Failed Legislative Efforts to Improve Oversight. endobj All states license residential care such as assisted living, and most states license small adult care homes, often referred to as adult foster care (Carder, O'Keeffe, & O'Keeffe, 2015). 2O 6@@ zR"k4 LARA is proud to be recognized as a Veteran-Friendly Employer committed to military veteran recruitment, training and retention practices. In 1999 legislation (PA 99-80) passed, authorizing trained, unlicensed personnel to administer medication to elderly people in residential care homes (residents must be ambulatory and generally less frail than those in nursing homes). Although recognized as important, the state has not yet begun investigating cases of financial exploitation. Key informants described instances of operators making money off of vulnerable residents in a variety of ways that involved theft from residents and theft from government programs. In several cases at both the state and local level, unlicensed facilities were reported to authorities or licensure offices by the operators of licensed facilities. Few of the investigations focus solely on financial exploitation. However, gaps in our knowledge about unlicensed homes remain, and several issues raisedduring interviews with key informants warrant further investigation. 2 0 obj 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. Submitted to the Governor and the Texas Legislature and the Texas Health and Human Services Commission. Other estimates of the number of unlicensed care homes in the state range from 500 to 1,500 within one metropolitan area. No Legally Unlicensed Residential Care Homes Are Allowed in Some States. He also noted that they were not currently using the system in this way, and that it is mostly used to note unsafe locations (e.g., places known for drug trafficking and drug use, or for having dangerous dogs). Retrieved from http://www.miamiherald.com. However, Legally Unlicensed Residential Care Homes Are Possible in Several States. 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. Georgia: In one expose, the Atlanta Journal-Constitution analyzed thousands of inspection reports and interviewed state and local official, social service providers, and advocates, and then published an article on the status of affairs in unlicensed personal care homes. Incentives this modest provide little encouragement for residential care homes to incur the cost of licensure if their primary clientele has only SSI to pay for care. If the SSA implements this requirement, it could become a potential source for identifying unlicensed care homes. "Caretaker" Accused of Abusing and Neglecting Mentally Challenged Victims. Research about legally unlicensed care homes might focus on collecting information about characteristics of legally unlicensed care homes, the services they offer and the residents they serve, such as through a larger number of site visits and interviews with ombudsmen and state regulatory agencies or through a survey of the operators of legally unlicensed homes in states or areas that maintain lists of these homes, such as Florida, Georgia and Texas. The state is also unusual in that it allows a category of care homes to operate as legally unlicensed homes. Assistant Secretary for Planning and Evaluation, Room 415F The Pennsylvania State Lottery funds the Pennsylvania Department of Aging. Atlanta Journal-Constitution. While it is outside the scope of this project to investigate alternatives to unlicensed care homes, we speculate that increasing the supply of alternatives for affordable housing with services would reduce the market for unlicensed homes. The state regulatory agency can send letters to illegally operating facilities and fine them $500. Give Light and the People Will Find Their Own Way, Mom said she was drugged, abused under Michigan probate guardianship. But after a family friend told the Oakland County Probate Court that Plummer was having memory loss, court records show a Judge appointed a Southfield attorney as a co-guardian. If a home is illegally unlicensed, they tend to refer the case to the licensure agency for resolution. Pennsylvania: In 2012, the Secretary of the Department of Public Welfare stated that the state continues to struggle with illegal operators and asked all Pennsylvanians to join in the fight and report any unlicensed homes or activities because "unlicensed care is deadly.". Dirt was evident over the walls, floor and stairway.. Desperate, Plummers family hired an attorney. 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. 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. Based on the criteria noted above, we recommended six states to ASPE as possible site visit locations: Georgia, Indiana, Maryland, North Carolina, Pennsylvania, and Texas. In some states, facilities that provided room, board, and "control and security of medication" could be legally unlicensed. Georgia Association of Chiefs of Police Ad Hoc Committee on At-Risk Adult Abuse, Neglect and Exploitation. Office of the Assistant Secretary for Planning and Evaluation, Printer Friendly Version in PDF Format (81 PDF pages). In some states, residents can pay for their own personal or medical care in an unlicensed facility. In 2013, the minimum number of ADLs needs required for individuals to qualify for reimbursement for personal care services in group homes increased. If the homes are closed and the residents' identification cards and personal paperwork are not able to be retrieved, this poses challenges for residents to get SSI payments and medications. Referral and Placement Agencies and Discharge Planners. Key informants from Georgia and Pennsylvania reported that hospitals and hospital discharge planners (or their contractors) often place patients in unlicensed care homes (described in more detail in Section 4). 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). 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. Cooperative efforts are underway amongst state and local agencies in some states. One SME pointed out that many unlicensed care home cases are analogous to human trafficking, such as when residents are held against their will and then moved from one location to another to avoid detection; however, the current federal definition of human trafficking specifies that the trafficking is done for the purpose of labor or sex, and not for the collection of public benefits (U.S. Department of State, 2015). Key informants for each site visit location included representatives of local public safety organizations such as law enforcement or firefighters, Adult Protective Services (APS) staff, and ombudsmen. 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. PubMed and other database searches yielded very little literature related to unlicensed RCFs. The state primarily uses reports to their complaint system to identify illegally unlicensed personal care homes. 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. On the other hand, grey literature--that is, reporting databases, blogs, and media reports--produced more results about unlicensed care homes. Revised: 4/2017 Follow us These findings highlight a set of potentially serious problems and issues. Strategies for Identifying Unlicensed Care Homes, 5.4. 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. 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. Each of these factors is discussed in more detail in the sections that follow. In contrast, in Pennsylvania, the BHSL has the authority to execute a warrant to investigate a suspected illegally unlicensed care home. 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. We chose the Raleigh/Durham area for the site visit because it is where the state licensing agency is located and because of recent media reports of unlicensed group homes. It was outside the scope of this project to examine the alternatives to unlicensed care homes or the health, safety, or appropriateness of those other environments. 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. In Georgia, efforts are now under way to provide workshops for law enforcement that clarify the new laws about unlicensed care homes and how law enforcement and agencies, such as aging and licensure can work together to identify and investigate crimes against at-risk adults and prepare the necessary components for successful prosecutions. Dom Care homes, which also provide care to three or fewer individuals, are governed and regulated by the state with the authority to certify, supervise and monitor delegated to the local AAA. A facility that advertises or represents via verbal communication that it provides personal assistance is required to make personal services available to its residents. An Online Resource for Skilled Immigrants. Further, key informants reported that many operators require residents to surrender all forms of identification "for safe keeping" by the operator. Some state have too few inspectors to detect and investigate allegations about unlicensed homes and too little time and manpower to bring a prosecutable case to the AG's office. He called Glover-Hogan, and said did you visit? SMEs and key informants discussed a number of factors that may have an effect on the supply of and demand for unlicensed care homes. 1 0 obj Furthermore, some key informants noted that some unlicensed homes fail to provide or arrange treatment for residents' conditions in order to avoid bringing the attention of authorities. What is the scope of concerns in unlicensed care homes, including quality of care, safety, sexual or physical abuse, and financial exploitation concerns? Key informants were also concerned about a lack of specific services inside illegally unlicensed personal care homes. If you prefer to contact the state via mail, please click here. Some of these places are legally unlicensed, while others operate without a license illegally. 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). Rates for MHA residents range from $2,075 to $3,319 per month. 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. This key informant was concerned this had contributed to group homes closing, which may have resulted in a gap that unlicensed facilities are filling. Identification of unlicensed care homes is triggered by complaint calls to state or local authorities by community members or family members. Ombudsmen reported increasing numbers of RCFs operating without a license in both Maryland and Nevada. State inspection staff, already overwhelmed with large caseloads, were required to obtain search warrants to execute searches, a time-consuming process, when trying to follow up on reports of unlicensed homes. Local efforts were noted to be inconsistent and uncoordinated because authorities were unfamiliar with the laws. Concerns remain that agencies do not have the resources needed to monitor and follow through with the appropriate actions to cope with unlicensed care homes (e.g., finding emergency placements for residents, prosecuting violators, ensuring that the illegally unlicensed residential care home remains closed and has not reopened in another location). A few strategies exist in the state for addressing illegally unlicensed personal care homes. Multiple key informants reported that financial exploitation was the biggest concern surrounding unlicensed care homes. State and Local Policies Related to the Supply and Demand for Illegally Unlicensed Care Homes. 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. Another key informant suggested that it would be key to involve the LME-MCO because they cover a four county area and must receive calls that are about unlicensed care homes. Miami Herald.Retrieved from http://www.miamiherald.com. Currently, 46 states provide some type of SSP (SSA, 2015). Furthermore, many licensed facilities are unwilling to admit or retain individuals with challenging behaviors. Retrieved from http://www.ajc.com. Individuals who are poor, experiencing homelessness, or individuals with a mental illness who cannot return home orhave no home to return to after being discharged from the hospital are a source of clients for unlicensed care homes. More information exists about licensed RCFs than unlicensed care homes, thus knowledge of the unlicensed care homes is limited. This report describes the methods used to conduct the study, summarizes the information learned from an environmental scan and the results from interviews with subject matter experts (SMEs) and site visits, discusses implications of the findings and, based on the study findings, offers recommendations for future research on unlicensed care homes. (2012c). We also heard of operators not reporting the death of a resident to SSA so the operator could continue collecting the resident's checks from the government. The information collected as part of this exploratory study was intended to provide a foundation for a more complete understanding about unlicensed care homes and the gaps these homes might fill as housing options for persons with low incomes. The environmental scan and SME interviews informed state selection for site visits. 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. A few key informants suggested cross-referencing different agency lists as another potential source for identifying unlicensed 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. One key informant from Pennsylvania spoke about the difficulty in handling reports of neglect or abuse in legally unlicensed care homes: "we will have repeated incidences, or alleged incidences [at legally unlicensed residential care homes] and we don't report to anyone [any agency or the state] either. 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. Thirty states require residential care homes to be licensed if they have at least one bed.7 Massachusetts exempts small private-pay homes from licensure. Newspaper and media reports generally focus on what they view as the dramatic; the positive aspects of unlicensed care homes are often omitted from these reports. 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. State and Local Policies Related to the Supply of and Demand for Illegally Unlicensed Care Homes. Detecting, investigating and addressing elder abuse in residential long-term care facilities. Michigan Office of Administrative Hearings and Rules. An individual thats incapacitated that needs a higher level of service, the likelihood is that that type of facility would require a license, said Larry Horvath, the Director of Michigans Bureau of Community and Health Systems. 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. Ombudsman programs are not adequately involved. 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. We did not find any report where a government agency was proactive and discovered the case on its own initiative or because of routine monitoring of unlicensed residential care homes. 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. Most key informants stated that many unlicensed care home operators receive the income from the SSA directly, either in the name of the resident or by requiring the resident to name the operator or someone else as a representative payee. The State of Michigan does not license assisted living or independent living facilities. Many key informants noted that regulatory loopholes provided potential ways that operators of illegally unlicensed personal care homes can persist and evade licensure. Carter applied for a license 11 months ago, but refused to answer our questions about why she was operating the home before being approved by the state. However, the long-term placement of individuals after discharge to an unlicensed care home may be unstable, and no follow-up by the hospital with the patient after placement was described. Retrieved from http://www.dallasmorningnews.com. The LME-MCO oversees contract services in a four county area. Many SMEs reported that persons with severe and persistent mental illness are the majority of residents in unlicensed residential care homes. Cases of physical abuse, such as residents being beaten and burned as described in the environmental scan, were also reported during interviews. A few interviewees agreed that in cases such as this, the operators are motivated by their desire to care for people; they are just not aware of the licensure requirements. They indicated that these unlicensed personal care homes are filling the gap left by the closing of licensed personal care homes. 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. 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. The information focused on specific cases, but not on how many of these places exist in these states. One key informant described a recent (2015) case of human trafficking in which a care home operator who was closing a home was explicitly selling residents for $100 each to other personal care home operators. Estimates of the number of unlicensed RCFs, as detailed in this report, were in the hundreds in two states: one state estimated more than 200 unlicensed homes in contrast to their 400 licensed facilities; and the other state estimated more than several hundred unlicensed homes but noted there was no reliable count. Zoning Approval for Group Child Care Homes only (BCAL-3748). <> 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. One strategy recommended by key informants to address unlicensed care homes is to change the regulations to reduce the number of unlicensed care homes that operate legally. Areas for Future Research and Potential Data Sources. Unlicensed care homes are not required by law to open their doors to the state licensure office because the state licensure office does not have the legal authority to enter them. 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. Government staff lack of respect for the care provided in small residential care homes by non-professional licensed staff. (2011). One key informant also emphasized that the limited monitoring of legally unlicensed care homes limits the state's ability to identify and subsequently address any issues of quality or safety in these settings. 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. A referral . Please update to a modern browser such as Chrome, Firefox or Edge to experience all features Michigan.gov has to offer. We relied on a targeted literature review, interviews with a small number of SMEs, and site visits to just three communities, all of which limit the scope of our findings. Schneider, C., & Simmons, A. Most commonly, interviewees depicted unlicensed personal care homes operating in residential areas within single family houses that are rented by the unlicensed care home operator, but some interviewees described unlicensed care homes operating in a variety of other structures (e.g., closed churches and schools). 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. 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. Along with funding to cover relocation of residents, this legislation empowers state and local multidisciplinary teams to collaboratively plan and coordinate efforts to identify, investigate, and pursue any necessary regulatory enforcement or legal action against unlicensed facilities. 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. In Florida, the Secretary of the Agency for Health Care Administration told a senate committee that the agency wanted to work more with law enforcement. According to key informants, this graduated fine system is intended to be a "bigger hammer" to stop "belligerent repeat illegal operators. Homeowners, for example, may have property they cannot rent because the building is not up to code, so to generate income from the property, they begin operating an illegally unlicensed personal care home. The state has also been in the news based on actions resulting from state compliance with the Olmstead decision which has moved adults with mental illness from institutional settings into less segregated settings in the community. The first, a six-state study on elder abuse in RCFs conducted by Hawes & Kimbell (2010) for the U.S. Department of Justice found that unlicensed homes remain a serious, largely unaddressed problem in some states, with the magnitude of the problem remaining unknown. Atlanta Journal-Constitution. Additionally, interviewee discussions revealed a lack of ombudsman involvement in unlicensed care homes, which is another area for future research. MACOMB. 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