(2004). 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. This includes bothprescription and over-the- counter medications. Interviewees pointed to financial incentives related to managing SSI recipients' checks as one specific motivator. Most state licensure offices, county offices, or advocacy agencies use a complaint system to identify unlicensed care homes. Group homes generally charge less than larger assisted living communities, in . They indicated that they are unaware of any assessment of need related to licensed mental health group homes in the state. At the local level, APS and the ombudsman have informational brochures on their agency websites for the purpose of educating individuals and families about residents' rights. 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. The Michigan Legislature Website is a free service of the Legislative Internet Technology Team in cooperation with the Michigan Legislative Council, the Michigan House of Representatives, and the Michigan Senate. One strategy recommended by key informants to address unlicensed care homes is to change the regulations to reduce the number of unlicensed care homes that operate legally. Miami Herald. 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. Please note a group home for adults may require a Home for the Aged or Adult Foster Care Home license if the level of care provided at the facility meets the licensing requirements of one of these license types, see the Department of Licensing & Regulatory Affairs, Bureau of Community & Health Systems. In addition to the church-affiliated home described above, examples of the types of places where unlicensed homes operate included an old elementary school as well as single family homes in residential neighborhoods. 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. In one court case, the judge deemed a "boarding house" as an unlicensed residential care home because only three of the six people renting rooms received personal care from the owner's licensed home care agency, even though four actually needed those services. For example, in Allegheny County, Pennsylvania, informants noted that the closure of Mayview Psychiatric Hospital in 2008 resulted in the displacement of persons with mental illness. But several judges in metro Detroit like to appoint Public Administrators as professional guardians for adults who are considered legally incapacitated.. Finally, as noted in the report, many individuals seek care in unlicensed care homes because they are in other undesirable situations, such as experiencing chronic homelessness or unnecessarily institutionalized. Some states allow legally unlicensed facilities to assist with ADLs and administer medication, but do not allow them to provide 24-hour supervision. Making changes to licensed care home regulations is one example of how states may address unlicensed care homes. As such, limited information is available about the quality of care and services provided in legally unlicensed care homes. 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). 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. Following the environmental scan, we conducted interviews with SMEs on the topic of unlicensed care homes. 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. 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). Below are examples from the environmental scan that provide some estimates of the number of unlicensed care homes: Maryland: A representative of the licensure agency estimated 500 unlicensed illegal assistive living facilities and noted the fine line between a boarding home and assisted living. ", 3.4.2. One state, Pennsylvania, begins licensure with four beds, but the state has locally certified Dom Care homes that serve 1-3 residents. 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. As noted above, placement agencies work with Allegheny County hospitals and discharge planners, therefore these agencies may also have lists that include illegally unlicensed personal care homes. 3.2.1. Available at https://aspe.hhs.gov/basic-report/compendium-residential-care-and-assisted-living-regulations-and-policy-2015-edition. 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. Furthermore, illegally unlicensed care homes continue to exist because they try to avoid detection; therefore, favorable reports of unlicensed care homes are minimal. File the complaint form by mail, fax, or e-mail. Very little discussion centered on improving the quality of unlicensed care homes. Complaints can also be received by fax, letter, or email. The State of Michigan does not license assisted living . Massachusetts exempts small private-pay homes from licensure. The nature of health and safety concerns described by key informants were wide-ranging and often included neglect and the risk of death to residents. One of the points made by key informants is that states have very few, if any, strategies to easily identify unlicensed care homes. Key informants in all three site visit states provided examples of how this might happen. 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. Costs for bringing the building up to code to meet state regulatory requirements may be another reason why operators of care homes choose to remain unlicensed. 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. Multiple key informants also stated that a Dom Care operator with the maximum of three individuals may be considering adding other residents or has possibly tried it before, therefore interviews with some Dom Care Operators may yield a unique perspective on the motivations to operate unlicensed care homes. In addition, states differ in whether they provide additional funds to the ombudsman program, over and above the federal funds from the Older Americans Act. Most interviewees reported that the personal care home regulation change in 2005 caused a loss of small personal care homes due to the increased costs associated with meeting the standards set forth in the regulations. Discussions with key informants in the state suggest Georgia has a high prevalence of these homes. Key informants described a coordinated effort between the state licensure offices and the local group care monitoring office once there is recognition that a complaint call is about an unlicensed facility. Currently human trafficking is defined as "the act of recruiting, harboring, transporting, providing, or obtaining a person for compelled labor or commercial sex acts" (U.S. Department of State, 2015), however, one SME recommended expanding this definition to include the situation in which an administrator for the unlicensed care homes seize and maintain control of vulnerable individuals in order to maximize revenue by taking the public benefits that the individual may be receiving. Two of our three site visit states aimed to enhance awareness of poor and inadequate unlicensed care homes by increasing education for the public and key stakeholders: Pennsylvania held a statewide education and marketing campaign to inform the public about unlicensed care homes, and Georgia conducted training sessions to educate law enforcement and first responders about these homes. Texas Department of Aging and Disability Services. 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.". These are Alaska, Arizona, Arkansas, Connecticut, Florida, Hawaii, Idaho, Indiana, Kansas, Kentucky, Massachusetts, Michigan, Minnesota, Montana, Nebraska, Nevada, New Hampshire, New York, North Dakota, Ohio, Oregon, South Dakota, Texas, Utah, Virginia, West Virginia, Wisconsin, and Wyoming. Areas for future research and potential data sources related to unlicensed care homes. (2013). 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. Maryland, Mississippi, and the District of Columbia have no minimum bed size for licensure, implying that some residential care homes can be legally unlicensed. As described by the majority of key informants, the primary motivation to maintain an unlicensed care home is to maximize profit. What is the scope of concerns in unlicensed care homes, including quality of care, safety, sexual or physical abuse, and financial exploitation concerns? However, our key informants (including representatives of adult protective services, ombudsmen programs, and police and fire departments) were informed about unlicensed care homes only in response to complaints or emergencies, which may have biased their views of these homes. Retrieved from https://aspe.hhs.gov/report/medicaid-residential-care. Retrieved from http://www.ajc.com. SMEs and key informants consistently noted that many low-income individuals cannot afford licensed facilities, which makes the less expensive unlicensed care home an attractive option, and thus contributes to the existence of unlicensed care homes. 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. In contrast, one key informant stated that one repeat illegally unlicensed facility had housed residents who had thrived there and had benefited from living in the home. One key informant noted that the state or the LME-MCO can conduct follow-up to assess whether a facility that received a cease and desist letter does, in fact, close down. Some of these homes also serve mixed populations (e.g., elderly residents as well as individuals with severe and persistent mental illness). He said, well youre supposed to and I can name several violations right off the top, said Klavinger. Most of the literature or media reports were not specific about the types of residents served in unlicensed residential care. The state's annual Personal Care Homes Report provides the number of illegally unlicensed personal care homes that result in enforcement actions and details the historical trend of the number of enforcement actions taken against illegal unlicensed personal care homes. Some of these housed mainly older residents. 3.4.4. As states are working to meet their ADA obligations as reaffirmed in Olmstead vs. State inspection staff, already overwhelmed with large caseloads, were required to obtain search warrants to execute searches, a time-consuming process, when trying to follow up on reports of unlicensed homes. Federal government websites often end in .gov or .mil. The licensing rules for Adult Foster Care and Home for the Aged facilities provide minimum standards for these regulated facilities. Some residents were also described as transitional or homeless, while others were described as persons with substance use disorders. 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. 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. Local efforts were noted to be inconsistent and uncoordinated because authorities were unfamiliar with the laws. One key informant shared a specific example of an operator targeting individuals in hospitals: "Hospitals are putting them on the street. 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. 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. New stringent eligibility criteria for state plans to cover services in group homes serving persons with mental illness have reportedly made it financially difficult for the adult care homes and group homes to continue operating, and some have reportedly been forced to close. Finally, in some states, SMEs and the environmental scan identified legally and illegally unlicensed residential care homes that were referred to as boarding homes or board and care homes. The issue of financial exploitation is described in detail in Section 3.3.2. Hawes, C. & Kimbell, A.M. (2010). (2015). There was not much attention paid to the original sources who identified an unlicensed facility, but in some articles or media reports, the case came to light due to a death that occurred in the facility that had to be investigated, neighborhood complaints of numerous vans, ambulances or police cars at the home, or calls from concerned family members about the status of a resident. Additionally, several SMEs and key informants noted that in many cases unlicensed homes are the only option, other than homeless shelters or living on the streets, for some of these 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. Information from interviews with key informants also revealed incidents of emotional and physical abuse, including intimidation, and threats. It is worth noting that this research activity would require developing an operational definition of "unlicensed residential care home," since definitions vary considerably across and sometimes within states, as some focus on services offered, some on size, and some on the characteristics of the residents. 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. However, residents may pay for such services or receive them through Medicaid waivers. One SME pointed out that many unlicensed care home cases are analogous to human trafficking, such as when residents are held against their will and then moved from one location to another to avoid detection; however, the current federal definition of human trafficking specifies that the trafficking is done for the purpose of labor or sex, and not for the collection of public benefits (U.S. Department of State, 2015). Clarisse Carter runs Due Season Residential Services LLC, the unlicensed group home in Warren. 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. 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. Future research examining the role of hospital discharge planners and strategies to prevent discharge to unlicensed care homes appear warranted. This material may not be published, broadcast, rewritten, or redistributed. 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. Notably, most key informants said the operator of a licensed home may also operate one or more unlicensed homes, often in the same neighborhood and often in collaboration with friends or family members. Interview findings indicate that a key element of a successful strategy is collaboration across multiple agencies. If you want to see if a certain group home is licensed, please click here. One Florida media report estimated there were hundreds of congregate living facilities across the state that escaped state oversight because no agency regulates them (Savchuk, 2013). The objective of the literature review was to identify current information (2009-2014) on both legally and illegally unlicensed RCFs and to inform the conduct of SME interviews and site visits to communities in three states. Calvin Leslie agreed to a sentence of 10 to 25 . Potential Data Sources or Listings of Unlicensed Care Homes, 5.3. QX;zI!({?^2'hy^xe(z>! 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. According to the report, these warehoused residents are vulnerable older adults with "hard to place" mental health needs and paroled individuals. Thus, unlicensed care home operators are known to directly market themselves to hospitals and to pick up patients at the hospitals when they are discharged, and some hospitals have been known to pay a month of the residents' fees at the unlicensed home to secure a quick discharge from the hospital. Other estimates of the number of unlicensed care homes in the state range from 500 to 1,500 within one metropolitan area. 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. Illinois: A story released on the This American Life radio podcast described a scam where individuals with substance use disorders were sent from Puerto Rico to supposed rehabilitation centers in Chicago where they were to be provided with housing, food and counseling services, only to find themselves in crowded, unlicensed rehabilitation centers, their passports and other identifying information taken from them. Some publish notices of how and where to report unlicensed care facilities. The research team interviewed 12 key informants in Georgia. In addition, SMEs noted variability across states in the availability of resident advocacy and protection through such agencies as the ombudsman program. Licensure agencies in only three (Texas, Alabama, and New Mexico) of the six states studied in the U.S. Department of Justice Report (Hawes & Kimbell, 2010) acknowledged a significant problem with unlicensed facilities. Zoning Approval for Group Child Care Homes only (BCAL-3748). Sallah, M., Miller. Three states (District of Columbia, Maryland, and Mississippi) have no minimum bed size for licensure, implying that some residential care homes can be lawfully unlicensed. 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. Both the information we collected about unlicensed homes in the literature review and that which we collected through interviews mostly paint a negative view of these settings. The state regulatory agency can send letters to illegally operating facilities and fine them $500. 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. 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. Retrieved from http://www.ajc.com. One key informant indicated that this reduction is due to the increasing numbers of HCBS waivers giving potential Dom Care residents the option to live alone in apartments. Which agencies get involved when addressing unlicensed care homes? Residents of unlicensed care homes are vulnerable adults. If you seek a pleasant peninsula, look about you. Michigans official state motto holds many truths our state is a land of great splendors. 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. 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. Adult residential licensing, 2010 annual report: A report on licensed personal care homes. 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. 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. Her e-mail addresses is: Emily.Rosenoff@hhs.gov. They also noted that, despite receiving payment for room, board, and services, some unlicensed care home operators provide subpar or poor quality accommodations and services to residents. This implies that the LME-MCO does not always check licensure status before coordinating services in unlicensed group homes. Tobia, M. (2014). ~DNe*FYil2`#T*$E9=`pJ. Glass, I. 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. Failing to have safety equipment available, such as smoke detectors and fire extinguishers. 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. 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.". Full of natural beauty, historical importance, and a talented, resourceful population, Michigan has it all. She was getting good care and it was something the mother could afford. From our review of states' regulatory information on licensed residential care categories during the development of the sampling frame for the 2014 National Study of Long-Term Care Providers, and our review of ASPE's Compendium of Residential Care and Assisted Living Regulations and Policy (2015), we found that 30 states require residential care homes to be licensed if they have at least one bed. 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. This had a direct impact on the operating budgets of licensed group homes. All key informants described how the Local Management Entity-Managed Care Organization (LME-MCO) oversees the provision of mental health services in Durham County. An individual thats incapacitated that needs a higher level of service, the likelihood is that that type of facility would require a license, said Larry Horvath, the Director of Michigans Bureau of Community and Health Systems. 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. Troubled Group Homes Escape State Scrutiny. We would strongly try to encourage the courts and educate the courts on that, to make sure that those guardians and placing agencies are placing them in a proper setting, said Horvath. The City of Houston established legislation that requires boarding homes housing three or more individuals to register with the city. The study by Hawes & Kimbell also provided reasons operators do not seek licensure, including: inability to meet fire safety codes (e.g., installing sprinklers), lack of state supplemental payment for SSI residents or Medicaid waiver funds (which can be restricted to licensed facilities), and avoidance of inspections and sanctions/fines for not meeting state regulation. The site is secure. Additionally key informants indicated that many unlicensed care home residents who receive SSI payments participate in Social Security's Representative Payment Program, whereby payments are managed by an individual or organization that is representing the beneficiary because the beneficiary is unable to manage the payments independently. 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. 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