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. Areas for future research and potential data sources related to unlicensed care homes. Oversight was spread across several agencies and depicted as convoluted and overstretched. Tobia, M. (2014). However, even if the home continues to operate, the fines are rarely enforced or collected. One of our study states made it a crime to operate an illegally unlicensed residential care home, and some states have the capacity to penalize unlicensed care homes with monetary fines. This research might also address whether the Keys Amendment is achieving its goal of protecting the well-being of SSI recipients. So you have a document that you want to show me indicating that its unlicensed, asked Glover-Hogan. Three-bed residential care homes are lawfully allowed in at least one state. A 2010 report from the Pennsylvania BHSL noted that enforcement actions against illegal personal care homes had increased from four homes in 2009 to 27 in 2010 (most were located in the Philadelphia area). Others described instances where the unlicensed care homes can be located in either low-income neighborhoods or higher-income neighborhoods, and that they blend in with other houses, which makes them difficult to identify or locate unless reported by the community. Zoning Approval for Group Child Care Homes only (BCAL-3748). The licensing rules for Adult Foster Care and Home for the Aged facilities provide minimum standards for these regulated facilities. Below we present a sample of the varying state definitions of lawfully unlicensed and illegally unlicensed residential 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. 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. 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). In these cases, the hospital reportedly pays the placement agencies a fee to find a personal care home, and the placement agencies also receive monetary incentives from the personal care homes for referrals. We targeted site visits in communities that varied according to whether the state: (1) has legally unlicensed care homes; (2) has a list of unlicensed care homes; and (3) ranks among the highest or lowest in HCBS waiver expenditures. (2013). By interviewing residents of unlicensed care homes, HFR is trying to understand the pathways that individuals take to end up in these situations. Most of the literature we found referenced problems in and the prevalence of unlicensed residential care homes prior to 2009, or addressed abuse and exploitation of adults living in licensed facilities. Interview findings indicate that many residents of unlicensed care home are Supplemental Security Income (SSI) beneficiaries. 1 0 obj The new regulations were implemented to monitor and provide oversight of personal care homes with four or more residents, while reducing the number of homes that legally did not require licensure. In one state, Pennsylvania, three bed residential care homes are legally unlicensed. This results in different payment streams and different regulatory agencies that have responsibility for different residents in the same residence. U.S. Department of Health and Human Services In these cases, licensed operators were reportedly worried that the unlicensed operators would house residents from whom the licensed homes operators could have profited. Miami Herald. But after a family friend told the Oakland County Probate Court that Plummer was having memory loss, court records show a Judge appointed a Southfield attorney as a co-guardian. Consequently, although we attempted to elicit information about the positive aspects of unlicensed care homes, key informants largely provided us with a less favorable view of unlicensed care homes. In Iowa, boarding homes serving three or more individuals who require supervision or need assistance with ADLs are registered but not licensed. Six states (Colorado, Iowa, Illinois, Maine, Missouri, and Vermont) license starting at three beds, noting that Vermont, like Massachusetts, exempts small private-pay homes. State informants did not provide information on the services provided in the unlicensed care homes stating that that the sample of unlicensed care homes they see is too small to make an accurate approximation of the conditions. You may need to be personally licensed as a Certified Administrator of Group Homes, for instance. First Responders: EMS, Firefighters, and Police. The key informant likened these networked operations to organized crime: "The other thing we are seeing too is that people [operators] are well networked, and within a day or two people are identified and going back, herding them up againthey are well networked so we look at them as organized crime organizations.". Pennsylvania Health Law Project and North Penn Legal Services. % The goal of this study was to provide foundational information intended to answer or provide insight into the study research questions. We conducted most key informant interviews in Durham, with some additional interviews across the region, including Raleigh. To address the issues surrounding quality and safety in unlicensed care homes, key informants described a process involving the investigation of complaints by visiting the home and interviewing residents and staff (which may necessitate getting an inspection warrant if denied entry upon arrival), then providing a written cease and desist letter if the investigation results indicate that the home should be licensed, issuing fines of $100 per day per resident, and prosecuting the operator. Currently, 46 states provide some type of SSP (SSA, 2015). Assistant Secretary for Planning and Evaluation, Room 415F Unlicensed care home operators also were described as sometimes having select residents act in a role of authority over other residents, such as beating the other residents to control their behaviors. Notably, the strategy of responding to complaints limits the amount of information available about unlicensed care homes about which complaints are not made (i.e., possibly better quality homes). Retrieved from http://www.ncjrs.gov/pdffiles1/nij/grants/229299.pdf. As a result, Pennsylvania enacted a strategy to address the illegally unlicensed care homes, which included providing the Pennsylvania Bureau of Human Services and Licensure (BHSL) the ability to serve warrants and creating the PCRR team mentioned earlier and discussed in the next section. The scan included published peer-reviewed and grey literature, including abuse blogs and media reports about legally and illegally unlicensed residential care homes. The research team completed seven interviews with eight participants that included both state and local community stakeholders. 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. One was a fairly large ranch style house that accommodates 15-23 individuals at any one time. 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. The state investigates the types of services that are provided to residents on site in order to determine if a license is required. In addition, one key informant indicated that operators of unlicensed care homes have illegally obtained electrical service utilities through covert connections with neighboring homes. In response to media stories and a congressional request about abuse and neglect of developmentally disabled residents in group homes, OIG launched a series of audits that found that these residents often experienced serious injuries and medical conditions that resulted in emergency room visits. x][o~ ^/o{)u4M!"KH336jTp87O[Gdz>;OW~|mZ~Nf/OeT61J4IX>b]}X Those are just a few of the guardianship problems 7 Investigator Heather Catallo has . 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. One informant suggested research that examines the homeless population and the availability of affordable housing as a way to better understand the environment that may be conducive to supporting unlicensed care home operations. Another specific example included a resident moving from a home where the operator was their representative payee and the operator continued to collect their SSI check. Almost all SMEs and key informants recommended more proactive strategies to identify unlicensed care homes. Information from interviews with key informants also revealed incidents of emotional and physical abuse, including intimidation, and threats. Strategies for identifying and addressing quality in legally and illegally unlicensed care homes appear to differ across states. In some states, facilities that provided room, board, and "control and security of medication" could be legally unlicensed. In contrast, most key informants agreed that some operators start out with a smaller one to three bed legally unlicensed home and gradually end up caring for more residents, not realizing that doing so requires the home to be licensed. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely. According to reports and state-level investigators, many of the residents in unlicensed homes are living on SSI or Social Security Disability Income. One SME explained that the operators sell the food stamps for cash. In addition to serving the elderly, personal care homes can exclusively serve persons with serious mental illness and/or intellectual and developmental disabilities, on condition that the home is appropriately staffed and is capable of providing the needed care within the scope of its license. SMEs and key informants discussed a number of factors that may have an effect on the supply of and demand for unlicensed care homes. Before 2005, Pennsylvania allowed residential care homes with 1-8 individuals to be legally unlicensed. Another key informant suggested that it would be key to involve the LME-MCO because they cover a four county area and must receive calls that are about unlicensed care homes. nmpV[0VM.T1B2L3qHY' w|Z?paTjSy`6GEk1BL67d.VX7dNO!7hj. 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. Office of the Assistant Secretary for Planning and Evaluation, Printer Friendly Version in PDF Format (81 PDF pages). As one informant in Georgia reported, "the hospital will say 'this is an expensive bed, you need to get [the patient] out.' They noted that some unlicensed care homes provide good care; however, SMEs and other informants consistently reported substantial concerns about neglect, unmet health needs, unsafe and unsanitary conditions, abuse, financial exploitation, false imprisonment, and moving residents to different care homes across communities and states to evade detection. It was outside the scope of this project to examine the alternatives to unlicensed care homes or the health, safety or appropriateness of those environments. Georgia: In one expose, the Atlanta Journal-Constitution analyzed thousands of inspection reports and interviewed state and local official, social service providers, and advocates, and then published an article on the status of affairs in unlicensed personal care homes. Some of these homes are legally unlicensed while others operate illegally. 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. According to the regulations, some states also allow residential care homes to be legally unlicensed if they have 1-2 beds. Also, new HHS Centers for Medicare and Medicaid Services (CMS) policies on waivers and where waiver services may be provided may alter the prevalence of legally and illegally unlicensed care homes across the nation. For many of these individuals, their only option may be unlicensed facilities. They noted that the following may have heightened the demand for unlicensed care homes: The admission and discharge policies of licensed care homes. In Connecticut, the Department of Developmental Services (formerly the Department of Mental Retardation) handles licensing for group homes for the mentally disabled. The team conducted interviews with key informants in each of these communities. Most state licensure offices, county offices, or advocacy agencies use a complaint system to identify unlicensed care homes. Carder, P., O'Keeffe, J., & O'Keeffe, C. (2015). 2. 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. One key informant estimated there are approximately 526 Dom Care operations in the state. 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. Specific concerns included: Managing resident medications improperly. Based on the information gathered, we determined key criteria for site visit location selection, including having good leads/contacts for identifying key informants in the state, and having geographic variation across states. Interviewees had varying opinions on the causes for Dom Care homes closing. As a result of the newspaper expos, Georgia enacted new stronger laws. Further, key informants reported that many operators require residents to surrender all forms of identification "for safe keeping" by the operator. Submitted to the Governor and the Texas Legislature and the Texas Health and Human Services Commission. The following section presents individual research topics and identifies the related questions that might guide future research on unlicensed residential care homes. 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. A core pattern of exploitation described in interviews included the operator of unlicensed homes finding vulnerable individuals who need housing and supportive services (such as from hospitals or homeless shelters), requiring these individuals to transfer their SSI payments to the operator or one of the operator's agents in order to become a resident of the unlicensed care home, severely limiting the residents' ability to leave the facility, and relocating the residents to alternate locations to avoid detection. Ultimately, several key informants acknowledged and emphasized that remaining unlicensed is lucrative if the care home operator successfully avoids detection by the authorities. The state's annual Personal Care Homes Report provides the number of illegally unlicensed personal care homes that result in enforcement actions and details the historical trend of the number of enforcement actions taken against illegal unlicensed personal care homes. One SME, who works on the Representative Payee Project,4 mentioned that this project only investigates a sample of individuals who are representative payees for 15 or more individuals. 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. In regard to the prevalence of unlicensed care homes, state-level estimates were only reported for Georgia, Maryland, and Florida. And regardless of whether states have regulations concerning unlicensed homes, many operators choose to operate illegally unlicensed homes. Tracking Public Benefits and Representative Payees. We found a number of publications and media reports in both Florida and Texas (e.g., the Miami Herald newspaper series in Florida, and the U.S. Department of Justice report in Texas), and a few media reports and a research report on unlicensed care homes in Maryland; however, these states were not selected as site visit states. Licensure offices and other agencies or organizations respond to complaints made by concerned citizens, including family members and friends of residents, neighbors of unlicensed care home operators, health care providers serving unlicensed care home residents, firemen, ambulance services, police, and licensed care home operators. LARA is dedicated to bridging the gap between civilian and military employment and helping veterans gain and retain employment. Multiple key informants suggested that, as a result, these residents are primarily being served by illegally unlicensed personal care homes. To reduce abuse, several informants indicated that state officials should target closing unlicensed care homes. The majority of examples of mistreatment included resident physical and emotional abuse, neglect, or financial exploitation. Texas Department of Aging and Disability Services. Future research could be conducted to describe the nature of ombudsman involvement in unlicensed care homes and how it differs across states. Hancock, L. (2007). Further details on findings from the environmental scan can be found in Appendix B. Interviewees noted that unlicensed care home operators often take the residents' identification cards and personal paperwork upon admission. Multiple SMEs and key informants suggested following or tracking these benefits as a way to identify individuals in unlicensed care homes. 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. Adult children separated from their ailing parents. This had a direct impact on the operating budgets of licensed group homes. <>/ExtGState<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> 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. 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, as in some other states, APS in Pennsylvania can act on referrals of abuse for elderly residents (age 60+). From our review of the regulations, we identified that North Carolina likely has legally unlicensed care homes (e.g., boarding homes serving 4-5 residents who do not require 24 hour supervision), and we suspect that illegally unlicensed care homes also exist. 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. (2012c). 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. As part of our year-long investigation into Michigans probate courts, the 7 Investigators have uncovered an alarming practice: court appointed guardians putting the people theyre supposed to be caring for into unlicensed group homes. There are three ways to file a LARA report with the State of Michigan. Poor quality of care, instances of physical abuse, toxic combinations of medication, and use of stun guns, were also reported (National Association of Medicaid Fraud Control Units, 2015). Additionally, several SMEs and key informants noted that in many cases unlicensed homes are the only option, other than homeless shelters or living on the streets, for some of these residents. 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. 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. He noted that residents with disabilities in unlicensed homes were at risk during fires and natural disasters such as tornados, hurricanes, and severe storms. 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). Michigan Agency Michigan Department of Licensing and Regulatory Affairs, Bureau of Community Health Systems, Adult Foster Care and Homes for the Aged Licensing Division Contact Ashley Harris E-mail HarrisA29@michigan.gov Phone (866) 856-0126 or (517) 284-9700 (2004). What information exists reflects a concern about the conditions under which residents in these places live. 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. The web Browser you are currently using is unsupported, and some features of this site may not work as intended. 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. Figueroa, L. (2011). The web Browser you are currently using is unsupported, and some features of this site may not work as intended. Potential Data Sources or Listings of Unlicensed Care Homes, 5.3. 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. Multiple SMEs stated that licensure offices and agencies like APS are not equipped to track unlicensed care homes. A facility that advertises or represents via verbal communication that it provides personal assistance is required to make personal services available to its residents. As part of this study, we sought to identify potential data sources or listings of unlicensed care homes that may be useful in efforts to understand how widespread unlicensed care homes might be, and whether these settings can be identified for future research purposes, both in the states we visited and in other states. 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