LIMITATIONS, CONCLUSIONS AND POLICY IMPLICATIONS. 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. 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. According to the report, these warehoused residents are vulnerable older adults with "hard to place" mental health needs and paroled individuals. 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. While no comprehensive nationwide list of unlicensed care homes exists, the environmental scan identified one state (Florida) and one city (Houston, Texas) that maintain listings of unlicensed care homes. Carder, P., O'Keeffe, J., & O'Keeffe, C. (2015). Licensure staff only learnabout the unlicensed residential care homes when someone reports them. The 2014 annual report for DADS shows that the number of referrals to the AG increased from two to nine for injunctive/other relief and civil penalties. 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.). Most interviewees also agreed that there are likely more illegally unlicensed personal care homes than they are aware of. During site visits, key informants reported that owners of licensed care homes often report operators of unlicensed care homes to authorities. DISCLAIMER: The opinions and views expressed in this report are those of the authors. These unlicensed care homes are referred to by several different names in different states, such as "board and care homes," "boarding homes," and "adult care homes." 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. Three-bed residential care homes are lawfully allowed in at least one state. 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. 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. 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. Maximum employee meal and room costs are established under California Employment Law. However, site visit key informants and SMEs we interviewed were unaware of any such lists of unlicensed homes and could not identify existing methods for tracking them. Preventing residents from using the bathrooms after a certain time at night and providing buckets for residents to use rather than toilets. This website uses cookies to improve your experience while you navigate through the website. Retrieved from http://www.dhs.state.pa.us/cs/groups/webcontent/documents/report/p_011015.pdf. No. Finally, a peer-reviewed publication by Perkins, Ball, Whittington, & Combs (2004) provides insights into why an operator continues to operate an unlicensed care home. Having a license attempts to ensure the home has met minimal health and safety requirements placed upon it by the State of California. 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). 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. Florida publishes a listing but it does not correspond with the media reports of the number of unlicensed care homes identified by state inspectors. Retrieved from http://www.namfcu.net/resources/medicaid-fraud-reports-newsletters. This key informant shared a list of seven placement agencies that work with hospitals in Allegheny County. A copy of the Room and Board Residency Agreement must be provided to ODP or its In some cases, a tenant who receives room and board is considered a lodger as opposed to a tenant. Residents of unlicensed care homes are vulnerable adults. Tracking Public Benefits and Representative Payees. As described by the majority of key informants, the primary motivation to maintain an unlicensed care home is to maximize profit. Managing the care needs of low-income board-and-care home residents: A process of negotiating risks. In California, the basic principles of landlord-tenant law apply to room-and-board facilities. Furthermore, illegally unlicensed care homes continue to exist because they try to avoid detection; therefore, favorable reports of unlicensed care homes are minimal. As one informant in Georgia reported, "the hospital will say 'this is an expensive bed, you need to get [the patient] out.' Multiple key informants described unlicensed care homes as primarily serving persons with mental illness. Very little discussion centered on improving the quality of unlicensed care homes. SMEs mentioned the lack of SSPs to residential care home residents who receive SSI as a factor that encourages the existence of 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. One key informant estimated there are approximately 526 Dom Care operations in the state. According to SMEs and key informants, the following factors are likely drivers of the demand for unlicensed care homes in their communities or states: The policies that licensed care homes have against admitting residents who exhibit behavior problems and those who have substance use disorders, or to discharge residents who develop these problems. Through a targeted series of interviews and a scan of the literature, we sought to contribute foundational information about unlicensed care homes. One key informant in North Carolina indicated that fines for the operation of unlicensed care homes have little impact on closing the homes, are rarely collected, and are not enforceable by their agency because the operation of an unlicensed care home is considered a criminal offense, and thus under the purview of law enforcement. The cookie is set by the GDPR Cookie Consent plugin and is used to store whether or not user has consented to the use of cookies. Leases are for a fixed period of time-usually a month or longer. 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. 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. Strategies for Addressing Unlicensed Care Homes. L.C., they may need to pay particular attention to ensuring the availability of sufficient and affordable licensed care homes or other supportive housing options that offer person-centered care in a safe and appropriate environment. Necessary cookies are absolutely essential for the website to function properly. The cookie is used to store the user consent for the cookies in the category "Analytics". In other types of residential care, if the care is arranged or managed by the owner, manager, or staff of the building, home, or community, then the facility must be licensed. However, key informants told us that often in these cases,the operator may have another building where the residents could be moved. In contrast, in North Carolina (and other states not included in our site visits) ombudsmen have no authority in or responsibility for residents in unlicensed care homes according to state regulations. Below we present a sample of the varying state definitions of lawfully unlicensed and illegally unlicensed residential care homes. The Pennsylvania BHSL provides specific documentation to potential operators and consumers outlining situations that do not have to be licensed by the state. San Jose, California 95112 Toll-Free (800) 248-MHAP Fax (408) 350-1158 Telephone (408) 294-9730 TDD (408) 294-5667 . 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. Although these regulatory changes occurred ten years ago, multiple key informants reported that many more licensed personal care homes have continued to close in recent years. Other states also track complaint calls as a means for identifying unlicensed care homes. For many of these individuals, their only option may be unlicensed facilities. With regard to recruiting residents from hospitals, we also heard of unlicensed care home operators receiving payments of up to a month's fees from hospitals anxious to discharge the residents to free up hospital beds. 3.2.3. This key informant also noted that the residents frequently transition in and out of the home, as is often the case with illegally unlicensed personal care homes. 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, key informants emphasized that in some cases,the residents become tethered to the operators through financial exploitation and emotional manipulation, and as a result are unable to leave these abusive and exploitative situations. Business and Professions Code Section 2052 states that any person who practices or attempts to practice or who advertises or holds him/herself out as practicing any system or mode of treating the sick or afflicted or who diagnoses, treats, operates for or prescribes for any ailment, blemish, deformity, disease, disfigurement, disorder, injury or other . An oral agreement may be legally binding for short terms of less than one year. 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. We conducted most key informant interviews in Durham, with some additional interviews across the region, including Raleigh. They indicated that these unlicensed personal care homes are filling the gap left by the closing of licensed personal care homes. It is now a misdemeanor to operate an unlicensed RCF. 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. The City of Houston established legislation that requires boarding homes housing three or more individuals to register with the city. 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. Findings from our limited number of interviews with site visit key informants and SMEs are consistent with the information found during the environmental scan. In Georgia, much of the current focus on unlicensed personal care home investigations involves cases of resident abuse and neglect. In response, the legislature has appropriated $260,000 to relocate residents identified as living in unlicensed care homes. The team works together to track homes they identify as unlicensed and then monitors them until the home is closed. Although recognized as important, the state has not yet begun investigating cases of financial exploitation. A local ombudsman in Maryland stated that they had no authority to inspect an unlicensed home and therefore did not have reliable knowledge about whether unlicensed care homes exist, how many individuals are living in such homes or what level of care or assistance those residents needed (Tobia, 2014). Several examples of unlicensed personal care homes were described by key informants during the site visit. These included: (1) tracking individuals' public benefits; (2) obtaining lists of unlicensed care homes from health care and advocacy organizations that refer individuals to them; (3) accessing information from emergency response personnel; and (4) utilizing owners of licensed facilities as a source to identify illegally unlicensed 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. . One key informant estimated this hospital served 3,700 patients at its peak. A phone number is provided if someone has a question about the licensure status of a facility. Others may require higher rates; these are called private pay homes. The research team completed seven interviews with eight participants that included both state and local community stakeholders. Office of the Assistant Secretary for Planning and Evaluation, Printer Friendly Version in PDF Format (81 PDF pages). In these cases, the hospital reportedly pays the placement agencies a fee to find a personal care home, and the placement agencies also receive monetary incentives from the personal care homes for referrals. Estimates of the prevalence of unlicensed residential care homes are lacking for most states. 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. No positive literature was found, which, as noted earlier, may be reflective of the fact that nothing is published about these places unless they are discovered because they are being investigated for poor care or resident exploitation or abuse. 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). Typically, the reports refer to physically or mentally disabled adults, some with disease specific conditions, or just described as mentally ill or elderly. Retrieved from http://www.ajc.com. Notably, most key informants said the operator of a licensed home may also operate one or more unlicensed homes, often in the same neighborhood and often in collaboration with friends or family members. Monitoring and Improving Quality in Legally Unlicensed Care Homes. Tobia's report (2014) described residents of unlicensed facilities as vulnerable older adults with "hard to place" mental health and paroled individuals who are warehoused. There exists confusion over the authority of other agencies. However, a representative from a state advocacy agency estimated that about 2%-3% of their 4,800 calls annually, or approximately 120 calls statewide per year, were related to unlicensed facilities. From a county perspective, one ombudsman and housing officer estimated that perhaps there may be less than 20 lawfully unlicensed facilities and less than five illegally unlicensed, however Tobia's team found that there may be as many as 78 unlicensed care homes serving as many as 400 individuals in that county. Cases of physical abuse, such as residents being beaten and burned as described in the environmental scan, were also reported during interviews. As a resident of a licensed residential care or unlicensed room and board facility, you have all the rights guaranteed by the Constitution of the United States and by the State of California. 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. 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. We will however, treat all complaints with respect and make every effort to address concerns in a timely fashion providing written findings, conclusions, or next step recommendations to resolve the issue brought to the attention of our staff. Also, new HHS Centers for Medicare and Medicaid Services (CMS) policies on waivers and where waiver services may be provided may alter the prevalence of legally and illegally unlicensed care homes across the nation. Of the approximately 1,400 complaints received by APS each year, an estimated 20% pertain to unlicensed personal care homes. Report on Texas boarding houses. Between 2012 and 2015, the California legislature enacted several laws that will affect the operation of these facilities. Other uncategorized cookies are those that are being analyzed and have not been classified into a category as yet. Informants expressed other specific concerns about unlicensed care homes, including improper management of residents' medications; unsafe, unsanitary, and uncomfortable living environments; theft of utilities from neighbors; and fraudulent collection of government payments (e.g., not reporting residents' deaths and continuing to collect their SSI payments). (n.d.). Additionally, states may implement public awareness campaigns to support identification of unlicensed care homes. Retrieved from http://www.state.gov/documents/organization/245365.pdf. Tobia, M. (2014). The PCRR team shares the complaints they receive about potential illegally unlicensed personal care homes between the AAA, APS, Disability Rights Network, code enforcement and state licensure office. In California, when an owner rents property to a resident, this typically creates a landlord-tenant relationship. With the passage of a new law in July 2012, it is a misdemeanor to operate an unlicensed personal care home, and if an unlicensed care home is linked to abuse, neglect, or exploitation, the violation is considered a misdemeanor. On the other hand, grey literature--that is, reporting databases, blogs, and media reports--produced more results about 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. Florida publishes a listing of unlicensed homes but it does not correspond with the media reports of the number of unlicensed care homes identified by state inspectors. The California Room & Board Advisory Coalition is committed to enriching the quality of life of those in the communities we serve while maintaining the highest level of advocacy for providers and consumers. However, even if the home continues to operate, the fines are rarely enforced or collected. In multiple interviews, unlicensed care home operators were described as being involved in human trafficking, and also were specifically noted by APS and law enforcement officials to traffic residents across state lines, specifically into Florida and Alabama, to avoid legal action in Georgia. Georgia was selected as a state for our site visit because of the state's actions surrounding unlicensed care homes described during interviews with SMEs, and the numerous news reports about unlicensed care homes in the state. Schneider, C., & Simmons, A. Ombudsmen program does not extend to unlicensed facilities (Hawes & Kimbell, 2010). By clicking Accept All, you consent to the use of ALL the cookies. (2013). This, they fear, could lead owners to operate illegal unlicensed personal homes. A few key informants suggested cross-referencing different agency lists as another potential source for identifying unlicensed care homes. Other Research Ideas Suggested by Subject Matter Experts or Individuals Interviewed in State Site Visits. 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. 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. North Carolina's Adult Care Licensure Office licenses two levels of adult care including family care homes and adult care homes. Hospital discharge planners are not required to check the licensure status of the place to which they are discharging patients, and often discharge them to unlicensed homes. Medication is visible. However, as in some other states, APS in Pennsylvania can act on referrals of abuse for elderly residents (age 60+). (2015). It does not store any personal data. How can I report illegal advertising by an unlicensed contractor. 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. Key informants from Georgia and Pennsylvania shared examples of efforts to increase awareness of unlicensed care homes through education or marketing for the general public or the agencies they involve in addressing unlicensed care homes. Those individuals who remained in the city were placed in day programs. Estimate of 2-year cost of implementing HB216. More information exists about licensed RCFs than unlicensed care homes, thus knowledge of the unlicensed care homes is limited. It is important to note that legally unlicensed care homes are not typically tracked by local community agencies, organizations or states. Key informants also mentioned other resident health concerns including neglect, lack of water, malnourishment, and bed sores or pressure ulcers resulting from inadequate care. Many publications also focused on quality of care or other issues related to unlicensed care staff. In California, lodgers maintain rights similar to tenants. 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. 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. Additionally, interviewee discussions revealed a lack of ombudsman involvement in unlicensed care homes, which is another area for future research. A six-state study conducted by Hawes & Kimbell in 2010 for the U.S. Department of Justice, National Institute of Justice, found that unlicensed homes remain a serious, largely unaddressed problem in some states, with the magnitude of the problem remaining unknown. Key informants expressed a desire for future research that helps to categorize the necessary organizations and the number of personnel hours needed from each organization at each phase of the processes to identify, investigate, and close unlicensed homes; determine the optimal tactics to effectively implement investigation and closure; and develop a safe and seamless relocation and follow-up plan for residents. As noted in earlier sections, many unlicensed care home residents receive federal SSI benefits, and many unlicensed care homes receive these benefits directly through the SSI representative payee program. Other charges included: murder, sex trafficking, sexual abuse from staff or other residents who were registered sex offenders, racketeering, forced labor, and fire setting by residents with severe and persistent mental illness. Several states (California, Pennsylvania, Maryland, and Mississippi) publish notices of how and where to report unlicensed care facilities, which implies that these states may be experiencing problems with unlicensed homes. If the facility is providing licensable services in an unlicensed setting, the state then sends a cease and desist letter, copying the LME-MCO and the local APS. Another strategy is the creation and involvement of interagency and multidisciplinary teams at the state and local levels, which based on our key informant interviewsappears to be a successful strategy. In California in the early 1970's, the 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. 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. Agencies have inadequate resources or authority. Both states use a penalty system to fine operators for illegal operations. Many low-income individuals cannot afford the cost of licensed residential care homes, and some residents exhaust their private funds in licensed facilities and are discharged with no options other than lower cost care homes, some of which may be unlicensed. Teri Parker CFP is a vice president for CAPTRUST Financial Advisors. 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. All of the key informants shared their perspectives about what is driving the closure of personal care homes. The cookie is used to store the user consent for the cookies in the category "Performance". State policies do not require hospital discharge planners to discharge patients to licensed care homes, thus permitting discharge to unlicensed care homes. In the states we visited, a common theme across interviews was that addressing quality in illegally unlicensed care homes tends to focus on shutting down the operations. Key informants in all three site visit states provided examples of how this might happen. 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. Many interviewees mentioned monetary motivations of operators as one factor. Some residents were also described as transitional or homeless, while others were described as persons with substance use disorders. Strategies for identifying and addressing quality in legally and illegally unlicensed care homes appear to differ across states. Available at http://www.ncjrs.gov/pdffiles1/nij/grants/229299.pdf. While experts may speculate on changing market dynamics, we do not have a reliable estimate of the unlicensed care home market prior to these policies taking effect, so we do not know what the market would have been without such policies. One SME from an advocacy organization in Pennsylvania shared that they use an Excel spreadsheet to track illegally unlicensed care homes identified as a result of a complaint. Retrieved from http://www.ajc.com. The issue of financial exploitation is described in detail in Section 3.3.2. What are the interviewees' thoughts on the best strategies to identify unlicensed care homes? 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. 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. Owners of current small licensed personal care homes are also potential sources of information; they will be able to fully describe the monetary costs associated with licensure, and these costs appear to be one reason why some people choose to operate illegally. UnCruise Adventures Small Ship Cruising Juneau, AK 1 month ago . 5. SMEs and key informants consistently noted that many low-income individuals cannot afford licensed facilities, which makes the less expensive unlicensed care home an attractive option, and thus contributes to the existence of unlicensed care homes.
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