PDF not licensed or regulated by the Department senior may arrange for (2012). Multiple key informants provided details of two specific cases of illegally unlicensed care homes. 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). 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. Anne Arundel County Fire Department, Millersville, Maryland. Key informants suggested interviewing individuals from other agencies to learn more about illegally unlicensed personal care homes or to obtain potential lists of illegally unlicensed personal care homes. We utilized the information obtained in the literature review, in addition to our own expertise, that of our consultant, as well as that of U.S. Department of Health and Human Services (HHS) Office of the Assistant Secretary for Planning and Evaluation (ASPE) and the HHS Administration for Community Living (ACL) staff familiar with unlicensed care homes, to develop an initial listing of SMEs to interview. They noted that some unlicensed care homes provide good care; however, SMEs and other informants consistently reported substantial concerns about neglect, unmet health needs, unsafe and unsanitary conditions, abuse, financial exploitation, false imprisonment, and moving residents to different care homes across communities and states to evade detection. However, cost can vary depending on the
Obtaining licensure would require operators to pay the costs of additional and qualified staff and service provision. Areas for future research and potential data sources related to unlicensed care homes. State and Local Policies Related to the Supply and Demand for Illegally Unlicensed Care Homes. Although this might not be the case in other states, in this community it appears that rural police may be more helpful than those in urban areas in identifying unlicensed care homes. There are two sizes of Texas personal care homes, small and large: Small Small facilities are defined as those with 16 residents or less. Key informants in Georgia described training sessions to educate law enforcement and first responders about unlicensed care homes. Retrieved from https://aspe.hhs.gov/report/medicaid-residential-care. Very little was mentioned about elderly residents living in unlicensed homes; only one informant reported that unlicensed adult care homes may serve a mixed population (e.g., elderly residents in addition to residents with mental illness). 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. Some SMEs suggested that state policies affect the mix of residents in unlicensed care homes. Strategies for Identifying Legally and Illegally Unlicensed Care Homes, 3.5. 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. Oversight was spread across several agencies and depicted as convoluted and overstretched. Some legislatures made it a felony to operate an unlicensed care home. In this study we sought to identify: Characteristics of unlicensed care homes and the residents they serve. Three nutritious meals daily with snacks available throughout the day. 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. Home [txhhs.force.com] 5. Monitoring and Improving Quality in Legally Unlicensed Care Homes. costs while your loved one is living at a certain facility. 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. 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. 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. The closure of large mental health institutions and concomitant transition of previously-institutionalized individuals with severe and persistent mental issues to community-based care settings, such as legally unlicensed care homes. 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. Interview findings indicate that a key element of a successful strategy is collaboration across multiple agencies. Additionally key informants indicated that many unlicensed care home residents who receive SSI payments participate in Social Security's Representative Payment Program, whereby payments are managed by an individual or organization that is representing the beneficiary because the beneficiary is unable to manage the payments independently. 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. One issue that remains to be determined is the conditions or criteria by which such places constitute "unlicensed residential care homes." 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. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely. Most interviewees also agreed that there are likely more illegally unlicensed personal care homes than they are aware of. These local and regional offices--as well as ombudsmen and other national, state, and local advocacy groups--receive complaint calls from a variety of sources including residents' family members; members of the general community such as neighbors or other providers; and medical and service providers (e.g., hospital or clinic doctors, nurses, social workers) who interact with residents inside and outside of unlicensed homes. An ALR must provide daily food service, 24 hour on-site monitoring, case management services, and an individualized service plan. Although limited in scope, the findings of this exploratory study provide important foundational information about current conditions in some unlicensed care homes, factors that may influence demand for these homes, and strategies to identify them and address their quality. emergency conditions. Complaints can also be received by fax, letter, or email. Large Large facilities are defined as those with 17 residents or more. In Pennsylvania informants described a public education campaign including advertisements warning people about placing their loved ones in unlicensed care homes. In addition, SMEs noted variability across states in the availability of resident advocacy and protection through such agencies as the ombudsman program. None of the reports provided evidence on the prevalence of unlicensed care homes in these states or the magnitude of the issue statewide. 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. Maryland, Mississippi, and the District of Columbia have no minimum bed size for licensure, implying that some residential care homes can be legally unlicensed. Much of the information we gathered from the environmental scan, from SME interviews, and from site visit informants raises concerns about the conditions experienced by residents in unlicensed residential care homes. Although licensed homes were generally depicted by key informants as safer than unlicensed homes, one key informant emphasized that quality of care is not contingent on licensure status; licensed homes may also have health and safety concerns. State and local funding that was designated for clean-up activities in preparation for the 1996 Summer Olympic Games in Atlanta was used to encourage homeless individuals (often with mental illness) to leave the city. 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. Health, Safety, and Sanitary Conditions. 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. No other coordinated agency efforts beyond the state licensure office, APS, and the LME-MCO were described by key informants. Monthly fees run anywhere from $1,500 a month to $4,500 each
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. We conducted an environmental scan primarily focused on information spanning a five year period from 2009 through 2014. The financial pressure hospitals feel to free up hospital beds sometimes results in discharges to unlicensed care homes, both unintentionally and for expediency. Nevada stated that no interagency procedures were in place to handle complaints about unlicensed board and care homes in a timely and efficient manner (Ryan, personal communication). 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). Moreover, the 1976 Keys Amendment to the Social Security Act requires states to assure that SSI recipients do not reside in substandard facilities, and states must annually certify that this is true. Retrieved from http://www.namfcu.net/resources/medicaid-fraud-reports-newsletters. What information exists reflects a concern about the conditions under which residents in these places live. (2012b). Schneider, C., & Simmons, A. Indeed, results from the National Survey of Residential Care Facilities indicate that only 40% of licensed RCFs admit individuals with behavior problems, and just 55% admit individuals with moderate to severe cognitive impairment (Greene et al., 2013). In addition, hospital discharge planners reportedly work with placement agencies to find housing for patients who cannot return home alone. In essence, unlicensed care home operators have several opportunities for gaining almost absolute control over these residents who are physically, cognitively, and financially vulnerable. 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. Neglected to death, part 1: Once pride of Florida; now scenes of neglect. 4610 Primary Home Care (PHC) and Community Attendant Services (CAS) Contracting. Retrieved from http://www.miamiherald.com. Unlicensed assistive personnel (UAP) are paraprofessionals who assist individuals with physical disabilities, mental impairments, and other health care needs with their activities of daily living (ADLs). Some interviewees reported that unlicensed care home operators sometimes run homes in more than one state, across state borders to avoid arrest, and may be trafficking residents across state borders as well. These fines ($50 for a first offense in North Carolina and $500 for a first offense in Pennsylvania) become more severe if criminal activity or a resident's death is involved. Licensed care home operators were also identified as potential sources for identifying unlicensed care homes. When HHSC has your information, it is subject to the HHSC privacy policy. Currently human trafficking is defined as "the act of recruiting, harboring, transporting, providing, or obtaining a person for compelled labor or commercial sex acts" (U.S. Department of State, 2015), however, one SME recommended expanding this definition to include the situation in which an administrator for the unlicensed care homes seize and maintain control of vulnerable individuals in order to maximize revenue by taking the public benefits that the individual may be receiving. Key informants described a coordinated effort between the state licensure offices and the local group care monitoring office once there is recognition that a complaint call is about an unlicensed facility. According to the report, these warehoused residents are vulnerable older adults with "hard to place" mental health needs and paroled individuals. As a direct result of this regulation change, many personal care homes in Pennsylvania became illegally unlicensed and either shut down, became licensed, or continued to operate illegally. In contrast, identifying and addressing quality in legally unlicensed care homes was only minimally discussed; however, in at least one of our site visit states, interviewees felt that it was feasible to identify these homes, given the existence of listings of these homes. Multiple interviewees suggested that it was important to quickly involve code enforcement and local health departments in efforts to close an illegally unlicensed personal care home. Detecting, investigating and addressing elder abuse in residential long-term care facilities. No Legally Unlicensed Residential Care Homes Are Allowed in Some States. 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. Provision of housing plus one or more personal services requires a personal care home (or other licensed facility) permit. PDF Medication Aide / Technician Categories By State Key informants in all three site visit states provided examples of how this might happen. 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. Figueroa, L. (2011). PubMed and other database searches yielded very little literature related to unlicensed RCFs. A 2010 annual report from the Department noted that the number of illegal residential care homes had increased from four homes in 2009 to 27 in 2010, most of them located in the Philadelphia area (Pennsylvania Department of Public Welfare, 2011). One was a fairly large ranch style house that accommodates 15-23 individuals at any one time. Currently at the state level, the primary strategy used in Georgia to identify unlicensed care homes is through complaints, including complaints from neighbors, residents, residents' family members, and hospitals serving residents of unlicensed care homes. New Jersey and Tennessee have a licensure category that specifies the maximum number of beds required for licensure, but not a minimum, which also implies that in these states some residential care homes may be legally unlicensed. 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. C., & Barry, R. (2011).Neglected to death, part 2: Assisted-living facility caretakers unpunished: 'There's a lack of justice.' 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. Licensure regulations lack clarity regarding requirements for minimum bed size. Similar to the information summarized in the environmental scan, interviews with key informants revealed that unlicensed care homes make money off of residents in sophisticated and profitable ways. For example, one SME from a state licensure office reported that their database does not include information on whether the call pertains to a licensed or unlicensed care home. One interviewee estimated that licensed personal care homes used to reserve 50% of their beds for individuals who only had SSI benefits and now this amount has decreased to fewer than 25%, leaving SSI recipients with fewer licensed options. Through these regulatory activities, DADS protects Texas citizens receiving home health, hospice and personal assistance services. (2013). 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. Benefit), may be available to help pay for room and board. Several informants reported that it is common for the operator of an unlicensed care home, or representatives designated by the care home operator, to serve as the representative payee for the residents. They noted that the following may have heightened the demand for unlicensed care homes: The admission and discharge policies of licensed care homes. This key informant shared a list of seven placement agencies that work with hospitals in Allegheny County. Key informants also commonly described the conditions in unlicensed care homes as abusive, financially exploitative, and neglectful of residents' basic needs, and depicted situations that involved false imprisonment of the residents and repeatedly moving the residents from one facility to another, both within and across states, to evade law enforcement. Each of these factors is discussed in more detail in the sections that follow. azmfairall. -- either at home or in a nursing or assisted-living facility --
Types of Assisted Living Facilities - Texas 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. Living in a residential care home is often half the cost of
Although there were some reports of clean and safe unlicensed homes, the negative findings about conditions were predominant. The Texas Assisted Living Association (TALA) is a Chapter of the Assisted Living Federation of America exclusively dedicated to representing professionally operated assisted-care living communities and residential homes for the aged for seniors. We completed 17 interviews with SMEs. For many of these individuals, their only option may be unlicensed facilities. A Description of Board and Care Facilities, Operators, and Residents - ASPE By taking control of the resident's benefits, the operator controls the resident's funds, and should be using those funds for room and board and other beneficiary expenses. In some cases they avoid licensure by holding themselves out as not providing services or housing residents that would require a license under state law. It is important to learn if such abuses and frauds are limited to a small number of communities or if they are more widespread. The Texas Department of Aging and Disability Services (DADS) licenses several types of assisted living facilities (ALFs): assisted living apartments (single-occupancy), residential care apartments (double-occupancy), and residential care non-apartments. One key informant stated this posted information, as well as general education sessions out in the community; for example, in senior centers or nursing homes, leads to some complaints that can generate investigations into personal care homes that may be identified as illegal operations. Available at https://aspe.hhs.gov/basic-report/compendium-residential-care-and-assisted-living-regulations-and-policy-2015-edition. resident does not require routine attendance during nighttime
After recommending six states for site visits, the U.S. Department of Health and Human Services Office of the Assistant Secretary for Planning and Evaluation and the research team selected three communities in three states for on-site visits: Atlanta, Georgia; Raleigh/Durham, North Carolina; and Allegheny County, Pennsylvania. Informants stated that Allegheny County has other specific contextual issues that may contribute to the existence of illegally unlicensed personal care homes. Key informants described the way the teams function. One key informant stated that if a call comes in and the name of the care home that is being reported is unknown, then the next step is to call the state licensure office. 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). In addition, many unlicensed care homes operate as family businesses in single family dwellings allowing shifting of residents to avoid detection by regulators (Tobia, 2014). 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. difference is that some personal care homes accept Medicaid to
In this section, we summarize results of the literature review and interviews with SMEs and key informants. PHC providers must be licensed as a Home and Community Support Services Agency (HCSSA) within the category of Licensed Home Health Services, Licensed and Certified Home Health Services, or Personal Assistance Services and have a contract with HHSC to provide PHC services. Properly complete and submit the license application. According to one key informant, this illegally unlicensed care home had recently housed a mix of residents and family members, including four related family members (two children and two adults), two persons under the care of a local hospice, and one individual who was receiving methadone treatment. Both programs require that recipients have . Key informants described both state and local infrastructure issues related to the prevalence of unlicensed care homes in the state. perform those activities without help. building safety features. Multiple key informants also described another illegally unlicensed personal care home with several tenants, including a 91 year old man who had been tied to a chair with a sheet so he would not fall when the owner had to leave the home. 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). Three reports are worth noting separately. 4600, Primary Home Care and Community Attendant Services - Texas Many SMEs reported that persons with severe and persistent mental illness are the majority of residents in unlicensed residential 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. Assistant Secretary for Planning and Evaluation, Room 415F For example, in Georgia it recently became a misdemeanor to operate an unlicensed care home,therefore we aimed to speak with law enforcement officials who had been involved in the process of investigating unlicensed care homes. 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. 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. The goal of this exploratory study was to understand how unlicensed care homes function as a residential care option; the types of individuals who reside in them; their characteristics, including their quality and safety; and policies that influence the supply of and demand for these homes. Miami Herald. safety features so be sure to ask what type of license they
Multiple key informants also stated that a Dom Care operator with the maximum of three individuals may be considering adding other residents or has possibly tried it before, therefore interviews with some Dom Care Operators may yield a unique perspective on the motivations to operate unlicensed care homes. Submit all required documents. sleeping hours and must be capable of following directions under
Several key informants reported that unlicensed care home operators "troll" the psychiatric wards of facilities like Grady Memorial Hospital, looking for residents. North Carolina's Adult Care Licensure Office licenses two levels of adult care including family care homes and adult care homes. The site is secure. 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.
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