The state investigates the types of services that are provided to residents on site in order to determine if a license is required. Retrieved from http://www.ajc.com. The regional and state licensure offices are closely involved in this process. In addition to private funds, other programs such as the. 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). Pennsylvania's BHSL and the North Carolina Adult Care Licensure Office and Mental Health Licensure Office will offer to work with unlicensed residential care homes to help facilitate licensure. Unlicensed care homes commonly will accept these individuals and many market themselves to discharge planners. Conditions (including quality and safety) of unlicensed care homes. In North Carolina, facilities providing or arranging for housing, food service, and 24-hour scheduled and unscheduled personal care services to two or more unrelated adults must be licensed as an adult care home or a group home. Key informants in metro Atlanta also indicate that the state conducts interviews with residents during investigations and closures of unlicensed home to gain a better understanding of how individuals end up in these homes. A few key informants suggested cross-referencing different agency lists as another potential source for identifying unlicensed care homes. Two key informants noted that they only see the worst cases of illegally unlicensed personal care homes, so they could not offer examples of adequate or good care that may occur in those they do not investigate. 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. Based on our exploratory research, we found that a number of factors may have an effect on the demand for unlicensed care homes. 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. Key informants did not offer any information on potential ways to identify unlicensed care homes or existing databases of these places. One key informant estimated this hospital served 3,700 patients at its peak. 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. Ombudsman programs are not adequately involved. By interviewing residents of unlicensed care homes, HFR is trying to understand the pathways that individuals take to end up in these situations. 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. Some SMEs noted that many licensed facilities are unwilling to admit or retain individuals with severe and persistent mental illness, intellectual disabilities, or challenging behaviors. One SME, who was a firefighter and paramedic who has responded to calls from several unlicensed care homes, stated that he often had more comprehensive listings of unlicensed care homes than the local ombudsman. This 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. Interview findings also suggest that research is needed on the best strategies for identifying unlicensed care homes and effectively closing them down. Like the SME interviews, each key informant interview began with a general question to ascertain what the interviewee knew about unlicensed care homes. However, as recently as 2013, the number had decreased to ten enforcement actions. sleeping hours and must be capable of following directions under For example, Georgia reported an increase in complaint calls about unlicensed residential care homes from 2013 to 2014. Funds are being allocated to relocate residents out of unlicensed residential care. In some states, residents can pay for their own personal or medical care in an unlicensed facility. (Hawes & Kimbell, 2010). 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. Miami Herald. need for senior care services and the choice of a facility is an 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. Following the development of the initial list of SMEs, we divided the list into two categories: (1) a subset of individuals identified as "key experts" who would be prioritized for interviewing because we determined they had relevant information related to unlicensed care homes; and (2) individuals identified as "potential experts" who would first be vetted to determine their level of knowledge about unlicensed care homes. 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. Personal board and care homes: A hidden population in Anne Arundel County. Retrieved from http://www.miamiherald.com. Ten states (Delaware, Georgia, Louisiana, New Jersey, New Mexico, North Carolina, Oklahoma, Rhode Island, South Carolina, and Washington) require residential care homes to be licensed if they have at least two beds. 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. However, unlicensed care homes, which provide room and board and some level of personal care services, but are notlicensed by the state, fill some of the gaps in the availability of housing and services for these populations. For example, key informants in Allegheny County, Pennsylvania, stated that police in rural areas of the county are more responsive to reports of unlicensed care homes than are the city police. Strategies for Addressing Conditions in Unlicensed Care Homes, 6.1. The scan included published peer-reviewed and grey literature, including abuse blogs and media reports about legally and illegally unlicensed residential care homes. Key informants recommended more proactive strategies for identifying unlicensed care homes, such as tracking individuals' benefits (e.g., SSI) to unlicensed care homes, obtaining lists of unlicensed care homes from health care and advocacy organizations that refer individuals to them, and utilizing owners of licensed or legally unlicensed facilities as a source of information about illegally unlicensed care homes. Licensed personal care homes are required to assist with personal services, supervise self-administration of medication, and provide social activities, as needed. Retrieved from http://www.dallasmorningnews.com. Key informants for each site visit location included representatives of local public safety organizations such as law enforcement or firefighters, Adult Protective Services (APS) staff, and ombudsmen. 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. Fourth, study findings also suggest that efforts are needed to understand the differences in conditions between legally and illegally unlicensed care homes, as well as how illegally unlicensed care homes successfully evade licensure. Available at https://aspe.hhs.gov/basic-report/compendium-residential-care-and-assisted-living-regulations-and-policy-2015-edition. 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. In 2012, the state mandated that large adult care homes (seven or more beds) housing only individuals with mental illness had to close because they were considered institutional settings. (2015). We found a number of publications and media reports in both Florida and Texas (e.g., the Miami Herald newspaper series in Florida, and the U.S. Department of Justice report in Texas), and a few media reports and a research report on unlicensed care homes in Maryland; however, these states were not selected as site visit states. Many publications also focused on quality of care or other issues related to unlicensed care staff. These increased costs have also impacted the populations that licensed care homes will accept, according to multiple key informants. Some of these homes also serve mixed populations (e.g., elderly residents as well as individuals with severe and persistent mental illness). Second, the findings highlight the need for federal and state agencies to determine the nature and scope of financial fraud being committed by operators of unlicensed residential care homes. Arizona Department of Health Services. Some larger facilities operate as unlicensed "residences" by requiring residents to contract with a separate corporation for provision of all ADL or nursing services. SMEs mentioned the lack of SSPs to residential care home residents who receive SSI as a factor that encourages the existence of unlicensed care 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. Per state regulations, this is not considered a permanent structure, and therefore does not meet the appropriate building requirements to be a licensed facility. supervision, assistance with activities of daily living and Therefore, it's always a good idea to ask 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. Failed Legislative Efforts to Improve Oversight. Personal care homes, also known as a residential care facility, provide 24-hour access to personal care, as well as nutrition and wellness services designed specifically for older. 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. However, gaps in our knowledge about unlicensed homes remain, and several issues raisedduring interviews with key informants warrant further investigation. Study findings should be viewed in light of these limitations. be physically and mentally capable of evacuating the facility Retrieved from http://www.gachiefs.com/pdfs/White%20Papers_Committee%20Reports/AtRiskAdultAbuseWhitePaper.pdf. Licensure offices and other agencies or organizations respond to complaints made by concerned citizens, including family members and friends of residents, neighbors of unlicensed care home operators, health care providers serving unlicensed care home residents, firemen, ambulance services, police, and licensed care home operators. 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. The NDRN P&A reportedly has suggested that SSA require representative payees to self-identify if they own a residential care home (licensed or unlicensed). In contrast, most key informants agreed that some operators start out with a smaller one to three bed legally unlicensed home and gradually end up caring for more residents, not realizing that doing so requires the home to be licensed. Several key informants reported that unlicensed care home operators "troll" the psychiatric wards of facilities like Grady Memorial Hospital, looking for residents. Strategies for Identifying Unlicensed Care Homes, 5.4. The frequently reported act whereby the operator of an unlicensed home makes money from their control of vulnerable residents and moves these residents from one unlicensed care home to another to avoid detection, led one SME to refer to it as "human trafficking." 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. 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. Multiple key informants reported that financial exploitation was the biggest concern surrounding unlicensed care homes. Media reports described operators that continued to operate after their licenses expired or were revoked. Residential care homes that serve three or fewer residents are legally unlicensed in this state. SMEs indicated that such reports can be used to identify unlicensed care home operators. In one state, Pennsylvania, three bed residential care homes are legally unlicensed. Advocates reported a growing number of unlicensed facilities and difficulties distinguishing them from boarding homes or other types of RCFs. Strategies to Identify Unlicensed Care Homes. Currently, 46 states provide some type of SSP (SSA, 2015). 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. 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. The fact that four people should have been receiving personal care services made the home eligible for licensure as a residential care home--not the fact that three people were receiving the services (which would make it under the legal limit). All states license residential care such as assisted living, and most states license small adult care homes, often referred to as adult foster care (Carder, O'Keeffe, & O'Keeffe, 2015). 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. Retrieved from http://www.dhs.state.pa.us/cs/groups/webcontent/documents/report/p_011015.pdf. The Assistant Secretary for Planning and Evaluation (ASPE) is the principal advisor to the Secretary of the U.S. Department of Health and Human Services on policy development, and is responsible for major activities in policy coordination, legislation development, strategic planning, policy research, evaluation, and economic analysis. Although exploratory in nature, these findings point toward concerning issues with unlicensed care homes as well as gaps in our knowledge, and have important implications for future research on unlicensed care homes. One key informant described a recent (2015) case of human trafficking in which a care home operator who was closing a home was explicitly selling residents for $100 each to other personal care home operators. 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 . Multiple key informants also described another illegally unlicensed personal care home with several tenants, including a 91 year old man who had been tied to a chair with a sheet so he would not fall when the owner had to leave the home. Though it is outside the time period of our environmental scan, the case study describes how regulatory requirements meant for large assisted living facilities are too stringent and expensive for small residential care homes. In response, the legislature has appropriated $260,000 to relocate residents identified as living in unlicensed care 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. In this study we sought to identify: Characteristics of unlicensed care homes and the residents they serve. This results in different payment streams and different regulatory agencies that have responsibility for different residents in the same residence. 3.4.3. If the facility is providing licensable services in an unlicensed setting, the state then sends a cease and desist letter, copying the LME-MCO and the local APS. 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. He argued that comprehensive emergency management planning and proactive practices were needed to protect those at risk in unlicensed homes. A wide range of specific concerns about unlicensed care homes were identified in this study, including improper management of residents' medications; unsafe, unsanitary, and inadequate living environments; failure to adequately feed residents; and monetary theft of benefits. In Maryland, licensure is not required for a provider who serves individuals who are dependent on the provider for room, board, and control and security of their medication but do not need assistance with any ADL. Notably, reliance on complaints to identify unlicensed care homes limits identification of these homes to those that raise concerns about safety or quality. Multiple SMEs and key informants suggested following or tracking these benefits as a way to identify individuals in unlicensed care homes. what type of license they have; Type A or B - large or small. The biggest difference is that some personal care homes accept Medicaid to help cover the costs of residency. 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). Unlicensed Personal Care Homes: What You Should Know The Ombudsman program has seen a sharp increase in complaints about unlicensed personal care homes. 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. 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. SMEs also discussed the fact that some residents are involuntarily discharged from licensed care homes when they exhaust their funds. 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.