A local ombudsman and APS supervisor lead the PCRR team and maintain lists of both known illegally operating homes and those that are potentially illegal operations. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely. Office of the Assistant Secretary for Planning and Evaluation, Printer Friendly Version in PDF Format (81 PDF pages). The goal of this exploratory study was to understand how unlicensed care homes function as a residential care option, the types of individuals who reside in them, their characteristics including quality and safety and the policies that influence the supply of and demand for these homes. Social Security Administration. 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. 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. Due to services being brought into these homes, interviewees thought further interviews with home health staff or hospice staff may yield additional information or lists of unlicensed personal care homes that may include illegally unlicensed establishments. Although we attempted to conduct interviews with operators of unlicensed care homes on our site visit states, we could not identify or gain access to any. 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. It is important to learn if such abuses and frauds are limited to a small number of communities or if they are more widespread. what is the first step. lists. 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. 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. have. In addition to serving the elderly, personal care homes can exclusively serve persons with serious mental illness and/or intellectual and developmental disabilities, on condition that the home is appropriately staffed and is capable of providing the needed care within the scope of its license. Hawes, C. & Kimbell, A.M. (2010). Pennsylvania begins licensure with four beds, but the state has locally certified domiciliary care (Dom Care) homes that serve 1-3 residents. Hawes, C., & Kimbell, A.M. (2010). Retrieved from http://www.dads.state.tx.us/providers/alf/howto.html. Veteran Aid and Attendance Benefits (part of an Improved Pension The Pennsylvania State Lottery funds the Pennsylvania Department of Aging. Dallas Morning News. Key informants described the way the teams function. 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. Spencer, D., & Mimica, L. (2014). In some states, residents can pay for their own personal or medical care in an unlicensed facility. States with concerns about vulnerable adults' access to housing with services may wish to examine their admission and discharge requirements for licensed care homes. In 2005, Pennsylvania state regulations for personal care homes were changed, reducing the minimum number of residents a personal care home could serve from seven to four. Health and safety concerns for residents were a major topic of interview discussion. what type of license they have; Type A or B - large or small. In regard to the prevalence of unlicensed care homes, state-level estimates were only reported for Georgia, Maryland, and Florida. Populations in Unlicensed Care Homes. However, even with those limitations, we know that in the communities we visited, there were significant health and safety concerns for residents, as well as concerns about financial exploitation and government fraud. Retrieved from http://www.azdhs.gov/als/hcb/index.htm. Indeed, many key informants emphasized that they only knew about unlicensed care homes because of complaints being made about them. This type of admission will allow the person to enter the NF without delay and the category will alert the local authority to conduct the PE as quickly as possible. Lists of both known illegal and potentially (identified but not yet confirmed) illegal operations are maintained by APS and the local ombudsman who lead the team. Key informants in two states confirmed that some hospitals there contract with placement agencies that, in turn, place individuals in unlicensed care homes, particularly individuals with limited resources and mental health issues. Although the scope of our research was limited--involving a small number of interviews with subject matter experts (SMEs) and interviews with informants in three communities in three states--the findings have relevance for national, state, and local policies and practices and for future research. Failed Legislative Efforts to Improve Oversight. National Association of Medicaid Fraud Control Units. Finally, a peer-reviewed publication by Perkins, Ball, Whittington, & Combs (2004) provides insights into why an operator continues to operate an unlicensed care home. 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. Strategies for identifying illegally unlicensed care homes. Thus, no more than nine individuals were ever asked the same question. Safety issues affect local fire departments. This button displays the currently selected search type. Frustrations continue among licensure agencies and advocates with unlicensed care homes, and residents are largely unprotected by licensing agencies (Hawes & Kimbell, 2010). 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). 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 Texas Assisted Living Association (TALA) is a Chapter of the Assisted Living Federation of America exclusively dedicated to representing professionally operated assisted-care living communities and residential homes for the aged for seniors. Key informants did not offer any information on potential ways to identify unlicensed care homes or existing databases of these places. Although little is known about unlicensed care homes, a variety of signals, including media reports, highlight potential safety and quality concerns. Informants said that many local sheriffs and District Attorneys are not supportive of following through to enforce penalties, nor do they press charges against the operators. 5. Conditions (including quality and safety) of unlicensed care homes. The goal of this exploratory study was to understand how unlicensed care homes function as a residential care option, the types of individuals who reside in them, their characteristics including quality and safety and the policies that influence the supply of and demand for these homes. In multiple interviews, unlicensed care home operators were described as being involved in human trafficking, and also were specifically noted by APS and law enforcement officials to traffic residents across state lines, specifically into Florida and Alabama, to avoid legal action in Georgia. Because these homes are legally unlicensed, the state licensure office has no jurisdiction to monitor them, but APS may receive complaints about them. The financial pressure hospitals feel to free up hospital beds sometimes results in discharges to unlicensed care homes, both unintentionally and for expediency. In addition, the reports of financial abuse also may represent considerable financial fraud of federal programs including SSI, food stamps, and the programs paying for resident medications (i.e., Medicare and Medicaid). They can fine the operator directly which may lead to the unlicensed care home being forced to shut down. 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. The closure of large mental health institutions and concomitant transition of previously-institutionalized individuals with severe and persistent mental issues to community-based care settings, such as legally unlicensed care homes. Legal homes serve as conduits to illegally unlicensed homes in some instances. Health, Safety, and Sanitary Conditions. 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. Although this might not be the case in other states, in this community it appears that rural police may be more helpful than those in urban areas in identifying unlicensed care homes. The AAA office, APS, Disability Rights Network, and state or regional licensure offices can receive complaints concerning resident care that may lead to the discovery of illegally unlicensed personal care homes. For example, some states have adopted policies including licensure regulations that allow legally unlicensed care homes to operate. This key informant shared a list of seven placement agencies that work with hospitals in Allegheny County. Most state informants said legally unlicensed care homes did not fall under state regulatory purview, and thus were not monitored (or investigated unless there is a complaint). Retrieved from http://www.miamiherald.com. Although recognized as important, the state has not yet begun investigating cases of financial exploitation. These steps include site visits to suspected illegally unlicensed care homes, during which an ombudsman may inform residents of their rights, APS may conduct abuse or neglect investigations, licensure staff may assess whether the residents should be in a licensed care home based on the level of service needs, and code enforcement staff may determine if the home meets regulatory code requirements. Retrieved from http://www.state.gov/documents/organization/245365.pdf. Key informant interviews were conducted in three communities across three states: Allegheny County, Pennsylvania; Atlanta, Georgia; and Raleigh/Durham, North Carolina. What concerns are there about the quality of care and safety in unlicensed care homes? These findings highlight a set of potentially serious problems and issues. Public funds, like state supplements, are inadequate. 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. The goal of this study was to provide foundational information intended to answer or provide insight into the study research questions. During each site visit we interviewed state licensure agency staff to obtain a broad perspective on the regulations surrounding residential care in each of the states. 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. The team conducted brief vetting calls with the second subset of SMEs to determine their appropriateness for an interview; if they were not deemed appropriate, they were asked whether they knew of any other potential interviewees. even more. Per state regulations, residential settings providing room, board and personal assistance with three or fewer residents who have at least one personal care need do not meet the requirements for licensure as a personal care home and are legally unlicensed. Licensure for adult care homes and mental health group homes falls under two separate state statutes, and therefore two separate regulatory offices oversee different types of licensed care homes. Dom Care homes, which also provide care to three or fewer individuals, are governed and regulated by the state with the authority to certify, supervise and monitor delegated to the local AAA. Information gathered from the environmental scan and SME interviews revealed reports that unlicensed care homes exist in North Carolina. Government staff lack of respect for the care provided in small residential care homes by non-professional licensed staff. One key informant shared a specific example of an operator targeting individuals in hospitals: "Hospitals are putting them on the street. Information from interviews with key informants also revealed incidents of emotional and physical abuse, including intimidation, and threats. One key informant suggested that lists of available housing maintained by a local homeless housing assistance program may include illegally unlicensed personal care homes. The Texas Department of Aging and Disability Services (DADS) licenses and inspects personal care homes to ensure compliance with state regulations. SMEs and key informants consistently noted that many low-income individuals cannot afford licensed facilities, which makes the less expensive unlicensed care home an attractive option, and thus contributes to the existence of unlicensed care homes. Indeed, results from the National Survey of Residential Care Facilities indicate that only 40% of licensed RCFs admit individuals with behavior problems, and just 55% admit individuals with moderate to severe cognitive impairment (Greene et al., 2013). What federal and state policies affect the supply and demand of unlicensed care homes? The vast majority of key informant reports emphasize often alarming conditions in unlicensed care homes. Key informants also noted that unlicensed care homes may serve mixed populations within the same home (e.g., elderly residents as well as individuals with severe and persistent mental illness). Education: Statewide or Interagency. Others described instances where the unlicensed care homes can be located in either low-income neighborhoods or higher-income neighborhoods, and that they blend in with other houses, which makes them difficult to identify or locate unless reported by the community. 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. SMEs mentioned the lack of SSPs to residential care home residents who receive SSI as a factor that encourages the existence of unlicensed care homes. Affordable Luxury Personal Care Home in the serenity of the woodlands. Treatment of residents as a commodity was a common theme across interviews. care facilities. Submit all required documents. Although exploratory in nature, these findings point toward concerning issues with unlicensed care homes as well as gaps in our knowledge, and have important implications for future research on unlicensed care homes. Concerns expressed across several interviews included providers locking residents in rooms; locking food away so that it is inaccessible to residents; using basements to house individuals, including individuals who are unable to climb the stairs and those on hospice; providing accommodations that are unclean, infested with bedbugs, and lack heat, air conditioning or running water. And regardless of whether states have regulations concerning unlicensed homes, many operators choose to operate illegally unlicensed homes. However, according to interview participants, fines have had little impact on closing the homes, as they were often unenforceable and rarely paid. Targeted searches of media reports in states with the lowest percentages (New Jersey, Mississippi, Indiana, Florida, and Michigan) did not yield a higher number of reports on unlicensed care facilities than those with the highest spending rates for HCBS (Arizona, Vermont, Alaska, Minnesota, and Oregon). Six states (Colorado, Iowa, Illinois, Maine, Missouri, and Vermont) license starting at three beds, noting that Vermont, like Massachusetts, exempts small private-pay homes. There exists confusion over the authority of other agencies. In addition to legally unlicensed residential care homes, there are a variety of places that operate illegally. care services, assistance and supervision to four or more persons. Strategies for Addressing Unlicensed Care Homes. Abuse, Neglect, and Financial Exploitation, 3.4. This implies that the LME-MCO does not always check licensure status before coordinating services in unlicensed group 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. Key informants were divided in their opinions on the motivations for operating illegally unlicensed personal care homes. Through these regulatory activities, DADS protects Texas citizens who receive long-term care services. Consistent with findings from the environmental scan, stakeholders (including SMEs and site visit key informants in the three communities we visited) repeatedly raised a variety of concerns about neglect of residents' health care needs and unsafe and unsanitary conditions in unlicensed care homes. Notably, the strategy of responding to complaints limits the amount of information available about unlicensed care homes about which complaints are not made (i.e., possibly better quality homes). As such, they could be a key source for learning about currently unlicensed care homes. Monograph for the National Institute of Justice, U.S. Department of Justice. This shifting of residents from one unlicensed home to another to avoid detection and oversight was also described by the media in Texas and Georgia. Retrieved from http://www.namfcu.net/resources/medicaid-fraud-reports-newsletters. In addition, hospital discharge planners reportedly work with placement agencies to find housing for patients who cannot return home alone. In contrast, identifying and addressing quality in legally unlicensed care homes was only minimally discussed; however, in at least one of our site visit states, interviewees felt that it was feasible to identify these homes, given the existence of listings of these homes. Site visit locations were based on the information gathered in the environmental scan, SME interviews, and a review of residential care regulations. Pennsylvania and North Carolina have some similarities in how they address unlicensed care homes. The inability or unwillingness to provide appropriate care for residents at an affordable cost also was noted by key informants as a motivator to not pursue 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. They noted that some unlicensed care homes provide good care; however, SMEs and other informants consistently reported substantial concerns about neglect, unmet health needs, unsafe and unsanitary conditions, abuse, financial exploitation, false imprisonment, and moving residents to different care homes across communities and states to evade detection. . The frequently reported act whereby the operator of an unlicensed home makes money from their control of vulnerable residents and moves these residents from one unlicensed care home to another to avoid detection, led one SME to refer to it as "human trafficking." 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. In another example of differing payment sources, a key informant described a housing situation with three Dom Care residents plus three other residents who can live independently; this care home did not require state licensure as a personal care home. In Texas, a residential care home (also known as a Retrieved from http://www.miamiherald.com. 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. Community safety personnel recommended interviewing local code enforcement divisions for thoughts on illegally operating unlicensed care homes, and consulting EMS personnel because they go out on every 911 call to a house or home and may have more experience with unlicensed care homes compared to firefighters. Financial abuse was the most commonly cited form of exploitation and the fastest growing form of abuse in illegally unlicensed personal care homes. Costs for bringing the building up to code to meet state regulatory requirements may be another reason why operators of care homes choose to remain unlicensed. Preventing residents from using the bathrooms after a certain time at night and providing buckets for residents to use rather than toilets. Regulatory changes and the role of multidisciplinary task forces (which are relevant to both legally and illegally unlicensed care homes) are described next, followed by a summary of the strategies discussed during interviews to identify and shut down illegally unlicensed care homes and to monitor and improve quality in legally unlicensed care homes. Areas for future research and potential data sources related to unlicensed care homes. Some have residents that receive Medicaid funded services. Consequently, although we attempted to elicit information about the positive aspects of unlicensed care homes, key informants largely provided us with a less favorable view of unlicensed care homes. As discussed earlier, Pennsylvania is a state that legally allows unlicensed residential care homes, if they serve three or fewer individuals. The state has started training sessions to educate law enforcement and first responders about unlicensed care homes, and these education efforts may contribute to the state's ability to identify unlicensed personal care homes. Following the environmental scan, we conducted interviews with SMEs on the topic of unlicensed care homes. There were reports that while unlicensed homes in some states (such as Maryland) serve elderly and physically disabled residents, many also serve a clientele who once were homeless, persons who may have substance use disorders, and individuals who were formerly incarcerated. 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 financial pressure hospitals feel to free up hospital beds quickly, which sometimes results in discharges to unlicensed care homes, both intentionally and unintentionally. Although the residents who were moved out of this hospital may have been relocated to licensed facilities when the hospital closed, the fact that such institutional settings are no longer an available option may have encouraged unlicensed care homes to open. Massachusetts exempts small private-pay homes from licensure. NBC News 4, Washington D.C. Retrieved from http://www.nbcwashington.com/news/local/Caretaker-Accused-of-Abusing-and-Neglecting-Kamara-Zanaib-268343912.html. With one exception--Georgia--the same held true for the ten states with the greatest increase in HCBS spending since 2010: Virginia, Ohio, Maine, Rhode Island, Alabama, Tennessee, Georgia, New Hampshire, Massachusetts, and Delaware. 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.