Residents of unlicensed care homes are vulnerable adults. 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. In addition, one key informant stated that penalties for operating unlicensed care homes are similar to only a Class C offense, which is "equivalent to fishing without a license." Retrieved from https://aspe.hhs.gov/report/medicaid-residential-care. State inspection staff, already overwhelmed with large caseloads, were required to obtain search warrants to execute searches, a time-consuming process, when trying to follow up on reports of unlicensed homes. During site visits, key informants reported that owners of licensed care homes often report operators of unlicensed care homes to authorities. The majority of examples of mistreatment included resident physical and emotional abuse, neglect, or financial exploitation. The state has started training sessions to educate law enforcement and first responders about unlicensed care homes, and these education efforts may contribute to the state's ability to identify unlicensed personal care homes. 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. There were no reports of varying frequencies of unlicensed facilities between urban and rural areas. Findings from the environmental scan highlighted issues of safety, abuse, and exploitation in unlicensed care homes; however, the source material, including media reports, tend to highlight negative and sometimes sensational stories, which may or may not represent the norm in unlicensed care homes. FINDINGS FROM THE ENVIRONMENTAL SCAN, http://www.stopelderabusepetition.blogspot.com/2013_06_01_archive.html, http://www.thisamericanlife.org/radio-archives/episode/554/not-it, http://www.namfcu.net/resources/medicaid-fraud-reports-newsletters, http://www.disabilityrightswa.org/stop-fraud-and-abuse-rep-payees, http://www.dhs.state.pa.us/cs/groups/webcontent/documents/report/c_102850.pdf, http://aspe.hhs.gov/office-disability-aging-and-long-term-care-policy-daltcp, HHS Office of the Assistant Secretary for Planning and Evaluation, Pennsylvania Bureau of Human Services and Licensure, HHS Centers for Medicare and Medicaid Services, Texas Department of Aging and Disability Services, 3.2. 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. Other states also track complaint calls as a means for identifying unlicensed care homes. One key informant also emphasized that the limited monitoring of legally unlicensed care homes limits the state's ability to identify and subsequently address any issues of quality or safety in these settings. The facility operators were authorized to make the decision on their own (Tobia, 2014). 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. Florida publishes a listing but it does not correspond with the media reports of the number of unlicensed care homes identified by state inspectors. Multiple key informants also spoke about the lack of affordable housing in Allegheny County. Maryland, Nevada, and Florida: The National Ombudsman Reporting System noted an increase in unlicensed care homes in these states, but no unlicensed care reports from any state provided evidence on the prevalence of unlicensed care. This results in different payment streams and different regulatory agencies that have responsibility for different residents in the same residence. These legally unlicensed residential care homes are exempt from licensure because they do not provide 24-hour supervision, though residents may be receiving intermittent skilled nursing care, and help with ADLs, medication administration, and social activities. In 2013, the minimum number of ADLs needs required for individuals to qualify for reimbursement for personal care services in group homes increased. Which agencies get involved when addressing unlicensed 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. Two key informants mentioned that changes to the state's Medicaid Personal Care Services program had a direct impact on available funding for group homes that serve individuals with mental illness. See http://www.dhs.state.pa.us/cs/groups/webcontent/documents/report/c_102850.pdf. Web log.Retrieved from http://www.stopelderabusepetition.blogspot.com/2013_06_01_archive.html. The research team completed seven interviews with eight participants that included both state and local community stakeholders. If states have reduced funding for HCBS needed by low-income elderly and disabled individuals, thenlicensed care homes, which may have higher rates and fees than unlicensed homes, may no longer be an option for these individuals, or they may be faced with a potentially longer waiting list for licensed care homes. The state primarily uses reports to their complaint system to identify illegally unlicensed personal care 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. Another specific example included a resident moving from a home where the operator was their representative payee and the operator continued to collect their SSI check. However, there were many reports of poor conditions in legally unlicensed care homes. The following section presents individual research topics and identifies the related questions that might guide future research on unlicensed residential care homes. Media and state reports have highlighted homes operating deliberately illegally--that is, they are avoiding required licensure or certification (Tobia, 2014; Georgia Association of Chiefs of Police Ad Hoc Committee on At-Risk Adult Abuse, Neglect & Exploitation, 2013). The recent changes to state regulations for community living arrangements are also reportedly becoming more favorable toward independent living, which may lead to an increase in the number of unlicensed facilities. 3.2.1. As noted in Section 3.4.1, one SME from an advocacy organization in Pennsylvania noted that they log specific information concerning names and dates into an Excel spreadsheet once a complaint has been lodged against an illegally unlicensed care home. 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. 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. A few strategies exist in the state for addressing illegally unlicensed personal care homes. 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. State investigators from the Bureau of Licensing and Regulatory Affairs inspected the home in October and found that Carter was violating the law. Finally, a peer-reviewed publication by Perkins, Ball, Whittington, & Combs (2004) provides insights into why an operator continues to operate an unlicensed care home. This was described as limiting the capacity of the resident to relocate. The state investigates the types of services that are provided to residents on site in order to determine if a license is required. The web Browser you are currently using is unsupported, and some features of this site may not work as intended. Information gathered from the environmental scan and SME interviews revealed reports that unlicensed care homes exist in North Carolina. Few peer-reviewed articles have been published on unlicensed care homes, but numerous media reports were examined. With the passage of a new law in July 2012, it is a misdemeanor to operate an unlicensed personal care home, and if an unlicensed care home is linked to abuse, neglect, or exploitation, the violation is considered a misdemeanor. 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. Individuals who are poor, experiencing homelessness, or individuals with a mental illness who cannot return home orhave no home to return to after being discharged from the hospital are a source of clients for unlicensed care homes. We then examined if those percentages might be related to the number of unlicensed care facilities in those states. The Scope of Abuse and Exploitation Concerns. Costs for operating a licensed personal care home can include state fees for licensure, structural renovations or changes to meet required building codes, paying for staff to be on-site 24 hours per day, and paying for and providing adequate staff training. 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. 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. And regardless of whether states have regulations concerning unlicensed homes, many operators choose to operate illegally unlicensed homes. )'ROR'~z~OR~+~|h|`Gff8'_K Tx)XLCFJN?.YquCth2/F Referral and Placement Agencies and Discharge Planners. Given the types of key informants interviewed for this study, and the limited viewpoints captured, more information is needed to understand the characteristics of unlicensed care homes and the residents they serve. Research about legally unlicensed care homes might focus on collecting information about characteristics of legally unlicensed care homes, the services they offer and the residents they serve, such as through a larger number of site visits and interviews with ombudsmen and state regulatory agencies or through a survey of the operators of legally unlicensed homes in states or areas that maintain lists of these homes, such as Florida, Georgia and Texas. A house at East Tamara Costa Court where Calvin Leslie, not photographed, was renting it is seen on Wednesday, Dec. 18, 2019, in Las Vegas. Interview findings also suggest that research is needed on the best strategies for identifying unlicensed care homes and effectively closing them down. Estimates of the prevalence of unlicensed residential care homes are lacking for most states. Hawes, C. & Kimbell, A.M. (2010). They indicated that these unlicensed personal care homes are filling the gap left by the closing of licensed personal care homes. Media reports described operators with licensed facilities who also operated a series of unlicensed homes in secret. 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. That makes it difficult for the licensing agencies to understand what's going on because they don't have the information and aren't privy to it.". Please update to a modern browser such as Chrome, Firefox or Edge to experience all features Michigan.gov has to offer. Multiple key informants provided details of two specific cases of illegally unlicensed care homes. The most prevalent strategy used by state and local officials to identify illegally unlicensed care homes is responding to complaints. Interview questions were based on respondent expertise, and were tailored for each respondent. Furthermore, illegally unlicensed care homes continue to exist because they try to avoid detection; therefore, favorable reports of unlicensed care homes are minimal. 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. What federal and state policies affect the supply and demand of unlicensed care homes? This key informant indicated that this change likely increased the need for licensed group homes, and unlicensed group homes may have also opened as a way to fill the need created as a result of these closures. 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. If the facility does not close, law enforcement (not the state licensure offices) fines the illegal operation $50 for the first offense and $500 for each additional offense. 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. restriction of group homes, both their siting and operation. Each of these factors is discussed in more detail in the sections that follow. 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. (2009). According to one key informant, this illegally unlicensed care home had recently housed a mix of residents and family members, including four related family members (two children and two adults), two persons under the care of a local hospice, and one individual who was receiving methadone treatment. Anecdotal examples of residents wandering outside of their home and onto neighbor's property, which typically generates a complaint call from the neighboring homeowner, were also provided. This lack of knowledge contributes to the need for the government and policy makers to have a better understanding of unlicensed care homes. Local key informants gave more specific examples of how operators evade licensure by having a mixed population living in their homes. The AAA office, APS, Disability Rights Network, and state or regional licensure offices can receive complaints concerning resident care that may lead to the discovery of illegally unlicensed personal care homes. For many such individuals, their only options may be unlicensed facilities or homelessness. This had a direct impact on the operating budgets of licensed group homes. 3.4.4. Key informants described a coordinated effort between the state licensure offices and the local group care monitoring office once there is recognition that a complaint call is about an unlicensed facility. Some legislatures made it a felony to operate an unlicensed care home. Safety issues affect local fire departments. With regards to the safety of unlicensed care homes, the majority of key informants agreed that the lack of clean and safe housing was a primary safety concern. Retrieved from http://www.ncjrs.gov/pdffiles1/nij/grants/229299.pdf. Furthermore, some key informants noted that some unlicensed homes fail to provide or arrange treatment for residents' conditions in order to avoid bringing the attention of authorities. Strategies for Addressing Unlicensed Care Homes. One key informant noted that residents of unlicensed care homes commonly require assistance with activities of daily living (ADLs), such as getting dressed, as well as assistance with instrumental activities of daily living (IADLs), such as taking medications and managing and accessing transportation to medical appointments. A phone number is provided if someone has a question about the licensure status of a facility. These calls spur investigations that sometimes result in the identification of unlicensed care homes. Revised: 4/2017 Follow us 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. In addition, SMEs noted variability across states in the availability of resident advocacy and protection through such agencies as the ombudsman program. Georgia was selected as a state for our site visit because of the state's actions surrounding unlicensed care homes described during interviews with SMEs, and the numerous news reports about unlicensed care homes in the state. One was a fairly large ranch style house that accommodates 15-23 individuals at any one time. A few interviewees agreed that in cases such as this, the operators are motivated by their desire to care for people; they are just not aware of the licensure requirements. 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. Although a coordinated, multidisciplinary effort appears necessary to comprehensively address unlicensed care homes, several key informants discussed the lack of ombudsman jurisdiction to access residents in unlicensed care homes. Monograph for the National Institute of Justice, U.S. Department of Justice. Even with relatively low payment rates, operators can make profits by cutting corners in housing and services and trafficking in the federal benefits they seize from residents. Anne Arundel County Fire Department, Millersville, Maryland. They can fine the operator directly which may lead to the unlicensed care home being forced to shut down. At risk adult abuse, neglect and exploitation in Georgia: Review and recommendations. Lax enforcement in personal care homes. Residential care homes that are legal often serve as covers for or conduits to illegal homes. Informants said that many local sheriffs and District Attorneys are not supportive of following through to enforce penalties, nor do they press charges against the operators. "=H@tLh,j;jDLOTY$%6?T@cFBQm14X$`CX"fGQX@":S\Q()*fT6?3(#,R)1EQ Treatment of residents as a commodity was a common theme across interviews. 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 research team interviewed 12 key informants in Georgia. In other cases, the unlicensed facility simply ignores the law and operates below official "radar.". 3.4.3. 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. Leslie was arrested on multiple counts of abuse and. Some have residents that receive Medicaid funded services. 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. 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. The annual cost of care for an institutionalized resident is. Each interview began with a general question to ascertain what the interviewee knew about unlicensed care homes. Unlicensed homes to face more state scrutiny. 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. Based on the findings from this exploratory study, unlicensed care homes appear to be widespread in some areas within some states. Key informants stated that many illegally unlicensed personal care homes they investigate are being operated by repeat offenders who have done this in the past; these same operators just open new illegally unlicensed personal care homes once they are found out. I dont have anything indicating that that was the case, said Glover-Hogan. One key informant shared a specific case of a repeat offender that operates an unlicensed adult care home out of a double-wide trailer. Both states use a penalty system to fine operators for illegal operations. Atlanta Journal-Constitution. From our review of the regulations, we identified that North Carolina likely has legally unlicensed care homes (e.g., boarding homes serving 4-5 residents who do not require 24 hour supervision), and we suspect that illegally unlicensed care homes also exist. 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