Although such issues are not restricted to unlicensed care homes, as they are known to occur in licensed care facilities as well, future research might examine and describe the mechanisms states use to detect, investigate, and resolve allegations of abuse or neglect in unlicensed residential care homes and how they compare to the mechanisms used to identify and resolve instances of abuse and neglect in licensed care homes. Her e-mail addresses is: Emily.Rosenoff@hhs.gov. These findings suggest that as states continue to move toward serving more of their Medicaid beneficiaries in the community rather than in institutions, consideration should be given to ensure appropriate safeguards are in place for these beneficiaries. LIMITATIONS, CONCLUSIONS AND POLICY IMPLICATIONS. In addition, SMEs noted variability across states in the availability of resident advocacy and protection through such agencies as the ombudsman program. 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. Site visit findings were largely consistent with those of the environmental scan, and despite increased attention to unlicensed care homes in some states, key informants highlighted issues of safety, abuse, and exploitation. The state's annual Personal Care Homes Report provides the number of illegally unlicensed personal care homes that result in enforcement actions and details the historical trend of the number of enforcement actions taken against illegal unlicensed personal care homes. Web log.Retrieved from http://www.stopelderabusepetition.blogspot.com/2013_06_01_archive.html. Informants noted that unlicensed care homes vary in their appearance and condition. Pennsylvania's BHSL and the North Carolina Adult Care Licensure Office and Mental Health Licensure Office will offer to work with unlicensed residential care homes to help facilitate licensure. In Georgia, key informants also noted that hospitals directly discharge individuals to unlicensed care homes and some pay the first month of the resident's fees. 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. Also, the information gathered during informant interviews about unlicensed homes primarily painted a negative picture of these places. Maryland, Nevada, and Florida: The National Ombudsman Reporting System noted an increase in unlicensed care homes in these states, but no unlicensed care reports from any state provided evidence on the prevalence of unlicensed care. Retrieved from http://www.phlp.org/wp-content/uploads/2011/03/PCH_manual-for-advocates-Feb-20071.pdf. Interview questions were based on respondent expertise, and were tailored for each respondent. 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. (2015). Funds are being allocated to relocate residents out of unlicensed residential care. Strategies for Addressing Conditions in Unlicensed Care Homes, 6.1. 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. Private schools need to obtain a permit from Licensing for any program or service that offers care for children under 3 years of age. as those who are in wheelchairs or electric carts and have the capacity to transfer and evacuate themselves in an emergency. Some states permit unlicensed care homes to operate legally under the guidance of state regulation; others do not. Pennsylvania was selected as a site visit location because of the state's past and current experiences with illegally unlicensed personal care homes. What federal and state policies affect the supply and demand of unlicensed care homes? Pennsylvania and North Carolina have some similarities in how they address unlicensed care homes. 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. One key informant in Allegheny County shared a list of seven current placement agencies that likely have registers of illegally unlicensed care homes. Detecting, investigating and addressing elder abuse in residential long-term care facilities. One key informant estimated this hospital served 3,700 patients at its peak. 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. These are important issues since they affect many vulnerable adults who have physical, intellectual, or cognitive disabilities. As states are working to meet their ADA obligations as reaffirmed in Olmstead vs. Texas Health & Human Services Commission. Using the 2012 annual Medicaid LTSS expenditures report produced by Truven, we identified ten states that spent the highest percentage of their LTSS expenditures on HCBS and those that spent the least. monitoring and personal care services and/or home care services in a home-like setting to five or more adult residents unrelated to the assisted living operator. There were several reports of false imprisonment of residents who were kept locked in residential homes, sometimes deprived of their identification papers in Florida, Georgia, Indiana and Texas. One issue that remains to be determined is the conditions or criteria by which such places constitute "unlicensed residential care homes." 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. Savchuk, K. (2013). The site is secure. Services, including those provided by unlicensed personnel under the delegation of a registered nurse or physical therapist, provided to the person in care or their family as part of a coordinated program. Because these homes are legally unlicensed, the state licensure office has no jurisdiction to monitor them, but APS may receive complaints about them. 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. Ombudsmen reported increasing numbers of RCFs operating without a license in both Maryland and Nevada. (2012b). unlicensed personal care homes are a . Some key informants described illegally unlicensed personal care homes as filthy and potentially filled with rodents and insects; they also noted that these homes are unsafe structures that could be condemned. Another interviewee suggested that it is becoming more difficult to recruit individuals to be Dom Care operators because of the competing demands on their time. 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. Hospice. One SME, who was a firefighter and paramedic who has responded to calls from several unlicensed care homes, stated that he often had more comprehensive listings of unlicensed care homes than the local ombudsman. Typically, the reports refer to physically or mentally disabled adults, some with disease specific conditions, or just described as mentally ill or elderly. Some states allow legally unlicensed facilities to assist with ADLs and administer medication, but do not allow them to provide 24-hour supervision. However, residents may pay for such services or receive them through Medicaid waivers. Second, the findings highlight the need for federal and state agencies to determine the nature and scope of financial fraud being committed by operators of unlicensed residential care homes. Although the scope of our research was limited--involving a small number of interviews with subject matter experts (SMEs) and interviews with informants in three communities in three states--the findings have relevance for national, state, and local policies and practices and for future research. Ombudsmen. State informants did not provide information on the services provided in the unlicensed care homes stating that that the sample of unlicensed care homes they see is too small to make an accurate approximation of the conditions. What populations do unlicensed care homes serve? The same message was also sent to hospital discharge planners and to rehabilitation discharge planners. Local key informants primarily expressed concerns regarding inadequate nutrition provided to residents and inappropriate medication management practices. It is now a misdemeanor to operate an unlicensed RCF. Health Management Associates. In the past few years, Georgia has developed an interagency task force including law enforcement and social services agencies which has trained and prepared many staff to deal with these 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. During site visits, key informants reported that owners of licensed care homes often report operators of unlicensed care homes to authorities. endorsement or approval of such websites, products, services or (2013). 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). One of the key informants, who operatesa day program that serves many individuals who are residents of unlicensed care homes, also described the 20 year history surrounding the operation of unlicensed care homes. Each of these agencies is able to address different elements of the complex situations that exist within unlicensed care homes, including the needs of residents, as well as issues with the building and any criminal acts of the operators. Several SMEs and key informants noted that individuals who had only SSI to pay for care have few options for housing and care, and often end up in unlicensed care homes. Unlicensed Assisted Living Facilities What are personal care services? Further, in site visits and the literature, we found reports of situations that were repeatedly depicted as involving activity that was similar to "human trafficking" and "false imprisonment" of vulnerable individuals. Similar to the information summarized in the environmental scan, interviews with key informants revealed that unlicensed care homes make money off of residents in sophisticated and profitable ways. 3.4.3. The financial pressure hospitals feel to free up hospital beds quickly, which sometimes results in discharges to unlicensed care homes, both intentionally and unintentionally. 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. Key informants in Georgia described training sessions to educate law enforcement and first responders about unlicensed care homes. Press Release.Retrieved from http://www.bizjournals.com/prnewswire/press_releases/2012/04/17/DC88926. All of the key informants shared their perspectives about what is driving the closure of personal care homes. Benefit), may be available to help pay for room and board. 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. However, the effectiveness of these strategies in monitoring or otherwise addressing the prevalence of unlicensed care homes is unknown. According to the regulations, some states also allow residential care homes to be legally unlicensed if they have 1-2 beds. Ten states (Delaware, Georgia, Louisiana, New Jersey, New Mexico, North Carolina, Oklahoma, Rhode Island, South Carolina, and Washington) require residential care homes to be licensed if they have at least two beds. In the latter state, it was said that unlicensed homes "flourished in the larger cities, particularly those that had significant populations of poor elders and persons with mental illness who had been released from state mental hospitals" (Hawes & Kimbell, 2010). Tracking Public Benefits and Representative Payees. From our review of the regulations, we identified that North Carolina likely has legally unlicensed care homes (e.g., boarding homes serving 4-5 residents who do not require 24 hour supervision), and we suspect that illegally unlicensed care homes also exist. 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. Washington, D.C. 20201, U.S. Department of Health and Human Services, Collaborations, Committees, and Advisory Groups, Understanding Unlicensed Care Homes: Final Report, Biomedical Research, Science, & Technology, Long-Term Services & Supports, Long-Term Care, Prescription Drugs & Other Medical Products, Physician-Focused Payment Model Technical Advisory Committee (PTAC), Office of the Secretary Patient-Centered Outcomes Research Trust Fund (OS-PCORTF), Health and Human Services (HHS) Data Council, LIMITATIONS, CONCLUSIONS AND POLICY IMPLICATIONS, 4.1. Personal care homes offer a more home-like setting than nursing homes. The Pennsylvania BHSL provides specific documentation to potential operators and consumers outlining situations that do not have to be licensed by the state. On average the cost ranges between $1500 and $3000 per month for room and board. In Pennsylvania, one key informant noted that this assistance is given only to those operators who have opened their first illegally unlicensed care home without realizing they needed to be licensed; assistance is not provided for those who are repeat offenders. Failed Legislative Efforts to Improve Oversight. Locking refrigerators or pantries to limit resident access to food between meals, with some residents being malnourished and dehydrated and one resident breaking into a neighbor's home for food. There exists confusion over the authority of other agencies. Multiple key informants expressed concern about other state policies related to reductions in funding for mental health services and supports as potential contributors to a gap that illegally unlicensed personal care homes can fill. As noted in Section 4.1, states use a variety of definitions or criteria that allow some homes to operate legally without a license. Multiple key informants reported that financial exploitation was the biggest concern surrounding unlicensed care homes. States with concerns about vulnerable adults' access to housing with services may wish to examine their admission and discharge requirements for licensed care homes. One state key informant stated that her office receives one to two calls a month pertaining to unlicensed adult care homes, but she noted that these calls are sporadic. Findings also indicate that conditions in some unlicensed care homes are unsafe, abusive, financially exploitative, and neglectful of residents' basic needs. These preliminary findings are worth considering as policy makers implement federal, state, and local policies and practices that may relate to unlicensed care homes. State and Local Policies Related to the Supply and Demand for Illegally Unlicensed Care Homes. Before 2005, Pennsylvania allowed residential care homes with 1-8 individuals to be legally unlicensed. All rights reserved. Traditionally, Medicare does not cover Locking residents in rooms or chaining the doors at night to prevent residents from leaving the facility, which imprisoned residents and placed them at risk in case of fire. You can call this number to report abuse that occurs in: Nursing homes Assisted living facilities Day activity and health services You can also report care concerns about home health and hospice agencies and intermediate care facilities. U.S. Department of State, Office of the Under Secretary for Civilian Security, Democracy and Human Rights. The aging housing stock in Allegheny County was also a cause of concern for a few key informants, as it relates to the number of pre-existing buildings that cannot meet the state regulatory building code requirements for licensed personal care homes. The NDRN P&A reportedly has suggested that SSA require representative payees to self-identify if they own a residential care home (licensed or unlicensed). Miami Herald. We completed 17 interviews with SMEs. This home initially drew the attention of the authorities because of a sexual assault case in which one of the residents was raped by a sex offender. Monthly fees run anywhere from $1,500 a month to $4,500 each According to the key informant, these individuals were given one-way bus tickets out of the city under the stipulation that they never return. Several key informants mentioned that hospital discharge planners sometimes discharge patients to unlicensed care homes (described in more detail in Section 4), and as such they might be a potential source for compiling a list of these homes. 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. 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. 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. 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. In some instances, these places may be certified or otherwise listed at a local level, but they may not be monitored by the state for quality and safety issues. One of our study states made it a crime to operate an illegally unlicensed residential care home, and some states have the capacity to penalize unlicensed care homes with monetary fines. At the local level, one key informant estimated that members of the Allegheny PCRR, along with the state licensing office, have investigated approximately five illegally unlicensed personal care homes in their specific geographic region over the past two years. Similarly, by nature of their jobs, many of our interview participants, including APS staff, ombudsmen, police, and fire department personnel, typically hear about care homes when there are complaints or emergencies. Both states use a penalty system to fine operators for illegal operations. Given these diverse concerns, SMEs and site visits interviewees suggested that coordinated efforts across a range of stakeholders, including state licensure agencies, ombudsmen, APS, law enforcement, and others may be necessary to address unlicensed care homes. Texas personal care homes which are residential facilities offering personal care services, assistance and supervision to four or more persons. sleeping hours and must be capable of following directions under Poor quality of care, instances of physical abuse, toxic combinations of medication, and use of stun guns, were also reported (National Association of Medicaid Fraud Control Units, 2015). Fraud reports have been filed with the U.S Department of Housing and Urban Development for the misuse of funds to send users from Puerto Rico to unlicensed rehabilitation centers in the United States. North Carolina's Adult Care Licensure Office licenses two levels of adult care including family care homes and adult care homes. SMEs and key informants also noted that states varied in their licensure laws and their ability to enter and investigate unlicensed care homes without a warrant issued by a judge. 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. Key informants at the state level were able to provide estimates of the number of complaints they have received pertaining to unlicensed care homes, but not estimates of the number of unlicensed care homes. Hospitals and hospital discharge planners are responsible for the safe discharge of individuals into the community, but some hospitals may have policies that incentivize the discharge of individuals to unlicensed care homes. Based on this information, we chose three states, and subsequently identified three communities within those states, to visit and conduct case studies.2 Following is a summary of the literature, media coverage, and regulations for those three states (Georgia, Pennsylvania, and North Carolina). Future research could be conducted to describe the nature of ombudsman involvement in unlicensed care homes and how it differs across states. According to findings from these interviews, there are a few different pathways into unlicensed care homes, including unlicensed homes receiving residents directly from hospital discharges, representatives of unlicensed homes picking up residents from homeless shelters, and owners of licensed facilities taking residents to unlicensed homes. The Allegheny County PCRR has sent letters to hospitals and their discharge planners informing them about known illegally unlicensed personal care homes to which they should not discharge patients; however, according to two key informants, discharges to these homes have continued. 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. Resident Case Mix. Currently human trafficking is defined as "the act of recruiting, harboring, transporting, providing, or obtaining a person for compelled labor or commercial sex acts" (U.S. Department of State, 2015), however, one SME recommended expanding this definition to include the situation in which an administrator for the unlicensed care homes seize and maintain control of vulnerable individuals in order to maximize revenue by taking the public benefits that the individual may be receiving. Unlicensed assisted living facilities are those that are operating in violation of the Health and Safety Code (HSC) Chapter 247. 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. Copyright 2016-2023. 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. In fact, these concerns extended across illegally and legally unlicensed homes, and some stakeholders reported these concerns also exist about care being provided in some licensed residential care homes. There was not much attention paid to the original sources who identified an unlicensed facility, but in some articles or media reports, the case came to light due to a death that occurred in the facility that had to be investigated, neighborhood complaints of numerous vans, ambulances or police cars at the home, or calls from concerned family members about the status of a resident. In essence, unlicensed care home operators have several opportunities for gaining almost absolute control over these residents who are physically, cognitively, and financially vulnerable. Several examples of unlicensed personal care homes were described by key informants during the site visit.
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