Some of these ideas may be relevant for agencies other than or in addition to ASPE, such as the National Institute of Justice, CMS, or ACL. 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. Also, the information collected from newspapers, ombudsmen, APS staff, or other agency reports (by their very nature) skew towards negative events. (2009). They provide room, board, housekeeping, supervision, and personal care assistance with basic activities like personal hygiene, dressing, eating, and walking. Some trawl for residents, picking residents up off the street, from homeless shelters, and from hospitals, and routinely shift residents from one facility to another in order to keep their occupancy rates high. 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). 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. One of the key informants, who operatesa day program that serves many individuals who are residents of unlicensed care homes, also described the 20 year history surrounding the operation of unlicensed care homes. There is a critical challenge of providing housing and supportive services for particularly vulnerable groups, including individuals: who have severe and persistent mental illness or other disabilities, were formerly homeless, or older adults who have limited financial resources. (n.d.). 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. 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. While this may be a promising source of unlicensed homes only in Allegheny County, Pennsylvania, similar tracking mechanisms may be used or developed for use in other communities as well. Since 1983, California Advocates for Nursing Home Reform has been fighting for the rights of long-term care . These findings suggest that as states continue to move toward serving more of their Medicaid beneficiaries in the community rather than in institutions, consideration should be given to ensure appropriate safeguards are in place for these beneficiaries. In North Carolina, facilities providing or arranging for housing, food service, and 24-hour scheduled and unscheduled personal care services to two or more unrelated adults must be licensed as an adult care home or a group home. Policies affecting the supply of and demand for unlicensed care homes. As one informant in Georgia reported, "the hospital will say 'this is an expensive bed, you need to get [the patient] out.' Due to services being brought into these homes, interviewees thought further interviews with home health staff or hospice staff may yield additional information or lists of unlicensed personal care homes that may include illegally unlicensed establishments. 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. Concerns about abuse and neglect were a major topic of discussion during interviews, and they extended across illegally and legally unlicensed homes. Referral and Placement Agencies and Discharge Planners. This home initially drew the attention of the authorities because of a sexual assault case in which one of the residents was raped by a sex offender. 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. 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. 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. One key informant estimated there are approximately 526 Dom Care operations in the state. Residents in need of medical assistance such as nursing care can pay for such care from an outside provider, and the facility does not have to be licensed as "assisted living." Some continue to operate after their license expired or was revoked. In the recent past, the state has had public education campaigns to inform the public about illegally unlicensed personal care homes. 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. Dont let a bargain price influence your choice. Abuse, Neglect, and Financial Exploitation, 3.4. 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. The three-day notice must include the amount of rent that is due and where to pay the rent. 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. 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. 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. 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. And regardless of whether states have regulations concerning unlicensed homes, many operators choose to operate illegally unlicensed homes. 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. 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. Health and safety concerns for residents were a major topic of interview discussion. A six-state study conducted by Hawes & Kimbell in 2010 for the U.S. Department of Justice, National Institute of Justice, found that unlicensed homes remain a serious, largely unaddressed problem in some states, with the magnitude of the problem remaining unknown. For example, as part of interviews with SMEs, we asked them to recommend potential key informants to meet with during site visits. 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. Each interview began with a general question to ascertain what the interviewee knew about unlicensed care homes. 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. If you suspect that a facility is not licensed or in violation of its license, call 1-844- LET US NO (1-844-538-8766) to file a complaint with the Department of Social Services. Retrieved from http://www.miamiherald.com. Most interviewees also agreed that there are likely more illegally unlicensed personal care homes than they are aware of. In Arizona, a bill to strengthen the elder abuse and fraud laws failed to pass again after being introduced in three previous sessions. Which agencies get involved when addressing unlicensed care homes? 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. We use cookies on our website to give you the most relevant experience by remembering your preferences and repeat visits. Each of these factors is discussed in more detail in the sections that follow. 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. Barry, R., Sallah, M., & Miller, C. (2011). Local key informants primarily expressed concerns regarding inadequate nutrition provided to residents and inappropriate medication management practices. unlicensed room and board california. Additionally, states may implement public awareness campaigns to support identification of unlicensed care homes. 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. Two key informants mentioned that changes to the state's Medicaid Personal Care Services program had a direct impact on available funding for group homes that serve individuals with mental illness. These cookies ensure basic functionalities and security features of the website, anonymously. See http://www.disabilityrightswa.org/stop-fraud-and-abuse-rep-payees. You must fill out a separate complaint form for each physician or other healthcare provider you wish to file a complaint against. In Pennsylvania, one key informant noted that this assistance is given only to those operators who have opened their first illegally unlicensed care home without realizing they needed to be licensed; assistance is not provided for those who are repeat offenders. For example, if the tenant has not paid rent, the landlord typically must give the tenant an opportunity to pay the rent before the three days expire. revision is needed, completion of a new Room and Board Residency Agreement is required. All of the key informants shared their perspectives about what is driving the closure of personal care homes. Key informants were also concerned about a lack of specific services inside illegally unlicensed personal care homes. Several key informants discussed the role hospitals and hospital discharge planners potentially play in referring patients to unlicensed care homes. To accomplish this we conducted an environmental scan, including a review of the peer-reviewed and grey literature and interviews with SMEs. 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. Savchuk, K. (2013). In the states we visited, a common theme across interviews was that addressing quality in illegally unlicensed care homes tends to focus on shutting down the operations. After completing the vetting calls, we emailed an introductory letter explaining the purpose and goals of the research to the potential interviewees. azmfairall. 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. Unlicensed care homes commonly will accept these individuals and many market themselves to discharge planners. Strategies for Addressing Issues in Legally and Illegally Unlicensed Care Homes, 3.6. How can I report illegal advertising by an unlicensed contractor. Reports of financial abuse include fraud of federal programs, including SSI, Medicare, and Medicaid. 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. Positive Actions by States to Improve Oversight of Unlicensed Facilities. Some key informants reported that the living conditions in these places can be subpar. 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). These are important issues since they affect many vulnerable adults who have physical, intellectual, or cognitive disabilities. These cookies will be stored in your browser only with your consent. Most state informants said legally unlicensed care homes did not fall under state regulatory purview, and thus were not monitored (or investigated unless there is a complaint). One key informant in Allegheny County shared a list of seven current placement agencies that likely have registers of illegally 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. Interview results indicate that police may also be helpful in identifying unlicensed care homes, but the extent of that help may vary from state to state and across communities within states. Retrieved from http://www.azdhs.gov/als/hcb/index.htm. There is a lack of knowledge regarding the licensure requirements or about how to navigate the different government agencies. Key informants in Georgia described training sessions to educate law enforcement and first responders about unlicensed care homes. Who do I contact for complaints against Community Care Facilities? (2012c). Legally Unlicensed Residential Care Homes, 6.2. Targeted searches of media reports in states with the lowest percentages (New Jersey, Mississippi, Indiana, Florida, and Michigan) did not yield a higher number of reports on unlicensed care facilities than those with the highest spending rates for HCBS (Arizona, Vermont, Alaska, Minnesota, and Oregon). The reporters described cases of abuse in which residents were being beaten and burned, locked in basements/rooms, given buckets for toilets, and had their benefit checks stolen from them (Schneider & Simmons, 2012a; Schneider & Simmons, 2012b; Schneider & Simmons, 2012c). Humphrey Building, 200 Independence Avenue, S.W., Washington, D.C. 20201. 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. Each landlord must adhere to applicable housing laws, based on the type of room and board offered. The modest payments made by SSI or State Supplemental Payments to residential care homes, which may be inadequate to cover expenses in licensed facilities. Although they did not know about exiting listings, several informants suggested potential ways to develop a list of unlicensed care homes. The fact that four people should have been receiving personal care services made the home eligible for licensure as a residential care home--not the fact that three people were receiving the services (which would make it under the legal limit). Detecting, investigating and addressing elder abuse in residential long-term care facilities. The cookie is used to store the user consent for the cookies in the category "Performance". 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. These individuals do not pay taxes, have insurance or bonds. The environmental scan did not yield peer-reviewed publications or reports about unlicensed residential care in North Carolina. 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). The CMHPC's Policy and System Development Committee conducted a brief While this was a limited exploratory study, our findings point toward serious issues with unlicensed care homes, as well as gaps in our knowledge, and they have important implications for future research on unlicensed care homes. 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. Regulatory changes and the role of multidisciplinary task forces (which are relevant to both legally and illegally unlicensed care homes) are described next, followed by a summary of the strategies discussed during interviews to identify and shut down illegally unlicensed care homes and to monitor and improve quality in legally unlicensed care homes. 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. Retrieved August 6, 2015 from 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. We found little published information about unlicensed residential care homes; in fact, the scan revealed that most of the literature about conditions in RCFs covered licensed residential care or were about unlicensed care staff. As noted by one SME, unlicensed care homes that provide good care and a safe environment may intentionally not be brought to the attention of state agencies nor be reported by these agencies when they learn of these homes: "We do receive reports, about 6 months ago someone wrote to me about their mother who was getting care in an unlicensed homeshe was getting wonderful care, she wasn't going to report it. We exist to empower, promote self-advocacy, and make available safe and supportive housing for adults, low income individuals, residents and Behavioral Health Consumers. Disability Rights California have investigated squalid conditions at a number of unlicensed room and board homes serving adults with psychiatric disabilities across the state. What is Residential Care for the Elderly? National Association of Medicaid Fraud Control Units. 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. 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. To reduce abuse, several informants indicated that state officials should target closing unlicensed care homes. However, this likely is not a viable method for detecting the population of illegally unlicensed residential care homes. 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. In addition, the reports of financial abuse also may represent considerable financial fraud of federal programs including SSI, food stamps, and the programs paying for resident medications (i.e., Medicare and Medicaid). The rental agreement can be an oral agreement, periodic rental agreement or lease. Conditions (including quality and safety) of unlicensed care homes. 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. She has practiced in the field of financial planning and investment management since 2000. Out of these, the cookies that are categorized as necessary are stored on your browser as they are essential for the working of basic functionalities of the website. One of the points made by key informants is that states have very few, if any, strategies to easily identify unlicensed care homes. A landlord must ensure that the room-and-board tenant has access to a working toilet, running water, trash disposal, natural light and proper ventilation for each room. In August 2013, the law to prosecute an unlicensed personal care home operator was used for the first time. However, a few states (such as Georgia and Texas) provide those supplements only to residents in residential care homes certified to offer services covered by Medicaid. 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). 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. The facility operators were authorized to make the decision on their own (Tobia, 2014). Interview findings also suggest that research is needed on the best strategies for identifying unlicensed care homes and effectively closing them down. 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. States have a variety of options for reducing the prevalence of both legally and illegally unlicensed residential care homes, such as changing regulations and coordinating across agencies to address these homes. The state is also unusual in that it allows a category of care homes to operate as legally unlicensed homes. Very little discussion centered on improving the quality of unlicensed care homes. Residents may not have access to their personal identification cards due to the care provider retaining those items, which can limit the capacity of the resident to relocate. Next, the local group monitoring office or the state would attempt a site visit.
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