Ron Wyden Leads Senate Finance Committee Hearing On Youth Residential Treatment Facilities

6 months ago

On Wednesday, the Senate Finance Committee held a hearing entitled, “Youth Residential Treatment Facilities: Examining Failures and Evaluating Solutions.”

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Transcript

00:00:00will come to order. Today, the Finance Committee meets to discuss the horrific abuses and neglect

00:00:09of children at too many residential treatment facilities. Places that say they provide behavioral

00:00:17health care to vulnerable kids, but often leave them harmed and more traumatized than

00:00:26they started off. Just this morning, the committee released a new investigative report

00:00:32with shocking details about the treatment of kids in these facilities. And these facilities

00:00:40get big dollars from programs under the jurisdiction of this committee, specifically Medicaid and

00:00:49child welfare funds. There are endless examples of sexual, physical, and verbal abuse, improper

00:00:57restraint and seclusion on young children, unsafe and unsanitary conditions, and even

00:01:03a total lack of provision of behavioral health care. Unfortunately, it seems more often than

00:01:12not, abuse and neglect is the norm at these facilities. And they are set up in a way that

00:01:22makes it happen. The system is failing, except the providers running these treatment facilities

00:01:29who have figured out how to turn big profits off taxpayer-funded child abuse. I don't say

00:01:38that lightly. Our staff spent several years looking at the biggest companies in the industry,

00:01:46Universal Health Services, Acadia Healthcare, Devereux Advanced Behavioral Health, and Vivant

00:01:51Behavioral Health. Our investigative team reviewed 25,000 pages of company documents,

00:01:57had dozens of conversations with experts, pored over article after article and saw the

00:02:02problems firsthand when they visited the facilities. Overwhelmingly, it's clear that the operating

00:02:11model for these facilities is to warehouse as many kids as possible while keeping costs

00:02:17low in order to maximize profit. That means intentional understaffing with persons who

00:02:25have zero experience or qualifications to provide the care these children need. As Jay

00:02:32Ripley, the co-founder of Vivant and two other companies, once remarked, and I quote now,

00:02:38you can make money in this business if you control staffing. It also means facility conditions

00:02:45that are often unsanitary and dangerous. Facilities that feel more like a prison than a safe place

00:02:52to help a child get through a difficult time. In these conditions, children can't get the

00:02:57care they need like high quality and individualized treatment. As if profiting off rampant abuse

00:03:04and neglect of our kids' most vulnerable kids wasn't bad enough, these facilities rely on

00:03:10enormous amounts of federal funds. That means that American tax dollars are funding the

00:03:17kind of abuse our investigators found. In some cases, these facilities receive over

00:03:22$1,200 per day per child from the Medicaid program. The experiences and trauma these

00:03:29kids are left with reads like something from a horror novel. A facility routinely restrained

00:03:35children, for example, drugged them, placed them in seclusion in clear violation of federal

00:03:40rules. Another facility saw a child ran away from the program in the middle of the night

00:03:45and was fatally struck by a truck. The staff at the facility tried to cover up the neglect,

00:03:51falsified documents about the child's whereabouts. Another child was sexually abused by a staffer

00:03:58on an ongoing basis. When the facility caught on to the abuse instead of firing the staffer,

00:04:03they simply moved them to a different wing of the same facility. Each night the staffer

00:04:08returned to the child's window to say goodnight. There are instances of child fatalities, both

00:04:15at the hands of staff and death by suicide. Unfortunately, the accounts of abuse we hear

00:04:21about today are not outliers. They amount to a systemic culture of mistreating and abusing

00:04:29kids and turning a profit. We gave the CEO of the nation's largest provider the opportunity

00:04:35to testify before the committee today, and he could defend how the company treats the

00:04:41children in his care. It is disappointing but not surprising that he declined the invitation.

00:04:48His company's conduct and the very business model that we are talking about today is in

00:04:55my view indefensible. So the question everybody in this room ought to be asking themselves

00:05:00is where do we go from here? I want to work in a bipartisan way to shut off the fire hose

00:05:08of federal funding for these facilities to put an end to this cycle of abuse. The buck

00:05:16stops with this committee. In order to get a dime from Medicaid or any other program

00:05:20in our jurisdiction, all these facilities are going to have to start providing actual

00:05:26care. Systemic failures at even a handful of these facilities is an indictment of a

00:05:32flawed model. It's pretty simple. A facility shouldn't be getting taxpayer money if it

00:05:37can't prove that it's providing high quality care. Finally, none of this matters if there's

00:05:44not oversight and enforcement. These facilities are often located in rural areas and function

00:05:50as black boxes that get left virtually unchecked. As a result, practices that should be used

00:05:56only in rare extreme cases like restraint and seclusion are being used regularly and

00:06:02being used by staff that's unqualified and poorly trained. At one Acadia facility in

00:06:08Arkansas, restraint and seclusion was used 110 times in just a month. Without clear nationwide

00:06:16tracking of these facilities, this behavior just slips between the cracks. There also,

00:06:24as part of our work, is the priority of making sure there are more community-based alternatives

00:06:32for care. We know this based on research, this committee's own experience passing the

00:06:37bipartisan family first law and from doctors and patients themselves. The only people who

00:06:43disagree with this effort to have more community-based alternatives seem to be folks who have a financial

00:06:49interest in protecting the status quo. In order to reduce our reliance on fraudulent

00:06:54facilities and to reduce the number of kids that end up in them, investing in high quality

00:06:58community-based care must be a priority. It's simple. If you provide more care and support

00:07:05to kids up front, you reduce the need for residential treatment and the number of kids

00:07:10being subjected to these horrific abuses. What we found is that too often, kids in foster

00:07:17care are warehoused in these residential facilities for months or years with no plan to exit and

00:07:22no legitimate reason for being there. The federal government and American taxpayers

00:07:28have no business funding jail-like settings for foster care kids. So these findings demand

00:07:36bold action. In the coming months, I'm going to be working to bring my colleagues together

00:07:41behind legislation in this committee's jurisdiction to raise health and safety standards, require

00:07:46real oversight and enforcement, and invest in the community-based services that are proven

00:07:51to actually help kids. And I'm just going to wrap up and we'll go to the ranking member,

00:07:57but I just want to acknowledge all the survivors in this room. I met with many last night,

00:08:07again this morning, and I want them to know that your presence and the fact that you have

00:08:14been giving these accounts is what is providing the energy to finally get these long overdue

00:08:22changes. So my thanks to everybody who's with us today, who told me about their experiences

00:08:29last night and again this morning. Thank you for your bravery. As chairman of this committee,

00:08:34I am all in, all in, to stop the cycle of abuse that's been brought to light today.

00:08:40Senator Crapo. Thank you very much, Mr. Chairman. I appreciate

00:08:43your holding this hearing today. As Senator Wyden alluded to, just three weeks ago, the

00:08:51Senate Finance Committee held a hearing to celebrate the child welfare system's progress

00:08:56resulting from the enactment of the Family First Prevention Services Act. We heard from

00:09:02witnesses about the importance of investing in preventive services and that children are

00:09:06best served when they can receive care within their own homes and communities. While more

00:09:13work is needed to provide states with a diverse array of evidence-based programs to meet the

00:09:18needs of their communities, the chairman and I are committed to rigorous engagement

00:09:23with the Administration for Children and Families to fulfill our shared commitment of prioritizing

00:09:29familiar placement whenever possible. One of the goals of Family First was to reduce

00:09:36inappropriate placements for children in congregate care settings. To meet that objective, we

00:09:43must ensure that residential treatment interventions are a placement of last resort, with a focus

00:09:49on integrating patients back into the community as soon as is clinically possible. When home

00:09:56and community-based services fall short of a child's needs, family services and families

00:10:02deserve access to high-quality residential treatment facilities that provide medically

00:10:08necessary treatment in safe, therapeutic environments. Anything less risks causing

00:10:15further harm and escalating an already tragic and difficult situation. To the victims in

00:10:22the audience and around the country who suffered abuse and neglect in residential treatment,

00:10:28your experience is entirely unacceptable. Facilities entrusted with caring for our most

00:10:35vulnerable youth should be held to the highest standards and subject to routine and reliable

00:10:42oversight. Chronic patterns of failure must not go unnoticed or unaddressed. The incidents

00:10:50highlighted in Chairman Wyden's investigative report are deeply disturbing. Many of these

00:10:56facilities are reimbursed with federal Medicaid and Title IV-E dollars, as the chairman has

00:11:02said, making these deficiencies even more concerning. Hardworking taxpayers should not

00:11:08be funding anything less than superior care. Our child welfare and behavioral health systems

00:11:16have made a lot of progress in improving the quality of congregate care settings, but clearly

00:11:22gaps remain. As we consider reforms to remedy inadequacies, we must recognize the different

00:11:29forms of residential treatment facilities, the essential role they play in the care continuum,

00:11:36and the regulations and requirements that are unique to each setting. For example, Congress

00:11:42established Qualified Residential Treatment Programs, or QRTPs, as a high-quality, clinically

00:11:50informed treatment option for children in the child welfare system with behavioral health

00:11:57needs. Unfortunately, bureaucratic challenges have prevented many states from implementing

00:12:04this model. Additionally, psychiatric residential treatment facilities are subject to federal

00:12:11health and safety standards as a condition of participation in the Medicaid program.

00:12:18Congress and the administration should ensure that these requirements are patient-centered,

00:12:25informed by best practices, and promote access for those who require the most intensive services.

00:12:32I look forward to a productive conversation with our witnesses today about how to improve

00:12:37care quality and increase accountability of youth residential treatment facilities, including

00:12:43by empowering states to establish QRTPs and other treatment models that best serve children.

00:12:51Again, I thank the advocates for being here, and Chairman Wyden for his important work

00:12:56on this issue. Thank you, Mr. Chairman.

00:12:59Thank you, Senator Crapo. And let me just say that in a polarized political environment,

00:13:06it would be so valuable to have a bipartisan solution to the problems that the report has

00:13:13uncovered, and we're going to hear about today, and I'm going to do everything I can to make

00:13:18that possible. All right. With respect to the record, first, I'll ask unanimous consent

00:13:23to enter into the record. The committee's report titled Warehouses of Neglect, How Taxpayers

00:13:28Are Funding Systemic Abuse in Youth Residential Treatment Facilities, this report contains

00:13:33shocking examples of abuse and neglect at too many facilities.

00:13:37Second, I'm about to introduce a panel of witnesses that bring the committee valuable

00:13:42expertise from across the spectrum of these facilities, but one perspective that's not

00:13:48represented on the panel is the voices of former patients at these facilities, many

00:13:54of whom are survivors of abuse and neglect. There are over a hundred of these persons

00:13:59in the room today. Many have submitted testimony about their experiences. I ask unanimous consent

00:14:06that these statements be entered into the record. These are some of the statements that

00:14:11we have received from survivors, and we are deeply, deeply appreciative of their giving

00:14:18them to us. Finally, in addition to the written statements

00:14:22from survivors, Catherine Kubler and 1111 Media submitted a short video of survivor

00:14:28testimony that they asked be entered into the record. It is quite short. It is extremely

00:14:33powerful to hear these experiences in their own words. I ask unanimous consent to play

00:14:38this video so it can be entered into the record. Finally, after the video, I'm going

00:14:44to thank the survivors again and discuss where we go from here, but let us go to the short

00:14:51video.

00:14:52I went there for treatment, and instead I was punished and treated like the criminal.

00:15:00They degraded you. She told me that I was scum of the earth.

00:15:04I've seen people be sedated.

00:15:06Makes you a zombie.

00:15:07They'll restrain you.

00:15:08Like in a way, both of your shoulders are touching.

00:15:11Pick you up and put you into solitary confinement.

00:15:14Just me in the cell by myself.

00:15:16I felt completely violated.

00:15:18I remember him sticking his hands directly in my pants.

00:15:21I think that my son was neglected, abused, and had I not taken him out, he would have died.

00:15:29Feces on the floor, blood on the walls, and concrete slabs with thin mattresses for beds.

00:15:35The abuse was obviously widespread.

00:15:37There were people making big money off of the suffering of these children.

00:15:43It's a billion-dollar industry. I mean, so much money is being made off the abuse of

00:15:48these kids.

00:15:49I really needed help. The perception is you're going to get therapy, you'll be in a safe

00:15:54environment where you're monitored and we'll make sure that you're not a danger to yourself

00:15:59or other people.

00:16:00I was sent to 13 short-term mental health facilities before I was put into a long-term

00:16:05mental health facility.

00:16:06They just punished me. It probably made me even more suicidal.

00:16:11We had to sit at the nurse's station for phone calls, which means the nurse is right within

00:16:16earshot.

00:16:17The second you start to express how you're being treated, they have that option to cut

00:16:22the line.

00:16:23The staff member just hung up the phone, screamed at me, told me,

00:16:26you have your phone privileges taken away.

00:16:29They said that I could not sleep in my own bed or go outside or have any privileges until

00:16:34I wrote an apology letter to my parents.

00:16:36They would take myself and other girls into this room and they would perform medical exams.

00:16:43It wasn't even with a doctor, it was with a couple different staff members.

00:16:48They would have us lay on the table and put their fingers inside of us and I don't know

00:16:56what they were doing, but it was definitely not a doctor and it was really scary.

00:17:02Now looking back as an adult, that was definitely sexual abuse.

00:17:07These men with these strong arms are grabbing your arms, people are grabbing your legs,

00:17:11people are grabbing every part of your body.

00:17:13And then the staff put their knee on my temple.

00:17:16And I just remember my vision, the blackness was closing in.

00:17:21And you're like, oh my God, if I die, are they going to call my parents?

00:17:24Like, sorry, we know you sent your kid here to get help, but we accidentally killed them.

00:17:29Last April, a child in Michigan, Cornelius Fredericks, threw a piece of bread and as

00:17:36a result was violently restrained by numerous staff and died.

00:17:41There's video of this.

00:17:43Literally all he was doing was throwing bread.

00:17:45He was not a threat, but he's restrained for about 12 minutes.

00:17:49Cornelius died and there are thousands of other kids that experience these restraints

00:17:55multiple times a week or witness these restraints multiple times a week, which is very traumatic.

00:18:00It is a management technique to manage kids in a very violent way.

00:18:05How many more deaths do we need to decide that now is the time to act?

00:18:10With families like ours, we need extra help.

00:18:15Brandon can fall at any time.

00:18:17He needs somebody with him every single second of the day.

00:18:20He can't be left alone.

00:18:21They said that, you know, this hospital can deal with medically complex children.

00:18:25We have nursing care 24-7.

00:18:27I entered the hospital.

00:18:29I walk into my son's room.

00:18:31Brandon is seizing.

00:18:33There's no nurse in the room.

00:18:34There's mats flying around him.

00:18:37He has a high temperature.

00:18:39He has bruises all over him.

00:18:41They knowingly and willingly took Brandon on as a patient, even though they actually

00:18:49couldn't provide the medical care that he needed 24-7.

00:18:54They did that for profit.

00:18:57States and federal Medicaid dollars pay them to care for kids who often have nowhere else

00:19:01to go.

00:19:02Contracts obtained by NBC News show states pay between $275 and $800 a day per child.

00:19:09I had a bonus plan on my first year there as CFO to where I had to meet a certain ratio

00:19:15of how many patients to employees, and it wasn't even close to meeting the minimum staffing

00:19:21ratio of the Utah regulation.

00:19:23The corporate involvement is so strong.

00:19:25There's constant pressure to cut costs.

00:19:28Almost every single decision is about profit.

00:19:31It doesn't feel to me that they're managed to provide great patient care.

00:19:35So you have to have enough staffing to have an excellent program, but you can't have too

00:19:39much staffing to eat up your profit.

00:19:41The survivors have been telling us what's wrong for a long time.

00:19:44They've been telling us what's needed.

00:19:46These experiences of abuse are not just reserved to a few bad actors.

00:19:50It truly is institutional.

00:19:52It affects every state and every community.

00:19:55I thank my colleagues for listening to this, because I think that this has spelled out

00:20:04exactly what our job is all about, is to end this pattern of abuses.

00:20:11The reason we wanted to show that video is that we felt that even though we were not

00:20:19The reason we wanted to show that video is that we felt that even though this was a few

00:20:26minutes of video time, it could make an enormous difference in terms of actually bringing about

00:20:34change.

00:20:34So I want to thank Senator Crapo, my colleagues who are here, and let's get this message out

00:20:40to the rest of the United States Senate.

00:20:42I also want to thank the survivors from the video, and again, all those who have been

00:20:48laying out to me over the last 24 hours the accounts of their abuses that they have unfortunately

00:20:56had to deal with.

00:20:58Our first witness today was supposed to be Mr. Mark Miller, the President and CEO of

00:21:02Universal Health Services, one of the largest companies.

00:21:05This company is unique in the field.

00:21:08Months ago, when we first decided to hold the hearing, Mr. Miller was the first person

00:21:13we asked to testify.

00:21:15Instead of engaging the committee's request, the company stonewalled us, ignored repeated

00:21:20requests to even discuss his testimony.

00:21:23Finally, a few days ago, his team officially declined to participate in the hearing.

00:21:28So we held the spot for Mr. Miller in hopes that he might change his mind, but apparently,

00:21:34as of this morning, that's not the case.

00:21:36So today, the committee released a 130-page report detailing the failings of many of these

00:21:42facilities, many of which are run by Mr. Miller's company.

00:21:47Today is the first step in the committee's legislative process to address abuse and neglect

00:21:53at facilities like the one Mr. Miller's company operates.

00:21:57And the fact that that chair over there is empty speaks a lot to me about this company's

00:22:04commitment to really fixing these very serious problems.

00:22:08So let's now make sure everyone knows who our guests are who are in attendance.

00:22:14Ms. Stanford is the Abuse and Neglect Managing Attorney at Disability Rights Arkansas, which

00:22:20is a federally mandated legal aid organization that advocates on behalf of all people with

00:22:24disabilities and has congregate care monitoring services.

00:22:29She's previously worked with victims of domestic violence in shelters and community advocacy

00:22:34organizations.

00:22:35She's got a law degree from the Bowen School of Law.

00:22:39Ms. Manley is faculty and senior advisor for health and behavioral health policy at the

00:22:44University of Connecticut School of Social Work, the Innovation Institute.

00:22:48She has an LSW degree from Rutgers.

00:22:51Her work focuses on systems of care delivery, behavioral health, and children with intellectual

00:22:57and developmental disabilities.

00:23:00And prior to her current role, she served as assistant commissioner for New Jersey's

00:23:04Children's System of Care.

00:23:07And Ms. Lahren is the director of the Government Accountability's Office, Workforce, and Income

00:23:13Security Act.

00:23:15Ms. Catherine Lahren, we welcome you, and we know that your office has done considerable

00:23:20work there at the Governmental Accountability Office on these issues.

00:23:24We welcome you.

00:23:25We'll start with you, Ms. Stanford.

00:23:30Chairman Wyden, Ranking Member Crapo, and members of the Senate Finance Committee, thank

00:23:35you for the opportunity to testify here today.

00:23:36My name is Regan Stanford.

00:23:37I am the Abuse and Neglect Managing Attorney at Disability Rights Arkansas, Arkansas' Protection

00:23:41and Advocacy Agency.

00:23:43The Protection and Advocacy, or P&A, system is a federally mandated network of legally

00:23:47based agencies that advocate for and protect the rights of individuals with disabilities

00:23:51and have authority to access facilities in which individuals with disabilities reside

00:23:56and all relevant records.

00:23:58In my role, I oversee a team that uses that access authority to monitor conditions and

00:24:03investigate abuse to ensure that these individuals receive the services they need in a safe and

00:24:08therapeutic environment.

00:24:09Over the past five years, we have been focused on the 13 psychiatric residential treatment

00:24:13facilities in Arkansas.

00:24:16Through our years of spending time inside these facilities, reviewing records, and speaking

00:24:21with children, guardians, and staff members, we have seen firsthand how deeply flawed the

00:24:25overall RTF model is.

00:24:28The pervasive nature of abuse and neglect, lack of active treatment, and failure to provide

00:24:31a therapeutic environment.

00:24:33The public deserves this and as much information as possible to make informed decisions about

00:24:38care.

00:24:39So we created the Arkansas PRTF database, expending our limited resources to do what

00:24:46the government could and should be doing.

00:24:48In facilities across Arkansas, there are countless examples of abuse, violence, and neglect,

00:24:52such as a staff punching a child three times in the face or a child being held down by

00:24:56peers and sexually assaulted.

00:24:59But it is important not to focus so intensely on cases of extreme abuse that we are lulled

00:25:03into believing that the issue is a few bad actors and not the model.

00:25:08Far more widespread is the systemic, general lack of a therapeutic environment, treatment,

00:25:13and educational services.

00:25:14There is this pervasive assumption that some children need such intensive services that

00:25:19they cannot be served in the community.

00:25:22Residential treatment is often seen as the pinnacle of treatment, the best and most intensive

00:25:26services a state has to offer.

00:25:28In fact, the most restrictive placements generally offer a level of care that could

00:25:33be replicated or surpassed on an outpatient basis.

00:25:37And that, at most, comes to approximately five hours of therapeutic services a week.

00:25:42The failures of the treatment facilities to provide a safe and therapeutic environment,

00:25:46individualized and intensive services, and meaningful discharge planning and follow-through

00:25:51are imputed to the child.

00:25:53The child is often seen as the failure, not the treatment facility.

00:25:57And because they are viewed as the failure, all too often, the child is cycled back into

00:26:01residential placement.

00:26:03Treatment in these facilities is not individualized and is overwhelmingly not specialized.

00:26:09Many of these facilities purport to treat a wide range of conditions, yet the services

00:26:14the children receive are almost indistinguishable from one another.

00:26:18Interaction with clinicians and mental health professionals is limited.

00:26:21Children attend school at the facilities and classrooms that combine multiple age, grade,

00:26:25and ability levels.

00:26:27Children share bedrooms with peers and spend most of their time idle in communal spaces

00:26:32under the supervision of entry-level care staff, never alone but rarely engaged.

00:26:37Insufficient staffing levels and inadequate staff training lead to reliance on restraint,

00:26:42seclusion, and increasingly, law enforcement.

00:26:45The word that most comes to mind when I think of time I have spent monitoring these facilities

00:26:49is chaos.

00:26:52All together, this creates an environment that is incompatible with what children need

00:26:55to learn, grow, and thrive.

00:26:57The added trauma children experience within these facilities follows them through life

00:27:02and is compounded by society's refusal to acknowledge the detrimental effects these

00:27:06placements can have.

00:27:08All of this occurs without meaningful oversight at any level.

00:27:11With limited CMS regulation and oversight, most oversight falls to state agencies assessing

00:27:17compliance with state licensure, even though many providers operate in multiple states.

00:27:23There is also too heavy a reliance on national accreditation bodies, such as the Joint Commission,

00:27:28that are paid by the providers.

00:27:30What is clear is that often these facilities are operating as placements and not service

00:27:35alternatives.

00:27:36States have bought into and are now reliant on the model of residential treatment, failing

00:27:41to adequately invest in community-based services.

00:27:44States are so reliant on residential placements that they are hesitant or outright unwilling

00:27:50to hold the facilities accountable, instead considering them partners with the state.

00:27:55You cannot effectively regulate something that you are in partnership with.

00:27:59Through our work with the P&A Network, we know that these problems are not specific

00:28:03to Arkansas.

00:28:04They are well-documented in reports from all P&As across the United States.

00:28:10This is a national problem that demands congressional action.

00:28:15Ms. Manley.

00:28:19Chairman Wyden, Ranking Member Crapo, and members of the committee, thank you for the

00:28:23opportunity to appear before you today to address youth residential treatment facilities

00:28:28with a specific focus on failures and the evaluation of solutions.

00:28:32My name is Elizabeth Manley, and I'm a Senior Advisor for Health and Behavioral Policy at

00:28:36the Innovations Institute at the University of Connecticut School of Social Work.

00:28:40In this capacity, I serve as a subject matter expert on children's behavioral health systems

00:28:44design, financing, and implementation for state and local leaders.

00:28:49I currently work with several states and provider organizations on design, on implementation

00:28:55and best practice in mobile crisis response and stabilization services, home and community-based

00:29:01services, and residential interventions for children and youth.

00:29:04I am a former Assistant Commissioner for New Jersey's Children's System of Care, where I

00:29:09was responsible for the oversight of the comprehensive continuum of care.

00:29:15First, I want to state unequivocally that all children, youth, and young adults with

00:29:19complex and intensive behavioral health challenges need and deserve access to the most appropriate,

00:29:25least restrictive, high-quality, and effective treatment and intervention.

00:29:30Our goal must be to support children and families to receive services within their own homes

00:29:34and communities whenever possible and provide individualized, strength-based, culturally

00:29:39responsive care as early as possible.

00:29:43We must respond to the needs with urgency and elevate the voices of youth and families

00:29:48in every step of treatment, planning, and intervention.

00:29:52Residential treatment facilities have an important role in the provision of care for young people

00:29:56with complex behavioral health care needs.

00:29:59When they have a clinical and behavioral health treatment need that cannot be met in a family

00:30:03or community setting due to the intensity of their treatment and supervision needs.

00:30:08In those instances, we need the care to be delivered in trauma-responsive environments

00:30:13that embrace parent and caregiver engagement throughout the treatment intervention and

00:30:17continually focus on best practice.

00:30:19These residential treatment facilities can have a significant benefit to young people

00:30:24and their families.

00:30:26The challenges are multiple and include the need for federal, state, local, and provider

00:30:36changes.

00:30:39States that use systems of care approaches to address the unique needs of youth with

00:30:43complex needs have demonstrated improvement in their ability to meet the needs of individuals

00:30:48with complex needs and systems involvement.

00:30:51Some of these challenges for residentials include insufficient infrastructure inclusive

00:30:57of oversight and the technical assistance necessary to meet the unique needs of young

00:31:03people with complex needs.

00:31:06Not all children in residential facilities require the service of their residential and

00:31:11upfront work around ensuring that the right service is provided at the right time for

00:31:16the right duration is essential to ensuring the proper care.

00:31:20Our financing incentives incentivize the wrong door for services and supports.

00:31:27We build beds because it's what we know how to do when we really need to build home and

00:31:33community-based services inclusive of customized care in the mobile crisis response space.

00:31:42There are states who are doing this work well.

00:31:44New Jersey is one of those states that has some lessons to be learned for others as well.

00:31:50The best way for Congress to direct federal resources to impact the issues is to increase

00:31:55accessible, comprehensive, family and youth-driven, community-based, trauma-responsive behavioral

00:32:02health care.

00:32:03Thank you for the opportunity to address this very important issue.

00:32:08Thank you very much, Ms. Manley.

00:32:10Ms. Lerner.

00:32:12Good morning, Chairman Wyden, Ranking Member Crapo, and members of the committee.

00:32:17Thank you for inviting me here today to discuss GAO's work on maltreatment of youth in residential

00:32:21facilities.

00:32:23For over 20 years, GAO has reported on concerns with the physical, emotional, and sexual abuse

00:32:28of youth who have been placed in these facilities.

00:32:31In multiple reports, we've called on the Department of Health and Human Services to enhance its

00:32:36supports to states which are primarily responsible for oversight of these facilities.

00:32:42I'd like to start by talking about the youth who are placed in residential facilities.

00:32:46Many come through the foster care system as a result of abuse and neglect and have experienced

00:32:51significant trauma.

00:32:53While some are placed in residential facilities because there are not enough traditional foster

00:32:57homes, others may receive such placements because they have complex mental health, physical,

00:33:02or behavioral needs best addressed in a setting that can provide high-quality, specialized

00:33:08care.

00:33:10When these youth experience abuse by facility staff or other residents, it may exacerbate

00:33:14their trauma.

00:33:16In recent years, states have tried to reduce their reliance on residential facilities,

00:33:20and the Family First Prevention Services Act introduced new restrictions on when states

00:33:25can use Title IV-E funds for residential facility placements, and the numbers have fallen.

00:33:30In 2022, 34,000 youth were placed in residential facilities, down from over 100,000 in 2002.

00:33:38With regard to the number of youth who've experienced abuse, however, we don't have

00:33:42good information.

00:33:43This is in part because federal reporting of instances of abuse is voluntary, and not

00:33:48all states do it, and partly because staff and residents may be reluctant to report abuse,

00:33:53for example, if they fear retaliation.

00:33:56We identified several challenges states face in protecting youth in residential facilities

00:34:01from harm.

00:34:02First, monitoring of youth placed in out-of-state facilities.

00:34:06Youth are sometimes placed out-of-state if there are no available placements in their

00:34:10home state, and this makes monitoring difficult, because child welfare officials from the home

00:34:14state can't always visit regularly, and they have to rely on reports from the state where

00:34:18the facility is located.

00:34:21A second challenge is inappropriate use of psychotropic medications that affect mood,

00:34:25thought, and behavior.

00:34:27Such medications may be warranted in some cases, but inappropriate prescriptions carry

00:34:33health risks.

00:34:36Data on use of such medications among youth in foster care is limited, but historically,

00:34:41those in residential facilities have been prescribed these medications at much higher

00:34:44rates.

00:34:46Some states have taken steps to curb inappropriate prescriptions, for example, by developing

00:34:51prescription guidelines.

00:34:53The use of restraint and seclusion in some residential facilities creates additional

00:34:57challenges to keeping youth safe.

00:35:00Restraint and seclusion should not be used for coercion, discipline, or retaliation,

00:35:05and should not result in harm, but in some instances, staff injure youth while we're

00:35:09trying to restrain them.

00:35:11Some states have reviewed their use of restraints in response to such concerns.

00:35:16Regarding oversight, responsibility for overseeing residential facilities for youth in preventing

00:35:21abuse is fragmented.

00:35:23While HHS is the lead agency at the federal level, responsibility for monitoring facilities

00:35:28in preventing abuse is primarily a state role and can involve state child welfare agencies,

00:35:34law enforcement, and state licensing entities.

00:35:38We found that some states had taken steps to prevent abuse by requiring better background

00:35:42screenings, conducting training, improving interagency cooperation, but we also identified

00:35:48areas for improvement, for example, through better training on resolving conflict in trauma-informed

00:35:53care or by states imposing stiffer penalties for violations.

00:35:59We also found that HHS could be more proactive, and in 2022, we recommended that HHS facilitate

00:36:06information sharing between states on promising practices for preventing and addressing maltreatment

00:36:12in residential facilities.

00:36:14While HHS agreed with the recommendation, they have not yet implemented it.

00:36:19In sum, there are longstanding issues related to abuse and neglect in residential facilities.

00:36:24As states and HHS implement the residential facility requirements in FFPSA, there's a

00:36:31new opportunity to further assess the use of these facilities and consider whether additional

00:36:36steps are needed to protect youth from abuse and neglect.

00:36:40This concludes my statement.

00:36:41I'm happy to answer any questions.

00:36:42Thank you very much.

00:36:43Thank you, all three of you, and let me start with you, Ms. Stanford.

00:36:49You are the chief facility watchdog, as I understand it, for Arkansas, and obviously,

00:36:55in addition to the lack of care, we found acute harms like physical, sexual, verbal

00:37:02abuse and unacceptable living conditions, and taxpayers, as I've said, are paying for

00:37:09a significant amount of these harms, sometimes over $1,000 per day with Medicaid and child

00:37:16welfare dollars.

00:37:18And to me, these daily sums create an incentive for providers to admit as many kids as they

00:37:26can and then keep costs low to maximize their profits.

00:37:32So I want to start with you because you're an expert in the field so that we can take

00:37:37a look at what American taxpayers are actually paying for.

00:37:42So my first question to you is, since you've been working in this field for some time,

00:37:46have you seen the kind of abuse and neglect like the type of accounts documented on our

00:37:54report?

00:37:55Yes.

00:37:56I would say we see lots of abuse and neglect.

00:38:01Things are reported to us almost daily, different instances of abuse and neglect.

00:38:06They range in how they can, but kids are being raped.

00:38:11They're being raped by peers and by staff members.

00:38:15There's lots of abuse that's related to restraints, but just other abuse also for staff that are

00:38:20untrained and tasked with watching lots of children.

00:38:25They're failing to learn de-escalation techniques to be able to create a safe environment, but

00:38:31I would say it's very widespread that we see instances of abuse and neglect in the way

00:38:36of failure to prevent violence among peers.

00:38:40So would it be fair to say that serious problems at these facilities are not isolated incidents?

00:38:48Yes, that'd be very fair to say.

00:38:52Now you did some work in prisons, as I understand it.

00:38:57How would you say these facilities compare to jails?

00:39:04So I would say in comparison to jails, they're treated very similar.

00:39:09The kids, it's very rigid rules.

00:39:11They don't have a lot of access to the outside world, to calls to contact their family.

00:39:17They're cut off.

00:39:18They don't have a lot of personal belongings.

00:39:21They're very drab facilities that are very comparable to jail settings in many instances.

00:39:29So Ms. Laron, over at the GAO, our important agency that looks into these kinds of abuses,

00:39:39you've been looking into these issues for quite some time.

00:39:42I think something like 15 years or some such period.

00:39:47Have you identified similar types of issues in your reports to what we're talking about

00:39:53today?

00:39:54Yes, absolutely.

00:39:57Starting back in 2008, where we identified literally thousands of instances of abuse,

00:40:03and up to our most recent report in 2022, we found this is a pervasive issue that continues

00:40:09today.

00:40:10All right.

00:40:11Let me go back to you, Ms. Stanford, and ask you about one facility, the Piney Ridge Treatment

00:40:18Center in Arkansas.

00:40:20We reviewed countless reports from this facility, and as I understand it, you have seen it firsthand.

00:40:27The documents and the public reports that our investigative team reviewed are just horrifying.

00:40:34One report found the facility conducted 110 restraints and seclusions in a 30-day period.

00:40:40Another found that the facility regularly physically restrained children, injected them

00:40:45with drugs, placed them in seclusion in violation of federal rules, and the list, based on what

00:40:53we're picking up, goes on and on with endless failures there.

00:40:58And as is so often the case, some facilities seem to be doing a decent job.

00:41:08Others are just horrendous.

00:41:11So my question to you is, is the Piney Ridge Treatment Center an outlier?

00:41:18I'd like to know your thoughts on this, and can you give us an idea of the scope and prevalence

00:41:23of the kind of violations that I've been discussing?

00:41:29I would say that they are not an outlier.

00:41:31Certainly there are better and worse facilities, and ones that we get more complaints from

00:41:37than others.

00:41:38The conditions at Piney Ridge Treatment Center several years ago were absolutely appalling,

00:41:43and they were operating with full knowledge of Acadia Healthcare.

00:41:49And now they have improved slightly, they have improved recently, but it took years

00:41:54and years of sustained pressure, and pressure that had to come from outside that was not

00:41:58going to come inside from Acadia executives to improve that facility.

00:42:03But we see that at lots of other places.

00:42:06I'm over my time, and we'll have some questions for you in a bit, Ms. Manley.

00:42:11Senator Crapo.

00:42:12Thank you, Senator Wyden, and Ms. Stanford, I'd like to start with you as well.

00:42:19In your testimony, you indicated that we should not just assume that the model is working

00:42:27the way it should, that this is the model that we should be using.

00:42:31And you indicated that a significant amount of the kind of treatment that is referred

00:42:35to this model could be handled in a home setting with some number of hours a week of counseling

00:42:42or support outside the home.

00:42:44Could you expand on that notion a little bit?

00:42:47Yes, so I'm not a mental health professional, but absolutely from what we've seen, I think

00:42:52there's been this assumption that there's constant services and therapy that's being

00:42:56provided or time for self-reflection inside these facilities, and that's not what we see

00:43:00at all.

00:43:01It's chaos most of the time, and they're not being engaged, they're getting very little

00:43:06therapy.

00:43:07So there's, I mean, there are lots of models out there with different types of therapy

00:43:11involving the families, involving just the children, but different methods and supports

00:43:16that could be put in place.

00:43:17I think what kids need is individualized care, and when you put them in these facilities,

00:43:22it necessarily becomes about the efficiency of the facility and not the individual care

00:43:26that can be provided to each kid.

00:43:28They're all being provided the same thing that is what the model inside that facility

00:43:33is.

00:43:34And so just relying, just assuming that these places are providing intensive services and

00:43:38relying on that without looking further into what it is they're providing or what additional

00:43:43issues they're creating with the children is a real disservice to the children.

00:43:48Well, thank you.

00:43:49And we and each of you have already talked about the notion of the need for much more

00:43:54aggressive oversight of these facilities, but Ms. Manley, would you agree that, if I

00:43:59could kind of give a shorthand of what Ms. Stanford was saying, is we're over-utilizing

00:44:03this model because we should be focusing on getting more kids getting their treatment

00:44:09at home with the assistance from outside as needed.

00:44:11Is that something you would agree with?

00:44:16Absolutely.

00:44:19Providing good care up front means that many young people can be provided their care in

00:44:25their own homes.

00:44:26There are some young people who benefit from short, trauma-responsive, family-engaged residential

00:44:33interventions that are very close to home.

00:44:36And you emphasized the word short.

00:44:39Yes.

00:44:40And again, I can't remember which of you, several of you, referenced the fact that when

00:44:46we do, when abuse does happen, that there's concern about how to get it reported.

00:44:53Ms. Lahren, you indicated that the states and local communities are more in charge of

00:44:57the oversight than the federal government.

00:45:00But I think that several of you referenced the fact that whoever's in charge of oversight,

00:45:07the system, the way it works right now, is one in which the fear of retaliation may cause

00:45:12a block to being able to conduct that appropriate oversight.

00:45:17Is that correct?

00:45:18Ms. Lahren, would you like to comment about that?

00:45:20Yeah.

00:45:22That's definitely true.

00:45:24We talked about barriers to getting good information about how often this occurs.

00:45:29A big one is fear of retaliation, both by staff who may observe abuse and not want to

00:45:36report it, and by residents who don't have safe ways to report abuse.

00:45:41So I've only got about a minute and a half left.

00:45:43Could each of you take about 30 seconds and tell me how should we improve the oversight

00:45:49in those cases where children do need to be referred to this type of treatment?

00:45:54Ms. Lahren, let's start with you and then move down.

00:45:58While oversight is primarily a state responsibility, we really believe that HHS could do more to,

00:46:04for example, identify best practices for oversight and share those, facilitate the information

00:46:10sharing among states.

00:46:11This is something we've recommended that HHS has not acted on.

00:46:15Thank you.

00:46:16Ms. Manley?

00:46:18At the state level, state understanding of each of the residential interventions, but

00:46:22more importantly, putting intensive care coordination included for every young person who touches

00:46:29within residential.

00:46:30So there's an actual team of individuals who know that young person and spend time with

00:46:35that young person who can actually report back what is that's happening.

00:46:39And Ms. Stanford, I want to get to you, but I think Ms. Manley, in your testimony, you

00:46:42indicated that you thought that family members should be more involved at the facilities.

00:46:47Is that true?

00:46:48Yes.

00:46:49They should have access to young people 24 hours a day, seven days a week.

00:46:52I think that would help get to the reporting, frankly.

00:46:56Ms. Stanford?

00:46:57I think there could be a lot more of a focus on quality of care.

00:47:00Right now, the minimal federal regulations that relate to these facilities are very specific

00:47:05and don't overall cover that whether this place is providing a therapeutic environment

00:47:09or the quality of care or even the level of services that are being provided.

00:47:13So that information needs to be looked at and shared among states in a manner so people

00:47:19can see overall what these providers are providing across the nation.

00:47:24Thank you.

00:47:25Thank you, Senator Crapo.

00:47:26Senator Stabenow is next.

00:47:28We all saw those pictures of Michigan, and I know my colleague is very, very determined

00:47:34to fix these problems, and we appreciate it.

00:47:36Senator Stabenow.

00:47:37Well, thank you very much, Mr. Chairman.

00:47:40And first, welcome.

00:47:41I know we have survivors of Michigan facilities and Michigan advocates here.

00:47:47Welcome.

00:47:48Thank you very much for being here.

00:47:49And I just want to thank the staff that put together this report and all the important

00:47:54efforts here.

00:47:55This is really significant, really important investigation.

00:47:59Thank you for bringing this out.

00:48:01And it's true.

00:48:02In 2020, we saw the devastating death of Cornelius Frederick.

00:48:07He was 16 years old, living in a residential facility in Kalamazoo, Michigan.

00:48:13And after simply tossing sandwich crust at some nearby young people, Cornelius was knocked

00:48:24to the floor and restrained by seven staff members over the course of 10 minutes.

00:48:30Two days later, he passed away.

00:48:33This is a horrible tragedy.

00:48:36It's horrible what happened.

00:48:37And I know, based on what the comments here and the reports and so on, that this is not

00:48:43an isolated instance, which is why we're here today.

00:48:48It's wrong, and it's indefensible.

00:48:51The stories of harm to children while in care only highlight the need for strengthening

00:48:57investments in community-based models.

00:49:00And I just want to emphasize again, we actually have good news on this front.

00:49:08First let me go back, though, to say that President John F. Kennedy, the last bill he

00:49:11ever signed before his own death in 1963 was the Community Mental Health Act.

00:49:17It had two visions, one to eliminate what were called asylums at the time, and the other

00:49:22was to provide comprehensive community care, which we have not done until this point.

00:49:30And we now have, through a model that 20 states are receiving full funding for now through

00:49:37Medicaid, a health care model called Certified Community Behavioral Health Clinics.

00:49:43We have services being provided, over 500 clinics across the country, more that needs

00:49:50to be done, and certainly more to be understood, because this is a new model, comprehensive

00:49:56model based on federally qualified health centers funding behavioral health care as

00:50:01health care.

00:50:03But this is a really important model for us to be embracing, I believe.

00:50:11CCBHCs provide comprehensive services, they're equipped to care for children and youth with

00:50:16complex behavioral health needs, everything we're talking about today.

00:50:20According to the 2020 Department of Health and Human Services report on the first eight

00:50:26states being funded for these clinics, about one-fourth of the patients are children and

00:50:33adolescents.

00:50:34And just last week, the National Council for Mental Well-Being's latest report on the impact

00:50:40of CCBHCs nationwide, and by the way, they've said that one of the most important ways that

00:50:49services have been expanded through these clinics is for young people, services for

00:50:54young people.

00:50:55The same report showed that 82 percent of the clinics have established teams that are

00:51:00specifically child and youth focused, 82 percent, which is good news.

00:51:06And 83 percent of the clinics provide services in one or more school setting.

00:51:11So we're talking about clinics that require 24 psychiatric crisis services, comprehensive

00:51:17services, anybody who walks in the door can get care based on a health care model.

00:51:25And I hope, Mr. Chairman, we're going to be embracing and looking more at what is actually

00:51:31happening now to meet some of these issues.

00:51:34Obviously, we need inpatient, that's quality care also.

00:51:38But we are, in fact, moving forward on comprehensive behavioral care, and I hope we're going to

00:51:46be embracing this more and more.

00:51:48Ms. Stanford, in your testimony, you emphasized that there's a, quote, pervasive assumption

00:51:55that children's complex behavioral health needs can't be met in community-based settings.

00:52:02And you've talked about that today, which I appreciate very much.

00:52:05Could you talk more about the strategies you would suggest to help counteract that assumption?

00:52:12I think things like what we're doing here today is getting people to understand what

00:52:17residential treatment is actually providing is the first step.

00:52:20And it's something that we've been trying to do for five years and thought we'd be further

00:52:23along in by now.

00:52:24But if people think that there's an answer, they're not looking for a solution.

00:52:28So people think that if this is the place where you get that kind of treatment, they're

00:52:32not looking for those community-based treatment options.

00:52:35And a lot more research needs to be done in what could be effective in proving that those

00:52:39models can work so that they can be implemented for children.

00:52:42Yeah, absolutely.

00:52:43Thank you.

00:52:44And Ms. May, I know I'm out of my time here, but I agree with you.

00:52:49We've got to do more to establish clear pathways for community-based care.

00:52:53You mentioned New Jersey doing good things.

00:52:55I just want to say they are one of the first eight states to receive full funding for what

00:53:01I just talked about, community behavioral health clinics.

00:53:04And my guess is that is the services and funding that they're receiving in New Jersey to do

00:53:11what they are doing.

00:53:13So I would encourage us to really look more at this opportunity that we fully funded,

00:53:18finally, through the Safer Communities Act 18 months ago.

00:53:23The funding is there.

00:53:25The model is there.

00:53:26And I hope we're going to move forward and embrace that more specifically.

00:53:30Thank you, Mr. Chairman.

00:53:31Thank you, Senator Stabenow.

00:53:33And for those of you that haven't followed all of this debate, it's very hard to do so.

00:53:41We understand on this committee that there are several pieces to this puzzle.

00:53:47For example, the behavioral health effort that Senator Stabenow has led our whole committee

00:53:52on a bipartisan basis worked very hard to get some of those key provisions in other

00:53:58legislation.

00:54:00Chairman Hatch worked with all of us to pass a historic set of reforms called Families

00:54:07First.

00:54:08So what we're talking about today is essentially building on that progress, recognizing that

00:54:15the abuses that we're looking at specifically as it relates to these residential treatment

00:54:21facilities, they're a key part of this puzzle.

00:54:24We're not going to fix this unless we address it.

00:54:27And as we do so, we're going to try to build on matters like Senator Stabenow's legislation,

00:54:33Families First, and other measures.

00:54:34Senator Casey has been a great advocate for kids and families, and we really appreciate

00:54:38him being here.

00:54:39Mr. Chairman, thanks very much.

00:54:41And I want to thank you and the committee staff for this report.

00:54:47The findings in this report are beyond appalling.

00:54:51There's just no words to describe.

00:54:55As much as there's written in here, I'm not sure we have enough words in the dictionary

00:55:00to describe how disturbing this is for the American people.

00:55:04If it happened in any context, it would be disturbing and appalling, but when you consider

00:55:09that these facilities are using taxpayer dollars as the title of the report says, Warehouses

00:55:17of Neglect, and then the sub-headline is How Taxpayers are Funding Systemic Abuse in Youth

00:55:24Residential Treatment Facilities.

00:55:27So that goes without saying, but we have to keep saying it, how disturbing it is.

00:55:33Ms. Sanford, I wanted to speak to, in particular Pennsylvania, as of 2023, my home state had

00:55:41the most residential treatment facilities of any other state, 74, far greater than most

00:55:47states.

00:55:48Many of these facilities are specifically designated for children and youth with disabilities.

00:55:55The four facility operators highlighted in the committee report have been cited for violations

00:56:00for negligence of supervision, assault, sexual and physical abuse, and many other atrocities.

00:56:07In your written testimony, you state, and I'm quoting, youth residential facilities

00:56:15cannot provide an adequate therapeutic and educational environment, unquote.

00:56:21We're all concerned about children and youth in these facilities, no matter what their

00:56:27circumstance, but we're especially concerned, of course, with children with disabilities.

00:56:33In your experience, which I know includes expertise in disabilities, how are residential

00:56:39treatment facilities not meeting the needs of children and youth with disabilities?

00:56:44And then the second part of the question is, what alternatives should be in place to meet

00:56:48their needs?

00:56:49So I'm going to just ask a couple if you want to.

00:56:51So I would say in every way, they're not meeting the needs of children with disabilities.

00:56:55The psychiatric facilities that I'm most familiar with and we're most involved in,

00:56:59so all of the children in those facilities have been deemed at some time to have a disability.

00:57:05And these facilities are not individual.

00:57:08What people, everyone needs, and particularly children with disabilities, is individualized

00:57:12services that provides tailored supports to them.

00:57:15Instead, they're putting them all in small spaces together with one treatment modality

00:57:20that they're using with all of the children.

00:57:23But specifically, even with educational services, we've seen that these facilities don't understand

00:57:28federal regulations around special education services for children.

00:57:33So not only are they not getting an adequate education, they're not getting set up for

00:57:37when they are released to have those supports in place so that they can restart their education.

00:57:45And also, the committee report mentions multiple instances of the use of restraint and seclusion

00:57:52being used on children and youth in residential facilities.

00:57:55The report references the use of both chemical and physical restraints on children and youth.

00:58:02The report also details the terrible case of Cornelius Frederick that Senator Stabenow

00:58:08made reference to in her questions, that Cornelius was restrained in a prone position until ultimately

00:58:17dying because of the restraint.

00:58:20According to the Department of Education, the vast majority of children restrained and

00:58:24secluded in schools, in fact, have a disability.

00:58:28What's the harm that can occur to children as well as young people with disabilities

00:58:34who are both restrained and secluded?

00:58:39So any time restraint or seclusion are used, that can have a traumatizing effect on children.

00:58:45Restraint involves people physically holding the children, oftentimes on the ground.

00:58:50Prone restraints are still used in these facilities.

00:58:53So that disability or not, but particularly children with disabilities, can have a traumatizing

00:58:58effect.

00:58:59They're not taking into account their trauma histories if these kids have been sexually

00:59:03assaulted and then they're then holding them down, you know, with multiple staff members

00:59:07on them on the ground, as well as seclusion.

00:59:12Thank you very much.

00:59:13Thank you, Mr. Chairman.

00:59:15I want to thank my colleague for all his good work for kids.

00:59:17Senator Hassen is one of our experts on Medicaid and these health care issues, and I say to

00:59:22our guests, there are probably as many hearings today as I've seen in my time in the Senate.

00:59:29So colleagues are going to be coming in and out, and I want you to know that this is part

00:59:33of the challenge of today.

00:59:34Senator Hassen.

00:59:35Well, thank you very much, Mr. Chair and Ranking Member Crapo, for this hearing, and thank

00:59:40you to our witnesses for being here today and for the work that you do.

00:59:44Ms. Lahren, I want to start with you.

00:59:46Last year, while checking on two New Hampshire teenagers who were placed at a facility in

00:59:50Tennessee, a child advocate from New Hampshire uncovered horrific child abuse.

00:59:55These two children returned to New Hampshire after the abuse was uncovered, but it obviously

01:00:00never should have happened in the first place, and they will bear the trauma of that abuse

01:00:05for their lifetimes.

01:00:07States often have difficulty overseeing out-of-state residential placements for youths since they

01:00:12can't regularly monitor conditions at these facilities.

01:00:16How should states increase their oversight of out-of-state placements to help prevent

01:00:20this type of abuse in the future?

01:00:23Yeah, there are definitely steps that states can take to improve their oversight of out-of-state

01:00:29placements.

01:00:30For example, they can require caseworkers to do in-person visits, even if that means

01:00:35traveling out-of-state to do so.

01:00:38One state developed or put together an interagency task force with the sole purpose of monitoring

01:00:45out-of-state placements, but really the answer is to reduce or eliminate out-of-state placements.

01:00:51At least one state has stopped placing any children out-of-state, and others are thinking

01:00:57about that.

01:00:58That really is the answer.

01:00:59Well, thank you for that.

01:01:01To Ms. Stanford, we've heard today that residential treatment is common for youth who have complex

01:01:06mental health or behavioral conditions, but evidence suggests that community and home-based

01:01:10care is safer and more effective for children.

01:01:14Can you talk about the challenges families have getting home and community-based care

01:01:19services for their children?

01:01:20Sure.

01:01:21I would say there's a lack of services across the nation.

01:01:27We have, in Arkansas, but also across the nation, we take a lot of out-of-state kids,

01:01:32so we're seeing from every state that they're not getting ... Generally, maybe individual

01:01:37therapy is the only thing that is offered to a family prior to inpatient care being

01:01:41the next step.

01:01:42Right.

01:01:43There's a lot of steps in that scale of treatment options that should be available that are

01:01:47being missed.

01:01:49How does the current Medicaid reimbursement system incentivize for-profit residential

01:01:53care while further exacerbating challenges as access to home and community-based care?

01:01:59I would say that, as they've talked about the high rates of reimbursement, these facilities

01:02:03are expensive to operate, and the reimbursement rates are very high, and leaving a high profit

01:02:08margin.

01:02:09Anecdotally, I'm not a Medicaid reimbursement expert, but we have heard that providers find

01:02:14it not financially sustainable to have services or come up with different treatment models

01:02:20to offer in the community if there's not adequate funding to fund those.

01:02:26Thank you.

01:02:27To Ms. Manley, many residential treatment programs advertise that they provide addiction

01:02:32treatment for youth, but the services they provide often fall short of the standard of

01:02:36care.

01:02:37In a survey of residential treatment facilities that claim to treat addiction, only one in

01:02:42four facilities offered medication to treat opioid addiction for adolescents, the gold

01:02:47standard for evidence-based treatment.

01:02:50In your experience, are residential treatment programs offering evidence-based treatments

01:02:57for addiction, and what are the dangers to youth when facilities fail to offer clinically

01:03:02appropriate addiction treatment?

01:03:04Sure.

01:03:05It's a great question.

01:03:06Let me just start at the beginning and say that there are some residential interventions

01:03:09that actually do this work and do it incredibly well, but it's generally not just substance

01:03:15use treatment independent of behavioral health treatment.

01:03:20Treating the underlying or a worry about trauma and trauma experiences for young people

01:03:26is just really important in substance use, but providing the wrong care at the wrong

01:03:31time for the wrong duration is really not good for any young person, so ensuring that

01:03:40we get the right treatment at the right time and that the organization that's saying that

01:03:44they can do that work, we actually have to say, we actually have to know that they're

01:03:48doing that work.

01:03:50We really need to understand their experiences, their training, how that training is operating,

01:03:56so the oversight part of specialized care is incredibly important in the work of providing

01:04:02residential care.

01:04:03Well, I thank you very much for that, and Mr. Chair would just note with regard to the

01:04:09inpatient reimbursement rate, which can be as high as $1,000 a day, and our relative

01:04:16dearth of home and community-based services, if Medicaid incentivized things differently

01:04:21and we could really build up that home and community-based model, we might also reduce

01:04:27the number of young people who are inappropriately placed in these facilities, often out of state.

01:04:31You said it much more eloquently than I tried to do about an hour and a half ago.

01:04:35Thank you.

01:04:36Great minds.

01:04:37I mean, that's the bottom line.

01:04:38Yeah.

01:04:39You know, smart community-based services, dollar for dollar, give you the best value,

01:04:43and I'm going to ask you some questions about your good work in that area shortly, Ms. Manley.

01:04:48Senator Cortez-Nasdaq, who's also done a lot of work with Medicaid in these key programs.

01:04:53Senator.

01:04:54Thank you.

01:04:55First of all, let me thank the chairman and the ranking member.

01:04:57Such an important issue, and I agree.

01:04:59This is a bipartisan issue.

01:05:01Really is not partisan at all, and we should be looking and focusing on the best interests

01:05:04of our children, and I thank all my colleagues for being here.

01:05:09Ms. Manley, let me start with you, and I want to talk a little bit about quality interventions

01:05:14from Nevada.

01:05:15Nevada Medicaid is working to improve children's behavioral health by making changes to enhance

01:05:20quality in residential settings.

01:05:22This includes offering bonus payments for shorter stays, increasing oversight of discharge

01:05:27planning admissions, and preventing abrupt terminations and transfer of children.

01:05:33And I appreciate you highlighting the need for technical assistance and coaching for

01:05:37residential treatment facilities and oversight organizations.

01:05:41As the largest health insurer for youth and a major revenue source for the providers at

01:05:47issue in the committee's investigation, Medicaid has a crucial role in facility oversight and

01:05:55accountability, and you touched on that, and I made a note of that because I do think it

01:06:00is important.

01:06:02We hold the healthcare providers accountable, but as so many of you said, there's a partnership

01:06:07here.

01:06:08It's at the state level.

01:06:09It's at the federal level.

01:06:10It's so much.

01:06:11So let me ask you, what specific technical assistance and coaching do oversight entities

01:06:16like state Medicaid programs need to ensure residential treatment facilities maintain

01:06:21that continuous quality improvement and high quality interventions?

01:06:25And then how, because every state, obviously, is different how they manage Medicaid.

01:06:30How do we make sure they're doing right here?

01:06:35There's a lot to it, but I think for purposes of understanding the Medicaid program, making

01:06:39sure we're holding them accountable as well is just as important.

01:06:45Absolutely.

01:06:46And I think one of the challenges for state Medicaid folks is they have to have expertise

01:06:51in a lot of different areas.

01:06:52But the need for expertise around residential interventions in particular is a complicated

01:06:59issue because there's a very limited amount of expertise that exists.

01:07:03And so we really need to make sure that we help our Medicaid partners, as an example,

01:07:08our children's behavioral health folks, really understand the impact of what residential

01:07:15interventions are, what they do, but also how do you build in the upstream to ensure

01:07:20that young people don't need that intervention, don't get it, so that we're really providing

01:07:25the most expertise for children who do need it for the shortest period of time in the

01:07:29smallest, most family-friendly environment that we can.

01:07:34In order to do that, we actually have to talk about it.

01:07:37We have to provide resources.

01:07:38We have to work through particular care pathways for states and how young people end up where

01:07:46they do, and help our Medicaid folks understand when things are happening in those residential

01:07:52interventions, what do they need to do to both support the residential intervention

01:07:55and getting better and building a learning environment, but also how to mitigate against

01:08:01any kind of traumatic event that has occurred for that young person.

01:08:05Both of those things are necessary and have to happen.

01:08:07And I agree, and I know everybody knows this, and the challenge, and I see so many people

01:08:11in my state programs, Medicaid programs, who want to do the right thing, but then they're

01:08:16limited by the federal funds they get because the legislature hasn't provided enough funds.

01:08:20They're limited by the continuum of care, what may be available out there and what isn't

01:08:25available that we have to grow.

01:08:27So there's a lot of challenges, but at the end of the day for me, and I think everybody

01:08:31at this table, it's about doing better and doing more for our kids and making sure we're

01:08:36looking at outside the box and trying to address all of these issues to do right by them.

01:08:42Ms. Stanford, let me ask you this.

01:08:46Nevada is prioritizing new investments in community-based services for children with

01:08:51behavioral health needs.

01:08:53The state actually proposes using some hospital tax revenue to improve access to enhance placements

01:09:02at the appropriate level of care, and Nevada Medicaid plans to match these federal Medicaid

01:09:07dollars pending CMS approval, another federal partner here that's key.

01:09:12I understand, Ms. Stanford, you've worked closely with states on best practices for

01:09:15promoting this community-based care.

01:09:18In your view, what is driving the over-reliance on residential treatment facilities by states?

01:09:24And which often operate as a placement alternative than a service alternative, I'm curious.

01:09:29Something that we should be aware of.

01:09:30And by the way, and I know I have limited time, I could be here all day with you.

01:09:34I appreciate the model of best practices highlighting New Jersey, because I think we always should

01:09:39be highlighting and pointing out areas where other states can look to if they're looking

01:09:44for those best practices.

01:09:46But Ms. Stanford, if you would.

01:09:48I think residential treatment is relied on because it's an alluring model if you don't

01:09:52know what's really going on in there.

01:09:53They're selling this idea that they are specialized providers with expertise and high-quality

01:09:58people in there that are providing something that can't be provided anywhere else.

01:10:02And you've got a placement for the child, and you've gotten all the services they need.

01:10:05So that's a very alluring idea for states.

01:10:08But the reality is not that.

01:10:10And I think that in states, no one knows exactly how to make these places, even the providers,

01:10:17work effectively and be safe in therapeutic environments.

01:10:21And I think, and I know my time is up, but let me just say this one final thing, Ms.

01:10:24Chair.

01:10:25And I know you know this.

01:10:26I just say to my colleague, she's asking very important questions, and if you want to ask

01:10:29another question or two, go ahead.

01:10:31Oh, thank you.

01:10:32So my concern is CMS is a crucial partner here.

01:10:35Now Nevada has Willow Springs, it's in the report, and they're doing everything they

01:10:39can to improve.

01:10:41And literally our legislature, working with our state government, has put in place an

01:10:45improvement plan.

01:10:46But part of that improvement plan requires CMS to come out with waivers and be a part

01:10:50of the solution.

01:10:52And the challenge I find sometimes is CMS does not work fast enough or quick enough.

01:10:56I'm curious if any of you have any involvement with CMS and information that we need to be

01:11:03aware of as we are working with that federal agency as well.

01:11:12The one thing that I would say is that CMS does have the ability to cancel a contract

01:11:18if a facility, particularly a psychiatric residential facility, is not meeting their

01:11:24health and safety standards.

01:11:26But when we looked at this in 2020, during that year they had not exercised that authority

01:11:32even once.

01:11:33Well, and I think Ms. Stanford, you said there's limited CMS oversight and regulation.

01:11:40So do they have the oversight and regulation, or they don't, or they have it and they're

01:11:44not exercising it?

01:11:45I'm curious.

01:11:46I think both.

01:11:47There's very narrow regulations that are applicable to these facilities.

01:11:52So they're kind of pigeonholed into these very narrow things that can't look at the

01:11:55broader quality of care and what's going on and how services are being provided.

01:12:00But they also, even in our state sometimes, I mean, they're doing a better job at documenting

01:12:06what's going on, but that's it.

01:12:07There's no progressive discipline that's documented.

01:12:10You can look at the surveys.

01:12:11You can see that they've found things and that the facilities have come up with these

01:12:15rote plans of correction that are usually like retraining staff by the administration

01:12:20that is already in there and was probably part of the problem to begin with.

01:12:24And then that just keeps going on and on.

01:12:25Every day is a new day.

01:12:28There's no actual sanctions.

01:12:30No matter what happens to kids, no matter what goes on, there is not any actual financial

01:12:35sanctions or any kind of sanctions, at least in Arkansas, to any of the facilities.

01:12:40Thank you.

01:12:41Thank you, Mr. Chairman.

01:12:42I thank my colleague, and let me turn to you again, Ms. Manley.

01:12:49This committee has made a special priority of home and community-based services, and

01:12:55the late Senator Hatch worked very closely with all of us on Families First.

01:13:00And I had started back as a young member of Congress with a full head of hair and rugged

01:13:06good looks to start thinking about things like kinship care, which we built into Families

01:13:15First, a bigger role for grandparents and the like, helping keep folks at home.

01:13:22But as we look for promising ideas, you always want to look for ones that have an impressive

01:13:28track record.

01:13:29And it looks like you've got another one.

01:13:32You apparently, as the Assistant Commissioner for Children's Care in New Jersey, you came

01:13:40up with a single point of contact system of care, which emphasized home and community-based

01:13:46services and a full continuum of treatment.

01:13:49And I gather this has worked pretty well.

01:13:52So I'd be interested in your describing this, and then I'm going to have a follow-up question

01:13:56on this.

01:13:57Sure.

01:13:58So the question around home and community-based services, not even just do they exist and

01:14:02are they clinically appropriate, but how do parents access them?

01:14:06And so when you build a single point of access, one number, a 1-877 number that any parent

01:14:12could call 24 hours a day, seven days a week, and ask for help, and we send it, because

01:14:18we believe parents when they say that they're struggling, and we send that help within an

01:14:22hour anywhere in the state of New Jersey, things can change pretty dramatically.

01:14:29That help is really important, because parents don't call and ask help from a public system

01:14:36unless they need it.

01:14:38And so it's really important that we get there and get there fast.

01:14:40With that, we can actually then do a pretty good assessment that says, we're going to

01:14:44look at what's happening for your young person, we're going to look at what's going on for

01:14:48that young person in school, how do we connect the dots and bridge between home and school

01:14:52and have young people return back to school as quickly as possible.

01:14:56And that public health approach of really thinking through when and how young people

01:15:01need help, we're trying to decrease the amount of time it takes to get behavioral health

01:15:08care to that place, to that parent, to that caregiver.

01:15:12Sometimes it's before young people actually really recognize that something is going on,

01:15:17and so we can put in support for those young people.

01:15:20So that single point of access makes a huge difference in terms of accessing care.

01:15:24Is this something that we ought to be looking at as we go forward in a bipartisan way to

01:15:29create some national incentives for this sort of one point of contact that encourages help

01:15:37for the community health services?

01:15:40Yes.

01:15:41I see states really struggling with this idea of who do they call.

01:15:45When they have a really good service delivery system, they still have a struggle of how

01:15:49do parents know when to call and who to call in particular.

01:15:52They move across the county line or they go into a different part of the state.

01:15:56Knowing that the service delivery system is going to look the same no matter where you

01:15:59go within a state is incredibly important as well, so parents and young people can learn

01:16:05to rely on those services.

01:16:07One more point I think is important is that when you can get to young people early, we

01:16:13can change the trajectory of their experience, not only by providing good care, but actually

01:16:19allowing both parents and young people to come to trust a system that may not always

01:16:24be trustful for folks.

01:16:25So just that arriving when they need it is incredibly important, but it is a powerful

01:16:30tool.

01:16:31That's way too logical for the federal government.

01:16:34Let me ask you about the financial model for the programs that we're discussing.

01:16:41My concern is that these facilities get paid often with per diem payments that create this

01:16:50almost perverse incentive to drive down care quality and staffing in order to maximize

01:16:57profit.

01:16:59It's almost like this per diem operation almost bakes in some of the harms that we saw in

01:17:09our report.

01:17:10Do you share that view?

01:17:11I think it can.

01:17:12I think one of the challenges in oversight, as an oversight organization, was certainly

01:17:18one of my roles, was to ensure that the deliverers of service, those providers who are providing

01:17:24care, are really focused on the quality of care that's delivered at the time they need

01:17:30it for young people, and that we stay very focused on that part of the conversation,

01:17:35making sure that providers both don't lose money on this, but also that there's not a

01:17:42profit margin that puts the service into that place in which we're delivering care that's

01:17:48not necessary.

01:17:49But I also, just one other point on this, I think the access of making sure that young

01:17:54people need the service right up front, like having a group of people who know that young

01:18:01person in a teaming process, such as high-fidelity wraparound, make the decisions around whether

01:18:07or not a residential intervention is necessary in the first place, is really the first point

01:18:12of making sure that the profit on the other end is not incentivized by organizations saying

01:18:18they need this intervention, but by somebody else saying that.

01:18:24The three of you have been just superb in terms of laying out the challenge, and that's

01:18:31really what we wanted.

01:18:32And it seems to me that your comments are very much in line with our investigative report.

01:18:38You've heard me talk about the importance of dealing with this in a bipartisan way,

01:18:44because that's how you get lasting changes, because it puts everybody together to make

01:18:51an investment in these improvements.

01:18:53And I'm just going to close with a couple of thoughts.

01:18:55I look out over the room, I see the survivors and the families, and I heard comments last

01:19:01night and I heard comments this morning, and I've read a number of your accounts.

01:19:07And I just want you to know that you have not made this trip thousands of miles to Washington,

01:19:15D.C. just to hear us talk for a little bit and call it a day.

01:19:20You have laid out a blueprint for the kinds of changes that are necessary.

01:19:26These efforts, for example, for more home and community-based services and the health

01:19:31and safety issues that relate to Medicaid and child welfare rules.

01:19:37So I want everybody who's going to be faced with going back thousands of miles home to

01:19:44know that we are not just talking today.

01:19:48This is the first step of what you need to do to make change.

01:19:52I'm going to do everything I can as chairman of this committee to get a bipartisan approach

01:19:58going and hopefully we can have it up and running in the fall that focuses on the issues

01:20:03we're talking about today, which is beefing up health and safety for vulnerable kids and

01:20:09vulnerable families.

01:20:11And taxpayers should not be put in the position to just constantly be writing these

01:20:17enormous checks for the kind of care that we wish kids were getting but we end up seeing

01:20:26they don't actually get it.

01:20:29So we are going to be following up very quickly.

01:20:33I'm personally going to review the accounts that I put in the congressional record that

01:20:38come from all of you around the country.

01:20:42We've also included in the report some tips about where you may be able to get some help

01:20:47now and I put that out just in the context of from the time we wrap up today in a minute

01:20:55and I bang this gavel which is formally closing off today, I want everybody to know we're

01:20:59just getting started and we'll do everything we can to help eliminate the problems this

01:21:06report has discussed that our experts have talked about that you talk about in your testimony

01:21:11and we're going to be back to all of you soon.

01:21:15And for the members, I want everyone to know that they've got seven days to submit questions

01:21:20for the record.

01:21:21That's June 19th, that's Juneteenth so that means June 20th by close of business but you

01:21:28know we are here because of the survivors.

01:21:32All of you have told us that the business model today isn't doing what's needed to protect

01:21:38vulnerable kids and families and we're going to stay at this working with all of you until

01:21:43this is fixed.

01:21:44With that, the Senate Finance Committee is adjourned.

Ron Wyden Leads Senate Finance Committee Hearing On Youth Residential Treatment Facilities

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