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The 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


The Department of Health and Human Services (HHS), Administration for Children and Families (ACF), Office of Refugee Resettlement (ORR), has custody of and must provide care to minors (children younger than 18 years of age) in the Unaccompanied Alien Children (UAC) Program. ORR is responsible for providing a safe environment for all minors in the program. In recent years, ORR-funded facilities have reported allegations of sexual and physical abuse of minors in their care, some resulting in criminal convictions.


OIG analyzed Significant Incident Reports (SIRs) submitted to ORR by 45 ORR funded facilities between January 1, 2018, and July 31, 2018, to identify any challenges for the oversight of facilities to ensure the safety of children. In addition, we conducted an in-depth review of incident reports that described conduct of a sexual nature. This allowed us to provide information about these types of potentially egregious incidents and ORR's response to them. We could not determine whether the incidents were officially investigated or substantiated by an external agency, on the basis of the information in the reports. We also identified challenges in the SIR reporting process for oversight of facilities to ensure the safety of children. This assessment is based on our review of the SIRs and information gathered during OIG's site visits at the 45 facilities in August and September 2018. At each facility, we conducted interviews with key staff responsible for ensuring the safety of minors. We also interviewed the 28 ORR Federal field specialists assigned to the facilities and reviewed relevant policies and procedures.


We reviewed incident reports that 45 care provider facilities submitted to ORR between January 1, 2018, and July 31, 2018. Among these reports, 761 unique incidents described conduct of a sexual nature. Reports for most (704) of these incidents involved conduct between minors, fewer (48) involved conduct by an adult against a minor, and the remaining (9) incidents had an unknown perpetrator. 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. ORR's incident reporting system lacks designated fields to capture information that ORR can use to oversee facilities and to protect the minors in ORR care. Important information about facilities' actions are not systematically collected to help ORR determine whether facilities responded appropriately to incidents. In addition, the system does not effectively capture information in a way that allows for efficient identification of issues that require immediate attention and analysis to detect concerning trends. Further, facilities described challenges with staffing youth care workers-who are essential to preventing, detecting, and reporting incidents-and difficulties determining which incidents should be reported to ORR.


Our recommendations aim to improve the incident reporting system and reduce the challenges that facilities face. ACF should work with ORR to (1) systematically collect key information about incidents that allows for efficient and effective oversight, (2) track and trend incident report information to identify opportunities to better safeguard minors, (3) work with facilities to address staffing shortages of youth care workers, and (4) improve its guidance to help facilities consistently identify and report significant incidents. ACF concurred with all four of our recommendations.