Policies affecting the supply of and demand for unlicensed care homes. He also noted that they were not currently using the system in this way, and that it is mostly used to note unsafe locations (e.g., places known for drug trafficking and drug use, or for having dangerous dogs). The same message was also sent to hospital discharge planners and to rehabilitation discharge planners. However, it won't cover None of these approaches or strategies completely addresses the concern about providing a safe environment and quality services to the vulnerable individuals being served in unlicensed care homes. The agencies do not typically get complaints from residents inside the home, although if the home is bringing in services such as home health or hospice nurses, those outside agency staff could file reports that result in the identification of an illegally unlicensed personal care home. We relied on a targeted literature review, interviews with a small number of SMEs, and site visits to just three communities, all of which limited the scope of our findings. 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 issue of financial exploitation is described in detail in Section 3.3.2. Types of Assisted Living Facilities; Overview: ALF Types; Resident Characteristics; Residents of Type A Small or Large Facilities; Page 17; Residents of Type B Small or Large Facilities; Type C Facilities; Facilities with Alzheimer's Certification; License Fees . Some SMEs noted that many licensed facilities are unwilling to admit or retain individuals with severe and persistent mental illness, intellectual disabilities, or challenging behaviors. Unlicensed homes tended to flourish in larger cities where there were significant numbers of low-income elderly and people with mental illness released from state mental hospitals. 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. Two interviews were completed with representatives from the Federal Government, seven with representatives from state agencies, three with representatives from policy organizations, one with a representative from a national advocacy group, and four interviewees were researchers knowledgeable about unlicensed care homes. All of the key informants shared their perspectives about what is driving the closure of personal care homes. Licensure and APS have the same difficulties in terms of moving residents out of unlicensed facilities into good supportive housing sites (Hawes & Kimbell, 2010). However, site visit key informants and SMEs we interviewed were unaware of any such lists of unlicensed homes and could not identify existing methods for tracking them. 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. First, there is a lack of information about the effect of various state and national policies on the vulnerable individuals the policies were designed to protect and whose well-being they were intended to enhance. 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. Because the personal care homes included in NMES were restricted to those that provided hands-on assistance with ADLs and . Please make your own independent In more extreme cases, other personal care homes have stopped accepting any persons whose sole source of income is SSI. See http://www.disabilityrightswa.org/stop-fraud-and-abuse-rep-payees. We utilized the information obtained in the literature review, in addition to our own expertise, that of our consultant, as well as that of U.S. Department of Health and Human Services (HHS) Office of the Assistant Secretary for Planning and Evaluation (ASPE) and the HHS Administration for Community Living (ACL) staff familiar with unlicensed care homes, to develop an initial listing of SMEs to interview. A few articles described the difficulties in identifying unlicensed residential care, such as distinguishing them from places called boarding homes, shelter care, sober homes, rehabilitation homes and publicly subsidized housing that arranges services for residents. 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). The following section presents individual research topics and identifies the related questions that might guide future research on unlicensed residential 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. Licensure staff only learnabout the unlicensed residential care homes when someone reports them. 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. One state key informant stated that her office receives one to two calls a month pertaining to unlicensed adult care homes, but she noted that these calls are sporadic. SME interviews primarily focused on federal and state policies that may impact the prevalence of unlicensed 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. 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. Retrieved from http://www.dads.state.tx.us/providers/alf/howto.html. When HHSC has your information, it is subject to the HHSC privacy policy. State inspection staff, already overwhelmed with large caseloads, are required to obtain warrants to execute searches, a time-consuming process, when trying to follow up on reports of unlicensed homes and determine whether the home is illegal. 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. However, these are issues that warrant additional research. costs while your loved one is living at a certain facility. 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. Based on the findings from this exploratory study, unlicensed care homes appear to be widespread in some areas within some states. 3.4.4. references to products, services or publications do not imply the Figueroa, L. (2011). A few interviewees agreed that in cases such as this, the operators are motivated by their desire to care for people; they are just not aware of the licensure requirements. There exists confusion over the authority of other agencies. Most of the literature and media reports reviewed focused on the pitfalls of unlicensed care homes and the poor quality and safety provided in these settings. These fines ($50 for a first offense in North Carolina and $500 for a first offense in Pennsylvania) become more severe if criminal activity or a resident's death is involved. example, if your mother requires skilled care, Medicare will cover Retrieved from http://www.thisamericanlife.org/radio-archives/episode/554/not-it. 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. 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. Federal government websites often end in .gov or .mil. Three nutritious meals daily with snacks available throughout the day. 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. Retrieved from https://www.socialsecurity.gov/ssi/text-benefits-ussi.htm. At least two states have demonstrated that coordinated efforts can effect changes to laws and policies and create at least initial disincentives or barriers to the operation of illegally unlicensed care homes. As one informant in Georgia reported, "the hospital will say 'this is an expensive bed, you need to get [the patient] out.' Tobia, M. (2014). Managing the care needs of low-income board-and-care home residents: A process of negotiating risks. (2011). Adult residential licensing, 2010 annual report: A report on licensed personal care homes. In Iowa, boarding homes serving three or more individuals who require supervision or need assistance with ADLs are registered but not licensed. This key informant was concerned this had contributed to group homes closing, which may have resulted in a gap that unlicensed facilities are filling. All rights reserved. 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. North Carolina's Adult Care Licensure Office licenses two levels of adult care including family care homes and adult care homes. Because of licensure standard variations, for example, homes that were legally unlicensed in Texas (e.g., adult foster care homes with five or fewer beds) were required to be licensed in California and Oregon. In 2005, Pennsylvania changed the regulations so all residential care homes with four or more individuals had to be licensed by the state, but 1-3 bed residential care homes still could be legally unlicensed. A few key informants suggested cross-referencing different agency lists as another potential source for identifying unlicensed care homes. difference is that some personal care homes accept Medicaid to Local key informants gave more specific examples of how operators evade licensure by having a mixed population living in their homes. Most key informants and SMEs suggested that first responders such as EMS, firefighters, and police are potential sources for identifying unlicensed care homes because they respond to emergency calls received from or about them. 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. Health, Safety, and Sanitary Conditions. 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. Unlicensed Personal Care Homes: What You Should Know It is now a misdemeanor to operate an unlicensed RCF. At risk adult abuse, neglect and exploitation in Georgia: Review and recommendations. Miami Herald. Most key informants noted that hospital discharge is a critical juncture at which individuals can be directed to, or end up in, unlicensed care homes. If the SSA implements this requirement, it could become a potential source for identifying unlicensed care homes. Licensure agencies in only three (Texas, Alabama, and New Mexico) of the six states studied in the U.S. Department of Justice Report (Hawes & Kimbell, 2010) acknowledged a significant problem with unlicensed facilities. Humphrey Building, 200 Independence Avenue, S.W., Washington, D.C. 20201. personal are home) is a private The recent changes to state regulations for community living arrangements are also reportedly becoming more favorable toward independent living, which may lead to an increase in the number of unlicensed facilities. Primary Home Care (PHC) | Texas Health and Human Services Following the environmental scan, we conducted interviews with SMEs on the topic of unlicensed care homes. Two key informants mentioned that changes to the state's Medicaid Personal Care Services program had a direct impact on available funding for group homes that serve individuals with mental illness. What concerns are there about the quality of care and safety in unlicensed care homes? We found three cases in Florida of charges against unlicensed RCFs involving allegations of false imprisonment, resident neglect, grand theft, and/or operating an unlicensed assisted living facility; and three cases in Nevada of neglect and/or criminal offenses while operating without a license (one where the accused also operated a licensed facility). To address unlicensed care homes, states commonly use a strategy that includes penalty systems that fine operators as a way to try and close illegally unlicensed care homes. The Texas Department of Aging and Disability Services (DADS) licenses, certifies and surveys home and community support services agencies(HCSSAs)for compliance with state and federal laws and regulations. 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. 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. One interviewee estimated that at its peak, this hospital served 3,700 patients. 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. 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. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely. The primary concern expressed about the unlicensed homes that were otherwise safewas that they might not be able to provide the level of care and services needed by the residents (e.g., medication supervision for residents with severe and persistent mental illness). Additional key informants for the site visit interviews were selected based on information provided by the SMEs or what we learned from the environmental scan. 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. One interviewee, who interacts with residents of unlicensed care homes on a daily basis, estimated that for every licensed personal care home in Georgia there is one unlicensed care home. 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. 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). Hawes, C. & Kimbell, A.M. (2010). Social Security Administration. L.C., they may need to pay particular attention to ensuring the availability of sufficient and affordable licensed care homes or other supportive housing options that offer person-centered care in a safe and appropriate environment. Three states (District of Columbia, Maryland, and Mississippi) have no minimum bed size for licensure, implying that some residential care homes can be lawfully unlicensed. That makes it difficult for the licensing agencies to understand what's going on because they don't have the information and aren't privy to it.". 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. Pennsylvania's BHSL is currently working on an amendment to create a graduated fine system for those operators who continue their illegally unlicensed care homes after they have been ordered to cease operations. For many such individuals, their only options may be unlicensed facilities or homelessness. 3.2.3. The Texas Department of Health and Human Services licenses assisted-living facilities and personal care homes based on two things: The residents' mental and physical ability to evacuate in the event of an emergency Whether or not it is necessary to have nighttime staff. The complaint will then need to be called to 1-800-458-9858 or e-mailed to ciicomplaints@hhs.texas.gov for nursing homes, assisted living facilities, intermediate care facilities, state supported living centers, home health, hospice, personal assistance agencies and day activity and health services. Two key informants spoke about the lack of oversight of these homes and the concern for the well-being and safety of their residents. 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. 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. Key informants did not offer any information on potential ways to identify unlicensed care homes or existing databases of these places. Operators of small care homes lack knowledge of licensure regulations and how to navigate the different government agencies, and there is a perceived lack of respect from government staff regarding the quality of care that non-professional staff can provide in these small residential care homes. This results in different payment streams and different regulatory agencies that have responsibility for different residents in the same residence. (n.d.). Understanding Supplemental Security Income SSI benefits, 2015 edition. Fraud reports have been filed with the U.S Department of Housing and Urban Development for the misuse of funds to send users from Puerto Rico to unlicensed rehabilitation centers in the United States. As such, limited information is available about the quality of care and services provided in legally 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. Multiple SMEs and key informants suggested following or tracking these benefits as a way to identify individuals in unlicensed care homes. Below we present a sample of the varying state definitions of lawfully unlicensed and illegally unlicensed residential care homes. According to several key informants in the state, including APS and law enforcement officials, the property, which they referred to as a boarding home, was being rented by the operator, members of the church served as the representative payees for the residents, and the money was then pooled together and given to the operator. Retrieved from http://www.phlp.org/wp-content/uploads/2011/03/PCH_manual-for-advocates-Feb-20071.pdf. Additional potential research questions or issues were raised by one or more SMEs or arose from our state site visits or the environmental scan. Some of these homes are legally unlicensed while others operate illegally. The state statute defines personal care services as: Assistance with meals, dressing, bathing, movement, or other personal needs or maintenance; Administration of medication by a person licensed to administer medication Assistance with or supervision of medications; or Key informants were also concerned about a lack of specific services inside illegally unlicensed personal care homes. There are even different titles used to talk about caregivers, such as home care aides, homemakers, personal care assistants, and personal care aides. Residential care homes that are legal often serve as covers for or conduits to illegal homes. Each interview began with a general question to ascertain what the interviewee knew about unlicensed care homes. One key informant in North Carolina indicated that fines for the operation of unlicensed care homes have little impact on closing the homes, are rarely collected, and are not enforceable by their agency because the operation of an unlicensed care home is considered a criminal offense, and thus under the purview of law enforcement. LIMITATIONS, CONCLUSIONS AND POLICY IMPLICATIONS. Key informants in Pennsylvania speculated that owners of legally unlicensed care homes may have direct experience operating an illegally unlicensed home or know someone operating one, and therefore may be able to help identify unlicensed homes or their operators. 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. The research team interviewed 12 key informants in Georgia. 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. 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. A facility was licensed and the license was revoked. Through these regulatory activities, DADS protects Texas citizens who receive long-term care services. Key informants were divided in their opinions on the motivations for operating illegally unlicensed personal care homes. We also conducted site visits to a total of three communities in three states, including interviews with local and state-level key informants. 3.5.3. resident does not require routine attendance during nighttime This implies that the LME-MCO does not always check licensure status before coordinating services in unlicensed group homes. One key informant stated that one in four residents of Allegheny County are over age 60, and that this population presents a growing need for affordable residential care homes. A few key informants noted that this funding arrangement affords state and local agencies the resources and time needed to investigate illegally unlicensed personal care homes. Another strategy is the creation and involvement of interagency and multidisciplinary teams at the state and local levels, which based on our key informant interviewsappears to be a successful strategy. (2004). Understanding Unlicensed Care Homes: Final Report | ASPE The regional and state licensure offices are closely involved in this process. To reduce abuse, several informants indicated that state officials should target closing unlicensed care homes. For example, is it defined by the services the home offers, the services needed by residents, or the services provided to the residents in the unlicensed care setting. Properly complete and submit the license application. Miami Herald. Retrieved from http://www.ajc.com. be physically and mentally capable of evacuating the facility Strategies for Identifying Unlicensed Care Homes, 5.4. Further, key informants reported that many operators require residents to surrender all forms of identification "for safe keeping" by the operator. 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. No other coordinated agency efforts beyond the state licensure office, APS, and the LME-MCO were described by key informants.
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