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. Multiple key informants discussed the impact that policy changes regarding community-based care have had on unlicensed care homes in their communities, including state efforts to comply with the Americans with Disabilities Act (ADA) requirements. In other types of residential care, if the care is arranged or managed by the owner, manager, or staff of the building, home, or community, then the facility must be licensed. 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. In 2011, only two such warrants were obtained. The SME noted that this approach misses individuals who are representative payees for fewer than 15 individuals and as such may miss operators of small unlicensed residential care homes. They capture key variables such as the name and any aliases of the illegally unlicensed care home; the owner's name and whether they own more than one unlicensed care home; the licensure status (formerly licensed, never licensed, operating illegally); and any relevant information about the complaint (e.g., investigation dates, or dates any residents were moved/relocated). 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. Key informants also cited the process of discharging patients from hospitals in Allegheny County as a potential source for linking individuals with illegally unlicensed personal care homes. Unlicensed Practice. Between 2012 and 2015, the California legislature enacted several laws that will affect the operation of these facilities. 3.5.4. Policies affecting the supply of and demand for unlicensed care homes. 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. 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. Tenants may have a diagnosis of mental illness and are seeking a shared living arrangement. 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. Resident Case Mix. 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. Please contact the board at renewalstatus@dca.ca.gov for assistance. By clicking Accept All, you consent to the use of ALL the cookies. As noted, we found the prevalence of legally and illegally unlicensed residential care homes varies by state. Though outside the scope of our focus, some of the searches also produced media reports and grey literature about concerns in licensed care homes; however, reports about unlicensed care homes and the quality of care described therein was sometimes worse than those for licensed care homes. Monitoring and Improving Quality in Legally Unlicensed Care Homes. If the facility is providing licensable services in an unlicensed setting, the state then sends a cease and desist letter, copying the LME-MCO and the local APS. The PCRR team shares the complaints they receive about potential illegally unlicensed personal care homes between the AAA, APS, Disability Rights Network, code enforcement and state licensure office. Retrieved from http://www.dads.state.tx.us/providers/alf/howto.html. In the recent past, the state has had public education campaigns to inform the public about illegally unlicensed personal care homes. Some SMEs suggested that state policies affect the mix of residents in unlicensed care homes. 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. In some states, residents can pay for their own personal or medical care in an unlicensed facility. Although limited in scope, the findings of this exploratory study provide important foundational information about current conditions in some unlicensed care homes, factors that may influence demand for these homes, and strategies to identify them and address their quality. An official website of the United States government. 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. However, our literature search did not reveal any estimates of the prevalence of unlicensed residential care homes in most of these states. 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. Candidate forums provide an opportunity for the public to learn about the candidates and their views on the issues. What concerns are there about the quality of care and safety in unlicensed care homes? Some of these homes are legally unlicensed while others operate illegally. Tobia, M. (2014). Ombudsmen reported increasing numbers of RCFs operating without a license in both Maryland and Nevada. Future research examining the role of hospital discharge planners and strategies to prevent discharge to unlicensed care homes appear warranted. Alabama's APS agency estimated that there were more than 200 unlicensed homes in the state, in contrast to their 400 licensed facilities. In addition, one key informant stated that penalties for operating unlicensed care homes are similar to only a Class C offense, which is "equivalent to fishing without a license." Although there were some reports of clean and safe unlicensed homes, the negative findings about conditions were predominant. Some operators remain undetected by moving residents from one facility in one state to another facility in another state. Additional research on unlicensed care homes will be valuable to build our understanding of the role--intended or unintended--of these places in our long-term services and supports systems, and the policies affecting it. Licensed personal care homes are required to assist with personal services including ADLs and IADLs, and can include supervision of medication administration and provision of social activities, as needed. In these cases, licensed operators were reportedly worried that the unlicensed operators would house residents from whom the licensed homes operators could have profited. 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). Although the majority of key informants described unlicensed care homes as unsafe environments where residents are abused, neglected, or exploited, it also was noted that some unlicensed care homes may provide quality care in safe and clean environments. Atlanta Journal-Constitution. Informants said that many local sheriffs and District Attorneys are not supportive of following through to enforce penalties, nor do they press charges against the operators. Some key informants described frustration with the lack of monitoring and lack of jurisdiction by the licensing offices to access or track legally unlicensed care homes. The CMHPC's Policy and System Development Committee conducted a brief Following the development of the initial list of SMEs, we divided the list into two categories: (1) a subset of individuals identified as "key experts" who would be prioritized for interviewing because we determined they had relevant information related to unlicensed care homes; and (2) individuals identified as "potential experts" who would first be vetted to determine their level of knowledge about unlicensed care homes. A private residence, a care facility or an employer might offer room and board. (2004). ("Independent Living") As a resident of an unlicensed room & board or "independent living" home, you have all of the same rights given to all tenants in California. In addition, SMEs noted variability across states in the availability of resident advocacy and protection through such agencies as the ombudsman program. At risk adult abuse, neglect and exploitation in Georgia: Review and recommendations. However, gaps in our knowledge about unlicensed homes remain, and several issues raisedduring interviews with key informants warrant further investigation. 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. Retrieved from http://www.dallasmorningnews.com. 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. Most of the literature or media reports were not specific about the types of residents served in unlicensed residential care. If the tenant refuses to leave the premises after the three days expire, the landlord may file an unlawful detainer action with the California Superior Court to evict the tenant. It is important to note that we do not know whether the types of financial exploitation and abuse described by the SMEs and key informants occur in both legally and illegally unlicensed care homes, or how commonplace they are. One example, described by multiple key informants, looked like a nice physical environment and was affiliated with a local church, but the operator of the home was taking the residents' money while abusing, imprisoning, and exploiting them. Not only will you be protecting the individuals who live in the care facility, you will be providing a service to your community. 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. 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. The frequently reported act whereby the operator of an unlicensed home makes money from their control of vulnerable residents and moves these residents from one unlicensed care home to another to avoid detection, led one SME to refer to it as "human trafficking." Barry, R., Sallah, M., & Miller, C. (2011). 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. 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. We were only able to obtain an estimate on the number of unlicensed care homes from the Durham County Group Care Monitoring Office. No. Licensed personal care homes are required to assist with personal services, supervise self-administration of medication, and provide social activities, as needed. Unlicensed care homes--which provide room, board and some level of services for two or more unrelated individuals, but are not licensed or certified by the state--fill some of the gaps in the availability of housing and services for these populations. Once an unlicensed care home is identified, the PCRR team works closely with the both the state and regional licensure offices to take the necessary steps to deal with the home. Licensed Care Home Admission and Discharge Policies, http://www.agingavenues.com/topics/assisted-living-facilities-in-indianapolis-indiana, https://aspe.hhs.gov/basic-report/compendium-residential-care-and-assisted-living-regulations-and-policy-2015-edition, http://www.medicaid.gov/medicaid-chip-program-information/by-topics/long-term-services-and-supports/home-and-community-based-services/downloads/requirements-for-home-and-community-settings.pdf, http://www.gachiefs.com/pdfs/White%20Papers_Committee%20Reports/AtRiskAdultAbuseWhitePaper.pdf, https://aspe.hhs.gov/report/medicaid-residential-care, http://www.ncjrs.gov/pdffiles1/nij/grants/229299.pdf, http://www.dhs.state.pa.us/cs/groups/webcontent/documents/report/p_011015.pdf, http://www.bizjournals.com/prnewswire/press_releases/2012/04/17/DC88926, http://www.phlp.org/wp-content/uploads/2011/03/PCH_manual-for-advocates-Feb-20071.pdf, https://www.socialsecurity.gov/ssi/text-benefits-ussi.htm, http://www.nbcwashington.com/news/local/Caretaker-Accused-of-Abusing-and-Neglecting-Kamara-Zanaib-268343912.html, http://www.dads.state.tx.us/providers/alf/howto.html, http://www.state.gov/documents/organization/245365.pdf, APPENDIX B. Local efforts were noted to be inconsistent and uncoordinated because authorities were unfamiliar with the laws. Some of these housed mainly older residents. Washington, D.C. 20201, U.S. Department of Health and Human Services, Biomedical Research, Science, & Technology, Long-Term Services & Supports, Long-Term Care, Prescription Drugs & Other Medical Products, Collaborations, Committees, and Advisory Groups, Physician-Focused Payment Model Technical Advisory Committee (PTAC), Office of the Secretary Patient-Centered Outcomes Research Trust Fund (OS-PCORTF), Health and Human Services (HHS) Data Council, Understanding Unlicensed Care Homes: Final Report, LIMITATIONS, CONCLUSIONS AND POLICY IMPLICATIONS, 4.1. 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 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. Key informants mentioned that state funding and regulatory mechanisms specific to Pennsylvania had a direct influence on the state's capacity to address illegally unlicensed personal care homes. . Discussions with SMEs and key informants explicitly differentiated between legally and illegally unlicensed care homes only minimally, but the opinion of SMEs and key informants we interviewed seemed to be that state efforts to address legally unlicensed care homes should focus on monitoring and improving quality, whereas state efforts to address illegally unlicensed care homes should be on identifying these homes and shutting them down. This conflicted with other media reports that describe Arizona citizens calling for closing the loopholes in state laws to prevent "imposter" senior living facilities that use false advertising (Azmfairall, 2013). As a direct result of this regulation change, many personal care homes in Pennsylvania became illegally unlicensed and either shut down, became licensed, or continued to operate illegally. This key informant shared a list of seven placement agencies that work with hospitals in Allegheny County. Retrieved from http://www.dhs.state.pa.us/cs/groups/webcontent/documents/report/p_011015.pdf. CRBC does not maintain licensing or governing authority over the member facilities we recommend. The cookies is used to store the user consent for the cookies in the category "Necessary". Findings from our limited number of interviews with site visit key informants and SMEs are consistent with the information found during the environmental scan. Retrieved from http://www.miamiherald.com. We relied on a targeted literature review, interviews with a small number of SMEs, and site visits to just three communities, all of which limit the scope of our findings. Although little is known about unlicensed care homes, a variety of signals, including media reports, highlight potential safety and quality concerns. Key informants in two states confirmed that some hospitals there contract with placement agencies that, in turn, place individuals in unlicensed care homes, particularly individuals with limited resources and mental health issues. If the AOR is a PO Box, or a mail drop location . What types of reports of mistreatment do the agencies receive? U.S. Department of State, Office of the Under Secretary for Civilian Security, Democracy and Human Rights. Glass, I. Other uncategorized cookies are those that are being analyzed and have not been classified into a category as yet. Most state licensure offices, county offices, or advocacy agencies use a complaint system to identify unlicensed care homes. Florida can impose fines of up to $1,000 a day, however it was noted that owners often disappear when discovered to avoid being fined). 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. Sometimes the care providers require residents make the care home operator their representative payee for Supplemental Security Income (SSI) from Social Security. 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. Such practices violate residents' rights, and the profit-enhancing practices of the operators, such as limiting the availability of food, water, and other basic needs, endanger residents' lives and well-being. Thus, we lack information about unlicensed care homes in moststates, and even in our study states there were no reliable counts of illegal unlicensed care homes. 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. An estimate for another locality in Maryland was much higher, with twice as many unlicensed homes as licensed, or about 1,500 facilities, many of which operate out of single family dwellings (Tobia, 2014). Hospital discharge planners are not required to check the licensure status of the place to which they are discharging patients, and often discharge them to unlicensed homes. Consistent with findings from the environmental scan, stakeholders (including SMEs and site visit key informants in the three communities we visited) repeatedly raised a variety of concerns about neglect of residents' health care needs and unsafe and unsanitary conditions in unlicensed care homes. Lax enforcement in personal care homes. One key informant from Pennsylvania spoke about the difficulty in handling reports of neglect or abuse in legally unlicensed care homes: "we will have repeated incidences, or alleged incidences [at legally unlicensed residential care homes] and we don't report to anyone [any agency or the state] either. None of the reports provided evidence on the prevalence of unlicensed care homes in these states or the magnitude of the issue statewide. 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. Unlicensed contracting is part of California's estimated annual $60 to $140 billion dollar underground economy. 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. However, while SMEs reported variability in licensure requirements and the authority, responsibility and funding of ombudsmen agencies with respect to unlicensed homes, there is very little information available about legally unlicensed homes, including the characteristics of residents, their care and service needs, and their preferences. 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. 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. According to the American Elder Care Research Organization, the average cost of assisted living in 2018 in California is $4,070 per month. Key informants were also concerned about a lack of specific services inside illegally unlicensed personal care homes. Retrieved from http://www.ajc.com. Unlicensed care homes provide room, board and some level of services for two or more unrelated individuals, but they are unlicensed by the state. The same held true, with one exception (Georgia), for the top ten states with the greatest increase in HCBS spending since 2010: Virginia, Ohio, Maine, Rhode Island, Alabama, Tennessee, Georgia, New Hampshire, Massachusetts, and Delaware. National Association of Medicaid Fraud Control Units. For example, one key informant described a recent case of a representative payee in an unlicensed care home who was not managing a resident's money correctly, by providing food on a specific schedule and not providing it when the resident was hungry and requested food. (2015). Licensure for adult care homes and mental health group homes falls under two separate state statutes, and therefore two separate regulatory offices oversee different types of licensed care homes. However, landlord and tenant laws typically only apply to individuals who meet the legal definition of a landlord or a tenant. Key informants in all three site visit states provided examples of how this might happen. Specific concerns raised by SMEs and site visit informants are highlighted in this section. However, key informants at the state said that operators of suspected unlicensed care homes usually do open their door for inspection. This research might also address whether the Keys Amendment is achieving its goal of protecting the well-being of SSI recipients. Indeed, many key informants emphasized that they only knew about unlicensed care homes because of complaints being made about them. Several informants reported that it is common for the operator of an unlicensed care home, or representatives designated by the care home operator, to serve as the representative payee for the residents. First Responders: EMS, Firefighters, and Police. In more extreme cases, other personal care homes have stopped accepting any persons whose sole source of income is SSI. In California, when an owner rents property to a resident, this typically creates a landlord-tenant relationship. However, residents may pay for such services or receive them through Medicaid waivers. Family care homes serve 2-6 residents and adult care homes serve seven or more residents; both can choose to serve only elderly persons (55 years or older or any adult who has a primary diagnosis of Alzheimer's disease or other form of dementia) or to serve a mixed resident population. One Maryland media report suggested residents are those released from rehabilitation centers with no families in the area. Otherwise, standard room-and-board rental agreements typically include the amount of rent to be paid, meals included in the rent and terms of occupancy. A California report mentioned that disabled or homeless adults often prefer unlicensed facilities because they have fewer restrictions. Perils in personal care homes. Humphrey Building, 200 Independence Avenue, S.W., Washington, D.C. 20201. If ombudsmen become aware of such discharges, they will likely attempt to assist individuals or their families to find licensed options, but they can only provide aid if they are notified. 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. Informants noted that interagency, multidisciplinary teams at state and local levels are imperative to the success of shutting down unlicensed care homes, and to address the various issues involved in such closures, such as meeting the housing and services needs of residents, addressing any criminal behaviors of the care home operators, and ensuring the safety of the house or facility and neighboring properties. Provision of housing plus one or more personal services requires a personal care home (or other licensed facility) permit. Further, key informants reported that many operators require residents to surrender all forms of identification "for safe keeping" by the operator. However, we did not hear any specific examples of this from the state or local level.
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