income Security Issues 

For Release on Delivery

Expected at 10:00 a.m. EDT 

Thursday, April 24, 2008

 

GAO-08-696T 
What GAO Found

United States Government Accountability Office

Why GAO Did This Study

Highlights

Accountability Integrity Reliability

April 24, 2008

RESIDENTIAL FACILITIES

State and Federal Oversight Gaps May Increase Risk 

to Youth Well-Being

Highlights of GAO-08-696T, a report to the 

Committee on Education and Labor, 

House of Representatives

Nationwide, federal funding to 

states supported more than 200,000

youth in facilities seeking help for 

behavioral or emotional challenges

in 2004. Recent federal reviews 

and investigations highlighted

maltreatment in some facilities, 

resulting in hospitalizations and 

deaths. This testimony discusses 

(1) what is known about incidents

that adversely affect youth wellbeing in residential facilities, (2) 

the extent that state oversight 

ensures youth well-being in these 

facilities, and (3) the factors that

affect the ability of federal agencies

to hold states accountable for 

youth well-being in residential 

facilities. This testimony is based 

on GAO’s ongoing work, which 

included national surveys to state 

agencies of child welfare, health

and mental health, and juvenile 

justice for the year 2006. GAO

achieved an 85 percent response 

rate for each of the three surveys. 

The work also included site visits 

to four states (California, Florida, 

Maryland, and Utah) and 

discussions with the Departments 

of Education (Education), Justice 

(DOJ), and Health and Human

Services (HHS). Interim work 

related to this testimony was 

completed between November

2006 and March 2008, in 

accordance with generally

accepted government auditing

standards. 

What GAO Recommends

GAO recommendations will be 

included in its final report upon

completion of ongoing work. 

Survey respondents from 49 states reported investigating complaints of youth 

maltreatment in residential facilities in 2006, including physical abuse, neglect, 

and sexual abuse, and 28 states reported deaths. There were no discernable 

patterns in the types of facilities involved, including whether facilities were

operated by government or private entities, or located in urban or rural areas.

State officials said that the number of maltreatment incidents was greater than the

total reported to HHS—1,503 incidents in 2005--due to barriers in data collection 

and reporting, including inconsistent funding and authority. 

States license and monitor residential facilities, but state agencies reported

oversight gaps that may place youth in some facilities at higher risk for 

maltreatment and death. Some types of facilities are exempt from state licensing 

requirements—primarily state operated juvenile justice facilities and private 

residential schools and academies. Licensing standards did not always address 

suicide prevention and other common risks. State agencies reported an inability

to conduct yearly on-site visits to facilities because of fluctuating levels of staff 

resources dedicated by states, and infrequently sharing negative findings from

their oversight results.

Aspects of Well-Being Monitored by State Agencies in Private Residential Facilities That

Served Youth and Received Government Funding

Note: Other agency responses included no such facility in state, don’t know, and no response. 

HHS, DOJ, and Education hold states accountable for youth well-being, but 

federal efforts are hindered by the scope of the agencies’ oversight authority and 

practices. Most notably, these agencies do not have the authority to hold states 

accountable for youth in private residential facilities unless they serve youth in 

state programs that receive federal funds. For facilities that were under federal 

purview, federal requirements did not always address the identified risks to

youth—including such risks as suicide and inappropriate use of seclusion and 

restraint—and program requirements were inconsistent. In monitoring state 

compliance, federal agencies did not always include residential facilities in their 

oversight reviews.

To view the full product, including the scope 

and methodology, click on GAO-08-696T. For 

more information, contact Kay E. Brown (202) 

512-7215 or brownke@gao.gov.
Residential Facilities

Mr. Chairman and Members of the Committee: 

Thank you for inviting me here today to discuss our ongoing work 

reviewing how state and federal agencies protect the well-being of youth 

in residential facilities who are receiving services for their behavioral or 

emotional challenges. Nationwide, federal funding to states supported 

more than 200,000 youth in government or private facilities in 2004. In 

addition, an unknown number of youth are placed in facilities by parents 

or others. These facilities include boarding schools and academies, boot 

camps, and wilderness camps. Overall, residential facilities play an 

important role in serving youth who cannot be safely served in their 

communities while living at home, due to risk of running away or harm to 

themselves or others. However, recent federal reviews highlighted youth

fatalities in residential facilities due to neglect or maltreatment, and 

ongoing federal investigations continue to document incidents of abuse 

and neglect in some facilities for youth that in some cases have been 

severe enough to result in hospitalization or death. 

As you know, states are primarily responsible for ensuring the well-being 

of youth in facilities and other settings, and do so by setting their own 

standards of care certain facilities must meet to obtain and maintain an 

operating license. Federal agencies also set requirements for youth wellbeing that states agree to uphold in exchange for receiving federal 

program funds, such as those administered by the Department of Health 

and Human Services (HHS) to support state systems of care for child 

welfare, mental health, and substance abuse; the Department of Justice 

(DOJ), for state juvenile justice systems; and the Department of Education 

(Education), for state education systems. Further, if patterns of 

maltreatment are identified and found to violate the civil rights of youth in

certain facilities that are operated or substantially sponsored by state and

local governments, the federal Civil Rights of Institutionalized Persons Act 

(CRIPA) authorizes the Attorney General of the United States to conduct

investigations and bring actions against state and local governments. 

However, under the current regulatory framework, federal oversight 

authority does not extend to private facilities that serve only youth placed 

and funded by parents or other private entities. In some states, 

safeguarding youth in these facilities is the primary responsibility of 

parents and facility staff. 

My remarks today will focus on the following issues with regard to youth

well-being in residential facilities in terms of 

Page 1 GAO-08-696T
Residential Facilities

(1) what is known about the incidents that adversely affect the well-being 

of youth in residential facilities, 

(2) the extent that state oversight ensures the well-being of youth in 

residential facilities, and 

(3) the factors that affect the ability of federal agencies to hold states 

accountable for youth well-being in residential facilities. 

This testimony was developed using multiple methodologies, and was 

limited to residential facilities we defined as those that require youth—

ages 12 through 17—to reside at the facility and that provide program 

services1

 for youth with behavioral and emotional challenges. We surveyed 

three state agencies—child welfare, health and mental health, and juvenile 

justice2

—about residential facilities that were government operated, 

privately operated that received government funds, and privately operated 

with no government funding. To further our understanding, we visited four 

states—California, Florida, Maryland, and Utah—and interviewed relevant 

officials. These states were selected based on the diversity of their state 

licensing and monitoring policies for residential programs, reports of child 

maltreatment, and geographic location. The scope of our work did not 

include the quality of services provided at residential facilities. We also 

obtained data from HHS’s National Child Abuse and Neglect Data System 

(NCANDS); reviewed federal statutes, regulations, and guidance; and 

interviewed HHS, DOJ, and Education officials, as well as national 

association representatives and other experts on residential facilities for 

youth. The scope of our work did not include the quality of services 

provided at residential facilities. We performed our work between 

November 2006 and March 2008, in accordance with generally accepted 

government auditing standards. 

 1

Our review included facilities that provided one or more of the following types of 

programs: juvenile justice, youth offender, juvenile delinquency, and incorrigibility 

programs; treatment programs for youth with behavioral, emotional, mental health, and

substance abuse issues; homes for pregnant teens; schools for discipline or character 

education; and therapeutic group homes, such as a home that specializes in supporting and 

treating youth with severe emotional disorders. 

2

In this report, we use the term states to refer collectively to the 50 states plus the District 

of Columbia and Puerto Rico. We did not survey state education agencies because they 

generally do not license residential facilities for youth.

Page 2 GAO-08-696T
• Youth maltreatment and death occurred in government and private 

residential facilities across the nation, according to states we surveyed; 

however, data limitations hinder efforts to quantify the full extent of the 

problem. State-reported data collected by HHS in 2005 showed 1,503 

incidents of maltreatment by facility staff in 34 states, including physical

abuse, neglect or deprivation of necessities, and sexual abuse. Moreover, 

28 states responding to our survey reported at least one death in 

residential facilities in 2006, with accidents and suicides among the most 

common types of fatalities. These reported data, however, did not capture

information from all facilities. Many states lack authority under state law 

to collect data on exclusively private facilities, and data that states did 

report were often incomplete. As a result, the number of adverse incidents 

was likely more numerous and widespread than reported. 

In summary 

• All states have processes in place to license and monitor certain 

residential facilities, but states reported oversight gaps that may place 

youth in some facilities at higher risk for maltreatment and death. Most 

notably, state agencies exempted some types of government and private 

facilities from licensing requirements altogether, primarily juvenile justice 

facilities and private schools and academies. In addition, licensing 

standards do not always address suicide and other common risks to youth 

well-being. Although monitoring is key to ensuring facility compliance 

with standards, agencies in states we visited reported an inability to 

conduct yearly on-site reviews of conditions at each facility, because of 

fluctuating levels of staff resources committed by the state. Similarly, 

although information sharing can strengthen oversight for facilities shared 

by multiple agencies, many state agencies reported that they did not 

routinely share information with other state agencies about negative 

findings or when facility licenses were suspended or revoked. 

• HHS, DOJ, and Education all have processes to hold states accountable for 

the well-being of youth, but federal efforts are hindered by the scope of 

the agencies’ oversight authority and monitoring practices. Most notably, 

these agencies do not have the authority to hold states accountable for 

youth well-being in private residential facilities unless they serve youth in 

state programs that receive federal funds. For facilities under federal 

purview, federal requirements did not always address the primary risks to 

youth well-being, such as suicide, and requirements were inconsistent 

among programs. In monitoring state compliance, federal agencies did not 

always include residential facilities in their oversight reviews. 

Page 3 GAO-08-696T Residential Facilities
Nearly all states (49) responding to our survey reported investigating 

complaints of youth maltreatment in residential facilities in 2006, including

facilities operated by government as well as private entities, and located in 

both urban or rural areas. The types of maltreatment reported by states 

included physical abuse, neglect or deprivation of necessities, and sexual

abuse that sometimes resulted in hospitalization or death. State reported 

data to NCANDS from 2005 showed that 34 states reported 1,503 incidents 

of youth maltreatment by facility staff. Of these incidents, neglect or 

deprivation of necessities was the most frequent cause of youth 

maltreatment, followed by physical abuse, as shown in figure 1. 

Figure 1: Percentage of State-Reported Incidents of Youth Maltreatment by

Residential Facility Staff, Fiscal Year 2005 

a

”Other” incidents of youth maltreatment states reported to NCANDS include medical neglect and 

psychological or emotional maltreatment. 

Of the states we surveyed, 28 reported that at least one youth had died in a 

residential facility in 2006. These deaths were primarily due to accidents 

and suicide, but also due to homicide and application of seclusion and 

restraint (see fig. 2). 

Youth Maltreatment 

Occurred in Facilities 

Across the Nation, but 

Data Are Limited and 

Not Used to Target 

Federal Civil Rights 

Investigations 

0 10 20 30 40 50

Othera

Sexual abuse

Neglect or

deprivation of necessities

Physical abuse

Type of maltreatment

Percentage of state reported incidents

Source: NCANDS.

24

9

23

44

Page 4 GAO-08-696T Residential Facilities
Residential Facilities

Figure 2: Number of States That Reported Specific Causes of Youth Fatalities in

Residential Facilities, 2006 

Notes: 

The survey question was as follows: Of the total youth deaths that you reported, how many died from 

each of the following causes: (a) suicide, (b) homicide, (c) application of seclusion and restraint 

techniques, (d) medically related accident, (e) accident that occurred while in a runaway or absence

without leave status, (f) other accidental cause, and (g) other causes? 

Other causes of youth fatalities in residential facilities include natural causes, choking, and internal 

bleeding. 

Overall, officials from the states we visited said that the number of 

maltreatment incidents and deaths was greater than reported due to 

barriers in collecting and maintaining data. When available, 

comprehensive reporting of incident data can be used by state and federal 

agencies to assess the extent of maltreatment in residential facilities, 

inform risk assessments, target oversight resources, and develop policies 

to address trends. However, the lack of authority under state law hinders 

many states from collecting data on certain facilities—such as exclusively 

private facilities—and expanding oversight to cover them. In addition, 

states that have such authority reported difficulties sustaining data 

collection in times of budget shortages. National data in NCANDS for 

0 2 4 6 8 10 12 14 16 18

Did not know

Application of seclusion

 or restratint techniques

Medically related accident

Homicide

Other cause (specify)

Suicide

Accidental causes

Causes of youth fatalities

Number of states

Source: GAO analysis of state agency responses to survey.

16

9

9

3

3

2

4

Page 5 GAO-08-696T
Residential Facilities

2005—derived from state reports—suffers from these same limitations, as 

well as others. First, some states did not report data for residential 

facilities to NCANDS,3

 so the data may understate the number of 

maltreatments and fatalities. Second, many states (37) did not consistently 

identify whether the individual maltreating youth was facility staff, a 

parent, or other individual. Last, NCANDS only tracked fatalities resulting 

from maltreatment, not suicide or accidents that may be an indicator of 

neglect or other problem that needs resolution. 

In the states we visited, youth maltreatment in facilities was attributed to 

several factors—such as a lack of experienced staff, insufficient staff 

training, or lack of appropriate supervision—particularly in smaller 

facilities. For example, county officials in one state told us that adverse 

incidents were most likely to occur in contractor operated six-bed group 

homes—frequently used by state probation and child welfare agencies—

where the state reimbursement rate is generally not high enough to hire 

skilled personnel and provide staff with ongoing training, support, and 

oversight. 

However, while in most facilities youth maltreatment may occur 

infrequently as a result of isolated circumstances, investigations of 

government and private facilities serving youth conducted under DOJ’s 

Civil Rights Division (Division) have found a pattern or practice of civil 

rights violations in some facilities, including physical and sexual abuse, 

medical neglect, and inadequate education. At the end of fiscal year 2006, 

the latest year for which data were available, federal investigators 

reported active cases involving over 175 facilities in 34 states. 4 Annual 

reports from DOJ over the past several years have documented their 

findings of youth maltreatment in certain juvenile justice or mental health

facilities: 

Physical and sexual abuse occurred without management intervention. In 

one facility, staff hit youth and slammed them to the ground. Staff hog-tied 

and shackled youth to poles in public places, and girls were forced to eat

 3

In fiscal year 2005, 10 states did not submit reports showing the number of fatalities in 

residential facilities, 2 states did not submit a report, 7 states did not track facility incident 

data in a format that could be shared with NCANDS, and 1 state involved in litigation did 

not report facility data. 

4

For additional information see U.S. Department of Justice Department of Justice 

Activities Under the Civil Rights for Institutionalized Persons Act, Fiscal Year 2006, 

U.S. Department of Justice (Washington, D.C.: 2007). 

Page 6 GAO-08-696T
Residential Facilities

their own vomit if they threw up while exercising in the hot sun. Staff 

routinely broke and wired shut the jaws of youth who showed disrespect 

in another facility. In some facilities, staff engaged in sexual acts with 

boys. Youth-on-youth violence occurred on an almost daily basis in some 

facilities, at times resulting in injuries that required hospitalization. Youth 

were sexually assaulted and threatened with sexual assault by other youth

in some facilities, all without effective intervention from management. 

Severe neglect resulted in poor education, suffering, and death. In a 1-year 

period at one facility, three boys committed suicide. In one suicide, staff 

lacked the appropriate tool to cut the noose from a victim’s neck and also

did not have oxygen in the tank they brought to help resuscitate him. The 

dental clinic at one facility was full of mouse droppings, dead roaches, and 

cobwebs; medications in the cabinet had expired over 10 years ago. In a

state-operated mental health facility used by adolescents, older 

psychotropic medications, with serious side effects, were administered to 

sedate patients. One adolescent received 22 such psychotropic sedatives 

over a 2-month period. In another facility, youth were not provided with 

special education services as required by federal law. 

The Special Litigation Section of DOJ’s Civil Rights Division receives more 

credible allegations of violations of youth rights than it can investigate.

During fiscal year 2006 alone, the Division received approximately 5,000

citizen letters; hundreds of telephone complaints, and 135 inquiries from 

Congress and the White House. Division officials stated that with 

additional sources of information, they could better target their scarce 

investigative resources. Officials said that receiving more detailed 

information from NCANDS on the incidents of maltreatment and death

occurring in specific facilities would be helpful, as would the results of 

federal agency monitoring reviews of states that highlight findings related 

to residential facilities. Except in one instance,5

 officials said that no 

federal agencies—including HHS, Education, and DOJ’s Office of Juvenile

Justice and Delinquency Prevention (OJJDP)—were coordinating with the

Division to provide pertinent oversight results. 

 5

According to DOJ officials, the Civil Rights Division has been granted access to HHS’s

Centers for Medicare and Medicaid Services (CMS) database that contains the annual 

survey results for CMS oversight of residential facilities. 

Page 7 GAO-08-696T
Residential Facilities

All states have processes in place to license and monitor certain 

residential facilities, but our survey identified several gaps that allow some 

of the common causes of youth maltreatment and death to go 

unaddressed. These gaps include the fact that some types of government 

and private facilities are exempt from licensing requirements, licensing 

standards do not always address the primary causes of youth 

maltreatment and death, and state agencies inconsistently monitor and 

enforce facility compliance and share their monitoring results. 

Licensing all facilities in a state—government or private facilities—can 

help ensure that residential facilities meet relevant state standards. Among 

state-operated facilities, however, more than half (28) of juvenile justice 

agencies reported exempting facilities from licensing.6

 In addition, many 

state agencies reported that certain types of private facilities were also 

exempt from licensing, regardless of whether they received some 

government funding or were exclusively private. Private residential 

schools and academies—a category that includes boarding schools and 

training or reform schools—were exempted more often from licensing 

than other types of private facilities, according to survey respondents. 

Conversely, treatment facilities were the type most commonly required to 

have a license. Agencies in six states reported they exempted faith-based 

facilities from licensure.7

 In addition, many agencies reported not knowing 

the licensing status of certain types of private facilities or reported that 

Gaps in State 

Oversight of 

Residential Facilities 

May Place Well-being 

of Some Youth at Risk 

Certain Facilities Are 

Exempt from State 

Licensing Requirements 

 6

The survey question was as follows: Which, if any, of the following types of government

operated facilities providing residential targeted (child welfare, health mental health, 

juvenile justice) services for youth are currently exempt from licensing or monitoring in 

your state by statute or state regulations—state operated facilities? Response options were 

(a) exempt from licensing by our agency, (b) exempt from routine monitoring by our 

agency, (c) exempt from both, (d) not exempt from either, (e) no such facility in state, (f) 

don’t know, and (g) no response. 

7

These six states are Arizona, Arkansas, Iowa, Maine, Missouri, and South Carolina. In 

addition, licensing officials we interviewed in Florida stated that faith-based facilities had 

the option of being licensed by the state or by a faith-based licensing authority. The survey

question was as follows: Which, if any, of the following types of private facilities providing 

residential targeted services for youth are currently exempt from licensing or routine

monitoring in your state by statute or state regulation: Faith-based facilities? (a) exempt 

from licensure by our agency, (b) exempt from routine monitoring by our agency, (c)

exempt from both, (d) not exempt from either, (e) no such facility in state, (f) don’t know, 

and (g) no response. 

Page 8 GAO-08-696T
Residential Facilities

they did not have certain types of facilities in their state.8 Some states are 

considering laws that would expand their licensing authority for private 

facilities. 

One reason that private residential facilities may be exempt from licensing 

requirements is that state agencies do not have the necessary statutory or

regulatory authority. Regarding residential schools and academies, for 

example, all agencies in 15 of the 33 states that responded to all three 

agency surveys reported that they did not have either the authority or the

regulatory responsibility to license these facilities.9

The lack of licensing for all facilities serving youth has several 

consequences, in that there are no commonly accepted definitions of 

facility types. Within individual states, facility operators may bypass state 

licensing requirements by self-identifying their business as a type that is 

exempt from state licensing. In Texas, for example, a residential program 

self-identified as a private boarding school is not regulated by the state 

licensing agency, but the same facility would require a license if it selfidentified as a residential treatment center or therapeutic camp. 

Inconsistent licensing practices across states can have implications as 

well. For example, a 2007 directory showed that Utah, which only recently 

implemented licensing requirements covering wilderness camps, was 

home to over 25 percent of registered wilderness programs in the United 

States. 

Facility licensing is also important because parents and others considering 

placing youth in private facilities at their own expense do not always have 

the information they need to screen facilities and make an informed 

decision. In our testimony on private facilities last October,10 we described 

cases in which program leaders told parents their programs could provide 

 8

Across agencies, states most often responded that they did not have private boot camps, 

ranches, and wilderness camps. Among state juvenile justice agencies, for example, 25

reported having no private boot camps in their state that received government funding, 22

reported having no ranches, and 17 reported having no wilderness camps. Somewhat fewer 

states reported not having exclusively private boot camps (19), ranches (17), and

wilderness camps (14). 

9

Two of the 15 states—Massachusetts and Utah—have a central agency that is responsible 

for licensing residential facilities. While we did not receive all three surveys from Texas, it 

also exempts residential schools and academies from licensing. 

10GAO, Residential Treatment Programs: Concerns regarding Abuse and Death in

Certain Programs for Troubled Youth GAO-08-146T (Washington, D.C.: October 10, 2007) 

Page 9 GAO-08-696T
Residential Facilities

services that they were not qualified to offer, claimed to have credentials 

in therapy or medicine that they did not have, and led parents to trust 

them with youth who had serious mental disabilities. One national 

association for programs serving youth with behavioral and emotional 

difficulties testified before Congress that state licensing was important 

because the field does not currently have the capacity to certify facility 

integrity. 

Some states are considering laws that would expand their licensing 

authority for private facilities, while some use other methods to provide 

protections for youth. For example, Florida, among other states, includes 

requirements addressing youth well-being in contracts facilities must sign

to serve youth under state care. Florida officials estimated that 85 percent 

of residential facilities in the state’s juvenile justice system are private 

facilities under contract with the state. The agency uses the contract 

provisions to help ensure that facilities provide youth with needed 

services in compliance with agency regulations as well as state statutes.

Accreditation is another method used by some states in lieu of, or to 

augment, state licensing requirements. For example, Ohio and Wyoming 

require specific health-related facilities to obtain accreditation instead of 

licensure as a condition to serving youth under state care. Of the states 

responding to our survey, a greater number of health and mental health

agencies reported requiring facilities to be accredited by private 

organizations, due in part to conditions of participation for certain federal

programs.11 The accreditation process may require providers to meet 

higher standards than those required by state licensing bodies; however, 

accreditation does not necessarily ensure the safety and well-being of 

youth. Officials from an accrediting organization told us that they do not 

always inform the state if a facility’s accreditation status has been 

suspended or limited. In general, fewer states reported requiring 

accreditation than not across the three agencies we surveyed. 

 11For example, HHS’s Medicaid program, a federal-state health insurance program for lowincome and other specific populations, requires that providers of certain health or mental 

health services obtain accreditation from an approved accrediting organization to certify

that the facility meets standards for safety, quality of care, treatment, and services. 

Page 10 GAO-08-696T
Our survey results showed that the licensing standards that states have in 

place for certain government and private residential facilities address 

many, but not all, of the most common risks to youth well-being that states 

had identified in our survey. The extent that state licensing standards 

cover the various aspects of youth well-being is important to safeguard 

youth from harm. Almost all states reported that when they required 

licensing, they required facilities to meet standards related to the safety of 

the physical plant, proper use of seclusion and restraint techniques, 

reporting of adverse incidents, and qualification requirements and 

background checks for staff.12 These standards can help reduce the risk of 

harm due to accidental causes and staff maltreatment. However, other 

requirements addressing risks to youth are less often included as a part of 

licensing. For example, while states reported that almost all juvenile 

justice facilities are required to have written suicide prevention plans, 

about a third of state child welfare and health and mental health agencies 

reported that they do not have similar requirements for government 

facilities. In addition, most of the agencies in our survey did not require 

private facilities to have written suicide prevention plans. 

State agencies reported monitoring youth well-being in residential 

facilities, but survey results showed that certain aspects of youth wellbeing were not included in all monitoring activities, as shown in figure 3. 

Periodic on-site reviews to monitor and enforce facility compliance help 

ensure that licensing standards are taken seriously and that risks to youth 

well-being are quickly addressed. Among six different aspects of youth 

well-being we asked about in our survey, the quality of educational 

programming and the use of psychotropic medications were most likely to 

be reviewed at only some or none of the facilities monitored by child 

welfare, health and mental health, and juvenile justice agencies. 

Conversely, staffing issues were most often included in all monitoring 

reviews of government and private facilities. 

State Licensing Standards 

Do Not Address Some 

Primary Risks to Youth 

Well-being 

State Practices 

Inconsistent in Monitoring 

and Enforcing Facility 

Compliance 

 12Note: the survey question was as follows: When your agency develops or opens a 

government-operated residential facility that provides targeted services to youth, is the

facility required to meet state standards in any of the following areas? (a) pass inspection 

of physical plant, (b) provide evidence of safe child care practices, (c) have written 

procedures for reporting physical or sexual abuse or neglect of youth, (d) meet all staff 

qualifications requirements, including training, (e) perform staff background checks, (f) 

meet specified staff-to-child ratios (g) provide evidence of appropriate educational 

programming, (h) have procedures in place for use of approved seclusion and restraint

techniques, and (i) have written suicide prevention plans. A similar question was asked for 

private facilities. 

Page 11 GAO-08-696T Residential Facilities
Residential Facilities

Fig. 3: Aspects of Well-Being Monitored by State Agencies in Private Residential Facilities That Served Youth and Received 

Government Funding 

Note: The survey question was as follows: In 2006, did your agency routinely monitor or follow-up, or

authorize for monitoring or follow-up, any of the following issues—in the absence of a complaint—at 

private residential facilities that received government funding providing targeted services for youth? 

Response options for this question were: (a) yes, monitored for all; (b) yes, monitored for some; (c) 

no, did not monitor; (d) no such facility in the state; (e) don’t know; (f) no response. 

In addition, three of the four states we visited reported that they were 

unable to meet their goals for conducting annual monitoring visits at 

residential facilities due to a lack of resources. States reported that visiting 

Page 12 GAO-08-696T
Residential Facilities

facilities was necessary at least once a year, if not more often, to ensure 

that conditions for youth had not changed due to changes in personnel, 

ownership, or funding. However, the number of facilities visited each year 

depended on the fluctuating levels of resources committed by the state. In

Maryland, agency officials said that state resources were redirected, as 

necessary, to meet state goals for monitoring residential facilities for 

youth. In Florida and Utah, however, agency officials said that imbalances 

between the current workload and staff resources constrained the state’s 

capacity to conduct efficient, effective, and timely monitoring of 

residential facilities. A facility operator in California said that on-site 

monitoring had been as infrequent as once every 5 years. 

State agencies reported taking actions against facilities with identified 

problems in the last 3 years, but few reported suspending or revoking a 

facility’s operating license. Options used included increased monitoring or 

requiring corrective action plans. Maryland state officials said that they

may be less likely to close facilities when they fall below state standards if 

there is a shortage of facilities in the state and closing the facility would 

limit the state’s ability to serve the youth who would be displaced by a 

closing. In addition, these officials noted that shutting down a facility is 

extremely disruptive to the youth who are placed there. 

State Agencies Reported a 

Lack of Coordination to 

Share Oversight Results 

Many state agencies reported that they did not routinely share information 

with others regarding negative findings from their monitoring reviews. 

State agency coordination to share monitoring results can strengthen 

oversight in situations where facilities are used by multiple agencies and 

can help ensure that youth are not placed in facilities that another agency 

has already identified as having problems. However, one or more state 

agencies reported that they did not routinely share reports of adverse 

incidents (17) or when facility licenses had been suspended or revoked 

(12). 

Improving coordination among agencies across states is also important 

because almost all states reported in our survey that they placed some 

youth in out-of-state residential facilities. For example, child welfare 

agencies in the top 5 states reported placing over 3,500 youth in at least 26

states. Out-of-state placement can be difficult to manage, but may be used

when the demand for services exceeds the state’s capacity, particularly for 

cases requiring highly specialized services—such as therapeutic treatment 

for youth who committed arson, or who were involved in gangs. State 

agencies or parents may also place youth in other states where family 

members reside. Interstate coordination is important is to ensure that 

Page 13 GAO-08-696T
Residential Facilities

agencies sending youth for placement in other states are able to screen out

facilities that have had negative findings uncovered during monitoring 

reviews or have outstanding allegations of maltreatment. Information 

sharing about adverse conditions in facilities may be particularly 

important in cases where state licenses cannot serve to help in making 

appropriate placement decisions. Four of the top five states that received

the greatest number of out-of-state placements—according to child 

welfare agencies we surveyed—exempted one or more types of facilities 

from state licensing requirements. 

HHS, DOJ, and Education hold states accountable for youth well-being in

certain residential facilities, but their scope of authority is limited, and 

gaps in agency oversight practices result in inconsistent protections for 

youth. Most notably, these agencies can hold states accountable for 

conditions in facilities that serve youth through programs supported by 

federal funds13—whether government or private—but cannot hold states 

accountable for conditions in facilities that are exclusively private. When 

federal agencies do have oversight authority under certain federal 

programs, however, they do not always hold states accountable for 

addressing some of the primary risks to youth well-being. For example, in 

comparing requirements across HHS, DOJ, and Education, only HHS 

reported requiring states to address abuse and neglect prevention under 

certain federal programs. (See table 1.) 

Federal Agencies 

Challenged to 

Address Weaknesses 

in State Oversight of 

Residential Facilities 

 13 This derives from Congress’ powers under Article I, Section 8 of the U.S. Constitution 

and provisions of federal law establishing conditions for state grants. Congress, as part of 

its spending power, can attach conditions to states’ receipt of federal funds. 

Page 14 GAO-08-696T
Residential Facilities

Table 1: Federal Program Requirements for States that Address Certain Risks to

Youth Well-being in Residential Facilities 

Agency and program area 

Abuse and 

neglect

prevention

Suicide 

prevention

Use of

seclusion

and 

restraint 

Education 

quality

HHS 

Child welfare Yes No No Yes 

Medicaid Yes Yes YesaNo

Substance abuse and mental health Yes No No No 

DOJ 

Juvenile justice and delinquency 

prevention 

No No No No

Education 

Elementary and secondary education No No No Yesb

Special education and rehabilitative 

services 

No No No Yesb

Source: Analysis of HHS, DOJ, and Education documents. 

a

Applies only to psychiatric residential treatment facilities. 

b

Applies only to public agencies and children placed by public agencies in private facilities.

Federal program requirements are limited even for risks such as suicide, a 

problem documented by several federal agencies. For example, the 

Centers for Disease Control and Prevention (CDC)—which is part of 

HHS—have identified suicide as the third leading cause of death in 2004 

among all U.S. youth,14 and suicide was one of the leading causes of death 

among youth in residential facilities, as reported by states in this study. In 

addition, a study commissioned by DOJ recommends increased mental 

health screening for suicide prevention among incarcerated youth.15 DOJ 

officials we spoke with generally agreed with the need to focus on suicide 

prevention in residential facilities, and suggested that additional federal

requirements in this area would be helpful. DOJ and HHS have Web sites

that list resources states can use for this purpose, but HHS officials said 

 14For additional information, see Department of Health and Human Services’ Centers for 

Disease Control Morbidity and Mortality Weekly Report on Suicide Trends Among Youths

and Young Adults, aged 10-24 years—United States, 1990--2004.

15National Center on Institutions and Alternatives. Juvenile Suicide in Confinement: A

National Survey. February 2004. 

Page 15 GAO-08-696T
Residential Facilities

that states are more responsive to a requirement or more specific agency

guidance. 

Similarly, federal programs also do not generally require that states ensure 

the proper use of seclusion and restraint practices, which have come 

under intense scrutiny in recent years. Researchers and clinicians have 

chronicled the inherent physical and psychological risks in each use of 

these types of interventions—-including death, disabling physical injuries,

and significant trauma. Currently, federal seclusion and restraint 

requirements cover youth placed in psychiatric residential treatment 

facilities that receive Medicaid payments. However, requirements do not 

extend to other types of facilities, and federal officials told us that these 

techniques continue to be used in ways that sometimes cause injury and 

death. HHS is preparing a draft notice of proposed rulemaking concerning

the use of seclusion and restraint in non-medical community-based 

children’s facilities.16

Federal agencies have several means of oversight for youth well-being, but 

perhaps one of the most rigorous is unannounced site visits to the youth’s 

place of residence. According to the federal and state officials we spoke 

with, only an on-site visit to the facility can reveal whether services in the

administrative reports are provided under conditions that ensure youth 

well-being. For example, DOJ officials observed that students in one of the 

facilities they visited received their educational instruction while in cages, 

and reported that it would have been difficult to detect this practice in an

administrative review. 

Among the federal agencies we reviewed, all included visits to states to 

ensure compliance with federal requirements, but agencies did not always

include visits to residential facilities. DOJ officials target juvenile justice 

facilities, such as correctional facilities and detention centers, during onsite reviews, but HHS officials do not necessarily include residential 

facilities in their oversight reviews of state child welfare systems. HHS 

 16This draft notice has been submitted for departmental review and clearance. This rule is 

being promulgated in response to the Children’s Health Act of 2000 (Pub. L. No. 106-310, tit. 

XXXII, §3208) (amending Title V of the Public Health Service Act)), which requires that 

public or private non-medical, community-based facilities for children receiving support in 

any form from any program supported, in whole or part, with funds appropriated under the 

Children’s Health Act, shall protect and promote the rights of each resident of a facility, 

including the right to be free from any restraint or involuntary seclusion imposed for 

purposes of discipline or convenience. The statute requires HHS to define in regulation the 

types of facilities covered by this provision’s requirements. 

Page 16 GAO-08-696T
Residential Facilities

selects a sample of child case files for site visits, and because most 

children are in foster home settings, residential facilities are usually not 

included. 

Similarly, while federal programs contain provisions agencies can use to 

enforce state compliance with federal requirements, these provisions vary 

in their rigor and use, and only DOJ has levied financial penalties.17 To 

date, HHS and Education have required state corrective action plans as a 

method of enforcement, but officials said that they may also assess 

financial penalties in the future. 

As the results of our work show, protecting youth in residential facilities—

many of whom are troubled and vulnerable to harm from themselves or 

from others—requires particular vigilance on the part of parents and 

responsible government agencies. However, abuse, neglect, and civil rights

violations documented in all types of residential facilities—government 

and private, licensed and unlicensed—show that the current federal-state 

oversight structure is inadequate to protect youth from maltreatment. 

Comprehensive results of our work will be included in a report to be 

released next month. This report will provide some options for action that 

states, federal agencies, and Congress may consider in any restructuring 

effort. We anticipate our report will also include recommendations for 

action that federal agencies can implement now under the existing 

regulatory structure. 

Mr. Chairman, this completes my prepared statement. I would be happy to

respond to any questions you or other Members of the committee may 

have. 

For further information regarding this testimony, please contact me at 

(202) 512-7215. Individuals making key contributions to this testimony 

include Lacinda Ayers, Carolyn Boyce, Doreen Feldman, Art Merriam, Jim 

Rebbe, and Mark Ward. 

Concluding Remarks 

GAO Contacts and 

Acknowledgments 

 17Federal funding was reduced by $1,552,200 among 8 states and territories in 2007. 

Page 17 GAO-08-696T
Page 18 GAO-08-696T Residential Facilities

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