We also conducted site visits to a total of three communities in three states, including interviews with local and state-level key informants. 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. Since 2009, this business for sale has been serving the senior community and families in the region. Custodial care is non-medical assistance investigation. Cases of physical abuse, such as residents being beaten and burned as described in the environmental scan, were also reported during interviews. 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). care facilities. Retrieved from https://www.socialsecurity.gov/ssi/text-benefits-ussi.htm. The 2014 annual report for DADS shows that the number of referrals to the AG increased from two to nine for injunctive/other relief and civil penalties. Detecting, investigating and addressing elder abuse in residential long-term care facilities. Based on the findings from this exploratory study, unlicensed care homes appear to be widespread in some areas within some states. 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. 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. Some publish notices of how and where to report unlicensed care facilities. For example, it won't cover an Title: Microsoft Word - FAQ About Unlicensed Personal Care Homes.doc Author: tpride Created Date: 2/4/2009 1:59:02 PM 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. In the past 15 years, the issues surrounding unlicensed personal care homes in the state have become more prominent, and coordinated action across several agencies has been taken to address them. might not do well with the larger assisted living facilities. Types of Assisted Living Facilities - Texas However, even with those limitations, we know that in the communities we visited, there were significant health and safety concerns for residents, as well as concerns about financial exploitation and government fraud. Estimate of 2-year cost of implementing HB216. The state's BHSL office also has the legal authority to act as an enforcement agency. Local key informants gave more specific examples of how operators evade licensure by having a mixed population living in their homes. This shifting of residents from one unlicensed home to another to avoid detection and oversight was also described by the media in Texas and Georgia. Multiple key informants provided details of two specific cases of illegally unlicensed care homes. What information exists reflects a concern about the conditions under which residents in these places live. In Pennsylvania counties, a multidisciplinary team called the Personal Care Risk Reduction (PCRR) team helps to address illegally unlicensed care homes; thus we attempted to interview key informants involved in this process. Presumably, this led to an increase in need for LTSS for these populations. However, several SMEs and key informants noted that some unlicensed care homes are good and provide a clean, safe environment for individuals who might otherwise be homeless. Some illegally unlicensed facilities deny services are being provided. State and Local Policies Related to the Supply and Demand for Illegally Unlicensed Care Homes. 3.4.5. (2013). Personal menus for special diets. Medicaid in residential care. Assisted Living Facility - The Magnolia House Personal Care Home 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. States with concerns about the prevalence of unlicensed care homes may wish to examine their licensure regulations, as these may influence the supply of and demand for unlicensed care homes, either because the complexity of some regulations makes them hard for operators to understand, or because they might contain loopholes that operators can easily exploit. There were no reports of varying frequencies of unlicensed facilities between urban and rural areas. From a county perspective, one ombudsman and housing officer estimated that perhaps there may be less than 20 lawfully unlicensed facilities and less than five illegally unlicensed, however Tobia's team found that there may be as many as 78 unlicensed care homes serving as many as 400 individuals in that county. Some operators remain undetected by moving residents from one facility in one state to another facility in another state. Medicare does not cover the cost of personal care homes. While no comprehensive nationwide list of unlicensed care homes exists, the environmental scan identified one state (Florida) and one city (Houston, Texas) that maintain listings of unlicensed care homes. 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. Incentives this modest provide little encouragement for residential care homes to incur the cost of licensure if their primary clientele has only SSI to pay for care. Informants noted that unlicensed care homes vary in their appearance and condition. These local and regional offices--as well as ombudsmen and other national, state, and local advocacy groups--receive complaint calls from a variety of sources including residents' family members; members of the general community such as neighbors or other providers; and medical and service providers (e.g., hospital or clinic doctors, nurses, social workers) who interact with residents inside and outside of unlicensed homes. A facility was licensed and the license was revoked. Such practices violate residents' rights, and the profit-enhancing practices of the operators, such as limiting the availability of food, water, and other basic needs, endanger residents' lives and well-being. The most prevalent strategy used by state and local officials to identify illegally unlicensed care homes is responding to complaints. In addition, many unlicensed care homes operate as family businesses in single family dwellings allowing shifting of residents to avoid detection by regulators (Tobia, 2014). 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. In Texas, a residential care home (also known as a Making changes to licensed care home regulations is one example of how states may address unlicensed care homes. You can update your choices at any time in your settings. As noted in earlier sections, many unlicensed care home residents receive federal SSI benefits, and many unlicensed care homes receive these benefits directly through the SSI representative payee program. Several key informants expressed concern about neglect of the health needs of residents because of too few or inadequately trained staff, particularly in regard to the care of residents who have severe and persistent mental illness and need monitoring of their conditions and reactions to medications. 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. One key informant stated this posted information, as well as general education sessions out in the community; for example, in senior centers or nursing homes, leads to some complaints that can generate investigations into personal care homes that may be identified as illegal operations. Although little is known about unlicensed care homes, a variety of signals, including media reports, highlight potential safety and quality concerns. need for senior care services and the choice of a facility is an Licensure for adult care homes and mental health group homes falls under two separate state statutes, and therefore two separate regulatory offices oversee different types of licensed care homes. Retrieved from http://www.miamiherald.com. Media reports described operators with licensed facilities who also operated a series of unlicensed homes in secret. In addition, states differ in whether they provide additional funds to the ombudsman program, over and above the federal funds from the Older Americans Act. 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. PHC and CAS provide in-home personal attendant services (PAS) to individuals eligible under Title XIX Medicaid or under 1929 (b) (2) (B) of the Social Security Act, respectively. The Scope of Abuse and Exploitation Concerns. According to reports and state-level investigators, many of the residents in unlicensed homes are living on SSI or Social Security Disability Income. Currently at the state level, the primary strategy used in Georgia to identify unlicensed care homes is through complaints, including complaints from neighbors, residents, residents' family members, and hospitals serving residents of unlicensed care homes. This lack of knowledge contributes to the need for the government and policy makers to have a better understanding of unlicensed care homes. An estimate for another locality in Maryland was much higher, with twice as many unlicensed homes as licensed, or about 1,500 facilities, many of which operate out of single family dwellings (Tobia, 2014). One key informant estimated this hospital served 3,700 patients at its peak. While this may be a promising source of unlicensed homes only in Allegheny County, Pennsylvania, similar tracking mechanisms may be used or developed for use in other communities as well. 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. Assisted living provider resources: Unlicensed facilities. Informants noted that interagency, multidisciplinary teams at state and local levels are imperative to the success of shutting down unlicensed care homes, and to address the various issues involved in such closures, such as meeting the housing and services needs of residents, addressing any criminal behaviors of the care home operators, and ensuring the safety of the house or facility and neighboring properties. Miami Herald. However, this likely is not a viable method for detecting the population of illegally unlicensed residential care homes. This generally creates a care ratio of three guests to one care provider. We utilized the information obtained in the literature review, in addition to our own expertise, that of our consultant, as well as that of U.S. Department of Health and Human Services (HHS) Office of the Assistant Secretary for Planning and Evaluation (ASPE) and the HHS Administration for Community Living (ACL) staff familiar with unlicensed care homes, to develop an initial listing of SMEs to interview. Pennsylvania: In 2012, the Secretary of the Department of Public Welfare stated that the state continues to struggle with illegal operators and asked all Pennsylvanians to join in the fight and report any unlicensed homes or activities because "unlicensed care is deadly.". One interviewee estimated that at its peak, this hospital served 3,700 patients. The Texas Department of Aging and Disability Services (DADS) website (2015) states that the agency is aware of some unlicensed residential care homes and is either working to get the homes licensed and to comply with health and safety requirements or is in the process of closing them. Multiple key informants spoke about the significant impact of the closure of this hospital in Allegheny County and the western part of the state as it relates to the possible continued proliferation of illegally unlicensed personal 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. These findings highlight a set of potentially serious problems and issues. Retrieved from http://www.miamiherald.com. 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. What are the interviewees' thoughts on the best strategies to identify unlicensed care homes? 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. However, while SMEs reported variability in licensure requirements and the authority, responsibility and funding of ombudsmen agencies with respect to unlicensed homes, there is very little information available about legally unlicensed homes, including the characteristics of residents, their care and service needs, and their preferences. 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. Areas for future research and potential data sources related to unlicensed care 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. Most commonly, interviewees depicted unlicensed personal care homes operating in residential areas within single family houses that are rented by the unlicensed care home operator, but some interviewees described unlicensed care homes operating in a variety of other structures (e.g., closed churches and schools). Some assess fines for continuing to operate an unlicensed facility. Unlicensed Assisted Living Facilities What are personal care services? difference is that some personal care homes accept Medicaid to In essence, unlicensed care home operators have several opportunities for gaining almost absolute control over these residents who are physically, cognitively, and financially vulnerable. Tobia, M. (2014). Agencies have inadequate resources or authority. (n.d.).Retrieved from http://www.agingavenues.com/topics/assisted-living-facilities-in-indianapolis-indiana. Several SMEs also noted inadequate funding and housing options for persons with severe and persistent mental illness or intellectual disabilities who have been moved out of state facilities may contribute to demand for unlicensed care homes, because these individuals may not be able to afford the cost of a licensed care home. Licensure staff admitted they only learn about the unlicensed facilities when someone reports them. Austin, Texas. Traditionally, Medicare does not cover 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. The advocacy agency also collects information about whether the operators own more than one unlicensed care home. For example, in Allegheny County, Pennsylvania, informants noted that the closure of Mayview Psychiatric Hospital in 2008 resulted in the displacement of persons with mental illness. The facility operators were authorized to make the decision on their own (Tobia, 2014). Hancock, L. (2007). care services, assistance and supervision to four or more persons. 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. The state and local agencies mostly rely on complaints from the general public and county agencies. 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. Abuse, neglect, and financial exploitation of these vulnerable residents appear common. Indeed, many key informants emphasized that they only knew about unlicensed care homes because of complaints being made about them. The team works together to track homes they identify as unlicensed and then monitors them until the home is closed. As noted, we found the prevalence of legally and illegally unlicensed residential care homes varies by state. In one court case, the judge deemed a "boarding house" as an unlicensed residential care home because only three of the six people renting rooms received personal care from the owner's licensed home care agency, even though four actually needed those services. geographical location of the residential care home, as well as, Strategies for identifying illegally unlicensed care homes. PDF FAQ About Unlicensed Personal Care Homes - Department of Human Services Statutes & Rules State Texas Administrative Code, Title 40, Part 1, Chapter 46: Contracting to Provide Assisted Living and Residential Care Services 5. 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. In addition, SMEs noted variability across states in the availability of resident advocacy and protection through such agencies as the ombudsman program. Assisted Living Facility - Texas Health and Human Services Another state-level key informant was unable to estimate how many calls the agency receives that result in investigations of unlicensed group homes for persons with mental illness. 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. Miami Herald.Retrieved from http://www.miamiherald.com. In 2012, the Secretary of the Department of Public Welfare noted that the state continues to struggle with illegal operators and asked all Pennsylvanians to join in the fight and report any unlicensed homes or activities because "unlicensed care is deadly" (Pennsylvania Department of Public Welfare, 2012). In Pennsylvania and Georgia, key informants indicated ombudsmen are permitted to make site visits to unlicensed care homes if complaints are received, although access can be denied by the operator. We found little published information about unlicensed residential care homes; in fact, the scan revealed that most of the literature about conditions in RCFs covered licensed residential care or were about unlicensed care staff. We then looked to see if those percentages might be related to the number of number of unlicensed care facilities in those states. Retrieved from http://www.dhs.state.pa.us/cs/groups/webcontent/documents/report/p_011015.pdf. Multiple SMEs and key informants suggested following or tracking these benefits as a way to identify individuals in unlicensed care homes. As with health and safety concerns, the environmental scan and interviews conducted with SMEs and key informants revealed myriad concerns about abuse, neglect and financial exploitation. Office of the Assistant Secretary for Planning and Evaluation, Printer Friendly Version in PDF Format (81 PDF pages). These unlicensed care homes are referred to by several different names in different states, such as "board and care homes," "boarding homes," and "adult care homes." Nevada stated that no interagency procedures were in place to handle complaints about unlicensed board and care homes in a timely and efficient manner (Ryan, personal communication). Miami Herald. As noted, jurisdictional disagreements exist as to whether licensure agencies or APS agencies are responsible for the illegally unlicensed facilities. We hypothesized that states that do not have well-funded HCBS programs may have a higher incidence of illegally unlicensed homes than states with more robust HCBS programs.
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