One interviewee estimated that at its peak, this hospital served 3,700 patients. Multiple key informants spoke about a reduction in the number of Dom Care homes in the state and how this reduction may also give rise to illegally unlicensed personal care homes. In some states, residents can pay for their own personal or medical care in an unlicensed facility. State key informants emphasized that they could not make estimates about the scope of abuse and exploitation issues because unlicensed care homes are not systematically monitored. Abuse, neglect, and financial exploitation of these vulnerable residents appear common. However, our literature search did not reveal any estimates of the prevalence of unlicensed residential care homes in most of these states. Two states (New Jersey and Tennessee) have a category that specifies a maximum but not a minimum. The majority of key informants interviewed cited emotional abuse including intimidation and neglect as the most common forms of abuse observed or reported in unlicensed care homes. The biggest (Hawes & Kimbell, 2010). 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. Unlicensed care home operators also were described as sometimes having select residents act in a role of authority over other residents, such as beating the other residents to control their behaviors. This key informant also emphasized that unlicensed care home operators tend to work with a network of collaborators who support moving residents between homes to avoid detection by legal authorities, and also help with re-recruiting residents and reopening a care home after an unlicensed care home is closed down. Some residents were also described as transitional or homeless, while others were described as persons with substance use disorders. However, Medicare will cover qualified healthcare Unlicensed Assisted Living Facilities What are personal care services? 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. The state has also been in the news based on actions resulting from state compliance with the Olmstead decision which has moved adults with mental illness from institutional settings into less segregated settings in the community. Therefore, it's always a good idea to ask 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. All 35 people, ranging in age from 38 to 82 years old, were removed from the home. As described in Section 2, to inform the selection of states for site visits, we looked closely at the information available for six states where the environmental scan or SMEs indicated unlicensed care homes likely exist. 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). Large Large facilities are defined as those with 17 residents or more. Site visit locations were based on the information gathered in the environmental scan, SME interviews, and a review of residential care regulations. Personal menus for special diets. Some victims later found that their credit had been ruined by someone who illegally used their identity (Glass, 2015). The reporters described cases of abuse in which residents were being beaten and burned, locked in basements/rooms, given buckets for toilets, and had their benefit checks stolen from them (Schneider & Simmons, 2012a; Schneider & Simmons, 2012b; Schneider & Simmons, 2012c). Source: 26 TAC 553.27 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. Education: Statewide or Interagency. Discussions with key informants in the state suggest Georgia has a high prevalence of these homes. Residential care homes that are legal often serve as covers for or conduits to illegal homes. While the information herein is not generalizable--it is based on a targeted scan and a limited number of interviews--it does highlight the fact that unlicensed care homes appear to be a problem in at least some states. 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. See http://www.dhs.state.pa.us/cs/groups/webcontent/documents/report/c_102850.pdf. Other states also track complaint calls as a means for identifying unlicensed care homes. the costs of assisted living (personal care homes) or long-term 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. Key informants described both state and local infrastructure issues related to the prevalence of unlicensed care homes in the state. Findings from the interviews suggest that the majority of unlicensed care home residents in the metro Atlanta area have severe and persistent mental illness and are highly vulnerable to exploitation. Of these, three were determined to be unlicensed care homes. Resident Case Mix. Few of the investigations focus solely on financial exploitation. Locking residents in rooms or chaining the doors at night to prevent residents from leaving the facility, which imprisoned residents and placed them at risk in case of fire. 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. Assisted Living Facility - The Magnolia House Personal Care Home After recommending six states for site visits, the U.S. Department of Health and Human Services Office of the Assistant Secretary for Planning and Evaluation and the research team selected three communities in three states for on-site visits: Atlanta, Georgia; Raleigh/Durham, North Carolina; and Allegheny County, Pennsylvania. (2004). 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. The goal of this exploratory study was to understand how unlicensed care homes function as a residential care option, the types of individuals who reside in them, their characteristics including quality and safety and the policies that influence the supply of and demand for these homes. PDF HOUSE SB 200 Moncrief, et al. (Naishtat) ORGANIZATION Administrative They indicated that they are unaware of any assessment of need related to licensed mental health group homes in the state. In one case well publicized by the media, residents of one unlicensed facility in Pennsylvania were moved between Pennsylvania, Texas, Virginia and Florida to escape law enforcement. Funds are being allocated to relocate residents out of unlicensed residential care. In addition to private funds, other programs such as the. Managing the care needs of low-income board-and-care home residents: A process of negotiating risks. Benefit), may be available to help pay for room and board. 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. (2012c). A review of state regulations around long-term care ombudsmen could reveal gaps and opportunities in how ombudsmen can access and advocate for residents in unlicensed 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. As a result, Pennsylvania enacted a strategy to address the illegally unlicensed care homes, which included providing the Pennsylvania Bureau of Human Services and Licensure (BHSL) the ability to serve warrants and creating the PCRR team mentioned earlier and discussed in the next section. Most key informants and SMEs suggested that first responders such as EMS, firefighters, and police are potential sources for identifying unlicensed care homes because they respond to emergency calls received from or about them. Local key informants gave more specific examples of how operators evade licensure by having a mixed population living in their homes. At the local level, one key informant estimated that members of the Allegheny PCRR, along with the state licensing office, have investigated approximately five illegally unlicensed personal care homes in their specific geographic region over the past two years. One key informant described the selling of residents from an unlicensed care facility located in a house. Personal care home offers a smaller, more intimate setting, ideal for persons who might not do well with the larger assisted living facilities and are generally located in quiet residential neighborhoods. Efforts are now under way to provide workshops that clarify the new laws about unlicensed care facilities and how law enforcement and other agencies can work together to identify and investigate crimes against at-risk adults and prepare the necessary components for successful prosecutions. Some trawl for residents, picking residents up off the street, from homeless shelters, and from hospitals, and routinely shift residents from one facility to another in order to keep their occupancy rates high. Case-sensitive. The .gov means its official. Community safety personnel recommended interviewing local code enforcement divisions for thoughts on illegally operating unlicensed care homes, and consulting EMS personnel because they go out on every 911 call to a house or home and may have more experience with unlicensed care homes compared to firefighters. Assisted Living vs. A six-state study conducted by Hawes & Kimbell in 2010 for the U.S. Department of Justice, National Institute of Justice, found that unlicensed homes remain a serious, largely unaddressed problem in some states, with the magnitude of the problem remaining unknown. Retrieved from http://www.miamiherald.com. 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. In addition, SMEs noted variability across states in the availability of resident advocacy and protection through such agencies as the ombudsman program. Massachusetts exempts small private-pay homes from licensure. However, as recently as 2013, the number had decreased to ten enforcement actions. The determination of the Federal government websites often end in .gov or .mil. 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. Absent assistance from the ombudsman or other support in finding affordable licensed care options, unlicensed care homes may be the only option these individuals have. Similarly, APS and ombudsmen staff receive complaints about quality, violations of resident rights, and allegations of abuse. Assistant Secretary for Planning and Evaluation, Room 415F 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. building safety features. This generally creates a care ratio of three guests to one care provider. Unlicensed Assisted Living Facilities; Page 11; Does the facility need a license? 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. Unlicensed Assisted Living Facilities - Texas Multiple SMEs stated that licensure offices and agencies like APS are not equipped to track unlicensed care homes. Other Research Ideas Suggested by Subject Matter Experts or Individuals Interviewed in State Site Visits. A core pattern of exploitation described in interviews included the operator of unlicensed homes finding vulnerable individuals who need housing and supportive services (such as from hospitals or homeless shelters), requiring these individuals to transfer their SSI payments to the operator or one of the operator's agents in order to become a resident of the unlicensed care home, severely limiting the residents' ability to leave the facility, and relocating the residents to alternate locations to avoid detection. Troubled residents languish in flophouses. For example, Georgia reported an increase in complaint calls about unlicensed residential care homes from 2013 to 2014. Multiple key informants provided details of two specific cases of illegally unlicensed care homes. 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). 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. in addition to private funds other programs such as the Veterans Aid and Attendance Benefits program may be available to help pay for room and board. The Pennsylvania State Lottery funds the Pennsylvania Department of Aging. Thus, although our findings consistently highlight concerns about safety and quality, we cannot assess the generalizability of these findings and concerns, and our findings only minimally address unlicensed care homes that are safe and provide quality care. Failing to promptly report resident deaths, including more than one instance of leaving a dead body in the facility or back yard. Owners of current small licensed personal care homes are also potential sources of information; they will be able to fully describe the monetary costs associated with licensure, and these costs appear to be one reason why some people choose to operate illegally. 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. ", 3.5.5. Hospice. 3.2.1. 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. 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). Following the Olympics, funding for these day programs was not renewed, and all but one of these programs ceased operations. Call 800-458-9858 to report suspected abuse or neglect of people who are older or who have disabilities. Failed Legislative Efforts to Improve Oversight. 5. Key informants in two states confirmed that some hospitals there contract with placement agencies that, in turn, place individuals in unlicensed care homes, particularly individuals with limited resources and mental health issues. Isabel's Place Personal Care Home - Hospice - Visiting Physician available - 24 hrs monitoring and assistance - Coordination with visiting physicians, home health, hospice, physical therapy and podiatry - Incontinence care - Medication management - Holidays celebration - Personalized care plans - Home made meals Testimonials Vicki J Strategies for Addressing Issues in Legally and Illegally Unlicensed Care Homes, 3.6. It might also determine which states provide additional state funding to the ombudsman program, and whether the level of available resources is a limitation on ombudsman involvement in unlicensed care homes. 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. If you are not able to locate the following . In some cases they avoid licensure by holding themselves out as not providing services or housing residents that would require a license under state law. Some key informants described frustration with the lack of monitoring and lack of jurisdiction by the licensing offices to access or track legally unlicensed care homes. Tobia, M. (2014). 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. In Georgia, key informants also noted that hospitals directly discharge individuals to unlicensed care homes and some pay the first month of the resident's fees. 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. In other types of residential care, if the care is arranged or managed by the owner, manager, or staff of the building, home, or community, then the facility must be licensed. 3.4.4. 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. Submit all required documents. However, in Allegheny County, key informants stated that locally the regulation is interpreted and applied differently, and that a Dom Care facility could not have more than three residents total, regardless of the case mix or payment mix. Most state licensure offices, county offices, or advocacy agencies use a complaint system to identify 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. Title: Microsoft Word - FAQ About Unlicensed Personal Care Homes.doc Author: tpride Created Date: 2/4/2009 1:59:02 PM Key informants included representatives from the state licensure office. (Producer). Information from interviews with key informants also revealed incidents of emotional and physical abuse, including intimidation, and threats. Findings from this study are necessarily limited by the number of experts we identified and states we visited. If the homes are closed and the residents' identification cards and personal paperwork are not able to be retrieved, this poses challenges for residents to get SSI payments and medications. 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. Compendium of residential care and assisted living regulations and policy, 2015 edition.Prepared for U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. As with assisted living facilities, the cost of personal care homes (aka care homes) varies from location to location. The complaint will then need to be called to 1-800-458-9858 or e-mailed to ciicomplaints@hhs.texas.gov for nursing homes, assisted living facilities, intermediate care facilities, state supported living centers, home health, hospice, personal assistance agencies and day activity and health services. Troubled group homes escape state scrutiny. The team conducted interviews with key informants in each of these communities. Key informants were divided in their opinions on the motivations for operating illegally unlicensed personal care homes. This results in different payment streams and different regulatory agencies that have responsibility for different residents in the same residence. Positive Actions by States to Improve Oversight of Unlicensed Facilities. These steps include site visits to suspected illegally unlicensed care homes, during which an ombudsman may inform residents of their rights, APS may conduct abuse or neglect investigations, licensure staff may assess whether the residents should be in a licensed care home based on the level of service needs, and code enforcement staff may determine if the home meets regulatory code requirements. The financial pressure hospitals feel to free up hospital beds sometimes results in discharges to unlicensed care homes, both unintentionally and for expediency. In Texas, anyone with three or less residents (unrelated to them) does not have to be licensed. 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. One Maryland media report suggested residents are those released from rehabilitation centers with no families in the area. 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. Presumably, this led to an increase in need for LTSS for these populations. Key informants were also concerned about a lack of specific services inside illegally unlicensed personal care homes. 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. What types of reports of mistreatment do the agencies receive? Homeowners, for example, may have property they cannot rent because the building is not up to code, so to generate income from the property, they begin operating an illegally unlicensed personal care home. Further, in site visits and the literature, we found reports of situations that were repeatedly depicted as involving activity that was similar to "human trafficking" and "false imprisonment" of vulnerable individuals. A Description of Board and Care Facilities, Operators, and Residents - ASPE Interview results indicate that the majority of unlicensed care homes investigated by state officials and local APS agencies involve situations in which residents are not being cared for properly. In 2011, only two such warrants were obtained. UAPs also provide bedside careincluding basic nursing proceduresall under the supervision of a registered nurse, licensed practical nurse or other health care professional. Perkins, M., Ball, M., Whittington, F., & Combs, B. The advocacy agency also collects information about whether the operators own more than one unlicensed care home. Consistent with findings from the environmental scan, stakeholders (including SMEs and site visit key informants in the three communities we visited) repeatedly raised a variety of concerns about neglect of residents' health care needs and unsafe and unsanitary conditions in unlicensed care homes. After completing the vetting calls, we emailed an introductory letter explaining the purpose and goals of the research to the potential interviewees. One of the SMEs shared comments from ombudsmen that the numbers of unlicensed homes in some states are increasing, while in other states, they reported that they had not heard about unlicensed care homes. Several key informants discussed the role hospitals and hospital discharge planners potentially play in referring patients to unlicensed 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. The Texas Department of Health and Human Services licenses assisted-living facilities and personal care homes based on two things: The residents' mental and physical ability to evacuate in the event of an emergency Whether or not it is necessary to have nighttime staff. Perils in personal care homes. As noted by one SME, unlicensed care homes that provide good care and a safe environment may intentionally not be brought to the attention of state agencies nor be reported by these agencies when they learn of these homes: "We do receive reports, about 6 months ago someone wrote to me about their mother who was getting care in an unlicensed homeshe was getting wonderful care, she wasn't going to report it.