Additional research on unlicensed care homes will be valuable to build our understanding of the role--intended or unintended--of these places in our long-term services and supports systems, and the policies affecting it. 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. The vast majority of key informant reports emphasize often alarming conditions in unlicensed care homes. 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. 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. Office of the Assistant Secretary for Planning and Evaluation, Printer Friendly Version in PDF Format (81 PDF pages). Further, when a licensed facility surrenders its license (or the license is revoked) but it operates as an unlicensed residential care home, regulatory and advocacy agencies no longer have the authority to inspect the facility, unless there is a complaint filed (Tobia, 2014). One SME pointed out that many unlicensed care home cases are analogous to human trafficking, such as when residents are held against their will and then moved from one location to another to avoid detection; however, the current federal definition of human trafficking specifies that the trafficking is done for the purpose of labor or sex, and not for the collection of public benefits (U.S. Department of State, 2015). Other SMEs reported that efforts to discharge or divert residents from nursing facilities to community-based settings led to greater use of licensed RCFs and noted instances in which residents who exhausted their private funds might have no options other than unlicensed residential care homes. State and Local Policies Related to the Supply and Demand for Illegally Unlicensed Care Homes. Tobia, M. (2014). Targeted searches of media reports in states with the lowest percentages of their LTSS expenditures on HCBS (New Jersey, Mississippi, Indiana, Florida, and Michigan) did not yield more reports on unlicensed care facilities than those with the highest spending rates for HCBS (Arizona, Vermont, Alaska, Minnesota, and Oregon). In addition to legally unlicensed residential care homes, there are a variety of places that operate illegally. Legally Unlicensed and Licensed Care Home Operators. Failed Legislative Efforts to Improve Oversight. Contact Information: HealthProgram Law Foundation of Silicon Valley 4 North Second Street, Suite 1300 San Jose, CA 95113 INTAKE LINE: 1 (408) 280-2420 Fax: (408) 886-3850 Hours: Monday - Friday 9:00 a.m. - 12:00 p.m., 1:00 p.m. - 4:00, except for major holidays E-mail: [email protected] Website: Law Foundation of Silicon Valley 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. Based on the criteria noted above, we recommended six states to ASPE as possible site visit locations: Georgia, Indiana, Maryland, North Carolina, Pennsylvania, and Texas. Dallas Morning News. These cookies ensure basic functionalities and security features of the website, anonymously. These complaints may be made to the police, APS, ombudsmen, and the Department of Community Health, HFR Division. Some larger facilities operate as unlicensed "residences" by requiring residents to contract with a separate corporation for provision of all ADL or nursing services. This makes it difficult, if not impossible, for residents to leave the facility, a difficulty sometimes exacerbated by limiting residents' access to their funds, to the facility phone, and, as noted above, by locking residents in their rooms or the facility. 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. 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. However, key informants told us that often in these cases,the operator may have another building where the residents could be moved. The goal of this exploratory study was to understand how unlicensed care homes function as a residential care option, the types of individuals who reside in them, their characteristics including quality and safety and the policies that influence the supply of and demand for these homes. Key informants indicated financial exploitation in unlicensed care homes is an area for future research. Unlicensed care home operators also were described as sometimes having select residents act in a role of authority over other residents, such as beating the other residents to control their behaviors. Though outside the scope of our focus, some of the searches also produced media reports and grey literature about concerns in licensed care homes; however, reports about unlicensed care homes and the quality of care described therein was sometimes worse than those for licensed care homes. One informant suggested research that examines the homeless population and the availability of affordable housing as a way to better understand the environment that may be conducive to supporting unlicensed care home operations. California state housing laws establish regulations for hotels, apartment houses and other facilities that provide room and board. As noted in Section 4.1, states use a variety of definitions or criteria that allow some homes to operate legally without a license. 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. A few key informants noted that this funding arrangement affords state and local agencies the resources and time needed to investigate illegally unlicensed personal care homes. This cost ranges widely based on the geographic region you live in. Detecting, investigating and addressing elder abuse in residential long-term care facilities. Referral and Placement Agencies and Discharge Planners. SME interviews primarily focused on federal and state policies that may impact the prevalence of unlicensed care homes. Thirty states require residential care homes to be licensed if they have at least one bed.7 Massachusetts exempts small private-pay homes from licensure. (2012b). Unlicensed Practice. Residents in need of medical assistance such as nursing care can pay for such care from an outside provider, and the facility does not have to be licensed as "assisted living." What types of reports of mistreatment do the agencies receive? It is not unusual for them to be involved in other illegal activities as well. 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. In 2005, Pennsylvania changed the regulations so all residential care homes with four or more individuals had to be licensed by the state, but 1-3 bed residential care homes still could be legally unlicensed. Anne Arundel County Fire Department, Millersville, Maryland. Retrieved from http://www.dads.state.tx.us/providers/alf/howto.html. Read More: Termination of Tenancy in California: Types of Eviction Notices. Of the approximately 1,400 complaints received by APS each year, an estimated 20% pertain to unlicensed personal care homes. The modest payments made by SSI or State Supplemental Payments to residential care homes, which may be inadequate to cover expenses in licensed facilities. It is worth noting that this research activity would require developing an operational definition of "unlicensed residential care home," since definitions vary considerably across and sometimes within states, as some focus on services offered, some on size, and some on the characteristics of the residents. They do not necessarily reflect the views of the Department of Health and Human Services, the contractor or any other funding organization. One key informant estimated this hospital served 3,700 patients at its peak. 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). While this was a limited exploratory study, our findings point toward serious issues with unlicensed care homes, as well as gaps in our knowledge, and they have important implications for future research on unlicensed care homes. It is important to note that we do not know whether the types of financial exploitation and abuse described by the SMEs and key informants occur in both legally and illegally unlicensed care homes, or how commonplace they are. Adult residential licensing, 2010 annual report: A report on licensed personal care homes. 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. They indicated that they are unaware of any assessment of need related to licensed mental health group homes in the state. 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. This cookie is set by GDPR Cookie Consent plugin. Functional cookies help to perform certain functionalities like sharing the content of the website on social media platforms, collect feedbacks, and other third-party features. In these cases, licensed operators were reportedly worried that the unlicensed operators would house residents from whom the licensed homes operators could have profited. Additionally key informants indicated that many unlicensed care home residents who receive SSI payments participate in Social Security's Representative Payment Program, whereby payments are managed by an individual or organization that is representing the beneficiary because the beneficiary is unable to manage the payments independently. 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). The facility operators were authorized to make the decision on their own (Tobia, 2014). The cookie is used to store the user consent for the cookies in the category "Performance". Hawes, C., & Kimbell, A.M. (2010). In the view of the majority of key informants, the operators of unlicensed homes do not want to have to pay for more staff to provide needed services. Here's how you go about opening and RCFE in the state of California. Without having a qualified, certified administrator on your team, none of the rest can follow. Another key informant suggested that it would be key to involve the LME-MCO because they cover a four county area and must receive calls that are about unlicensed care 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. 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. Thus, although our findings consistently highlighted concerns about safety and quality, we cannot assess the generalizability of these findings and concerns. These cookies will be stored in your browser only with your consent. We operate unlicensed room and board homes, some owner-occupied and all managed 24/7. Future research could be conducted to describe the nature of ombudsman involvement in unlicensed care homes and how it differs across states. Family care homes serve 2-6 residents and adult care homes serve seven or more residents; both can choose to serve only elderly persons (55 years or older or any adult who has a primary diagnosis of Alzheimer's disease or other form of dementia) or to serve a mixed resident population. General searchterms included unlicensed, not licensed, unregulated, adult, elderly, residential care, and assisted living. Our residents include men, women and residents who do not need continual supervision and guidance. Facilities provide two types of services in addition to room and board: (1) basic services, which include personal . 200 Independence Avenue, SW 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. 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. Additionally, what we heard about the policies that affect demand for and supply of unlicensed homes, and how unlicensed homes can be identified or detected, may not be representative of the situation in other states. Findings indicate that a variety of policies may have an impact on the supply of and demand for unlicensed care homes. Other issues were identified during the subsequent sexual assault investigation, including abuse at the hands of the operator who beat the residents, false imprisonment in which individuals were locked inside rooms, and financial exploitation. Moreover, unlicensed care home operators have an opportunity to operate virtually unchecked in terms of seizing control of the residents' government benefits. Interview findings indicate that a key element of a successful strategy is collaboration across multiple agencies. If ombudsmen become aware of such discharges, they will likely attempt to assist individuals or their families to find licensed options, but they can only provide aid if they are notified. A paper by Tobia (2014) describes the state of unlicensed residential care in one county in Maryland, where as many as 78 unlicensed care homes may be serving as many as 400 individuals. He argued that comprehensive emergency management planning and proactive practices were needed to protect those at risk in unlicensed homes. The inability or unwillingness to provide appropriate care for residents at an affordable cost also was noted by key informants as a motivator to not pursue licensure. My family member has brought a pit bull puppy onto the property and is keeping in a fenced area. Schneider, C., & Simmons, A. Licensure regulations lack clarity regarding requirements for minimum bed size. Estimate of 2-year cost of implementing HB216. Key agencies and team members involved in local or state teams to address unlicensed care homes include APS, ombudsmen, building code enforcement, social workers and first responders such as EMS, police, or firefighters, and other representatives from local advocacy groups such as Disability Rights. Policies affecting the supply of and demand for unlicensed care homes. Media reports described operators that continued to operate after their licenses expired or were revoked. Her e-mail addresses is: [email protected]. Conditions (including quality and safety) of unlicensed care homes. What concerns are there about the quality of care and safety in unlicensed care homes? The goal of this study was to provide foundational information intended to answer or provide insight into the study research questions. Please read and acknowledge the disclosure below: CRBC makes no representation or guarantee regarding the outcome and confidentiality of information provided through complaint process, whether in person, via phone or in writing. These preliminary findings are worth considering as policy makers implement federal, state, and local policies and practices that may relate to unlicensed care homes. While exploratory in nature, the findings highlight potential issues of safety, abuse and financial exploitation in unlicensed care homes. One of the points made by key informants is that states have very few, if any, strategies to easily identify unlicensed care homes. 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. At least two states have demonstrated that coordinated efforts can effect changes to laws and policies and create at least initial disincentives or barriers to the operation of illegally unlicensed care homes. How to Become Licensed Public Information and Policies Resources for Residents and their Families Contact Us Community Care Licensing Adult and Senior Care Program 744 P Street, MS 9-14-820 Sacramento, CA 95814 Telephone: (916) 657-2592 Fax: (916) 653-9335 [email protected] Regional Offices Contact Information 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. Connie's Room and Board Independent Living 2 3333 Hickerson Drive San Jose CA 95127 Connie Reyes 408-649-6452 or 408-518-2088 txt conniesroomandboard2 Downtown Independent's [email protected] Home 1188 East Santa Clara St San Jose CA 95112 408-849-8404 Complaints Some operators use homes that do not meet personal care home building code regulations; for example, the home may lack proper ramps for wheelchair access. While we were specifically told by two key informants that the LME-MCO can only contract mental health services and supports to licensed group homes, these same key informants also shared specific examples of the LME-MCO unknowingly contracting services to unlicensed group homes. In several cases, the potential interviewees did not have direct knowledge on the topic of unlicensed care homes, and were not interviewed, but referred us to interviewees with more knowledge on the topic. As described by the majority of key informants, the primary motivation to maintain an unlicensed care home is to maximize profit. In this kind of scam, food stamp benefits are reportedly stolen from residents, who are then provided with little or outdated food, and may subsequently go hungry or beg or steal food from neighbors. Although recognized as important, the state has not yet begun investigating cases of financial exploitation. . We also use third-party cookies that help us analyze and understand how you use this website. Savchuk, K. (2013). Florida: A media report stated that in 2012 the licensure agency received more than 200 complaints about unlicensed activity and confirmed 62 were unlicensed--a 60% increase since 2010. Remaining unlicensed can be lucrative to care providers, if they can avoid detection by the authorities. The rental agreement can be an oral agreement, periodic rental agreement or lease. These individuals do not pay taxes, have insurance or bonds. This cookie is set by GDPR Cookie Consent plugin. One-bed and two-bed residential care homes are lawfully allowed in several states. 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. A coordinated, interagency, multidisciplinary effort across state and local agency and organizational levels is an important component to addressing unlicensed care homes. While many key informants stated that illegally unlicensed personal care homes primarily serve adults with a wide spectrum of mental health disorders, they also noted that some of the residents in unlicensed care homes are frail and elderly individuals. Pennsylvania's BHSL is currently working on an amendment to create a graduated fine system for those operators who continue their illegally unlicensed care homes after they have been ordered to cease operations. The team conducted interviews with key informants in each of these communities. In this example, the residents would have to be relocated, and the PCRR team would assist in this effort. I have allowed a family member to rent a room from me but we don't have a written rental agreement. The Pennsylvania BHSL provides specific documentation to potential operators and consumers outlining situations that do not have to be licensed by the state. Failing to have safety equipment available, such as smoke detectors and fire extinguishers. This key informant was concerned this had contributed to group homes closing, which may have resulted in a gap that unlicensed facilities are filling. Given their direct linkage to unlicensed care homes, these three sources (hospitals, homeless shelters, and licensed personal care homes) are potential sources of information for identifying unlicensed care homes. Licensure staff admitted they only learn about the unlicensed facilities when someone reports them. Key informants were also concerned about a lack of specific services inside illegally unlicensed personal care homes. Centers for Medicare and Medicaid Services. 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). Cases of physical abuse, such as residents being beaten and burned as described in the environmental scan, were also reported during interviews. The scan included published peer-reviewed and grey literature, including abuse blogs and media reports about legally and illegally unlicensed residential care homes. Many adult facilities, those licensed for ages 18-59 , accept the current SSI board and care rate as payment in full. Fiscal note, 81st legislative regular session. Some of these ideas may be relevant for agencies other than or in addition to ASPE, such as the National Institute of Justice, CMS, or ACL. Almost all SMEs and key informants we interviewed offered strategies to identify, monitor, or close unlicensed care homes. The cookie is used to store the user consent for the cookies in the category "Performance". 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. However, our literature search did not reveal any estimates of the prevalence of unlicensed residential care homes in most of these states. First Responders: EMS, Firefighters, and Police. There appears to be a general lack of recognition about the extent of the problems with unlicensed residential care homes in the United States. As such, key informants speculated that these types of organizations may maintain lists of residential care homes. We use cookies on our website to give you the most relevant experience by remembering your preferences and repeat visits. Teri Parker CFP is a vice president for CAPTRUST Financial Advisors. 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. Typically, the reports refer to physically or mentally disabled adults, some with disease specific conditions, or just described as mentally ill or elderly. Ombudsman programs are not adequately involved. These homes often serve very vulnerable individuals such as individuals with serious mental illness or other disabilities, or older adults with functional limitations and limited financial resources. Key informants noted that it is important to know the history of Pennsylvania's personal care home regulation changes in order to understand why and how the state has addressed illegally unlicensed personal care homes. U.S. Department of Health and Human Services Provision of housing plus one or more personal services requires a personal care home (or other licensed facility) permit. Licensure staff only learnabout the unlicensed residential care homes when someone reports them. There are no visible smoke or fire alarms. However, the individual may have been arrested with no criminal conviction, convicted of a minor traffic offense or adjudicated as a juvenile. According to several key informants in the state, including APS and law enforcement officials, the property, which they referred to as a boarding home, was being rented by the operator, members of the church served as the representative payees for the residents, and the money was then pooled together and given to the operator. 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. Notably, the strategy of responding to complaints limits the amount of information available about unlicensed care homes about which complaints are not made (i.e., possibly better quality homes). Three reports are worth noting separately. 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. While some unlicensed homes reportedly serve elderly and physically disabled residents, key informants noted that many also serve persons who were formerly homeless, persons who may have substance use disorders, persons with severe and persistent mental illness, and parolees. 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. Thus, we lack information about unlicensed care homes in moststates, and even in our study states there were no reliable counts of illegal unlicensed care homes. 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. According to many of the key informants interviewed, hospitals are increasingly under financial pressure to discharge patients to free up beds, which is believed to contribute to the ability of unlicensed care homes to fill beds and stay in business. 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. Identification of unlicensed care homes is triggered by complaint calls to state or local authorities by community members or family members. Key informants in Pennsylvania speculated that owners of legally unlicensed care homes may have direct experience operating an illegally unlicensed home or know someone operating one, and therefore may be able to help identify unlicensed homes or their operators. She was getting good care and it was something the mother could afford. States with concerns about quality and safety in unlicensed care homes may also wish to examine their requirements for monitoring legally unlicensed care homes and the information available about safety and quality in these places. Site visit summaries, which provide more state-specific information, and information on other states considered for site visits, are included in Appendix A. Residents may not have access to their personal identification cards due to the care provider retaining those items, which can limit the capacity of the resident to relocate. In California in the early 1970's, the This website uses cookies to improve your experience while you navigate through the website. 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. An operator with this population mix can avoid licensure because each agency is only responsible for the residents that are enrolled in their program or waiver. Operators of small care homes lack knowledge of licensure regulations and how to navigate the different government agencies, and there is a perceived lack of respect from government staff regarding the quality of care that non-professional staff can provide in these small residential care homes. In contrast, identifying and addressing quality in legally unlicensed care homes was only minimally discussed; however, in at least one of our site visit states, interviewees felt that it was feasible to identify these homes, given the existence of listings of these homes.