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. Monograph for the National Institute of Justice, U.S. Department of Justice. A California report mentioned that disabled or homeless adults often prefer unlicensed facilities because they have fewer restrictions. Operators often gain control of residents' funds by becoming the representative payee for residents receiving SSI, a common payer source in unlicensed residential care homes. 3.4.3. 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. Other Research Ideas Suggested by Subject Matter Experts or Individuals Interviewed in State Site Visits. Using the 2012 annual Medicaid LTSS expenditures report produced by Truven, we identified the ten states that spent the highest percentage of their LTSS expenditures on HCBS and the ten that spent the least. Retrieved from http://www.miamiherald.com. 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. 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. This was described as limiting the capacity of the resident to relocate. 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. document.getElementById( "ak_js_1" ).setAttribute( "value", ( new Date() ).getTime() ); 2021 California Room and Board Coalition, All Rights Reserved. See http://www.dhs.state.pa.us/cs/groups/webcontent/documents/report/c_102850.pdf. Anne Arundel County Fire Department, Millersville, Maryland. A landlord must ensure that the room-and-board tenant has access to a working toilet, running water, trash disposal, natural light and proper ventilation for each room. The landlord may also issue a three-day notice immediately to a tenant who uses his room for illegal activities. Interviewees had varying opinions on the causes for Dom Care homes closing. In response, the legislature has appropriated $260,000 to relocate residents identified as living in unlicensed care homes. Pennsylvania begins licensure with four beds, but the state has locally certified domiciliary care (Dom Care) homes that serve 1-3 residents. The research team completed seven interviews with eight participants that included both state and local community stakeholders. Another motivation to operate an unlicensed care home, equally mentioned by key informants, relates to costs directly associated with meeting building code requirements specified in the regulations. Answer: A psychological associate must provide a valid address as the Address of Record (AOR) to the Board for all correspondence (e.g., renewal applications, updates, etc.). For example, if the tenant has not paid rent, the landlord typically must give the tenant an opportunity to pay the rent before the three days expire. Allegheny County was specifically chosen as the site visit community because of their currently active PCRR team, which continues to address illegally unlicensed personal care homes. Three-bed residential care homes are lawfully allowed in at least one state. 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. Savchuk, K. (2013). They speculated that there may not be enough licensed mental health group homes available to care for persons with mental illness, and that unlicensed group homes can potentially fill that gap. Following the environmental scan, we conducted interviews with SMEs on the topic of unlicensed care homes. These rules and regulations require that beds be kept in clean and sanitary condition, hotplates meet health and safety codes and onsite caretakers manage larger facilities with 12 or more guests rooms, or 16 or more apartment houses. Often these homes serve very vulnerable populations, such as individuals with serious mental illness or older adults with functional limitations and limited financial resources. The following acronyms are mentioned in this report and/or appendices. In some states (Arizona and Vermont), it is illegal to refer an individual to an unlicensed facility. Regulatory changes and the role of multidisciplinary task forces (which are relevant to both legally and illegally unlicensed care homes) are described next, followed by a summary of the strategies discussed during interviews to identify and shut down illegally unlicensed care homes and to monitor and improve quality in legally unlicensed care homes. Media reports described operators with licensed facilities who also operated a series of unlicensed homes in secret. Through a targeted series of interviews and a scan of the literature, we sought to contribute foundational information about unlicensed care homes. 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. In 2013, the minimum number of ADLs needs required for individuals to qualify for reimbursement for personal care services in group homes increased. Some illegally unlicensed facilities deny services are being provided. These cookies ensure basic functionalities and security features of the website, anonymously. Pennsylvania Department of Public Welfare. 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 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. North Carolina's Adult Care Licensure Office licenses two levels of adult care including family care homes and adult care homes. Estimates of the prevalence of unlicensed residential care homes are lacking for most states. One key informant estimated that approximately 3,000 licensed personal care homes have ceased operations in Allegheny County since the 2005 regulatory changes. One interviewee, who interacts with residents of unlicensed care homes on a daily basis, estimated that for every licensed personal care home in Georgia there is one unlicensed care home. The fact that four people should have been receiving personal care services made the home eligible for licensure as a residential care home--not the fact that three people were receiving the services (which would make it under the legal limit). Such practices violate residents' rights, and the profit-enhancing practices of the operators, such as limiting the availability of food, water, and other basic needs, endanger residents' lives and well-being. 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. One SME also noted that some unlicensed care home operators take residents' veteran's benefits. Maryland, Mississippi, and the District of Columbia have no minimum bed size for licensure, implying that some residential care homes can be legally unlicensed. In regard to the prevalence of unlicensed care homes, state-level estimates were only reported for Georgia, Maryland, and Florida. The most prevalent strategy used by state and local officials to identify illegally unlicensed care homes is responding to complaints. 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. Florida publishes a listing but it does not correspond with the media reports of the number of unlicensed care homes identified by state inspectors. Many key informants and SMEs discussed how homeless shelters, advocacy organizations, and churches or other faith-based organizations often serve as a resource to link vulnerable individuals who cannot afford the expense of a licensed care home to unlicensed care homes instead. A few articles described the difficulties in identifying unlicensed residential care, such as distinguishing them from places called boarding homes, shelter care, sober homes, rehabilitation homes and publicly subsidized housing that arranges services for residents. to be able to live in unlicensed, supportive housing environments. Six states (Colorado, Iowa, Illinois, Maine, Missouri, and Vermont) license starting at three beds, noting that Vermont, like Massachusetts, exempts small private-pay homes. In preparation for closing, the operator "turned over the residents to other operators for a fee of $100 per resident.". Dont let a bargain price influence your choice. 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. Identification of unlicensed care homes is triggered by complaint calls to state or local authorities by community members or family members. In addition, the reports of financial abuse also may represent considerable financial fraud of federal programs including SSI, food stamps, and the programs paying for resident medications (i.e., Medicare and Medicaid). Although the majority of key informants described unlicensed care homes as unsafe environments where residents are abused, neglected, or exploited, it also was noted that some unlicensed care homes may provide quality care in safe and clean environments. Multiple key informants also spoke about the lack of affordable housing in Allegheny County. We exist to empower, promote self-advocacy, and make available safe and supportive housing for adults, low income individuals, residents and Behavioral Health Consumers. It is now a misdemeanor to operate an unlicensed RCF. Miami Herald. 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. Thus, unlicensed care homes close and leave one area of the city, but reopen in another area, contributing to the difficulty of identifying and permanently shutting down these places, while also disrupting the residents' access to day services and other community-based sources of support nearby the original care home location. Living conditions are dirty and unsafe, beds may be infested with bed bugs; heating and air conditioning may be lacking. It is important to learn if such abuses and frauds are limited to a small number of communities or if they are more widespread. Each of these factors is discussed in more detail in the sections that follow. Future research examining the role of hospital discharge planners and strategies to prevent discharge to unlicensed care homes appear warranted. Residential Care Facilities for the Elderly (RCFEs) serve persons 60 and older. Health and safety concerns for residents were a major topic of interview discussion. The administrator may request any amount he or she can get. Sometimes the care providers require residents make the care home operator their representative payee for Supplemental Security Income (SSI) from Social Security. Legally Unlicensed and Licensed Care Home Operators. (2015) Assisted living provider resources: Unlicensed facilities. In another state in that study, only consumer advocates and ombudsmen reported the existence of unlicensed facilities. In addition, SMEs noted variability across states in the availability of resident advocacy and protection through such agencies as the ombudsman program. As such, they could be a key source for learning about currently 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. The environmental scan and SME interviews informed state selection for site visits. Per state regulations, this is not considered a permanent structure, and therefore does not meet the appropriate building requirements to be a licensed facility. 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). Some states allow legally unlicensed facilities to assist with ADLs and administer medication, but do not allow them to provide 24-hour supervision. Some of these places are legally unlicensed, while others operate without a license illegally. One key informant noted that residents of unlicensed care homes commonly require assistance with activities of daily living (ADLs), such as getting dressed, as well as assistance with instrumental activities of daily living (IADLs), such as taking medications and managing and accessing transportation to medical appointments. The landlord also has an obligation to provide adequate electrical wiring, heating and cooling. 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. 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. Schneider, C., & Simmons, A. Based in Los Angeles, Victoria McGrath has been writing law-related articles since 2004. 3.2.3. Preventing residents from using the bathrooms after a certain time at night and providing buckets for residents to use rather than toilets. Lack of clarity in licensure regulations regarding minimum bed size required by licensure also exists in a few states. According to one key informant in the state, moving individuals from institutions for mental illness with an inadequate plan for housing these individuals has contributed to an increase in the numbers of people available for unlicensed personal care homes to serve, thus motivating the opening of unlicensed care homes. Although some SMEs and key informants provided a few examples of unlicensed care homes where residents receive what they categorized as good care, it appears that abuse, neglect, and financial exploitation of these vulnerable residents is commonplace. Key informants did not offer any information on potential ways to identify unlicensed care homes or existing databases of these places. Overall, the local agency representatives described the condition of unlicensed care homes as unsafe. Given the types of key informants interviewed for this study, and the limited viewpoints captured, more information is needed to understand the characteristics of unlicensed care homes and the residents they serve. 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. 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. The site is secure. 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. reported by the California Department of Justice. One key informant estimated there are approximately 526 Dom Care operations in the state. Multiple key informants also stated that interviews with small licensed personal care home operators may result in learning more about the motivations for operating an illegally unlicensed personal care home. Strategies used to address health, quality and safety issues in unlicensed care homes. As discussed earlier, Pennsylvania is a state that legally allows unlicensed residential care homes, if they serve three or fewer individuals. According to the regulations, some states also allow residential care homes to be legally unlicensed if they have 1-2 beds. First, there is a lack of information about the effect of various state and national policies on the vulnerable individuals the policies were designed to protect and whose well-being they were intended to enhance. We conducted an environmental scan primarily focused on information spanning a five year period from 2009 through 2014. The California Room and Board Advisory Coalition provides innovative and affordable solutions that makes efficient use of existing housing availability, helps preserve the fabric of the neighborhood and can lessen the need for costly care services or long-term institutional care. 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. The state regulatory agency can send letters to illegally operating facilities and fine them $500. 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). Pennsylvania and North Carolina have some similarities in how they address unlicensed care homes. 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. Pennsylvania Health Law Project and North Penn Legal Services. In some states, APS has very limited responsibility and involvement. Costs for operating a licensed personal care home can include state fees for licensure, structural renovations or changes to meet required building codes, paying for staff to be on-site 24 hours per day, and paying for and providing adequate staff training. Retrieved from http://www.ajc.com. Further, evidence exists from several states that there are still unlicensed residential care homes and that, in some states at least, the number of unlicensed facilities is increasing. Barry, R., Sallah, M., & Miller, C. (2011). Advertisement cookies are used to provide visitors with relevant ads and marketing campaigns. There are no visible smoke or fire alarms. Except for special circumstances, complaints must be filed in writing. 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. 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. The team conducted interviews with key informants in each of these communities. Complaints can also be received by fax, letter, or email. Funds are being allocated to relocate residents out of unlicensed residential care. Unlicensed Practice. There is a lack of knowledge regarding the licensure requirements or about how to navigate the different government agencies. The primary concern expressed about the unlicensed homes that were otherwise safewas that they might not be able to provide the level of care and services needed by the residents (e.g., medication supervision for residents with severe and persistent mental illness). Study findings should be viewed in light of these limitations. Thus, one implication of the study is that it may be worthwhile in one or more states or communities to test and evaluate other methods of detecting illegally unlicensed care homes. Yes. 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. What types of reports of mistreatment do the agencies receive? State policies do not require hospital discharge planners to discharge patients to licensed care homes, thus permitting discharge to unlicensed care homes. Six states (Colorado, Iowa, Illinois, Maine, Missouri, and Vermont) license starting at three beds; Vermont exempts small private-pay homes. (2012). According to the American Elder Care Research Organization, the average cost of assisted living in 2018 in California is $4,070 per month. 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. One provider in San Bernardino County was housing residents with psychiatric disabilities in chicken coops which had been converted into barracks-style housing. Anne Arundel County Fire Department, Millersville, Maryland. 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. We were only able to obtain an estimate on the number of unlicensed care homes from the Durham County Group Care Monitoring Office. According to a six-state study conducted by Hawes & Kimbell for the U.S. Department of Justice (National Institute of Justice) in 2010, when seriously substandard quality, neglect or abuse were discovered in unlicensed facilities, some closed the home in question but shifted residents to other legally or illegally unlicensed care homes to avoid detection or penalties. In this study we sought to identify: Characteristics of unlicensed care homes and the residents they serve. The information focused on specific cases, but not on how many of these places exist in these states. 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. A review of state regulations around long-term care ombudsmen could reveal gaps and opportunities in how ombudsmen can access and advocate for residents in unlicensed care homes. On the other hand, grey literature--that is, reporting databases, blogs, and media reports--produced more results about unlicensed care homes. A private residence, a care facility or an employer might offer room and board. Performance cookies are used to understand and analyze the key performance indexes of the website which helps in delivering a better user experience for the visitors. 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. Miami Herald. In addition to legally unlicensed residential care homes, there are a variety of places that operate illegally. No other coordinated agency efforts beyond the state licensure office, APS, and the LME-MCO were described by key informants. I live in California and operate an unlicensed room and board home for the homeless/mentally-ill. 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. Others described instances where the unlicensed care homes can be located in either low-income neighborhoods or higher-income neighborhoods, and that they blend in with other houses, which makes them difficult to identify or locate unless reported by the community. Presumably, this led to an increase in need for LTSS for these populations. Ombudsmen. However, several SMEs and key informants noted that some unlicensed care homes are good and provide a clean, safe environment for individuals who might otherwise be homeless. Education: Statewide or Interagency. Hawes, C., & Kimbell, A.M. (2010). 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. NBC News 4, Washington D.C. Retrieved from http://www.nbcwashington.com/news/local/Caretaker-Accused-of-Abusing-and-Neglecting-Kamara-Zanaib-268343912.html. Further details on findings from the environmental scan can be found in Appendix B. As states are working to meet their ADA obligations as reaffirmed in Olmstead vs. For example, one key informant described a recent case of a representative payee in an unlicensed care home who was not managing a resident's money correctly, by providing food on a specific schedule and not providing it when the resident was hungry and requested food. Costs for bringing the building up to code to meet state regulatory requirements may be another reason why operators of care homes choose to remain unlicensed. There are no scheduled activities during the day. 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. 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. If residents are able to self-determine and choose where they want to live, they may choose to go with the operator to a new residence. Based on the collective feedback of a diverse group of key informants, unlicensed personal care homes appear to be prevalent and problematic in the state. SMEs indicated that such reports can be used to identify unlicensed care home operators. This cookie is set by GDPR Cookie Consent plugin. The vast majority of key informant reports emphasize often alarming conditions in unlicensed care homes. Schneider, C., & Simmons, A. U.S. Department of Justice settlements were also discussed by one key informant. Unlicensed contracting is part of California's estimated annual $60 to $140 billion dollar underground economy. Licensure and APS have the same difficulties in terms of moving residents out of unlicensed facilities into good supportive housing sites (Hawes & Kimbell, 2010). From our review of states' regulatory information on licensed residential care categories during the development of the sampling frame for the 2014 National Study of Long-Term Care Providers, and our review of ASPE's Compendium of Residential Care and Assisted Living Regulations and Policy (2015), we found the following. 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. Frustrations continue among licensure agencies and advocates with unlicensed care homes, and residents are largely unprotected by licensing agencies (Hawes & Kimbell, 2010). Operators seizing the residents' food stamps and selling them for cash. (n.d.). Other uncategorized cookies are those that are being analyzed and have not been classified into a category as yet. A separate search of a few state Attorney General (AG) reports of unlicensed RCFs identified six cases of successful prosecutions in New York, Nevada, Florida, and California for operating an RCF without a license--and, in several cases, for gross neglect. This is evidenced by the number of reports and complaints received about unlicensed personal care homes, the number of hours spent by law enforcement officials on investigating unlicensed personal care homes, and the estimates given of the numbers of unlicensed care homes that are operating in the state (reported by one informant as one unlicensed care home for every licensed home).