Residential Programs: Selected Cases of Death, Abuse, and
Deceptive Marketing (24-APR-08, GAO-08-713T).
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.
-------------------------Indexing Terms-------------------------
REPORTNUM: GAO-08-713T
ACCNO: A81865
TITLE: Residential Programs: Selected Cases of Death, Abuse, and
Deceptive Marketing
DATE: 04/24/2008
SUBJECT: Child abuse
Children
Crime victims
Criminal liability
Employee training
Employees
Foundations (organizations)
Information and referral services
Investigations by federal agencies
Marketing
Mental health care services
Noncompliance
Program abuses
Program evaluation
Program management
Regulation
Schools
State-administered programs
Teenagers
Therapy
Training utilization
Wrongful death
Program implementation
Social programs
******************************************************************
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GAO-08-713T
* [1]Summary of Investigation
* [2]Background
* [3]Cases of Death and Abuse at Selected Residential Programs
* [4]Case 3 (Death)
* [5]Case 4 (Death)
* [6]Case 5 (Abuse)
* [7]Deceptive Marketing and Questionable Practices in Selected P
* [8]Contacts and Acknowledgments
* [9]GAO's Mission
* [10]Obtaining Copies of GAO Reports and Testimony
* [11]Order by Mail or Phone
* [12]To Report Fraud, Waste, and Abuse in Federal Programs
* [13]Congressional Relations
* [14]Public Affairs
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Testimony:
Before the Committee on Education and Labor, House of Representatives:
United States Government Accountability Office:
GAO:
For Release on Delivery:
Expected at 10:00 a.m. EDT:
Thursday, April 24, 2008:
Residential Programs:
Selected Cases of Death, Abuse, and Deceptive Marketing:
Statement of Gregory D. Kutz, Managing Director:
Forensic Audits and Special Investigations:
GAO-08-713T:
GAO Highlights:
Highlights of GAO-08-713T, a testimony before the Committee on
Education and Labor, House of Representatives.
Why GAO Did This Study:
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.
What GAO Found:
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. See the table below for
detailed information related to three of the case studies.
Examples of Case Studies GAO Examined:
Sex/age: Male, 14�18;
Date of death/abuse: 1994 to 1998;
Case details:
* Victim was restrained over 250 times while attending the program; in
at least two cases, restraint lasted over 12 hours;
* One method of restraint included wrapping the victim in a blanket and
tying him up;
* Was required to attend the program for 4 years and was held against
his will after his 18th birthday.
Sex/age: Male, 16;
Date of death/abuse: March 1998;
Case details:
* For several weeks, victim complained of chest pain and difficulty
breathing;
* Staff forced him to do push-ups and carry cinder blocks as punishment
for refusing an assigned task;
* Victim died from an accumulation of infectious pus in his chest;
* Autopsy found more than 70 injuries on his body, including some from
blunt force.
Sex/age: Male, 16;
Date of death/abuse: February 2006;
Case details:
* Three staff members held the victim facedown to restrain him;
* After 10 minutes of restraint, victim said he could not breathe and
was eventually taken to the hospital;
* School was aware victim suffered from asthma, but staff members who
restrained him said they were not;
* Victim died of abnormal heartbeat.
Source: Records including police reports, legal documents, and state
investigative documents.
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.
To view the full product, including the scope and methodology, click on
[hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-08-713T]. For more
information, contact Gregory Kutz at (202) 512-6722 or [email protected].
[End of section]
Mr. Chairman and Members of the Committee:
Thank you for the opportunity to continue the discussion of private
residential programs for troubled youth that we began last fall.
[Footnote 1] In the context of this and our prior testimony, we are
using the term residential program to refer to those private entities
across the country and abroad that call themselves wilderness therapy
programs, therapeutic boarding schools, academies, behavioral
modification facilities, ranches, and boot camps, among other names.
Many of these programs are privately owned and operated. Private
residential programs typically market their services to the parents of
troubled teenagers--boys and girls with a variety of addiction,
behavioral, and emotional problems--and provide a range of services,
including drug and alcohol treatment, confidence building, and
psychological counseling for illnesses such as depression and attention
deficit disorder. Parents trying to help their troubled child may also
seek help from referral services and educational consultants, which
generally purport to assess the needs of the child and recommend an
appropriate program.
Many cite positive outcomes associated with specific types of
residential programs. However, in our previous testimony, we identified
thousands of allegations of abuse, some of which resulted in death, at
residential programs across the country and in American-owned and
American-operated facilities abroad. We also examined 10 closed civil
or criminal cases where a teenager died while enrolled in a private
program and found significant evidence of ineffective management in
most of the 10 cases, with program leaders neglecting the needs of
program participants and staff. This ineffective management compounded
the negative consequences of (and sometimes directly resulted in) the
hiring of untrained staff; a lack of adequate nourishment for enrolled
children; and reckless or negligent operating practices, including a
lack of adequate equipment.
Due to your continuing concern about the safety and well-being of youth
enrolled in private residential programs, and to assist the Committee
in its consideration of the need for federal legislation in this area,
you requested that we (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 other questionable practices
in the private residential program industry.
To identify case studies, we reviewed numerous closed criminal or civil
cases in which a court or state agency was asked to decide whether a
private residential program was responsible for the death or abuse of
an enrolled teenager. We also reviewed administrative cases where state
agencies made rulings regarding the death or abuse of a teenager. When
identifying cases, we specifically excluded public programs such as
state-sponsored foster programs, juvenile justice programs for
delinquent youth, or programs that exclusively treat psychological
disorders or substance abuse in a hospital setting. We also excluded
cases related to the programs we examined for our October 10, 2007,
testimony. We focused on deaths or instances of abuse between the years
1994 and 2006 to illustrate the long-standing issues presented by
private residential programs. We limited our cases to closed criminal
cases and, thus, did not include ongoing cases from the last several
years. We selected eight cases--four cases of death and four cases of
abuse--based on several factors including the victim's age, the program
location, the type of program the victim attended, and the date of
death or abuse. We then examined, in more detail, the facts and
circumstances of the case. To validate the facts and circumstances, and
to the extent possible, we conducted interviews with related parties,
including current and former program staff and officials, attorneys and
law enforcement officials involved in the cases, and the parents of the
victims. Further, we reviewed available documentation to support the
facts of each case including, but not limited to, marketing materials,
police reports, autopsy reports, and state agency oversight reviews and
investigations.
To identify cases of deceptive marketing or other questionable
practices in the private residential program industry, we used a
variety of approaches and investigative techniques. Posing as
fictitious parents with fictitious troubled children, our undercover
investigators made telephone calls to a nonrepresentative selection of
10 private residential programs and 4 referral services. Like
legitimate parents with troubled teenagers, we identified these
programs and referral services through Internet searches and magazine
advertisements. To assess the accuracy and reasonableness of the
information we obtained during each undercover call, we performed
additional follow-up work that included, but was not limited to, making
additional undercover calls; comparing the information we received with
other marketing information provided by the program; reviewing relevant
laws, regulations, and trade organization statements; performing
announced, agreed upon site visits (i.e., not undercover); and speaking
with cognizant state and federal officials, including the Internal
Revenue Service (IRS).
We performed our work from November 2007 through April 2008 in
accordance with the quality standards for investigations set forth by
the President's Council on Integrity and Efficiency. As we noted in our
prior testimony, it is important to emphasize that residential programs
are intended to help youth with serious problems, including life-
threatening addictions and diseases. We did not attempt to evaluate the
benefits of residential programs in dealing with these serious
problems. In addition, it is not possible to generalize the results of
our investigation as applying to all residential programs, whether
privately or publicly funded, or referral services and educational
consultants and others in the residential program industry. Moreover,
it is difficult to develop a picture of the overall industry, its
practices, and efforts to oversee it. For example, while states often
regulate publicly funded programs, a number of states do not license or
otherwise regulate certain types of private programs. GAO is completing
a more comprehensive review of state and federal oversight of
residential programs and expects to issue a report soon.
Summary of Investigation:
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. In the most
egregious cases of death and abuse, the cases exposed problems with the
entire operation of the program. 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. Examples of some case studies follow:
* A 16 year-old male who suffered from asthma and chronic bronchitis
complained of chest pain and had difficulty breathing for several
weeks. Staff at the Arizona boot camp he was attending punished him for
refusing to do an assigned task and forced him to do push-ups and carry
cinder blocks; meanwhile, a program nurse told him the breathing
problems were "in your head." In March 1998, the victim died from an
accumulation of infectious pus in his chest, and an autopsy found more
than 70 injuries, including blunt-force injuries, on his body--
indicating he had been physically abused before his death.
* A teenage male was required to attend a behavior modification program
in New Jersey for 4 years, and was held against his will after he
turned 18. Records show that the victim was restrained more than 250
times while attending the program. 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. Restraints were imposed any time he showed reluctance to
participate in the program, and for other reasons; on one occasion, he
said he was wrapped in a blanket and tied up after attempting to escape
the program.
* In February 2006, a 16-year-old male with a history of asthma became
unresponsive while being restrained at a Pennsylvania treatment
facility. He died 3 hours later in a hospital. An investigation into
the death 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 youth with asthma. However, all three staff members
involved in the restraint that led to the victim's death told
investigators that they were unaware of any medical conditions that
needed to be considered when restraining the victim.
In three of the eight cases we examined, the victim was placed in the
program by the state or in consultation with state authorities.
Posing as fictitious parents with fictitious troubled teenagers, we
also found examples of deceptive marketing and questionable practices
in the private residential program industry. Deceptive marketing
included potential fraud, false statements, and misleading
representations related to a range of issues including tax deductions,
education, and admissions policies. We also found undisclosed conflicts
of interest. Examples of deceptive marketing included the following:
* One Montana boarding school told us that parents must submit an
application form in order for their child to be considered for
admission in the program. However, after a separate call by a
fictitious parent, a program representative e-mailed us that our
fictitious daughter had been approved for admission into the program
and subsequently sent an acceptance letter. This acceptance into the
school was based on a 30-minute telephone conversation. We did not fill
out any application form.
* The Web site for one referral service we called says: "We will look
at your special situation and help you select the best school for your
teen with individual attention." However, we 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, but this relationship
was never disclosed during the call, raising the issue of conflict of
interest.
* The representative for a 501(c)(3) foundation suggested our
fictitious parents take advantage of a fund-raising approach that is
potentially a fraudulent tax scheme. The representative said that this
"popular" option would allow friends, family, business acquaintances,
churches, and other organizations to make tax-deductible donations that
would then be credited to our fictitious child's tuition in a private
program. After we briefed an IRS official on the representation by this
foundation, he told us that the foundation is potentially committing
tax fraud and that those who obtain tax benefits for donations in the
suggested manner may be responsible for back taxes, as well as
penalties and interest.
A link to selected audio clips from these calls is available at:
[hyperlink, http://www.gao.gov/media/video/gao-08-713t/].
Background:
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.[Footnote 2]
Cases of Death and Abuse at Selected Residential Programs:
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.[Footnote 3]
See table 1 for a summary of the cases of death we examined.
Table 1: Summary of Eight Closed Cases (Four Deaths):
Case: 1;
Victim information: Male, 16, California resident;
Program Attended: Arizona boot camp;
Date of death: March 1998;
Cause of death: Empyema (accumulation of infectious pus in the chest);
Case details:
* Victim suffered from asthma and chronic bronchitis;
* For a period of several weeks, victim complained of chest pain and
difficulty breathing, but a program nurse said that his breathing
problems were in his head;
* Staff punished him for refusing an assigned task, and forced him to
do push-ups and carry cinder blocks;
* Victim eventually became unresponsive, at which point staff finally
realized that his condition required medical attention;
* Victim was declared dead at a hospital;
* Autopsy found more than 70 injuries, including some from blunt force,
on his body, indicating that the victim had been physically abused
before his death.
Case: 2;
Victim information: Male, 14, Texas resident;
Program Attended: Texas wilderness therapy program;
Date of death: September 2004;
Cause of death: Cardiopulmonary Arrest;
Case details:
* Victim's hiking group became lost and spent several unforeseen hours
in temperatures that reached 98 degrees (a reported heat index of near
105 degrees);
* During the hike, victim stopped and complained that he was too hot
and tired and refused to go on, but he was encouraged to continue;
* Victim said he didn't feel well and was dizzy, then stumbled and
fell;
* Staff thought he was "faking";
* When victim began to vomit, staff rolled him on his side;
* Victim stopped breathing and was later pronounced dead;
* Died on federal land.
Case: 3;
Victim information: Male, 12, Texas resident;
Program Attended: Texas residential treatment center;
Date of death: December 2005;
Cause of death: Suffocation;
Case details:
* Victim was angry and started banging his head against the ground;
* A 5 feet 10 inch, muscular staff member placed the 87-pound victim
into a facedown restraint;
* Several witnesses claimed they saw the staff member lying across the
back of the victim;
* Victim complained he couldn't breathe and eventually became
unresponsive, at which point the staff member removed the restraint;
* After the victim had lain unresponsive for about a minute, the staff
member rolled him over and found that he was pale;
* Attempts to revive victim failed.
Case: 4;
Victim information: Male, 16, Pennsylvania resident;
Program Attended: Pennsylvania psychiatric residential treatment
center;
Date of death: February 2006;
Cause of death: Abnormal heartbeat;
Case details:
* Victim was placed under "intense observation" for attempting to run
away from the program;
* Victim was ordered to put the hood of his sweatshirt down so that
staff could see his face, but victim refused;
* Three staff members brought the victim to another room and placed him
in restraint face down;
* After 10 minutes of the restraint, victim complained that he couldn't
breathe;
* Despite staff attempts to make the victim more comfortable, victim
became unresponsive;
* Victim died at the hospital 3 hours later from an abnormal heartbeat;
* Program was aware victim suffered from asthma, but staff members who
restrained the victim claimed they were not aware of this.
Source: Records including police reports, legal documents, and state
investigative documents.
[End of table]
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.
Table 2: Summary of Eight Closed Cases (Four Abuse):
Case: 5;
Victim information: Male, 14-18, New York resident;
Program attended: New Jersey residential behavior modification program;
Date(s) of abuse: 1994 to 1998;
Case details:
* Victim and parents were interviewed separately by staff during his
first visit to the program;
* Victim encountered 6 hours of intense questioning during which he
felt forced to confess to activities he says he did not take part in,
such as illegal drug use and sex;
* Victim was restrained more than 250 times while attending the
program; in at least two cases restraint lasted longer than 12 hours;
* One method of restraint included wrapping the victim in a blanket and
tying him up;
* Victim was required to attend the program for 4 years and was held
against his will after his 18th birthday.
Case: 6;
Victim information: Male, 17, Washington resident;
Program attended: Mississippi faith-based academy and boot camp;
Date(s) of abuse: April 1999;
Case details:
* Victim jumped off a building and broke his left arm; the bone of his
arm was exposed, but he was not given medical attention for 2 weeks;
* Students and staff harassed the victim, with some boys subjecting him
to physical abuse;
* On one occasion, victim was beaten unconscious by staff and other
students;
* On another occasion, a staff member's pit bull bit the victim in the
crotch;
* Victim had previously attended boarding school in case 7.
Case: 7;
Victim information: Male, 15, California resident;
Program attended: Utah boarding school;
Date(s) of abuse: November 2004;
Case details:
* Victim was verbally abused and punched, kicked, and slapped by other
students, under direction of one of the school's owners;
* Victim was hit and pushed down stairs by the same school owner;
* On multiple occasions throughout his stay in the school, victim was
locked in a bathroom and a closet and forced to sleep on a shelf as
punishment.
Case: 8;
Victim information: Male, 14, California resident;
Program attended: Colorado boarding school;
Date(s) of abuse: May 2006;
Case details:
* Staff member assaulted victim by grabbing him by the arm, pushing him
into a stairwell, and slamming his face into a wall;
* Victim's face was visibly bruised, including a black eye;
* Victim was forced to kneel on the floor for hours with his knees at
the point where the floor meets the wall and his nose touching the
wall.
Source: Records including police reports, legal documents, and state
investigative documents.
[End of table]
The following three narratives describe selected cases in further
detail.
Case 3 (Death):
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� 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.
Case 4 (Death):
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.
Case 5 (Abuse):
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.
Deceptive Marketing and Questionable Practices in Selected Programs and
Services:
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:
[hyperlink, http://www.gao.gov/media/video/gao-08-713t/]. See table 3
for a selection of representations made by programs and referral
agents.
Table 3: Cases of Deceptive Marketing and Questionable Practices:
Source: 1. 501(c)(3) charity foundation;
Representation: Foundation representative described a funding mechanism
whereby (1) parents solicit friends, relatives, and others to make
financial donations to the foundation and have them specify on their
donation checks a numbered code representing the child; (2) the
foundation tracks the donation amount on behalf of the child, then
deducts an administrative fee and pays the program the remaining
donation amount on behalf of that child; and (3) friends and family
deduct the charitable donations on their tax return;
Comments: An IRS official told us that the foundation is potentially
committing tax fraud and that individuals who follow the program's
recommendation may be responsible for back taxes, as well as penalties
and interest for taking an improper charitable deduction.
Source: 2. Montana boarding school;
Representation: Program representatives told one fictitious parent that
an application form must be filled out before a child is admitted to
the boarding school;
Comments: After a call to this program by a different fictitious
parent, we received an acceptance letter for our fictitious child even
though we never applied for admission.
Source: 3. Texas wilderness program;
Representation: Program representative stated that earth science
credits earned in the program are "fully transferable" and that other
institutions "can't deny" the credit;
Comments: Education credits can be denied by schools for any reason and
are not intrinsically transferable.
Source: 4. Texas wilderness program (same as case number 3);
Representation: Program representative said that the program will
provide parents with a detailed bill after their child completes the
program and that health insurance companies will reimburse expenses;
Comments: 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.
Source: 5. Texas wilderness program (same as case numbers 3 and 4);
Representation: Program representative said a trade organization, the
National Association of Therapeutic Schools and Programs (NATSAP),
"absolutely" performs inspections of the program;
Comments: NATSAP does not perform inspections of its member programs.
Source: 6. Referral service "A";
Representation: Referral agent stated that behavioral modification
schools are "specialty schools" and that tuition costs are tax
deductible under Section 213 of the Internal Revenue Tax code;
Comments: The two programs recommended by the referral agent do not
appear to meet the requirements of IRS regulations for special schools;
according to an IRS authority on Section 213 with whom we spoke, this
is questionable tax advice and parents should consult a tax advisor.
Source: 7. Referral service "A";
Representation: The referral agent warned our fictitious parent that
his wife might "freak out" about sending her daughter to a boarding
school, and stated: "I want you to tell her it's a college prep
boarding school...if she thinks that you want to send her daughter to a
place where there are drug addicts and people that are all screwed up,
she will look at you and say 'no way'";
Comments: In order to secure the business of our fictitious parent, the
referral agent gave us questionable ethical advice.
Source: 8. Referral service "B";
Representation: Referral agent stated that the program he recommended
"feed[s] the child a whole-grain diet" and that along with exercise and
rest, "the bipolar, the depression, those kind of things, they just go
away after awhile";
Comments: Although diet and sleep may be beneficial, there was no
discussion during the call for a health care provider to confirm the
child's diagnosis of bipolar disorder or depression and whether to
continue medication.
Source: 9. Referral service "B";
Representation: Web site for this referral service states: "We will
look at your special situation and help you select the best school for
your teen with individual attention";
Comments: Referral agents recommended the same Missouri boot camp to
three different fictitious parents with three fictitious children
having very different problems; the referral service is owned by the
husband of the woman who owns the Missouri boot camp, but the conflict
of interest was not disclosed.
Source: 10. Referral services "A" and "C";
Representation: When investigators called the phone number of referral
service "A" the receptionist answered the call using the name of
referral service "C";
Comments: Referral services "A" and "C" represent themselves as
separate entities, with separate names, Web sites, phone numbers, and
magazine advertisements, suggesting that they provide objective advice.
Source: GAO.
[End of table]
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.
Contacts and Acknowledgments:
[End of section]
For further information about this testimony, please contact Gregory D.
Kutz at (202) 512-6722 or [email protected]. Contact points for our Offices
of Congressional Relations and Public Affairs may be found on the last
page of this testimony.
[End of section]
Appendix I: Private Residential Program Locations:
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.
Figure 1: Map of Case Study Victims from October 2007 Testimony and
This Testimony:
[See PDF for image]
This figure is a map of the United States depicting the state of
residence of victims and the location of the residence programs they
attended. The following data is depicted:
State of residence (male/female): Connecticut (male);
Location of residential program: West Virginia.
State of residence (male/female): New York (male);
Location of residential program: New Jersey.
State of residence (male/female): Pennsylvania (male);
Location of residential program: Pennsylvania.
State of residence (male/female): Virginia (female);
Location of residential program: Utah.
State of residence (male/female): Florida (female);
Location of residential program: Utah.
State of residence (male/female): Texas (male);
Location of residential program: Texas.
State of residence (male/female): Texas (male);
Location of residential program: Texas.
State of residence (male/female): Texas (male);
Location of residential program: Utah.
State of residence (male/female): Arizona (male);
Location of residential program: Arizona.
State of residence (male/female): Arizona (male);
Location of residential program: Utah.
State of residence (male/female): Arizona (female);
Location of residential program: Nevada.
State of residence (male/female): California (male);
Location of residential program: Arizona.
State of residence (male/female): California (male);
Location of residential program: Colorado.
State of residence (male/female): California (male);
Location of residential program: Utah.
State of residence (male/female): California (male);
Location of residential program: Missouri.
State of residence (male/female): California (female);
Location of residential program: Utah.
State of residence (male/female): Oregon (male);
Location of residential program: Oregon.
State of residence (male/female): Washington (male);
Location of residential program: Mississippi.
Note: The icons in figure 1 represent the state of residence for each
case study victim and the state in which each residential program is
located. The icons do not reflect specific geographic locations within
states.
Source: GAO.
[End of figure]
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.
Figure 2: Private Residential Programs Nationwide:
[See PDF for image]
This figure is a map of the United States depicting the location of
Private Residential Programs. The following data is depicted:
State: Alabama:
One or more boarding schools located in state;
One or more therapeutic boarding schools located in state;
One or more wilderness programs located in state.
State: Alaska:
One or more therapeutic boarding schools located in state.
State: Arizona:
One or more boarding schools located in state;
One or more therapeutic boarding schools located in state;
One or more wilderness programs located in state;
One or more ranch programs located in state.
State: Arkansas:
One or more boarding schools located in state;
One or more therapeutic boarding schools located in state.
State: California:
One or more boarding schools located in state;
One or more therapeutic boarding schools located in state;
One or more wilderness programs located in state;
One or more ranch programs located in state.
State: Colorado:
One or more boarding schools located in state;
One or more therapeutic boarding schools located in state;
One or more wilderness programs located in state;
One or more ranch programs located in state.
State: Connecticut:
One or more boarding schools located in state;
One or more therapeutic boarding schools located in state.
State: Delaware:
One or more therapeutic boarding schools located in state.
State: Florida:
One or more boarding schools located in state;
One or more therapeutic boarding schools located in state;
One or more wilderness programs located in state.
State: Georgia:
One or more boarding schools located in state;
One or more therapeutic boarding schools located in state;
One or more wilderness programs located in state.
State: Hawaii:
One or more boarding schools located in state;
One or more therapeutic boarding schools located in state.
State: Idaho:
One or more boarding schools located in state;
One or more therapeutic boarding schools located in state;
One or more wilderness programs located in state;
One or more ranch programs located in state.
State: Illinois:
One or more boarding schools located in state;
One or more therapeutic boarding schools located in state;
One or more ranch programs located in state.
State: Indiana:
One or more boarding schools located in state;
One or more therapeutic boarding schools located in state;
One or more wilderness programs located in state.
State: Iowa:
One or more therapeutic boarding schools located in state.
State: Kansas:
One or more boarding schools located in state;
One or more therapeutic boarding schools located in state.
State: Kentucky:
One or more therapeutic boarding schools located in state;
One or more wilderness programs located in state.
State: Louisiana:
One or more boarding schools located in state;
One or more therapeutic boarding schools located in state;
One or more ranch programs located in state.
State: Maine:
One or more boarding schools located in state;
One or more therapeutic boarding schools located in state;
One or more wilderness programs located in state;
One or more ranch programs located in state.
State: Maryland:
One or more boarding schools located in state;
One or more therapeutic boarding schools located in state;
One or more wilderness programs located in state.
State: Massachusetts:
One or more boarding schools located in state;
One or more therapeutic boarding schools located in state;
One or more wilderness programs located in state.
State: Michigan:
One or more boarding schools located in state;
One or more therapeutic boarding schools located in state;
One or more wilderness programs located in state.
State: Minnesota:
One or more boarding schools located in state;
One or more therapeutic boarding schools located in state;
One or more wilderness programs located in state.
State: Mississippi:
One or more therapeutic boarding schools located in state.
State: Missouri:
One or more boarding schools located in state;
One or more therapeutic boarding schools located in state;
One or more wilderness programs located in state.
State: Montana:
One or more boarding schools located in state;
One or more therapeutic boarding schools located in state;
One or more wilderness programs located in state;
One or more ranch programs located in state.
State: Nevada:
One or more boarding schools located in state;
One or more therapeutic boarding schools located in state;
One or more wilderness programs located in state.
State: New Hampshire:
One or more boarding schools located in state;
One or more therapeutic boarding schools located in state;
One or more wilderness programs located in state.
State: New Jersey:
One or more boarding schools located in state;
One or more therapeutic boarding schools located in state.
State: New Mexico:
One or more boarding schools located in state;
One or more therapeutic boarding schools located in state;
One or more wilderness programs located in state;
One or more ranch programs located in state.
State: New York:
One or more boarding schools located in state;
One or more therapeutic boarding schools located in state;
One or more wilderness programs located in state.
State: North Carolina:
One or more boarding schools located in state;
One or more therapeutic boarding schools located in state;
One or more wilderness programs located in state.
State: North Dakota:
One or more therapeutic boarding schools located in state.
State: Ohio:
One or more boarding schools located in state;
One or more therapeutic boarding schools located in state.
State: Oklahoma:
One or more therapeutic boarding schools located in state.
State: Oregon:
One or more boarding schools located in state;
One or more therapeutic boarding schools located in state;
One or more wilderness programs located in state;
One or more ranch programs located in state.
State: Pennsylvania:
One or more boarding schools located in state;
One or more therapeutic boarding schools located in state;
One or more wilderness programs located in state;
One or more ranch programs located in state.
State: Rhode Island:
One or more boarding schools located in state;
One or more wilderness programs located in state.
State: South Carolina:
One or more boarding schools located in state;
One or more therapeutic boarding schools located in state;
One or more wilderness programs located in state;
One or more ranch programs located in state.
State: Tennessee:
One or more boarding schools located in state;
One or more therapeutic boarding schools located in state;
One or more wilderness programs located in state;
One or more ranch programs located in state.
State: Texas:
One or more boarding schools located in state;
One or more therapeutic boarding schools located in state;
One or more wilderness programs located in state;
One or more ranch programs located in state.
State: Utah:
One or more boarding schools located in state;
One or more therapeutic boarding schools located in state;
One or more wilderness programs located in state;
One or more ranch programs located in state.
State: Vermont:
One or more boarding schools located in state;
One or more therapeutic boarding schools located in state;
One or more wilderness programs located in state;
One or more ranch programs located in state.
State: Virginia:
One or more boarding schools located in state;
One or more therapeutic boarding schools located in state;
One or more wilderness programs located in state.
State: Washington:
One or more boarding schools located in state;
One or more therapeutic boarding schools located in state;
One or more wilderness programs located in state;
One or more ranch programs located in state.
State: West Virginia:
One or more boarding schools located in state;
One or more therapeutic boarding schools located in state;
One or more wilderness programs located in state.
State: Wisconsin:
One or more boarding schools located in state;
One or more therapeutic boarding schools located in state.
State: Wyoming:
One or more boarding schools located in state.
States with no programs:
Nebraska;
South Dakota.
Source: GAO analysis of information available on referral service Web
sites.
[End of figure]
[End of section]
Appendix II: Cost of Private Residential Programs:
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.
Table 4: Basic Monthly Costs of Programs:
Number: 1;
Type of program: Boarding school;
Location: Georgia;
Source of information: Referral service;
Basic monthly cost: $3,166.
Number: 2;
Type of program: Boot camp;
Location: Missouri;
Source of information: Referral service;
Basic monthly cost: $4,500.
Number: 3;
Type of program: Boarding school;
Location: North Carolina;
Source of information: Referral service;
Basic monthly cost: $4,500.
Number: 4;
Type of program: Boarding school;
Location: South Carolina;
Source of information: Referral service;
Basic monthly cost: $3,166.
Number: 5;
Type of program: Boarding school;
Location: South Carolina;
Source of information: Referral service;
Basic monthly cost: $2,795.
Number: 6;
Type of program: Boarding school;
Location: Colorado;
Source of information: Program;
Basic monthly cost: $2,795 - $2,995.
Number: 7;
Type of program: Boarding school;
Location: Georgia;
Source of information: Program;
Basic monthly cost: $8,120[A].
Number: 8;
Type of program: Boarding school;
Location: Montana;
Source of information: Program;
Basic monthly cost: $3,495.
Number: 9;
Type of program: Boarding school;
Location: New York;
Source of information: Program;
Basic monthly cost: $5,160.
Number: 10;
Type of program: Boarding school;
Location: Tennessee;
Source of information: Program;
Basic monthly cost: $8,700[B].
Number: 11;
Type of program:
Boarding school;
Location: Utah;
Source of information: Program;
Basic monthly cost: $6,500[B].
Number: 12;
Type of program: Wilderness program;
Location: Georgia;
Source of information: Program;
Basic monthly cost: $12,600.
Number: 13;
Type of program: Wilderness program;
Location: North Carolina;
Source of information: Program;
Basic monthly cost: $13,020.
Number: 14;
Type of program: Wilderness program;
Location: Texas;
Source of information:
Program; Basic monthly cost: $13,020.
Source: GAO analysis of information obtained during undercover calls to
programs and referral services.
[A] This is for the first 90 days; the cost drops afterwards.
[B] This includes therapy.
[End of table]
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.
[End of section]
Footnotes:
[1] GAO, Residential Treatment Programs: Concerns Regarding Abuse and
Death in Certain Programs for Troubled Youth, [hyperlink,
http://www.gao.gov/cgi-bin/getrpt?GAO-08-146T] (Washington, D.C.: Oct.
10, 2007).
[2] 42 C.F.R. �� 483.350-.376.
[3] For an illustration showing the states where victims resided and
the location of the programs they attended, both for this testimony and
our October 2007 testimony, see app. I.
[End of section]
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