Since the early 1990s, state agencies and private companies have set up hundreds of residential programs and facilities in the United States. Many of these programs are intended to provide a less restrictive alternative to incarceration or hospitalization for youth who may require intervention to address emotional or behavioral challenges. A wide array of government or private entities, including government agencies and faith-based organizations, operate these programs. Some residential programs advertise themselves as focusing on a specific client type, such as those with substance abuse disorders or suicidal tendencies. As we reported in our October 2007 testimony, no federal laws define what constitutes a residential program, nor are there any standard, commonly recognized definitions for specific types of programs. For our purposes, we define programs based on the characteristics we have identified during our work. For example: Wilderness therapy programs place youth in different natural environments, including forests, mountains, and deserts. According to wilderness therapy program material, these settings are intended to remove the "distractions" and "temptations" of modern life from teens, forcing them to focus on themselves and their relationships. These programs are typically 28 days in length at a minimum, but parents can continue to enroll their child for longer at an additional cost. Boot camps are residential programs in which strict discipline and regime are dominant principles. Many boot camps emphasize behavioral modification elements, and some military-style boot camps also emphasize uniformity and austere living conditions. Boot camps might be included as part of a wilderness therapy school or therapeutic boarding, but many boot camps exist independently. These programs are offered year-round and some summer programs last up to 3 months. Boarding schools (also called academies) are generally advertised as providing academic education beyond the survival skills a wilderness therapy program might teach. These programs frequently enroll youth whose parents force them to attend against their will. The schools can include fences and other security measures to ensure that youth do not leave without permission. While these programs advertise year-round education, the length of stay varies for each student; contracts can require stays of up to 21 months or more. Ranch programs typically emphasize remoteness and large, open spaces available on program property. Many ranch programs advertise the therapeutic value of ranch-related work. These programs also generally provide an opportunity for youth to help care for horses and other animals. Although we could not determine the length of a typical stay at ranch programs, they operate year-round and take students for as long as 18 months. See appendix I for further information about the location of various types of residential programs across the United States. In addition to these programs, the industry includes a variety of ancillary services. These include referral services and educational consultants to assist parents in selecting a program, along with transport services to pick up a youth and bring him or her to the program location. Parents frequently use a transport service if their child is unwilling to attend the program. Private programs generally charge high tuition costs. For example, one wilderness program stated that their program costs over $13,000 for 28 days. In addition to tuition costs, these programs frequently charge additional fees for enrollment, uniforms, medical care, supplemental therapy, and other services--all of which vary by program and can add up to thousands of extra dollars. Costs for ancillary services vary. The cost for transport services depends on a number of factors, including distance traveled and the means of transportation. Referral services do not charge parents fees, but educational consultants do and typically charge thousands of dollars. Financial and loan services are also available to assist parents in covering the expense of residential programs and are often advertised by programs and referral services. See appendix II for further information about the cost of residential programs across the United States. There are no federal oversight laws--including reporting requirements-- pertaining specifically to private residential programs, referral services, educational consultants, or transportation services, with one limited exception. The U.S. Department of Health and Human Services oversees psychiatric residential treatment facilities (PRTFs) receiving Medicaid funds. In order to be eligible to receive funds under Medicaid, PRTFs must abide by regulations that govern the use of restraint and seclusion techniques on patients. They are also required to report serious incidents to both state Medicaid agencies and, unless prohibited by state law, state Protection and Advocacy agencies. In addition, the regulations require PRTFs to report patient deaths to the Centers for Medicare and Medicaid Services Regional Office. In the eight closed cases we examined, ineffective management and operating practices, in addition to untrained staff, contributed to the death and abuse of youth enrolled in selected programs. Furthermore, two cases of death were very similar to cases from our October 2007 testimony, in that staff ignored the serious medical complaints of youth until it was too late. The practice of physical restraint figured prominently in three of the cases. The restraint used for these cases primarily involved one or more staff members physically holding down a youth. Ineffective operating practices led to the most egregious cases of death and abuse, as the cases exposed problems with the entire operation of the program. Specifically, the failure of program leaders to ensure that appropriate policies and procedures were in place to deal with the serious problems of youth; ineffective management practices that led to questionable therapeutic or operational practices; and the failure of the program to share information about enrolled youth with the staff members who were attending to them created the environments that resulted in abuse and death. Moreover, in cases involving abuse, the abuse was systemic in the program and not limited to the incident discussed in our case studies. In three of the eight cases we examined, the victim was placed in the program by the state or in consultation with state authorities. See table 1 for a summary of the cases of death we examined. See table 2 for a summary of the cases of abuse we examined. For reporting purposes, we continue the numbering of case studies in this table, starting with five. The following three narratives describe selected cases in further detail. The victim, who died in 2005, was a 12-year-old male. Documents obtained from the Texas Department of Family and Protective Services indicate that the victim had a troubled family background. He was taken into state care along with his siblings at the age of 6. According to child protective service workers who visited the family's home, the victim and his siblings were found unsupervised and without electricity, water, or food. Some of the children were huddled over a space heater, which was connected to a neighbor's house by extension cord, in order to keep warm. As a ward of the state, the victim spent several years in various foster placements and youth programs before being placed in a private residential treatment center in August 2005. The program advertised itself as a "unique facility" that specialized in services for boys with learning disabilities and behavioral or emotional issues. The victim's caretakers chose to place him in this program because he was emotionally disturbed. Records indicate that he was covered by Medicaid. On the evening of his death, the victim refused to take a shower and was ordered to sit on an outside porch. According to police reports, the victim began to bang his head repeatedly against the concrete floor of the porch, leading a staff member to drag him away from the porch and place him in a "lying basket restraint" for his own protection. During this restraint, the 4 feet 9 1/2 inch tall, 87-pound boy was forced to lie on his stomach with his arms crossed under him as the staff member, a muscular male 5 feet 10 inches tall, held him still. Some of the children who witnessed the restraint said they saw the staff member lying across the victim's back. During the restraint, the victim fought against the staff member and yelled at him to stop. The staff member told police that the victim complained that he could not breathe, but added that children "always say that they cannot breathe during a restraint." According to police reports, after about 10 minutes of forced restraint, the staff member observed that the victim had calmed down and was no longer fighting back. The staff member slowly released the restraint and asked the victim if he wanted a jacket. The victim did not respond. The staff member told police he interpreted the victim's silence as an unwillingness to talk due to anger about the restraint. He said he waited for a minute while the victim lay silently on the ground. When the victim did not respond to his question a second time, he tapped the victim on the shoulder and rolled him over. The staff member observed that the victim was pale and could not detect a pulse. All efforts to revive the victim failed, and he was declared dead at a nearby hospital. When the staff member demonstrated his restraint technique for the police, they found that his technique violated the restraint policies of the program. These policies prohibited staff from placing any pressure on the back of a person being restrained. The report added that this staff member was reprimanded for injuring a youth in 2002 as a result of improper restraint. After this incident, program administrators banned the staff member from participating in restraints for 1 month. The reprimand issued by program administrators over this incident noted that the staff member had actually trained other staff members in performing restraints, making the matter more serious. The police reports also cite one of the staff member's performance evaluations that noted that he had problems with his temper. According to the reports, one of the youth in the program said the staff member could become agitated when putting youth in restraint. Although the Texas Department of Family and Protective Services alleged that the victim's death was due to physical abuse, the official certificate of death stated that it was an accident and a grand jury declined to press charges against the staff member performing the restraint. However, the victim's siblings obtained a civil settlement against the program and the staff member for an undisclosed amount. The program remained open until May 2006, when a 12-year-old boy drowned on a bike outing with the program. According to records from law enforcement, child protection workers, and the program, the boy fell into the water of a rain-swollen creek and was sucked into a culvert. He died after several weeks on life support. The Texas Department of Family and Protective Services cited negligent staff supervision in its review of this second death and revoked the program's license to operate as a residential treatment center. However, the program's directors also ran a summer camp for children with learning disabilities and social disorders licensed by the Texas Department of State Health Services, until they resigned from their positions in March 2008. The victim was 16 years old when he died, in February 2006, at a private psychiatric residential treatment facility in Pennsylvania for boys with behavioral or emotional problems. He was a large boy--6 feet 1 inch in height and weighing about 250 pounds--and suffered from bipolar disorder and asthma. The cost for placement in this facility was primarily paid for by Medicaid. According to state investigative documents we obtained, the victim was placed in intensive observation after he attempted to run away. As part of the intensive observation, he was forced to sit in a chair in the hallway of the facility and was restricted from participating in some activities with other residents. On the day of his death, staff allowed the victim to participate in arts, crafts, and games with the other youth, but would not let him leave the living area to attend other recreational activities. Instead, staff told the victim that he would have to return to his chair in the hallway. In addition, staff told him that he would have to move his chair so that he could not see the television in another room. The victim complied, moving his chair out of view of the television, but put up the hood of his sweatshirt and turned his back toward the staff. The staff ordered him to take down his hood but he refused. When one of the staff walked up to him and pulled his hood down, the victim jumped out of his chair and made a threatening posture with his fists, saying he did not want to be touched. The staff member and two coworkers then brought the victim to another room and held him facedown on the floor with his arms pulled up behind his back. The victim struggled against the restraint, yelling and trying to kick the three staff members holding him down. After about 10 minutes, the victim became limp and started breathing heavily. He complained that he was having difficulties breathing. One staff member unzipped his sweatshirt and loosened the collar of his shirt, but rather than improve, the victim became unresponsive. The staff called emergency services and began CPR. The victim was taken by ambulance to a hospital, where he died a little more than 3 hours later. In the victim's autopsy report his death was ruled accidental, as caused by asphyxia and an abnormal heartbeat (cardiac dysrhythmia). Following the victim's death, an investigation by the Pennsylvania Department of Health found that the policies and procedures for youth under intense observation do not prohibit them from watching television, nor do they require that youth keep their face visible to staff at all times. The investigation also found that the facility had documentation of the victim's history of asthma, and that its training manual for restraint procedures cautioned against the risk of decreased oxygen intake during restraints for children with asthma. However, all three staff members involved in the restraint told investigators that they were unaware of any medical conditions that needed to be considered when restraining the victim. In addition, the investigation found that the facility did not provide timely training on the appropriate and safe use of restraint. The state's Protection and Advocacy organization, Pennsylvania Protection & Advocacy, Inc. (PP&A), conducted its own investigation of the facility and found that staff members inappropriately restrained children in lieu of appropriate behavioral interventions, which resulted in neglect and abuse. Of the 45 residents interviewed by PP&A investigators, 29 said that staff at the facility subjected them to restraints. The residents reported that the restraints could last as long as 90 minutes and caused breathing difficulties. They also stated that staff often placed their knees on residents' backs and necks during restraints. One resident reported that the blood vessels in his eyes "popped" during a restraint. Another resident said that his nose hit the ground during the restraint, causing him to choke on his own blood. Further, some of the residents reported that staff provoked them and that staff did not make any effort to de-escalate the provocations before implementing a restraint. No criminal charges were filed in regard to the victim's death. The victim's mother filed a civil suit over her son's death against the facility, which is currently pending. Her son's death was not the only fatal incident at this facility. Only 2 months before the victim's death, in December 2005, a 17- year-old boy collapsed at the facility after a physical education class, and later died at a nearby hospital. His death was attributed to an enlarged heart. This facility remains open. This abuse victim was sent to a private drug and addiction treatment program in July 1994 at the age of 14. He was attending public school in the major metropolitan area where his family lived. The abuse victim told us that he had problems at school, including poor grades, truancy, a fight with other students, and that he had been suspended. After the victim was questioned by police about an assault on a girl at his school, a family friend with ties to the behavior modification program recommended the program to the victim's parents. According to the victim, his first visit to the school turned into an intense intake session where he was interviewed by two program patients. Although the victim denied using drugs, the interviewers insisted that he was not being honest. After about 6 hours of questioning, the victim told the interviewers what he thought they wanted to hear--that he was smoking pot, did cocaine, and cut school to get high--so that he could end the interview. The interviewers used these statements to convince the victim's parents to sign him into the program for immediate intervention and treatment. He ended up staying in the program for the next 4 years--even after he turned 18 and was held against his will. According to program records, the program's part-time psychiatrist did not examine or diagnose him until he had been in the program for 14 days. This lack of psychological care continued, as program records indicate he was examined by the psychiatrist only four times during his entire stay. He was restrained more than 250 times while in the program, with at least 46 restraints lasting one hour or longer. The victim said some restraints were applied by a group of four or five staff members and fellow patients. According to the victim, they held him on his back, with one person holding his head and one person holding each limb. These restraints were imposed whenever the victim showed any reluctance to do what he was told, or, the victim told us, for doing some things without first obtaining permission from program staff. On one occasion, while he was staying with a host family and other patients, he attempted to escape from the program. The victim claims that they restrained him by wrapping him in a blanket and tying him up. According to the victim, when he turned 18, he submitted a request to leave the program but his request was denied because he had not followed the proper procedure and was a danger to himself. For expressing his desire to leave the program, he was stripped of all progress he had made to that point, and was prevented from further advancing until the program director decided he was be eligible. Incident reports filed by program staff document that after he had turned 18, the victim was restrained on 26 separate days, with at least two restraints lasting more than 12 hours. According to program rules, failure of the parents to follow program rules and fully support and participate in the program would jeopardize their son's treatment and progress and put him at risk of expulsion. Having been led to believe that the program was the only way to help him overcome his alleged addictions and problems, his family complied with the program's demands. Moreover, the program required parents and siblings over age 8 to attend twice weekly group therapy meetings. According to the victim, these meetings lasted for many hours, sometimes stretching into the early morning. He added that when the victim's father refused to attend the therapy meetings for fear of losing his job, the program told him to quit. When he would not quit his job or miss work to attend the meetings, the victim said that the program convinced his mother to leave her husband. After his parents separated, the program would not allow the victim to have contact with his father. The victim said that the program never told the victim's family that all the drug tests they performed on him returned negative results, including the initial tests done when he entered the program. In February 1998, the State of New Jersey terminated the program's participation in the Medicaid program, holding that the program did not qualify as a children's partial care mental health program because of its noncompliance with client rights standards and its failure to meet various staff requirements, such as staff-to-client ratios and requisite education and experience levels for staff. The program subsequently closed in November 1998, citing financial problems. About a year later, in September 1999, an administrative law judge rejected an appeal by the program to overrule the state's termination of its Medicaid participation. The judge noted in his decision that the program effectively operated as a full-time residential facility. Moreover, he noted that all group staff at the program were either current or former patients, and only two members of the program staff met the educational requirements to qualify as direct- care professionals. The victim filed a civil lawsuit against the program, director, and a psychiatrist, which resulted in a $3.75 million settlement. Other civil suits filed by former patients included one patient who was committed to the program at the age of 13 and spent 13 years in the program. This patient reached a similar settlement against the program, director, and psychiatrists for the sum of $6.5 million. In addition, a third former patient secured a $4.5 million settlement against the program, director, and psychiatrists. Posing as fictitious parents with fictitious troubled teenagers, we found examples of deceptive marketing and questionable practices related to 10 private residential programs and 4 referral services. The most egregious deceptive marketing practices related to tax incentives and health insurance reimbursement, and were intended to make the high price of the programs appear more manageable for our fictitious parents. We also found examples of false statements and misleading representations related to a range of issues including education and admissions, as well as undisclosed conflicts of interest. In addition, we identified examples of questionable practices related to the health of youth enrolled in programs and the method of convincing reluctant parents to enroll their children. Although general consumer protection laws apply to these programs and services, there are no federal laws or regulations on marketing content and practices specific to the residential program industry. A link to selected audio clips from these calls is available at: http://www.gao.gov/media/video/gao-08-713t/. See table 3 for a selection of representations made by programs and referral agents. Case 1: One of our fictitious parents called this foundation pretending to be a parent who could not afford the cost of a residential program for his child. A representative of the foundation explained that their "most popular" method of fund-raising involved the friends and relatives of the enrolled youth making tax-deductible donations to the foundation, which in turn credited 90 percent of these "donations" specifically to pay for tuition in a program the child was attending. The foundation assigns a code number to each child, which parents ensure is listed on the donation checks. The representative also provided a fund-raising packet by mail that instructs the parents of troubled teens: "You are able to contact family, friends, business acquaintances, affiliates, churches, and professional/fraternal organizations that you know. Don't forget corporate matching funds opportunities from your employer too." The packet also included two template letters to send in soliciting the funds. According to an IRS official with the Tax Exempt and Governmental Entities Division, this practice is inappropriate and represents potential tax fraud on the part of the foundation. Furthermore, those who claim inappropriate deductions in this fashion would be responsible for back taxes, as well as penalties and interest. Based on this information, we referred this nonprofit foundation to the IRS for criminal investigation. Case 2: The program representative at a Montana boarding school told our fictitious parent that they must submit an application form before their child can be accepted to the school. However, after a separate undercover call made to this school by one of our fictitious parents, the program representative e-mailed us stating that our fictitious daughter had been approved for admission into the program and subsequently sent an acceptance letter. The acceptance letter stated that our fictitious child "has been approved for our school here in Montana." This admission was based entirely on one 30-minute telephone conversation, in which our fictitious parent described his daughter as a 13-year-old who takes the psychotropic medication Risperdal, attends weekly therapy sessions, has bipolar disorder, and been diagnosed with Reactive Attachment Disorder. We did not fill out an application form for the school. Moreover, this program had previously recommended that our fictitious parents seek advice from the 501(c)(3)foundation discussed in Case 1 to help finance the cost of the program. It appears that parents do not have assurance about the integrity of the admissions process at this boarding school. Case 4: One fictitious parent asked the representative for a Texas wilderness therapy program whether there was any possibility that a health insurance company would cover the cost of the program. The representative replied that, at the completion of the program, the bookkeeper for the program would generate an itemized statement of billable charges that could be submitted to an insurance company for reimbursement. She emphasized that we should not call ahead of time to seek pre-approval, because then we would be "up the creek." She added that this was "just the way insurance companies like it" and stated that health insurance companies reimburse "quite a bit." She gave an example of one insurance company that reimbursed for over $11,000--almost the entire cost of the 28-day wilderness program. Representatives for both a health care insurer and a behavioral health company told us that parents who follow this advice run a real risk of not being reimbursed, especially if the health insurance company requires pre-approval of counseling or other mental health services. In this case, our fictitious parent was being led into believing that a large portion of the tuition for the program would be covered by health insurance even if pre-approval for the charges was not obtained in writing in advance of the services. Case 6: One referral agent we called stated that behavioral modification schools are "specialty schools" and that tuition costs are tax deductible under Section 213 of the Internal Revenue Tax code. The referral agent also stated that transportation costs related to bringing our fictitious child to and from the school were tax deductible under this section. However, the two programs recommended by the referral service do not appear to meet the requirements of IRS regulations for special schools. Our review of Section 213 of the Internal Revenue Tax code shows that it relates to medical expenses and specifies that, if medical expenses and transportation for treatment exceed 7.5 percent of a taxpayer's adjusted gross income, the excess costs can be deducted on Schedule A of IRS Form 1040. Even if these expenses were deductible under this section, only expenses above 7.5 percent of the adjusted gross income would be deductible, rather than the full amount as suggested by the referral agent. An IRS authority on Section 213 with whom we spoke stated that the referral service provided us with questionable tax advice and that parents should consult a tax advisor before attempting to claim a deduction under this section. Parents improperly taking this deduction could be responsible for back taxes, as well as penalties and interest. Case 9: On its Web site, referral service "B" invites parents to call a toll- free number and states: "We will look at your special situation and help you select the best school for your teen with individual attention." Our undercover investigators called this referral service pretending to be three separate fictitious parents and described three separate fictitious children to the agents who answered the phone. Despite these three different scenarios, we found the referral service recommended the same residential program all three times--a Missouri boot camp. Our investigation into this referral service revealed that the owner of the referral service is the husband of the boot camp owner. This relationship, was not disclosed to our fictitious parents during our telephone calls, which raises the issue of a potential conflict of interest. It appears that parents who call this referral service will not receive the objective advice they expect based on marketing information on the Web site. Mr. Chairman and Members of the Committee, this concludes my statement. We would be pleased to answer any questions that you may have at this time. For further information about this testimony, please contact Gregory D. Kutz at (202) 512-6722 or kutzg@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this testimony. In our examination of case studies for this testimony and our prior testimony, we found that the victims of death and abuse came from across the country and attended programs that were similarly located in numerous states. Figure 1 contains a map indicating where victims lived and the location of the program they attended. Private residential programs are located nationwide and rely heavily on the Internet for their marketing. Although Web sites list 48 of the 50 states where parents can find various types of programs, we found that they do not list programs in Nebraska and South Dakota, nor do they indicate the existence of programs in the District of Columbia. Notably, we did not find Web sites that list states with boot camps but instead instruct parents to call for locations and details. Figure 2 illustrates the types of programs and the states in which they are located, excluding boot camps. Our undercover calls to selected programs revealed that most private programs charge a high tuition for their services. Table 4 contains information related to the high cost of these programs based these phone calls. According to program and service representatives with whom we spoke, the basic cost could be discounted. For example, one program told us if parents paid for a full year upfront, they would be given a $200-per-month discount. This does not include fees by transport services for taking a child to a program. Moreover, although program and service representatives quoted these as basic program costs, they also mentioned additional one-time charges, such as an enrollment fee that can be as much as $4,600, uniform costs, or other items such as supplies. In addition, some programs charge extra for therapy, including one-on-one therapy. This is a work of the U.S. government and is not subject to copyright protection in the United States. It 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.

Summary:
In October 2007, GAO testified before the Committee regarding allegations of abuse and death in private residential programs across the country such as wilderness therapy programs, boot camps, and boarding schools. GAO also examined selected closed cases where a youth died while enrolled in one of these private programs. Many cite positive outcomes associated with specific types of residential programs. However, due to continuing concerns about the safety and well-being of youth enrolled in private programs, the Committee requested that GAO (1) identify and examine the facts and circumstances surrounding additional closed cases where a teenager died, was abused, or both, while enrolled in a private program; and (2) identify cases of deceptive marketing or questionable practices in the private residential program industry. To develop case studies of death and abuse, GAO conducted numerous interviews and examined documents from eight closed cases from 1994 to 2006. GAO used covert testing along with other investigative techniques to identify, for selected cases, deceptive marketing or questionable practices. Specifically, posing as fictitious parents with fictitious troubled teenagers, GAO called 14 programs and related services. GAO did not attempt to evaluate the benefits of private residential programs and its results cannot be projected beyond the specific programs and services that GAO reviewed. In the eight closed cases GAO examined, ineffective management and operating practices, in addition to untrained staff, contributed to the death and abuse of youth enrolled in selected programs. The practice of physical restraint also figured prominently in three of the cases. The restraint used for these cases primarily involved one or more staff members physically holding down a youth. Posing as fictitious parents with fictitious troubled teenagers, GAO found examples of deceptive marketing and questionable practices in certain industry programs and services. For example, one Montana boarding school told GAO's fictitious parents that their child must apply using an application form before they are admitted. But after a separate call, a program representative e-mailed an acceptance letter for GAO's fictitious child even though an application was never submitted. In another example, the Web site for one referral service states: "We will look at your special situation and help you select the best school for your teen with individual attention." However, GAO called this service three times using three different scenarios related to different fictitious children, and each time the referral agent recommended a Missouri boot camp. Investigative work revealed that the owner of the referral service is married to the owner of the boot camp. GAO also called a program established as a 501(c)(3) charity that advocated a potentially fraudulent tax scheme. The scheme involves the friends and family of a child making tax-deductible "donations" to the charity, which are then credited to an account in the program the child is enrolled in. GAO referred this charity to the Internal Revenue Service for criminal investigation.