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HHS Should Improve Internal Coordination Regarding Unaccompanied Children


OIG initiated this review to assess coordination within the Department of Health and Human Services (HHS) regarding a CDC public health order that significantly affected operations of the Office of Refugee Resettlement (ORR), a program office within ACF. Specifically, in March 2020, citing the risk of COVID-19, CDC issued a "Title 42 order" to suspend entry of certain persons into the United States. Under that order, most noncitizen children entering the United States without a parent ("unaccompanied children") were expelled to their home countries. Before the Title 42 order, these children generally would have been referred to ORR, which provides temporary care for unaccompanied children until they are released to a sponsor or otherwise leave ORR custody. Therefore, as a result of the Title 42 order, the number of children in ORR's care dropped substantially. Our retrospective analysis of the Title 42 order's development and initial implementation in 2020 serves to identify steps that HHS can take to improve internal coordination in the future and better ensure that ORR has the information necessary to effectively care for unaccompanied children.


This review focuses primarily on events that occurred from March through November 2020.

Our findings are based on interviews with officials and staff within CDC and ACF; written responses to questions submitted to CDC, ACF, and others within HHS; and internal HHS documents, such as emails and memoranda. We also reviewed relevant public documents. We conducted a qualitative analysis of these materials to establish the timeline and content of coordination between CDC and ORR; the context for that coordination; and factors that assisted or challenged effective coordination to protect the well-being of unaccompanied children and to address the impact of the Title 42 order on ORR operations.


Despite the Title 42 order's impact on ORR, OIG found that CDC did not inform the Assistant Secretary for ACF, the ORR Director, or ORR career staff in advance about the Title 42 order. This lack of communication was due, in part, to the fact that CDC career staff who typically coordinate with ORR staff regarding migration-related health issues were not involved in developing or managing the Title 42 order.

OIG also found a lack of communication during the Title 42 order's ongoing implementation. Approximately 2,000 children were excepted from the order and referred to ORR's care between April and September 2020. However, ORR staff reported that they had not been informed about criteria for these exceptions. Incomplete information about the factors driving referrals can complicate efforts to predict ORR's facility capacity and programmatic needs.

Finally, OIG found that CDC did not inform ORR about a timeline or process for lifting the Title 42 order, despite the likelihood that this action would lead to a significant increase in the number of children referred to ORR and the need for ORR to rapidly increase capacity. CDC reported to OIG that it considered a variety of factors to determine, every 30 days, whether the Title 42 order would remain in effect; however, CDC did not provide to OIG any targets or benchmarks associated with these criteria. Without specific metrics that would trigger a decision to lift the Title 42 order, CDC had limited ability to advise ORR about a possible timeline for rescission.


Past OIG work noted that poor internal communication had impeded ORR's ability to provide prompt and appropriate care for unaccompanied children in 2018. OIG's findings in this review demonstrate a similar lack of internal communication regarding unaccompanied children from March through November 2020, during the development and early implementation of CDC's Title 42 order. Given these findings, as well as OIG's prior findings regarding poor internal communication about unaccompanied children, OIG recommends that HHS: (1) take steps to improve internal coordination and communication about unaccompanied children and (2) ensure that CDC coordinates with ORR when making future decisions that could affect the number of unaccompanied children placed in ORR's care, including any Title 42 order.

ACF and CDC concurred with both of our recommendations. ACF stated that it has already taken significant steps to implement the recommendations and affirmed that it will continue these efforts to support effective operation of the Unaccompanied Children Program. CDC also provided examples of recent coordination and stated that it will continue to improve internal coordination and communication efforts.