United States Government Accountability Office

GAO Report to the Chairman, Committee on 

Education and Labor, House of 

Representatives 

RESIDENTIAL 

FACILITIES 

Improved Data and 

Enhanced Oversight 

Would Help Safeguard 

the Well-Being of 

Youth with Behavioral 

and Emotional 

Challenges 

May 2008

 

GAO-08-346 
What GAO Found

United States Government Accountability Office

Why GAO Did This Study

Highlights

Accountability Integrity Reliability

May 2008

RESIDENTIAL FACILITIES 

Improved Data and Enhanced Oversight Would Help 

Safeguard the Well-Being of Youth with Behavioral 

and Emotional Challenges

Highlights of GAO-08-346, a report to the 

Chairman, Committee on Education and 

Labor, House of Representatives 

What GAO Recommends

Federal funding to states supported 

more than 200,000 youth in residential 

facilities in 2004, many seeking help to

address behavioral or emotional 

challenges. However, federal 

investigations have identified 

maltreatment and civil rights abuses in 

some facilities. GAO was asked to 

provide national information about (1)

the nature of incidents that adversely 

affect youth well-being in residential 

facilities, (2) how state licensing and 

monitoring requirements address youth 

well-being in these facilities, and (3) 

what factors affect federal agencies’ 

ability to hold states accountable for

youth well-being in residential 

facilities. GAO conducted national 

Web-based surveys of state child 

welfare, health and mental health, and 

juvenile justice agencies and achieved 

an 85 percent response rate for each of

the three surveys. We also visited four 

states, interviewed program officials, 

and reviewed laws and documentation. 

GAO recommends that the Secretary of 

Health and Human Services (HHS) 

work to address state barriers in 

reporting maltreatment data for 

residential facilities, that the Attorney

General work with federal agencies to 

access information for targeting civil 

rights investigations, and that the 

Attorney General and the Secretaries of 

HHS and Education work to enhance

their state oversight efforts. GAO also 

discusses the implications of options 

that states, federal agencies, and 

Congress may use to safeguard and 

improve the civil rights and well-being 

of youth in residential facilities. While 

HHS and the Department of Justice 

(DOJ) generally agreed with our 

recommendations and suggested 

further action that could be taken, 

Education did not directly respond to 

the recommendations in its comments. 

Youth in some residential facilities have experienced maltreatment including sexual 

assault, physical and medical neglect, and bodily assault that sometimes resulted in civil 

rights violations, hospitalization, or death. Survey respondents from 28 states reported at

least one death in residential facilities in 2006. National data submitted to HHS from states 

show that 34 states reported 1,503 incidents of youth abuse and neglect by facility staff in 

2005, but these data are understated due to state barriers in collecting and reporting

facility-level information. Specific facility information that was reported and that could 

help target federal investigations was generally not shared with relevant agencies, such as

DOJ’s Civil Rights Division, because there was no formal mechanism to share this 

information. 

All states have processes in place to license and monitor certain types of residential 

facilities, but state agencies reported several oversight gaps. Some government and private 

facilities—particularly juvenile justice facilities and boarding schools—are often exempt 

from licensing requirements by law or regulation. In addition, licensing standards do not

always address some of the most common risks to youth well-being, such as suicide. State 

officials reported that they are unable to conduct annual on-site reviews at facilities, in part

because of fluctuating levels of staff resources. Few state agencies reported suspending or

revoking a facility’s operating license, in some cases due to lack of alternatives in placing 

the displaced youth. 

Number of State Agencies Reporting That They Do Not Exempt or Exempt Private Residential 

Facilities from Licensing Requirements, 2006 

Facility type Not exempt

Detention center

Residential schools 

and academiesa

Boot camp

Wilderness camp

Treatment facility

Exempt

0

20

Child welfare Health and mental health Juvenile justice

Source: GAO analysis of state agencies’ responses to survey.

39

35

n/a n/a

n/a n/a n/a n/a

0

1

1

3

3

3

2

6

11

14

10

19 18

15

14

14

10

6

4

13

24

16

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

a

Residential schools and academies includes both government and private facilities.

HHS, DOJ, and Education hold states accountable for youth well-being under federal grant

programs, but their authority is limited and monitoring practices are inconsistent. These 

agencies do not have the legal authority to hold states accountable for youth well-being in 

private residential facilities unless they serve youth under programs that receive federal 

funds. Agency officials also said they lack authority to require suicide prevention, and other 

requirements were inconsistent across programs. Agencies did not always include facilities 

in their state oversight reviews, and were inconsistent in addressing state noncompliance. 

To view the full product, including the scope 

and methodology, click on GAO-08-346.To 

view the e-supplement online, click on GAO08-631SP. For more information, contact Kay 

Brown, (202) 512-7215 or brownke@gao.gov. 
Contents 

Letter 1

Results in Brief 3

Background 5

Fatalities and Maltreatment Occurred in Government and Private 

Facilities, but State and National Data Do Not Fully Capture the 

Extent and Nature of the Problem 11

State Licensing and Monitoring Exclude Some Facilities and Do 

Not Address All Risks to Youth Well-Being 19

Federal Agencies Challenged to Address Weaknesses in State 

Oversight of Residential Facilities 32

Options for Taking Action to Promote Youth Well-Being in 

Residential Facilities 36

Conclusion 38

Recommendations for Executive Action 39

Agency Comments and Our Evaluation 40

Appendix I Objectives, Scope, and Methodology 44 

Appendix II Circumstances Surrounding State-Reported 

Suicides in Residential Facilities for Youth, 2006 50 

Appendix III State-Reported Incidents of Staff Maltreatment of 

Youth in Residential Facilities, Fiscal Year 2005 52 

Appendix IV Licensing Status for Selected Residential Facilities 55 

Appendix V State Agency Accreditation Requirements for 

Residential Facilities for Youth 71 

Appendix VI Selected State Licensing Standards for Residential 

Facilities for Youth 72 

Page i GAO-08-346 Residential Facilities 
Appendix VII Selected State Monitoring Requirements for 

Residential Facilities for Youth 74 

Appendix VIII State Agency Actions Taken within the Last 

3 Years against Government and Private 

Residential Facilities 76 

Appendix IX Comments from the Department of Education 78 

Appendix X Comments from the Department of Health and 

Human Services 81 

Appendix XI Comments from the Department of Justice 84 

Appendix XII GAO Contacts and Staff Acknowledgments 86 

Related GAO Products 87 

Tables 

Table 1: Selected Federal Funds That Can Be Used to Support 

Youth in Residential Facilities, by Federal Agency and 

Subagency 8

Table 2: Estimated Number of Youth in Residential Settings per 

Latest Available Agency Data 9

Table 3: State Child Welfare Agencies Reporting the Greatest 

Number of Youth Placed in Out-of-State Residential 

Facilities 31

Table 4: State Child Welfare Agencies Reporting the Greatest 

Number of Youth Received from Other States for 

Placement in Residential Facilities 31

Page ii GAO-08-346 Residential Facilities 
Table 5: Federal Program Requirements for States That Address 

Certain Risks to Youth Well-Being in Residential Facilities 33

Table 6: Status of State Agency Responses to GAO Survey on 

Residential Facilities for Youth 45

Table 7: States Reporting Youth Suicides by Type of Facility, 

Authorization for Providing Services, and Related

Investigatory Findings, 2006 50

Table 8: State-Reported Incidents of Staff Maltreatment of Youth in 

Residential Facilities, Fiscal Year 2005 52

Table 9: Licensing Status for Selected State-Operated Residential 

Facilities 55

Table 10: State Agencies Reporting the Licensing Status for StateOperated Residential Facilities That Serve Youth 55

Table 11: Licensing Status for Selected Residential Facilities That 

Receive Government Funds 57

Table 12: State Child Welfare Agencies Reporting the Licensing 

Status for Selected Private Residential Facilities That 

Serve Youth and Receive Government Funding 58

Table 13: State Health and Mental Health Agencies Reporting the 

Licensing Status for Selected Private Residential Facilities 

That Serve Youth and Receive Government Funding 60

Table 14: State Juvenile Justice Agencies Reporting the Licensing 

Status for Selected Private Residential Facilities That 

Serve Youth and Receive Government Funding 62

Table 15: Licensing Status for Selected Exclusively Private 

Residential Facilities 64

Table 16: State Child Welfare Agencies Reporting the Licensing 

Requirements for Selected Exclusively Private Residential 

Facilities That Serve Youth and Receive No Government 

Funding 65

Table 17: State Health and Mental Health Agencies Reporting the 

Licensing Requirements for Selected Exclusively Private 

Residential Facilities That Serve Youth and Receive No 

Government Funding 67

Table 18: State Juvenile Justice Agencies Reporting the Licensing 

Status for Selected Exclusively Private Residential 

Facilities That Serve Youth and Receive No Government 

Funding 69

Table 19: Number of States that Require at Least Some of the 

Residential Facilities That They License or Certify to Have 

Independent Accreditation 71

Page iii GAO-08-346 Residential Facilities 
Table 20: Number of State Agencies Reporting That They Require 

Licensed Government-Operated and Private Residential 

Facilities to Meet Certain Standards, 2006 72

Table 21: Number of State Agencies Reporting That They 

Monitored, for All or Less Than All, Selected Issues at 

Residential Facilities for Youth, 2006 74

Table 22: Number of State Agencies Taking Actions against 

Government and Private Residential Facilities within the 

Last 3 Years 76

Figures 

Figure 1: States That Reported at Least One Fatality in Residential 

Facilities, 2006 12

Figure 2: Number of State-Reported Fatalities by Type of 

Residential Facility and Agency, 2006 13

Figure 3: Number of States That Reported Specific Causes of Youth 

Fatalities in Residential Facilities, 2006 14

Figure 4: Percentage of State-Reported Incidents of Youth 

Maltreatment by Residential Facility Staff, Fiscal Year 

2005 15

Figure 5: State Agencies Reporting the Licensing Status of StateOperated Residential Facilities That Serve Youth 20

Figure 6: Number of State Agencies Reporting That They Do Not 

Exempt or Exempt Private Residential Facilities 

Receiving Government Funds from Licensing 

Requirements, 2006 22

Figure 7: Aspects of Well-Being Monitored by State Agencies in 

Private Residential Facilities That Served Youth and 

Received Government Funding 26

Figure 8: State Agency Actions Taken within the Last 3 Years 

against Government Residential Facilities 28

Figure 9: Number of State Agencies Reporting That They Did Not 

Routinely Share Oversight Information Regarding Certain 

Residential Facilities 30

Page iv GAO-08-346 Residential Facilities 
Abbreviations 

AWOL Absent Without Leave 

CAPTA Child Abuse Prevention and Treatment Act 

CARF Commission on Accreditation Rehabilitation 

 Facilities 

CMS Centers for Medicare & Medicaid Services 

COA Council on Accreditation 

CRIPA Civil Rights of Institutionalized Persons Act 

DOJ Department of Justice 

HHS Department of Health and Human Services 

JC The Joint Commission 

NCANDS National Child Abuse and Neglect Data System 

OJJDP Office of Juvenile Justice and Delinquency Prevention 

Education Department of Education 

This is a work of the U.S. government and is not subject to copyright protection in the 

United States. The published product may be reproduced and distributed in its entirety 

without further permission from GAO. However, because this work may contain 

copyrighted images or other material, permission from the copyright holder may be 

necessary if you wish to reproduce this material separately. 

Page v GAO-08-346 Residential Facilities 
United States Government Accountability Office

Washington, DC 20548 

May 13, 2008

The Honorable George Miller 

Chairman 

Committee on Education and Labor

House of Representatives 

Dear Mr. Chairman: 

Since the 1990s, government and private entities have established hundreds of 

residential facilities—including boarding schools and academies, boot camps, 

and wilderness camps—to serve youth with behavioral and emotional 

challenges. Nationwide, federal funding to states supported more than 200,000 

youth in facilities in 2004, and an unknown number of youth were placed in 

facilities by parents or others. These facilities can provide youth who cannot be 

served in their communities with a less restrictive alternative to hospitalization or

incarceration. However, annual investigations by the Civil Rights Division within

the Department of Justice, have detailed incidents of abuse and neglect, which in 

some cases have been severe enough to result in hospitalization or death. 

States are primarily responsible for ensuring the well-being of youth in 

facilities and other settings, and states vary in how they license and 

monitor facilities in accordance with individual state standards of care. In 

addition, in return for receiving funds under various federal grant 

programs, state agencies agree to comply with federal program 

requirements, including those related to youth well-being. These programs 

generally fall under the purview of three federal agencies: The Department 

of Health and Human Services (HHS) provides funds to states for child 

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

(DOJ), for serving delinquent youth; and the Department of Education 

(Education), for educating youth. These agencies have authority to hold 

states accountable for state-operated or private facilities that serve youth

under federally funded state programs. However, the federal government 

does not have oversight authority for other private facilities that serve only 

youth placed and funded by parents or other private entities. In this report 

we refer to facilities that receive no government funding as exclusively 

private facilities. 

Page 1 GAO-08-346 Residential Facilities 
In an October 2007 testimony on residential treatment programs for 

troubled youth we looked specifically at abuse and neglect of youth in 

certain types of private facilities.1

 This report provides national 

information about (1) the nature of the incidents that adversely affect the 

well-being of youth in government and private residential facilities, (2) 

how state licensing and monitoring requirements address the well-being of 

youth in residential facilities, and (3) what factors affect federal agencies’ 

ability to hold states accountable for youth well-being in residential 

facilities. We are also providing information on options that states, federal 

agencies, and Congress may use to better promote youth well-being in 

residential facilities. 

For purposes of this study, we defined residential facilities as those that 

require youth—ages 12 through 17—to reside at the facility and that 

provide program services for youth with behavioral and emotional 

challenges.2

 There are no uniform definitions for the types of residential 

facilities, and we worked with states to identify definitions that would be 

commonly understood, including boarding schools and academies, 

training and reform schools, wilderness camps, ranches, and treatment 

centers. We surveyed state child welfare, health and mental health, and 

juvenile justice directors in the 50 states, the District of Columbia, and 

Puerto Rico to determine how states oversee child well-being3

 in 

residential facilities. 4

 We received at least one completed survey from 

each state except Puerto Rico, completed surveys from all 3 agencies in 33 

states, and completed surveys from a total of 44 child welfare agencies, 45

health and mental health agencies, and 44 juvenile justice agencies. In the 

surveys, we asked about residential facilities that were government 

 1

 For additional information see GAO, Residential Treatment Programs: Concerns

Regarding Abuse and Death in Certain Programs for Troubled Youth, GAO-08-146T, 

Washington, D.C.: Oct. 10, 2007. 

2

 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. 

3

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

of Columbia and Puerto Rico. 

4

 We did not survey state education agencies, because they generally do not license 

residential facilities for youth. 

Page 2 GAO-08-346 Residential Facilities 
operated; privately operated that received any government funds; 5 and 

privately operated with no government funding. This report does not 

contain all of the results from the survey. The survey and a more complete 

tabulation of the results can be viewed by accessing the following link: 

http://www.gao.gov/cgi-bin/getrpt?GAO-08-631SP. To further our 

understanding, we visited 4 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. We also obtained state-reported data that HHS collects and 

maintains in its National Child Abuse and Neglect Data System (NCANDS). 

We reviewed federal statutes, regulations, and guidance concerning the

roles and responsibilities of selected agencies, and interviewed HHS, DOJ, 

and Education officials, as well as national association representatives and 

other experts on residential facilities for youth. We analyzed reports, 

studies, evaluations, and other documents regarding state licensing and 

monitoring of residential facilities for youth, but the scope of our work did 

not include the quality of services provided at residential facilities. See 

appendix I for more information on our scope and methodology. We 

performed our work between November 2006 and April 2008, in 

accordance with generally accepted government auditing standards. 

Youth in some government and private residential facilities have 

experienced maltreatment including physical abuse, neglect or deprivation 

of necessities, and sexual abuse that sometimes resulted in death or 

hospitalization, but data limitations hinder efforts to quantify the problem. 

Survey respondents from 28 states reported at least one death in a 

residential facility in 2006, often in accidents or suicides that, in some 

cases, may have been attributable to a lack of supervision or neglect by 

staff. In terms of youth maltreatment, NCANDS data show that 34 states 

reported 1,503 incidents of youth abuse and neglect by facility staff in 

2005, but these data are underreported. Many state agencies we surveyed

reported having information gaps, in part due to barriers in collecting 

facility specific information on deaths and maltreatment for all or some 

facilities. Facility-specific information for facilities that states did report to 

Results in Brief 

 5

 Private facilities may receive government funds through contracts with state or county 

agencies to serve youth under state systems of care, such as juvenile justice, or as certified 

providers of care under government health insurance programs, such as Medicaid. Private

funding may be provided by parents or others placing youth in a facility who are not under 

the cognizance of a government agency. 

Page 3 GAO-08-346 Residential Facilities 
NCANDS was not shared with agencies, such as the DOJ Civil Rights 

Division, that may use such information to prioritize civil rights

investigations at the federal level. DOJ annual reports convey the severity 

of maltreatment and civil rights violations uncovered by investigations in

both government and private facilities receiving government funds across 

the nation. 

All states have processes in place to license and monitor certain types of 

residential facilities, but state agencies reported several gaps in coverage 

that may place some youth at higher risk for maltreatment and death. 

First, some government-operated and private facilities—such as juvenile 

justice facilities and residential schools and academies—are often exempt

from licensing requirements altogether by law or regulation. Additionally, 

licensing requirements do not always address suicide and other common 

risks to youth well-being, and requirements that do exist may be 

inconsistently applied across different types of agencies and facilities. For

example, almost all state juvenile justice agencies we surveyed required

facilities to have written suicide prevention plans, compared to about twothirds of state child welfare and health and mental health agencies. State 

agencies also reported gaps in their monitoring processes for residential 

facilities. Some state agencies reported that monitoring did not occur at 

some facilities or reported that certain aspects of youth well-being, such as 

the quality of education programming and the use of psychotropic 

medications, were not included in their monitoring reviews. State officials 

also reported that they are unable to conduct yearly on-site reviews at 

facilities they monitor, because of fluctuating levels of staff resources 

committed by the state. Few state agencies reported taking action to 

suspend or revoke a facility’s operating license, in some cases because the 

state had no alternatives for serving the youth who would have been 

displaced. Finally, interagency coordination to ensure that facilities are 

providing an appropriate education, or other specialized services, is often

lacking. Several officials also noted the importance of increasing 

coordination to share monitoring results as agencies may place youth in 

common facilities within and across state lines. 

HHS, DOJ, and Education all have oversight processes to hold states 

accountable for the well-being of youth under the grant programs they 

administer, but the scope of the agencies’ oversight authority and different 

monitoring practices hinder their efforts. Most notably, these agencies do

not have the legal 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, agency 

officials said that they do not have authority to modify youth well-being 

Page 4 GAO-08-346 Residential Facilities 
requirements established in law, and such requirements vary by federal

agency and program. For example, in comparing requirements across 

relevant HHS, DOJ, and Education programs, only HHS had requirements 

for states to address abuse and neglect prevention. Requirements were 

inconsistent even among programs within the same agency. HHS, for 

example, had requirements for states to address suicide prevention under 

Medicaid programs, but not under child welfare programs or programs for 

substance abuse and mental health. In monitoring state compliance with 

federal program requirements, agencies did not always include residential 

facilities in their oversight reviews. While on-site reviews conducted by 

DOJ specifically included these facilities, HHS reviews of states’ child 

welfare systems targeted individual children, and did not necessarily 

include those in residential facilities. Federal agencies were also 

inconsistent in how they addressed state noncompliance with federal 

program requirements. In fiscal year 2007, for example, DOJ assessed 

financial penalties against 8 states and Puerto Rico, while other federal 

agencies reported that they did not assess penalties against noncompliant 

states. 

Weaknesses in the current federal-state regulatory structure have failed to

safeguard the civil rights and well-being of some of the nation’s most 

vulnerable youth, and we discuss the implications of some options for 

action that states, federal agencies, and Congress may consider in any 

restructuring effort. In addition, we remain concerned about the gaps in 

reported data that have persisted over a decade since the reporting 

requirement has been in place. We are also making recommendations for 

action that federal agencies can implement now under the existing 

regulatory structure, including that the Secretary of Health and Human 

Services explore options to address state barriers in reporting 

maltreatment data for residential facilities; the Attorney General work 

with other federal agencies to access information that could help target 

civil rights investigations; and HHS, DOJ, and Education work to enhance 

their oversight of state accountability for youth well-being in residential

facilities. HHS and DOJ either generally agreed, or did not disagree, with 

each of our recommendations. They also suggested further action that 

could be taken to address the report findings related to oversight for 

residential facilities. Education did not directly respond to the report 

recommendations but rather discussed its role and responsibilities for 

oversight of certain programs. 

In the continuum of care for youth with behavioral and emotional 

challenges, residential facilities can provide an alternative to Background 

Page 5 GAO-08-346 Residential Facilities 
hospitalization or incarceration for youth who cannot live at home and 

receive services in their communities.6

 Youth in these facilities range from 

young children through those who are transitioning to adulthood. These 

youth can exhibit a wide range of challenging behaviors, including 

antisocial or suicidal behaviors, substance abuse, and delinquency. 

The array of residential facilities reflects the diversity of the population 

they serve. There are no uniform definitions of residential facilities, and 

for those facilities treating children with mental illness, states reported at 

least 71 different facility types, according to a 2006 HHS report.7

 Facilities 

can provide a range of services, such as those for youth suffering from 

substance abuse or severe emotional disorders, either on-site or through 

links with community programs, including educational, medical, 

psychiatric, and clinical/mental health services. A wide range of 

government or private entities, including faith-based organizations, can 

operate these facilities. The cost to support youth in a residential setting 

can amount to thousands of dollars per month at some residential 

facilities. 

Youth Maltreatment Data HHS maintains and disseminates state-reported child abuse and neglect data in 

NCANDS to fulfill requirements in the Child Abuse Prevention and Treatment Act 

(CAPTA). Enacted in 1974, CAPTA established a focal point in the federal 

government to identify and address issues of child abuse and neglect in all 

settings, including residential facilities, and support effective methods of

prevention and treatment.8

 Under CAPTA, all states receiving funds from the 

state grant program are required to work with HHS to provide—to the maximum 

extent practicable—specific data on child maltreatment, including the number of 

 6

 Parents may determine that it is best for some youth to live in an alternative setting, or 

youth who are at risk of running away or are a danger to themselves or others may be

placed in a facility. 

7

 U.S. Department of Health and Human Services, State Regulation of Residential 

Facilities for Children with Mental Illness. DHHS Pub. No. (SMA) 07-4167. Rockville, 

Maryland: Center for Mental Health Services, Substance Abuse and Mental Health Services

Administration, 2006. 

8

 Last reauthorized in 2003, CAPTA authorizes state grants to help states with their child 

protective service functions, and Children’s Justice Act grants to improve states’ 

investigation and prosecution of child maltreatment. 

Page 6 GAO-08-346 Residential Facilities 
children reported to have been abused or neglected and the number of deaths 

resulting from abuse and neglect. 9

In addition, CAPTA requires that states receiving grants have laws or programs in 

effect for the investigation of child abuse and neglect.10 The law also requires

states receiving grants to establish citizen review panels to review state and local 

child protection activities, which may include child fatality review committees

established by states to review child fatalities for evidence of maltreatment, and 

to forward such cases for prosecution.

State Oversight Processes States have systems in place to license a wide range of businesses, and 

have general licensing requirements that include obtaining permits for 

land use, meeting building and safety codes, and establishing a basis for 

taxation. Beyond these general licensing requirements, states may have 

additional requirements that are specific to a category of business 

declared by the owner, such as a residential facility, or more specific types

of businesses within this category, such as a boarding school or 

wilderness camp. Some states have centralized all licensing and 

monitoring of facilities serving youth within a single agency, while other 

states have decentralized these functions among three or more different 

agencies, including state child welfare, mental health, and juvenile justice 

agencies. In addition, other agencies may provide oversight, such as the 

local fire and health departments, and the agency that places youth in the 

facility. State education agencies may also provide oversight for a facility’s 

educational programs. Oversight activities typically include licensing or 

certifying government or privately operated facilities, investigating 

complaints, and monitoring facility compliance with state or local 

standards, but there are no minimum standards commonly used by 

licensing agencies. 

States may also require residential facilities to seek accreditation in 

addition to obtaining a license to operate in their state. Accrediting 

agencies are private, peer-based, member-funded agencies designed to 

encourage and promote high-quality care. Accreditation is typically 

 9

 U.S. Department of Health and Human Services, Child Maltreatment 2005, Appendix A 

lists the required data elements. 

10 How a state organizes its child abuse and neglect reporting and investigation systems, 

and therefore whether it investigates and captures reports of abuse and neglect at 

exclusively private facilities, is the state’s prerogative. 

Page 7 GAO-08-346 Residential Facilities 
obtained by a self-initiated application and guided self-evaluation, 

followed by an on-site visit by a voluntary committee associated with the 

accrediting agency.

11 Some of the benefits to accreditation that states 

provide include strengthening confidence in the quality of care, fulfilling 

regulatory requirements in some states, and improving risk management 

and risk reduction. 

Federal Oversight of 

Programs That Support 

Residential Facilities 

Three federal agencies—HHS, DOJ, and Education—administer federal 

programs that states may use to support youth with community-based 

services while living at home or, when needed, in residential facilities or 

other settings. This support is provided primarily through certain 

subagencies, as shown in table 1.

Table 1: Selected Federal Funds That Can Be Used to Support Youth in Residential 

Facilities, by Federal Agency and Subagency 

Agency and Subagency

Program authority and

fiscal year 2007 funding Purpose 

HHS 

Title IV-B of the Social 

Security Act—$287 million 

Support for state 

child welfare system 

Administration for Children and

Families 

Title IV-E of the Social 

Security Act—$6.9 billion 

Support for state 

child welfare system 

Block Grants for 

Prevention and Treatment 

of Substance Abuse—

$1.8 billion 

Support for state 

substance abuse 

prevention and

treatment 

 systems 

Substance Abuse and Mental Health 

Services Administration 

Block Grants for 

Community Mental Health 

Services—$428 million 

Support for state 

mental health 

systems 

 11 Three major national accreditation organizations for residential facilities include the

Council on Accreditation (COA), the Commission on Accreditation of Rehabilitation 

Facilities (CARF), and the Joint Commission (JC). COA partners with human service 

organizations worldwide to improve service delivery outcomes by developing, applying,

and promoting accreditation standards. CARF is an independent, nonprofit accreditor of 

human service providers in the areas of behavioral health, child and youth services, and

medical rehabilitation. JC accredits and certifies health care organizations and programs in

the United States in an effort to improve the safety and quality of care provided to the

public through the provision of health care accreditation and related services that support

performance improvement in health care organizations. 

Page 8 GAO-08-346 Residential Facilities 
Agency and Subagency

Program authority and

fiscal year 2007 funding Purpose 

Center for Medicare and Medicaid 

Services 

Title XIX of the Social 

Security Act—$189.1 

billion 

Support for medical 

assistance for lowincome persons

DOJ 

Office of Juvenile Justice and 

Delinquency Prevention 

Juvenile Justice 

Delinquency Prevention 

Act—$320 million 

Support for state 

juvenile justice 

system 

Education 

Office of Special Education and 

Rehabilitative Services 

Individuals with

Disabilities Education 

Act—$11.8 billion 

Support for state 

special education 

systems 

Office of Elementary and Secondary 

Education 

Elementary and 

Secondary Education Act 

as Amended by the No 

Child Left Behind Act of 

2001—$14.7 billion 

Support for state 

education systems 

Source: GAO analysis of federal budget documents. 

In 2004, HHS and DOJ reported that states served more than 200,000 youth 

in residential settings under certain federal programs for child welfare, 

mental health, and juvenile justice as shown in table 2. 

Table 2: Estimated Number of Youth in Residential Settings per Latest Available

Agency Data 

State agencies

Placement Child welfare Mental healtha

Juvenile justice

Number of youth 107,000 11,000 93,000

Source: Child welfare data: Child Welfare League of America: National Data Analysis System, Number of Children in Out-of-Home 

Care, by Placement Setting 2004. 

Notes: Mental health data: Office of Applied Studies, Substance Abuse and Mental Health Services

Administration, National Survey of Substance Abuse Treatment Services, March 31, 2006. 

Juvenile justice data: Office of Juvenile Justice and Delinquency Protection: Census of Juveniles in 

Residential Placement, 2006. 

a

According to HHS’s Substance Abuse and Mental Health Services Administration officials, the 

approximately 11,000 youth include those receiving treatment at public and private facilities as of 

March 31, 2006, most with a primary focus of substance abuse treatment and many fewer with a 

mental health focus. 

To receive federal funds under these programs, states generally develop 

and submit to the relevant agency a multiyear plan that addresses federal 

Page 9 GAO-08-346 Residential Facilities 
program requirements.12 The relevant federal agency reviews and approves 

state plans, along with any annual performance reports that states submit 

describing progress in meeting goals. Federal agencies also audit states’ 

use of grant funds via reviews of state records and site visits in the settings 

where youth reside, such as residential facilities. States that fail to meet 

the required standards may face the withholding of federal funds. 

Federal Investigations of 

Civil Rights Abuses in 

Residential Facilities 

The Civil Rights of Institutionalized Persons Act (CRIPA), enacted in 1980, 

authorizes the Attorney General of the United States to conduct 

investigations and bring actions against state and local governments 

relating to conditions of confinement in institutions that are owned, 

operated, or managed by or provide services on behalf of, state or local 

governments.13 Institutions covered by CRIPA include youth residential 

facilities. 

CRIPA is implemented by the Special Litigation Section within DOJ’s Civil 

Rights Division. Under CRIPA, the Special Litigation Section investigates 

covered facilities to determine whether there is a pattern or practice of 

violations of residents’ federal rights. According to DOJ, to date, the 

Special Litigation Section has been successful in resolving the majority of 

CRIPA investigations that have uncovered unlawful conditions by 

obtaining voluntary correction or a judicially enforceable settlement 

designed to improve conditions. 

 12 For example, states receiving Title IV-B funds are required to submit a 5-year child and

family services plan that sets forth the goals that the state intends to accomplish and 

assurances that that states will review their progress. 

13 Whether a private facility is covered by CRIPA would depend on the level of 

governmental involvement. For example, if a state or local government enters into a

contract with a private facility to house certain juveniles, the facility might be considered

an institution covered by the statute. However, CRIPA states that privately owned and 

operated facilities are not covered by the statute where the only connection between the

facility and the state is a state license or the facility’s receipt of Medicaid and certain other 

federal payments on behalf of residents of the facility.

Page 10 GAO-08-346 Residential Facilities 
States we surveyed reported fatalities as well as incidents of physical 

abuse, sexual abuse, and neglect of youth in both government and private 

facilities in 2006, but data limitations hinder efforts to quantify the 

problem. Accidents and suicides—often attributable to a lack of 

supervision by staff—were among the most common types of youth 

fatalities, according to surveyed states; while in the four states we visited, 

the most common causes of youth maltreatment were abusive staff and 

lack of appropriate supervision. Many states had inconsistent or 

incomplete data on adverse incidents—especially from exclusively private 

facilities. National data, derived from state reports, suffer from these same 

limitations, leaving states with little opportunity to identify the extent of 

the problem and find solutions. State-reported information also fails to 

convey the severity of civil rights violations uncovered in some facilities 

each year—that show extreme cases of sexual assault, medical neglect, 

and bodily assault requiring hospitalization. 

Youth fatalities occurred in both government and private residential facilities, in

states across the nation. Of the states we surveyed, 28 reported that at least one 

youth had died in this setting in 2006, as shown in figure 1.14

Fatalities and 

Maltreatment 

Occurred in 

Government and 

Private Facilities, but 

State and National 

Data Do Not Fully 

Capture the Extent 

and Nature of the 

Problem 

Youth Fatalities Occurred 

in Government and Private 

Facilities across the 

Nation, with Accidents 

and Suicide among the 

Primary Causes 

 14 We could not determine the number of deaths in each state because of the possibility of 

duplicative reporting across agencies. 

Page 11 GAO-08-346 Residential Facilities 
Figure 1: States That Reported at Least One Fatality in Residential Facilities, 2006 

Source: GAO analysis of state agency responses to survey; map, Map Resources.

No fatality reported 

Fatality reported

N.H.

Mass.

R.I.

Conn.

N.J.

Del.

Md.

D.C.

Hawaii

Ala.

Ariz. Ark.

Calif.

Ga.

Ill. Ind.

Iowa

Kans.

La.

Maine

Mo.

Nebr.

N.Mex.

N.Y.

N.Dak.

Oreg.

Pa.

Tex.

Wisc.

Fla.

Miss.

N.C.

Ohio

Okla.

S.Dak.

Wyo.

Idaho

Mont.

Wash.

Nev.

Utah

Colo.

Mich.

Minn.

Va.

W.

Va.

Ky.

S.C.

Tenn.

Alaska

Vt.

Note: The survey question was as follows: In 2006, how many youth aged 12-17 died in each of the 

following categories of residential facilities providing targeted services in your state? Include youth 

who died at the facility as well as youth in AWOL status or others who died or were pronounced dead 

outside the facility: (a) total deaths in 2006, (b) deaths of youth under the care and supervision of your

agency at government-operated facilities, (c) deaths of youth under the care and supervision of your 

agency at private facilities that receive any government funds, (d) deaths of youth under parental or 

non-government custodial care at private facilities that receive any government funds, and (e) deaths

of youth under parental or nongovernment custodial care at private facilities that do not receive 

government funds (including faith-based facilities). 

Child welfare agencies reported more deaths in residential facilities than 

other agencies, and nearly three times as many states reported deaths in 

private facilities that received government funds than in governmentoperated facilities (see fig. 2). However, this may bear little or no relation 

to the relative risk of death in either facility type due to differences in the 

proportion and risk factors of youth served, among other factors. While no 

state we surveyed reported fatalities in exclusively private facilities, one or

Page 12 GAO-08-346 Residential Facilities 
more agencies in 45 states reported that they did not have data for these 

types of facilities. 

Figure 2: Number of State-Reported Fatalities by Type of Residential Facility and 

Agency, 2006

State agencies

Number of fatalities

Source: GAO analysis of state responses to surveys.

0 5 10 15 20 25 30 35 40 45 50

Juvenile justice

Health and mental health

Child welfare

Government facilities

Private facility that received government funds

Fatalities not categorized by facility type

4 28 10 42

3 13 16

3 8 11

In our survey, deaths in the 28 states were most often attributed to 

accidental causes (see fig. 3), but sometimes accidental deaths, if 

investigated, are attributable to abuse or neglect. In Florida, for example, 

juvenile justice officials said that a youth death in a county-operated boot 

camp was first classified as an accident, but after investigation by a child 

fatality review committee, was reclassified as a death caused by 

maltreatment and referred for prosecution. 

Page 13 GAO-08-346 Residential Facilities 
Figure 3: Number of States That Reported Specific Causes of Youth Fatalities in

Residential Facilities, 2006 

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

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

AWOL status, (f) other accidental cause, and (g) other causes? 

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

bleeding. 

Suicide was among the most common causes of fatalities in residential 

facilities reported by states we surveyed, and can be related in some 

instances to inadequate staff supervision and services. In Alaska, for 

example, a youth participating in a sex offender program hanged himself 

at night while residing in a private facility contracting with the state. After

the state agency and the local law enforcement agency investigated, the 

facility corrected substandard practices in staffing, supervision, and 

clinical services. In Wisconsin, after three youth hanged themselves in 

private residential facilities under contract with a state agency, the state 

increased staff training and monitoring of residents and sponsored 

statewide suicide awareness and prevention training for those who work 

with youth in residential settings. See appendix II for more information on 

the results of suicide investigations in the states we surveyed. 

Page 14 GAO-08-346 Residential Facilities 
Youth Maltreatment Was 

Primarily Related to 

Inexperienced Staff, Lack 

of Supervision, or 

Insufficient Training 

States responding to our survey reported that they investigated complaints 

of physical abuse, sexual abuse, or neglect in both government and private 

facilities (49 states), including those that are exclusively private (37 

states). Similarly, NCANDS data from 2005 showed that 34 states reported 

incidents of youth abuse and neglect in residential facilities. Of the 1,503 

reported incidents, neglect was the most frequent cause of youth 

maltreatment, followed by physical abuse. (See fig. 4 and app. III.) 

Figure 4: Percentage of State-Reported Incidents of Youth Maltreatment by

Residential Facility Staff, Fiscal Year 2005 

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

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

psychological or emotional maltreatment. 

In the states we visited, abuse and neglect of youth in residential facilities 

was often associated with staff resource concerns—such as a lack of 

experienced staff, insufficient training, or lack of appropriate 

supervision—particularly in smaller facilities. In California, for example, 

county officials 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. 

Another cause of youth maltreatment may be attributable to the improper 

application of seclusion and restraint, according to state officials. State 

officials in Florida said that improper application of seclusion and 

restraint techniques may result in staff restraining youth for too long, or 

with too much force, causing injury or death. 

Page 15 GAO-08-346 Residential Facilities 
State and federal information systems for tracking and reporting incidents 

of maltreatment have limitations in helping state and federal agencies 

monitor the well-being of youth in residential facilities and address 

outstanding problems. 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, although states responding to our survey reported that the 

ability to collect and maintain data on all facilities in the state was a high 

priority, state officials we interviewed reported barriers in addressing 

these activities: First, 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; second, states 

that have such authority reported difficulties sustaining data collection in 

times of budget shortages. As a result, state officials said that the number 

of adverse incidents was likely more widespread and numerous than 

reported. 

Data Limitations Preclude 

Identifying the Extent of 

the Maltreatment or 

Finding Solutions 

NCANDS, which is derived from state reports, suffers from these same 

limitations, as well as others. First, some states do not report data for 

residential facilities to NCANDS,15 so it may understate the number of 

fatalities and maltreatments. Second, many states do not consistently 

identify whether the individual maltreating youth was facility staff, a 

parent, or other individual.16 Finally, NCANDS only tracks fatalities 

resulting from maltreatment, not suicide or accidents that may be an

indicator of neglect or another problem that needs resolution. Cognizant

HHS officials said that its NCANDS contractor routinely works with states 

to improve data quality, but cannot enforce state participation as data 

reporting is voluntary under the law.

HHS highlighted the need to improve the quality of data reported by states

in a 2005 report to Congress,17 noting that national collection of data on 

 15 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. 

16 In 2005, 37 states were unable to consistently identify whether the individual maltreating 

youth was facility staff, a parent, or other individual. 

17 For additional information see U.S. Department of Health and Human Services, 

Administration on Youth and Families, Child Maltreatment 2005 (Washington, DC: U.S.

Government Printing Office, 2007). 

Page 16 GAO-08-346 Residential Facilities 
child fatalities is complicated by the many steps that are needed to 

establish the cause of death. The report stated that while state child 

fatality review committees can investigate and help classify deaths 

correctly, they are not implemented in every community, nor do they have 

the resources to review each suspicious death of a child or adolescent. In 

this report, HHS suggested that Congress fund research on ways to 

improve national reporting of youth fatality data, including procedures for 

investigating and documenting the cause of fatalities. 

Federal Investigations 

Highlight the Severity of 

Civil Rights Violations 

Occurring in Some 

Residential Facilities 

In most facilities, youth maltreatment may occur infrequently as a result of

isolated circumstances, but over the years, DOJ investigations of facilities

serving youth have found a pattern or practice of civil rights violations, 

including physical and sexual abuse, medical neglect, and inadequate

education in some government and private facilities receiving government 

funds. At the end of fiscal year 2006, the latest year for which data were 

available, DOJ’s Civil Rights Division reported active cases involving over

175 facilities and 34 states. 18 Annual reports from the division 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 hogtied and shackled youth to poles in public places, and girls were forced to 

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

routinely broke the jaws of youth who showed disrespect in another 

facility. In some facilities, staff engaged in sexual acts with boys. Youth-onyouth 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, 

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

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

(Washington, D.C. 2007). 

Page 17 GAO-08-346 Residential Facilities 
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. 

DOJ’s Civil Rights Division reports that it receives more credible 

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

fiscal year 2006 alone, the division reported receiving approximately 5,000

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

Congress and the White House. In the 26 years CRIPA had been in effect, 

through September 2006, the division investigated conditions in 433 

facilities. Division officials said that they also receive many allegations of 

civil rights violations in exclusively private facilities, such as private 

boarding schools. 

DOJ Civil Rights Division officials stated they rely on advocacy groups and 

media stories to identify investigations, but with additional sources of 

information, they could better target their scarce investigative resources. 

Division officials said that they were unaware that NCANDS tracked statereported maltreatment data, and that obtaining case-level NCANDS 

information on the incidents of maltreatment and death occurring in 

specific facilities would be helpful. Division officials said that the results 

of federal agency monitoring reviews of states that highlight findings 

related to residential facilities would also be useful, but that there was no 

formal mechanism to share oversight findings for residential facilities 

under the purview of multiple federal programs. Except in one instance,19

officials said that no federal agencies—including HHS, Education, and 

DOJ’s Office of Juvenile Justice and Delinquency Prevention—were 

coordinating with DOJ’s Civil Rights Division to provide pertinent 

oversight results. 

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

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

results for CMS oversight of residential facilities. 

Page 18 GAO-08-346 Residential Facilities 
All states have processes in place to license and monitor certain types of 

residential facilities, but our survey identified several gaps that exempt 

certain types of facilities from oversight and allow some of the common 

causes of youth death and maltreatment to go unaddressed. These gaps 

include the fact that some types of government-operated and private 

facilities are exempt from licensing requirements, licensing requirements 

do not always address the primary causes of youth death and

maltreatment, and state agencies inconsistently monitor facilities and 

share their monitoring results. Increasing coordination and information 

sharing among state agencies—both within and across states—was a highpriority activity states identified to improve the oversight of youth wellbeing in residential facilities. 

All states reported licensing certain types of residential facilities for youth, 

but their responses to our survey also showed gaps in licensing coverage 

(see app. IV). Licensing all facilities, public or private, can help ensure that 

residential facilities meet the relevant standards for protecting youth wellbeing. Among state-operated facilities, juvenile justice agencies were more 

likely to exempt facilities from licensing than child welfare and mental 

health agencies (see fig. 5). The juvenile justice officials we interviewed 

said that this was because some state statutes do not require stateoperated juvenile facilities to have a license in order to operate. 

State Licensing and 

Monitoring Exclude 

Some Facilities and 

Do Not Address All 

Risks to Youth WellBeing 

Juvenile Justice Facilities 

and Residential Schools 

and Academies Are Often 

Excluded from Agency 

Licensing Requirements 

Page 19 GAO-08-346 Residential Facilities 
Figure 5: State Agencies Reporting the Licensing Status of State-Operated

Residential Facilities That Serve Youth 

0

5

10

15

20

25

30

Health and Juvenile justice

mental health

Child welfare

Number of state agencies

Type of facilities

Source: GAO analysis of state agencies’ responses to survey. 

Not exempt

Exempt

13

7

23

6

13

28

Note: 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 regulation—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, (g) no response. 

Many state agencies also reported that certain types of private facilities 

were exempt from licensing, regardless of whether they received some 

government funding or were exclusively private (see fig. 6). 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 

Page 20 GAO-08-346 Residential Facilities 
exempted faith-based facilities from licensure.20 However, many agencies 

reported not knowing the licensing status of certain types of private 

facilities or reported that they did not have certain types of facilities in 

their state. Across agencies, states most often responded that they did not 

have private boot camps, ranches, and wilderness camps.21

 20 These six states were 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. Note: 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, (g) no response. 

21 Among state juvenile justice survey respondents, 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 survey 

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

wilderness camps (14). 

Page 21 GAO-08-346 Residential Facilities 
Figure 6: Number of State Agencies Reporting That They Do Not Exempt or Exempt Private Residential Facilities Receiving 

Government Funds from Licensing Requirements, 2006 

Number of state agencies that do not exempt certain

Type of residential facility types of residential facilities

Detention center

Residential schools

and academiesa

Boot camp

Wilderness camp

Treatment facility

Number of state agencies that exempt certain

types of residential facilities

0 10

20

-40 -35 -30 -25 -20 -15 -10 -5 0 30 40

Child welfare

Health and mental health

Juvenile justice

Source: GAO analysis of state agencies’ responses to survey.

39

35

n/a n/a

n/a n/a

n/a n/a

0

1

1

3

3

3

2

6

11

14

10

19 18

15

14

14

10

6

4

13

24

16

Notes: The total number of agency responses for a specific facility type does not include instances in 

which agencies reported that there was no such facility in the state, they did not know, or that they did 

not respond. 

The survey question was as follows: Which, if any of the following types of residences that provide 

targeted services for youth are currently exempt from licensing or routine monitoring in your state by 

statute or state regulations? The response options were (a) exempt from licensure, (b) exempt from

monitoring, (c) exempt from both, (d) not exempt from either, (e) no such residence in the state, (f) 

don’t know, and (g) no response. 

a

Responses for this type include all private facilities, not just those receiving government funding. 

Page 22 GAO-08-346 Residential 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.22

The lack of licensing for all facilities serving youth has several 

consequences. 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 treatment 

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

state licensing agency, but the same facility would be required to obtain a 

license if it self-identified 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, we described 

cases in which program leaders told parents their programs could provide 

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. 

Certain states have taken different approaches to improve oversight of 

residential facilities. Some states are considering laws that would expand 

their licensing authority for private facilities, while other states use 

alternative methods to provide protections for youth. For example, some 

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

for licensing residential facilities. 

Page 23 GAO-08-346 Residential Facilities 
state agencies include 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.

Florida’s juvenile justice system 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 compared to other agencies reported requiring facilities to be 

accredited by private organizations, due in part to conditions of

participation for certain federal programs.23 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; such information sharing is 

dependent on how well state agencies coordinate with them. In general, 

fewer states reported requiring accreditation than not across the three 

agencies we surveyed, as shown in appendix V. 

State Licensing Standards 

Do Not Consistently

Address Suicide and Other 

Identified Risks to Youth 

Well-Being 

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. Standards 

based on sound research can help ensure that youth receive minimum 

standards of care that address risks to well-being across facility types. 

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 

 23 For example, HHS’s Medicaid program, a joint federal-state program to provide health 

care coverage for certain low-income, aged, or disabled individuals, requires that states 

providing inpatient psychiatric services in a nonhospital setting to individuals under age 21 

must ensure that such services are accredited by one of three specified accrediting 

organizations or a comparable one recognized by the state. 

Page 24 GAO-08-346 Residential Facilities 
staff.24 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. (See app. VI.) 

Monitoring May Not Be 

Comprehensive or 

Frequent Enough to 

Protect All Aspects of 

Youth Well-Being 

State agencies reported monitoring youth well-being in residential 

facilities, but certain aspects of youth well-being were not included in all

monitoring activities. Among six different aspects of youth well-being we 

asked about in our survey, the quality of educational programming and 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. (See fig. 7 for results pertaining to private facilities that receive 

government funds, and app. VII for results pertaining to state-operated 

facilities, private facilities that received government funds, and exclusively 

private facilities.) 

 24 The survey question was as follows: When your agency develops or opens a governmentoperated 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, (i) have written suicide 

prevention plans. A similar question was asked for asked for private facilities. 

Page 25 GAO-08-346 Residential Facilities 
Figure 7: Aspects of Well-Being Monitored by State Agencies in Private Residential Facilities That Served Youth and 

Received Government Funding 

Monitoring requirement Monitored for less than all residential facilities

Staffing issues

Physical plant

Use of approved 

seclusion and restraint

Use of psychotropic 

medications

Presence of educational 

programming

Quality of educational 

programming

Monitored for all facilities

0 5 10 15

20

-40 -32 -24 -16 -8 25 30 35 40

Child welfare

Health and mental health

Juvenile justice

Source: GAO analysis of state agencies’ responses to survey.

23

8

17 18

15 22

5 35

23

11

23

16

30

22

30

25

22

23

32

23

24

22

4 35

16

13

13

7

13

14

10

9

13

15

7

18

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

authorize for monitoring or followup, 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; (d) 

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

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. Periodic on-site reviews to monitor facility 

Page 26 GAO-08-346 Residential Facilities 
compliance with licensing requirements helps ensure that licensing 

standards are taken seriously, and that risks to youth well-being are 

quickly addressed. States reported that visiting 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 on actions taken against facilities in the last 3 

years, but few reported suspending or revoking a facility’s operating 

license. A full range of enforcement options allows states to respond to 

maltreatment in accordance with the severity of the incident and to 

escalate penalties as necessary to help prevent reoccurrence. Survey 

respondents, however, often reported that they did not employ the full 

range of enforcement options against the residential facilities under their 

purview. For example, most state agencies in our survey reported taking

action to increase monitoring of facilities with identified problems, or 

requiring corrective action plans (See app. VIII and fig. 8). 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. For these reasons, states may agree to keep a program open 

if a facility meets certain conditions. For example, we previously reported 

that, in West Virginia, a program’s owners pleading no contest to the 

charge of child neglect resulting in death negotiated an agreement with the 

state to keep the program open in exchange for a change in ownership and 

management. 

Page 27 GAO-08-346 Residential Facilities 
Figure 8: State Agency Actions Taken within the Last 3 Years against Government Residential Facilities 

Action taken State agency took action

Youth were removed

Banned new 

admissions or 

instituted admission 

restrictions

Government facility 

was closed or license, 

certification, or 

operating authority was

suspended or revoked

Increased monitoring

Required program 

improvement or 

corrective action plan

State agency did not take action

0 5 10 15

20

-35 -30 -25 -20 -15 -10 -5 25 30 35

0

Child welfare

Health and mental health

Juvenile justice

Source: GAO analysis of state agencies’ responses to survey.

19

17

32 4

2 16

7 12

2

2

6

8

5

8

11

30

10

15

14

26

34

18

1 19

0

3

11

7

4

24

7

10

32

7

16

10

Referred or 

recommended criminal 

investigations for abuse 

or neglect that carry fines

or imprisonment

Note: The survey question was as follows: Over the last 3 reporting years, did your agency take any 

of the following actions at its government-operated facilities as a result of allegations or findings of 

noncompliance, improper operations, physical abuse or sexual abuse or neglect of youth, or other 

negative outcomes? Respondents could also answer “don’t know” or “no response.” 

Page 28 GAO-08-346 Residential Facilities 
Improving coordination to share information among state agencies was a

high priority for improving oversight of residential facilities according to 

survey respondents. Such coordination is needed because some youth may 

have needs requiring a multi-agency response. A lack of coordination in 

these instances can result in situations where monitoring activities overlap 

at some facilities and aspects of youth well-being in other facilities fall 

through the cracks. Officials in the states we visited raised concerns that 

ensuring facilities have appropriate education programs for youth is 

particularly challenging unless state agencies coordinate their oversight 

efforts. Lack of coordination, particularly with the state education agency, 

has resulted in cases where facilities remain licensed to operate even 

though education quality is poor and youth may be unable to transfer 

education credits upon returning to schools within their communities. 

Coordination Needed 

within and among States 

for Youth Served by 

Multiple Agencies or 

across State Lines 

Many state agencies we surveyed reported that they did not routinely 

share information with other state agencies regarding negative findings 

from their monitoring reviews of residential facilities, or when facility 

licenses were suspended or revoked (see fig. 9). Sharing such information 

is important because it may influence another agency’s decision to place 

youth in the facility. 

Page 29 GAO-08-346 Residential Facilities 
Figure 9: Number of State Agencies Reporting That They Did Not Routinely Share 

Oversight Information Regarding Certain Residential Facilities 

0 2 4 6 8 10 12 14 16 18 20 22 24

Findings of noncompliance,

sanctions, or other consequences

Reports of adverse incidents

Results of monitoring activities

Licenses suspended or revoked

Oversight actions

Number of state agencies

Child welfare agencies

Health and mental health agencies

Juvenile justice agencies

12

18

18

22

17

17

17

18

20

20

14

12

Source: GAO analysis of state agencies’ responses to survey.

Note: The survey question was as follows: What oversight information regarding residential facilities

does your agency routinely share with other state or local government agencies or place on an

accessible Web site? Response options for this question were (a) new licenses issued; (b) licenses 

suspended or revoked; (c) plans to expand or reduce programs; (d) schedule of upcoming routine 

monitoring activities (e.g., record reviews or site visits); (e) results of monitoring activities; (f) reports 

of adverse incidents; (g) findings of noncompliance, sanctions, or other consequences not listed 

above. 

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. These interstate placements can

be initiated by state agencies or private parties, such as parents. Out-ofstate placement is more difficult than in-state placement, 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. Table 3 shows the top five states in which state child

welfare agencies we surveyed reported the greatest number of youth in 

out-of-state residential facilities. 

Page 30 GAO-08-346 Residential Facilities 
Table 3: State Child Welfare Agencies Reporting the Greatest Number of Youth

Placed in Out-of-State Residential Facilities 

Sending state Total number of youth Number of placement states

California 1,903 26

Pennsylvania 593 18

Alaska 482 14

Rhode Island 330 11

Connecticut 282 13

Source: GAO analysis of state child welfare agency survey responses. 

Note: The survey questions were as follows: (1) As of October 1, 2006, how many youth from your 

state were residing in residential facilities providing targeted services in other states? Response

options: (a) number of youth under the care and supervision of your agency residing in facilities

operated by another state or local government agency, (b) number of youth under the care and 

supervision of your agency residing in private facilities in the other state, (c) number of youth under 

parental or nongovernment custodial care residing in private facilities in the other state? Respondents

could also check not available. And (2) On October 1, 2006, in what other states were youth under 

the care and supervision of your agency residing? 

Another reason that interstate coordination is important is to ensure that 

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. Such information 

may be particularly important in cases where state licenses cannot serve 

this purpose. Four of the top five states that received the greatest number 

of out-of-state youth (see table 4)—according to child welfare agencies we 

surveyed—exempted one or more types of facilities from state licensing 

requirements. 

Table 4: State Child Welfare Agencies Reporting the Greatest Number of Youth

Received from Other States for Placement in Residential Facilities 

Receiving state Number of youth Number of sending states 

Utah 1,827 38

Pennsylvania 1,778 5

Montana 1,060 5

Massachusetts 628 15

South Carolina 336 26

Source: GAO analysis of state child welfare agency survey responses. 

Page 31 GAO-08-346 Residential Facilities 
Note: The survey questions were as follows: (1) As of October 1, 2006, how many youth under the 

care and supervision of other states, any trial jurisdictions, or countries other than the United States

were residing in residential facilities providing targeted services in your state? Response options:

Number of (a) youth placed in facilities operated by your state agency and (b) youth placed in private 

facilities in your state? Respondents could also check not available. And (2) On October 1, 2006, 

from what other states were youth aged 12 to 17 residing in residential facilities providing targeted

services in your state? 

Finally, our testimony last October showed that information sharing 

across states is also important because operators of programs shut down 

in one state for youth maltreatment or death due to negligence sometimes 

open new programs in another state, and states with weaker licensing and 

monitoring practices may be especially vulnerable to this practice. Our 

testimony last October highlighted a 1990 case where a wilderness camp 

operator moved from Utah to Nevada, and back to Utah as facilities were 

repeatedly shut down by authorities, and how many youth died in two of 

these programs.25

HHS, DOJ, and Education all have oversight processes to hold states 

accountable for the well-being of youth in certain residential settings 

under the grant programs they administer. However, limitations in federal

oversight authority and inconsistent monitoring practices hinder federal 

efforts to ensure that states are keeping youth in residential facilities safe 

from harm. Most notably, these agencies cannot hold state agencies 

accountable for conditions in private facilities unless the facilities serve 

youth in state programs supported by federal funds. When they did have 

the authority, agencies differed in their oversight practices regarding the 

extent that agencies had established program requirements specific to 

residential facilities, had conducted on-site reviews of residential facilities, 

and had taken actions to enforce compliance with federal requirements. 

HHS, DOJ, and Education have some authority to hold states accountable for 

certain aspects of youth well-being in facilities that serve youth under the grant 

programs they administer—whether state operated or private—but cannot hold 

states accountable for conditions in facilities that are exclusively private. The 

federal government has oversight authority in cases where states voluntarily 

choose to accept federal requirements in exchange for receiving federal 

Federal Agencies 

Challenged to 

Address Weaknesses 

in State Oversight of 

Residential Facilities 

HHS, DOJ, and Education 

Cannot Hold States 

Accountable for 

Exclusively Private 

Facilities

 25 GAO, Residential Treatment Programs: Concerns Regarding Abuse and Death in Certain 

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

Page 32 GAO-08-346 Residential Facilities 
program funds.26 In practice, states have agreed to comply with federal 

oversight requirements in exchange forfunds supporting their state systems of 

child welfare, health and mental health, juvenile justice, and education. 

Accordingly, under the federal programs that we examined at HHS, DOJ, and 

Education, states are accountable for ensuring that facilities receiving funds 

through these programs are in compliance with federal program requirements. 

However, these agencies cannot hold states accountable for conditions in 

exclusively private facilities. 

Federal Requirements Do 

Not Always Address 

Suicide Prevention and 

Other Risks to Youth WellBeing 

Federal agencies and programs do not always hold states accountable for

addressing some of the primary risks to youth well-being in residential 

facilities. 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 5.) 

Table 5: Federal Program Requirements for States That Address Certain Risks to

Youth Well-Being in Residential Facilities 

Agency and subagency 

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 

No No No No

DOJ 

Juvenile Justice and Delinquency 

Prevention 

No No No Yes

Education 

Elementary and Secondary 

Education 

No No No Yesb

Special Education and 

Rehabilitative Services 

No No No Yesb

Source: Analysis of U.S. Department of Health and Human Services, 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.

 26 Congress, as part of its spending power under Article I, Section 8, of the U.S. 

Constitution, can attach conditions to states’ receipt of federal funds. 

Page 33 GAO-08-346 Residential Facilities 
HHS, DOJ, and Education all reported that they do not have the authority 

to require that states have suicide prevention plans as a criterion for 

receiving funds under the grant programs that they administer, although 

HHS and DOJ have documented a need to address suicide prevention. The

Centers for Disease Control and Prevention—which is part of HHS—

issued a report that identified suicide as the third leading cause of death in 

2004 among all U.S. youth.27 In addition, a 2004 study commissioned by 

DOJ recommends increased mental health screening for suicide 

prevention among incarcerated youth.

28 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 that states are more 

responsive to a requirement or more specific agency guidance. 

Similarly, agency officials said that federal programs also do not 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 rule 

 27 For 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, 1990-200, (Atlanta, Georgia, Sept. 7, 

2007 / 56(35); 905-908). 

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

National Survey. February 2004. 

Page 34 GAO-08-346 Residential Facilities 
making concerning the use of seclusion and restraint in nonmedical 

community-based children’s facilities.29

Federal Oversight Does 

Not Ensure States Are 

Monitoring Youth WellBeing in Residential 

Facilities

Federal agencies have several means of ensuring that states are 

monitoring youth well-being in residential facilities that receive 

government funds, 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 on-site 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 on-site reviews to determine state compliance with specific 

statutory requirements, but HHS oversight reviews of state child welfare 

systems do not necessarily include children in residential facilities. HHS 

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 agencies have authority to enforce state 

compliance with federal requirements, these provisions vary in their rigor 

and use, and only DOJ has levied financial penalties.30 To date, HHS and 

Education have required state corrective action plans as a method of 

 29 This 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, 

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

that public or private nonmedical, 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. 

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

Page 35 GAO-08-346 Residential Facilities 
enforcement, but officials said that they may also assess financial 

penalties in the future. 

Protecting youth in residential facilities—many of whom are troubled and 

vulnerable to harm either from themselves or from others—requires 

particular vigilance on the part of parents and responsible governmental 

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. States, federal agencies, 

and Congress have several options that they can use to improve standards

of well-being for youth in residential facilities, monitor facility compliance 

with the standards, and take necessary corrective action. Although 

individual states are primarily responsible for taking action to improve the 

welfare of youth domiciled within their borders, federal agencies may 

establish additional safeguards for those youth that are served in 

residential facilities under federally funded state programs. Further, 

Congress has several options to consider—such as direct regulation of 

residential facilities, modifying conditions of participation for existing 

federal programs, and creating new program funding and requirements. 

Each of these options entails trade-offs among the cost to the government,

the extent of federal involvement, and the extent that protections would 

apply to youth in various types of facilities. 

Options for Taking 

Action to Promote 

Youth Well-Being in 

Residential Facilities 

• States. States could take action to improve the well-being of youth in 

residential facilities through their licensing processes, contract provisions, 

or accreditation requirements. Expanding licensing coverage would allow 

states to establish minimum standards for youth in all facilities, but may 

require state legislation to provide necessary authority, as well as 

increased funding for oversight and enforcement. Creating common 

contract provisions for facilities serving youth is another way state 

agencies could safeguard youth well-being across state agencies for those 

private facilities under contract with the state. Accreditation for all 

facilities that serve youth is another option that could benefit states in 

several ways. Accreditation by a national organization provides universal 

standards that are applied not only within states, but across state lines. 

Accreditation in lieu of licensing requirements may help minimize 

increases in state spending as a result of expanding oversight coverage. 

• Federal agencies. Federal agencies could also take action by holding 

states accountable for the well-being of youth in residential facilities that 

participate in programs supported by federal funding—such as state child 

Page 36 GAO-08-346 Residential Facilities 
welfare, health and mental health, and juvenile justice programs. Federal 

agencies could increase state accountability by modifying the conditions 

of participation for relevant programs. These program conditions could 

include priorities for placing youth first in facilities that are accredited or 

held to recognized standards of care, or include specific standards of wellbeing and oversight, such as suicide prevention and seclusion and 

restraint. This may be most effective if the federal agencies worked 

together to develop minimum standards for all relevant federal programs, 

possibly through an interagency council or the Office of Management and 

Budget. If the federal agencies determine they do not have authority to 

modify program conditions of participation, they could seek such 

authority from Congress. This option would not increase federal program 

spending, but federal agency action would not extend to exclusively 

private facilities. 

• Congress. Congress also has several options to consider. These options 

include direct federal regulation of facilities that house youth under 

certain conditions, or establishing conditions of participation in existing or

new federal programs.31 These options are not mutually exclusive—some 

may be taken in combination with other federal or state action. 

• Direct regulation. States have reported that thousands of youth are placed

in out-of-state facilities, and we have previously testified before Congress 

on the extent of marketing and advertising across states lines. Under the 

Constitution, Congress would have a basis to directly regulate private 

facilities that participate in activities involving interstate commerce.32

Congress might regulate such facilities by establishing a federal program 

that preempts state law and regulation, or provide states the option of 

carrying out an equivalent state program. These actions would result in 

increased federal spending. Congress could choose to minimize federal 

spending and oversight activities by requiring accreditation of residential 

 31 See related discussion in a recent report by the Congressional Research Service, Family 

Law: Congress’s Authority to Legislate on Domestic Relations Questions, Updated 

October 25, 2007, Washington, D.C. (RL31201). 

32 For example, the Commerce Clause serves as the basis for federal regulation of child 

pornography that moves in interstate or foreign commerce. Moreover, courts have found 

that the Child Support Recovery Act, which criminalizes failure to pay past child support

obligations to a child residing in a different state than the parent, is a constitutional 

exercise of congressional authority under the Commerce Clause. 

Page 37 GAO-08-346 Residential Facilities 
facilities by a national organization.33 In considering a federal mandate, 

Congress may need to evaluate concerns about federal versus state 

responsibilities, practical feasibility, and the ability to offset attendant 

costs to the federal government. This option would have the benefit of 

capturing exclusively private facilities, but only those facilities that have 

the requisite connection to interstate commerce. 

• Add requirements in law to existing federal programs. Congress could 

change existing program law to add requirements states must meet to 

receive federal programs funds. For example, it could include specific 

standards of well-being and oversight in areas where youth are known to 

be at risk, such as suicide prevention and seclusion and restraint. This 

would provide the advantage of developing minimum requirements for 

youth well-being that cut across agencies and programs. This option would 

not increase federal program spending. However, because it is directed at 

federal programs that provide funding to states, it would not safeguard 

youth in exclusively private facilities.

• Establish a new federal program. Congress could also establish a new 

federal program that would provide financial assistance to states that 

agree to comply with federal requirements, such as those to expand the 

scope and rigor of oversight to cover all residential facilities. This option 

would address oversight coverage for youth in all facilities in a state, but 

would be effective only in states that choose to comply with federal 

requirements in exchange for the new program funding. This option would 

also increase spending for the federal government. 

States’ freedom to legislate and the existing patchwork of federal 

legislation and oversight addressing youth well-being have led to 

substantial disparity in protecting the well-being and civil rights of some of 

the nation’s most vulnerable youth. There are no easy solutions. However, 

states, federal agencies, and Congress have various options to consider in

restructuring the current federal-state oversight system to better protect 

youth from harm. While Congress, federal agencies, and states will need 

time to consider these options, and weigh the trade-offs that each option

Conclusion 

 33 The Centers for Medicare & Medicaid Services, for example, have accreditation 

requirements for certain facilities as a condition of payment under its programs. To be

effective, this approach would require a mechanism to ensure that the accrediting body 

communicates any problems or loss of accreditation to the appropriate state and federal

entities. 

Page 38 GAO-08-346 Residential Facilities 
entails, more can be done now within the existing regulatory structure to 

address outstanding concerns. 

State and federal agencies acknowledge the need for comprehensive and

complete data for each case of death, maltreatment, and other adverse 

incidents that occur in residential facilities, but barriers remain in 

collecting and reporting this information. Absent complete data and 

mechanisms to share information among relevant state and federal 

oversight agencies, officials are missing opportunities to assess the full 

magnitude of child maltreatment in residential facilities and respond to the 

extent of their authority in addressing issues or targeting investigations, 

such as those conducted by DOJ’s Civil Rights Division. Further, absent 

enhanced oversight among federal agencies, these agencies will continue 

to miss opportunities to use available information to address identified 

risks to youth and hold states accountable for youth well-being under the 

current regulatory structure. Unless sufficient accountability is set up 

within state or federal regulatory structures using the oversight processes 

provided by federal program authority, state licensing systems, national 

accreditation, or other options, the well-being and civil rights of youth in

some facilities will remain at risk. 

To help policymakers craft solutions that best address the magnitude of 

maltreatment and other threats to youth well-being in residential facilities, 

and also to facilitate federal oversight across states and agencies, we 

recommend that the Secretary of HHS take action to determine what 

barriers remain in those states that do not report case-file data for 

residential facilities to NCANDS and explore options to help states address 

existing barriers. 

To help target federal civil rights investigations among states and facilities 

that can provide maximum benefit, we recommend that the U.S. Attorney 

General work with the Secretary of HHS to obtain access to the NCANDS 

case-file data for residential facilities. We also recommend that the 

Attorney General work with HHS, the Office of Juvenile Justice and 

Delinquency Prevention, and Education to obtain access to other sources 

of relevant information within relevant subagencies, such as HHS’ Centers 

for Disease Control and Prevention.

To help ensure that the existing federal regulatory structure protects youth 

well-being across government and private residential facilities supported by

federal programs, we recommend that HHS, DOJ, and Education work to

enhance their oversight of state accountability for youth well-being in

Recommendations for 

Executive Action 

Page 39 GAO-08-346 Residential Facilities 
residential facilities. Such efforts could include ensuring that residential 

facilities are included in federal oversight reviews and on-site visits to states.

We provided a draft of this report to HHS, DOJ, and Education for 

comment. HHS’ comments are reproduced in appendix X, and DOJ’s 

comments are reproduced in appendix XI. Education’s Office of Special

Education and Rehabilitative Services provided comments on behalf of the 

department that are reproduced in appendix IX. HHS and DOJ also 

provided technical comments that we incorporated, as appropriate. 

Overall, HHS and DOJ either generally agreed, or did not disagree, with 

each of our recommendations. They also suggested further action that 

could be taken to address the report findings related to gaps in data and 

oversight for residential facilities. Education did not directly respond to 

the report recommendations but rather discussed its role and 

responsibilities for oversight of certain programs. 

HHS did not agree or disagree with our recommendation that the 

Secretary take action to identify and help states address barriers in 

reporting case-file data for residential facilities to NCANDS, and DOJ did 

not comment on this recommendation. HHS stated that the number of 

states reporting case-level data and the quality of data submitted has 

improved over the years, and that its Administration for Children and 

Families (ACF) will continue to work with states to improve the collection 

of information wherever possible and feasible. We recognize that federal 

law provides states with some latitude in reporting data “to the maximum 

extent practicable.” However, we remain concerned about the gaps in 

reported data that have persisted over a decade since the reporting 

requirement has been in place, which is why we have recommended that

HHS take action to help address remaining barriers. 

DOJ agreed with our recommendation that the Attorney General work 

with the Secretary of HHS to obtain NCANDS data that can help target 

civil rights investigations. HHS stated that ACF would be pleased to work 

with DOJ in implementing this recommendation; however, ACF was 

unclear how the NCANDS data would be useful in targeting investigations. 

As our report shows (see app. III), custom data analysis provided by HHS’s 

NCANDS contractor provides important information on the number and 

type of maltreatment incidents by facility staff in each state that DOJ can 

use, in combination with other information sources, to prioritize 

investigations among states. 

Agency Comments 

and Our Evaluation 

Federal Agency Comments 

on GAO Report 

Recommendations

Page 40 GAO-08-346 Residential Facilities 
DOJ also agreed with our recommendation that the Attorney General work 

with its Office of Juvenile Justice and Delinquency Prevention, HHS, and 

Education to obtain access to other sources of relevant oversight 

information within the subagencies of these departments. HHS did not 

address this recommendation. 

In regard to our recommendation that HHS, DOJ, and Education work to 

enhance their oversight of state accountability for youth well-being in 

residential facilities, DOJ and HHS indicated that they are conducting state 

oversight consistent with existing statutory authority and resources. In 

addition, DOJ cited several measures it has implemented, such as training

and technical assistance to states as well as use of interdepartmental 

working relationships, which will help ensure that the existing federal 

regulatory structure protects youth well-being across facilities supported 

by federal programs. We agree that the efforts cited by DOJ can help to 

improve conditions for youth in residential facilities. However, given the 

continued reports of maltreatment in residential facilities by state agencies 

we surveyed, and results of investigations by DOJ’s Civil Rights Division, 

we continue to recommend that HHS, DOJ, and Education seek to identify 

ways to enhance their oversight of state accountability for youth wellbeing. For example, HHS and Education could include residential facilities 

in federal oversight reviews. Also, our recommendations focus on agency 

actions that could be done or begun quickly under the current legal and 

regulatory framework; however, in our discussion of policy options we 

identify additional longer-term measures that federal agencies could 

consider taking. For example, agencies could modify the conditions of 

participation for relevant grant programs to require states to give priority 

to facilities that are accredited or held to recognized standards of care. We 

further note that if these agencies determine they do not have authority to 

do this, they could request it from Congress. 

DOJ and HHS also commented on further actions that federal agencies 

could take beyond the GAO recommendations. Specifically, DOJ 

identified interagency coordination as an important way to enhance youth 

well-being in residential facilities and stated that the existing Coordinating 

Council on Juvenile Justice and Delinquency Prevention could be used for 

this purpose. DOJ suggested that this council could be a vehicle

establishing minimum standards of care for all relevant federal programs. 

We offer a similar approach in our discussion of longer-term policy 

options. HHS noted the likely benefits of requiring facilities to notify 

parents of certain actions, such as disciplinary actions, restraint, or 

seclusion. 

Page 41 GAO-08-346 Residential Facilities 
Finally, HHS stated that the report findings and recommendations should 

more prominently address the issue of unlicensed facilities. In our 

discussion of longer-term policy options, we note that states could 

improve the well-being of youth in residential facilities by expanding their 

licensing coverage, among other options. We also describe actions 

Congress could take to address gaps in licensing and oversight since, 

under the current framework, federal agencies do not have oversight 

authority for private facilities unless those facilities serve youth in state 

programs supported by federal funds. However, we also note that many 

facility types are licensed and that licensing alone, absent comprehensive 

standards, regular monitoring, and effective use of sanctions for 

noncompliance, cannot ensure youth well-being in residential facilities. 

Education commented that while it is responsible for ensuring state 

compliance with certain federal education programs for youth—and 

recognizing that a protective and safe school environment is necessary for 

all students—it is not in the department’s statutory or regulatory authority 

to ensure oversight of the total well-being of youth in residential facilities. 

Although Education would not be responsible for the total well-being of 

these youth, we believe that the report findings highlighting the gaps in 

safeguarding the educational well-being of youth in residential facilities 

warrant greater Education oversight of state accountability for the 

education of youth in residential facilities. 

HHS commented that table 5 of the report shows that the Substance Abuse 

and Mental Health Services Administration has no program requirements 

that address certain risks to youth well-being, and noted that the agency 

has no regulatory oversight of individual residential facilities at the local 

level. To clarify, the federal program requirements in table 5 do not relate 

to federal requirements for individual facilities, but to federal program 

requirements for state oversight of residential facilities, as stated. The 

report text following the table states the position of HHS, DOJ, and 

Education that they do not have the authority to require states to address 

these risks in their oversight of facilities. 

Federal Agency Comments 

on GAO Report Findings 

Page 42 GAO-08-346 Residential Facilities 
Copies of this report are being sent to the Honorable Margaret Spellings, 

Secretary of Education; the Honorable Michael O. Leavitt, Secretary of 

Health and Human Services; the Honorable Michael B. Mukasey, U.S. 

Attorney General; and relevant congressional committees and other 

interested parties. We will also make copies available to others upon 

request. In addition, the report will be made available at no charge on 

GAO’s Web site at http://www.gao.gov. Please contact me on (202) 512-

7215 if you or your staff have any questions about this report. Other 

contacts and major contributors are listed in appendix XII. 

Sincerely yours, 

Kay E. Brown 

Director, 

Education, Workforce, and Income Security Issues 

Page 43 GAO-08-346 Residential Facilities 
Appendix I: Objectives, Scope, and 

Methodology 

Page 44 GAO-08-346 Residential Facilities 

Appendix I: Objectives, Scope, and 

Methodology 

We were asked to examine (1) the nature of the incidents that adversely 

affect the well-being of youth in residential facilities, (2) how state 

licensing and monitoring requirements address the well-being of youth in 

residential facilities, and (3) how federal agencies hold states accountable

for youth well-being in residential facilities. We used multiple data 

collection methods to obtain this information. We conducted three Webbased surveys of state child welfare, health and mental health, and juvenile 

justice directors and conducted site visits in four states where we 

interviewed state officials. Because of overlapping state agency program 

jurisdictions, and differences in how residential treatment centers and the 

services they provide are defined, we were unable to quantify the number 

of residential facilities and youth served. We also interviewed federal child 

welfare, health and mental health, juvenile justice, and education officials

and representatives from national organizations concerning state child 

welfare, health and mental health, and juvenile justice programs and 

federal roles and responsibilities for overseeing residential facilities. In 

addition, we reviewed several national studies and related GAO reports to 

identify adverse incidents affecting youth in residential facilities and key

federal and state oversight policies and practices. Finally, we analyzed 

agency documentation, legislation, and other documentation related to 

child welfare, health and mental health, and juvenile justice programs and 

requirements. We performed our work between November 2006 and April 

2008, in accordance with generally accepted government auditing 

standards. 

For purposes of this study, we defined residential facilities as those that 

require youth—ages 12 through 17—to reside at the facility and that 

provide program services for youth with behavioral and emotional 

challenges. These types of facilities include (1) juvenile justice, youth 

offender, juvenile delinquency, and incorrigibility programs; (2) treatment 

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

substance abuse issues and homes for pregnant teens; (3) alternative 

schools, e.g., schools for discipline or character education; and (4) 

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

and treating youth with severe emotional disorders. The types of residence 
Appendix I: Objectives, Scope, and 

Methodology 

include schools, academies, camps, ranches, boarding homes, dormitories, 

treatment centers, and juvenile detention centers.1

To obtain state perspectives on our objectives, we conducted three Webbased surveys of state child welfare, health and mental health, and juvenile 

justice directors in the 50 states, the District of Columbia, and Puerto Rico. 

The surveys were conducted using a self-administered electronic 

questionnaire posted on the Web. We contacted directors via e-mail 

announcing the survey and sent follow-up e-mails to encourage responses. 

The survey data were collected between May and September 2007. We 

received at least one completed survey from 50 states and the District of 

Columbia. We received completed surveys from 44 child welfare agencies, 

45 health and mental health agencies, and 44 juvenile justice agencies. In 

32 states and the District of Columbia, all three agencies completed the

survey. We received at least one survey back from each state, except

Puerto Rico. We invited Puerto Rico to participate in the survey but did 

not receive any response from its offices. This report does not contain all 

of the results from the survey. The survey and a more complete tabulation 

of the results can be viewed by accessing the following link: 

http://www.gao.gov/cgi-bin/getrpt?GAO-08-631SP. 

Table 6: Status of State Agency Responses to GAO Survey on Residential Facilities 

for Youth 

Web-based survey 

State Child welfare Health/mental health Juvenile justice 

States that responded to all three surveys 

Alaska √ √ √

Ark. √ √ √

Calif. √ √ √

Colo. √ √ √

Conn. √ √ √

D.C. √ √ √

 1

 As a result of this definition, the following facilities were excluded from the review as 

they do not primarily serve adolescents or provide behavior modification services: (1) adult 

prisons; (2) hospitals, nursing homes, and facilities that serve youth who are medically 

fragile; (3) family or group foster care homes, orphanages, homeless shelters, halfway 

houses, and other facilities where the primary services are housing and ordinary child care;

(4) recreational facilities such as summer sports camps; (5) college preparatory schools; 

and (6) facilities that serve only children under 12 years of age. 

Page 45 GAO-08-346 Residential Facilities 
Appendix I: Objectives, Scope, and 

Methodology 

State Child welfare Health/mental health Juvenile justice 

Del. √ √ √

Fla. √ √ √

Ga. √ √ √

Hawaii √ √ √

Idaho √ √ √

Ind. √ √ √

Kans. √ √ √

Mass. √ √ √

Md. √ √ √

Maine √ √ √

Mich. √ √ √

Minn. √ √ √

Mo. √ √ √

Mont. √ √ √

N.C. √ √ √

N.Dak. √ √ √

Neb. √ √ √

N.H. √ √ √

N.Y. √ √ √

Ohio √ √ √

Pa. √ √ √

S.C. √ √ √

Tenn. √ √ √

Utah √ √ √

Va. √ √ √

Wash. √ √ √

Wis. √ √ √

States that responded to two surveys 

Ala. √ √ — 

Ariz. — √ √

Iowa — √ √

Ill. √ √ — 

Ky. — √ √

La. √ √ — 

Miss. √ √ — 

N.Mex. √ — √

Okla. √ — √

Page 46 GAO-08-346 Residential Facilities 
Appendix I: Objectives, Scope, and 

Methodology 

State Child welfare Health/mental health Juvenile justice 

Ore. √ — √

R.I. √ √ — 

S.Dak. √ — √

Tex. √ √ — 

Vt. — √ √

W.Va. — √ √

Wyo. √ √ — 

States that responded to one survey 

N.J. — — √

Nev. — — √

Source: GAO analysis of state agencies’ survey responses. 

Note: √ = survey received, — = no survey received.

To develop the survey questions, we reviewed several national studies and 

related GAO reports to determine issues pertaining to the licensing and 

monitoring of residential facilities for youth. We analyzed agency 

documentation to identify the oversight roles and responsibilities of the 

departments of Health and Human Services, Justice, and Education. In 

addition, we examined related surveys administered by other

organizations to identify relevant issues pertaining to adverse incidents 

affecting youth and state practices regarding their licensing and 

monitoring of residential facilities. 

We worked to develop the questionnaire with social science survey 

specialists. Because these were not sample surveys, there are no sampling 

errors. However, the practical difficulties of conducting any survey may 

introduce errors, commonly referred to as nonsampling errors. For 

example, differences in how a particular question is interpreted, in the 

sources of information that are available to respondents, or how the data

are entered into a database can introduce unwanted variability into the 

survey results. We took steps in the development of the questionnaires, the 

data collection, and data analysis to minimize these nonsampling errors. 

For example, prior to administering the survey, we pretested the content

and format of the questionnaire with several states to determine whether 

(1) the survey questions were clear, (2) the terms used were precise, (3) 

respondents were able to provide the information we were seeking, and 

(4) the questions were unbiased. We made changes to the content and 

format of the final questionnaire based on pretest results. In that these 

were Web-based surveys in which respondents entered their responses 

directly into our database, there was a reduced possibility of data entry 

Page 47 GAO-08-346 Residential Facilities 
Appendix I: Objectives, Scope, and 

Methodology 

error. We also performed computer analyses to identify inconsistencies in 

responses and other indications of possible error and called back 

respondents to verify responses as needed. We also collected paper 

documentation to support survey responses from the agencies in our case 

study states. 

We used standard descriptive statistics to analyze survey questions. For 

certain open-ended survey questions, such as other causes of deaths and 

interstate locations where youth were placed, we used standard content 

analysis methods, including independent coding by two raters and tests of 

concurrence and rates of agreement. All disagreements between raters 

were resolved by discussion. In addition, an independent analyst verified 

that the computer programs used to analyze the data were written 

correctly. 

While we asked state officials to complete the survey for their agency, 

some officials responded for their state as a whole. This includes Alaska 

and Nebraska’s health, mental health, and substance abuse survey; 

Colorado’s juvenile justice and rehabilitation survey; and Montana’s child 

welfare services survey. In a few states, residential facilities are licensed 

by a central licensing agency whose information was not included among 

the three surveyed agency responses (e.g., Kansas’ Department of Health 

and Environment; Massachusetts’ Department of Early Education and 

Care; and Utah’s Office of Licensing).

We visited four states—California, Florida, Maryland, and Utah. We based

our criteria for selecting these states on the following five criteria: (1) the

breadth of state policies regarding processes for licensing and monitoring 

residential programs; (2) reports of child abuse, neglect, and fatalities; (3) 

administration of residential programs by states or by county 

governments; (4) initiation of broad changes to licensing and monitoring 

policies; and (5) geographic location of the state. During these visits, we 

interviewed state child welfare, health and mental health, and juvenile

justice officials and collected relevant state agency policies and 

procedures and reports. In addition, we obtained information on adverse 

incidents and state licensing and monitoring practices from protection and 

advocacy agencies, state attorney general offices, state auditors, and U.S. 

Attorneys’ offices in each of the four selected states. Information that we 

gathered on our site visits represents only the conditions present in the 

states and local areas at the time of our site visits. We cannot comment on 

any changes that may have occurred after our fieldwork was completed. 

Furthermore, our fieldwork focused on in-depth analysis of only a few 

Site visits 

Page 48 GAO-08-346 Residential Facilities 
Appendix I: Objectives, Scope, and 

Methodology 

selected states. On the basis of our site visit information, we cannot 

generalize our findings beyond the states we visited. 

We also obtained data on the extent, nature, and cause of youth abuse and

neglect in residential facilities from Cornell University—the designated 

archive for the National Child Abuse and Neglect Data System (NCANDS). 

The Department of Health and Human Services (HHS) conducts extensive 

edit checks of the NCANDS for internal reliability. All edit check programs 

are shared with the states. HHS also funds the National Resource Center 

for Information Technology in Child Welfare. This resource center 

provides technical assistance to states to improve reporting to NCANDS, 

improve statewide information systems, and better utilize state data. We 

obtained NCANDS data for fiscal year 2005, the latest year for which such 

data are available, from Cornell University, the designated archive for 

NCANDS. We worked with representatives from Cornell who manage 

NCANDS to develop appropriate databases for identifying the extent, 

nature, and cause of youth abuse and neglect in residential facilities. Our 

analysis of NCANDS, however, showed that the reliability of the data 

could be affected by several factors, including missing state data, the 

differences in state definitions for NCANDS data elements, the 

nonparticipation of 2 states, and the inability of 37 states to identify the 

type of perpetrator in all instances of abuse and neglect. NCANDS data 

weaknesses are also summarized in the report. As a result of these issues, 

we found that it is likely that the total number of national incidents of 

abuse and neglect by residential facility staff is underreported. 

NCANDS Data Reliability 

Page 49 GAO-08-346 Residential Facilities 
Appendix II: Circumstances Surrounding 

State-Reported Suicides in Residential 

Facilities for Youth, 2006

Page 50 GAO-08-346 Residential Facilities 

Nearly all state-reported suicides occurred in licensed private residential

facilities that received government funds. Generally, these residential 

facilities provided health and mental health services. Pennsylvania also 

reported that a suicide occurred in a government correctional facility that 

was not required to be licensed. Recommendations intended to address 

the circumstances surrounding state-reported suicides included steps to 

provide statewide training in suicide awareness and prevention and 

improved suicide prevention protocols in residential facilities. 

Table 7: States Reporting Youth Suicides by Type of Facility, Authorization for Providing Services, and Related Investigatory 

Findings, 2006

Statea

Type of facility in 

which fatality 

occurred

Type of authorization for

providing services 

(licensure, accreditation,

general contractor

authority) Findings and recommendations from related investigations

Alaska Private treatment

facility for health 

services that received 

government funds 

Licensed The state agency recommended physical modifications to the 

building and changed policies and procedures to address 

staffing, supervision, and clinical services. 

Ariz. Private treatment

facility for health and 

mental health services 

that received

government funds 

Licensed The investigations prompted recommendations to provide staff 

training on interventions and hire additional staff to be present 

during crisis episodes. 

Calif. Private group home for 

child welfare services 

that received

government funds 

Licensed The state agency instructed the facility administrator to discuss 

with staff behaviors that may lead to suicide. The agency also 

recommended additional training for facility staff. In addition,

facility staff and clients were to receive counseling regarding the 

incident. Following the investigation, the agency cited the facility 

for lack of care and supervision and closed it.

Iowa Private facility for child 

welfare and juvenile 

justice treatment 

services that received 

government funds 

Licensed and accredited Residential facilities initiated improved suicide prevention 

protocols and one facility improved its communication among 

staff. 

Neb. Private treatment

facility for health and 

mental health services 

that received

government funds 

Licensed and accredited No formal recommendations resulted from the agency’s internal 

investigation and it did not know whether other agencies made 

recommendations. 

Pa. Government

correctional facility for 

juvenile justice 

services 

Unlicensed (state did not 

require government 

facilities to be licensed) 

The state agency contracted with an expert on suicides in

residential facilities to provide recommendations for preventing 

future suicides.

Appendix II: Circumstances Surrounding 

State-Reported Suicides in Residential 

Facilities for Youth, 2006 
Appendix II: Circumstances Surrounding 

State-Reported Suicides in Residential 

Facilities for Youth, 2006

Statea

Type of facility in 

which fatality 

occurred

Type of authorization for

providing services 

(licensure, accreditation,

general contractor

authority) Findings and recommendations from related investigations

Tex. Private treatment

facility for health and 

mental health services 

that received

government funds 

Licensed The state agency provided a residential facility with technical

assistance on implementing policies to search for contraband

that youth might bring to the facility. 

Wis. Private treatment

facility for health and 

mental health services 

that received

government funds 

Licensed The facility implemented a quality improvement plan that 

includes revisions to facility’s policy on suicide precautions and 

staff orientation, development, and in-service training. In 

addition, the agency sponsored statewide training in suicide

awareness and prevention for managers and others who work

with youth in group homes and residential settings. 

Source: GAO analysis of survey responses and additional state-reported information. 

a

Alabama did not respond to our request for additional information on the circumstances surrounding 

its reported suicide. 

Page 51 GAO-08-346 Residential Facilities 
Appendix III: State-Reported Incidents of

Staff Maltreatment of Youth in Residential 

Facilities, Fiscal Year 2005

Page 52 GAO-08-346 Residential Facilities 

NCANDS data show that 34 of 41 states that provide facility-level data

reported incidents where residential facility staff maltreated youth in fiscal 

year 2005. Reported incidents of neglect or deprivation of necessities in 

each state generally exceeded other types of maltreatment, although 

certain states reported more cases of physical or sexual abuse. In 22 

states, facility staff committed multiple maltreatments, as indicated by the 

number of maltreatment cases exceeding the number of unique 

perpetrators. Among the 10 states that did not provide facility level data, 7 

states did not track data for residential facilities in a form that could be 

shared with NCANDS, 1 state did not report data in 2005 due to

outstanding legal issues, and 2 states did not report any data to NCANDS. 

Table 8: State-Reported Incidents of Staff Maltreatment of Youth in Residential Facilities, Fiscal Year 2005 

Maltreatment type

State 

Unique

perpetrators 

Unique

maltreatments 

Physical 

abuse

Neglect or

deprivation 

of 

necessities

Medical 

neglect

Sexual 

abuse

Psychological

or emotional 

maltreatment Other 

Unknown 

or

Missing

Ala. 4 4 3 0 0 1 0 0 0

Ark. 2 2 1 0 1 0 0 0 0

Ariz. 9 18 0 17 0 1 0 0 0

Calif. 56 69 15 45 0 2 6 1 0

Colo. 25 70 8 54 0 4 2 0 2

D.C. 4 4 3 0 0 1 0 0 0

Fla. 46 87 7 52 4 6 6 12 0

Ill. 18 27 18 4 0 5 0 0 0

Ind. 47 75 27 36 0 12 0 0 0

Kans. 3 3 1 0 0 2 0 0 0

Ky. 15 17 9 4 0 4 0 0 0

La. 2 2 0 2 0 0 0 0 0

Mass. 95 153 29 116 0 8 0 0 0

Md. 1 1 0 1 0 0 0 0 0

Maine 1 1 0 0 0 1 0 0 0

Minn. 7 10 0 9 0 1 0 0 0

Mo. 27 34 11 6 2 15 0 0 0

Mont. 3 5 0 2 0 3 0 0 0

N.C. 45 71 4 56 1 6 0 4 0

Neb. 1 1 0 1 0 0 0 0 0

N.J. 66 66 12 45 6 2 1 0 0

Appendix III: State-Reported Incidents of 

Staff Maltreatment of Youth in Residential 

Facilities, Fiscal Year 2005 
Appendix III: State-Reported Incidents of

Staff Maltreatment of Youth in Residential 

Facilities, Fiscal Year 2005

N.Y.a186 469 97 92 5 14 53 208 0

Ohio 18 18 9 3 0 6 0 0 0

Pa. 38 40 24 1 0 15 0 0 0

R.I. 24 36 3 10 0 0 1 22 0

S.C. 21 28 8 14 0 6 0 0 0

S.Dak. 2 7 0 6 0 1 0 0 0

Tenn. 36 53 30 14 1 8 0 0 0

Tex. 56 82 34 45 0 3 0 0 0

Va. 6 12 3 5 0 4 0 0 0

Vt. 1 2 0 0 0 2 0 0 0

Wash. 1 1 1 0 0 0 0 0 0

Wis. 9 9 0 4 0 4 0 1 0

W.Va. 12 26 6 13 0 1 6 0 0

State reported no incidents of abuse and neglect in residential facilities 

Del. 0

Hawaii 0

Idaho 0

Iowa 0

N.H. 0

Nev. 0

Utah 0

State did not track data on abuse and neglect in residential facilities in a format compatible with NCANDS 

Alaska

Conn.

Mich.

Miss.

N.Mex.

Okla.

Wyo.

State did not report data on abuse and neglect in residential facilities

Ga.

State did not report any NCANDS data 

N.Dak.

Ore.

 Total 887 1,503 363 657 20 138 75 248 2

Source: NCANDS. 

Page 53 GAO-08-346 Residential Facilities 
Appendix III: State-Reported Incidents of

Staff Maltreatment of Youth in Residential 

Facilities, Fiscal Year 2005

a

According to NCANDS data archive officials, the large number of incidents in New York, including 

“other” maltreatment types, may be attributable to the child welfare agency’s broader definition of 

what constitutes a residential facility and “other” types of abuse and neglect compared to narrower 

definitions used by other states. The comparability of data among states is difficult because of the 

variability in state definitions and state compliance with report requirements.

Page 54 GAO-08-346 Residential Facilities 
Appendix IV: Licensing Status for Selected 

Residential Facilities 

Page 55 GAO-08-346 Residential Facilities 

Table 9: Licensing Status for Selected State-Operated Residential Facilities 

Facility type and state agency Required Exempt 

No such

facility in 

state

No 

oversight

State-Operated facilities

Child welfare 13 7 3 20

Health and mental health 23 6 1 14

Juvenile justice 13 28 2 1

Source: GAO analysis of state agencies’ survey responses. 

Note: Other responses included “Don’t know” and “No response.”

Table 10: State Agencies Reporting the Licensing Status for State-Operated

Residential Facilities That Serve Youth 

State Child welfare Health and mental health Juvenile justice 

Alaska NO NO Exempt

Ala. NO NO NS

Ariz. NS Required Required

Ark. NO Required NO

Calif. Exempt NR Exempt

Colo. Required Required Required

Conn. Exempt Exempt Exempt

D.C. DK NO Required

Del. Exempt Required Exempt

Fla. NO Required Exempt

Ga. NO Exempt Exempt

Hawaii NO Required Exempt

Iowa NS Required Exempt

Idaho NF NF Exempt

Ill. NO Required NS

Ind. Required Required Required

Kans. Exempt Required Exempt

Ky. NS NO Required

La. NO Required NS

Mass. NO NO Required

Md. NO Required Exempt

Maine NO NO Exempt

Mich. Required Required Required

Appendix IV: Licensing Status for Selected 

Residential Facilities 
Appendix IV: Licensing Status for Selected 

Residential Facilities 

State Child welfare Health and mental health Juvenile justice 

Minn. Required Required Required

Mo. NO Required Exempt

Miss. NO Required NS

Mont. Required Required Exempt

N.C. NO Exempt Exempt

N.Dak. NF NO Exempt

Neb. NO Required Exempt

N.H. Required NO Exempt

N.J. NS NS Exempt

N.Mex. Required NS NF

Nev. NS NS Required

N.Y. NF NO Exempt

Ohio Exempt Exempt Required

Okla. Required NS Exempt

Ore. NO NS Exempt

Pa. Exempt Exempt Exempt

R.I. Required NO NS

S.C. Required Required Required

S.Dak. NO NS Exempt

Tenn. Required Required NF

Tex. NO Required NS

Utah NO NO Exempt

Va. Required Required Required

Vt. NS NO Exempt

Wash. NO Exempt Exempt

Wis. Required NO Exempt

W.Va. NS Required Required

Wyo. Exempt NO NS

Source: GAO analysis of state agencies’ survey responses. 

Notes: NF = no such facility in state, NO = no oversight, DK = don’t know, NS = no survey, NR = no 

response. 

The survey questions were as follows: Which, if any, of the following types 

of government-operated facilities providing residential [targeted; health, 

mental health, substance abuse; juvenile justice or rehabilitation] services 

for youth are currently exempt from licensing or monitoring in your state 

by statute or state regulation? State-operated facility: (a) exempt from 

licensing, (b) exempt from monitoring, (c) exempt from both, (d) exempt 

Page 56 GAO-08-346 Residential Facilities 
Appendix IV: Licensing Status for Selected 

Residential Facilities 

from neither; (e) no such facility in state, (f) don’t know, and (g) no 

response. The question was administered only to agencies that reported 

that their agency operates or has oversight over government-operated 

residential facilities providing services to youth age 12-17. 

Table 11: Licensing Status for Selected Residential Facilities That Receive Government Funds 

Facility type and state agency 

Licensure 

required

Exempt from 

licensing

No such facility 

in state 

Don’t know or no 

response

Treatment Centers 

Child welfare 39 1 1 3

Health and mental health 35 0 2 8

Juvenile justice N/A N/A N/A N/A

Wilderness camps 

Child welfare 24 3 10 7

Health and mental health 16 3 9 17

Juvenile justice 13 1 17 13

Ranches

Child welfare 14 3 20 7

Health and mental health 8 3 16 18

Juvenile justice 6 2 22 14

Boot camps

Child welfare 10 6 20 8

Health and mental health 6 2 15 22

Juvenile justice 4 3 25 12

Residential schools and 

academies 

Child welfare 19 18 4 3

Health and mental health 15 10 1 19

Juvenile justice 14 14 5 11

Detention centers 

Child welfare N/A N/A N/A N/A

Health and mental health N/A N/A N/A N/A

Juvenile justice 14 11 6 13

Source: GAO analysis of state agencies’ survey responses. 

Page 57 GAO-08-346 Residential Facilities 
Appendix IV: Licensing Status for Selected 

Residential Facilities 

Table 12: State Child Welfare Agencies Reporting the Licensing Status for Selected

Private Residential Facilities That Serve Youth and Receive Government Funding 

State 

Treatment

facilities 

Wilderness 

camps Ranch

Boot 

camps

Residential schools

and academiesa

Alaska NR NR NF DK NR

Ala. Required Required Required Required Exempt

Ariz. NS NS NS NS NS

Ark. Required Required Required DK DK

Calif. Required NF Required NF Exempt

Colo. Required Required Required NF Required

Conn. Required Required NF NF Exempt

D.C. Required DK DK DK NF

Del. Required NF NF NF Required

Fla. Required DK DK DK Exempt

Ga. Required Required NF NF Exempt

Hawaii NR NR NR NR Exempt

Iowa NS NS NS NS NS

Idaho Required Required NF NF Required

Ill. Required DK NF DK NF

Ind. NF Exempt Exempt Exempt Required

Kans. Required NF NF NF Required

Ky. NS NS NS NS NS

La. Required Required DK NF DK

Mass. NR NR NR NR Required

Md. Required Required Required Required Required

Maine Required NF NF NF Required

Mich. Required Required Required Required Exempt

Minn. Required NF NF NF NF

Mo. Required Exempt Required Exempt Exempt

Miss. Required NF NF NF Required

Mont. Required Required Exempt Required Required

N.C. Required Required DK Exempt Exempt

N.Dak. Required NF Required NF Exempt

Neb. Required NF NF NF NF

N.H. Required Required NF NF Required

N.J. NS NS NS NS NS

Page 58 GAO-08-346 Residential Facilities 
Appendix IV: Licensing Status for Selected 

Residential Facilities 

State 

Treatment

facilities 

Wilderness 

camps Ranch 

Boot 

camps

Residential schools

and academiesa

N.Mex. Required Exempt Exempt Exempt Exempt

Nev. NS NS NS NS NS

N.Y. Exempt NF NF NF Exempt

Ohio Required NR Required Required Exempt

Okla. Required Required Required Required Required

Ore. Required Required NF Exempt Required

Pa. Required Required Required Required Exempt

R.I. Required Required NF NF Required

S.C. Required Required NF Required Exempt

S.Dak. Required NF NF NF Exempt

Tenn. Required Required NF NF Required

Tex. Required Required NR NR Exempt

Utah Required Required NF NF Required

Va. Required Required Required Required Required

Vt. NS NS NS NS NS

Wash. Required Required Required Exempt Required

Wis. Required Required Required Required Exempt

W.Va. NS NS NS NS NS

Wyo. Required Required NF NF Required

Source: GAO analysis of state agencies’ survey responses. 

Note: N/A = not applicable, NF = No such facility in state, DK = don’t know, NS = no survey, NR = no 

response. 

a

The survey question for private residential schools and academies did not distinguish between 

private facilities that received government funding and those that did not. 

The survey questions pertaining to private residential facilities that 

received or did not receive government funds for state child welfare, 

health and mental health, and juvenile justice agencies were as follows: 

Which, if any, of the following types of residences that provide [targeted; 

health, mental health, or substance abuse; juvenile justice and

rehabilitation] services for youth are currently exempt from licensing or 

routine monitoring in your state by statute or state regulations: (a) exempt 

from licensure, (b) exempt from monitoring, (c) exempt from both, (d) not 

exempt from either, (e) no such residence in state, (f) don’t know, and (g) 

no response? Check only one for each row. 

Are residential educational institutions, such as schools or academies that

specialize in serving students with behavior or discipline problems (e.g., 

providing discipline, character education, or behavior modification 

Page 59 GAO-08-346 Residential Facilities 
Appendix IV: Licensing Status for Selected 

Residential Facilities 

training in addition to more traditional education), exempt from licensing 

or monitoring by your agency by statute or state regulation: (a) exempt 

from licensure, (b) exempt from monitoring, (c) exempt from both, (d) not 

exempt from either, (e) no such residence in state, (f) don’t know, and (g) 

no response? Check only one for each row. 

Table 13: State Health and Mental Health Agencies Reporting the Licensing Status

for Selected Private Residential Facilities That Serve Youth and Receive 

Government Funding 

State 

Treatment

facilities 

Wilderness 

camps Ranch Boot camps

Residential 

schools and 

academiesa

Alaska Required Required NF Required Exempt

Ala. Required DK DK DK Exempt

Ariz. Required Required NF DK DK

Ark. DK DK NF DK DK

Calif. Required NR NR NR Required

Colo. NR NR NR NR Required

Conn. Required Exempt Required NF Exempt

D.C. Required NR NR NR DK

Del. Required NF NF NF DK

Fla. Required DK DK DK NR

Ga. NR Required Required DK Required

Hawaii Required Exempt Exempt Exempt DK

Iowa Required NR NR NR Required

Idaho Required Required NF NF Required

Ill. Required Exempt Exempt Exempt Required

Ind. DK DK DK DK Required

Kans. NF NF NF NF DK

Ky. DK DK DK DK DK

La. Required DK DK DK DK

Mass. Required Required NF Required Required

Md. Required NR NR NR Exempt

Maine Required DK DK DK DK

Mich. Required Required DK DK DK

Minn. Required NF NF NF NF

Mo. Required DK DK DK DK

Miss. Required NF NF NF Required

Mont. Required Required Exempt Required Required

Page 60 GAO-08-346 Residential Facilities 
Appendix IV: Licensing Status for Selected 

Residential Facilities 

State 

Treatment

facilities 

Wilderness 

camps Ranch Boot camps

Residential 

schools and 

academiesa

N.C. Required Required NR NR Exempt

N.Dak. NR DK DK DK DK

Neb. Required NF Required NF Required

N.H. Required Required NF NF Required

N.J. NS NS NS NS NS

N.Mex. NS NS NS NS NS

Nev. NS NS NS NS NS

N.Y. Required DK DK DK Exempt

Ohio Required NF NF NF NR

Okla. NS NS NS NS NS

Ore. NS NS NS NS NS

Pa. Required Required Required Required Exempt

R.I. Required NF NF NF DK

S.C. Required NF NF NF Exempt

S.Dak. NS NS NS NS NS

Tenn. Required Required Required Required Exempt

Tex. Required Required Required DK DK

Utah Required Required Required NF Required

Va. Required Required NF Required Exempt

Vt. Required Required NF NF Required

Wash. DK DK DK DK NR

Wis. DK DK DK DK DK

W.Va. Required Required Required NF Required

Wyo. NF NF NF NF DK

Source: GAO analysis of state agencies’ survey responses. 

Notes: NF = no such facility in state, DK = don’t know, NS = no survey, NR = no response. 

a

The survey question for private residential schools and academies did not distinguish between 

private facilities that received government funding and those that did not. 

Page 61 GAO-08-346 Residential Facilities 
Appendix IV: Licensing Status for Selected 

Residential Facilities 

Table 14: State Juvenile Justice Agencies Reporting the Licensing Status for 

Selected Private Residential Facilities That Serve Youth and Receive Government 

Funding 

State 

Detention 

centers

Wilderness 

camps Ranch Boot camps

Residential 

schools and 

academiesa

Alaska NR NR NR NR NR

Ala. NS NS NS NS NS

Ariz. DK DK DK DK Exempt

Ark. Exempt Exempt Exempt Exempt Exempt

Calif. DK DK DK DK DK

Colo. Exempt Required Exempt Exempt Required

Conn. Exempt NF NF NF Exempt

D.C. Exempt NF NF NF NF

Del. Required NF NF NF Required

Fla. Exempt Required NF NF Exempt

Ga. Exempt Required DK DK Required

Hawaii Exempt DK NF NF DK

Iowa Required NF NF Required Exempt

Idaho Exempt DK DK DK DK

Ill. NS NS NS NS NS

Ind. Required NF NF NF DK

Kans. NF NF NF NF NF

Ky. Required Required Required Required Required

La. NS NS NS NS NS

Mass. Required NF NF NF Exempt

Md. NF NF NF NF Required

Maine DK NF NF NF DK

Mich. DK DK DK DK NR

Minn. Required Required Required NF Exempt

Mo. DK DK DK DK Required

Miss. NS NS NS NS NS

Mont. NR NR NR NR Required

N.C. NR NR NR NR Required

N.Dak. Required NF Required NF NF

Neb. NR NR NR NR NR

N.H. Exempt Required NF NF Required

N.J. NR NF NF NF DK

Page 62 GAO-08-346 Residential Facilities 
Appendix IV: Licensing Status for Selected 

Residential Facilities 

State 

Detention 

centers

Wilderness 

camps Ranch Boot camps

Residential 

schools and 

academiesa

N.Mex. DK DK DK DK Exempt

Nev. DK NF NF NF DK

N.Y. Required NF NF NF Exempt

Ohio Required DK DK DK Exempt

Okla. Required Required DK Required Exempt

Ore. Exempt Required NF NF Required

Pa. Required Required Required Required Exempt

R.I. NS NS NS NS NS

S.C. NF Required NF NF Required

S.Dak. NF NF Required NF NF

Tenn. Required Required Required NF Required

Tex. NS NS NS NS NS

Utah Required Required NF NF Required

Va. NF NF NF NF Exempt

Vt. NF Required NF NF Required

Wash. DK NF NF Exempt Exempt

Wis. Exempt DK DK NF DK

W.Va. Required NF NF NF NF

Wyo. NS NS NS NS NS

Source: GAO analysis of state agencies’ survey responses. 

Notes: NF = no such facility in state, DK = don’t know, NS = no survey, NR = no response. 

a

The survey question for private residential schools and academies did not distinguish between 

private facilities that received government funding and those that did not. 

Page 63 GAO-08-346 Residential Facilities 
Appendix IV: Licensing Status for Selected 

Residential Facilities 

Table 15: Licensing Status for Selected Exclusively Private Residential Facilities 

Facility type and state agency 

Licensure 

required

Exempt from 

licensing

No such 

facility in state 

Don’t know or

no response

Treatment centers 

Child welfare 30 3 3 8

Health and mental health 30 0 4 11

Juvenile justice N/A N/A N/A N/A

Wilderness camps 

Child welfare 18 3 11 12

Health and mental health 14 2 9 20

Juvenile justice 5 4 15 20

Ranches

Child welfare 11 1 18 14

Health and mental health 11 2 12 20

Juvenile justice 2 5 17 20

Boot camps

Child welfare 8 2 22 12

Health and mental health 6 1 14 24

Juvenile justice 0 5 19 20

Residential schools and 

academies

Child welfare 19 18 4 3

Health and mental health 15 10 1 19

Juvenile justice 14 14 5 11

Detention centers 

Child welfare N/A N/A N/A N/A

Health and mental health N/A N/A N/A N/A

Juvenile justice 3 5 18 18

Source: GAO analysis of state agencies’ survey responses. 

Page 64 GAO-08-346 Residential Facilities 
Appendix IV: Licensing Status for Selected 

Residential Facilities 

Table 16: State Child Welfare Agencies Reporting the Licensing Requirements for 

Selected Exclusively Private Residential Facilities That Serve Youth and Receive No 

Government Funding 

State 

Treatment

facilities 

Wilderness 

camps Ranch Boot camps

Residential 

schools and 

academiesa

Alaska Required Exempt NR NR NR

Ala. DK DK DK DK Exempt

Ariz. NS NS NS NS NS

Ark. Required DK DK DK DK

Calif. Required NF Required NF Exempt

Colo. Required Required Required NF Required

Conn. Required NF NF NF Exempt

D.C. Required DK DK DK NF

Del. NF NF NF NF Required

Fla. NR NR NR NR Exempt

Ga. Required Required NF NF Exempt

Hawaii NR NR NR NR Exempt

Iowa NS NS NS NS NS

Idaho Required Required NF NF Required

Ill. Required DK NF DK NF

Ind. NF DK DK DK Required

Kans. Exempt NF NF NF Required

Ky. NS NS NS NS NS

La. Required DK DK NF DK

Mass. NR NR NR NR Required

Md. Required Required Required Required Required

Maine NR NF NF NF Required

Mich. Required Required Required Required Exempt

Minn. Required NF NF NF NF

Mo. Required Exempt Required Exempt Exempt

Miss. Exempt NF NF NF Required

Mont. Required Required Exempt Required Required

N.C. Required Required DK Exempt Exempt

N.Dak. NR NR NR NR Exempt

Neb. Required NF NF NF NF

N.H. DK NF NF NF Required

N.J. NS NS NS NS NS

Page 65 GAO-08-346 Residential Facilities 
Appendix IV: Licensing Status for Selected 

Residential Facilities 

State 

Treatment

facilities 

Wilderness 

camps Ranch Boot camps

Residential 

schools and 

academiesa

N.Mex. Required DK DK DK Exempt

Nev. NS NS NS NS NS

N.Y. Exempt NF NF NF Exempt

Ohio Required NR NF Required Exempt

Okla. Required Required Required Required Required

Ore. Required Required NF NF Required

Pa. Required Required Required Required Exempt

R.I. Required Required NF NF Required

S.C. NF Exempt NF NF Exempt

S.Dak. Required NF NF NF Exempt

Tenn. Required Required NF NF Required

Tex. Required Required NR NR Exempt

Utah DK Required Required NF Required

Va. Required Required Required Required Required

Vt. NS NS NS NS NS

Wash. Required Required Required NF Required

Wis. Required Required Required Required Exempt

W.Va. NS NS NS NS NS

Wyo. Required Required NF NF Required

Source: GAO analysis of state agencies’ survey responses. 

Notes: NF = no such facility in state, DK = don’t know, NS = no survey, NR = no response. 

a

The survey question for private residential schools and academies did not distinguish between 

private facilities that received government funding and those that did not. 

Page 66 GAO-08-346 Residential Facilities 
Appendix IV: Licensing Status for Selected 

Residential Facilities 

Table 17: State Health and Mental Health Agencies Reporting the Licensing

Requirements for Selected Exclusively Private Residential Facilities That Serve 

Youth and Receive No Government Funding 

State 

Treatment

facilities 

Wilderness 

camps Ranch Boot camps

Residential 

schools and 

academiesa

Alaska Required Required NF Required Exempt

Ala. Required DK DK DK Exempt

Ariz. Required Required NF DK DK

Ark. DK DK DK DK DK

Calif. NR NR NR NR Required

Colo. Required Required Required NF Required

Conn. Required Exempt Required NF Exempt

D.C. Required NR NR NR DK

Del. Required NF NF NF DK

Fla. Required DK DK DK NR

Ga. Required Required Required DK Required

Hawaii NF NF NF NF DK

Iowa NF NR NR NR Required

Idaho Required Required NF NF Required

Ill. Required Exempt Exempt Exempt Required

Ind. DK DK DK DK Required

Kans. NR NR NR NR DK

Ky. DK DK DK DK DK

La. Required DK DK DK DK

Mass. Required Required Required DK Required

Md. NF NF NF NF Exempt

Maine Required DK DK DK DK

Mich. Required Required DK DK DK

Minn. Required NF NF NF NF

Mo. DK DK DK DK DK

Miss. Required Required Required Required Required

Mont. Required Required Exempt Required Required

N.C. Required Required NR NR Exempt

N.Dak. DK DK DK DK DK

Neb. Required NF Required NF Required

N.H. DK DK DK DK Required

N.J. NS NS NS NS NS

Page 67 GAO-08-346 Residential Facilities 
Appendix IV: Licensing Status for Selected 

Residential Facilities 

State 

Treatment

facilities 

Wilderness 

camps Ranch Boot camps

Residential 

schools and 

academiesa

N.Mex. NS NS NS NS NS

Nev. NS NS NS NS NS

N.Y. NF DK DK DK Exempt

Ohio Required NF NF NF NR

Okla. NS NS NS NS NS

Ore. NS NS NS NS NS

Pa. Required NF NF NF Exempt

R.I. Required NF NF NF DK

S.C. Required Required Required Required Exempt

S.Dak. NS NS NS NS NS

Tenn. Required Required Required Required Exempt

Tex. Required DK Required DK DK

Utah Required Required Required NF Required

Va. Required Required NF Required Exempt

Vt. DK DK DK DK Required

Wash. DK DK DK DK NR

Wis. DK DK DK DK DK

W.Va. Required NR Required NF Required

Wyo. Required NF NF NF DK

Source: GAO analysis of state agencies’ survey responses. 

Note: NF = no such facility in state, DK = don’t know, NS = no survey, NR = no response. 

a

The survey question for private residential schools and academies did not distinguish between 

private facilities that received government funding and those that did not. 

Page 68 GAO-08-346 Residential Facilities 
Appendix IV: Licensing Status for Selected 

Residential Facilities 

Table 18: State Juvenile Justice Agencies Reporting the Licensing Status for 

Selected Exclusively Private Residential Facilities That Serve Youth and Receive No 

Government Funding 

State 

Detention 

centers

Wilderness 

camps Ranch Boot camps

Residential 

schools and 

academiesa

Alaska NR NR NR NR NS

Ala. NS NS NS NS NS

Ariz. DK DK DK DK Exempt

Ark. Exempt Exempt Exempt Exempt Exempt

Calif. DK DK DK DK DK

Colo. Exempt Required Exempt Exempt Required

Conn. Exempt NF NF NF Exempt

D.C. NF NF NF NF NF

Del. NF NF NF NF Required

Fla. Exempt Exempt Exempt Exempt Exempt

Ga. NF DK DK DK Required

Hawaii DK DK DK DK DK

Iowa NF NF NF NF Exempt

Idaho NF DK DK DK DK

Ill. NS NS NS NS NS

Ind. DK DK DK DK DK

Kans. NF NF NF NF NF

Ky. NR NR NR NR Required

La. NS NS NS NS NS

Mass. DK DK DK DK Exempt

Md. NF NF NF NF Required

Maine NF NF NF NF DK

Mich. DK DK DK DK NR

Minn. NF NF NF NF Exempt 

Mo. DK DK DK DK Required

Miss. NS NS NS NS NS

Mont. NR NR NR NR Required

N.C. NR NR NR NR Required

N.Dak. NF NF NF NF NF

Neb. NR NR NR NR NR

N.H. NF NF NF NF Required

N.J. NR NR NR NR DK

Page 69 GAO-08-346 Residential Facilities 
Appendix IV: Licensing Status for Selected 

Residential Facilities 

State 

Detention 

centers

Wilderness 

camps Ranch Boot camps

Residential 

schools and 

academiesa

N.Mex. DK DK DK DK Exempt

Nev. DK NF NF NF DK

N.Y. Required Exempt Exempt Exempt Exempt

Ohio Exempt Exempt Exempt Exempt Exempt

Okla. Required DK DK DK Exempt

Ore. NF Required NF NF Required

Pa. DK DK DK DK Exempt

R.I. NS NS NS NS NS

S.C. DK DK DK DK Required

S.Dak. NF NF NF NF NF

Tenn. Required Required Required NF Required

Tex. NS NS NS NS NS

Utah NF Required Required NF Required

Va. NF NF NF NF Exempt

Vt. NF Required NF NF Required

Wash. NF NF NF NF Exempt

Wis. DK DK DK DK DK

W.Va. NF NF NF NF NF

Wyo. NS NS NS NS NS

Source: GAO analysis of state agencies’ survey responses. 

Notes: NF = no such facility in state, DK = don’t know, NS = no survey, NR = no response. 

a

The survey question for private residential schools and academies did not distinguish between 

private facilities that received government funding and those that did not. 

Page 70 GAO-08-346 Residential Facilities 
Appendix V: State Agency Accreditation 

Requirements for Residential Facilities for

Youth 

Page 71 GAO-08-346 Residential Facilities 

Appendix V: State Agency Accreditation 

Requirements for Residential Facilities for 

Youth 

Table 19: Number of States that Require at Least Some of the Residential Facilities That They License or Certify to Have 

Independent Accreditation

Child welfare agencies Health and mental health agencies Juvenile justice agencies 

Facility type 

Accreditation

required for at 

least some 

Accreditation

not required

Accreditation

required for at 

least some

Accreditation

not required

Accreditation

required for at 

least some

Accreditation

not required

Government 

operated 

8 15 16 12 12 29

Private receiving 

government 

funds 

8 27 16 19 7 27

Exclusively 

private pay 

4 26 5 21 2 11

Source: GAO analysis of state agencies’ survey responses. 

The survey questions were as follows: Are government-operated facilities, 

including county-operated facilities, required to have any of the following in 

order to provide residential [targeted; health, mental health, or substance 

abuse; juvenile or rehabilitation] services to youth: independent accreditation 

to provide services, such as Council on Accreditation (COA), Commission on 

Accreditation Rehabilitation Facilities (CARF), Joint Commission on 

Accreditation of Health Care Organizations (JCAHO): (a) required for all, (b) 

required for most, (c) required for some, (d) not required, (e) don’t know, and

(f) no response. Which if any of the following types of initial licensure or 

certification does your agency require for private facilities that plan to provide 

residential [targeted; health, mental health, or substance abuse; juvenile or 

rehabilitation] services to youth age 12 to 17 and receive [any government 

funds, e.g., facilities with state or county contracts or facilities certified to 

accept Medicaid or Medicare): independent accreditation to provide services, 

such as Council on Accreditation (COA), Commission on Accreditation 

Rehabilitation Facilities (CARF), Joint Commission on Accreditation of Health 

Care Organizations (JCAHO): (a) required, (b) not required, (c) don’t know, and

(d) no response. Which if any of the following types of initial licensure or 

certification does your agency require for private facilities that plan to provide 

residential [targeted; health, mental health, or substance abuse; juvenile or 

rehabilitation] to youth age 12 to 17 and receive no government funds (e.g., 

faith-based and other private facilities that are totally funded by the private 

sector): independent accreditation to provide services, such as Council on 

Accreditation, Commission on Accreditation Rehabilitation Facilities, Joint 

Commission on Accreditation of Health Care Organizations: (a) required, (b) 

not required, (c) don’t know, and (d) no response. 
Appendix VI: Selected State Licensing 

Standards for Residential Facilities for Youth 

Page 72 GAO-08-346 Residential Facilities 

Table 20: Number of State Agencies Reporting That They Require Licensed Government-Operated and Private Residential 

Facilities to Meet Certain Standards, 2006 

Child welfare Health and mental health Juvenile justice 

Standards 

Governmentoperated facilities Private 

facilities

Governmentoperated facilitiesPrivate 

facilities

Governmentoperated facilitiesPrivate 

facilities

Pass inspection of

physical plant 

Required for all 20 37 27 35 41 16

Required for less than 

all 

2 0 1 1 2 0

Provide evidence of

safe child care 

practices

Required for all 19 35 23 30 37 16

Required for less than 

all 

3 1 3 3 5 0

Have written

procedures for 

reporting physical or

sexual abuse or

neglect of youth 

Required for all 21 37 28 35 43 16

Required for less than 

all 

1 0 0 1 0 0

Meet all staff 

qualifications 

requirements,

including training 

Required for all 20 36 26 34 42 16

Required for less than 

all 

2 0 1 2 1 0

Perform staff 

background checks 

Required for all 21 37 26 31 43 16

Required for less than 

all 

1 0 2 4 0 0

Meet staff-to-child 

ratios 

Required for all 20 34 22 28 32 15

Required for less than 

all 

2 3 5 8 10 1

Appendix VI: Selected State Licensing 

Standards for Residential Facilities for Youth 
Appendix VI: Selected State Licensing 

Standards for Residential Facilities for Youth 

Child welfare Health and mental health Juvenile justice 

Standards 

Governmentoperated facilities Private 

facilities

Governmentoperated facilitiesPrivate 

facilities

Governmentoperated facilitiesPrivate 

facilities

Provide evidence of

appropriate

educational 

programming 

Required for all 19 31 23 31 41 16

Required for less than 

all 

2 1 6 4 2 0

Have procedures in

place for use of

approved seclusion

and restraint

techniques

Required for all 19 34 23 31 41 16

Required for less than 

all 

3 3 5 4 2 0

Have written suicide 

prevention plans 

Required for all 13 20 15 20 40 12

Required for less than 

all 

8 14 9 13 3 4

Source: GAO analysis of state agencies’ survey responses. 

Note: Other responses included “Don’t know” and “No response.”

The survey questions were as follows: When your state 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 staff qualifications requirements, including 

training; (e) perform staff background check; (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 technique; (i) 

have written suicide prevention plan. Are each of the following items required 

for private residential facilities providing targeted services for youth to obtain 

initial licensure from your agency? (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 staff 

qualifications requirements, including training; (e) perform staff background 

check; (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 technique; (i) have written suicide prevention

plan. 

Page 73 GAO-08-346 Residential Facilities 
Appendix VII: Selected State Monitoring

Requirements for Residential Facilities for

Youth 

Page 74 GAO-08-346 Residential Facilities 

Table 21: Number of State Agencies Reporting That They Monitored, for All or Less Than All, Selected Issues at Residential 

Facilities for Youth, 2006 

Child welfare Health and mental health Juvenile justice

Issues 

Governmentoperated 

facility 

Private 

facility that

received any 

government 

funds 

Exclusively 

private 

facility

Government

-operated 

facility

Private 

facility 

receiving 

government 

funds

Exclusively 

private 

facility

Government

-operated 

facility 

Private 

facility 

receiving 

government 

funds

Exclusively 

private 

facility

Physical plant 

Monitored for all 15 35 29 14 22 16 34 24 9

Monitored for 

less than all 

6 4 6 13 16 14 8 13 14

Staffing issues 

(e.g., 

background 

checks, 

qualifications,

ongoing

training)

Monitored for all 16 35 28 15 22 16 34 23 8

Monitored for 

less than all 

6 5 7 13 15 14 7 13 14

Use of 

approved 

seclusion and 

restraint 

Monitored for all 14 32 26 14 23 13 32 25 10

Monitored for 

less than all 

7 7 9 11 13 16 10 10 12

Use of 

psychotropic 

medications 

Monitored for all 13 30 24 13 22 12 27 22 9

Monitored for 

less than all 

8 9 9 12 15 16 14 14 13

Number of

complaints of

physical or 

sexual abuse 

Monitored for all 13 34 27 15 26 15 34 28 12

Monitored for 

less than all 

9 5 8 12 12 15 15 8 10

Appendix VII: Selected State Monitoring 

Requirements for Residential Facilities for 

Youth 
Appendix VII: Selected State Monitoring

Requirements for Residential Facilities for

Youth 

Child welfare Health and mental health Juvenile justice

Issues 

Governmentoperated 

facility 

Private 

facility that

received any 

government 

funds 

Exclusively 

private 

facility

Government

-operated 

facility

Private 

facility 

receiving 

government 

funds

Exclusively 

private 

facility

Government

-operated 

facility 

Private 

facility 

receiving 

government 

funds

Exclusively 

private 

facility

Number of

other 

complaints, if 

any (e.g. health 

or safety 

concerns) 

Monitored for all 15 32 26 16 26 14 33 28 10

Monitored for 

less than all 

7 7 9 11 12 15 9 8 11

Presence of

educational 

programming 

Monitored for all 15 30 24 13 16 12 35 23 9

Monitored for 

less than all 

5 7 9 13 18 14 6 13 12

Quality of

educational 

programming 

Monitored for all 6 11 6 7 8 6 27 18 8

Monitored for 

less than all 

14 23 23 16 23 20 13 17 12

Source: GAO analysis of state agencies’ survey responses. 

Note: Other responses included “Don’t know”, “No response” and “No such facility in the state.” 

We asked state child welfare, health and mental health, and juvenile justice 

agencies the following question: 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 government-operated residential 

facilities, private residential facilities that received government funding, and

exclusively private pay residential facilities providing targeted services for 

youth? Response options for this question were: (a) yes, monitored for all, (b) 

yes, monitored for most, (c) yes, monitored for some, (d) no, did not monitor, 

(e) no such facility in the state, (f) don’t know, (g) no response. 

Page 75 GAO-08-346 Residential Facilities 
Appendix VIII: State Agency Actions Taken 

within the Last 3 Years against Government 

and Private Residential Facilities 

Page 76 GAO-08-346 Residential Facilities 

Table 22: Number of State Agencies Taking Actions against Government and

Private Residential Facilities within the Last 3 Years 

Child welfare

Health and

mental health Juvenile justice

Action taken Yes No Yes No Yes No

Government facility was closed or license, certification, or operating 

authority was suspended or revoked

Government operated 1 19 0 18 3 34

Private license or authority to operate was suspended

Private receiving 

government funds 

11 21 4 18 9 16

Exclusively private 4 28 3 19 3 22

Private license or authority to operate was revoked or not renewed, 

or facility was closed 

Private receiving 

government funds 

17 15 8 13 11 13

Exclusively private 7 25 3 18 1 23

Youth were removed

Government operated 7 12 2 16 11 26

Private receiving 

government funds 

26 9 13 8 18 12

Exclusively private 5 30 4 17 4 26

Banned new admissions or instituted admission restrictions

Government operated 7 14 4 15 7 30

Private receiving 

government funds 

27 8 16 6 22 7

Exclusively private 4 31 4 18 4 25

Referred or recommended criminal investigations for abuse or neglect that 

carry fines or imprisonment 

Government operated 10 11 7 8 24 10

Private receiving 

government funds 

19 11 11 9 17 11

Exclusively private 6 24 3 17 7 21

Increased monitoring

Government operated 16 5 10 8 32 6

Private receiving 

government funds 

32 3 20 2 30 0

Exclusively private 6 29 8 14 8 22

Appendix VIII: State Agency Actions Taken 

within the Last 3 Years against Government 

and Private Residential Facilities 
Appendix VIII: State Agency Actions Taken 

within the Last 3 Years against Government 

and Private Residential Facilities 

Child welfare

Health and

mental health Juvenile justice

Required program improvement or corrective action plan

Government operated 19 2 17 2 32 4

Private receiving 

government funds 

35 0 22 1 28 1

Exclusively private 12 23 10 13 7 22

Source: GAO analysis of state agencies’ survey responses. 

We asked state child welfare, health and mental health, and juvenile 

justice agencies the following question: Over the last 3 reporting years, did 

your agency take any of the following actions at its government-operated 

facilities, private facilities that received government funds, or private 

facilities that did not receive government funds as a result of allegations or 

findings of noncompliance, improper operations, physical abuse or sexual 

abuse or neglect of youth, or other negative outcomes? Respondents could 

also answer “don’t know” or “no response.” 

Page 77 GAO-08-346 Residential Facilities 
Appendix IX: Comments from the Department 

of Education 

Page 78 GAO-08-346 Residential Facilities 

Appendix IX: Comments from the 

Department of Education 
Appendix IX: Comments from the Department 

of Education 

Page 79 GAO-08-346 Residential Facilities 
Appendix IX: Comments from the Department 

of Education 

Page 80 GAO-08-346 Residential Facilities 
Appendix X: Comments from the Department 

of Health and Human Services 

Page 81 GAO-08-346 Residential Facilities 

Appendix X: Comments from the Department 

of Health and Human Services 
Appendix X: Comments from the Department 

of Health and Human Services 

Page 82 GAO-08-346 Residential Facilities 
Appendix X: Comments from the Department 

of Health and Human Services 

Page 83 GAO-08-346 Residential Facilities 
Appendix XI: Comments from the Department 

of Justice 

Page 84 GAO-08-346 Residential Facilities 

Appendix XI: Comments from the 

Department of Justice 
Appendix XI: Comments from the Department 

of Justice 

Page 85 GAO-08-346 Residential Facilities 
Appendix XII: 

A

GAO Contacts and Staff 

cknowledgments 

Page 86 GAO-08-346 Residential Facilities 

Kay E Brown, (202)512-7215, brownke@gao.gov

Cindy Ayers (Assistant Director) and Arthur T. Merriam Jr. (Analyst-inCharge) managed all aspects of the assignment. Kathleen Drennan, 

Vernette Shaw, and Mark E. Ward made significant contributions to this 

report, in all aspects of the work. In addition, Denise M. Fantone 

contributed to the initial design of the engagement; Carolyn Boyce 

provided technical support in design and methodology, survey research, 

and statistical analysis; Doreen Feldman and James Rebbe provided legal 

support; and Charles Willson assisted in the message and report 

development. 

Appendix XII: GAO Contacts and Staff 

Acknowledgments 

GAO Contact 

Staff 

Acknowledgments 
Related GAO Products 

Page 87 GAO-08-346 Residential Facilities 

Residential Facilities: State and Federal Oversight Gaps May Increase 

Risks to Youth Well-Being, GAO-08-696T, (Washington, D.C.: April 24, 

2008). 

Residential Programs: Selected Cases of Death, Abuse, and 

Deceptive Marketing, GAO-08-713T, (Washington, D.C.: April 24, 2008).

Residential Treatment Programs: Concerns Regarding Abuse and Death 

in Certain Programs for Troubled Youth. GAO-08-146T. Washington. D.C.: 

October 10, 2007. 

Child Welfare and Juvenile Justice: Federal Agencies Could Play a 

Stronger Role in Helping States Reduce the Number of Children Placed 

Solely to Obtain Mental Health Services. GAO-03-397. Washington, D.C.: 

April 21, 2003. 

Mental Health: Extent of Risk from Improper Restraint or Seclusion Is

Unknown. T-HEHS-00-26. Washington, D.C.: October 26, 1999.

Mental Health: Improper Restraint or Seclusion Use Places People at 

Risk. HEHS-99-176. Washington, D.C.: September 7, 1999. 

Prison Boot Camps: Short-Term Prison Costs Reduced, but Long-Term 

Impact Uncertain. GGD-93-69 Washington, D.C.: April 29, 1993. 

Related GAO Products 

(130617) 
The Government Accountability Office, the audit, evaluation, and 

investigative arm of Congress, exists to support Congress in meeting its 

constitutional responsibilities and to help improve the performance and 

accountability of the federal government for the American people. GAO 

examines the use of public funds; evaluates federal programs and policies; 

and provides analyses, recommendations, and other assistance to help

Congress make informed oversight, policy, and funding decisions. GAO’s 

commitment to good government is reflected in its core values of 

accountability, integrity, and reliability. 

The fastest and easiest way to obtain copies of GAO documents at no cost

is through GAO’s Web site (www.gao.gov). Each weekday, GAO posts 

newly released reports, testimony, and correspondence on its Web site. To

have GAO e-mail you a list of newly posted products every afternoon, go 

to www.gao.gov and select “E-mail Updates.” 

The first copy of each printed report is free. Additional copies are $2 each. 

A check or money order should be made out to the Superintendent of 

Documents. GAO also accepts VISA and Mastercard. Orders for 100 or 

more copies mailed to a single address are discounted 25 percent. Orders 

should be sent to: 

U.S. Government Accountability Office 

441 G Street NW, Room LM 

Washington, DC 20548 

To order by Phone: Voice: (202) 512-6000 

TDD: (202) 512-2537 

Fax: (202) 512-6061 

Contact: 

Web site: www.gao.gov/fraudnet/fraudnet.htm

E-mail: fraudnet@gao.gov

Automated answering system: (800) 424-5454 or (202) 512-7470 

Ralph Dawn, Managing Director, dawnr@gao.gov, (202) 512-4400 

U.S. Government Accountability Office, 441 G Street NW, Room 7125 

Washington, DC 20548 

Chuck Young, Managing Director, youngc1@gao.gov, (202) 512-4800 

U.S. Government Accountability Office, 441 G Street NW, Room 7149 

Washington, DC 20548 

GAO’s Mission 

Obtaining Copies of 

GAO Reports and 

Testimony

Order by Mail or Phone 

To Report Fraud,

Waste, and Abuse in 

Federal Programs 

Congressional 

Relations 

Public Affairs 

PRINTED ON RECYCLED PAPER