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. This was described as limiting the capacity of the resident to relocate. In Georgia, they advertised themselves as licensed and admitted residents to the licensed facility and then shifted residents to their illegally unlicensed homes. Three-bed residential care homes are lawfully allowed in at least one state. Several states have taken steps in improve oversight of unlicensed facilities, often as a result of newspaper exposs on unlicensed residential care homes. 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). How to Become an ALF Provider | Texas Health and Human Services According to reports and state-level investigators, many of the residents in unlicensed homes are living on SSI or Social Security Disability Income. Licensing Requirements for Texas Personal Care Homes. - LinkedIn Given the types of key informants interviewed for this study, and the limited viewpoints captured, more information is needed to understand the characteristics of unlicensed care homes and the residents they serve. Because the personal care homes included in NMES were restricted to those that provided hands-on assistance with ADLs and . 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 quality and safety and the policies that influence the supply of and demand for these homes. 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. Atlanta Journal-Constitution. Schneider, C., & Simmons, A. Unlicensed care homes commonly will accept these individuals and many market themselves to discharge planners. Texas Health & Human Services Commission. 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. care facilities. According to SMEs and key informants, the following factors are likely drivers of the demand for unlicensed care homes in their communities or states: The policies that licensed care homes have against admitting residents who exhibit behavior problems and those who have substance use disorders, or to discharge residents who develop these problems. For a residence to receive a home dialysis designation, it must meet the licensing standards specified in 26 TAC 558.405. These preliminary findings are worth considering as policy makers implement federal, state, and local policies and practices that may relate to unlicensed care homes. 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. Interagency and Multidisciplinary Teams. Miami Herald. To become licensed, a location must: Complete the pre-survey, computer-based training and submit a copy of the certificate of completion (ALFs only). There were no reports of varying frequencies of unlicensed facilities between urban and rural areas. Key informants described instances of operators making money off of vulnerable residents in a variety of ways that involved theft from residents and theft from government programs. States with concerns about vulnerable adults' access to housing with services may wish to examine their admission and discharge requirements for licensed care homes. Our search of state AG reports of unlicensed RCFs identified only six cases of successful prosecutions in New York, Nevada, Florida, and California for operating a residential care home without a license--and in several cases, gross neglect in these homes. Multiple key informants spoke about a reduction in the number of Dom Care homes in the state and how this reduction may also give rise to illegally unlicensed personal care homes. However, we did not focus on these populations in the interview. As described by the majority of interviewees, the primary populations residing in illegally unlicensed personal care homes are vulnerable, with few financial resources. The following acronyms are mentioned in this report and/or appendices. 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. States with concerns about quality and safety in unlicensed care homes may also wish to examine their requirements for monitoring legally unlicensed care homes and the information available about safety and quality in these places. 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. Memory care, Parkinsons, ALS, Stroke, Alzheimers, Dementia and more. Unlicensed group home with 35 adults found in southeast Harris County Please make your own independent If the facility does not close, law enforcement (not the state licensure offices) fines the illegal operation $50 for the first offense and $500 for each additional offense. The modest payments made by SSI or State Supplemental Payments to residential care homes, which may be inadequate to cover expenses in licensed facilities. In addition, states differ in whether they provide additional funds to the ombudsman program, over and above the federal funds from the Older Americans Act. Isabel's Place Personal Care Home - Hospice - Visiting Physician available - 24 hrs monitoring and assistance - Coordination with visiting physicians, home health, hospice, physical therapy and podiatry - Incontinence care - Medication management - Holidays celebration - Personalized care plans - Home made meals Testimonials Vicki J Fiscal note, 81st legislative regular session. Some residents were also described as transitional or homeless, while others were described as persons with substance use disorders. Although they did not know about exiting listings, several informants suggested potential ways to develop a list of unlicensed care homes. In 2012, the state mandated that large adult care homes (seven or more beds) housing only individuals with mental illness had to close because they were considered institutional settings. Site visit summaries, which provide more state-specific information, and information on other states considered for site visits, are included in Appendix A. (2015). They can fine the operator directly which may lead to the unlicensed care home being forced to shut down. This report describes the methods used to conduct the study, summarizes the information learned from an environmental scan and the results from interviews with subject matter experts (SMEs) and site visits, discusses implications of the findings and, based on the study findings, offers recommendations for future research on unlicensed care 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. Understanding Supplemental Security Income SSI benefits, 2015 edition. 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. Additional potential research questions or issues were raised by one or more SMEs or arose from our state site visits or the environmental scan. One key informant explained how North Carolina regulations restrict ombudsman activity in unlicensed care homes, stating "our structure is pretty clear as far as the accountability," implying that the regulations make ombudsmen unaccountable for residents in unlicensed care homes. Residential Care | Texas Health and Human Services In addition to legally unlicensed residential care homes, there are a variety of places that operate illegally. From our review of states' regulatory information on licensed residential care categories during the development of the sampling frame for the 2014 National Study of Long-Term Care Providers, and our review of ASPE's Compendium of Residential Care and Assisted Living Regulations and Policy (2015), we found that 30 states require residential care homes to be licensed if they have at least one bed. activity programs. Several reports noted that local law enforcement, EMS, and fire departments had frequent interactions with unlicensed residential care homes. 3.4.5. Monthly fees run anywhere from $1,500 a month to $4,500 each NBC News 4, Washington D.C. Retrieved from http://www.nbcwashington.com/news/local/Caretaker-Accused-of-Abusing-and-Neglecting-Kamara-Zanaib-268343912.html. In Georgia, much of the current focus on unlicensed personal care home investigations involves cases of resident abuse and neglect. This key informant shared a list of seven placement agencies that work with hospitals in Allegheny County. The vast majority of key informant reports emphasize often alarming conditions in unlicensed care homes. 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. As described earlier, some of our key informants noted that hospital discharge planners knowingly discharge these individuals to unlicensed care homes to alleviate the immense pressure they are under to facilitate quick patient turnover, and some hospitals reportedly will pay unlicensed care homes to admit these individuals. Senior Care & Assisted Living Services South Carolina Assisted Living Facilities, Care Homes, Senior Housing $249,000. This research might also address whether the Keys Amendment is achieving its goal of protecting the well-being of SSI recipients. 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. Several key informants reported that unlicensed care home operators "troll" the psychiatric wards of facilities like Grady Memorial Hospital, looking for residents. However, key informants emphasized that in some cases,the residents become tethered to the operators through financial exploitation and emotional manipulation, and as a result are unable to leave these abusive and exploitative situations. Interviewees noted that unlicensed care home operators often take the residents' identification cards and personal paperwork upon admission. To accomplish this we conducted an environmental scan, including a review of the peer-reviewed and grey literature and interviews with SMEs. We chose the Raleigh/Durham area for the site visit because it is where the state licensing agency is located and because of recent media reports of unlicensed group homes. This key informant was concerned this had contributed to group homes closing, which may have resulted in a gap that unlicensed facilities are filling. 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. Clarifying this definition will be critical to understand the prevalence of unlicensed residential care homes, as well as the characteristics of residents in these homes. 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. Thus, although our findings consistently highlighted concerns about safety and quality, we cannot assess the generalizability of these findings and concerns. Although licensed homes were generally depicted by key informants as safer than unlicensed homes, one key informant emphasized that quality of care is not contingent on licensure status; licensed homes may also have health and safety concerns. Retrieved from http://www.namfcu.net/resources/medicaid-fraud-reports-newsletters. In Arizona, a bill to strengthen the elder abuse and fraud laws failed to pass again after being introduced in three previous sessions. Owners of current small licensed personal care homes are also potential sources of information; they will be able to fully describe the monetary costs associated with licensure, and these costs appear to be one reason why some people choose to operate illegally. For example, SMEs indicated that law enforcement investigators have discovered operators of unlicensed homes with scores of electronic cards for food stamp benefits that belonged to current and former residents. This may include the mobile non-ambulatory persons such 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. Ombudsmen. Finally, as noted in the report, many individuals seek care in unlicensed care homes because they are in other undesirable situations, such as experiencing chronic homelessness or unnecessarily institutionalized. According to a six-state study conducted by Hawes & Kimbell for the U.S. Department of Justice (National Institute of Justice) in 2010, when seriously substandard quality, neglect or abuse were discovered in unlicensed facilities, some closed the home in question but shifted residents to other legally or illegally unlicensed care homes to avoid detection or penalties. These include tapping into fire/EMS databases to identify addresses of care homes that could be unlicensed, and tracking multiple SSI payments that go to a single representative payee at the same address. Pennsylvania's BHSL and the North Carolina Adult Care Licensure Office and Mental Health Licensure Office will offer to work with unlicensed residential care homes to help facilitate licensure. A phone number is provided if someone has a question about the licensure status of a facility. There is a lack of knowledge regarding the licensure requirements or about how to navigate the different government agencies. Below are examples from the environmental scan that provide some estimates of the number of unlicensed care homes: Maryland: A representative of the licensure agency estimated 500 unlicensed illegal assistive living facilities and noted the fine line between a boarding home and assisted living. Notably, reliance on complaints to identify unlicensed care homes limits identification of these homes to those that raise concerns about safety or quality. One of the SMEs shared comments from ombudsmen that the numbers of unlicensed homes in some states are increasing, while in other states, they reported that they had not heard about unlicensed care homes. As a result, 3,000 individuals with mental illness were transitioned into community-based supported housing. With regards to the safety of unlicensed care homes, the majority of key informants agreed that the lack of clean and safe housing was a primary safety concern. Personal board and care homes: A hidden population in Anne Arundel County. (2015) Assisted living provider resources: Unlicensed facilities. required. Other Research Ideas Suggested by Subject Matter Experts or Individuals Interviewed in State Site Visits. 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. If you are not able to locate the following . However, it won't cover 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. (2013). 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. Licensing Exemptions | Texas Health and Human Services Consistent with information from the environmental scan, key informant interviews indicate that some unlicensed homes use basements to house residents, including residents who do not have the capacity to exit safely in the event of a fire or similar emergency, such as those who are unable to climb the stairs and those receiving hospice care. A paper by Tobia (2014) describes the state of unlicensed residential care in one county in Maryland, where as many as 78 unlicensed care homes may be serving as many as 400 individuals. Although we attempted to conduct interviews with operators of unlicensed care homes on our site visit states, we could not identify or gain access to any. Is there a seminar I can attend? Monograph for the National Institute of Justice, U.S. Department of Justice. There is no systematic information about the actual nature or range of conditions in legally unlicensed homes (e.g., safety, quality of care, issues of abuse and neglect), or provision of services and care through Medicare or Medicaid home health, private attendants, or HCBS waivers. Informants stated that Allegheny County has other specific contextual issues that may contribute to the existence of illegally unlicensed personal care homes. In August 2013, the law to prosecute an unlicensed personal care home operator was used for the first time. While experts may speculate on changing market dynamics, we do not have a reliable estimate of the unlicensed care home market prior to these policies taking effect, so we do not know what the market would have been without such policies. Complaints can also be received by fax, letter, or email. These calls spur investigations that sometimes result in the identification of unlicensed care homes. Some continue to operate after their license expired or was revoked. Based on the findings from this exploratory study, unlicensed care homes appear to be widespread in some areas within some states. Many residents in unlicensed care homes receive SSI, and some residents may qualify for waivers to provide long-term care services in HCBS. The study by Hawes & Kimbell also provided reasons operators do not seek licensure, including: inability to meet fire safety codes (e.g., installing sprinklers), lack of state supplemental payment for SSI residents or Medicaid waiver funds (which can be restricted to licensed facilities), and avoidance of inspections and sanctions/fines for not meeting state regulation. Residents of unlicensed care homes are vulnerable adults. Monograph for the National Institute of Justice, U.S. Department of Justice. In some instances, these places may be certified or otherwise listed at a local level, but they may not be monitored by the state for quality and safety issues. 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. Unlicensed Assisted Living Facilities; Page 11; Does the facility need a license? You can update your choices at any time in your settings. Illinois: A story released on the This American Life radio podcast described a scam where individuals with substance use disorders were sent from Puerto Rico to supposed rehabilitation centers in Chicago where they were to be provided with housing, food and counseling services, only to find themselves in crowded, unlicensed rehabilitation centers, their passports and other identifying information taken from them. 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. 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. County and District Attorney referralsdeclined from 29 in 2010 to six in 2014. 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. 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. at-home health aide unless one is determined to be medically In 1999 legislation (PA 99-80) passed, authorizing trained, unlicensed personnel to administer medication to elderly people in residential care homes (residents must be ambulatory and generally less frail than those in nursing homes). Texas Department of Aging and Disability Services. Custodial care is non-medical assistance We did not find any report where a government agency was proactive and discovered the case on its own initiative or because of routine monitoring of unlicensed residential care homes. The regional and state licensure offices are closely involved in this process. Lack of clarity in licensure regulations regarding minimum bed size required by licensure also exists in a few states. This Moreover, the 1976 Keys Amendment to the Social Security Act requires states to assure that SSI recipients do not reside in substandard facilities, and states must annually certify that this is true. To reduce abuse, several informants indicated that state officials should target closing unlicensed care homes. Making changes to licensed care home regulations is one example of how states may address unlicensed care homes. Savchuk, K. (2013). Atlanta Journal-Constitution. 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. 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). Similar to the information summarized in the environmental scan, interviews with key informants revealed that unlicensed care homes make money off of residents in sophisticated and profitable ways. 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. 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). One key informant indicated that this reduction is due to the increasing numbers of HCBS waivers giving potential Dom Care residents the option to live alone in apartments. Assisted Living Facility - Texas Health and Human Services The .gov means its official. One SME from an advocacy organization in Pennsylvania shared that they use an Excel spreadsheet to track illegally unlicensed care homes identified as a result of a complaint. Demographic trends are placing an increasing number of older persons at-risk for needing residential long-term care, but many of these same individuals have out-lived their savings or had low incomes to start. Pennsylvania Department of Public Welfare. 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. The .gov means its official. Failing to consistently provide running water and electricity, or having unsafe or illegal electrical wiring. Local key informants gave more specific examples of how operators evade licensure by having a mixed population living in their homes. 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. Future research could be conducted to describe the nature of ombudsman involvement in unlicensed care homes and how it differs across states. National Association of Medicaid Fraud Control Units. The site is secure. In one state, the AG only received nine cases in the entire year; in another state they handled only 2-3 cases a year. 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). Perkins, M., Ball, M., Whittington, F., & Combs, B. All of the key informants shared their perspectives about what is driving the closure of personal care homes. However, as in some other states, APS in Pennsylvania can act on referrals of abuse for elderly residents (age 60+). From a county perspective, one ombudsman and housing officer estimated that perhaps there may be less than 20 lawfully unlicensed facilities and less than five illegally unlicensed, however Tobia's team found that there may be as many as 78 unlicensed care homes serving as many as 400 individuals in that county. SMEs and key informants discussed a number of factors that may have an effect on the supply of and demand for unlicensed care homes. 1 reported dead after 25 people removed from unlicensed Rosenberg group FINDINGS FROM THE ENVIRONMENTAL SCAN, http://www.stopelderabusepetition.blogspot.com/2013_06_01_archive.html, http://www.thisamericanlife.org/radio-archives/episode/554/not-it, http://www.namfcu.net/resources/medicaid-fraud-reports-newsletters, http://www.disabilityrightswa.org/stop-fraud-and-abuse-rep-payees, http://www.dhs.state.pa.us/cs/groups/webcontent/documents/report/c_102850.pdf, http://aspe.hhs.gov/office-disability-aging-and-long-term-care-policy-daltcp, HHS Office of the Assistant Secretary for Planning and Evaluation, Pennsylvania Bureau of Human Services and Licensure, HHS Centers for Medicare and Medicaid Services, Texas Department of Aging and Disability Services, 3.2. Most commonly, interviewees depicted unlicensed personal care homes operating in residential areas within single family houses that are rented by the unlicensed care home operator, but some interviewees described unlicensed care homes operating in a variety of other structures (e.g., closed churches and schools). Failing to have safety equipment available, such as smoke detectors and fire extinguishers. After discussions with ASPE, we identified three states and communities within each state as site visit locations: Atlanta, Georgia; Raleigh/Durham, North Carolina; and Allegheny County, Pennsylvania. Potential Data Sources or Listings of Unlicensed Care Homes, 5.3. Because of the potential for a large loss of life from fires in these places, comprehensive emergency management planning and practices are reported to be needed to proactively protect those at risk (Tobia, 2014). Interview findings indicate that many residents of unlicensed care home are Supplemental Security Income (SSI) beneficiaries. PDF FAQ About Unlicensed Personal Care Homes - Department of Human Services