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In addition, one key informant stated that penalties for operating unlicensed care homes are similar to only a Class C offense, which is "equivalent to fishing without a license." In another example of differing payment sources, a key informant described a housing situation with three Dom Care residents plus three other residents who can live independently; this care home did not require state licensure as a personal care home. An official website of the United States government. Regardless of what they are called, this study focuses on places that provide room and board and sometimes provide personal care to two or more unrelated individuals, but whose operators are not licensed or certified by the state. Another safety official stated that their department can keep automated notes on potentially dangerous places, like unlicensed personal care homes, so that if they are called out to a repeat offender, the team on call automatically gets the notes. Most of the literature we found referenced problems in and the prevalence of unlicensed residential care homes prior to 2009, or addressed abuse and exploitation of adults living in licensed facilities. The North Carolina Mental Health Licensure Office licenses group homes for adults with mental illness.5 These homes also serve two or more adults. We conducted nine total interviews with ten key informants, including state licensure officials and staff from the North Carolina NAMI in Raleigh. You must fill out a separate complaint form for each physician or other healthcare provider you wish to file a complaint against. One Maryland media report suggested residents are those released from rehabilitation centers with no families in the area. (n.d.).Retrieved from http://www.agingavenues.com/topics/assisted-living-facilities-in-indianapolis-indiana. Consistent with information from the environmental scan, key informant interviews indicate that some unlicensed homes use basements to house residents, including residents who do not have the capacity to exit safely in the event of a fire or similar emergency, such as those who are unable to climb the stairs and those receiving hospice care. 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. Here's how you go about opening and RCFE in the state of California. 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. 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. Primary data collection in 385 licensed and 129 unlicensed board and care homes, including interviews with 490 operators, 1,138 staff, 3,257 residents, and observations of the physical environment and care of residents. 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). Our examination of the Medicaid Fraud Control Unit reports (2009-2013) showed that only a couple cases were reported to the media; the rest had not made the news. The following acronyms are mentioned in this report and/or appendices. Pennsylvania begins licensure with four beds, but the state has locally certified domiciliary care (Dom Care) homes that serve 1-3 residents. The Assistant Secretary for Planning and Evaluation (ASPE) is the principal advisor to the Secretary of the U.S. Department of Health and Human Services on policy development, and is responsible for major activities in policy coordination, legislation development, strategic planning, policy research, evaluation, and economic analysis. In North Carolina, facilities providing or arranging for housing, food service, and 24-hour scheduled and unscheduled personal care services to two or more unrelated adults must be licensed as an adult care home or a group home. Between 2012 and 2015, the California legislature enacted several laws that will affect the operation of these facilities. McGrath pursued both her Bachelor of Arts and Master of Fine Arts at University of California, Los Angeles, in film and television production. However, some SMEs and key informants also noted that many of these individuals with psychiatric conditions are older, having aged in state institutions, and that persons 65 years of age and older who receive SSI payments also often live in unlicensed care homes. Licensed personal care homes are required to assist with personal services, supervise self-administration of medication, and provide social activities, as needed. Key informants described the regulatory agency's ability to work with an operator of an illegally unlicensed personal care home to help facilitate the home obtaining licensure. Positive Actions by States to Improve Oversight of Unlicensed Facilities. Characteristics of Residents and Unlicensed Care Homes. One issue that remains to be determined is the conditions or criteria by which such places constitute "unlicensed residential care homes." 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. None of these approaches or strategies completely addresses the concern about providing a safe environment and quality services to the vulnerable individuals being served in unlicensed care homes. This cost ranges widely based on the geographic region you live in. Many adult facilities, those licensed for ages 18-59 , accept the current SSI board and care rate as payment in full. Boarding homes are allowed to provide the following services beyond room and board: light housecleaning, transportation, money management, and assistance with self-administration of medication, but no personal care service. The reporters described cases of abuse in which residents were being beaten and burned, locked in basements or other rooms, given buckets for toilets, and had their benefit checks taken from them. This had a direct impact on the operating budgets of licensed group homes. A few strategies exist in the state for addressing illegally unlicensed personal care homes. Key informants indicated financial exploitation in unlicensed care homes is an area for future research. Interview findings indicate that a key element of a successful strategy is collaboration across multiple agencies. 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. Retrieved from http://www.gachiefs.com/pdfs/White%20Papers_Committee%20Reports/AtRiskAdultAbuseWhitePaper.pdf. Alabama's APS agency estimated that there were more than 200 unlicensed homes in the state, in contrast to their 400 licensed facilities. It is important to note that most key informants did not speak to or have direct experience with very small (1-3 beds) legally unlicensed personal care homes, and therefore could not estimate the prevalence of these types of homes or compare them to illegally unlicensed personal care homes. Retrieved from http://www.phlp.org/wp-content/uploads/2011/03/PCH_manual-for-advocates-Feb-20071.pdf. Future research examining the role of hospital discharge planners and strategies to prevent discharge to unlicensed care homes appear warranted. In August 2013, the law to prosecute an unlicensed personal care home operator was used for the first time. To reduce abuse, several informants indicated that state officials should target closing unlicensed care homes. As described by the majority of key informants, the primary motivation to maintain an unlicensed care home is to maximize profit. 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 that 30 states require residential care homes to be licensed if they have at least one bed. Multiple key informants discussed the impact that policy changes regarding community-based care have had on unlicensed care homes in their communities, including state efforts to comply with the Americans with Disabilities Act (ADA) requirements. No. A phone number is provided if someone has a question about the licensure status of a facility. First Responders: EMS, Firefighters, and Police. It does not store any personal data. There exists confusion over the authority of other agencies. I'm not going to report it. State Law, Jurisdiction, and Penalties for Illegally Unlicensed Care Homes. That makes it difficult for the licensing agencies to understand what's going on because they don't have the information and aren't privy to it.". Once a room-and-board tenant is served with a termination notice, the landlord must offer the tenant an opportunity to cure some types of violations but not all violations. 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. Available at https://aspe.hhs.gov/basic-report/compendium-residential-care-and-assisted-living-regulations-and-policy-2015-edition. PubMed and other database searches yielded very little literature related to unlicensed RCFs. Yes. And APS often plays a critical role in relocating residents with an illegally unlicensed home is closed. 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. Lax enforcement in personal care homes. 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. For example, SMEs indicated that law enforcement investigators have discovered operators of unlicensed homes with scores of electronic cards for food stamp benefits that belonged to current and former residents. Study staff screened each of the collected articles, blogs, and reports to identify relevant material for review. For many such individuals, their only options may be unlicensed facilities or homelessness. Although the residents who were moved out of this hospital may have been relocated to licensed facilities when the hospital closed, the fact that such institutional settings are no longer an available option may have encouraged unlicensed care homes to open. (n.d.).Regulatory requirements for home and community-based settings. Licensure regulations lack clarity regarding requirements for minimum bed size. In the view of the majority of key informants, the operators of unlicensed homes do not want to have to pay for more staff to provide needed services. He noted that residents with disabilities in unlicensed homes were at risk during fires and natural disasters such as tornados, hurricanes, and severe storms. We found reports of Medicaid fraud in unlicensed care homes in Florida and Nevada between 2009 and 2014 involving charges of false imprisonment, resident neglect, grand theft, and/or operating an unlicensed assisted living facility (National Association of Medicaid Fraud Control Units, n.d.). Very little discussion centered on improving the quality of unlicensed care homes. 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. 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. Unlicensed care home operators also were described as sometimes having select residents act in a role of authority over other residents, such as beating the other residents to control their behaviors. Room-and-board facilities typically provide residents with a room, a bed and prepared meals for a set price. Presumably, this led to an increase in need for LTSS for these populations. Further, receipt of a complaint was the most commonly cited method to spur identification of an unlicensed care home. Ombudsmen reported increasing numbers of RCFs operating without a license in both Maryland and Nevada. Failing to consistently provide running water and electricity, or having unsafe or illegal electrical wiring. 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. 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. Providing unsafe housing conditions, including overcrowding of resident rooms, housing many more residents in bedrooms than is allowed by state licensure regulations, housing residents in storage sheds, basements, and attics that were unsafe, unsanitary, and made egress difficult for frail or disabled residents. They do not necessarily reflect the views of the Department of Health and Human Services, the contractor or any other funding organization. Maryland, Nevada, and Florida: The National Ombudsman Reporting System noted an increase in unlicensed care homes in these states, but no unlicensed care reports from any state provided evidence on the prevalence of unlicensed care. Failing to promptly report resident deaths, including more than one instance of leaving a dead body in the facility or back yard. Monograph for the National Institute of Justice, U.S. Department of Justice. Hawes, C. & Kimbell, A.M. (2010). 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. The following are some examples of financial exploitation depicted during interviews; these examples are discussed at greater detail below: Operators of unlicensed care homes collecting the residents' medications and selling the medications on the street for cash. Fiscal note, 81st legislative regular session. Abuse, Neglect, and Financial Exploitation, 3.4. Additionally, several SMEs and key informants noted that in many cases unlicensed homes are the only option, other than homeless shelters or living on the streets, for some of these residents. Informants stated that Allegheny County has other specific contextual issues that may contribute to the existence of illegally unlicensed personal care homes. Miami Herald. California state housing laws establish regulations for hotels, apartment houses and other facilities that provide room and board. The objective of the literature review was to identify current information (2009-2014) on both legally and illegally unlicensed RCFs and to inform the conduct of SME interviews and site visits to communities in three states. Some of these housed mainly older residents. 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). Residents may not have access to their personal identification cards due to the care provider retaining those items, which can limit the capacity of the resident to relocate. Several informants explained that some unlicensed care home operators require residents to make the care home operator or the operator's designee their representative payee for SSI benefits, and that some operators also collect food stamps, medications, or other resources from residents, which the operators can then sell for profit. Savchuk, K. (2013). Key agencies and team members involved in local or state teams to address unlicensed care homes include APS, ombudsmen, building code enforcement, social workers and first responders such as EMS, police, or firefighters, and other representatives from local advocacy groups such as Disability Rights. That's what they're doing, targeting individuals with cognitive impairment.". Interviewees noted that unlicensed care home operators often take the residents' identification cards and personal paperwork upon admission. 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. Retrieved from http://www.miamiherald.com. Please read and acknowledge the disclosure below: CRBC makes no representation or guarantee regarding the outcome and confidentiality of information provided through complaint process, whether in person, via phone or in writing. 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. Licensure staff admitted they only learn about the unlicensed facilities when someone reports them. Reports of financial abuse include fraud of federal programs, including SSI, Medicare, and Medicaid. Examples of financial exploitation described by key informants include the operator becoming a resident's representative payee and then withholding a resident's money, and pocketing profits while providing inadequate care and services or no services at all. For example, as part of interviews with SMEs, we asked them to recommend potential key informants to meet with during site visits. Almost all SMEs and key informants recommended more proactive strategies to identify unlicensed care homes. We found three cases in Florida of charges against unlicensed RCFs involving allegations of false imprisonment, resident neglect, grand theft, and/or operating an unlicensed assisted living facility; and three cases in Nevada of neglect and/or criminal offenses while operating without a license (one where the accused also operated a licensed facility). (2012b). In 2012, the Secretary of the Department of Public Welfare noted 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" (Pennsylvania Department of Public Welfare, 2012). 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). 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