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HHS-OIG: Significant Incidents Involving Unaccompanied Children Not Effectively Captured in Reporting System; Facility Physical Security Inspection Checklists Need Improvement

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WASHINGTON—A reporting system meant to track incidents that affect the health, well-being, or safety of children in the care of the U.S. Department of Health and Human Services did not effectively capture data, thus undercutting efforts to protect this population, according to a report released today by the HHS Office of Inspector General.

The report also identified other challenges in the reporting process, including shortages of youth care workers - who are essential to preventing, detecting and reporting incidents—and difficulty understanding federal policy regarding which incidents should be reported to HHS's Office of Refugee Resettlement, which manages the Unaccompanied Alien Children Program. The program serves children who have no lawful immigration status in the United States and do not have a parent or legal guardian available in the United States to provide care and physical custody.

Also released today is an issue brief finding that inspection checklists used by facilities to self-identify whether required physical security measures were present and functioning were not always comprehensive. For example, 39 of the 40 facilities reviewed lacked prompts for facility staff to check at least one of the three physical security measures required by ORR.

"It is an essential and ongoing responsibility for the Department of Health and Human Services to ensure that children in its custody are in a safe environment and protected from harm. Our oversight efforts, including the work that we released today, prioritize the protection of children in the Department's care," said HHS-OIG Principal Deputy Inspector General Christi A. Grimm. "We appreciate the steps that HHS is taking to implement our recommendations and encourage their continued efforts to ensure the well-being of children in their care."

Incident Reporting System Not Effectively Capturing Data

To ensure that the ORR-funded facilities that directly care for minors are appropriately preventing and addressing harmful incidents, the report, Office of Refugee Resettlement's Incident Reporting System Is Not Effectively Capturing Data To Assist Its Efforts To Ensure the Safety of Minors in HHS Custody, provides a review of significant incident reports submitted to ORR by 45 ORR funded facilities between January 1, 2018, and July 31, 2018. In addition, the report presents an in-depth review of incident reports that described conduct of a sexual nature.

ORR requires facility staff to report to ORR any incidents that include medical emergencies, physical or verbal aggression between minors, self-harm (e.g., suicidal ideation), runaway attempts, and incidents of a sexual nature. According to ORR policy, the process is intended to "ensure that serious issues are immediately elevated to ORR and that all incidents are resolved quickly to protect children in ORR care."

The facilities submitted reports for 761 unique incidents to ORR involving alleged sexual conduct. Of these, 704 involved conduct between minors, and 48 involved conduct by an adult (in 43 cases, a facility staff member) against a minor. In the remaining nine incidents, the perpetrator was unknown.

The incidents varied widely in type and severity. For example, the conduct described in these incidents included a minor opening a bathroom door while another minor was inside, as well as a staff member kissing a minor.

Overall, OIG found that ORR's incident reporting system is not an efficient or effective oversight tool for allowing ORR to ensure that facilities appropriately report and respond to incidents. The system does not effectively capture key information, including information about facilities' response to incidents. For example, it is not designed so ORR can quickly and easily identify whether facilities have taken appropriate and required actions after an incident, including whether they have suspended staff involved in a sexual abuse incident. In addition, the information it does capture is often collected in a manner that requires extensive manual review.

Insufficient information can hamper ORR's oversight of the UAC Program, including its ability to protect minors by using data to identify threats and prevent future incidents. According to OIG, this ability is critical because even a single individual can cause immeasurable harm if he or she poses a threat to the well-being of minors in ORR's care. OIG provided recommendations to improve the efficiency and effectiveness of the incident reporting system for ORR's oversight of facilities and to reduce the challenges that facilities face in staffing youth care workers and determining which incidents should be reported to ORR.

Facilities Do Not Include All Required Physical Security Measures in Checklists

The issue brief, Unaccompanied Alien Children Program Care Provider Facilities Do Not Include All Required Security Measures in their Checklists, assesses the extent to which facilities included physical security measures required by ORR in their site inspection checklists. It also examines ORR's oversight of facilities' use of inspection checklists.

ORR requires facilities to provide care in a child-friendly environment that does not pose a safety risk and has a non-institutional, home-like atmosphere. ORR requires facilities to install and maintain three physical security measures: (1) controlled entry and exit, (2) alarm systems, and (3) video monitoring.

OIG found that almost all facilities that submitted checklists (39 out of 40) lacked prompts for staff to inspect at least one of the ORR-required physical security measures. The security measure most frequently missing from facilities' checklists was video monitoring (29 out of 40 facilities).

Video monitoring was also an area of concern in the OIG report on significant incidents. The incident reporting system does not include a designated field to systematically capture whether video footage of the incident is available and has been reviewed. This finding is of particular concern because video footage can effectively substantiate incidents.

OIG was unable to determine whether all incidents were substantiated or refuted, due to the limited information in the incident reporting system. While OIG found only 11 percent of incident reports (81 of 761) indicated that video footage of the alleged conduct had been reviewed, for over half of these 81 incidents, facilities indicated that video footage helped to substantiate 33 incidents and refute or call into question 10 incidents.

When facilities included physical security measures in their inspection checklists, they did not always describe in detail what elements to check. According to OIG, if facilities do not regularly check that their security measures are in place and functioning, children could be exposed to safety risks. For example, inadequate controlled entry and exit measures could lead to unauthorized individuals entering a facility or children leaving unnoticed.

OIG also found that ORR does not provide guidance or routine oversight on facilities' use of the inspection checklists. ORR relies primarily on facilities to self-identify and correct concerns with the physical security measures it requires.

OIG provided several recommendations for practical steps that ORR can take to ensure that facilities routinely check all required physical security measures to better protect children in ORR care from risks.

The agency that oversees ORR, the Administration for Children and Families, submitted comments concurring with all recommendations and outlined corrective actions that are underway or planned in order to address the findings in the reports.

To read the full reports and access other OIG completed work products related to the UAC Program, visit