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. One key informant described a recent (2015) case of human trafficking in which a care home operator who was closing a home was explicitly selling residents for $100 each to other personal care home operators. I dont have anything indicating that that was the case, said Glover-Hogan. Perkins, M., Ball, M., Whittington, F., & Combs, B. 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. During interviews, informants talked about situations in which the operators of unlicensed care homes continue to be the representative payee and continue collecting the SSI checks of residents even after the resident moved out of home. Multiple key informants also spoke about the lack of affordable housing in Allegheny County. { J\5s-Qy&`DA!o+Z46sA. Klavinger says he was outraged when Glover-Hogan moved Plummer into an unlicensed group home in Warren -- a home that was operating illegally as an Adult Foster Care facility. Greene, A.M., Wiener, J.M., Khatutsky, G., Johnson, R., & O'Keeffe, J. I'm not going to report it. Informants did note that while some places are bad, some unlicensed care homes may be fairly decent. In response to media stories and a congressional request about abuse and neglect of developmentally disabled residents in group homes, OIG launched a series of audits that found that these residents often experienced serious injuries and medical conditions that resulted in emergency room visits. An Online Resource for Skilled Immigrants. (2013). Desperate, Plummers family hired an attorney. Currently, 46 states provide some type of SSP (SSA, 2015). We targeted site visits in communities that varied according to whether the state: (1) has legally unlicensed care homes; (2) has a list of unlicensed care homes; and (3) ranks among the highest or lowest in HCBS waiver expenditures. As noted in Section 4.1, states use a variety of definitions or criteria that allow some homes to operate legally without a license. In Pennsylvania informants described a public education campaign including advertisements warning people about placing their loved ones in unlicensed care homes. Characteristics of Residents and Unlicensed Care Homes. Pennsylvania: In 2012, the Secretary of the Department of Public Welfare stated that the state continues to struggle with illegal operators and asked all Pennsylvanians to join in the fight and report any unlicensed homes or activities because "unlicensed care is deadly.". Some have residents that receive Medicaid funded services. In Michigan, residential care homes that provide room, board, supervision, and protective oversight, but not personal assistance with ADLs or medication assistance (residents can contract out for personal care), are not required to be licensed. Other estimates of the number of unlicensed care homes in the state range from 500 to 1,500 within one metropolitan area. In California, assisted living services can be provided by a licensed home health agency in unlicensed publicly subsidized housing (low-income housing projects, apartment houses, retirement hotels, village models, and private homes). Settings Note: Home Help services cannot be approved if a client is residing in a licensed or an unlicensed foster care home. 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. 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. One SME, who works on the Representative Payee Project,4 mentioned that this project only investigates a sample of individuals who are representative payees for 15 or more individuals. The following section presents individual research topics and identifies the related questions that might guide future research on unlicensed residential care homes. In the District of Columbia, an ombudsman reported that they were involved in collaborative efforts with University Legal Services, Department of Mental Health, Department of Accountability and other groups, such as APS. In one state, Pennsylvania, three bed residential care homes are legally unlicensed. We conducted nine total interviews with ten key informants, including state licensure officials and staff from the North Carolina NAMI in Raleigh. In 2013, the minimum number of ADLs needs required for individuals to qualify for reimbursement for personal care services in group homes increased. The informants recommended the formation of teams including a range of stakeholders, including state licensure officials, Adult Protective Services (APS), ombudsmen, police, firefighters, emergency medical services, code enforcement, and local advocacy organization workers.1. 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. Finally, as noted later in the report, many individuals seek care in unlicensed care homes because they are in other undesirable situations, such as experiencing chronic homelessness or being unnecessarily institutionalized. LIMITATIONS, CONCLUSIONS AND POLICY IMPLICATIONS. Two key informants noted that they only see the worst cases of illegally unlicensed personal care homes, so they could not offer examples of adequate or good care that may occur in those they do not investigate. Some of these housed mainly older residents. Unlicensed homes to face more state scrutiny. Zoning Approval for Group Child Care Homes only (BCAL-3748). endobj Several key informants mentioned that hospital discharge planners sometimes discharge patients to unlicensed care homes (described in more detail in Section 4), and as such they might be a potential source for compiling a list of these homes. Finally, in some states, SMEs and the environmental scan identified legally and illegally unlicensed residential care homes that were referred to as boarding homes or board and care homes. 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. However, while SMEs reported variability in licensure requirements and the authority, responsibility and funding of ombudsmen agencies with respect to unlicensed homes, there is very little information available about legally unlicensed homes, including the characteristics of residents, their care and service needs, and their preferences. No other coordinated agency efforts beyond the state licensure office, APS, and the LME-MCO were described by key informants. 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. Multiple key informants spoke about the significant impact of the closure of this hospital in Allegheny County and the western part of the state as it relates to the possible continued proliferation of illegally unlicensed personal care homes. On the other hand, grey literature--that is, reporting databases, blogs, and media reports--produced more results about unlicensed care homes. Charlene Glover-Hogan is a Public Administrator, a lawyer appointed by Michigans Attorney General to handle probate estates after someone dies. Specific concerns raised by SMEs and site visit informants are highlighted in this section. Furthermore, many licensed facilities are unwilling to admit or retain individuals with challenging behaviors. 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. Presumably, this led to an increase in need for LTSS for these populations. Moreover, unlicensed care home operators have an opportunity to operate virtually unchecked in terms of seizing control of the residents' government benefits. 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. LARA is dedicated to bridging the gap between civilian and military employment and helping veterans gain and retain employment. 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. It is important to note that legally unlicensed care homes are not typically tracked by local community agencies, organizations or states. Key informants described the way the teams function. A phone number is provided if someone has a question about the licensure status of a facility. 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. These local and regional offices--as well as ombudsmen and other national, state, and local advocacy groups--receive complaint calls from a variety of sources including residents' family members; members of the general community such as neighbors or other providers; and medical and service providers (e.g., hospital or clinic doctors, nurses, social workers) who interact with residents inside and outside of unlicensed homes. Failed Legislative Efforts to Improve Oversight. 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. 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. In the recent past, the state has had public education campaigns to inform the public about illegally unlicensed personal care homes. 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. Because these homes are legally unlicensed, the state licensure office has no jurisdiction to monitor them, but APS may receive complaints about them. Populations in Unlicensed Care Homes. Many residents in unlicensed care homes receive SSI, and some residents may qualify for waivers to provide long-term care services in HCBS. Study staff screened each of the collected articles, blogs, and reports to identify relevant material for review. Unlicensed care homes commonly will accept these individuals and many market themselves to discharge planners. 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. 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. Key informants recommended several tactics to address poor quality in unlicensed care homes, but the overall strategy consistently discussed was to shut down these homes. Furthermore, illegally unlicensed care homes continue to exist because they try to avoid detection; therefore, favorable reports of unlicensed care homes are minimal. LARA is proud to be recognized as a Veteran-Friendly Employer committed to military veteran recruitment, training and retention practices. Through a targeted series of interviews and a scan of the literature, we sought to contribute foundational information about unlicensed care homes. It was outside the scope of this project to examine the alternatives to unlicensed care homes or the health, safety, or appropriateness of those other environments. Detecting, investigating and addressing elder abuse in residential long-term care facilities. Concerns remain that agencies do not have the resources needed to monitor and follow through with the appropriate actions to cope with unlicensed care homes (e.g., finding emergency placements for residents, prosecuting violators, ensuring that the illegally unlicensed residential care home remains closed and has not reopened in another location). Although limited in scope, the findings of this exploratory study provide important foundational information about current conditions in some unlicensed care homes, factors that may influence demand for these homes, and strategies to identify them and address their quality. Although some SMEs and key informants provided a few examples of unlicensed care homes where residents receive what they categorized as good care, it appears that abuse, neglect, and financial exploitation of these vulnerable residents is commonplace. Miami Herald. In Pennsylvania counties, a multidisciplinary team called the Personal Care Risk Reduction (PCRR) team helps to address illegally unlicensed care homes; thus we attempted to interview key informants involved in this process. Currently human trafficking is defined as "the act of recruiting, harboring, transporting, providing, or obtaining a person for compelled labor or commercial sex acts" (U.S. Department of State, 2015), however, one SME recommended expanding this definition to include the situation in which an administrator for the unlicensed care homes seize and maintain control of vulnerable individuals in order to maximize revenue by taking the public benefits that the individual may be receiving. The Department of Public Welfare also can take action against boarding homes and similar facilities that house four or more people if they are providing personal care services because they are considered illegally unlicensed. For example, one ombudsman report from Florida noted the difficulty in identifying an unlicensed care home due to the quantity and quality of evidence needed to obtain a search warrant in order to enter the home and positively identify a place as providing unlicensed care or housing residents who must be cared for in a licensed facility. A coordinated, interagency, multidisciplinary effort across state and local agency and organizational levels is an important component to addressing unlicensed care homes. A paper by Tobia (2014) describes the state of unlicensed residential care in one county in Maryland, where as many as 78 unlicensed care homes may be serving as many as 400 individuals. New Jersey and Tennessee have a licensure category that specifies the maximum number of beds required for licensure, but not a minimum, which also implies that in these states some residential care homes may be legally unlicensed. 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. (2015) Assisted living provider resources: Unlicensed facilities. If youre interested in a career that allows you to make a difference, check out the state of Michigan career portal for a list of current openings in state government. In several cases at both the state and local level, unlicensed facilities were reported to authorities or licensure offices by the operators of licensed facilities. 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. 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. 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. The operator of the facility had recently received and accepted an offer to sell the house, and so was closing down the facility. d8 krDlxS^ s P,R^RDS=52oXj]]>b4M|{4q 4OH,kaG/ 4+P}COWz`)29z+QO i#.i[Yuv42 A::E%~wA/N^H[of=8"v~=Gk` *Xl?( J[J#'I@hSh 8 =;z+MZ>7x0mF D7& 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. Almost all SMEs and key informants recommended more proactive strategies to identify unlicensed care homes. 3.4.3. Preventing residents from using the bathrooms after a certain time at night and providing buckets for residents to use rather than toilets. Specific concerns included: Managing resident medications improperly. 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.). As discussed earlier, Pennsylvania is a state that legally allows unlicensed residential care homes, if they serve three or fewer individuals. Trafficking in persons report. 3.4.5. Most state licensure offices, county offices, or advocacy agencies use a complaint system to identify 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. Medicaid in residential care. In one court case, the judge deemed a "boarding house" as an unlicensed residential care home because only three of the six people renting rooms received personal care from the owner's licensed home care agency, even though four actually needed those services. The Pennsylvania BHSL provides specific documentation to potential operators and consumers outlining situations that do not have to be licensed by the state. Findings also indicate that conditions in some unlicensed care homes are unsafe, abusive, financially exploitative, and neglectful of residents' basic needs. Some of these places are legally unlicensed, while others operate without a license illegally. New stringent eligibility criteria for state plans to cover services in group homes serving persons with mental illness have reportedly made it financially difficult for the adult care homes and group homes to continue operating, and some have reportedly been forced to close. This implies that the LME-MCO does not always check licensure status before coordinating services in unlicensed group homes. U.S. Department of State, Office of the Under Secretary for Civilian Security, Democracy and Human Rights. Also, Indiana state law requires legally unlicensed assisted living facilities to submit disclosure forms to the Family and Social Services Administration within the Division of Aging; thus, the state may be able to compile a listing of legally unlicensed facilities. While exploratory in nature, the findings highlight potential issues of safety, abuse and financial exploitation in unlicensed care homes. There is a critical challenge of providing housing and supportive services for particularly vulnerable groups, including individuals: who have severe and persistent mental illness or other disabilities, were formerly homeless, or older adults who have limited financial resources. Several examples of unlicensed personal care homes were described by key informants during the site visit. In regard to the prevalence of unlicensed care homes, state-level estimates were only reported for Georgia, Maryland, and Florida. It was outside the scope of this project to examine the alternatives to unlicensed care homes or the health, safety or appropriateness of those environments. The web Browser you are currently using is unsupported, and some features of this site may not work as intended. Frustrations continue among licensure agencies and advocates with unlicensed care homes, and residents are largely unprotected by licensing agencies (Hawes & Kimbell, 2010). An official website of the United States government. Failing to have safety equipment available, such as smoke detectors and fire extinguishers. Many interviewees mentioned monetary motivations of operators as one factor. (n.d.).Retrieved from http://www.agingavenues.com/topics/assisted-living-facilities-in-indianapolis-indiana. 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. One key informant estimated that approximately 3,000 licensed personal care homes have ceased operations in Allegheny County since the 2005 regulatory changes. According to findings from these interviews, there are a few different pathways into unlicensed care homes, including unlicensed homes receiving residents directly from hospital discharges, representatives of unlicensed homes picking up residents from homeless shelters, and owners of licensed facilities taking residents to unlicensed homes. 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. In addition, one key informant indicated that operators of unlicensed care homes have illegally obtained electrical service utilities through covert connections with neighboring homes. Texas Department of Aging and Disability Services. 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 their quality and safety; and policies that influence the supply of and demand for these homes. 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. Please update to a modern browser such as Chrome, Firefox or Edge to experience all features Michigan.gov has to offer. Referral and Placement Agencies and Discharge Planners. Multiple SMEs stated that licensure offices and agencies like APS are not equipped to track unlicensed care homes. (2009). 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. A review of state regulations around long-term care ombudsmen could reveal gaps and opportunities in how ombudsmen can access and advocate for residents in unlicensed care homes. Another specific example included a resident moving from a home where the operator was their representative payee and the operator continued to collect their SSI check. [12] State licensing for your facility is likely only the start of the process. In another state in that study, only consumer advocates and ombudsmen reported the existence of unlicensed facilities. A separate search of a few state Attorney General (AG) reports of unlicensed RCFs identified six cases of successful prosecutions in New York, Nevada, Florida, and California for operating an RCF without a license--and, in several cases, for gross neglect. 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. We also heard of operators not reporting the death of a resident to SSA so the operator could continue collecting the resident's checks from the government. The enactment of state laws or penalties and fines related to the operation of illegally unlicensed care homes is a strategy that states can use to address illegal unlicensed care homes. Ombudsmen reported increasing numbers of RCFs operating without a license in both Maryland and Nevada. Overall, key informants were able to provide little information about the prevalence of illegally unlicensed care homes (henceforth referred to as unlicensed care homes); informants we spoke with at both the state, local licensure office and APS reported that they do not currently systematically monitor or track unlicensed care homes. There were no reports of varying frequencies of unlicensed facilities between urban and rural areas. Licensure regulations lack clarity regarding requirements for minimum bed size. 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