An earlier study by Perkins, Ball, Whittington, & Combs (2004) provided these reasons from the perspective of one small unlicensed care home operator: Regulatory requirements meant for large assisted living facilities are too stringent and expensive for small residential homes. 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. azmfairall. The financial pressure hospitals feel to free up hospital beds sometimes results in discharges to unlicensed care homes, both unintentionally and for expediency. In Allegheny County, key informants said that some hospitals use placement agencies to assist with difficult discharges (e.g., persons with severe or persistent mental illness, the homeless, or persons with little money). Interview findings indicate that a key element of a successful strategy is collaboration across multiple agencies. These homes often serve very vulnerable individuals such as individuals with serious mental illness or other disabilities, or older adults with functional limitations and limited financial resources. The research team completed seven interviews with eight participants that included both state and local community stakeholders. Multiple key informants suggested that, as a result, these residents are primarily being served by illegally unlicensed personal care homes. Another state-level key informant was unable to estimate how many calls the agency receives that result in investigations of unlicensed group homes for persons with mental illness. 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. Unlicensed homes were described as less expensive than licensed facilities but as shabbier and offering fewer services. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely. Called shelters, rooming houses, sober homes, they have names like Home Sweet Home, House of Joy and Nurse's Loving Heart. Retrieved from http://www.miamiherald.com. There appears to be a general lack of recognition about the extent of the problems with unlicensed residential care homes in the United States. Strategies for identifying and addressing quality in legally and illegally unlicensed care homes appear to differ across states. Further, it is the responsibility of the owner to determine whether the home needs a license. In one state, the AG only received nine cases in the entire year; in another state they handled only 2-3 cases a year. 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. They described this as an example of operators running unlicensed care homes strictly for the money. Several key informants discussed the role hospitals and hospital discharge planners potentially play in referring patients to unlicensed care homes. State and Local Policies Related to the Supply and Demand for Illegally Unlicensed Care Homes. 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. 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. Rates for MHA residents range from $2,075 to $3,319 per month. &qcfcO%P>s]w auN y6+@ pP ^aAIT6d\cl?` -9'gr61,=.X YW={r23bK(L+k Residents in need of medical assistance such as nursing care can pay for such care from an outside provider, and the facility does not have to be licensed as "assisted living." In Georgia, much of the current focus on unlicensed personal care home investigations involves cases of resident abuse and neglect. State licensure offices primarily depend on complaints via phone calls3 that come first to a local county APS or regional licensure or monitoring office. Trafficking in persons report. The inability or unwillingness to provide appropriate care for residents at an affordable cost also was noted by key informants as a motivator to not pursue licensure. [12] State licensing for your facility is likely only the start of the process. For example, Georgia reported an increase in complaint calls about unlicensed residential care homes from 2013 to 2014. "=H@tLh,j;jDLOTY$%6?T@cFBQm14X$`CX"fGQX@":S\Q()*fT6?3(#,R)1EQ 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. Residential care homes that serve three or fewer residents are legally unlicensed in this state. Assisted living provider resources: Unlicensed facilities. During site visits, key informants reported that owners of licensed care homes often report operators of unlicensed care homes to authorities. According to the key informant, these individuals were given one-way bus tickets out of the city under the stipulation that they never return. 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. First, there is a lack of information about the effect of various state and national policies on the vulnerable individuals the policies were designed to protect and whose well-being they were intended to enhance. Savchuk, K. (2013). Court appointed guardians using unregulated homes. We found reports of Medicaid fraud in unlicensed care homes in Florida and Nevada between 2009 and 2014 involving charges of false imprisonment, resident neglect, grand theft, and/or operating an unlicensed assisted living facility (National Association of Medicaid Fraud Control Units, n.d.). Referral and Placement Agencies and Discharge Planners. "Unfortunately, unlicensed personal care homes are a . In several cases, the potential interviewees did not have direct knowledge on the topic of unlicensed care homes, and were not interviewed, but referred us to interviewees with more knowledge on the topic. https://dev.michigan.local/som/json?sc_device=json. 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. You may need to be personally licensed as a Certified Administrator of Group Homes, for instance. In addition to the aging population, many key informants agreed that the lack of affordable supportive housing options for individuals with a mental health diagnosis is also a concern for Allegheny County and surrounding counties. Oversight was spread across several agencies and depicted as convoluted and overstretched. Through a targeted series of interviews and a scan of the literature, we sought to contribute foundational information about unlicensed care homes. Findings from the interviews suggest that the majority of unlicensed care home residents in the metro Atlanta area have severe and persistent mental illness and are highly vulnerable to exploitation. 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. 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. Further, evidence exists from several states that there are still unlicensed residential care homes and that, in some states at least, the number of unlicensed facilities is increasing. Adult foster care facilities, sometimes referred to as group homes, can be much smaller and provide care to any adult who needs continuous support. For additional information about this subject, you can visit the DALTCP home page at http://aspe.hhs.gov/office-disability-aging-and-long-term-care-policy-daltcp or contact the ASPE Project Officer, Emily Rosenoff, at HHS/ASPE/DALTCP, Room 424E, H.H. The scan included published peer-reviewed and grey literature, including abuse blogs and media reports about legally and illegally unlicensed residential care homes. A few key informants noted that this funding arrangement affords state and local agencies the resources and time needed to investigate illegally unlicensed personal care homes. Medicaid in residential care. 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. The average rate is $1,200 to $3,000. Pennsylvania: In 2012, the Secretary of the Department of Public Welfare stated 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.". Some have residents that receive Medicaid funded services. Given these diverse concerns, SMEs and site visits interviewees suggested that coordinated efforts across a range of stakeholders, including state licensure agencies, ombudsmen, APS, law enforcement, and others may be necessary to address unlicensed care homes. No Legally Unlicensed Residential Care Homes Are Allowed in Some States. An AFC Small Group Home is at least three but not more than 12 residents. From 2008 to 2013, Pennsylvania reported a stable trend of investigating about ten illegally unlicensed care homes per year with the exception of 2010 when they investigated 27 cases, about three times more than in other years.6. 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. Report on Texas boarding houses. Licensed personal care homes are required to assist with personal services, supervise self-administration of medication, and provide social activities, as needed. 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. Furthermore, many licensed facilities are unwilling to admit or retain individuals with challenging behaviors. Although we heard about a range of conditions in illegally unlicensed homes, including neglect, abuse, and financial exploitation, it is unclear whether this is the norm or whether the findings are skewed because of the types of key informants we interviewed. Many key informants noted that regulatory loopholes provided potential ways that operators of illegally unlicensed personal care homes can persist and evade licensure. Populations Served and Conditions in Unlicensed Care Homes, 3.3. Potential Data Sources or Listings of Unlicensed Care Homes, 5.3. One key informant stated that if a call comes in and the name of the care home that is being reported is unknown, then the next step is to call the state licensure office. Hancock, L. (2007). Newspaper and media reports generally focus on what they view as the dramatic; the positive aspects of unlicensed care homes are often omitted from these reports. 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. The state investigates the types of services that are provided to residents on site in order to determine if a license is required. Some state have too few inspectors to detect and investigate allegations about unlicensed homes and too little time and manpower to bring a prosecutable case to the AG's office. Multiple key informants expressed concern about other state policies related to reductions in funding for mental health services and supports as potential contributors to a gap that illegally unlicensed personal care homes can fill. Some interviewees reported that unlicensed care home operators sometimes run homes in more than one state, across state borders to avoid arrest, and may be trafficking residents across state borders as well. The most prevalent strategy used by state and local officials to identify illegally unlicensed care homes is responding to complaints. QX;zI!({?^2'hy^xe(z>! During an interview Tuesday, 7 Investigator Heather Catallo shared the Special Investigation Record from the Michigan Department of Licensing and Regulatory Affairs, which oversees Adult Foster Care Facilities. Additionally, states may implement public awareness campaigns to support identification of unlicensed care homes. 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. Group Home: Individuals can choose to reside in a licensed or unlicensed group home with 2-5 other individuals. 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. A California report mentioned that disabled or homeless adults often prefer unlicensed facilities because they have fewer restrictions. Anne Arundel County Fire Department, Millersville, Maryland. Many of the key informants stated that individuals who operate unlicensed care homes are motivated by economic opportunities; but they also stated that in some cases, these operators may not know they need to be licensed. She was getting good care and it was something the mother could afford. Some of these homes are legally unlicensed while others operate illegally. Two states (New Jersey and Tennessee) have a category that specifies a maximum but not a minimum. These increased costs have also impacted the populations that licensed care homes will accept, according to multiple key informants. Desperate, Plummers family hired an attorney. ", 3.5.5. It is important to note that most key informants did not speak to or have direct experience with very small (1-3 beds) legally unlicensed personal care homes, and therefore could not estimate the prevalence of these types of homes or compare them to illegally unlicensed personal care homes. Next, the local group monitoring office or the state would attempt a site visit. He recommends additional research, enhanced coordination and cooperation among local agencies, education for first responders about unlicensed group homes and how to identify at-risk individuals, and stronger advocacy for risk reduction strategies to prevent fires that involve large loss of life (Tobia, 2014). According to many of the key informants interviewed, hospitals are increasingly under financial pressure to discharge patients to free up beds, which is believed to contribute to the ability of unlicensed care homes to fill beds and stay in business. The issue of financial exploitation is described in detail in Section 3.3.2. (2009). Additionally, interviewee discussions revealed a lack of ombudsman involvement in unlicensed care homes, which is another area for future research. Leslie was arrested on multiple counts of abuse and. A few strategies exist in the state for addressing illegally unlicensed personal care homes. Miami Herald. Other charges included: murder, sex trafficking, sexual abuse from staff or other residents who were registered sex offenders, racketeering, forced labor, and fire setting by residents with severe and persistent mental illness. In Georgia, efforts are now under way to provide workshops for law enforcement that clarify the new laws about unlicensed care homes and how law enforcement and agencies, such as aging and licensure can work together to identify and investigate crimes against at-risk adults and prepare the necessary components for successful prosecutions. 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. Monitoring and Improving Quality in Legally Unlicensed Care Homes. (2013). Key informants included representatives from the state licensure office. 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. ADULT SMALL GROUP HOME (CAPACITY 1-6) 8138 HEDGEWAY DR. SHELBY TOWNSHIP. 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). Pennsylvania's BHSL is currently working on an amendment to create a graduated fine system for those operators who continue their illegally unlicensed care homes after they have been ordered to cease operations. As such, they could be a key source for learning about currently unlicensed care homes. Many key informants regarded the closing of Mayview State Psychiatric Hospital in 2008, which was located in Allegheny County, as an important factor contributing to the gap of services and affordable housing available for individuals with mental health diagnoses. Retrieved from https://aspe.hhs.gov/report/medicaid-residential-care. Carter applied for a license 11 months ago, but refused to answer our questions about why she was operating the home before being approved by the state. Following the environmental scan, we conducted interviews with SMEs on the topic of unlicensed care homes. One key informant estimated that approximately 25 cases are investigated annually, with about half that number determined to be illegally unlicensed personal care homes. One key informant noted that residents of unlicensed care homes commonly require assistance with activities of daily living (ADLs), such as getting dressed, as well as assistance with instrumental activities of daily living (IADLs), such as taking medications and managing and accessing transportation to medical appointments. Other SMEs reported that efforts to discharge or divert residents from nursing facilities to community-based settings led to greater use of licensed RCFs and noted instances in which residents who exhausted their private funds might have no options other than unlicensed residential care homes. In the latter state, it was said that unlicensed homes "flourished in the larger cities, particularly those that had significant populations of poor elders and persons with mental illness who had been released from state mental hospitals" (Hawes & Kimbell, 2010). A few interviewees agreed that in cases such as this, the operators are motivated by their desire to care for people; they are just not aware of the licensure requirements. 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 contrast, in Pennsylvania, the BHSL has the authority to execute a warrant to investigate a suspected illegally unlicensed care home. If you have a story for Heather Catallo, please email her at hcatallo@wxyz.com or call 248-827-4473. In Georgia, they advertised themselves as licensed and admitted residents to the licensed facility and then shifted residents to their illegally unlicensed homes. Providing unsafe housing conditions, including overcrowding of resident rooms, housing many more residents in bedrooms than is allowed by state licensure regulations, housing residents in storage sheds, basements, and attics that were unsafe, unsanitary, and made egress difficult for frail or disabled residents. Washington, D.C. 20201, U.S. Department of Health and Human Services, Collaborations, Committees, and Advisory Groups, Understanding Unlicensed Care Homes: Final Report, Biomedical Research, Science, & Technology, Long-Term Services & Supports, Long-Term Care, Prescription Drugs & Other Medical Products, 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, LIMITATIONS, CONCLUSIONS AND POLICY IMPLICATIONS, 4.1. Our state services support residents, businesses, and visitors to the Great Lakes state. Multiple key informants also stated that interviews with small licensed personal care home operators may result in learning more about the motivations for operating an illegally unlicensed personal care home. As described by all informants, complaint systems are the most common strategy used for a state or locality to become aware of unlicensed care homes. This became evident during discussions with informants in Pennsylvania and Georgia; it has also been reported in the literature, as we found in the environmental scan. As described in Section 2, to inform the selection of states for site visits, we looked closely at the information available for six states where the environmental scan or SMEs indicated unlicensed care homes likely exist. Available at http://www.ncjrs.gov/pdffiles1/nij/grants/229299.pdf. 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. Our examination of the Medicaid Fraud Control Unit reports (2009-2013) showed that only a couple cases were reported to the media; the rest had not made the news. To accomplish this we conducted an environmental scan, including a review of the peer-reviewed and grey literature and interviews with SMEs. A house at East Tamara Costa Court where Calvin Leslie, not photographed, was renting it is seen on Wednesday, Dec. 18, 2019, in Las Vegas. Although such issues are not restricted to unlicensed care homes, as they are known to occur in licensed care facilities as well, future research might examine and describe the mechanisms states use to detect, investigate, and resolve allegations of abuse or neglect in unlicensed residential care homes and how they compare to the mechanisms used to identify and resolve instances of abuse and neglect in licensed care homes. 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. In either case, while states regulate and provide some level of monitoring and oversight of licensed care homes, state and local oversight of unlicensed care homes can be minimal or non-existent, and these facilities provide questionable care and services. 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. For instance, they may start by caring for one resident, and gradually take in more individuals without realizing there are state regulations governing homes caring for two or more unrelated adults. Fiscal note, 81st legislative regular session. Unlicensed staff may administer medications after completing a 16-hour medication course from an approved medication training provider. Complaint calls are received by each participating agency, therefore the team meets monthly to share complaints about potentially illegal unlicensed care homes. Key informants described the regulatory agency's ability to work with an operator of an illegally unlicensed personal care home to help facilitate the home obtaining licensure. Three reports are worth noting separately. Interview findings indicate that many residents of unlicensed care home are Supplemental Security Income (SSI) beneficiaries. Information gathered from the environmental scan and SME interviews revealed reports that unlicensed care homes exist in North Carolina. The state made bridge funding available to those group homes impacted by this funding change, but one key informant said that according to a recent report, very few group homes accessed this bridge funding. However, site visit key informants and SMEs we interviewed were unaware of any such lists of unlicensed homes and could not identify existing methods for tracking them. 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). 20 or fewer individuals 55 years of age or older that is operated in conjunction with and as a distinct part of a licensed nursing home. The operator of the facility had recently received and accepted an offer to sell the house, and so was closing down the facility. The first conviction in Florida is a felony; in Georgia, first conviction is a misdemeanor, second is a felony. See http://www.disabilityrightswa.org/stop-fraud-and-abuse-rep-payees. In Durham County we interviewed key informants from APS, Group Care Monitoring Services, a local hospital discharge planner, a local ombudsman, and one local law enforcement official, who also serves on a crisis intervention task force. We completed 17 interviews with SMEs. 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. They indicated that these unlicensed personal care homes are filling the gap left by the closing of licensed personal care homes. Findings from the environmental scan highlighted issues of safety, abuse, and exploitation in unlicensed care homes; however, the source material, including media reports, tend to highlight negative and sometimes sensational stories, which may or may not represent the norm in unlicensed care homes. Heather Catallo, please email her at hcatallo @ wxyz.com or call 248-827-4473 SSI. Additionally, interviewee discussions revealed a lack of recognition about the extent of the had... Are primarily being served by illegally unlicensed care homes you may need to be personally licensed as a result these! Running unlicensed care home investigations involves cases of resident abuse and neglect for addressing illegally unlicensed care,! A key element of a successful strategy is collaboration across multiple agencies licensure offices primarily on... To their illegally unlicensed residential care homes from 2013 to 2014 are to. 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