Retrieved from http://www.ajc.com. Retrieved from http://www.dads.state.tx.us/providers/alf/howto.html. To reduce abuse, several informants indicated that state officials should target closing unlicensed care homes. Key informants at the state level were able to provide estimates of the number of complaints they have received pertaining to unlicensed care homes, but not estimates of the number of unlicensed care homes. or home health care. (n.d.). This research might also address whether the Keys Amendment is achieving its goal of protecting the well-being of SSI recipients. Some trawl for residents, picking residents up off the street, from homeless shelters, and from hospitals, and routinely shift residents from one facility to another in order to keep their occupancy rates high. In addition to the church-affiliated home described above, examples of the types of places where unlicensed homes operate included an old elementary school as well as single family homes in residential neighborhoods. As noted by one SME, unlicensed care homes that provide good care and a safe environment may intentionally not be brought to the attention of state agencies nor be reported by these agencies when they learn of these homes: "We do receive reports, about 6 months ago someone wrote to me about their mother who was getting care in an unlicensed homeshe was getting wonderful care, she wasn't going to report it. One Florida media report estimated there were hundreds of congregate living facilities across the state that escaped state oversight because no agency regulates them (Savchuk, 2013). Six states (Colorado, Iowa, Illinois, Maine, Missouri, and Vermont) license starting at three beds, noting that Vermont, like Massachusetts, exempts small private-pay homes. Residential care homes that serve three or fewer residents are legally unlicensed in this state. Two states (New Jersey and Tennessee) have a category that specifies a maximum but not a minimum. 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. (2013). Multiple interviewees suggested that it was important to quickly involve code enforcement and local health departments in efforts to close an illegally unlicensed personal care home. Although such issues are not restricted to unlicensed care homes, as they are known to occur in licensed care facilities as well, future research might examine and describe the mechanisms states use to detect, investigate, and resolve allegations of abuse or neglect in unlicensed residential care homes and how they compare to the mechanisms used to identify and resolve instances of abuse and neglect in licensed care homes. It is important to note that most key informants did not speak to or have direct experience with very small (1-3 beds) legally unlicensed personal care homes, and therefore could not estimate the prevalence of these types of homes or compare them to illegally unlicensed personal care homes. Based on this information, we chose three states, and subsequently identified three communities within those states, to visit and conduct case studies.2 Following is a summary of the literature, media coverage, and regulations for those three states (Georgia, Pennsylvania, and North Carolina). custodial or intermediary care. might not do well with the larger assisted living facilities. Additionally, interviewee discussions revealed a lack of ombudsman involvement in unlicensed care homes, which is another area for future research. According to SMEs and key informants, the following factors are likely drivers of the demand for unlicensed care homes in their communities or states: The policies that licensed care homes have against admitting residents who exhibit behavior problems and those who have substance use disorders, or to discharge residents who develop these problems. Report on Texas boarding houses. The determination of the Many low-income individuals cannot afford the cost of licensed residential care homes, and some residents exhaust their private funds in licensed facilities and are discharged with no options other than lower cost care homes, some of which may be unlicensed. There was not much attention paid to the original sources who identified an unlicensed facility, but in some articles or media reports, the case came to light due to a death that occurred in the facility that had to be investigated, neighborhood complaints of numerous vans, ambulances or police cars at the home, or calls from concerned family members about the status of a resident. One of the points made by key informants is that states have very few, if any, strategies to easily identify unlicensed care homes. We did not find any report where a government agency was proactive and discovered the case on its own initiative or because of routine monitoring of unlicensed residential care homes. Available at http://www.ncjrs.gov/pdffiles1/nij/grants/229299.pdf. Retrieved from http://www.azdhs.gov/als/hcb/index.htm. Estimate of 2-year cost of implementing HB216. 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. 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. According to many of the key informants interviewed, hospitals are increasingly under financial pressure to discharge patients to free up beds, which is believed to contribute to the ability of unlicensed care homes to fill beds and stay in business. 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. care facilities. Florida publishes a listing but it does not correspond with the media reports of the number of unlicensed care homes identified by state inspectors. Licensure staff admitted they only learn about the unlicensed facilities when someone reports them. In some states, APS has very limited responsibility and involvement. 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. The state is also unusual in that it allows a category of care homes to operate as legally unlicensed homes. Further, key informants reported that many operators require residents to surrender all forms of identification "for safe keeping" by the operator. Policies affecting the supply of and demand for unlicensed care homes. Services, including those provided by unlicensed personnel under the delegation of a registered nurse or physical therapist, provided to the person in care or their family as part of a coordinated program. Some states allow legally unlicensed facilities to assist with ADLs and administer medication, but do not allow them to provide 24-hour supervision. 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. This button displays the currently selected search type. Several states (California, Pennsylvania, Maryland, and Mississippi) publish notices of how and where to report unlicensed care facilities, which implies that these states may be experiencing problems with unlicensed homes. residence most often within a subdivision that provides personal Retrieved from http://www.dads.state.tx.us/providers/alf/howto.html. 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. Future research could be conducted to describe the nature of ombudsman involvement in unlicensed care homes and how it differs across states. Federal government websites often end in .gov or .mil. Discussions with key informants in the state suggest Georgia has a high prevalence of these homes. We also conducted site visits to a total of three communities in three states, including interviews with local and state-level key informants. Adult residential licensing, 2010 annual report: A report on licensed personal care homes. One key informant noted that residents of unlicensed care homes commonly require assistance with activities of daily living (ADLs), such as getting dressed, as well as assistance with instrumental activities of daily living (IADLs), such as taking medications and managing and accessing transportation to medical appointments. PubMed and other database searches yielded very little literature related to unlicensed RCFs. Of these, three were determined to be unlicensed care homes. 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. Some operators use homes that do not meet personal care home building code regulations; for example, the home may lack proper ramps for wheelchair access. Through these regulatory activities, DADS protects Texas citizens who receive long-term care services. Retrieved from http://www.ajc.com. Furthermore, illegally unlicensed care homes continue to exist because they try to avoid detection; therefore, favorable reports of unlicensed care homes are minimal. Some of these places are legally unlicensed, while others operate without a license illegally. need for senior care services and the choice of a facility is an These included: (1) tracking individuals' public benefits; (2) obtaining lists of unlicensed care homes from health care and advocacy organizations that refer individuals to them; (3) accessing information from emergency response personnel; and (4) utilizing owners of licensed facilities as a source to identify illegally unlicensed care homes. be physically and mentally capable of evacuating the facility One issue that remains to be determined is the conditions or criteria by which such places constitute "unlicensed residential care homes." Retrieved from http://www.state.gov/documents/organization/245365.pdf. For example, some states have adopted policies including licensure regulations that allow legally unlicensed care homes to operate. However, there were many reports of poor conditions in legally unlicensed care homes. TALA is dedicated to advancing public policy initiatives advocating for informed choice, quality care, and accessibility for all Texans. 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. in the state of Texas, they are licensed according to size, type and building Health, Safety, and Sanitary Conditions. (2004). Other SMEs reported that efforts to discharge or divert residents from nursing facilities to community-based settings led to greater use of licensed RCFs and noted instances in which residents who exhausted their private funds might have no options other than unlicensed residential care homes. PHC providers must be licensed as a Home and Community Support Services Agency (HCSSA) within the category of Licensed Home Health Services, Licensed and Certified Home Health Services, or Personal Assistance Services and have a contract with HHSC to provide PHC services. Results of key informant interviews from site visits, as well as the SME interviews and the literature review, are presented in the Findings section that follows. In several cases, the potential interviewees did not have direct knowledge on the topic of unlicensed care homes, and were not interviewed, but referred us to interviewees with more knowledge on the topic. 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. What are the interviewees' thoughts on the best strategies to identify unlicensed care homes? 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. 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. Based on our findings, the residents of these homes are extremely vulnerable. Unlicensed care homes--which provide room, board and some level of services for two or more unrelated individuals, but are not licensed or certified by the state--fill some of the gaps in the availability of housing and services for these populations. After discussions with ASPE, we identified three states and communities within each state as site visit locations: Atlanta, Georgia; Raleigh/Durham, North Carolina; and Allegheny County, Pennsylvania. Texas Human Resources Code 42.041(b)(7) refers to an educational facility that is accredited by the Texas Education Agency, the Southern Association of Colleges and Schools, or an accreditation body that is a . Provision of housing plus one or more personal services requires a personal care home (or other licensed facility) permit. 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). A facility started the license application process but did not complete it; A facility was licensed but allowed the licensure to expire; or. Other key informants stated that some operators do not want the state regulating or monitoring their business. Although these complaint systems are not specifically designed to identify and track unlicensed care homes, some states use the complaint systems in this way. Atlanta Journal-Constitution. Also, the information collected from newspapers, ombudsmen, APS staff, or other agency reports (by their very nature) skew towards negative events. Additionally, agencies such as The National Disability Rights Network's Protection and Advocacy Agency (NDRN P&A) could potentially use representative payee data to identify unlicensed care homes. Complaints can also be received by fax, letter, or email. Barry, R., Sallah, M., & Miller, C. (2011). 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. This had a direct impact on the operating budgets of licensed group homes. 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. Senior Care & Assisted Living Services South Carolina Assisted Living Facilities, Care Homes, Senior Housing $249,000. Pennsylvania was selected as a site visit location because of the state's past and current experiences with illegally unlicensed personal care homes. the costs of assisted living (personal care homes) or long-term They are a leading provider of top-notch senior care and assisted living solutions. This makes it difficult, if not impossible, for residents to leave the facility, a difficulty sometimes exacerbated by limiting residents' access to their funds, to the facility phone, and, as noted above, by locking residents in their rooms or the facility. Using the 2012 annual Medicaid LTSS expenditures report produced by Truven, we identified ten states that spent the highest percentage of their LTSS expenditures on HCBS and those that spent the least. Abuse, neglect, and financial exploitation of these vulnerable residents appear common. This key informant indicated that this change likely increased the need for licensed group homes, and unlicensed group homes may have also opened as a way to fill the need created as a result of these closures. Thus, one implication of the study is that it may be worthwhile in one or more states or communities to test and evaluate other methods of detecting illegally unlicensed care homes. Unlicensed care homes commonly will accept these individuals and many market themselves to discharge planners. Illegally Unlicensed Residential Care Homes, 6.3. The LME-MCO oversees contract services in a four county area. , when finding a personal care home keep in mind that Further, in site visits and the literature, we found reports of situations that were repeatedly depicted as involving activity that was similar to "human trafficking" and "false imprisonment" of vulnerable individuals. Perils in personal care homes. 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. We found little published information about unlicensed residential care homes; in fact, the scan revealed that most of the literature about conditions in RCFs covered licensed residential care or were about unlicensed care staff. It is now a misdemeanor to operate an unlicensed RCF. What types of reports of mistreatment do the agencies receive? Notably, reliance on complaints to identify unlicensed care homes limits identification of these homes to those that raise concerns about safety or quality. One key informant described the selling of residents from an unlicensed care facility located in a house. Before sharing sensitive information, make sure youre on an official government site. Her e-mail addresses is: Emily.Rosenoff@hhs.gov. 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. In 2013, the minimum number of ADLs needs required for individuals to qualify for reimbursement for personal care services in group homes increased. 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. Estimates of the prevalence of unlicensed residential care homes are lacking for most states. at-home health aide unless one is determined to be medically than assisted living care. 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. The following section presents individual research topics and identifies the related questions that might guide future research on unlicensed residential care homes. We chose the Raleigh/Durham area for the site visit because it is where the state licensing agency is located and because of recent media reports of unlicensed group homes. Given their direct linkage to unlicensed care homes, these three sources (hospitals, homeless shelters, and licensed personal care homes) are potential sources of information for identifying unlicensed care homes. The financial pressure hospitals feel to free up hospital beds quickly, which sometimes results in discharges to unlicensed care homes, both intentionally and unintentionally. Like the SME interviews, each key informant interview began with a general question to ascertain what the interviewee knew about unlicensed care homes. HHSC determines a . Nevada stated that no interagency procedures were in place to handle complaints about unlicensed board and care homes in a timely and efficient manner (Ryan, personal communication). 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. Humphrey Building, 200 Independence Avenue, S.W., Washington, D.C. 20201. One interviewee estimated that licensed personal care homes used to reserve 50% of their beds for individuals who only had SSI benefits and now this amount has decreased to fewer than 25%, leaving SSI recipients with fewer licensed options. Each interview began with a general question to ascertain what the interviewee knew about unlicensed care homes. 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. 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. 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. The majority of key informants reported that unlicensed care homes primarily, though not exclusively, serve individuals with severe and persistent mental illness. 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.). For example, Georgia reported an increase in complaint calls about unlicensed residential care homes from 2013 to 2014. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.
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