3.4.3. Carder, P., O'Keeffe, J., & O'Keeffe, C. (2015). 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. File the complaint form by mail, fax, or e-mail. Legally Unlicensed and Licensed Care Home Operators. As described by the majority of key informants, the primary motivation to maintain an unlicensed care home is to maximize profit. This shifting of residents from one unlicensed home to another to avoid detection and oversight was also described by the media in Texas and Georgia. The team conducted interviews with key informants in each of these communities. However, a representative from a state advocacy agency estimated that about 2%-3% of their 4,800 calls annually, or approximately 120 calls statewide per year, were related to unlicensed facilities. Florida: A media report stated that in 2012 the licensure agency received more than 200 complaints about unlicensed activity and confirmed 62 were unlicensed--a 60% increase since 2010. Future research could be conducted to describe the nature of ombudsman involvement in unlicensed care homes and how it differs across states. Legally Unlicensed Residential Care Homes, 6.2. 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. Pennsylvania Department of Public Welfare. While many key informants stated that illegally unlicensed personal care homes primarily serve adults with a wide spectrum of mental health disorders, they also noted that some of the residents in unlicensed care homes are frail and elderly individuals. 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. 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. This lack of knowledge contributes to the need for the government and policy makers to have a better understanding of unlicensed care homes. 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). The operator of the facility had recently received and accepted an offer to sell the house, and so was closing down the facility. Key informants for each site visit location included representatives of local public safety organizations such as law enforcement or firefighters, Adult Protective Services (APS) staff, and ombudsmen. Strategies for Addressing Unlicensed Care Homes. In addition, investigations by Georgia law enforcement officials indicated that there is considerable fraud with respect to SSI, Social Security, residents' personal needs allowances, Medicare and Medicaid, and the food stamp program. Preventing residents from using the bathrooms after a certain time at night and providing buckets for residents to use rather than toilets. APS professionals there estimate three reports or complaints about unlicensed personal care homes every month in the metro Atlanta area, and about one complaint or report about unlicensed personal care homes every three months in rural areas of the state. 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. Key informants indicated financial exploitation in unlicensed care homes is an area for future research. Retrieved from http://www.miamiherald.com. Many key informants noted that regulatory loopholes provided potential ways that operators of illegally unlicensed personal care homes can persist and evade licensure. They can also be found in document form on the LARA website. 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). Further details on findings from the environmental scan can be found in Appendix B. During each site visit we interviewed state licensure agency staff to obtain a broad perspective on the regulations surrounding residential care in each of the states. However, we did not hear any specific examples of this from the state or local level. What are the interviewees' thoughts on the best strategies to identify unlicensed care homes? Facilities providing or arranging for housing, food service, and one or more personal services for two or more unrelated adults must be licensed by the state as a personal care home. All key informants described how the Local Management Entity-Managed Care Organization (LME-MCO) oversees the provision of mental health services in Durham County. Pennsylvania and North Carolina have some similarities in how they address unlicensed care homes. (2007).Personal care homes in Pennsylvania: A guide for advocates. Based on the collective feedback of a diverse group of key informants, unlicensed personal care homes appear to be prevalent and problematic in the state. They deny services such as assistance with medication are being provided to residents, or assert they are only providing housing for alcoholics, ex-convicts or people with mental health issues to avoid having to become licensed. Thus, although our findings consistently highlighted concerns about safety and quality, we cannot assess the generalizability of these findings and concerns. 1 0 obj Perils in personal care homes. Neglected to death, part 1: Once pride of Florida; now scenes of neglect. This is evidenced by the number of reports and complaints received about unlicensed personal care homes, the number of hours spent by law enforcement officials on investigating unlicensed personal care homes, and the estimates given of the numbers of unlicensed care homes that are operating in the state (reported by one informant as one unlicensed care home for every licensed home). Office of the Assistant Secretary for Planning and Evaluation, Printer Friendly Version in PDF Format (81 PDF pages). This key informant also noted that the residents frequently transition in and out of the home, as is often the case with illegally unlicensed personal care homes. These complaints may be made to the police, APS, ombudsmen, and the Department of Community Health, HFR Division. Findings from this study are necessarily limited by the number of experts we identified and states we visited. As such, key informants speculated that these types of organizations may maintain lists of residential care homes. In preparation for closing, the operator "turned over the residents to other operators for a fee of $100 per resident.". One of the points made by key informants is that states have very few, if any, strategies to easily identify unlicensed care homes. Further, it is the responsibility of the owner to determine whether the home needs a license. 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. 20 or fewer individuals 55 years of age or older that is operated in conjunction with and as a distinct part of a licensed nursing home. azmfairall. Media and state reports have highlighted homes operating deliberately illegally--that is, they are avoiding required licensure or certification (Tobia, 2014; Georgia Association of Chiefs of Police Ad Hoc Committee on At-Risk Adult Abuse, Neglect & Exploitation, 2013). (n.d.).Retrieved from http://www.agingavenues.com/topics/assisted-living-facilities-in-indianapolis-indiana. https://dev.michigan.local/som/json?sc_device=json. However, our key informants (including representatives of adult protective services, ombudsmen programs, and police and fire departments) were informed about unlicensed care homes only in response to complaints or emergencies, which may have biased their views of these homes. We conducted nine total interviews with ten key informants, including state licensure officials and staff from the North Carolina NAMI in Raleigh. In the view of the majority of key informants, the operators of unlicensed homes do not want to have to pay for more staff to provide needed services. 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. Atlanta Journal-Constitution. 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. However, some SMEs and key informants also noted that many of these individuals with psychiatric conditions are older, having aged in state institutions, and that persons 65 years of age and older who receive SSI payments also often live in unlicensed care homes. Adult Foster Care These findings highlight a set of potentially serious problems and issues. Targeted searches of media reports in states with the lowest percentages of their LTSS expenditures on HCBS (New Jersey, Mississippi, Indiana, Florida, and Michigan) did not yield more reports on unlicensed care facilities than those with the highest spending rates for HCBS (Arizona, Vermont, Alaska, Minnesota, and Oregon). Residents of unlicensed care homes are vulnerable adults. (2013). 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. Many key informants regarded the closing of Mayview State Psychiatric Hospital in 2008, which was located in Allegheny County, as an important factor contributing to the gap of services and affordable housing available for individuals with mental health diagnoses. Retrieved from http://www.phlp.org/wp-content/uploads/2011/03/PCH_manual-for-advocates-Feb-20071.pdf. Overall, the local agency representatives described the condition of unlicensed care homes as unsafe. 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. Operators forcing the resident to name the operator as the representative payee for government payments, such as SSI, and controlling the use of that money. 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. While some unlicensed homes reportedly serve elderly and physically disabled residents, key informants noted that many also serve persons who were formerly homeless, persons who may have substance use disorders, persons with severe and persistent mental illness, and parolees. Retrieved from http://www.dhs.state.pa.us/cs/groups/webcontent/documents/report/p_011015.pdf. Conditions (including quality and safety) of unlicensed care homes. 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. 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. Operators seizing the residents' food stamps and selling them for cash. Targeted search terms incorporated specific licensure category names for each specific state. 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. The information focused on specific cases, but not on how many of these places exist in these states. Strategies for Identifying Unlicensed Care Homes, 5.4. restriction of group homes, both their siting and operation. We also heard from nearly all state-level informants that some operators routinely shifted residents from one address to another if an APS worker, other advocate, or potential regulator showed up at the facility asking questions. 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. Another interviewee suggested that it is becoming more difficult to recruit individuals to be Dom Care operators because of the competing demands on their time. The nature of health and safety concerns described by key informants were wide-ranging and often included neglect and the risk of death to residents. Dom Care homes, which also provide care to three or fewer individuals, are governed and regulated by the state with the authority to certify, supervise and monitor delegated to the local AAA. Populations in Unlicensed Care Homes. Licensed care home operators were also identified as potential sources for identifying unlicensed care homes. The regional and state licensure offices are closely involved in this process. Retrieved from http://www.dallasmorningnews.com. All states license residential care such as assisted living, and most states license small adult care homes, often referred to as adult foster care (Carder, O'Keeffe, & O'Keeffe, 2015). Unlicensed care homes provide room, board and some level of services for two or more unrelated individuals, but are not licensed or certified by the state. Assisted living provider resources: Unlicensed facilities. Many interviewees mentioned monetary motivations of operators as one factor. Our examination of the Medicaid Fraud Control Unit reports (2009-2013) showed that only a couple cases were reported to the media; the rest had not made the news. Indeed, several key informants in Allegheny County reported that the closure of Mayview Psychiatric Hospital led to an increase in the prevalence of illegally unlicensed care homes in the county. Personal board and care homes: A hidden population in Anne Arundel County. . A facility that advertises or represents via verbal communication that it provides personal assistance is required to make personal services available to its residents. The main goal of these efforts is to shut down facilities where residents are financially exploited, abused, neglected, or subject to unsanitary and unsafe conditions. 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. Provision of housing plus one or more personal services requires a personal care home (or other licensed facility) permit. Court appointed guardians using unregulated 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. MACOMB. This protection results from the application to group homes of basic and longstanding principles of FHA adjudi-cation. In more extreme cases, other personal care homes have stopped accepting any persons whose sole source of income is SSI. Locking residents in rooms or chaining the doors at night to prevent residents from leaving the facility, which imprisoned residents and placed them at risk in case of fire. These are important issues since they affect many vulnerable adults who have physical, intellectual, or cognitive disabilities. Carter applied for a license 11 months ago, but refused to answer our questions about why she was operating the home before being approved by the state. The state has also been in the news based on actions resulting from state compliance with the Olmstead decision which has moved adults with mental illness from institutional settings into less segregated settings in the community. While no comprehensive nationwide list of unlicensed care homes exists, the environmental scan identified one state (Florida) and one city (Houston, Texas) that maintain listings of unlicensed care homes. (2015). 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. Several key informants discussed the role hospitals and hospital discharge planners potentially play in referring patients to unlicensed care homes. stream Multiple SMEs stated that licensure offices and agencies like APS are not equipped to track unlicensed care homes. The payments also vary considerably from state to state, and are quite modest in some states (e.g., from $46 to $100 per month). Interagency and Multidisciplinary Teams. 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. Informants expressed other specific concerns about unlicensed care homes, including improper management of residents' medications; unsafe, unsanitary, and uncomfortable living environments; theft of utilities from neighbors; and fraudulent collection of government payments (e.g., not reporting residents' deaths and continuing to collect their SSI payments). 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. Perkins, M., Ball, M., Whittington, F., & Combs, B. Anecdotal examples of residents wandering outside of their home and onto neighbor's property, which typically generates a complaint call from the neighboring homeowner, were also provided. 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. Some of these homes also serve mixed populations (e.g., elderly residents as well as individuals with severe and persistent mental illness). 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. State regulations appear to vary widely in regards to ombudsman jurisdiction. 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. Study staff screened each of the collected articles, blogs, and reports to identify relevant material for review. 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. The LME-MCO oversees contract services in a four county area. These calls spur investigations that sometimes result in the identification of unlicensed care homes. Key agencies and team members involved in local or state teams to address unlicensed care homes include APS, ombudsmen, building code enforcement, social workers and first responders such as EMS, police, or firefighters, and other representatives from local advocacy groups such as Disability Rights. In 2013, the minimum number of ADLs needs required for individuals to qualify for reimbursement for personal care services in group homes increased. Although a substantial amount of information and suggestions about methods of identifying unlicensed care homes came from site visits to communities in three states (Pennsylvania, North Carolina, and Georgia), whether any of these strategies will apply to other states or other communities is unclear. 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. Greene, A.M., Wiener, J.M., Khatutsky, G., Johnson, R., & O'Keeffe, J. Two key informants thought that the ongoing statewide mental health reform, which began in 2002, has exacerbated issues related to the general lack of infrastructure and knowledge about needs of persons with mental illness. Estimates of the prevalence of unlicensed residential care homes are lacking for most states. Failed Legislative Efforts to Improve Oversight. Some SMEs suggested that state policies affect the mix of residents in 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. 3.5.3. Complaint calls are received by each participating agency, therefore the team meets monthly to share complaints about potentially illegal unlicensed care homes. Thus, unlicensed care homes close and leave one area of the city, but reopen in another area, contributing to the difficulty of identifying and permanently shutting down these places, while also disrupting the residents' access to day services and other community-based sources of support nearby the original care home location. However, this likely is not a viable method for detecting the population of illegally unlicensed residential care homes. They took her dignity from her, they took everything from her, said Peter Klavinger. For example, one SME from a state licensure office reported that their database does not include information on whether the call pertains to a licensed or unlicensed care home. Thirty states require residential care homes to be licensed if they have at least one bed.7 Massachusetts exempts small private-pay homes from licensure. 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. Some have residents that receive Medicaid funded services. That's what they're doing, targeting individuals with cognitive impairment.". 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. (586) 819-7573. Licensure staff admitted they only learn about the unlicensed facilities when someone reports them. One way to collect this information to develop a frame of unlicensed care homes and conduct a small scale study of unlicensed care home operators. While the information herein is not generalizable--it is based on a targeted scan and a limited number of interviews--it does highlight the fact that unlicensed care homes appear to be a problem in at least some states. Monitoring and Improving Quality in Legally Unlicensed Care Homes. This implies that the LME-MCO does not always check licensure status before coordinating services in unlicensed group homes. "Children's therapeutic group home" means a child caring institution receiving not more than 6 minor children who are diagnosed . Fourth, study findings also suggest that efforts are needed to understand the differences in conditions between legally and illegally unlicensed care homes, as well as how illegally unlicensed care homes successfully evade licensure. Although recognized as important, the state has not yet begun investigating cases of financial exploitation. 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. In Pennsylvania informants described a public education campaign including advertisements warning people about placing their loved ones in unlicensed care homes. Media reports described operators that continued to operate after their licenses expired or were revoked. Michigan Office of Administrative Hearings and Rules. The vast majority of key informant reports emphasize often alarming conditions in unlicensed care homes. 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. Potential SMEs were included in the initial listing based on their familiarity with residential care regulations, experience in and research about residential care, experience working with the potential target populations of unlicensed care homes, and knowledge of Medicare and Medicaid payment policies and home and community-based services (HCBS) waiver programs. Although little is known about unlicensed care homes, a variety of signals, including media reports, highlight potential safety and quality concerns. The remainder of this section summarizes findings from interviews with SMEs and site visit key informants, and also includes additional information from the environmental scan. 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. Cases of physical abuse, such as residents being beaten and burned as described in the environmental scan, were also reported during interviews. x][o~ ^/o{)u4M!"KH336jTp87O[Gdz>;OW~|mZ~Nf/OeT61J4IX>b]}X According to one key informant, this illegally unlicensed care home had recently housed a mix of residents and family members, including four related family members (two children and two adults), two persons under the care of a local hospice, and one individual who was receiving methadone treatment. Further, key informants reported that many operators require residents to surrender all forms of identification "for safe keeping" by the operator. Many key informants and SMEs discussed how homeless shelters, advocacy organizations, and churches or other faith-based organizations often serve as a resource to link vulnerable individuals who cannot afford the expense of a licensed care home to unlicensed care homes instead. The Allegheny County PCRR has sent letters to hospitals and their discharge planners informing them about known illegally unlicensed personal care homes to which they should not discharge patients; however, according to two key informants, discharges to these homes have continued. As such, they could be a key source for learning about currently unlicensed care homes. (2012c). 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. While it is outside the scope of this project to investigate alternatives to unlicensed care homes, we speculate that increasing the supply of alternatives for affordable housing with services would reduce the market for unlicensed homes. One key informant shared that, as part of such a campaign in 2012, advertisements were placed in metropolitan areas warning the public against placing people in illegally unlicensed personal care homes. Further, implementation of the Olmstead decision has increased the demand for residential long-term care settings and services. State licensure offices primarily depend on complaints via phone calls3 that come first to a local county APS or regional licensure or monitoring office. Many SMEs reported that persons with severe and persistent mental illness are the majority of residents in unlicensed residential care homes. Concerns expressed across several interviews included providers locking residents in rooms; locking food away so that it is inaccessible to residents; using basements to house individuals, including individuals who are unable to climb the stairs and those on hospice; providing accommodations that are unclean, infested with bedbugs, and lack heat, air conditioning or running water. Based on the findings from this exploratory study, illegally unlicensed care homes appear to be a problem for at least some states; the residents of these homes are extremely vulnerable, and while some are elderly and physically disabled, many have severe and persistent mental illness. State and Local Policies Related to the Supply of and Demand for Unlicensed Care Homes. , a variety of signals, including state licensure officials and staff from the North NAMI! 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