Report: Nevada violated federal law by unnecessarily institutionalizing children with behavioral health problems
Nevada has routinely failed to provide adequate treatment and services to youth with behavioral health disabilities, instead over-relying on institutional settings such as hospitals or residential treatment facilities to a degree that likely violates federal law.
That’s according to an investigation by the U.S. Department of Justice, which on Tuesday published a 25-page report detailing the state’s failure to provide “community-based services” (such as therapy, crisis support, and behavioral support programs) that led to hundreds of children being “isolated in residential treatment facilities each year” in lieu of remaining with their families if those services existed.
“The department’s investigation found Nevada lacks needed community-based services such as intensive in-home services, crisis services, intensive care coordination, respite, therapeutic foster care and other family-based supports,” the agency said in a press release. “As a result, hundreds of Nevada children are segregated for months, often very far from home.”
More than 1,700 Nevada children were admitted to a hospital for psychiatric care in the 2020 fiscal year, according to the report, and more than 480 received services in residential treatment facilities. But once there, “children stay for a long time” — an average of nine to 12 months in residential placements and institutional settings. More than a quarter of children admitted to these facilities between August and October 2019 stayed for more than a year.
The long residential stays run contrary to a 2013 Centers for Medicare and Medicaid Services bulletin, cited by the DOJ report, that says offering community-based services are cheaper (saving an average of $40,000 per child annually) and more effective.
Children served in the community typically experience a decrease in clinical symptoms, an increase in emotional strengths, better school outcomes and fewer suicide attempts, the report notes. On the flip side, residential care is associated with “significant harms,” including higher rates of abuse, delayed development and emotional attachment disorders.
The report concludes with finding “reasonable cause” that the state’s failures to provide services constituted a violation of the Americans with Disabilities Act (ADA) and could lead to a lawsuit seeking corrective action. Even so, the investigation notes that the state government had provided “exceptional assistance, cooperation, and candor” and had expressed a desire to “work with the department to resolve the identified issues.”
The report laid out the following pathways for the state to remedy its ADA violation:
- Ensuring community-based services are “accessible and available with sufficient intensity”
- Adjusting state rules and procedures to increase the number of Medicaid providers for children’s behavior health
- Enacting “robust oversight” of community-based providers
- Providing a rapid assessment of children who are “at serious risk of institutional placement”
- Working with children and parents on a transition plan after they are discharged from treatment facilities or placements
Gov. Steve Sisolak acknowledged in a statement Tuesday that the DOJ investigation found the state was “lacking” services and said the state government was “committed to working with the federal government and other partners to resolve issues raised in the report.”
The governor’s statement also touted millions in federal money allocated to Nevada that had been directed toward related programs over the last year, noting that additional funds were “already being built into my recommended budget” for the next fiscal biennium. Those federal funds include $5 million specifically earmarked for in-home treatment options meant to keep children and teens at home while being provided intensive therapeutic and behavioral support services.
“For far too long, Nevada has not invested in the appropriate health resources for our children and our families – this new report shines a bright light on that fact,” Sisolak said in the statement.
During an August meeting of the state’s Interim Finance Committee, lawmakers approved more than $45 million in federal relief funds to support an array of mental health services primarily aimed at improving youth treatments. Assemblywoman Maggie Carlton (D-Las Vegas) described the urgency of allocating those funds, characterizing children’s mental health as a “crisis in this state.”
“We can't wait a year to start, we need to start now,” she said. “We have an opportunity. These folks have gotten together for over a year to come up with a plan to move forward on children's mental health. We will not delay. We need to take action now.”
The investigation’s origins
The federal agency opened the investigation in December 2020 based on complaints submitted to the department, leading to an extensive review of documents, interviews with dozens of state officials, community-based providers, advocates, family members of children with behavioral health disabilities and children who had received services in hospitals or other institutional settings. Investigators also visited psychiatric hospitals, residential treatment facilities, juvenile justice facilities and a child welfare shelter.
The lack of access to community-based services means families and children “frequently turn to hospitals as a first stop for treatment,” cycling through hospitalizations, the report states.
The report interviewed the mother of a 14-year-old boy who, unable to get needed behavioral health treatments, was admitted to four different hospitals over a period of several years.
“This parent told us that if she knew about the State’s lack of behavioral health services, she never would have moved [her son] to Nevada,” the report states.
The department’s report also described the state’s use of out-of-state residential treatment facilities as “persistent,” a continued sign of the lack of in-state resources for behavioral health treatment for youth.
“Consistent with what we heard from parents and children, one therapist at an out-of-state residential facility stated that ‘every kid here wants to go home,’” the report states, adding that, “clinical staff at an out-of-state residential treatment center we spoke with told us that Nevada children were particularly difficult to discharge because of inadequate services available to them.”
Nevada officials repeated that assessment, the report said, with one telling investigators that there was a “mindset” that “children need to go to residential” because of the lack of community services.
Investigators also criticized the state’s wraparound services, or “team-based” implementation of individualized care plans for children with complex needs.
The number of children serviced through Nevada’s system, Wraparound in Nevada (WIN), dropped 60 percent between 2017 and 2020, the report said, amid staffing shortages spurred by low pay and high turnover rates. And even for the children who were enrolled in wraparound services, the lack of availability for additional supports — including therapy and psychiatric care — meant those children often went without those services.
“Wraparound doesn’t really offer anything. They just try to connect you with different people,” one parent told investigators. “But the problem with Nevada is there isn’t [sic] a lot of services without a 6-18 month wait.”
A 2019 state report on out-of-state placements, mandated by AB298 passed that year, found that Nevada sent more than 150 children in its juvenile justice and child welfare systems out of state for behavioral health treatment within the span of a year. Some went as far away as Georgia and Tennessee. A 2021 version of the report found that the number dropped to 53 youth in out-of-state residential facilities, though that number includes only those covered under Medicaid or paid for by the state.
Such out-of-state placements can result in children spending months at a time thousands of miles away from home.
The Department of Justice report described the experiences of a child named Martin, “who was appropriate for community-based services but instead received treatment at two residential treatment facilities.”
After experiencing abuse and family disruption as a child, Martin went through a psychiatric hospitalization at age 8, before staying for eight months at a facility in Nevada, followed by a seven-month stay at a facility in Colorado nearly 1,000 miles away from his home in Reno.
“At his admission to that facility, he reported that his only wish was ‘to not be here,’” the report states.