They do not have to pass inspections by state health care authorities, even though they dispense powerful drugs, provide intensive therapy and place patients in restraints and seclusion.

The federal government doesn’t regulate them, either, even though they receive millions of dollars from Medicaid.

Nor do they have to be accredited by national organizations that monitor and inspect hospitals, even though the treatment closely resembles that found in hospital settings.

Residential treatment centers for emotionally disturbed children are among the most unregulated institutions in the health care industry.

“No one has pushed strongly for standards,” said Clarke Ross, deputy executive director for public policy at the National Alliance for the Mentally Ill. “You can do almost anything you want in the name of children. You don’t have to answer to too many people.”

In Florida, hospitals and nursing homes, which prescribe and dispense medications, are licensed and monitored by the Agency for Health Care Administration. But residential treatment centers, which also prescribe and dispense heavy-duty medications, restrain children and, in some cases, keep them in locked buildings, are licensed as “child-caring” agencies through the state Department of Children & Families. Foster families and maternity homes are licensed under the same provision.

“I don’t think facilities that have the same kind of license as a foster home should be locked and use restraints,” said Patty Cooper of the Advocacy Center for Persons with Disabilities, a federally funded watchdog agency. “I want a higher degree of monitoring and scrutiny.”

Oversight falls on DCF, which is responsible not only for monitoring treatment centers but also for hundreds of other services, including drug treatment and programs for mentally ill adults.

Treatment centers are inspected annually to determine their compliance with requirements such as developing individual plans for children to complete the program successfully. But much of the monitoring focuses on record keeping, and centers get plenty of notice to prepare.Kathleen Kearney, who took over DCF in January, said the agency has not been well equipped to keep close tabs on residential treatment centers. Most of its monitors came to work for the agency as social workers and were moved into the jobs without proper training.

“I do not think [monitoring has] been adequate in the past,” Kearney said.

Kearney said she plans several changes to improve oversight, including requirements that centers be accredited by national organizations, monitor themselves more rigorously and report the results to the state.

The federal government also has not kept a close eye on residential treatment centers. The federal Health Care Financing Administration proposed regulations in 1994 but has yet to adopt them.

Inadequate oversight has been a long-standing problem in Florida.

In 1995, Illinois sent a team of experts led by Ron Davidson, a psychologist and director of the mental health policy program at the University of Illinois at Chicago, to check on children from that state who were in Florida psychiatric centers. Illinois had run out of places for troubled children and had resorted to paying private institutions in other states $250 to $400 a day per child.

“We were getting ripped off,” Davidson said.

In visits to psychiatric centers in Clearwater and Orlando, Davidson said, his team found children living in filth. At one center, the teacher had quit several months earlier.

“The only education the kids were getting was watching cartoons,” Davidson said.

Illinois child welfare authorities, acting on Davidson’s recommendation, vowed never again to send children to Florida.

“We essentially quarantined the entire state of Florida,” Davidson said. “The state was doing such a poor job of monitoring these facilities, we just felt like we could not trust Florida with our kids.”

Florida has since taken no steps to improve oversight, Davidson said. One of the institutions is still open. The other closed last year.

Improvement cited

State social services officials said they have improved monitoring.

“If we find that a program is deficient or not coming up to standards … we simply don’t use it,” said Cecka Green, DCF spokeswoman.

The state historically has devoted few people to monitoring. Those assigned to the job must split their time between hundreds of private agencies that have contracts with the state to operate programs for drug and alcohol addicts, the elderly, abused children, and the mentally ill.

Last fall, DCF in Miami-Dade County doubled its monitoring team — from two to four supervisors. They were responsible for overseeing 250 contracts worth $116 million, records say.

Broward County has 64 contracts at a cost of $33 million, yet no one is devoted full time to monitoring them. The task is divided among 12 employees, said Pat Kramer, who oversees mental health and drug abuse programs for the agency in Broward.

“That’s really our major function,” Kramer said. But “the importance of that responsibility gets diminished.”

In Palm Beach County, eight people are responsible for overseeing 52 contracts worth $55 million, state officials said.

Last November, after a 17-year-old girl died at a West Palm Beach treatment center, a coroner determined workers had cut off her air supply during a restraint procedure. The Medical Examiner’s Office ruled her death a homicide.

A week later, DCF officials visited the center for its annual inspection. Their 25-page report never mentions the girl’s death, except to say center officials should do their own analysis of the “recent sentinel event” and allow the state to review the findings.

Standards vary

Critical standards, such as whether children are safe and are receiving appropriate treatment, vary considerably within the 15 regional districts of the social services agency. Conditions that are considered dangerous by one district are accepted by others.

Last year, for instance, Broward County removed a dozen children from SandyPines in Tequesta, which houses emotionally disturbed children from throughout Florida.

SandyPines had a pattern of using excessive restraints and seclusion, Rod Ellis, child welfare director for DCF in Broward, wrote in a memo to his colleagues in other counties. Children were placed in straitjackets. Some were lethargic and may have been inappropriately medicated, his memo said.

Other counties took no action. SandyPines administrators said they received a few phone calls about Ellis’ memo, but no one shared his concerns. SandyPines remained full, with a waiting list.

State workers sometimes must keep programs open because they have no alternatives for troubled foster children in their custody, former social services officials said.

“What do you do with them?” said Ellis, who is now a professor of social work at the University of Tennessee. “There’s no place to put them.”

Social services workers check on children in residential treatment centers at least quarterly, officials said, and child abuse investigators visit if a complaint is made.

The more comprehensive inspections, designed to determine whether centers are providing quality care and treating children appropriately, are done annually.

But the agency lacks the resources to monitor the centers properly, and inspections focus largely on record keeping and cleanliness.

The state warns centers several weeks in advance of scheduled inspections and sometimes provides an agenda for the visit. Officials even alert administrators to the specific records they will be reviewing and the standards of care they will measure.

Savvy administrators know just what it takes to pass.

“It is that time of the year again!” Harry Henshaw, executive director of Walden Community School in Miami Springs, wrote in a memo to his staff before a 1997 state inspection. “It is important that the entire campus be clean and orderly during this visit as appearance is extremely important.”

Henshaw instructed employees to call him if they had questions about the inspection and “what will be needed to successfully complete it.”

Anita Bock, former head of DCF in Miami-Dade and Monroe counties, said such monitoring by the state is inadequate.

“Dealing with such vulnerable citizens, they [treatment centers] should be visited unannounced at least quarterly,” Bock said.

Kearney, the new state social services chief, persuaded the Legislature this year to give the agency money to hire 27 additional monitors around the state.

Emphasis on costs

The new monitors are in place now, but their focus is largely financial, making sure institutions aren’t cheating taxpayers, Kearney said. She plans to ask the Legislature next year for another 30 monitors whose focus will be on the care provided by treatment centers and other private social services agencies.

In the meantime, Kearney has formed a team of officials to inspect centers when problems are reported. The team has already been to Brown Schools in Sunrise and issued a critical report that found the center was restraining children too often.

Kearney is also working with her counterpart at the Health Care Administration to require treatment centers to be licensed through that agency, a change that would require legislative approval.

“They’re giving out psychotropic medications; they are taking care of children in a quasi-medical capacity,” Kearney said. “I think [licensure] provides an additional level of safety and security for the children.”

DCF has relied largely on the treatment centers to police themselves. The centers are supposed to notify the state of anything unusual, such as a fight, an injury or a child who has run away.

Compliance varies widely. Some centers report problems as often as twice a day, while others send in only one or two reports a year.

DCF has found problems at treatment centers, ranging from keeping children in seclusion too long to failing to monitor kids’ progress. The state puts the centers under “corrective action plans” to improve, but the state doesn’t always follow up on its orders.

In 1997, social services officials told Walden to “immediately” stop making children stand for an hour at a time for disobeying or misbehaving, records show. But Walden continued and even sent in reports to the state that clearly showed children still were being forced to stand, records show.

Clout often unused

DCF has the authority to close problem institutions but rarely does.

In 1994, a 23-year-old resident died at Montanari Treatment Center in Hialeah, one of the state’s largest centers for disturbed children and young adults. Staff members forced the man, an epileptic, to run in place until he collapsed and suffered a seizure, according to a lawsuit. Social services officials stopped sending children to Montanari and ordered improvements, but they left the center open.

A year later, the governor of South Carolina sent a plane to retrieve 21 youths from his state who lived at Montanari after they described widespread physical abuse.

Florida officials then uncovered numerous abuse allegations and complaints that staff encouraged fighting among the residents, forced girls to take birth control pills and overmedicated youths, court records show.

Montanari decided to close after 43 years of operation. Social services officials had to scramble to find places to put the 200 Montanari residents, many of them foster children.

In 1997 and again earlier this year, following repeated complaints of abuse and excessive use of restraints, state officials considered closing Walden, records show.

“As it was with Montanari, because there is nowhere else [to place the children] doesn’t cut it,” Anne Brennan, the second in command at the social services agency in Miami, wrote in 1997.

Her boss, Bock, agreed.

“I think we would be unwise not to act,” Bock wrote in a 1997 e-mail to her staff. But as with Montanari, the state had no place else for the children, Bock said. Walden remained open.

Davidson, who headed the Illinois inspection team, said he has stayed in contact with child welfare officials in Florida. The state is still doing a poor job of monitoring, he said.

“Nothing has changed,” Davidson said. “Florida is still passing the buck.”