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. Key informants for each site visit location included representatives of local public safety organizations such as law enforcement or firefighters, Adult Protective Services (APS) staff, and ombudsmen. Troubled Group Homes Escape State Scrutiny. This key informant was concerned this had contributed to group homes closing, which may have resulted in a gap that unlicensed facilities are filling. Most state informants said legally unlicensed care homes did not fall under state regulatory purview, and thus were not monitored (or investigated unless there is a complaint). 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. { J\5s-Qy&`DA!o+Z46sA. These key informants agreed that because discharge planners are under pressure to quickly discharge hospital patients to contain hospital costs, they must have a list of care homes (including licensed and illegally unlicensed personal care homes) that they can reference if the discharge planner has no other option for placement. One SME, who works on the Representative Payee Project,4 mentioned that this project only investigates a sample of individuals who are representative payees for 15 or more individuals. APS professionals there estimate three reports or complaints about unlicensed personal care homes every month in the metro Atlanta area, and about one complaint or report about unlicensed personal care homes every three months in rural areas of the state. More recently within the City of Atlanta, the gentrification of some neighborhoods has resulted in increased property values and rents, which has caused some unlicensed care home operations to relocate to less expensive areas. In some states, residents can pay for their own personal or medical care in an unlicensed facility. 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. Austin, Texas. Other states also track complaint calls as a means for identifying unlicensed 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. Multiple interviewees suggested that it was important to quickly involve code enforcement and local health departments in efforts to close an illegally unlicensed personal care home. Medicaid fraud reports, 2009-2013. According to key informants from APS and law enforcement, care home operators and residents crossing state borders poses several challenges that make it difficult to ensure the safety of residents and address the criminal activities of the operators. Media reports were usually about an action by a licensing agency, Medicaid Fraud Unit, APS, or the police arresting an operator; these reports do not provide much information about the extent to which unlicensed homes exist in the state. ~DNe*FYil2`#T*$E9=`pJ. 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. Several states have taken steps in improve oversight of unlicensed facilities, often as a result of newspaper exposs on unlicensed residential care homes. General searchterms included unlicensed, not licensed, unregulated, adult, elderly, residential care, and assisted living. In this example, the residents would have to be relocated, and the PCRR team would assist in this effort. 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. (2012). "Caretaker" Accused of Abusing and Neglecting Mentally Challenged Victims. Massachusetts exempts small private-pay homes from licensure. Retrieved from http://www.ajc.com. State Law, Jurisdiction, and Penalties for Illegally Unlicensed Care Homes. In multiple interviews, unlicensed care home operators were described as being involved in human trafficking, and also were specifically noted by APS and law enforcement officials to traffic residents across state lines, specifically into Florida and Alabama, to avoid legal action in Georgia. Key informants also mentioned other resident health concerns including neglect, lack of water, malnourishment, and bed sores or pressure ulcers resulting from inadequate care. As a direct result of this regulation change, many personal care homes in Pennsylvania became illegally unlicensed and either shut down, became licensed, or continued to operate illegally. 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. 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. Below are examples from the environmental scan that provide some estimates of the number of unlicensed care homes: Maryland: A representative of the licensure agency estimated 500 unlicensed illegal assistive living facilities and noted the fine line between a boarding home and assisted living. Multidisciplinary PCRR teams were then formed at the county level to address the relocation of residents to licensed facilities and to investigate illegally unlicensed personal care homes in coordination with the state licensure office. The following acronyms are mentioned in this report and/or appendices. 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. After years of personal and professional experience, I founded The Group Home Connect Academy, where we provide 1:1 Coaching to help entrepreneurs make their business dreams a reality. 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. 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. Retrieved from http://www.ajc.com. Illegally Unlicensed Residential Care Homes, 6.3. 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. Some SMEs noted that many licensed facilities are unwilling to admit or retain individuals with severe and persistent mental illness, intellectual disabilities, or challenging behaviors. According to the report, these warehoused residents are vulnerable older adults with "hard to place" mental health needs and paroled individuals. Alabama's APS agency estimated that there were more than 200 unlicensed homes in the state, in contrast to their 400 licensed facilities. 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. Retrieved from http://www.miamiherald.com. An Online Resource for Skilled Immigrants. After a legal challenge this fall, Mrs. Plummers son and cousin are now her guardians, and she is now living at home with relatives. One-bed and two-bed residential care homes are lawfully allowed in several states. HOUSTON - KPRC 2 recently reported on Blessed Hands Independent Homes, an unlicensed group home operating in southeast Harris County. A few strategies exist in the state for addressing illegally unlicensed personal care homes. Government staff lack of respect for the care provided in small residential care homes by non-professional licensed staff. 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. Findings also indicate that conditions in some unlicensed care homes are unsafe, abusive, financially exploitative, and neglectful of residents' basic needs. Theft of government benefit checks (e.g., SSI, Social Security, food stamps, Medicaid, veteran's checks) was common, with one case in which operators diverted more than $790,000 to themselves. Balancing a rewarding career with the ability to have a high-quality lifestyle is important. However, key informants emphasized that in some cases,the residents become tethered to the operators through financial exploitation and emotional manipulation, and as a result are unable to leave these abusive and exploitative situations. As described by the majority of interviewees, the primary populations residing in illegally unlicensed personal care homes are vulnerable, with few financial resources. 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. In this section, we summarize results of the literature review and interviews with SMEs and key informants. Strategies for Addressing Conditions in Unlicensed Care Homes, 6.1. The latest thing with hospitals, not only discharging to substandard places, the hospital is paying for the first month because it's cheaper than an expensive hospital bed.". States have a variety of options for reducing the prevalence of both legally and illegally unlicensed residential care homes, such as changing regulations and coordinating across agencies to address these homes. Treatment of residents as a commodity was a common theme across interviews. 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. Per state regulations, residential settings providing room, board and personal assistance with three or fewer residents who have at least one personal care need do not meet the requirements for licensure as a personal care home and are legally unlicensed. In more extreme cases, other personal care homes have stopped accepting any persons whose sole source of income is SSI. 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. This results in different payment streams and different regulatory agencies that have responsibility for different residents in the same residence. As a result of the newspaper expos, Georgia enacted new stronger laws. This task force has also coordinated raids on unlicensed homes and has pushed for changes to laws regarding these homes. Humphrey Building, 200 Independence Avenue, S.W., Washington, D.C. 20201. Lists of both known illegal and potentially (identified but not yet confirmed) illegal operations are maintained by APS and the local ombudsman who lead the team. However, these are issues that warrant additional research. A 2010 report from the Pennsylvania BHSL noted that enforcement actions against illegal personal care homes had increased from four homes in 2009 to 27 in 2010 (most were located in the Philadelphia area). Georgia: In one expose, the Atlanta Journal-Constitution analyzed thousands of inspection reports and interviewed state and local official, social service providers, and advocates, and then published an article on the status of affairs in unlicensed personal care homes. Interview findings indicate that many residents of unlicensed care home are Supplemental Security Income (SSI) beneficiaries. 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. Retrieved from http://www.gachiefs.com/pdfs/White%20Papers_Committee%20Reports/AtRiskAdultAbuseWhitePaper.pdf. 20 or fewer individuals 55 years of age or older that is operated in conjunction with and as a distinct part of a licensed nursing home. Few peer-reviewed articles have been published on unlicensed care homes, but numerous media reports were examined. 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. He also noted that they were not currently using the system in this way, and that it is mostly used to note unsafe locations (e.g., places known for drug trafficking and drug use, or for having dangerous dogs). One issue that remains to be determined is the conditions or criteria by which such places constitute "unlicensed residential care homes." Despite this lack of information about prevalence, we heard about many strategies for addressing the existence of unlicensed care homes and the conditions in them. Key informants described instances of operators making money off of vulnerable residents in a variety of ways that involved theft from residents and theft from government programs. Residents of unlicensed care homes are vulnerable adults. 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. Additionally, some of what we heard about policies that affect demand for and supply of unlicensed care homes was based on the opinions of the individuals interviewed and may not be representative of others' views, and we do not have data to support these viewpoints. endobj Trafficking in persons report. Health, Safety, and Sanitary Conditions. You may need to be personally licensed as a Certified Administrator of Group Homes, for instance. The Scope of Abuse and Exploitation Concerns. Of the approximately 1,400 complaints received by APS each year, an estimated 20% pertain to unlicensed personal care homes. Several informants explained that some unlicensed care home operators require residents to make the care home operator or the operator's designee their representative payee for SSI benefits, and that some operators also collect food stamps, medications, or other resources from residents, which the operators can then sell for profit. More information exists about licensed RCFs than unlicensed care homes, thus knowledge of the unlicensed care homes is limited. Further, implementation of the Olmstead decision has increased the demand for residential long-term care settings and services. m'C{:4hQ*7/^=5"}}XOiE04>f{3c y `'#U#"+ezaC T%YXJ4&l-!~?# ,5gvHRD3|LcGZ@' L=$bo-}w={&vT-)>/bcSG{K1DCIqEV8w $Ts7 .&S`1MSaqI&Q:NY3p v)ybUB@H K,q(.U w^t{N Some continue to operate after their license expired or was revoked. However, our literature search did not reveal any estimates of the prevalence of unlicensed residential care homes in most of these states. We relied on a targeted literature review, interviews with a small number of SMEs, and site visits to just three communities, all of which limit the scope of our findings. Concerns remain that agencies do not have the resources needed to monitor and follow through with the appropriate actions to cope with unlicensed care homes (e.g., finding emergency placements for residents, prosecuting violators, ensuring that the illegally unlicensed residential care home remains closed and has not reopened in another location). 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. Florida publishes a listing but it does not correspond with the media reports of the number of unlicensed care homes identified by state inspectors. (Hawes & Kimbell, 2010). (c) "Assisted living facility" means an unlicensed establishment that offers community-based residential care for at least three unrelated adults who are either over the age of 65 or need assistance with activities of daily living (ADLs), including personal, supportive, and intermittent health-related services available 24-hours a day. Although a substantial amount of information and suggestions about methods of identifying unlicensed care homes came from site visits to communities in three states (Pennsylvania, North Carolina, and Georgia), whether any of these strategies will apply to other states or other communities is unclear. There is a lack of knowledge regarding the licensure requirements or about how to navigate the different government agencies. Indeed, several key informants in Allegheny County reported that the closure of Mayview Psychiatric Hospital led to an increase in the prevalence of illegally unlicensed care homes in the county. Most key informants noted that hospital discharge is a critical juncture at which individuals can be directed to, or end up in, unlicensed care homes. He called Glover-Hogan, and said did you visit? However, we did not focus on these populations in the interview. Unlicensed care homes commonly will accept these individuals and many market themselves to discharge planners. . 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. Ombudsmen program does not extend to unlicensed facilities (Hawes & Kimbell, 2010). Dirt was evident over the walls, floor and stairway.. Sec. Charlene Glover-Hogan is a Public Administrator, a lawyer appointed by Michigans Attorney General to handle probate estates after someone dies. A 2010 annual report from the Department noted that the number of illegal residential care homes had increased from four homes in 2009 to 27 in 2010, most of them located in the Philadelphia area (Pennsylvania Department of Public Welfare, 2011). Key informants recommended several tactics to address poor quality in unlicensed care homes, but the overall strategy consistently discussed was to shut down these homes. Zoning approval is required under the Zoning Enabling Act (2006 PA 110, MCL 325.32016). The financial pressure hospitals feel to free up hospital beds quickly, which sometimes results in discharges to unlicensed care homes, both intentionally and unintentionally. 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. Six states (Colorado, Iowa, Illinois, Maine, Missouri, and Vermont) license starting at three beds; Vermont exempts small private-pay homes. Interviewees pointed to financial incentives related to managing SSI recipients' checks as one specific motivator. None of these approaches or strategies completely addresses the concern about providing a safe environment and quality services to the vulnerable individuals being served in unlicensed care homes. Following the Olympics, funding for these day programs was not renewed, and all but one of these programs ceased operations. In contrast, one key informant stated that one repeat illegally unlicensed facility had housed residents who had thrived there and had benefited from living in the home. Clarisse Carter runs Due Season Residential Services LLC, the unlicensed group home in Warren. Providing unsafe housing conditions, including overcrowding of resident rooms, housing many more residents in bedrooms than is allowed by state licensure regulations, housing residents in storage sheds, basements, and attics that were unsafe, unsanitary, and made egress difficult for frail or disabled residents. Indiana: An Indianapolis news article stated that the area had far more unlicensed than licensed facilities. Like the SME interviews, each key informant interview began with a general question to ascertain what the interviewee knew about unlicensed care homes. This research might also address whether the Keys Amendment is achieving its goal of protecting the well-being of SSI recipients. We conducted an environmental scan primarily focused on information spanning a five year period from 2009 through 2014. 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. From 2008 to 2013, Pennsylvania reported a stable trend of investigating about ten illegally unlicensed care homes per year with the exception of 2010 when they investigated 27 cases, about three times more than in other years.6. Several informants reported that it is common for the operator of an unlicensed care home, or representatives designated by the care home operator, to serve as the representative payee for the residents. Key informants noted that the possibility for theft from residents and from government programs also exits with the practice of operators taking control of residents' monthly income from SSA. Entrance of unlicensed group home with door broken, Wednesday, Sept. 23, 2020, in Houston. Although licensed homes were generally depicted by key informants as safer than unlicensed homes, one key informant emphasized that quality of care is not contingent on licensure status; licensed homes may also have health and safety concerns. In Maryland, licensure is not required for a provider who serves individuals who are dependent on the provider for room, board, and control and security of their medication but do not need assistance with any ADL. 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. Figueroa, L. (2011). 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. Managing the care needs of low-income board-and-care home residents: A process of negotiating risks. 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. Each interview began with a general question to ascertain what the interviewee knew about unlicensed care homes. 4 0 obj One key informant estimated this hospital served 3,700 patients at its peak. 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. Retrieved from http://www.dads.state.tx.us/providers/alf/howto.html. Failed Legislative Efforts to Improve Oversight. Findings indicate that a variety of policies may have an impact on the supply of and demand for unlicensed care homes. 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). (2009). So you have a document that you want to show me indicating that its unlicensed, asked Glover-Hogan. 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 strategy recommended by key informants to address unlicensed care homes is to change the regulations to reduce the number of unlicensed care homes that operate legally. California, Pennsylvania, Maryland, and Mississippi publish notices of how and where to report unlicensed care homes, which implies that these states may be experiencing problems with unlicensed homes. (2013). Our examination of the Medicaid Fraud Control Unit reports (2009-2013) showed that only a couple cases were reported to the media; the rest had not made the news. For example, as part of interviews with SMEs, we asked them to recommend potential key informants to meet with during site visits. Key informants also cited the process of discharging patients from hospitals in Allegheny County as a potential source for linking individuals with illegally unlicensed personal care homes. 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). 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. 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). However, SSI payments are low, and most states supplement these payments with a State Supplementary Payment (SSP). Many interviewees mentioned monetary motivations of operators as one factor. Savchuk, K. (2013). The Adult Foster Care Act (PA 218 of 1979) and the Public Health Code (PA 368 of 1978) provides the Departments authority to establish these rules. However, some SMEs and key informants also noted that many of these individuals with psychiatric conditions are older, having aged in state institutions, and that persons 65 years of age and older who receive SSI payments also often live in unlicensed care homes. Presumably, this led to an increase in need for LTSS for these populations. There are three ways to file a LARA report with the State of Michigan. Lax enforcement in personal care homes. 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. The residents would have to be personally licensed as a result of newspaper on! 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