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. Ombudsmen reported increasing numbers of RCFs operating without a license in both Maryland and Nevada. Although these regulatory changes occurred ten years ago, multiple key informants reported that many more licensed personal care homes have continued to close in recent years. These cookies will be stored in your browser only with your consent. Facilities provide two types of services in addition to room and board: (1) basic services, which include personal . A wide range of specific concerns about unlicensed care homes were identified in this study, including improper management of residents' medications; unsafe, unsanitary, and inadequate living environments; failure to adequately feed residents; and monetary theft of benefits. These unlicensed care homes are referred to by several different names in different states, such as "board and care homes," "boarding homes," and "adult care homes." Examples of financial exploitation described by key informants include the operator becoming a resident's representative payee and then withholding a resident's money, and pocketing profits while providing inadequate care and services or no services at all. The payments also vary considerably from state to state, and are quite modest in some states (e.g., from $46 to $100 per month). With regard to recruiting residents from hospitals, we also heard of unlicensed care home operators receiving payments of up to a month's fees from hospitals anxious to discharge the residents to free up hospital beds. 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. Key informants were divided in their opinions on the motivations for operating illegally unlicensed personal care homes. For example, some states have adopted policies including licensure regulations that allow legally unlicensed care homes to operate. Efforts are now under way to provide workshops that clarify the new laws about unlicensed care facilities and how law enforcement and other agencies can work together to identify and investigate crimes against at-risk adults and prepare the necessary components for successful prosecutions. Retrieved from http://www.phlp.org/wp-content/uploads/2011/03/PCH_manual-for-advocates-Feb-20071.pdf. Additional key informants participating in interviews during site visits included local hospital discharge planners (North Carolina), representatives of organizations providing services to residents of unlicensed care homes (Georgia), and local advocacy organizations including National Alliance on Mental Illness (NAMI), Disability Rights North Carolina and Disability Rights Network of Pennsylvania. Web log.Retrieved from http://www.stopelderabusepetition.blogspot.com/2013_06_01_archive.html. For additional information, interested parties can contact the Paso Robles AAUW's Marty Diffley at (805) 440-2078 or pstevens4044@gmail.com, or the League of Women Voters at (805) 242-6990 or candidateforums@lwvslo.org. 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. They speculated that there may not be enough licensed mental health group homes available to care for persons with mental illness, and that unlicensed group homes can potentially fill that gap. Pennsylvania Department of Public Welfare. However, these are issues that warrant additional research. This section describes illegal contracting and the programs CSLB has in place to combat the activity. Alabama's APS agency estimated that there were more than 200 unlicensed homes in the state, in contrast to their 400 licensed facilities. CALIFORNIA-DSS-MANUAL-CCL This cookie is set by GDPR Cookie Consent plugin. Retrieved from http://www.namfcu.net/resources/medicaid-fraud-reports-newsletters. 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. As noted in Section 4.1, states use a variety of definitions or criteria that allow some homes to operate legally without a license. Potential Data Sources or Listings of Unlicensed Care Homes, 5.3. San Jose, California 95112 Toll-Free (800) 248-MHAP Fax (408) 350-1158 Telephone (408) 294-9730 TDD (408) 294-5667 . Discussions with key informants in the state suggest Georgia has a high prevalence of these homes. If the facility is providing licensable services in an unlicensed setting, the state then sends a cease and desist letter, copying the LME-MCO and the local APS. In preparation for closing, the operator "turned over the residents to other operators for a fee of $100 per resident.". 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. (2004). Many SMEs reported that persons with severe and persistent mental illness are the majority of residents in unlicensed residential care homes. 3.5.3. The following section presents individual research topics and identifies the related questions that might guide future research on unlicensed residential care homes. In August 2013, the law to prosecute an unlicensed personal care home operator was used for the first time. 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. We are here to support operators who desire to provide safe and affordable housing for the people living in their facilities as an alternative to homelessness and institutionalization. Medication is visible. For example, key informants in Allegheny County, Pennsylvania, stated that police in rural areas of the county are more responsive to reports of unlicensed care homes than are the city police. (2012a). (2012c). SMEs and key informants discussed a number of factors that may have an effect on the supply of and demand for unlicensed care homes. The majority of key informants interviewed cited emotional abuse including intimidation and neglect as the most common forms of abuse observed or reported in unlicensed care homes. Some key informants described illegally unlicensed personal care homes as filthy and potentially filled with rodents and insects; they also noted that these homes are unsafe structures that could be condemned. Hancock, L. (2007). Strategies for Addressing Conditions in Unlicensed Care Homes, 6.1. In one case well publicized by the media, residents of one unlicensed facility in Pennsylvania were moved between Pennsylvania, Texas, Virginia and Florida to escape law enforcement. Informants noted that unlicensed care homes vary in their appearance and condition. 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. In regard to the prevalence of unlicensed care homes, state-level estimates were only reported for Georgia, Maryland, and Florida. The state's BHSL office also has the legal authority to act as an enforcement agency. research and enforcement purposes. Three-bed residential care homes are lawfully allowed in at least one state. Using information from a HHS Administration on Aging report, provided by the National Ombudsman Reporting System (2009-2013), we identified reports regarding unlicensed facilities in five states: Maryland, Michigan, Nevada, Florida, and Georgia, as well as the District of Columbia. For example, as part of interviews with SMEs, we asked them to recommend potential key informants to meet with during site visits. Trafficking in persons report. LeasesandRentalAgreements Leases state the amount of rent and the rights and duties of the landlord and tenant. Other issues were identified during the subsequent sexual assault investigation, including abuse at the hands of the operator who beat the residents, false imprisonment in which individuals were locked inside rooms, and financial exploitation. Very little was mentioned about elderly residents living in unlicensed homes; only one informant reported that unlicensed adult care homes may serve a mixed population (e.g., elderly residents in addition to residents with mental illness). A few strategies exist in the state for addressing illegally unlicensed personal care homes. The PCRR teams in Pennsylvania are similar, and are based at the local level working in coordination with state licensure offices. 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). In Georgia, efforts are now under way to provide workshops for law enforcement that clarify the new laws about unlicensed care homes and how law enforcement and agencies, such as aging and licensure can work together to identify and investigate crimes against at-risk adults and prepare the necessary components for successful prosecutions. Much of the information we gathered from the environmental scan, from SME interviews, and from site visit informants raises concerns about the conditions experienced by residents in unlicensed residential care homes. Ultimately, several key informants acknowledged and emphasized that remaining unlicensed is lucrative if the care home operator successfully avoids detection by the authorities. 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. A few key informants suggested cross-referencing different agency lists as another potential source for identifying unlicensed care homes. In addition to legally unlicensed residential care homes, there are a variety of places that operate illegally. 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. Texas: A 2007 media report, outside the scope of this review but important to mention, notes that city officials in Dallas estimated that there were at least 350 unlicensed, unregulated board and care homes that house 2,500 people across the city, and likely there were more than that (Hancock, 2007). 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. At the local level, one key informant estimated that members of the Allegheny PCRR, along with the state licensing office, have investigated approximately five illegally unlicensed personal care homes in their specific geographic region over the past two years. 3.4.4. Thus, we lack information about unlicensed care homes in moststates, and even in our study states there were no reliable counts of illegal unlicensed care homes. Retrieved from http://www.miamiherald.com. How can I report illegal advertising by an unlicensed contractor. Ombudsmen program does not extend to unlicensed facilities (Hawes & Kimbell, 2010). 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. 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). States with concerns about vulnerable adults' access to housing with services may wish to examine their admission and discharge requirements for licensed care homes. Referral and Placement Agencies and Discharge Planners. Overall, the local agency representatives described the condition of unlicensed care homes as unsafe. The SME noted that this approach misses individuals who are representative payees for fewer than 15 individuals and as such may miss operators of small unlicensed residential care homes. 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. Reports of financial abuse include fraud of federal programs, including SSI, Medicare, and Medicaid. Licensed Care Home Admission and Discharge Policies, http://www.agingavenues.com/topics/assisted-living-facilities-in-indianapolis-indiana, https://aspe.hhs.gov/basic-report/compendium-residential-care-and-assisted-living-regulations-and-policy-2015-edition, http://www.medicaid.gov/medicaid-chip-program-information/by-topics/long-term-services-and-supports/home-and-community-based-services/downloads/requirements-for-home-and-community-settings.pdf, http://www.gachiefs.com/pdfs/White%20Papers_Committee%20Reports/AtRiskAdultAbuseWhitePaper.pdf, https://aspe.hhs.gov/report/medicaid-residential-care, http://www.ncjrs.gov/pdffiles1/nij/grants/229299.pdf, http://www.dhs.state.pa.us/cs/groups/webcontent/documents/report/p_011015.pdf, http://www.bizjournals.com/prnewswire/press_releases/2012/04/17/DC88926, http://www.phlp.org/wp-content/uploads/2011/03/PCH_manual-for-advocates-Feb-20071.pdf, https://www.socialsecurity.gov/ssi/text-benefits-ussi.htm, http://www.nbcwashington.com/news/local/Caretaker-Accused-of-Abusing-and-Neglecting-Kamara-Zanaib-268343912.html, http://www.dads.state.tx.us/providers/alf/howto.html, http://www.state.gov/documents/organization/245365.pdf, APPENDIX B. These calls spur investigations that sometimes result in the identification of unlicensed care homes. In one state, the AG only received nine cases in the entire year; in another state they handled only 2-3 cases a year. At least one administrator, on-site manager, or responsible person must be on duty 24 hours per day, seven days a week, and all staff must be trained as personal care workers within 60 days of hire. Both states use a penalty system to fine operators for illegal operations. 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. Per state regulations, this is not considered a permanent structure, and therefore does not meet the appropriate building requirements to be a licensed facility. In other cases, the unlicensed facility simply ignores the law and operates below official "radar.". 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). Similarly, by nature of their jobs, many of our interview participants, including APS staff, ombudsmen, police, and fire department personnel, typically hear about care homes when there are complaints or emergencies. A 2010 annual report from the Department noted that the number of illegal residential care homes had increased from four homes in 2009 to 27 in 2010, most of them located in the Philadelphia area (Pennsylvania Department of Public Welfare, 2011). The LME-MCO oversees contract services in a four county area. The majority of examples of mistreatment included resident physical and emotional abuse, neglect, or financial exploitation. 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. In essence, unlicensed care home operators have several opportunities for gaining almost absolute control over these residents who are physically, cognitively, and financially vulnerable. 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. If you live on the coast, youll pay a premium; the cost of care as you head inland is usually 25-35 percent lower than in coastal communities. Residents lack personal hygiene and are not properly groomed. State Law, Jurisdiction, and Penalties for Illegally Unlicensed Care Homes. to be able to live in unlicensed, supportive housing environments. Having buildings that were infested with bedbugs, other insects, and rodents. Unscrupulous care providers are unlikely to obtain the proper licensing and hire qualified staff due to the cost. Performance cookies are used to understand and analyze the key performance indexes of the website which helps in delivering a better user experience for the visitors. Given these diverse concerns, SMEs and site visits interviewees suggested that coordinated efforts across a range of stakeholders, including state licensure agencies, ombudsmen, APS, law enforcement, and others may be necessary to address unlicensed care homes. This key informant also emphasized that unlicensed care home operators tend to work with a network of collaborators who support moving residents between homes to avoid detection by legal authorities, and also help with re-recruiting residents and reopening a care home after an unlicensed care home is closed down. Interviews with key informants also indicate that many residents are poor and receive Supplemental Security Income (SSI) benefits from the U.S. Social Security Administration (SSA); the SSI program pays benefits to disabled adults and children who have limited income and resources. In the recent past, the state has had public education campaigns to inform the public about illegally unlicensed personal care homes. The information collected as part of this exploratory study was intended to provide a foundation for a more complete understanding about unlicensed care homes and the gaps these homes might fill as housing options for persons with low incomes. Miami Herald. PDF Consumer's Guide to Licensed Board and Care Homes - NAMI Santa Clara The NDRN P&A reportedly has suggested that SSA require representative payees to self-identify if they own a residential care home (licensed or unlicensed). In contrast, in Pennsylvania, the BHSL has the authority to execute a warrant to investigate a suspected illegally unlicensed care home. Therefore, the purpose of this project was to conduct exploratory research on unlicensed care homes to understand more about their prevalence, factors contributing to their prevalence, their characteristics (including their overall quality and safety), and the types of residents they serve. Allegheny County was specifically chosen as the site visit community because of their currently active PCRR team, which continues to address illegally unlicensed personal care homes. Unlicensed Room & Boards: These facilities are not licensed or certified by any state or local agencies. One strategy recommended by key informants to address unlicensed care homes is to change the regulations to reduce the number of unlicensed care homes that operate legally. The North Carolina Mental Health Licensure Office licenses group homes for adults with mental illness.5 These homes also serve two or more adults. Information from interviews with key informants also revealed incidents of emotional and physical abuse, including intimidation, and threats. 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. Based on our exploratory research, we found that a number of factors may have an effect on the demand for unlicensed care homes. This key informant was concerned this had contributed to group homes closing, which may have resulted in a gap that unlicensed facilities are filling. Locking refrigerators or pantries to limit resident access to food between meals, with some residents being malnourished and dehydrated and one resident breaking into a neighbor's home for food. . What concerns are there about the quality of care and safety in unlicensed care homes? (2013). licensed board and care beds in California. Multiple key informants also described another illegally unlicensed personal care home with several tenants, including a 91 year old man who had been tied to a chair with a sheet so he would not fall when the owner had to leave the home. Except for special circumstances, complaints must be filed in writing. One of the points made by key informants is that states have very few, if any, strategies to easily identify unlicensed care homes. These complaints may be made to the police, APS, ombudsmen, and the Department of Community Health, HFR Division. Findings from our limited number of interviews with site visit key informants and SMEs are consistent with the information found during the environmental scan. Additionally, what we heard about the policies that affect demand for and supply of unlicensed homes, and how unlicensed homes can be identified or detected, may not be representative of the situation in other states. Boarding homes are allowed to provide the following services beyond room and board: light housecleaning, transportation, money management, and assistance with self-administration of medication, but no personal care service. Social Security Administration. 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. KCMH currently links clients with approximately 30 homes ranging from 1-21 beds, usually 2 persons/room. In addition, many unlicensed care homes operate as family businesses in single family dwellings allowing shifting of residents to avoid detection by regulators (Tobia, 2014). Several key informants discussed the role hospitals and hospital discharge planners potentially play in referring patients to unlicensed care homes. We then examined if those percentages might be related to the number of unlicensed care facilities in those states. 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. Detecting, investigating and addressing elder abuse in residential long-term care facilities. Key informant interviews focused on local context, state and local policies that may impact or affect the demand for unlicensed care homes, and informants' direct experiences with unlicensed care homes. According to one key informant in the state, moving individuals from institutions for mental illness with an inadequate plan for housing these individuals has contributed to an increase in the numbers of people available for unlicensed personal care homes to serve, thus motivating the opening of unlicensed care homes. Strategies to Identify Unlicensed Care Homes. As such, limited information is available about the quality of care and services provided in legally unlicensed care homes. 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. 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. Of the approximately 1,400 complaints received by APS each year, an estimated 20% pertain to unlicensed personal care homes. Texas Legislative Budget Board. One former fire department battalion chief reported that the elderly living in unlicensed residential care homes are hidden from the view of public health agencies, social service agencies, and ombudsman programs --the entities that generally protect and advocate for older people and individuals with disabilities. Other key informants stated that some operators do not want the state regulating or monitoring their business. 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.". We operate unlicensed room and board homes, some owner-occupied and all managed 24/7. One key informant provided additional information, stating that hospitals in Allegheny County use placement agencies to help find residential settings for discharges, and that illegally unlicensed personal care homes are used as an option. Further, receipt of a complaint was the most commonly cited method to spur identification of an unlicensed care home. We hypothesized that states that do not have well-funded HCBS programs may have a higher incidence of illegally unlicensed homes than states with more robust HCBS programs. The California Room & Board Advisory Coalition is committed to enriching the quality of life of those in the communities we serve while maintaining the highest level of advocacy for providers and consumers. 3.5.2. One SME explained that the operators sell the food stamps for cash. Based on our findings, the residents of these homes are extremely vulnerable. Advocates reported a growing number of unlicensed facilities and difficulties distinguishing them from boarding homes or other types of RCFs. Hawes, C. & Kimbell, A.M. (2010). document.getElementById( "ak_js_1" ).setAttribute( "value", ( new Date() ).getTime() ); 2021 California Room and Board Coalition, All Rights Reserved. In 2012, the Secretary of the Department of Public Welfare noted 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" (Pennsylvania Department of Public Welfare, 2012). Site visit locations were based on the information gathered in the environmental scan, SME interviews, and a review of residential care regulations. The cookie is set by GDPR cookie consent to record the user consent for the cookies in the category "Functional". No other coordinated agency efforts beyond the state licensure office, APS, and the LME-MCO were described by key informants. If you know of unlicensed activity and just want to report it, then you are in the proper section. Financial abuse was the most commonly cited form of exploitation and the fastest growing form of abuse in illegally unlicensed personal care homes. 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. However, several SMEs and key informants noted that some unlicensed care homes are good and provide a clean, safe environment for individuals who might otherwise be homeless. Monograph for the National Institute of Justice, U.S. Department of Justice. While North Carolina's licensure offices do not have this same authority, key informants in North Carolina did note that most unlicensed care home operators allow them entry even without legal authority. Personal board and care homes: A hidden population in Anne Arundel County. 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.). State licensure offices primarily depend on complaints via phone calls3 that come first to a local county APS or regional licensure or monitoring office. In some cases they avoid licensure by holding themselves out as not providing services or housing residents that would require a license under state law. Concerns about abuse and neglect were a major topic of discussion during interviews, and they extended across illegally and legally unlicensed homes. However, SSI payments are low, and most states supplement these payments with a State Supplementary Payment (SSP). One interviewee estimated that at its peak, this hospital served 3,700 patients. 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.
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