Information gathered from the environmental scan and SME interviews revealed reports that unlicensed care homes exist in North Carolina. 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. In addition to the $100 per resident per day fine placed levied against unlicensed facilities, a representative of the state reported that the Georgia legislature has added operating an unlicensed personal care home, which is a criminal offense, to the list of crimes that make it impossible to apply for a license to operate a personal care home. One key informant estimated that approximately 3,000 licensed personal care homes have ceased operations in Allegheny County since the 2005 regulatory changes. In regard to the prevalence of unlicensed care homes, state-level estimates were only reported for Georgia, Maryland, and Florida. To reduce abuse, several informants indicated that state officials should target closing unlicensed care homes. Texas Legislative Budget Board. Before sharing sensitive information, make sure youre on an official government site. Potential Data Sources or Listings of Unlicensed Care Homes, 5.3. 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. A facility that advertises or represents via verbal communication that it provides personal assistance is required to make personal services available to its residents. During interviews, informants talked about situations in which the operators of unlicensed care homes continue to be the representative payee and continue collecting the SSI checks of residents even after the resident moved out of home. In Iowa, legislation to restrict the actions of some operators of large licensed assisted living facilities to recategorize or redefine themselves as a "residence," (e.g., boarding home) that does not require licensure was proposed but did not pass. Specific concerns raised by SMEs and site visit informants are highlighted in this section. Cases of physical abuse, such as residents being beaten and burned as described in the environmental scan, were also reported during interviews. Indeed, results from the National Survey of Residential Care Facilities indicate that only 40% of licensed RCFs admit individuals with behavior problems, and just 55% admit individuals with moderate to severe cognitive impairment (Greene et al., 2013). Pennsylvania Health Law Project and North Penn Legal Services. 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. building safety features. To accomplish this we conducted an environmental scan, including a review of the peer-reviewed and grey literature and interviews with SMEs. Three-bed residential care homes are lawfully allowed in at least one state. (n.d.).Regulatory requirements for home and community-based settings. Although this regulation reduced the number of legally unlicensed care homes and reduced their capacity to three or fewer residents, many key informants in Pennsylvania noted that this had the unintended consequence of spurring many more illegally unlicensed care homes to open. DISCLAIMER: The opinions and views expressed in this report are those of the authors. Home Health Aide at Elkins home health care, How do i go by starting my home health care business in getting clients in the homes, Dedicated to the field of Social Work and Helping Others, Is there anyone that can provide info on starting a group home for children 13-18 where would I find that information. However, cost can vary depending on the (2009). Retrieved from http://www.ncjrs.gov/pdffiles1/nij/grants/229299.pdf. Next, the local group monitoring office or the state would attempt a site visit. the costs of assisted living (personal care homes) or long-term Large Large facilities are defined as those with 17 residents or more. Some key informants reported that the living conditions in these places can be subpar. I am interested in opening a personal care home in Texas and having difficulty with knowing which application and requirements to look for. Web log.Retrieved from http://www.stopelderabusepetition.blogspot.com/2013_06_01_archive.html. 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. In addition, investigations by Georgia law enforcement officials indicated that there is considerable fraud with respect to SSI, Social Security, residents' personal needs allowances, Medicare and Medicaid, and the food stamp program. We primarily heard about phone complaints. Based on our exploratory research, we found that a number of factors may have an effect on the demand for unlicensed care homes. A local ombudsman in Maryland stated that they had no authority to inspect an unlicensed home and therefore did not have reliable knowledge about whether unlicensed care homes exist, how many individuals are living in such homes or what level of care or assistance those residents needed (Tobia, 2014). custodial or intermediary care. Further, it is the responsibility of the owner to determine whether the home needs a license. Also, Indiana state law requires legally unlicensed assisted living facilities to submit disclosure forms to the Family and Social Services Administration within the Division of Aging; thus, the state may be able to compile a listing of legally unlicensed facilities. Most of the literature and media reports reviewed focused on the pitfalls of unlicensed care homes and the poor quality and safety provided in these settings. However, Medicare will cover qualified healthcare 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. 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. 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. Because of licensure standard variations, for example, homes that were legally unlicensed in Texas (e.g., adult foster care homes with five or fewer beds) were required to be licensed in California and Oregon. 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. 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. The determination of the Licensure agencies in many states lack the legal authority to inspect, require plans of correction, or fine these unlicensed facilities. (2013). Texas Health & Human Services Commission. In these cases, the hospital reportedly pays the placement agencies a fee to find a personal care home, and the placement agencies also receive monetary incentives from the personal care homes for referrals. in the state of Texas, they are licensed according to size, type and building lists. 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. 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. Centers for Medicare and Medicaid Services. (Hawes & Kimbell, 2010). Before sharing sensitive information, make sure youre on a federal government site. Some larger facilities operate as unlicensed "residences" by requiring residents to contract with a separate corporation for provision of all ADL or nursing services. 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. In Allegheny County we interviewed key informants from APS, and local ombudsmen and placement coordinators from the local Area Agency on Aging (AAA) who work directly with licensed and unlicensed personal care homes, as well as other staff from a local disability advocacy agency and a local fire department. (NMES). 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. There were no reports of varying frequencies of unlicensed facilities between urban and rural areas. Texas and Georgia had numerous cases of unlicensed homes in deplorable conditions: infested with insects, lacking air conditioning or heat, residents sleeping on the floor, faulty wiring, no bathroom access, residents deprived of food or fed scraps, and theft of medications. Demographic trends are placing an increasing number of older persons at-risk for needing residential long-term care, but many of these same individuals have out-lived their savings or had low incomes to start. All states license residential care such as assisted living, and most states license small adult care homes, often referred to as adult foster care (Carder, O'Keeffe, & O'Keeffe, 2015). Site visit summaries, which provide more state-specific information, and information on other states considered for site visits, are included in Appendix A. As discussed earlier, Pennsylvania is a state that legally allows unlicensed residential care homes, if they serve three or fewer individuals. Nursing Homes: What's the Difference? SMEs and key informants consistently noted that many low-income individuals cannot afford licensed facilities, which makes the less expensive unlicensed care home an attractive option, and thus contributes to the existence of unlicensed care homes. (n.d.).Retrieved from http://www.agingavenues.com/topics/assisted-living-facilities-in-indianapolis-indiana. Retrieved from http://www.namfcu.net/resources/medicaid-fraud-reports-newsletters. We found a number of publications and media reports in both Florida and Texas (e.g., the Miami Herald newspaper series in Florida, and the U.S. Department of Justice report in Texas), and a few media reports and a research report on unlicensed care homes in Maryland; however, these states were not selected as site visit states. 200 Independence Avenue, SW For example, some states have adopted policies including licensure regulations that allow legally unlicensed care homes to operate. There were reports that while unlicensed homes in some states (such as Maryland) serve elderly and physically disabled residents, many also serve a clientele who once were homeless, persons who may have substance use disorders, and individuals who were formerly incarcerated. SMEs and key informants discussed a number of factors that may have an effect on the supply of and demand for unlicensed care homes. 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. Thus, one implication of the study is that it may be worthwhile in one or more states or communities to test and evaluate other methods of detecting illegally unlicensed care homes. 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. Assisted Living Facilities in Indianapolis, Indiana. In Texas, when the bill that would have authorized DADs to inspect and license unlicensed residential care homes, legislation was enacted that permitted cities to license RCFs not licensed by the state licensure agency. We also heard of operators not reporting the death of a resident to SSA so the operator could continue collecting the resident's checks from the government. Georgia Association of Chiefs of Police Ad Hoc Committee on At-Risk Adult Abuse, Neglect and Exploitation. This American life, episode 554: Not it! Very little was mentioned about elderly residents living in unlicensed homes; only one informant reported that unlicensed adult care homes may serve a mixed population (e.g., elderly residents in addition to residents with mental illness). The .gov means its official. 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. Those individuals who remained in the city were placed in day programs. Retrieved from http://www.dhs.state.pa.us/cs/groups/webcontent/documents/report/p_011015.pdf. Some publish notices of how and where to report unlicensed care facilities. One state key informant told us that the state licensure office is currently working on an amendment to add a graduated fine system which would increase fines overtime for those operators who are repeat offenders which could potentially serve as a deterrent to continuing illegal operations. Regulatory changes and the role of multidisciplinary task forces (which are relevant to both legally and illegally unlicensed care homes) are described next, followed by a summary of the strategies discussed during interviews to identify and shut down illegally unlicensed care homes and to monitor and improve quality in legally unlicensed care homes. Atlanta Journal-Constitution. Retrieved from http://www.dads.state.tx.us/providers/alf/howto.html. Also, the information gathered during informant interviews about unlicensed homes primarily painted a negative picture of these places. We heard stories from SMEs and site visit informants of operators recruiting vulnerable individuals from psychiatric wards of hospitals, from acute care hospitals through the hospital discharge planners, from homeless shelters, and directly from the street, similar to those we found in media reports (see Appendix B for details). Although recognized as important, the state has not yet begun investigating cases of financial exploitation. In Durham County we interviewed key informants from APS, Group Care Monitoring Services, a local hospital discharge planner, a local ombudsman, and one local law enforcement official, who also serves on a crisis intervention task force. These fines ($50 for a first offense in North Carolina and $500 for a first offense in Pennsylvania) become more severe if criminal activity or a resident's death is involved. Interview findings also suggest that research is needed on the best strategies for identifying unlicensed care homes and effectively closing them down. 3.2.1. Providing 24-hour live-in care manager. Further, evidence exists from several states that there are still unlicensed residential care homes and that, in some states at least, the number of unlicensed facilities is increasing. Assisted living facilities must be licensed to operate in Texas. 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. There are all sorts of assisted living and personal care homes to choose from when deciding which place would best suit your loved one. 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. 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. Informants stated that Allegheny County has other specific contextual issues that may contribute to the existence of illegally unlicensed personal care homes. In some states, residents can pay for their own personal or medical care in an unlicensed facility. 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 Law, Jurisdiction, and Penalties for Illegally Unlicensed Care Homes. This report describes the methods used to conduct the study, summarizes the information learned from an environmental scan and the results from interviews with subject matter experts (SMEs) and site visits, discusses implications of the findings and, based on the study findings, offers recommendations for future research on unlicensed care homes. At least one administrator, on-site manager, or responsible person must be on duty 24 hours per day, seven days a week, and all staff must be trained as personal care workers within 60 days of hire. 3.5.2. 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. Most residential care homes have private rooms available 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. We then asked questions specific to the type of SME, including: What gaps unlicensed care homes may fill in the spectrum of long-term services and supports (LTSS)? Identification of unlicensed care homes is triggered by complaint calls to state or local authorities by community members or family members. In these cases, licensed operators were reportedly worried that the unlicensed operators would house residents from whom the licensed homes operators could have profited. 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. One key informant noted that the state or the LME-MCO can conduct follow-up to assess whether a facility that received a cease and desist letter does, in fact, close down. In Florida, operators of illegal homes use a variety of schemes to hold themselves out as not requiring licensure. Interviews with key informants also indicate that many residents are poor and receive Supplemental Security Income (SSI) benefits from the U.S. Social Security Administration (SSA); the SSI program pays benefits to disabled adults and children who have limited income and resources.
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