One key informant in Allegheny County shared a list of seven current placement agencies that likely have registers of illegally unlicensed care homes. Although recognized as important, the state has not yet begun investigating cases of financial exploitation. The North Carolina Office for Mental Health Licensure also licenses group homes for adults with developmental disabilities (5600B) and group homes for adults with substance abuse issues or chemical dependency. For example, key informants in Allegheny County, Pennsylvania, stated that police in rural areas of the county are more responsive to reports of unlicensed care homes than are the city police. Copyright 2017 Scripps Media, Inc. All rights reserved. Schneider, C., & Simmons, A. Finally, in some states, SMEs and the environmental scan identified legally and illegally unlicensed residential care homes that were referred to as boarding homes or board and care homes. Available at https://aspe.hhs.gov/basic-report/compendium-residential-care-and-assisted-living-regulations-and-policy-2015-edition. Discussions with SMEs and key informants explicitly differentiated between legally and illegally unlicensed care homes only minimally, but the opinion of SMEs and key informants we interviewed seemed to be that state efforts to address legally unlicensed care homes should focus on monitoring and improving quality, whereas state efforts to address illegally unlicensed care homes should be on identifying these homes and shutting them down. State and Local Policies Related to the Supply of and Demand for Illegally Unlicensed Care Homes. Although little is known about unlicensed care homes, a variety of signals, including media reports, highlight potential safety and quality concerns. They noted that the following may have heightened the demand for unlicensed care homes: The admission and discharge policies of licensed care homes. Office of the Assistant Secretary for Planning and Evaluation, Printer Friendly Version in PDF Format (81 PDF pages). Additionally, agencies such as The National Disability Rights Network's Protection and Advocacy Agency (NDRN P&A) could potentially use representative payee data to identify unlicensed care homes. Key informants from Georgia and Pennsylvania reported that hospitals and hospital discharge planners (or their contractors) often place patients in unlicensed care homes (described in more detail in Section 4). In one state, the AG only received nine cases in the entire year; in another state they handled only 2-3 cases a year. Klavinger says he was outraged when Glover-Hogan moved Plummer into an unlicensed group home in Warren -- a home that was operating illegally as an Adult Foster Care facility. One key informant indicated that this reduction is due to the increasing numbers of HCBS waivers giving potential Dom Care residents the option to live alone in apartments. One key informant estimated that approximately 25 cases are investigated annually, with about half that number determined to be illegally unlicensed personal care homes. 722.622 Definitions. Unlicensed homes tended to flourish in larger cities where there were significant numbers of low-income elderly and people with mental illness released from state mental hospitals. LARA is dedicated to bridging the gap between civilian and military employment and helping veterans gain and retain employment. Key informants included representatives from the state licensure office. Research about legally unlicensed care homes might focus on collecting information about characteristics of legally unlicensed care homes, the services they offer and the residents they serve, such as through a larger number of site visits and interviews with ombudsmen and state regulatory agencies or through a survey of the operators of legally unlicensed homes in states or areas that maintain lists of these homes, such as Florida, Georgia and Texas. A 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. 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 also described another illegally unlicensed personal care home with several tenants, including a 91 year old man who had been tied to a chair with a sheet so he would not fall when the owner had to leave the home. Residential care homes that serve three or fewer residents are legally unlicensed in this state. 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. One key informant shared a specific example of an operator targeting individuals in hospitals: "Hospitals are putting them on the street. They deny services such as assistance with medication are being provided to residents, or assert they are only providing housing for alcoholics, ex-convicts or people with mental health issues to avoid having to become licensed. Based on our findings, the residents of these homes are extremely vulnerable. You can: Use the online form to file your complaint. One-bed and two-bed residential care homes are lawfully allowed in several states. 2. 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. State and Local Policies Related to the Supply and Demand for Illegally Unlicensed Care Homes. The frequently reported act whereby the operator of an unlicensed home makes money from their control of vulnerable residents and moves these residents from one unlicensed care home to another to avoid detection, led one SME to refer to it as "human trafficking." However, as recently as 2013, the number had decreased to ten enforcement actions. In Pennsylvania informants described a public education campaign including advertisements warning people about placing their loved ones in unlicensed care homes. Glass, I. The licensing rules for Adult Foster Care and Home for the Aged facilities provide minimum standards for these regulated facilities. Future research could be conducted to describe the nature of ombudsman involvement in unlicensed care homes and how it differs across states. Assisted Living Facilities in Indianapolis, Indiana. If the illegally unlicensed personal care home can be deemed unsafe, code enforcement has the authority to condemn the building and shut the illegal operation down. Multiple key informants also stated that a Dom Care operator with the maximum of three individuals may be considering adding other residents or has possibly tried it before, therefore interviews with some Dom Care Operators may yield a unique perspective on the motivations to operate unlicensed care homes. Dallas Morning News. This became evident during discussions with informants in Pennsylvania and Georgia; it has also been reported in the literature, as we found in the environmental scan. One key informant explained how North Carolina regulations restrict ombudsman activity in unlicensed care homes, stating "our structure is pretty clear as far as the accountability," implying that the regulations make ombudsmen unaccountable for residents in unlicensed care homes. 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. The same held true, with one exception (Georgia), for the top ten states with the greatest increase in HCBS spending since 2010: Virginia, Ohio, Maine, Rhode Island, Alabama, Tennessee, Georgia, New Hampshire, Massachusetts, and Delaware. Many interviewees mentioned monetary motivations of operators as one factor. The vast majority of key informant reports emphasize often alarming conditions in unlicensed care homes. 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. Licensure offices and other agencies or organizations respond to complaints made by concerned citizens, including family members and friends of residents, neighbors of unlicensed care home operators, health care providers serving unlicensed care home residents, firemen, ambulance services, police, and licensed care home operators. 4GEMS ADULT FOSTER CARE. He argued that comprehensive emergency management planning and proactive practices were needed to protect those at risk in unlicensed homes. In addition, as one ombudsman report noted, it is often difficult to determine whether a place is an illegally unlicensed residential care home because of the difficulty of obtaining access to the suspected home to make the determination. Failing to consistently provide running water and electricity, or having unsafe or illegal electrical wiring. It was outside the scope of this project to examine the alternatives to unlicensed care homes or the health, safety or appropriateness of those environments. FINDINGS FROM THE ENVIRONMENTAL SCAN, http://www.stopelderabusepetition.blogspot.com/2013_06_01_archive.html, http://www.thisamericanlife.org/radio-archives/episode/554/not-it, http://www.namfcu.net/resources/medicaid-fraud-reports-newsletters, http://www.disabilityrightswa.org/stop-fraud-and-abuse-rep-payees, http://www.dhs.state.pa.us/cs/groups/webcontent/documents/report/c_102850.pdf, http://aspe.hhs.gov/office-disability-aging-and-long-term-care-policy-daltcp, HHS Office of the Assistant Secretary for Planning and Evaluation, Pennsylvania Bureau of Human Services and Licensure, HHS Centers for Medicare and Medicaid Services, Texas Department of Aging and Disability Services, 3.2. Multiple key informants described unlicensed care homes as primarily serving persons with mental illness. However, as in some other states, APS in Pennsylvania can act on referrals of abuse for elderly residents (age 60+). 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. As described by the majority of interviewees, the primary populations residing in illegally unlicensed personal care homes are vulnerable, with few financial resources. Licensing is the process by which the Department of Licensing and Regulatory Affairs (LARA), Bureau of Community and Health Systems (BCHS) regulates adult foster care group homes. One SME also noted that some unlicensed care home operators take residents' veteran's benefits. 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. Thus, although our findings consistently highlighted concerns about safety and quality, we cannot assess the generalizability of these findings and concerns. Audio podcast. For example, one SME from a state licensure office reported that their database does not include information on whether the call pertains to a licensed or unlicensed care home. Michigan Department of Licensing and Regulatory Affairs Bureau of Community and Health Systems P.O. 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. Additionally, several SMEs and key informants noted that in many cases unlicensed homes are the only option, other than homeless shelters or living on the streets, for some of these residents. 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. Some of these homes also serve mixed populations (e.g., elderly residents as well as individuals with severe and persistent mental illness). But after a family friend told the Oakland County Probate Court that Plummer was having memory loss, court records show a Judge appointed a Southfield attorney as a co-guardian. However, a shared bedroom in a six-bed group home costs about $34,000 a year, and a private room runs from $48,000 to $78,000, according to William Young, founder and president of Residential Care Facilities for the Elderly, an association of California group homes. Multiple key informants reported that financial exploitation was the biggest concern surrounding unlicensed care homes. Retrieved from http://www.state.gov/documents/organization/245365.pdf. As noted above, placement agencies work with Allegheny County hospitals and discharge planners, therefore these agencies may also have lists that include illegally unlicensed personal care homes. Several states have taken steps in improve oversight of unlicensed facilities, often as a result of newspaper exposs on unlicensed residential care homes. Clarifying this definition will be critical to understand the prevalence of unlicensed residential care homes, as well as the characteristics of residents in these homes. New Jersey and Tennessee have a licensure category that specifies the maximum number of beds required for licensure, but not a minimum, which also implies that in these states some residential care homes may be legally unlicensed. 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. 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