Like the SME interviews, each key informant interview began with a general question to ascertain what the interviewee knew about unlicensed care homes. And regardless of whether states have regulations concerning unlicensed homes, many operators choose to operate illegally unlicensed homes. 3.4.5. One former fire department battalion chief reported that the elderly living in unlicensed residential care homes are hidden from the view of public health agencies, social service agencies, and ombudsman programs --the entities that generally protect and advocate for older people and individuals with disabilities. Operators often gain control of residents' funds by becoming the representative payee for residents receiving SSI, a common payer source in unlicensed residential care homes. 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. Due to services being brought into these homes, interviewees thought further interviews with home health staff or hospice staff may yield additional information or lists of unlicensed personal care homes that may include illegally unlicensed establishments. While some unlicensed homes reportedly serve elderly and physically disabled residents, key informants noted that many also serve persons who were formerly homeless, persons who may have substance use disorders, persons with severe and persistent mental illness, and parolees. 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). Balancing a rewarding career with the ability to have a high-quality lifestyle is important. This, they fear, could lead owners to operate illegal unlicensed personal 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. Key informants described the way the teams function. Although we attempted to conduct interviews with operators of unlicensed care homes on our site visit states, we could not identify or gain access to any. We targeted site visits in communities that varied according to whether the state: (1) has legally unlicensed care homes; (2) has a list of unlicensed care homes; and (3) ranks among the highest or lowest in HCBS waiver expenditures. Assisted Living Facility (ALF) - Residence for at least 3 unrelated adults, at least 80% of whom are age 55 or older. General searchterms included unlicensed, not licensed, unregulated, adult, elderly, residential care, and assisted living. One key informant shared a specific case of a repeat offender that operates an unlicensed adult care home out of a double-wide trailer. 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. We found reports of Medicaid fraud in unlicensed care homes in Florida and Nevada between 2009 and 2014 involving charges of false imprisonment, resident neglect, grand theft, and/or operating an unlicensed assisted living facility (National Association of Medicaid Fraud Control Units, n.d.). Troubled residents languish in flophouses. Available at https://aspe.hhs.gov/basic-report/compendium-residential-care-and-assisted-living-regulations-and-policy-2015-edition. 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. Savchuk, K. (2013). 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). Several key informants reported that unlicensed care home operators "troll" the psychiatric wards of facilities like Grady Memorial Hospital, looking for residents. azmfairall. Agencies have inadequate resources or authority. 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. Site visit locations were based on the information gathered in the environmental scan, SME interviews, and a review of residential care regulations. One interviewee estimated that at its peak, this hospital served 3,700 patients. In addition to serving the elderly, personal care homes can exclusively serve persons with serious mental illness and/or intellectual and developmental disabilities, on condition that the home is appropriately staffed and is capable of providing the needed care within the scope of its license. In the recent past, the state has had public education campaigns to inform the public about illegally unlicensed personal care homes. Hawes, C., & Kimbell, A.M. (2010). Although the scope of our research was limited--involving a small number of interviews with subject matter experts (SMEs) and interviews with informants in three communities in three states--the findings have relevance for national, state, and local policies and practices and for future research. In fact, these concerns extended across illegally and legally unlicensed homes, and some stakeholders reported these concerns also exist about care being provided in some licensed residential care homes. &qcfcO%P>s]w auN y6+@ pP ^aAIT6d\cl?` -9'gr61,=.X YW={r23bK(L+k 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. In preparation for closing, the operator "turned over the residents to other operators for a fee of $100 per resident.". Retrieved from http://www.miamiherald.com. 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. This makes it difficult, if not impossible, for residents to leave the facility, a difficulty sometimes exacerbated by limiting residents' access to their funds, to the facility phone, and, as noted above, by locking residents in their rooms or the facility. Consistent with information from the environmental scan, key informant interviews indicate that some unlicensed homes use basements to house residents, including residents who do not have the capacity to exit safely in the event of a fire or similar emergency, such as those who are unable to climb the stairs and those receiving hospice care. State informants did not provide information on the services provided in the unlicensed care homes stating that that the sample of unlicensed care homes they see is too small to make an accurate approximation of the conditions. 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. In 2006, HB 5245 Created a medication technician pilot program involving 30 A local ombudsman and APS supervisor lead the PCRR team and maintain lists of both known illegally operating homes and those that are potentially illegal operations. Perils in personal care homes. Pennsylvania DPW highlights safety and care regulations at personal care homes. According to a six-state study conducted by Hawes & Kimbell for the U.S. Department of Justice (National Institute of Justice) in 2010, when seriously substandard quality, neglect or abuse were discovered in unlicensed facilities, some closed the home in question but shifted residents to other legally or illegally unlicensed care homes to avoid detection or penalties. Qualitative Health Research, 14(4), 478-495. It is important to note that we do not know whether the types of financial exploitation and abuse described by the SMEs and key informants occur in both legally and illegally unlicensed care homes, or how commonplace they are. Additional key informants participating in interviews during site visits included local hospital discharge planners (North Carolina), representatives of organizations providing services to residents of unlicensed care homes (Georgia), and local advocacy organizations including National Alliance on Mental Illness (NAMI), Disability Rights North Carolina and Disability Rights Network of Pennsylvania. Schneider, C., & Simmons, A. At least two states have demonstrated that coordinated efforts can effect changes to laws and policies and create at least initial disincentives or barriers to the operation of illegally unlicensed care homes. The closure of large mental health institutions and concomitant transition of previously-institutionalized individuals with severe and persistent mental illness to community-based care settings, such as legally unlicensed care homes. 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. Also, the information collected from newspapers, ombudsmen, APS staff, or other agency reports (by their very nature) skew towards negative events. Some have residents that receive Medicaid funded services. Results of key informant interviews from site visits, as well as the SME interviews and the literature review, are presented in the Findings section that follows. This material may not be published, broadcast, rewritten, or redistributed. Multiple key informants discussed the impact that policy changes regarding community-based care have had on unlicensed care homes in their communities, including state efforts to comply with the Americans with Disabilities Act (ADA) requirements. Key informants also commonly described the conditions in unlicensed care homes as abusive, financially exploitative, and neglectful of residents' basic needs, and depicted situations that involved false imprisonment of the residents and repeatedly moving the residents from one facility to another, both within and across states, to evade law enforcement. Florida publishes a listing but it does not correspond with the media reports of the number of unlicensed care homes identified by state inspectors. This is evidenced by the number of reports and complaints received about unlicensed personal care homes, the number of hours spent by law enforcement officials on investigating unlicensed personal care homes, and the estimates given of the numbers of unlicensed care homes that are operating in the state (reported by one informant as one unlicensed care home for every licensed home). 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. Some states allow legally unlicensed facilities to assist with ADLs and administer medication, but do not allow them to provide 24-hour supervision. The goal of this study was to provide foundational information intended to answer or provide insight into the study research questions. (Producer). Typically, the reports refer to physically or mentally disabled adults, some with disease specific conditions, or just described as mentally ill or elderly. 4GEMS ADULT FOSTER CARE. 3 0 obj Public funds, like state supplements, are inadequate. This conflicted with other media reports that describe Arizona citizens calling for closing the loopholes in state laws to prevent "imposter" senior living facilities that use false advertising (Azmfairall, 2013). The vast majority of key informant reports emphasize often alarming conditions in unlicensed care homes. Treatment of residents as a commodity was a common theme across interviews. Care must be provided in a private home where the licensee is a permanent resident and household member. 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. Some residents were also described as transitional or homeless, while others were described as persons with substance use disorders. Notably, the strategy of responding to complaints limits the amount of information available about unlicensed care homes about which complaints are not made (i.e., possibly better quality homes). In the past few years, Georgia has developed an interagency task force including law enforcement and social services agencies which has trained and prepared many staff to deal with these homes. Many SMEs reported that persons with severe and persistent mental illness are the majority of residents in unlicensed residential care homes. He noted that residents with disabilities in unlicensed homes were at risk during fires and natural disasters such as tornados, hurricanes, and severe storms. 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. 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. Key informants also mentioned other resident health concerns including neglect, lack of water, malnourishment, and bed sores or pressure ulcers resulting from inadequate care. We did not find any report where a government agency was proactive and discovered the case on its own initiative or because of routine monitoring of unlicensed residential care homes. One issue that remains to be determined is the conditions or criteria by which such places constitute "unlicensed residential care homes." Estimates of the prevalence of unlicensed residential care homes are lacking for most states. A few key informants suggested cross-referencing different agency lists as another potential source for identifying unlicensed care homes. Some legislatures made it a felony to operate an unlicensed care home. They do not necessarily reflect the views of the Department of Health and Human Services, the contractor or any other funding organization. Although limited in scope, the findings of this exploratory study provide important foundational information about current conditions in some unlicensed care homes, factors that may influence demand for these homes, and strategies to identify them and address their quality. SMEs indicated that such reports can be used to identify unlicensed care home operators. (2015). Clarifying this definition will be critical to understand the prevalence of unlicensed residential care homes, as well as the characteristics of residents in these homes. Some of these homes are legally unlicensed while others operate illegally. Most interviewees also agreed that there are likely more illegally unlicensed personal care homes than they are aware of. Box 30664 Lansing, MI 48909-8164 1. 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. Thus, we lack information about unlicensed care homes in moststates, and even in our study states there were no reliable counts of illegal unlicensed care homes. Estimates of the number of unlicensed RCFs, as detailed in this report, were in the hundreds in two states: one state estimated more than 200 unlicensed homes in contrast to their 400 licensed facilities; and the other state estimated more than several hundred unlicensed homes but noted there was no reliable count. (2012a). 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. ", 3.5.5. As described by the majority of key informants, the primary motivation to maintain an unlicensed care home is to maximize profit. 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. Many interviewees mentioned monetary motivations of operators as one factor. The primary concern expressed about the unlicensed homes that were otherwise safewas that they might not be able to provide the level of care and services needed by the residents (e.g., medication supervision for residents with severe and persistent mental illness). The agencies do not typically get complaints from residents inside the home, although if the home is bringing in services such as home health or hospice nurses, those outside agency staff could file reports that result in the identification of an illegally unlicensed personal care home. Key informants did not offer any information on potential ways to identify unlicensed care homes or existing databases of these places. This report was prepared under contract #HHSP23320100021WI between the U.S. Department of Health and Human Services (HHS), Office of Disability, Aging and Long-Term Care Policy (DALTCP) and Research Triangle Institute. Health, Safety, and Sanitary Conditions. According to findings from these interviews, there are a few different pathways into unlicensed care homes, including unlicensed homes receiving residents directly from hospital discharges, representatives of unlicensed homes picking up residents from homeless shelters, and owners of licensed facilities taking residents to unlicensed homes. We also heard from nearly all state-level informants that some operators routinely shifted residents from one address to another if an APS worker, other advocate, or potential regulator showed up at the facility asking questions. Adult Protective Services and Rosenberg police were on the scene along with EMS personnel. Local key informants primarily expressed concerns regarding inadequate nutrition provided to residents and inappropriate medication management practices. One key informant stated that if a call comes in and the name of the care home that is being reported is unknown, then the next step is to call the state licensure office. The financial pressure hospitals feel to free up hospital beds quickly, which sometimes results in discharges to unlicensed care homes, both intentionally and unintentionally. All key informants described how the Local Management Entity-Managed Care Organization (LME-MCO) oversees the provision of mental health services in Durham County. The Department of Public Welfare also can take action against boarding homes and similar facilities that house four or more people if they are providing personal care services because they are considered illegally unlicensed. 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. <> However, the long-term placement of individuals after discharge to an unlicensed care home may be unstable, and no follow-up by the hospital with the patient after placement was described. In essence, unlicensed care home operators have several opportunities for gaining almost absolute control over these residents who are physically, cognitively, and financially vulnerable. Informants consistently emphasized the critical need for collaboration between multiple agencies, including law enforcement, APS, ombudsmen, the Department of Behavioral Health, and HFR, in order to address the potentially unsafe environments in unlicensed care homes, ensure the needs of the residents are met, address the criminal acts of the operators, and attend to the buildings themselves. Each of these factors is discussed in more detail in the sections that follow. However, as recently as 2013, the number had decreased to ten enforcement actions. L.C., they may need to pay particular attention to ensuring the availability of sufficient and affordable licensed care homes or other supportive housing options that offer person-centered care in a safe and appropriate environment. Residential care homes that serve three or fewer residents are legally unlicensed in this state. 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. Some key informants noted that EMS personnel are a better source than firefighters to learn about unlicensed care homes in a community because EMS personnel respond to all emergency calls while firefighters do not. Much of the information we gathered from the environmental scan, from SME interviews, and from site visit informants raises concerns about the conditions experienced by residents in unlicensed residential care homes. Research could also examine whether and how federal or state policies might affect the resident mix in unlicensed care homes. As such, key informants speculated that these types of organizations may maintain lists of residential care homes. 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. Discussions with key informants in the state suggest Georgia has a high prevalence of these homes. 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. Compared to our other site visit states, Georgia has the harshest law against operators of unlicensed care homes. He called Glover-Hogan, and said did you visit? Retrieved from http://www.namfcu.net/resources/medicaid-fraud-reports-newsletters. According to the regulations, some states also allow residential care homes to be legally unlicensed if they have 1-2 beds. 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. Almost all adult care home operators receive $2,608 per month. To address the issues surrounding quality and safety in unlicensed care homes, key informants described a process involving the investigation of complaints by visiting the home and interviewing residents and staff (which may necessitate getting an inspection warrant if denied entry upon arrival), then providing a written cease and desist letter if the investigation results indicate that the home should be licensed, issuing fines of $100 per day per resident, and prosecuting the operator. Before sharing sensitive information, make sure youre on a federal government site. AS800397501. Abuse, neglect, and financial exploitation of these vulnerable residents appear common. We focused on a range of questions, including: How do agencies handle specific complaints about unlicensed 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. 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. For many of these individuals, their only option may be unlicensed facilities. In another example of differing payment sources, a key informant described a housing situation with three Dom Care residents plus three other residents who can live independently; this care home did not require state licensure as a personal care home. In 2005, Pennsylvania changed the regulations so all residential care homes with four or more individuals had to be licensed by the state, but 1-3 bed residential care homes still could be legally unlicensed. After a legal challenge this fall, Mrs. Plummers son and cousin are now her guardians, and she is now living at home with relatives. Key informants from Georgia and Pennsylvania shared examples of efforts to increase awareness of unlicensed care homes through education or marketing for the general public or the agencies they involve in addressing unlicensed care homes. Handle specific complaints about unlicensed care home operators receive $ 2,608 per month is discussed in detail! Funding organization state inspectors $ 2,608 per month the state suggest Georgia has the harshest law against operators of care... One issue that remains to be legally unlicensed while others operate illegally another potential source for unlicensed! Has had public education campaigns to inform the public about illegally unlicensed personal homes. source for identifying care... Interviewees also agreed that there are likely more illegally unlicensed homes. not allow them to provide information... 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