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. Because of licensure standard variations, for example, homes that were legally unlicensed in Texas (e.g., adult foster care homes with five or fewer beds) were required to be licensed in California and Oregon. A 2010 report from the Pennsylvania BHSL noted that enforcement actions against illegal personal care homes had increased from four homes in 2009 to 27 in 2010 (most were located in the Philadelphia area). Unlicensed homes tended to flourish in larger cities where there were significant numbers of low-income elderly and people with mental illness released from state mental hospitals. Several key informants reported that unlicensed care home operators "troll" the psychiatric wards of facilities like Grady Memorial Hospital, looking for residents. Further details on findings from the environmental scan can be found in Appendix B. Anne Arundel County Fire Department, Millersville, Maryland. 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 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. required. Another interviewee suggested that it is becoming more difficult to recruit individuals to be Dom Care operators because of the competing demands on their time. Key informants in all three site visit states provided examples of how this might happen. Retrieved from http://www.dads.state.tx.us/providers/alf/howto.html. might not do well with the larger assisted living facilities. Miami Herald. Large Large facilities are defined as those with 17 residents or more. While it is outside the scope of this project to investigate alternatives to unlicensed care homes, we speculate that increasing the supply of alternatives for affordable housing with services would reduce the market for unlicensed homes. 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). 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. 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. (2015). Key informant interviews focused on local context, state and local policies that may impact or affect the demand for unlicensed care homes, and informants' direct experiences with unlicensed care homes. Additionally, what we heard about the policies that affect demand for and supply of unlicensed homes, and how unlicensed homes can be identified or detected, may not be representative of the situation in other states. unlicensed personal care homes are a . Strategies used to address health, quality and safety issues in unlicensed care homes. The aging housing stock in Allegheny County was also a cause of concern for a few key informants, as it relates to the number of pre-existing buildings that cannot meet the state regulatory building code requirements for licensed personal care homes. Qualitative Health Research, 14(4), 478-495. The PCRR teams in Pennsylvania are similar, and are based at the local level working in coordination with state licensure offices. 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. 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. 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. Residential care homes that are legal often serve as covers for or conduits to illegal homes. lists. Incentives this modest provide little encouragement for residential care homes to incur the cost of licensure if their primary clientele has only SSI to pay for care. In Michigan, residential care homes that provide room, board, supervision, and protective oversight, but not personal assistance with ADLs or medication assistance (residents can contract out for personal care), are not required to be licensed. As part of this study, we sought to identify potential data sources or listings of unlicensed care homes that may be useful in efforts to understand how widespread unlicensed care homes might be, and whether these settings can be identified for future research purposes, both in the states we visited and in other states. Six states (Colorado, Iowa, Illinois, Maine, Missouri, and Vermont) license starting at three beds; Vermont exempts small private-pay homes. These findings highlight a set of potentially serious problems and issues. Some states allow them to assist with medication storage but not with ADLs. APS professionals there estimate three reports or complaints about unlicensed personal care homes every month in the metro Atlanta area, and about one complaint or report about unlicensed personal care homes every three months in rural areas of the state. 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. Each of these agencies is able to address different elements of the complex situations that exist within unlicensed care homes, including the needs of residents, as well as issues with the building and any criminal acts of the operators. One key informant suggested that lists of available housing maintained by a local homeless housing assistance program may include illegally unlicensed personal care homes. We completed 17 interviews with SMEs. In the view of the majority of key informants, the operators of unlicensed homes do not want to have to pay for more staff to provide needed services. 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. Nevada stated that no interagency procedures were in place to handle complaints about unlicensed board and care homes in a timely and efficient manner (Ryan, personal communication). (n.d.).Retrieved from http://www.agingavenues.com/topics/assisted-living-facilities-in-indianapolis-indiana. 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. Although little is known about unlicensed care homes, a variety of signals, including media reports, highlight potential safety and quality concerns. Also, the information collected from newspapers, ombudsmen, APS staff, or other agency reports (by their very nature) skew towards negative events. This department can request administrative search warrants to enter suspected illegally unlicensed personal care homes. There were several reports of false imprisonment of residents who were kept locked in residential homes, sometimes deprived of their identification papers in Florida, Georgia, Indiana and Texas. 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. Newspaper articles regularly highlight the plight of frail elderly residents being abused, neglected, and financially exploited by "caretakers." In accordance with your contract, and contracting rules at 40 Texas Administrative Code 49.302(g), you must subscribe to receive HHSC email updates, using this GovDelivery signup, and select Information Letters, Provider Alerts and the contract program type(s). Perkins, M., Ball, M., Whittington, F., & Combs, B. As a result, we also examined HCBS expenditures in a select number of states. Detecting, investigating and addressing elder abuse in residential long-term care facilities. Pennsylvania Department of Public Welfare. When you sign up for email updates, you are giving your information to both HHSC and to Granicus. 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. More information exists about licensed RCFs than unlicensed care homes, thus knowledge of the unlicensed care homes is limited. 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. Some of these homes are legally unlicensed while others operate illegally. A few strategies exist in the state for addressing illegally unlicensed personal care homes. 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. The following acronyms are mentioned in this report and/or appendices. In Iowa, legislation to restrict the actions of some operators of large licensed assisted living facilities to recategorize or redefine themselves as a "residence," (e.g., boarding home) that does not require licensure was proposed but did not pass. Although these regulatory changes occurred ten years ago, multiple key informants reported that many more licensed personal care homes have continued to close in recent years. Public funds, like state supplements, are inadequate. help cover the costs of residency but typically have long wait They residence most often within a subdivision that provides personal Key informants described the way the teams function. Health Management Associates. 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. The first, a six-state study on elder abuse in RCFs conducted by Hawes & Kimbell (2010) for the U.S. Department of Justice found that unlicensed homes remain a serious, largely unaddressed problem in some states, with the magnitude of the problem remaining unknown. Because these homes are legally unlicensed, the state licensure office has no jurisdiction to monitor them, but APS may receive complaints 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. Consequently, although we attempted to elicit information about the positive aspects of unlicensed care homes, key informants largely provided us with a less favorable view of unlicensed care homes. Arizona Department of Health Services. Key informants noted that it is important to know the history of Pennsylvania's personal care home regulation changes in order to understand why and how the state has addressed illegally unlicensed personal care 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. There is a critical challenge of providing housing and supportive services for particularly vulnerable groups, including individuals: who have severe and persistent mental illness or other disabilities, were formerly homeless, or older adults who have limited financial resources. 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. Miami Herald. 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. 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. costs while your loved one is living at a certain facility. 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. In Pennsylvania, facilities providing or arranging for housing, food service, and one or more personal care needs for four or more unrelated adults must be licensed as personal care homes. (2012). Residential care homes that serve three or fewer residents are legally unlicensed in this state. They are not inspected by licensing agency survey staff, and it is very rare to see fire and other alarm systems in those settings. State inspection staff, already overwhelmed with large caseloads, are required to obtain warrants to execute searches, a time-consuming process, when trying to follow up on reports of unlicensed homes and determine whether the home is illegal. States with concerns about vulnerable adults' access to housing with services may wish to examine their admission and discharge requirements for licensed care homes. For example, one ombudsman report from Florida noted the difficulty in identifying an unlicensed care home due to the quantity and quality of evidence needed to obtain a search warrant in order to enter the home and positively identify a place as providing unlicensed care or housing residents who must be cared for in a licensed facility. Financial Exploitation, Abuse of Residents' Rights, and Program Fraud in Unlicensed Residential Care Homes, 6.4. Positive Actions by States to Improve Oversight of Unlicensed Facilities. 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. However, we did not focus on these populations in the interview. Other issues were identified during the subsequent sexual assault investigation, including abuse at the hands of the operator who beat the residents, false imprisonment in which individuals were locked inside rooms, and financial exploitation. Pennsylvania Department of Public Welfare. Interview findings indicate that many residents of unlicensed care home are Supplemental Security Income (SSI) beneficiaries. 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. Through these regulatory activities, DADS protects Texas citizens who receive long-term care services. 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). And regardless of whether states have regulations concerning unlicensed homes, many operators choose to operate illegally unlicensed homes.
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