Tobia's report (2014) described residents of unlicensed facilities as vulnerable older adults with "hard to place" mental health and paroled individuals who are warehoused. For additional information about this subject, you can visit the DALTCP home page at http://aspe.hhs.gov/office-disability-aging-and-long-term-care-policy-daltcp or contact the ASPE Project Officer, Emily Rosenoff, at HHS/ASPE/DALTCP, Room 424E, H.H. The state made bridge funding available to those group homes impacted by this funding change, but one key informant said that according to a recent report, very few group homes accessed this bridge funding. Of these, three were determined to be unlicensed care homes. Key informants noted that it is important to know the history of Pennsylvania's personal care home regulation changes in order to understand why and how the state has addressed illegally unlicensed personal care homes. Pennsylvania begins licensure with four beds, but the state has locally certified domiciliary care (Dom Care) homes that serve 1-3 residents. According to a six-state study conducted by Hawes & Kimbell for the U.S. Department of Justice (National Institute of Justice) in 2010, when seriously substandard quality, neglect or abuse were discovered in unlicensed facilities, some closed the home in question but shifted residents to other legally or illegally unlicensed care homes to avoid detection or penalties. Facilities provide two types of services in addition to room and board: (1) basic services, which include personal . Retrieved from http://www.namfcu.net/resources/medicaid-fraud-reports-newsletters. (2012). Interview findings also suggest that research is needed on the best strategies for identifying unlicensed care homes and effectively closing them down. But there are homes providing room, board, and personal care that either fall outside the bounds of the state licensure requirements or are deliberately avoiding state licensure requirements. One-bed and two-bed residential care homes are lawfully allowed in several states. Informants consistently emphasized the critical need for collaboration between multiple agencies, including law enforcement, APS, ombudsmen, the Department of Behavioral Health, and HFR, in order to address the potentially unsafe environments in unlicensed care homes, ensure the needs of the residents are met, address the criminal acts of the operators, and attend to the buildings themselves. These challenges include differences in laws and regulations pertaining to care homes across states, and the lack of cooperative arrangements across states to facilitate tracking residents or operators who traverse state borders. The aging housing stock in Allegheny County was also a cause of concern for a few key informants, as it relates to the number of pre-existing buildings that cannot meet the state regulatory building code requirements for licensed personal care homes. Several states have taken steps in improve oversight of unlicensed facilities, often as a result of newspaper exposs on unlicensed residential care homes. An official website of the United States government. Third, the findings suggest it is important to determine the nature and scope of abuse neglect and unsafe conditions experienced by people who have low incomes and physical and intellectual or cognitive disabilities. However, SSI payments are low, and most states supplement these payments with a State Supplementary Payment (SSP). I have allowed a family member to rent a room from me but we don't have a written rental agreement. The environmental scan and SME interviews informed state selection for site visits. A follow-up story revealed that these unlicensed rehabilitation centers may have been selling the identities of the victims on the black market for as much as $2,500. By taking control of the resident's benefits, the operator controls the resident's funds, and should be using those funds for room and board and other beneficiary expenses. They capture key variables such as the name and any aliases of the illegally unlicensed care home; the owner's name and whether they own more than one unlicensed care home; the licensure status (formerly licensed, never licensed, operating illegally); and any relevant information about the complaint (e.g., investigation dates, or dates any residents were moved/relocated). The first and most important step is to find a certified administrator. One key informant specifically mentioned a 10% cut to state funding for mental health in 2012 while another key informant mentioned block grants as a potential contributor to lower funding amounts for mental health services and supports. Providing unsafe housing conditions, including overcrowding of resident rooms, housing many more residents in bedrooms than is allowed by state licensure regulations, housing residents in storage sheds, basements, and attics that were unsafe, unsanitary, and made egress difficult for frail or disabled residents. On the other hand, grey literature--that is, reporting databases, blogs, and media reports--produced more results about unlicensed care homes. These individuals do not pay taxes, have insurance or bonds. Moreover, the 1976 Keys Amendment to the Social Security Act requires states to assure that SSI recipients do not reside in substandard facilities, and states must annually certify that this is true. The 2014 annual report for DADS shows that the number of referrals to the AG increased from two to nine for injunctive/other relief and civil penalties. Texas and Georgia had numerous cases of unlicensed homes in deplorable conditions: infested with insects, lacking air conditioning or heat, residents sleeping on the floor, faulty wiring, no bathroom access, residents deprived of food or fed scraps, and theft of medications. Many key informants regarded the closing of Mayview State Psychiatric Hospital in 2008, which was located in Allegheny County, as an important factor contributing to the gap of services and affordable housing available for individuals with mental health diagnoses. Another motivation to operate an unlicensed care home, equally mentioned by key informants, relates to costs directly associated with meeting building code requirements specified in the regulations. Some of these health and safety requirements include: The license also may require annual in-service staff training. The regional and state licensure offices are closely involved in this process. 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. Retrieved from http://www.ajc.com. Key informants were divided in their opinions on the motivations for operating illegally unlicensed personal care homes. More recently within the City of Atlanta, the gentrification of some neighborhoods has resulted in increased property values and rents, which has caused some unlicensed care home operations to relocate to less expensive areas. One informant suggested research that examines the homeless population and the availability of affordable housing as a way to better understand the environment that may be conducive to supporting unlicensed care home operations. The CMHPC's Policy and System Development Committee conducted a brief While no comprehensive nationwide list of unlicensed care homes exists, the environmental scan identified one state (Florida) and one city (Houston, Texas) that maintain listings of unlicensed care homes. The landlord may also issue a three-day notice immediately to a tenant who uses his room for illegal activities. The following section presents individual research topics and identifies the related questions that might guide future research on unlicensed residential care homes. Licensure staff only learnabout the unlicensed residential care homes when someone reports them. Barry, R., Sallah, M., & Miller, C. (2011). Unlicensed contracting is part of California's estimated annual $60 to $140 billion dollar underground economy. (2009). One provider in San Bernardino County was housing residents with psychiatric disabilities in chicken coops which had been converted into barracks-style housing. One key informant from Pennsylvania spoke about the difficulty in handling reports of neglect or abuse in legally unlicensed care homes: "we will have repeated incidences, or alleged incidences [at legally unlicensed residential care homes] and we don't report to anyone [any agency or the state] either. Two key informants spoke about the lack of oversight of these homes and the concern for the well-being and safety of their residents. Ombudsmen. The administrator may request any amount he or she can get. The 10 study States were: California, Florida, New Jersey, Oklahoma, and Oregon in the extensive regulatory stratum and . 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. These cookies will be stored in your browser only with your consent. Incentives this modest provide little encouragement for residential care homes to incur the cost of licensure if their primary clientele has only SSI to pay for care. Strategies used to address health, quality and safety issues in unlicensed care homes. 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. In the past 15 years, the issues surrounding unlicensed personal care homes in the state have become more prominent, and coordinated action across several agencies has been taken to address them. The financial pressure hospitals feel to free up hospital beds sometimes results in discharges to unlicensed care homes, both unintentionally and for expediency. Pennsylvania and North Carolina have some similarities in how they address unlicensed care homes. Thus, we lack information about unlicensed care homes in moststates, and even in our study states there were no reliable counts of illegal unlicensed care homes. Some legislatures made it a felony to operate an unlicensed care home. Ombudsmen program does not extend to unlicensed facilities (Hawes & Kimbell, 2010). In more extreme cases, other personal care homes have stopped accepting any persons whose sole source of income is SSI. Compared to our other site visit states, Georgia has the harshest law against operators of unlicensed care homes. Which states have had an increase or decrease in the number of unlicensed care homes and why? First, try to resolve minor concerns or differences with the provider. Strategies for identifying illegally unlicensed care homes. Poor quality of care, instances of physical abuse, toxic combinations of medication, and use of stun guns, were also reported (National Association of Medicaid Fraud Control Units, 2015). Retrieved from http://www.ajc.com. In the first half of 2013, 37 other unlicensed homes had been identified. Perkins, M., Ball, M., Whittington, F., & Combs, B. To accomplish this we conducted an environmental scan, including a review of the peer-reviewed and grey literature and interviews with SMEs. Operators forcing the resident to name the operator as the representative payee for government payments, such as SSI, and controlling the use of that money. Key informants noted that the possibility for theft from residents and from government programs also exits with the practice of operators taking control of residents' monthly income from SSA. It does not store any personal data. If residents are able to self-determine and choose where they want to live, they may choose to go with the operator to a new residence. Federal government websites often end in .gov or .mil. Further, receipt of a complaint was the most commonly cited method to spur identification of an unlicensed care home. Further details on findings from the environmental scan can be found in Appendix B. Personal board and care homes: A hidden population in Anne Arundel County. Media and state reports have highlighted homes operating deliberately illegally--that is, they are avoiding required licensure or certification (Tobia, 2014; Georgia Association of Chiefs of Police Ad Hoc Committee on At-Risk Adult Abuse, Neglect & Exploitation, 2013). Informants stated that Allegheny County has other specific contextual issues that may contribute to the existence of illegally unlicensed personal care homes. For further information regarding the . Primary data collection in 385 licensed and 129 unlicensed board and care homes, including interviews with 490 operators, 1,138 staff, 3,257 residents, and observations of the physical environment and care of residents. 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. Out of these, the cookies that are categorized as necessary are stored on your browser as they are essential for the working of basic functionalities of the website. Instances or allegations of physical and psychological abuse and neglect of residents were reported by SMEs and key informants and highlighted in the environmental scan. Legally Unlicensed Residential Care Homes, 6.2. Similarly, APS and ombudsmen staff receive complaints about quality, violations of resident rights, and allegations of abuse. 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. Targeted search terms incorporated specific licensure category names for each specific state. This cookie is set by GDPR Cookie Consent plugin. Except for special circumstances, complaints must be filed in writing. And regardless of whether states have regulations concerning unlicensed homes, many operators choose to operate illegally unlicensed homes. Given these diverse concerns, SMEs and site visits interviewees suggested that coordinated efforts across a range of stakeholders, including state licensure agencies, ombudsmen, APS, law enforcement, and others may be necessary to address unlicensed care homes. This key informant also noted that the residents frequently transition in and out of the home, as is often the case with illegally unlicensed personal care homes. Multiple key informants described unlicensed care homes as primarily serving persons with mental illness. These homes often serve very vulnerable individuals such as individuals with serious mental illness or other disabilities, or older adults with functional limitations and limited financial resources. One state key informant told us that the state licensure office is currently working on an amendment to add a graduated fine system which would increase fines overtime for those operators who are repeat offenders which could potentially serve as a deterrent to continuing illegal operations. Sanitary conditions of the home must be in good condition at all times. In Indiana, legally unlicensed residential care homes serving fewer than five residents can provide assistance with at least one ADL, assistance with medications or meal reminders, or two scheduled supportive services, but cannot administer the medications. One of the points made by key informants is that states have very few, if any, strategies to easily identify unlicensed care homes. These increased costs have also impacted the populations that licensed care homes will accept, according to multiple key informants. Through a targeted series of interviews and a scan of the literature, we sought to contribute foundational information about unlicensed care homes. Second, the findings highlight the need for federal and state agencies to determine the nature and scope of financial fraud being committed by operators of unlicensed residential care homes. What populations do unlicensed care homes serve? Assisted living provider resources: Unlicensed facilities. Study findings should be viewed in light of these limitations. LeasesandRentalAgreements Leases state the amount of rent and the rights and duties of the landlord and tenant. Even with relatively low payment rates, operators can make profits by cutting corners in housing and services and trafficking in the federal benefits they seize from residents. What is Residential Care for the Elderly? Troubled residents languish in flophouses. The North Carolina Office for Mental Health Licensure also licenses group homes for adults with developmental disabilities (5600B) and group homes for adults with substance abuse issues or chemical dependency. In Florida, the Secretary of the Agency for Health Care Administration told a senate committee that the agency wanted to work more with law enforcement. SMEs also discussed the fact that some residents are involuntarily discharged from licensed care homes when they exhaust their funds. Key agencies and team members involved in local or state teams to address unlicensed care homes include APS, ombudsmen, building code enforcement, social workers and first responders such as EMS, police, or firefighters, and other representatives from local advocacy groups such as Disability Rights. It might also determine which states provide additional state funding to the ombudsman program, and whether the level of available resources is a limitation on ombudsman involvement in unlicensed care homes. In preparation for closing, the operator "turned over the residents to other operators for a fee of $100 per resident.". (2013). Greene, A.M., Wiener, J.M., Khatutsky, G., Johnson, R., & O'Keeffe, J. azmfairall. Residents who are unable to climb stairs may be housed in a basement or on a second story without access to an elevator. For example, key informants in Allegheny County, Pennsylvania, stated that police in rural areas of the county are more responsive to reports of unlicensed care homes than are the city police. Written complaints may be submitted to the Board's Central Complaint Unit by mail, via fax, or online. Our search of state AG reports of unlicensed RCFs identified only six cases of successful prosecutions in New York, Nevada, Florida, and California for operating a residential care home without a license--and in several cases, gross neglect in these homes. One key informant stated that if a call comes in and the name of the care home that is being reported is unknown, then the next step is to call the state licensure office. (2011). The same message was also sent to hospital discharge planners and to rehabilitation discharge planners. Strategies for Addressing Unlicensed Care Homes. Given the types of key informants interviewed for this study, and the limited viewpoints captured, more information is needed to understand the characteristics of unlicensed care homes and the residents they serve. Informants noted that interagency, multidisciplinary teams at state and local levels are imperative to the success of shutting down unlicensed care homes, and to address the various issues involved in such closures, such as meeting the housing and services needs of residents, addressing any criminal behaviors of the care home operators, and ensuring the safety of the house or facility and neighboring properties. They can fine the operator directly which may lead to the unlicensed care home being forced to shut down. 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. 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. Finally, a peer-reviewed publication by Perkins, Ball, Whittington, & Combs (2004) provides insights into why an operator continues to operate an unlicensed care home. In addition to the $100 per resident per day fine placed levied against unlicensed facilities, a representative of the state reported that the Georgia legislature has added operating an unlicensed personal care home, which is a criminal offense, to the list of crimes that make it impossible to apply for a license to operate a personal care home. 3.5.3. You must fill out a separate complaint form for each physician or other healthcare provider you wish to file a complaint against. Other uncategorized cookies are those that are being analyzed and have not been classified into a category as yet. Unlicensed care homes provide room, board and some level of services for two or more unrelated individuals, but they are unlicensed by the state. Unlicensed assisted living facilities. One woman was marketing heavy to the hospitals, and taking them to the licensed facilities, and then moving them to the unlicensed facilities, in result to those types of facilities. Please contact the board at renewalstatus@dca.ca.gov for assistance. During site visits, key informants reported that owners of licensed care homes often report operators of unlicensed care homes to authorities. Arizona Department of Health Services. Dallas Morning News. This conflicted with other media reports that describe Arizona citizens calling for closing the loopholes in state laws to prevent "imposter" senior living facilities that use false advertising (Azmfairall, 2013). Each landlord must adhere to applicable housing laws, based on the type of room and board offered. One key informant shared that, as part of such a campaign in 2012, advertisements were placed in metropolitan areas warning the public against placing people in illegally unlicensed personal care homes. Thus, unlicensed care homes close and leave one area of the city, but reopen in another area, contributing to the difficulty of identifying and permanently shutting down these places, while also disrupting the residents' access to day services and other community-based sources of support nearby the original care home location. Schneider, C., & Simmons, A. It is not unusual for them to be involved in other illegal activities as well. Report on Texas boarding houses. As a result, we also examined HCBS expenditures in a select number of states. Spencer, D., & Mimica, L. (2014). State regulations appear to vary widely in regards to ombudsman jurisdiction. In addition, states differ in whether they provide additional funds to the ombudsman program, over and above the federal funds from the Older Americans Act. Licensed care home operators were also identified as potential sources for identifying unlicensed care homes. Facilities providing or arranging for housing, food service, and one or more personal services for two or more unrelated adults must be licensed by the state as a personal care home. Identification of unlicensed care homes is triggered by complaint calls to state or local authorities by community members or family members. Future research could be conducted to describe the nature of ombudsman involvement in unlicensed care homes and how it differs across states. With regards to the safety of unlicensed care homes, the majority of key informants agreed that the lack of clean and safe housing was a primary safety concern. One of our study states made it a crime to operate an illegally unlicensed residential care home, and some states have the capacity to penalize unlicensed care homes with monetary fines. To address the issues surrounding quality and safety in unlicensed care homes, key informants described a process involving the investigation of complaints by visiting the home and interviewing residents and staff (which may necessitate getting an inspection warrant if denied entry upon arrival), then providing a written cease and desist letter if the investigation results indicate that the home should be licensed, issuing fines of $100 per day per resident, and prosecuting the operator. Targeted searches of media reports in states with the lowest percentages of their LTSS expenditures on HCBS (New Jersey, Mississippi, Indiana, Florida, and Michigan) did not yield more reports on unlicensed care facilities than those with the highest spending rates for HCBS (Arizona, Vermont, Alaska, Minnesota, and Oregon). In Allegheny County, key informants said that some hospitals use placement agencies to assist with difficult discharges (e.g., persons with severe or persistent mental illness, the homeless, or persons with little money). These cookies track visitors across websites and collect information to provide customized ads. Per one report, the Department of Public Welfare lacks the legal authority to inspect, require plans of correction, or fine these facilities; however, APS can act on referrals of abuse (Pennsylvania Health Law Project & North Penn Legal Services, 2007). (2012c). Per the California Registry (California Registry, 2017), "Residential Care facilities operate under the supervision of Community Care Licensing, a sub agency of the California Department of Social Services. Abuse and Neglect. Thus, although our findings consistently highlight concerns about safety and quality, we cannot assess the generalizability of these findings and concerns, and our findings only minimally address unlicensed care homes that are safe and provide quality care. State inspection staff, already overwhelmed with large caseloads, were required to obtain search warrants to execute searches, a time-consuming process, when trying to follow up on reports of unlicensed homes. Atlanta Journal-Constitution. 1. Pennsylvania DPW highlights safety and care regulations at personal care homes. Compendium of residential care and assisted living regulations and policy, 2015 edition.Prepared for U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. The research team completed seven interviews with eight participants that included both state and local community stakeholders. ("Independent Living") As a resident of an unlicensed room & board or "independent living" home, you have all of the same rights given to all tenants in California. Clarifying this definition will be critical to understand the prevalence of unlicensed residential care homes, as well as the characteristics of residents in these homes. The main goal of these efforts is to shut down facilities where residents are financially exploited, abused, neglected, or subject to unsanitary and unsafe conditions. However, even if the home continues to operate, the fines are rarely enforced or collected. Characteristics of Residents and Unlicensed Care Homes. In some instances, these places may be certified or otherwise listed at a local level, but they may not be monitored by the state for quality and safety issues. Family care homes serve 2-6 residents and adult care homes serve seven or more residents; both can choose to serve only elderly persons (55 years or older or any adult who has a primary diagnosis of Alzheimer's disease or other form of dementia) or to serve a mixed resident population. Multiple key informants also stated that interviews with small licensed personal care home operators may result in learning more about the motivations for operating an illegally unlicensed personal care home. Frustrations continue among licensure agencies and advocates with unlicensed care homes, and residents are largely unprotected by licensing agencies (Hawes & Kimbell, 2010).
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