stream One of the points made by key informants is that states have very few, if any, strategies to easily identify unlicensed care homes. The fact that four people should have been receiving personal care services made the home eligible for licensure as a residential care home--not the fact that three people were receiving the services (which would make it under the legal limit). All states license residential care such as assisted living, and most states license small adult care homes, often referred to as adult foster care (Carder, O'Keeffe, & O'Keeffe, 2015). Further, receipt of a complaint was the most commonly cited method to spur identification of an unlicensed care home. The nature of health and safety concerns described by key informants were wide-ranging and often included neglect and the risk of death to residents. After years of personal and professional experience, I founded The Group Home Connect Academy, where we provide 1:1 Coaching to help entrepreneurs make their business dreams a reality. We conducted nine total interviews with ten key informants, including state licensure officials and staff from the North Carolina NAMI in Raleigh. As noted above, placement agencies work with Allegheny County hospitals and discharge planners, therefore these agencies may also have lists that include illegally unlicensed personal care homes. Several informants explained that some unlicensed care home operators require residents to make the care home operator or the operator's designee their representative payee for SSI benefits, and that some operators also collect food stamps, medications, or other resources from residents, which the operators can then sell for profit. Legal homes serve as conduits to illegally unlicensed homes in some instances. More than 30 people were being housed there without adequate food or medication. Tobia, M. (2014). As noted, we found the prevalence of legally and illegally unlicensed residential care homes varies by state. Concerns remain that agencies do not have the resources to monitor and follow through with the appropriate actions (e.g., finding emergency placements for residents, prosecuting violators, ensuring that the facility remains closed and has not reopened in another location) for the unlicensed facilities. An operator with this population mix can avoid licensure because each agency is only responsible for the residents that are enrolled in their program or waiver. They described this as an example of operators running unlicensed care homes strictly for the money. ~DNe*FYil2`#T*$E9=`pJ. These findings highlight a set of potentially serious problems and issues. Calvin Leslie agreed to a sentence of 10 to 25 . Some SMEs suggested that state policies affect the mix of residents in unlicensed care homes. In either case, while states regulate and provide some level of monitoring and oversight of licensed care homes, state and local oversight of unlicensed care homes can be minimal or non-existent, and these facilities provide questionable care and services. Pennsylvania's BHSL and the North Carolina Adult Care Licensure Office and Mental Health Licensure Office will offer to work with unlicensed residential care homes to help facilitate licensure. Retrieved from http://www.state.gov/documents/organization/245365.pdf. Audio podcast. Using the 2012 annual Medicaid LTSS expenditures report produced by Truven, we identified the ten states that spent the highest percentage of their LTSS expenditures on HCBS and the ten that spent the least. As described in Section 2, to inform the selection of states for site visits, we looked closely at the information available for six states where the environmental scan or SMEs indicated unlicensed care homes likely exist. A 58-year-old man pleaded guilty to elder abuse on Tuesday for operating an unlicensed group home where about eight tenants lived without heating. Estimates of the number of unlicensed RCFs, as detailed in this report, were in the hundreds in two states: one state estimated more than 200 unlicensed homes in contrast to their 400 licensed facilities; and the other state estimated more than several hundred unlicensed homes but noted there was no reliable count. In Michigan, a group home must be licensed if the owner receives compensation for providing personal care, supervision, and protection, in addition to room and board to people who are mentally ill or disabled. Abuse, Neglect, and Financial Exploitation, 3.4. Monitoring and Improving Quality in Legally Unlicensed Care Homes. It smelled, she didnt look like her hair was brushed. Future research examining the role of hospital discharge planners and strategies to prevent discharge to unlicensed care homes appear warranted. In Georgia, the number of complaints about unlicensed facilities rose from 253 in fiscal year 2013 to 293 in fiscal year 2014, with at least one-third of claims being substantiated. Although there were some reports of clean and safe unlicensed homes, the negative findings about conditions were predominant. In one state, the AG only received nine cases in the entire year; in another state they handled only 2-3 cases a year. Strategies for Addressing Unlicensed Care Homes. Multiple key informants provided details of two specific cases of illegally unlicensed care homes. For example, in Georgia it recently became a misdemeanor to operate an unlicensed care home,therefore we aimed to speak with law enforcement officials who had been involved in the process of investigating unlicensed care homes. Thirty states require residential care homes to be licensed if they have at least one bed.7 Massachusetts exempts small private-pay homes from licensure. If you seek a pleasant peninsula, look about you. Michigans official state motto holds many truths our state is a land of great splendors. The objective of the literature review was to identify current information (2009-2014) on both legally and illegally unlicensed RCFs and to inform the conduct of SME interviews and site visits to communities in three states. Trafficking in persons report. While it is outside the scope of this project to investigate alternatives to unlicensed care homes, we speculate that increasing the supply of alternatives for affordable housing with services would reduce the market for unlicensed homes. In 1999 legislation (PA 99-80) passed, authorizing trained, unlicensed personnel to administer medication to elderly people in residential care homes (residents must be ambulatory and generally less frail than those in nursing homes). One SME, who was a firefighter and paramedic who has responded to calls from several unlicensed care homes, stated that he often had more comprehensive listings of unlicensed care homes than the local ombudsman. Revised: 4/2017 Follow us North Carolina's Adult Care Licensure Office licenses two levels of adult care including family care homes and adult care homes. The licensing rules for Adult Foster Care and Home for the Aged facilities provide minimum standards for these regulated facilities. Additional key informants participating in interviews during site visits included local hospital discharge planners (North Carolina), representatives of organizations providing services to residents of unlicensed care homes (Georgia), and local advocacy organizations including National Alliance on Mental Illness (NAMI), Disability Rights North Carolina and Disability Rights Network of Pennsylvania. Findings from this study are necessarily limited by the number of experts we identified and states we visited. Those are just a few of the guardianship problems 7 Investigator Heather Catallo has . While the information herein is not generalizable--it is based on a targeted scan and a limited number of interviews--it does highlight the fact that unlicensed care homes appear to be a problem in at least some states. As a direct result of this regulation change, many personal care homes in Pennsylvania became illegally unlicensed and either shut down, became licensed, or continued to operate illegally. (Hawes & Kimbell, 2010). Key informants described the regulatory agency's ability to work with an operator of an illegally unlicensed personal care home to help facilitate the home obtaining licensure. Key informants included representatives from several agencies, including the state Healthcare Facility Regulation (HFR) and APS offices, local fire departments, local and state law enforcement and ombudsmen, and a church-affiliated provider of day services used by individuals who live in unlicensed care homes. Atlanta Journal-Constitution. Retrieved from http://www.miamiherald.com. 20 or fewer individuals 55 years of age or older that is operated in conjunction with and as a distinct part of a licensed nursing home. The advocacy agency also collects information about whether the operators own more than one unlicensed care home. Also, new HHS Centers for Medicare and Medicaid Services (CMS) policies on waivers and where waiver services may be provided may alter the prevalence of legally and illegally unlicensed care homes across the nation. Multiple key informants said some operators know the regulations better than the state regulatory agency and can therefore find creative ways to evade licensure. One interviewee, who interacts with residents of unlicensed care homes on a daily basis, estimated that for every licensed personal care home in Georgia there is one unlicensed care home. Allegheny County was specifically chosen as the site visit community because of their currently active PCRR team, which continues to address illegally unlicensed personal care homes. Per state regulations, this is not considered a permanent structure, and therefore does not meet the appropriate building requirements to be a licensed facility. 722.622 Definitions. (2012a). The agencies do not typically get complaints from residents inside the home, although if the home is bringing in services such as home health or hospice nurses, those outside agency staff could file reports that result in the identification of an illegally unlicensed personal care home. Making changes to licensed care home regulations is one example of how states may address unlicensed care homes. In these cases, the hospital reportedly pays the placement agencies a fee to find a personal care home, and the placement agencies also receive monetary incentives from the personal care homes for referrals. One state, Pennsylvania, begins licensure with four beds, but the state has locally certified Dom Care homes that serve 1-3 residents. Troubled residents languish in flophouses. Our examination of the Medicaid Fraud Control Unit reports (2009-2013) showed that only a couple cases were reported to the media; the rest had not made the news. Both the information we collected about unlicensed homes in the literature review and that which we collected through interviews mostly paint a negative view of these settings. Some SMEs noted that many licensed facilities are unwilling to admit or retain individuals with severe and persistent mental illness, intellectual disabilities, or challenging behaviors. Treatment of residents as a commodity was a common theme across interviews. Presumably, this led to an increase in need for LTSS for these populations. In Georgia, much of the current focus on unlicensed personal care home investigations involves cases of resident abuse and neglect. However, several SMEs and key informants noted that some unlicensed care homes are good and provide a clean, safe environment for individuals who might otherwise be homeless. Multiple key informants expressed concern about other state policies related to reductions in funding for mental health services and supports as potential contributors to a gap that illegally unlicensed personal care homes can fill. Very little discussion centered on improving the quality of unlicensed care homes. A coordinated, interagency, multidisciplinary effort across state and local agency and organizational levels is an important component to addressing unlicensed care homes. Strategies used to address health, quality and safety issues in unlicensed care homes. These fines ($50 for a first offense in North Carolina and $500 for a first offense in Pennsylvania) become more severe if criminal activity or a resident's death is involved. 3.5.3. Corporations, Securities & Commercial Licensing Bureau. From a county perspective, one ombudsman and housing officer estimated that perhaps there may be less than 20 lawfully unlicensed facilities and less than five illegally unlicensed, however Tobia's team found that there may be as many as 78 unlicensed care homes serving as many as 400 individuals in that county. Some legislatures made it a felony to operate an unlicensed care home. The Texas Department of Aging and Disability Services (DADS) website (2015) states that the agency is aware of some unlicensed residential care homes and is either working to get the homes licensed and to comply with health and safety requirements or is in the process of closing them. Hawes, C., & Kimbell, A.M. (2010). What concerns are there about the quality of care and safety in unlicensed care homes? The DSP may only assist individuals with administration of medications that have been ordered and prescribed by a person licensed to do so by the Department of Licensing and Regulation (i.e., Doctor, Dentist, or Nurse Practitioner.) No positive literature was found, which, as noted earlier, may be reflective of the fact that nothing is published about these places unless they are discovered because they are being investigated for poor care or resident exploitation or abuse. The research team completed seven interviews with eight participants that included both state and local community stakeholders. 4GEMS ADULT FOSTER CARE. Based on the criteria noted above, we recommended six states to ASPE as possible site visit locations: Georgia, Indiana, Maryland, North Carolina, Pennsylvania, and Texas. As a result of the newspaper expos, Georgia enacted new stronger laws. Targeted search terms incorporated specific licensure category names for each specific state. However, according to interview participants, fines have had little impact on closing the homes, as they were often unenforceable and rarely paid. Site visit summaries, which provide more state-specific information, and information on other states considered for site visits, are included in Appendix A. 3.5.4. These include tapping into fire/EMS databases to identify addresses of care homes that could be unlicensed, and tracking multiple SSI payments that go to a single representative payee at the same address. Miami Herald. QX;zI!({?^2'hy^xe(z>! It is now a misdemeanor to operate an unlicensed RCF. Ultimately, several key informants acknowledged and emphasized that remaining unlicensed is lucrative if the care home operator successfully avoids detection by the authorities. The state investigates the types of services that are provided to residents on site in order to determine if a license is required. Interview findings indicate that a key element of a successful strategy is collaboration across multiple agencies. If you want to see if a certain group home is licensed, please click here. One key informant shared a specific example of an operator targeting individuals in hospitals: "Hospitals are putting them on the street. 2O 6@@ zR"k4 Many residents in unlicensed care homes receive SSI, and some residents may qualify for waivers to provide long-term care services in HCBS. Ombudsmen program does not extend to unlicensed facilities (Hawes & Kimbell, 2010). Like the SME interviews, each key informant interview began with a general question to ascertain what the interviewee knew about unlicensed care homes. The Scope of Abuse and Exploitation Concerns. L.C., they may need to pay particular attention to ensuring the availability of sufficient and affordable licensed care homes or other supportive housing options that offer person-centered care in a safe and appropriate environment. The goal of this study was to provide foundational information intended to answer or provide insight into the study research questions. Compared to our other site visit states, Georgia has the harshest law against operators of unlicensed care homes. Key informants included representatives from the state licensure office. Newspaper and media reports generally focus on what they view as the dramatic; the positive aspects of unlicensed care homes are often omitted from these reports. The facility operators were authorized to make the decision on their own (Tobia, 2014). Lax enforcement in personal care homes. They also noted that, despite receiving payment for room, board, and services, some unlicensed care home operators provide subpar or poor quality accommodations and services to residents. In another report, a representative of the Arizona Department of Health Services stated that unlicensed assisted living facilities were not a problem because licensed operators monitor the industry and report illegal activity (Arizona Department of Health Services, n.d.). While its not illegal for certain group homes in Michigan to operate without a license, when youre dealing with someone whos considered legally incapacitated, experts say most people in these situations do require care from a licensed facility. Additional key informants for the site visit interviews were selected based on information provided by the SMEs or what we learned from the environmental scan. We are cleaning our homes, facilities and offices routinely, including regularly sanitizing all high touchpoint surfaces. In Georgia, key informants also noted that hospitals directly discharge individuals to unlicensed care homes and some pay the first month of the resident's fees. Some victims later found that their credit had been ruined by someone who illegally used their identity (Glass, 2015). Therefore, the purpose of this project was to conduct exploratory research on unlicensed care homes to understand more about their prevalence, factors contributing to their prevalence, their characteristics (including their overall quality and safety), and the types of residents they serve. Licensure agencies in only three (Texas, Alabama, and New Mexico) of the six states studied in the U.S. Department of Justice Report (Hawes & Kimbell, 2010) acknowledged a significant problem with unlicensed facilities. The owner of the group home would not return our phone calls to comment on this story. Failing to have safety equipment available, such as smoke detectors and fire extinguishers. The closure of large mental health institutions and concomitant transition of previously-institutionalized individuals with severe and persistent mental illness to community-based care settings, such as legally unlicensed care homes. The financial pressure hospitals feel to free up hospital beds sometimes results in discharges to unlicensed care homes, both unintentionally and for expediency. Retrieved from http://www.dads.state.tx.us/providers/alf/howto.html. Operators often gain control of residents' funds by becoming the representative payee for residents receiving SSI, a common payer source in unlicensed residential care homes. LIMITATIONS, CONCLUSIONS AND POLICY IMPLICATIONS. One key informant estimated that approximately 25 cases are investigated annually, with about half that number determined to be illegally unlicensed personal care homes. The Adult Foster Care Act (PA 218 of 1979) and the Public Health Code (PA 368 of 1978) provides the Department's authority to establish these rules. Notably, most key informants said the operator of a licensed home may also operate one or more unlicensed homes, often in the same neighborhood and often in collaboration with friends or family members. Arizona Department of Health Services. Some residents were also described as transitional or homeless, while others were described as persons with substance use disorders. Key informants stated that many illegally unlicensed personal care homes they investigate are being operated by repeat offenders who have done this in the past; these same operators just open new illegally unlicensed personal care homes once they are found out. Hospitals and hospital discharge planners are responsible for the safe discharge of individuals into the community, but some hospitals may have policies that incentivize the discharge of individuals to unlicensed care homes. Additional research on unlicensed care homes will be valuable to build our understanding of the role--intended or unintended--of these places in our long-term services and supports systems, and the policies affecting it. The annual cost of care for an institutionalized resident is. They noted that the following may have heightened the demand for unlicensed care homes: The admission and discharge policies of licensed care homes. Ten states (Delaware, Georgia, Louisiana, New Jersey, New Mexico, North Carolina, Oklahoma, Rhode Island, South Carolina, and Washington) require residential care homes to be licensed if they have at least two beds. The state and local agencies mostly rely on complaints from the general public and county agencies. Lack of clarity in licensure regulations regarding minimum bed size required by licensure also exists in a few states. Finally, a peer-reviewed publication by Perkins, Ball, Whittington, & Combs (2004) provides insights into why an operator continues to operate an unlicensed care home. Media reports were usually about an action by a licensing agency, Medicaid Fraud Unit, APS, or the police arresting an operator; these reports do not provide much information about the extent to which unlicensed homes exist in the state. This task force has also coordinated raids on unlicensed homes and has pushed for changes to laws regarding these homes. Licensed Care Home Admission and Discharge Policies, http://www.agingavenues.com/topics/assisted-living-facilities-in-indianapolis-indiana, https://aspe.hhs.gov/basic-report/compendium-residential-care-and-assisted-living-regulations-and-policy-2015-edition, http://www.medicaid.gov/medicaid-chip-program-information/by-topics/long-term-services-and-supports/home-and-community-based-services/downloads/requirements-for-home-and-community-settings.pdf, http://www.gachiefs.com/pdfs/White%20Papers_Committee%20Reports/AtRiskAdultAbuseWhitePaper.pdf, https://aspe.hhs.gov/report/medicaid-residential-care, http://www.ncjrs.gov/pdffiles1/nij/grants/229299.pdf, http://www.dhs.state.pa.us/cs/groups/webcontent/documents/report/p_011015.pdf, http://www.bizjournals.com/prnewswire/press_releases/2012/04/17/DC88926, http://www.phlp.org/wp-content/uploads/2011/03/PCH_manual-for-advocates-Feb-20071.pdf, https://www.socialsecurity.gov/ssi/text-benefits-ussi.htm, http://www.nbcwashington.com/news/local/Caretaker-Accused-of-Abusing-and-Neglecting-Kamara-Zanaib-268343912.html, http://www.dads.state.tx.us/providers/alf/howto.html, http://www.state.gov/documents/organization/245365.pdf, APPENDIX B. It is important to note that we do not know whether the types of financial exploitation and abuse described by the SMEs and key informants occur in both legally and illegally unlicensed care homes, or how commonplace they are. Identification of unlicensed care homes is triggered by complaint calls to state or local authorities by community members or family members. Two key informants spoke about the lack of oversight of these homes and the concern for the well-being and safety of their residents. Group homes generally charge less than larger assisted living communities, in . Strategies for identifying illegally unlicensed care homes. A 2010 report from the Pennsylvania BHSL noted that enforcement actions against illegal personal care homes had increased from four homes in 2009 to 27 in 2010 (most were located in the Philadelphia area). Education: Statewide or Interagency. Other states also track complaint calls as a means for identifying unlicensed care homes. Licensure and APS have the same difficulties in terms of moving residents out of unlicensed facilities into good supportive housing sites (Hawes & Kimbell, 2010). One SME from an advocacy organization in Pennsylvania shared that they use an Excel spreadsheet to track illegally unlicensed care homes identified as a result of a complaint. In 2012, the state mandated that large adult care homes (seven or more beds) housing only individuals with mental illness had to close because they were considered institutional settings. "Caretaker" Accused of Abusing and Neglecting Mentally Challenged Victims. In addition to the aging population, many key informants agreed that the lack of affordable supportive housing options for individuals with a mental health diagnosis is also a concern for Allegheny County and surrounding counties. Two interviews were completed with representatives from the Federal Government, seven with representatives from state agencies, three with representatives from policy organizations, one with a representative from a national advocacy group, and four interviewees were researchers knowledgeable about unlicensed care homes. The following are some examples of financial exploitation depicted during interviews; these examples are discussed at greater detail below: Operators of unlicensed care homes collecting the residents' medications and selling the medications on the street for cash. However, we did not hear any specific examples of this from the state or local level. The PCRR team shares the complaints they receive about potential illegally unlicensed personal care homes between the AAA, APS, Disability Rights Network, code enforcement and state licensure office. Some illegally unlicensed facilities deny services are being provided. Web log.Retrieved from http://www.stopelderabusepetition.blogspot.com/2013_06_01_archive.html. Demographic trends are placing an increasing number of older persons at-risk for needing residential long-term care, but many of these same individuals have out-lived their savings or had low incomes to start. Abuse and Neglect. A referral . State and local funding that was designated for clean-up activities in preparation for the 1996 Summer Olympic Games in Atlanta was used to encourage homeless individuals (often with mental illness) to leave the city. Most key informants noted that hospital discharge is a critical juncture at which individuals can be directed to, or end up in, unlicensed care homes. Give Light and the People Will Find Their Own Way, Mom said she was drugged, abused under Michigan probate guardianship. States with concerns about quality and safety in unlicensed care homes may also wish to examine their requirements for monitoring legally unlicensed care homes and the information available about safety and quality in these places. Key informants expressed a desire for future research that helps to categorize the necessary organizations and the number of personnel hours needed from each organization at each phase of the processes to identify, investigate, and close unlicensed homes; determine the optimal tactics to effectively implement investigation and closure; and develop a safe and seamless relocation and follow-up plan for residents. Greene, A.M., Wiener, J.M., Khatutsky, G., Johnson, R., & O'Keeffe, J. In some states, residents can pay for their own personal or medical care in an unlicensed facility. Michigan Department of Licensing and Regulatory Affairs Bureau of Community and Health Systems P.O. That's what they're doing, targeting individuals with cognitive impairment.". If the SSA implements this requirement, it could become a potential source for identifying unlicensed care homes. Typically, the reports refer to physically or mentally disabled adults, some with disease specific conditions, or just described as mentally ill or elderly. However, SSI payments are low, and most states supplement these payments with a State Supplementary Payment (SSP). Findings indicate that a variety of policies may have an impact on the supply of and demand for unlicensed care homes. One key informant described the selling of residents from an unlicensed care facility located in a house. Some key informants described illegally unlicensed personal care homes as filthy and potentially filled with rodents and insects; they also noted that these homes are unsafe structures that could be condemned. One way to collect this information to develop a frame of unlicensed care homes and conduct a small scale study of unlicensed care home operators. Although little is known about unlicensed care homes, a variety of signals, including media reports, highlight potential safety and quality concerns. As described by the majority of interviewees, the primary populations residing in illegally unlicensed personal care homes are vulnerable, with few financial resources. There have been limited prosecutions by the legal system. These legally unlicensed residential care homes are exempt from licensure because they do not provide 24-hour supervision, though residents may be receiving intermittent skilled nursing care, and help with ADLs, medication administration, and social activities. Areas for future research and potential data sources related to unlicensed care homes. The literature review was not an exhaustive effort, but rather a targeted scan of information on unlicensed care homes in the peer-reviewed and grey literature, abuse blogs, and media reports. 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