DISCLAIMER: The opinions and views expressed in this report are those of the authors. No other coordinated agency efforts beyond the state licensure office, APS, and the LME-MCO were described by key informants. In addition, as one ombudsman report noted, it is often difficult to determine whether a place is an illegally unlicensed residential care home because of the difficulty of obtaining access to the suspected home to make the determination. They are not inspected by licensing agency survey staff, and it is very rare to see fire and other alarm systems in those settings. As noted in earlier sections, many unlicensed care home residents receive federal SSI benefits, and many unlicensed care homes receive these benefits directly through the SSI representative payee program. There appears to be a general lack of recognition about the extent of the problems with unlicensed residential care homes in the United States. 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. 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 utilized the information obtained in the literature review, in addition to our own expertise, that of our consultant, as well as that of U.S. Department of Health and Human Services (HHS) Office of the Assistant Secretary for Planning and Evaluation (ASPE) and the HHS Administration for Community Living (ACL) staff familiar with unlicensed care homes, to develop an initial listing of SMEs to interview. In 2013, the minimum number of ADLs needs required for individuals to qualify for reimbursement for personal care services in group homes increased. Cross-state human trafficking is another area for future research. Strategies for Identifying Unlicensed Care Homes, 5.4. Thus, no more than nine individuals were ever asked the same question. 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. 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. This task force has also coordinated raids on unlicensed homes and has pushed for changes to laws regarding these homes. One prominent case required more than 40 people in law enforcement and social service agencies to investigate and close a home, find placements for the residents being displaced, and prosecute the violators. Findings from this study are necessarily limited by the number of experts we identified and states we visited. 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. There have been limited prosecutions by the legal system. Interviewees had varying opinions on the causes for Dom Care homes closing. (2015). When HHSC has your information, it is subject to the HHSC privacy policy. 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). What types of reports of mistreatment do the agencies receive? However, there were many reports of poor conditions in legally unlicensed care homes. A facility started the license application process but did not complete it; A facility was licensed but allowed the licensure to expire; or. In California, assisted living services can be provided by a licensed home health agency in unlicensed publicly subsidized housing (low-income housing projects, apartment houses, retirement hotels, village models, and private 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. This type of admission will allow the person to enter the NF without delay and the category will alert the local authority to conduct the PE as quickly as possible. 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. The state primarily uses reports to their complaint system to identify illegally unlicensed personal care homes. We then asked questions specific to the type of SME, including: What gaps unlicensed care homes may fill in the spectrum of long-term services and supports (LTSS)? However, Medicare will cover qualified healthcare 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. One issue that remains to be determined is the conditions or criteria by which such places constitute "unlicensed residential care homes." Illegally Unlicensed Residential Care Homes, 6.3. Advocates reported a growing number of unlicensed facilities and difficulties distinguishing them from boarding homes or other types of RCFs. Because the personal care homes included in NMES were restricted to those that provided hands-on assistance with ADLs and . An ALR must provide daily food service, 24 hour on-site monitoring, case management services, and an individualized service plan. Multiple key informants described unlicensed care homes as primarily serving persons with mental illness. One key informant shared a specific case of a repeat offender that operates an unlicensed adult care home out of a double-wide trailer. State and Local Policies Related to the Supply of and Demand for Illegally Unlicensed Care Homes. In addition, the APS staff in Pennsylvania had recent communications with local hospital discharge coordinators informing them about known illegally unlicensed care homes and asking them not to discharge patients to these settings; however, key informants noted that hospital discharge planners continue discharge individuals to known unlicensed care homes. Thus, unlicensed care homes close and leave one area of the city, but reopen in another area, contributing to the difficulty of identifying and permanently shutting down these places, while also disrupting the residents' access to day services and other community-based sources of support nearby the original care home location. Notably, reliance on complaints to identify unlicensed care homes limits identification of these homes to those that raise concerns about safety or quality. SMEs also discussed the fact that some residents are involuntarily discharged from licensed care homes when they exhaust their funds. They can fine the operator directly which may lead to the unlicensed care home being forced to shut down. Another concern expressed by some of the individuals interviewed was that even those unlicensed homes that were clean or free of neglect and abuse, commonly have safety hazards and do not meet the fire safety codes required of licensed facilities. 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. Learn more in our Cookie Policy. 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. However, the effectiveness of these strategies in monitoring or otherwise addressing the prevalence of unlicensed care homes is unknown. Multiple key informants said some operators know the regulations better than the state regulatory agency and can therefore find creative ways to evade licensure. Ombudsmen program does not extend to unlicensed facilities (Hawes & Kimbell, 2010). Carder, P., O'Keeffe, J., & O'Keeffe, C. (2015). 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. Audio podcast. Once an illegally unlicensed personal care home is identified, it is tracked at the local level to see if it has moved, or, in the case of closure, if it has reopened. 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. Although a substantial amount of information and suggestions about methods of identifying unlicensed care homes came from site visits to communities in three states (Pennsylvania, North Carolina, and Georgia), whether any of these strategies will apply to other states or other communities is unclear. Copyright 2001-2022 One Maryland media report suggested residents are those released from rehabilitation centers with no families in the area. In addition to private funds, other programs such as the Learn more at www.tala.org, I am interested in opening an assisted living home in texas. This reactive strategy underscores the difficulty states and local agencies have in identifying unlicensed care homes. 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. 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. The Texas Assisted Living Association (TALA) is a Chapter of the Assisted Living Federation of America exclusively dedicated to representing professionally operated assisted-care living communities and residential homes for the aged for seniors. Health and safety concerns for residents were a major topic of interview discussion. The information collected as part of this exploratory study was intended to provide a foundation for a more complete understanding about unlicensed care homes and the gaps these homes might fill as housing options for persons with low incomes. Pennsylvania DPW highlights safety and care regulations at personal care homes. Durham County key informants estimated that since 2012, approximately five calls have resulted in cases being investigated as potential unlicensed care homes. Retrieved from http://www.miamiherald.com. 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. Some victims later found that their credit had been ruined by someone who illegally used their identity (Glass, 2015). residence most often within a subdivision that provides personal U.S. Department of Health and Human Services The scan included published peer-reviewed and grey literature, including abuse blogs and media reports about legally and illegally unlicensed residential care homes. By taking control of the resident's benefits, the operator controls the resident's funds, and should be using those funds for room and board and other beneficiary expenses. New Jersey and Tennessee have a licensure category that specifies the maximum number of beds required for licensure, but not a minimum, which also implies that in these states some residential care homes may be legally unlicensed. with the activities of daily life (such as bathing, eating, Multiple interviewees suggested that it was important to quickly involve code enforcement and local health departments in efforts to close an illegally unlicensed personal care home. The information focused on specific cases, but not on how many of these places exist in these states. One of the points made by key informants is that states have very few, if any, strategies to easily identify unlicensed care homes. On average the cost ranges between $1500 and $3000 per month for room and board. 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. 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. personal are home) is a private 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. 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. Other Research Ideas Suggested by Subject Matter Experts or Individuals Interviewed in State Site Visits. Texas Human Resources Code 42.041(b)(7) refers to an educational facility that is accredited by the Texas Education Agency, the Southern Association of Colleges and Schools, or an accreditation body that is a . In contrast, in North Carolina (and other states not included in our site visits) ombudsmen have no authority in or responsibility for residents in unlicensed care homes according to state regulations. The operator of the facility had recently received and accepted an offer to sell the house, and so was closing down the facility. These include tapping into fire/EMS databases to identify addresses of care homes that could be unlicensed, and tracking multiple SSI payments that go to a single representative payee at the same address. Schneider, C., & Simmons, A. 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). Licensure for adult care homes and mental health group homes falls under two separate state statutes, and therefore two separate regulatory offices oversee different types of licensed care homes. 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. 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. Retrieved from http://www.thisamericanlife.org/radio-archives/episode/554/not-it. Personal care homes, both licensed and unlicensed, have been found to have wide-ranging problems in meeting the health and safety needs of their residents. 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. In Georgia, they advertised themselves as licensed and admitted residents to the licensed facility and then shifted residents to their illegally unlicensed homes. 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). Revision 17-1; Effective March 15, 2017. 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. Which states have had an increase or decrease in the number of unlicensed care homes and why? Understanding Unlicensed Care Homes: Final Report | ASPE In one state, Pennsylvania, three bed residential care homes are legally unlicensed. Like the SME interviews, each key informant interview began with a general question to ascertain what the interviewee knew about unlicensed care homes. 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. Assistant Secretary for Planning and Evaluation, Room 415F 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. Regulatory changes and the role of multidisciplinary task forces (which are relevant to both legally and illegally unlicensed care homes) are described next, followed by a summary of the strategies discussed during interviews to identify and shut down illegally unlicensed care homes and to monitor and improve quality in legally unlicensed care homes. Texas Department of Aging and Disability Services. Senior Care & Assisted Living Services South Carolina Assisted Living Facilities, Care Homes, Senior Housing $249,000. In Texas, a residential care home (also known as a Also, new HHS Centers for Medicare and Medicaid Services (CMS) policies on waivers and where waiver services may be provided may alter the prevalence of legally and illegally unlicensed care homes across the nation. Medicare is more often used to pay for a skilled nursing facility endorsement or approval of such websites, products, services or One way to collect this information to develop a frame of unlicensed care homes and conduct a small scale study of unlicensed care home operators. Benefit), may be available to help pay for room and board. building safety features. Office of the Assistant Secretary for Planning and Evaluation, Printer Friendly Version in PDF Format (81 PDF pages). 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). Licensure agencies in many states lack the legal authority to inspect, require plans of correction, or fine these unlicensed facilities. Overall, the local agency representatives described the condition of unlicensed care homes as unsafe. Conditions (including quality and safety) of unlicensed care homes. See http://www.disabilityrightswa.org/stop-fraud-and-abuse-rep-payees. 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. The literature review was not an exhaustive effort, but rather a targeted scan of information on unlicensed care homes in the peer-reviewed and grey literature, abuse blogs, and media reports. Strategies for Addressing Issues in Legally and Illegally Unlicensed Care Homes, 3.6. Most residential care homes have private rooms available Many interviewees mentioned monetary motivations of operators as one factor. Policies affecting the supply of and demand for unlicensed care homes. Residential Care providers must be licensed as an assisted living facility and have a contract with the Texas Health and Human Services Commission. As a direct result of this regulation change, many personal care homes in Pennsylvania became illegally unlicensed and either shut down, became licensed, or continued to operate illegally. Glass, I. Although limited in scope, the study provides foundational information about unlicensed care homes based on a narrow review of the literature and the reports of select SMEs and key informants in three states. Each of these factors is discussed in more detail in the sections that follow.
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