Unlicensed care homes--which provide room, board and some level of services for two or more unrelated individuals, but are not licensed or certified by the state--fill some of the gaps in the availability of housing and services for these populations. 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. As part of this study, we sought to identify potential data sources or listings of unlicensed care homes that may be useful in efforts to understand how widespread unlicensed care homes might be, and whether these settings can be identified for future research purposes, both in the states we visited and in other states. What types of reports of mistreatment do the agencies receive? Statutes & Rules State Texas Administrative Code, Title 40, Part 1, Chapter 46: Contracting to Provide Assisted Living and Residential Care Services In addition to serving the elderly, personal care homes can exclusively serve persons with serious mental illness and/or intellectual and developmental disabilities, on condition that the home is appropriately staffed and is capable of providing the needed care within the scope of its license. 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. Cases of physical abuse, such as residents being beaten and burned as described in the environmental scan, were also reported during interviews. Examples of financial exploitation described by key informants include the operator becoming a resident's representative payee and then withholding a resident's money, and pocketing profits while providing inadequate care and services or no services at all. Traditionally, Medicare does not cover In Pennsylvania counties, a multidisciplinary team called the Personal Care Risk Reduction (PCRR) team helps to address illegally unlicensed care homes; thus we attempted to interview key informants involved in this process. We found three cases in Florida of charges against unlicensed RCFs involving allegations of false imprisonment, resident neglect, grand theft, and/or operating an unlicensed assisted living facility; and three cases in Nevada of neglect and/or criminal offenses while operating without a license (one where the accused also operated a licensed facility). Hawes, C. & Kimbell, A.M. (2010). ", 3.5.5. Is there a seminar I can attend? At least one administrator, on-site manager, or responsible person must be on duty 24 hours per day, seven days a week, and all staff must be trained as personal care workers within 60 days of hire. In this study we sought to identify: Characteristics of unlicensed care homes and the residents they serve. Many key informants and SMEs suggested that discharge planners face difficulty placing residents in licensed care homes because these homes often do not accept patients who only have SSI (or otherwise have little money), and they often will not accept individuals with a history of mental illness, substance abuse, or those who are homeless. UAPs also provide bedside careincluding basic nursing proceduresall under the supervision of a registered nurse, licensed practical nurse or other health care professional. care facilities. In Georgia, informants talked about the Abuse, Neglect and Exploitation Workgroup, which is led by the Georgia Bureau of Investigation and is comprised of individuals from several state, local and federal agencies. In Pennsylvania, facilities providing or arranging for housing, food service, and one or more personal care needs for four or more unrelated adults must be licensed as personal care homes. There is a lack of knowledge regarding the licensure requirements or about how to navigate the different government agencies. (2004). Dallas Morning News. 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. 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. 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. The state statute defines personal care services as: Assistance with meals, dressing, bathing, movement, or other personal needs or maintenance; Administration of medication by a person licensed to administer medication Assistance with or supervision of medications; or In one state, the AG only received nine cases in the entire year; in another state they handled only 2-3 cases a year. 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. 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. Of the approximately 1,400 complaints received by APS each year, an estimated 20% pertain to unlicensed personal care homes. help cover the costs of residency but typically have long wait Areas for Future Research and Potential Data Sources. In Texas, a residential care home (also known as a Additionally, states may implement public awareness campaigns to support identification of unlicensed care homes. Residential Care providers must be licensed as an assisted living facility and have a contract with the Texas Health and Human Services Commission. azmfairall. While North Carolina's licensure offices do not have this same authority, key informants in North Carolina did note that most unlicensed care home operators allow them entry even without legal authority. The agencies do not typically get complaints from residents inside the home, although if the home is bringing in services such as home health or hospice nurses, those outside agency staff could file reports that result in the identification of an illegally unlicensed personal care home. In many cases, the cost of care in other settings is too high for what individuals with severe and persistent mental illness can able to afford on their SSI stipend. While exploratory in nature, the findings highlight potential issues of safety, abuse and financial exploitation in unlicensed care homes. (n.d.). State regulations govern whether ombudsmen can access and advocate for residents in unlicensed care homes; thus ombudsmen may be limited in their ability to serve on these teams. They do not necessarily reflect the views of the Department of Health and Human Services, the contractor or any other funding organization. PubMed and other database searches yielded very little literature related to unlicensed RCFs. endorsement or approval of such websites, products, services or Schneider, C., & Simmons, A. need for senior care services and the choice of a facility is an 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. Media reports described operators that continued to operate after their licenses expired or were revoked. 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). They noted that the following may have heightened the demand for unlicensed care homes: The admission and discharge policies of licensed care homes. Assisted Living Facilities in Indianapolis, Indiana. PHC and CAS provide in-home personal attendant services (PAS) to individuals eligible under Title XIX Medicaid or under 1929 (b) (2) (B) of the Social Security Act, respectively. In Florida, operators of illegal homes use a variety of schemes to hold themselves out as not requiring licensure. help cover the costs of residency but typically have long wait At the state level, Pennsylvania investigates a relatively low number of illegally unlicensed personal care homes per year. 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. Consistent with findings from the environmental scan, stakeholders (including SMEs and site visit key informants in the three communities we visited) repeatedly raised a variety of concerns about neglect of residents' health care needs and unsafe and unsanitary conditions in unlicensed care homes. These calls spur investigations that sometimes result in the identification of unlicensed care homes. rehabilitation and nursing home care. 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). The closure of large mental health institutions and concomitant transition of previously-institutionalized individuals with severe and persistent mental illness to community-based care settings, such as legally unlicensed care homes. Three-bed residential care homes are lawfully allowed in at least one state. Some illegally unlicensed facilities deny services are being provided. A core pattern of exploitation described in interviews included the operator of unlicensed homes finding vulnerable individuals who need housing and supportive services (such as from hospitals or homeless shelters), requiring these individuals to transfer their SSI payments to the operator or one of the operator's agents in order to become a resident of the unlicensed care home, severely limiting the residents' ability to leave the facility, and relocating the residents to alternate locations to avoid detection. Licensed personal care homes are required to assist with personal services, supervise self-administration of medication, and provide social activities, as needed. Neglected to death, part 1: Once pride of Florida; now scenes of neglect. In Georgia, all unlicensed personal care homes are illegal, and thus to remain in operation they try to avoid being identified. Although these complaint systems are not specifically designed to identify and track unlicensed care homes, some states use the complaint systems in this way. (2015) Assisted living provider resources: Unlicensed facilities. SMEs also discussed the fact that some residents are involuntarily discharged from licensed care homes when they exhaust their funds. Abuse and Neglect. In another report, a representative of the Arizona Department of Health Services stated that unlicensed assisted living facilities were not a problem because licensed operators monitor the industry and report illegal activity (Arizona Department of Health Services, n.d.). This We conducted an environmental scan primarily focused on information spanning a five year period from 2009 through 2014. In North Carolina, facilities providing or arranging for housing, food service, and 24-hour scheduled and unscheduled personal care services to two or more unrelated adults must be licensed as an adult care home or a group home. Centers for Medicare and Medicaid Services. This button displays the currently selected search type. She was getting good care and it was something the mother could afford. Interview results indicate that the majority of unlicensed care homes investigated by state officials and local APS agencies involve situations in which residents are not being cared for properly. Media and state reports have highlighted homes operating deliberately illegally--that is, they are avoiding required licensure or certification (Tobia, 2014; Georgia Association of Chiefs of Police Ad Hoc Committee on At-Risk Adult Abuse, Neglect & Exploitation, 2013). Advocates reported a growing number of unlicensed facilities and difficulties distinguishing them from boarding homes or other types of RCFs. Properly complete and submit the license application. Fourth, study findings also suggest that efforts are needed to understand the differences in conditions between legally and illegally unlicensed care homes, as well as how illegally unlicensed care homes successfully evade licensure. nursing home care, and in some states, it is even more affordable 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). or home health care. Interview findings indicate that many residents of unlicensed care home are Supplemental Security Income (SSI) beneficiaries. All About Unlicensed Caregivers in the Home | Relias unassisted. Concerns remain that agencies do not have the resources to monitor and follow through with the appropriate actions (e.g., finding emergency placements for residents, prosecuting violators, ensuring that the facility remains closed and has not reopened in another location) for the unlicensed facilities. Multiple key informants described unlicensed care homes as primarily serving persons with mental illness. As described earlier, some of our key informants noted that hospital discharge planners knowingly discharge these individuals to unlicensed care homes to alleviate the immense pressure they are under to facilitate quick patient turnover, and some hospitals reportedly will pay unlicensed care homes to admit these individuals. 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. Tobia, M. (2014). Specific concerns raised by SMEs and site visit informants are highlighted in this section. An estimate for another locality in Maryland was much higher, with twice as many unlicensed homes as licensed, or about 1,500 facilities, many of which operate out of single family dwellings (Tobia, 2014). even more. 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. A follow-up story revealed that these unlicensed rehabilitation centers may have been selling the identities of the victims on the black market for as much as $2,500. Very little discussion centered on improving the quality of unlicensed care homes. In some states, residents can pay for their own personal or medical care in an unlicensed facility. 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. Office of the Assistant Secretary for Planning and Evaluation, Printer Friendly Version in PDF Format (81 PDF pages). Improper medication assistance and management were most commonly noted by key informants as problematic; informants were concerned that operators or staff of illegally licensed care homes may not be properly trained in medication management and administration. Call 800-458-9858 to report suspected abuse or neglect of people who are older or who have disabilities. Interviewees had varying opinions on the causes for Dom Care homes closing. 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 key informants expressed concern about neglect of the health needs of residents because of too few or inadequately trained staff, particularly in regard to the care of residents who have severe and persistent mental illness and need monitoring of their conditions and reactions to medications. However, a few states (such as Georgia and Texas) provide those supplements only to residents in residential care homes certified to offer services covered by Medicaid. The LME-MCO oversees contract services in a four county area. 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. Although we heard about a range of conditions in illegally unlicensed homes, including neglect, abuse, and financial exploitation, it is unclear whether this is the norm or whether the findings are skewed because of the types of key informants we interviewed. Retrieved from http://www.miamiherald.com. In the past 15 years, the issues surrounding unlicensed personal care homes in the state have become more prominent, and coordinated action across several agencies has been taken to address them. Facilities providing or arranging for housing, food service, and one or more personal services for two or more unrelated adults must be licensed by the state as a personal care home. Another concern expressed by some of the individuals interviewed was that even those unlicensed homes that were clean or free of neglect and abuse, commonly have safety hazards and do not meet the fire safety codes required of licensed facilities. As a result, 3,000 individuals with mental illness were transitioned into community-based supported housing. What is a Personal Care Home? - Elder Options of Texas To reduce abuse, several informants indicated that state officials should target closing unlicensed care homes. In some states, APS has very limited responsibility and involvement. 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. In addition to the aging population, many key informants agreed that the lack of affordable supportive housing options for individuals with a mental health diagnosis is also a concern for Allegheny County and surrounding counties. 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. For example, it won't cover an One key informant stated that one in four residents of Allegheny County are over age 60, and that this population presents a growing need for affordable residential care homes. Retrieved from http://www.dallasmorningnews.com. Local key informants primarily expressed concerns regarding inadequate nutrition provided to residents and inappropriate medication management practices. And regardless of whether states have regulations concerning unlicensed homes, many operators choose to operate illegally unlicensed homes. Pennsylvania and North Carolina have some similarities in how they address unlicensed care homes. costs while your loved one is living at a certain facility. 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. Ombudsmen program does not extend to unlicensed facilities (Hawes & Kimbell, 2010). Licensure and APS have the same difficulties in terms of moving residents out of unlicensed facilities into good supportive housing sites (Hawes & Kimbell, 2010). We focused on a range of questions, including: How do agencies handle specific complaints about unlicensed care homes? The following are some examples of financial exploitation depicted during interviews; these examples are discussed at greater detail below: Operators of unlicensed care homes collecting the residents' medications and selling the medications on the street for cash. Retrieved from http://www.dads.state.tx.us/providers/alf/howto.html. Two key informants spoke about the lack of oversight of these homes and the concern for the well-being and safety of their residents. On the other hand, grey literature--that is, reporting databases, blogs, and media reports--produced more results about unlicensed care homes. 3.5.4. typically provide meals, laundry, housekeeping, medication These are important issues since they affect many vulnerable adults who have physical, intellectual, or cognitive disabilities. In Iowa, legislation to restrict the actions of some operators of large licensed assisted living facilities to recategorize or redefine themselves as a "residence," (e.g., boarding home) that does not require licensure was proposed but did not pass. Texas: A 2007 media report, outside the scope of this review but important to mention, notes that city officials in Dallas estimated that there were at least 350 unlicensed, unregulated board and care homes that house 2,500 people across the city, and likely there were more than that (Hancock, 2007).
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