APS provided this breakdown of where the residents were being taken: 13 to four different licensed personal. As a result, 3,000 individuals with mental illness were transitioned into community-based supported housing. Furthermore, many licensed facilities are unwilling to admit or retain individuals with challenging behaviors. Pennsylvania Health Law Project and North Penn Legal Services. Some operators use homes that do not meet personal care home building code regulations; for example, the home may lack proper ramps for wheelchair access. Currently at the state level, the primary strategy used in Georgia to identify unlicensed care homes is through complaints, including complaints from neighbors, residents, residents' family members, and hospitals serving residents of unlicensed care homes. The payments also vary considerably from state to state, and are quite modest in some states (e.g., from $46 to $100 per month). Through these regulatory activities, DADS protects Texas citizens receiving home health, hospice and personal assistance services. Key informants suggested interviewing individuals from other agencies to learn more about illegally unlicensed personal care homes or to obtain potential lists of illegally unlicensed personal care homes. For example, Georgia reported an increase in complaint calls about unlicensed residential care homes from 2013 to 2014. personal are home) is a private 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. 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. Complaints can also be received by fax, letter, or email. For example, in Georgia it recently became a misdemeanor to operate an unlicensed care home,therefore we aimed to speak with law enforcement officials who had been involved in the process of investigating unlicensed care homes. Pennsylvania Department of Public Welfare. "Caretaker" Accused of Abusing and Neglecting Mentally Challenged Victims. Types of Assisted Living Facilities - Texas Thus, future research might be warranted to determine the characteristics of residents in unlicensed care homes and whether they differ across legally and illegally unlicensed homes. Retrieved from http://www.miamiherald.com. What federal and state policies affect the supply and demand of unlicensed care homes? One interviewee, who interacts with residents of unlicensed care homes on a daily basis, estimated that for every licensed personal care home in Georgia there is one unlicensed care home. Cases of physical abuse, such as residents being beaten and burned as described in the environmental scan, were also reported during interviews. Some have residents that receive Medicaid funded services. The team conducted interviews with key informants in each of these communities. Six states (Colorado, Iowa, Illinois, Maine, Missouri, and Vermont) license starting at three beds; Vermont exempts small private-pay homes. Media and state reports have highlighted homes operating deliberately illegally--that is, they are avoiding required licensure or certification (Tobia, 2014; Georgia Association of Chiefs of Police Ad Hoc Committee on At-Risk Adult Abuse, Neglect & Exploitation, 2013). Barry, R., Sallah, M., & Miller, C. (2011). Please make your own independent Most interviewees also agreed that there are likely more illegally unlicensed personal care homes than they are aware of. No Legally Unlicensed Residential Care Homes Are Allowed in Some States. Some illegally unlicensed facilities deny services are being provided. 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. As noted in Section 4.1, states use a variety of definitions or criteria that allow some homes to operate legally without a license. Stop elder abuse petition. California, Pennsylvania, Maryland, and Mississippi publish notices of how and where to report unlicensed care homes, which implies that these states may be experiencing problems with unlicensed homes. Interviews with key informants also indicate that many residents are poor and receive Supplemental Security Income (SSI) benefits from the U.S. Social Security Administration (SSA); the SSI program pays benefits to disabled adults and children who have limited income and resources. Unlicensed homes to face more state scrutiny. Interview discussions often touched on the question of how best to identify illegally unlicensed care homes, and key informants noted this as a major challenge. Tobia's report (2014) described residents of unlicensed facilities as vulnerable older adults with "hard to place" mental health and paroled individuals who are warehoused. 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 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. None of the reports provided evidence on the prevalence of unlicensed care homes in these states or the magnitude of the issue statewide. Although little is known about unlicensed care homes, a variety of signals, including media reports, highlight potential safety and quality concerns. than assisted living care. 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). need for senior care services and the choice of a facility is an Specific concerns raised by SMEs and site visit informants are highlighted in this section. emergency conditions. Called shelters, rooming houses, sober homes, they have names like Home Sweet Home, House of Joy and Nurse's Loving Heart. 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. Elder Options of Texas - A Home Care & Senior Housing Directory Media reports were usually about an action by a licensing agency, Medicaid Fraud Unit, APS, or the police arresting an operator; these reports do not provide much information about the extent to which unlicensed homes exist in the state. Unlicensed assistive personnel (UAP) are paraprofessionals who assist individuals with physical disabilities, mental impairments, and other health care needs with their activities of daily living (ADLs). 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. In one case well publicized by the media, residents of one unlicensed facility in Pennsylvania were moved between Pennsylvania, Texas, Virginia and Florida to escape law enforcement. Several key informants mentioned that hospital discharge planners sometimes discharge patients to unlicensed care homes (described in more detail in Section 4), and as such they might be a potential source for compiling a list of these homes. More information exists about licensed RCFs than unlicensed care homes, thus knowledge of the unlicensed care homes is limited. The state statute defines personal care services as: Assistance with meals, dressing, bathing, movement, or other personal needs or maintenance; Administration of medication by a person licensed to administer medication Assistance with or supervision of medications; or Residents of Type B Small or Large Facilities - Texas In this section, we summarize results of the literature review and interviews with SMEs and key informants. The state is also unusual in that it allows a category of care homes to operate as legally unlicensed homes. Available at http://www.ncjrs.gov/pdffiles1/nij/grants/229299.pdf. Texas Health & Human Services Commission. 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). Many SMEs reported that persons with severe and persistent mental illness are the majority of residents in unlicensed residential care homes. In Georgia, the number of complaints about unlicensed facilities rose from 253 in fiscal year 2013 to 293 in fiscal year 2014, with at least one-third of claims being substantiated. But there are homes providing room, board, and personal care that either fall outside the bounds of the state licensure requirements or are deliberately avoiding state licensure requirements. Examples of financial exploitation described by key informants include the operator becoming a resident's representative payee and then withholding a resident's money, and pocketing profits while providing inadequate care and services or no services at all. have. Along with funding to cover relocation of residents, this legislation empowers state and local multidisciplinary teams to collaboratively plan and coordinate efforts to identify, investigate, and pursue any necessary regulatory enforcement or legal action against unlicensed facilities. Arizona Department of Health Services. One key informant in North Carolina indicated that fines for the operation of unlicensed care homes have little impact on closing the homes, are rarely collected, and are not enforceable by their agency because the operation of an unlicensed care home is considered a criminal offense, and thus under the purview of law enforcement. And regardless of whether states have regulations concerning unlicensed homes, many operators choose to operate illegally unlicensed homes. Key informants at the state level were able to provide estimates of the number of complaints they have received pertaining to unlicensed care homes, but not estimates of the number of unlicensed care homes. State regulations appear to vary widely in regards to ombudsman jurisdiction. Pennsylvania DPW highlights safety and care regulations at personal care homes. State key informants emphasized that they could not make estimates about the scope of abuse and exploitation issues because unlicensed care homes are not systematically monitored. Retrieved from http://www.miamiherald.com. Another strategy is the creation and involvement of interagency and multidisciplinary teams at the state and local levels, which based on our key informant interviewsappears to be a successful strategy. It is important to note that legally unlicensed care homes are not typically tracked by local community agencies, organizations or states. That makes it difficult for the licensing agencies to understand what's going on because they don't have the information and aren't privy to it.". Specific concerns included: Managing resident medications improperly. The AAA office, APS, Disability Rights Network, and state or regional licensure offices can receive complaints concerning resident care that may lead to the discovery of illegally unlicensed personal care homes. Absent assistance from the ombudsman or other support in finding affordable licensed care options, unlicensed care homes may be the only option these individuals have. Poor quality of care, instances of physical abuse, toxic combinations of medication, and use of stun guns, were also reported (National Association of Medicaid Fraud Control Units, 2015). Ombudsmen. In Texas, a residential care home (also known as a PHC and CAS provide in-home personal attendant services (PAS) to individuals eligible under Title XIX Medicaid or under 1929 (b) (2) (B) of the Social Security Act, respectively. 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. (2013). This key informant indicated that this change likely increased the need for licensed group homes, and unlicensed group homes may have also opened as a way to fill the need created as a result of these closures. In addition to the $100 per resident per day fine placed levied against unlicensed facilities, a representative of the state reported that the Georgia legislature has added operating an unlicensed personal care home, which is a criminal offense, to the list of crimes that make it impossible to apply for a license to operate a personal care home. Georgia was selected as a state for our site visit because of the state's actions surrounding unlicensed care homes described during interviews with SMEs, and the numerous news reports about unlicensed care homes in the state. All Rights Reserved. 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. In the District of Columbia, an ombudsman reported that they were involved in collaborative efforts with University Legal Services, Department of Mental Health, Department of Accountability and other groups, such as APS. No positive literature was found, which, as noted earlier, may be reflective of the fact that nothing is published about these places unless they are discovered because they are being investigated for poor care or resident exploitation or abuse. custodial or intermediary care. Like the SME interviews, each key informant interview began with a general question to ascertain what the interviewee knew about unlicensed care homes. 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. 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). example, if your mother requires skilled care, Medicare will cover 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. 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. Reporters from the Atlanta Journal-Constitution analyzed thousands of inspection reports and interviewed state and local officials, social service providers, and advocates, and then published a series of articles on the status of affairs in unlicensed residential care homes (Schneider & Simmons, 2012a; Schneider & Simmons, 2012b; Schneider & Simmons, 2012c). 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. 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. PDF FAQ About Unlicensed Personal Care Homes - Department of Human Services Retrieved from http://www.dads.state.tx.us/providers/alf/howto.html. The Allegheny County PCRR has sent letters to hospitals and their discharge planners informing them about known illegally unlicensed personal care homes to which they should not discharge patients; however, according to two key informants, discharges to these homes have continued. Key informants from Georgia and Pennsylvania reported that hospitals and hospital discharge planners (or their contractors) often place patients in unlicensed care homes (described in more detail in Section 4). However, as recently as 2013, the number had decreased to ten enforcement actions. However, we did not hear any specific examples of this from the state or local level. 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. For example, is it defined by the services the home offers, the services needed by residents, or the services provided to the residents in the unlicensed care setting. Licensure staff admitted they only learn about the unlicensed facilities when someone reports them. This department can request administrative search warrants to enter suspected illegally unlicensed personal care homes. Site visit findings were largely consistent with those of the environmental scan, and despite increased attention to unlicensed care homes in some states, key informants highlighted issues of safety, abuse, and exploitation. Study findings should be viewed in light of these limitations. Three-bed residential care homes are lawfully allowed in at least one state. Another motivation to operate an unlicensed care home, equally mentioned by key informants, relates to costs directly associated with meeting building code requirements specified in the regulations. (2012a). With one exception--Georgia--the same held true for the ten states with the greatest increase in HCBS spending since 2010: Virginia, Ohio, Maine, Rhode Island, Alabama, Tennessee, Georgia, New Hampshire, Massachusetts, and Delaware. 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. State and Local Policies Related to the Supply of and Demand for Unlicensed Care Homes. 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. 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. These legally unlicensed residential care homes are exempt from licensure because they do not provide 24-hour supervision, though residents may be receiving intermittent skilled nursing care, and help with ADLs, medication administration, and social activities. In Texas, when the bill that would have authorized DADs to inspect and license unlicensed residential care homes, legislation was enacted that permitted cities to license RCFs not licensed by the state licensure agency. In the first half of 2013, 37 other unlicensed homes had been identified. Austin, Texas. Savchuk, K. (2013). The most prevalent strategy used by state and local officials to identify illegally unlicensed care homes is responding to complaints. 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. Ombudsman programs are not adequately involved. Because these homes are legally unlicensed, the state licensure office has no jurisdiction to monitor them, but APS may receive complaints about them. These locations were selected based on their differences across the selection criteria domains described above, as well as our understanding of the environments surrounding unlicensed care homes in each of the locations, and our ability to identify potential informants in each of the selected locations. perform those activities without help. One key informant estimated that approximately 3,000 licensed personal care homes have ceased operations in Allegheny County since the 2005 regulatory changes. Out of State Nursing Facility Admissions - Texas Informants stated that Allegheny County has other specific contextual issues that may contribute to the existence of illegally unlicensed personal care homes. 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. Office of the Assistant Secretary for Planning and Evaluation, Printer Friendly Version in PDF Format (81 PDF pages). 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. 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. Key informants in Pennsylvania speculated that owners of legally unlicensed care homes may have direct experience operating an illegally unlicensed home or know someone operating one, and therefore may be able to help identify unlicensed homes or their operators. 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. 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. Operators of small care homes lack knowledge of licensure regulations and how to navigate the different government agencies, and there is a perceived lack of respect from government staff regarding the quality of care that non-professional staff can provide in these small residential care homes.
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