However, our literature search did not reveal any estimates of the prevalence of unlicensed residential care homes in most of these states. In Georgia, much of the current focus on unlicensed personal care home investigations involves cases of resident abuse and neglect. Media reports described operators with licensed facilities who also operated a series of unlicensed homes in secret. 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. Clarifying this definition will be critical to understand the prevalence of unlicensed residential care homes, as well as the characteristics of residents in these homes. Two key informants mentioned that changes to the state's Medicaid Personal Care Services program had a direct impact on available funding for group homes that serve individuals with mental illness. We completed 17 interviews with SMEs. Key informants included representatives from several agencies, including the state Healthcare Facility Regulation (HFR) and APS offices, local fire departments, local and state law enforcement and ombudsmen, and a church-affiliated provider of day services used by individuals who live in unlicensed care homes. In these cases, licensed operators were reportedly worried that the unlicensed operators would house residents from whom the licensed homes operators could have profited. Given the types of key informants interviewed for this study, and the limited viewpoints captured, more information is needed to understand the characteristics of unlicensed care homes and the residents they serve. Additionally, agencies such as The National Disability Rights Network's Protection and Advocacy Agency (NDRN P&A) could potentially use representative payee data to identify unlicensed care homes. We then asked questions specific to the type of SME, including: What gaps unlicensed care homes may fill in the spectrum of long-term services and supports (LTSS)? Illegally Unlicensed Residential Care Homes, 6.3. Local efforts were noted to be inconsistent and uncoordinated because authorities were unfamiliar with the laws. Interviews with key informants also indicate that many residents are poor and receive Supplemental Security Income (SSI) benefits from the U.S. Social Security Administration (SSA); the SSI program pays benefits to disabled adults and children who have limited income and resources. 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. First Responders: EMS, Firefighters, and Police. Retrieved from http://www.miamiherald.com. Some states allow them to assist with ADLs, but do not allow them to administer medication. As part of our year-long investigation into Michigans probate courts, the 7 Investigators have uncovered an alarming practice: court appointed guardians putting the people theyre supposed to be caring for into unlicensed group homes. In contrast, one key informant stated that one repeat illegally unlicensed facility had housed residents who had thrived there and had benefited from living in the home. 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. Others described instances where the unlicensed care homes can be located in either low-income neighborhoods or higher-income neighborhoods, and that they blend in with other houses, which makes them difficult to identify or locate unless reported by the community. Findings also indicate that conditions in some unlicensed care homes are unsafe, abusive, financially exploitative, and neglectful of residents' basic needs. Which states have had an increase or decrease in the number of unlicensed care homes and why? Miami Herald. Before 2005, Pennsylvania allowed residential care homes with 1-8 individuals to be legally unlicensed. We conducted nine total interviews with ten key informants, including state licensure officials and staff from the North Carolina NAMI in Raleigh. In Arizona, a bill to strengthen the elder abuse and fraud laws failed to pass again after being introduced in three previous sessions. Because these homes are legally unlicensed, the state licensure office has no jurisdiction to monitor them, but APS may receive complaints about 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. (2012). At the local level, one key informant estimated that members of the Allegheny PCRR, along with the state licensing office, have investigated approximately five illegally unlicensed personal care homes in their specific geographic region over the past two years. We are providing our staff and residents with sanitation and safety supplies, including hand sanitizer and face coverings. 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. In addition, states differ in whether they provide additional funds to the ombudsman program, over and above the federal funds from the Older Americans Act. Informants noted that interagency, multidisciplinary teams at state and local levels are imperative to the success of shutting down unlicensed care homes, and to address the various issues involved in such closures, such as meeting the housing and services needs of residents, addressing any criminal behaviors of the care home operators, and ensuring the safety of the house or facility and neighboring properties. Adult residential licensing, 2010 annual report: A report on licensed personal care homes. Multiple SMEs and key informants suggested following or tracking these benefits as a way to identify individuals in unlicensed care homes. The state and local agencies mostly rely on complaints from the general public and county agencies. Second, the findings highlight the need for federal and state agencies to determine the nature and scope of financial fraud being committed by operators of unlicensed residential care homes. (2009). Information gathered from the environmental scan and SME interviews revealed reports that unlicensed care homes exist in North Carolina. Retrieved from http://www.ajc.com. She said no. A coordinated, interagency, multidisciplinary effort across state and local agency and organizational levels is an important component to addressing unlicensed care homes. Multiple key informants described unlicensed care homes as primarily serving persons with mental illness. Few peer-reviewed articles have been published on unlicensed care homes, but numerous media reports were examined. Key informants also mentioned other resident health concerns including neglect, lack of water, malnourishment, and bed sores or pressure ulcers resulting from inadequate care. The advocacy agency also collects information about whether the operators own more than one unlicensed care home. 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. States have a variety of options for reducing the prevalence of both legally and illegally unlicensed residential care homes, such as changing regulations and coordinating across agencies to address these homes. Illinois: A story released on the This American Life radio podcast described a scam where individuals with substance use disorders were sent from Puerto Rico to supposed rehabilitation centers in Chicago where they were to be provided with housing, food and counseling services, only to find themselves in crowded, unlicensed rehabilitation centers, their passports and other identifying information taken from them. Two states (New Jersey and Tennessee) have a category that specifies a maximum but not a minimum. 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. (2007).Personal care homes in Pennsylvania: A guide for advocates. Interview questions were based on respondent expertise, and were tailored for each respondent. No Legally Unlicensed Residential Care Homes Are Allowed in Some States. Several reports noted that local law enforcement, EMS, and fire departments had frequent interactions with unlicensed residential care homes. Finally, as noted in the report, many individuals seek care in unlicensed care homes because they are in other undesirable situations, such as experiencing chronic homelessness or unnecessarily institutionalized. Key informants in two states confirmed that some hospitals there contract with placement agencies that, in turn, place individuals in unlicensed care homes, particularly individuals with limited resources and mental health issues. Although exploratory in nature, these findings point toward concerning issues with unlicensed care homes as well as gaps in our knowledge, and have important implications for future research on unlicensed care homes. azmfairall. Targeted searches of media reports in states with the lowest percentages of their LTSS expenditures on HCBS (New Jersey, Mississippi, Indiana, Florida, and Michigan) did not yield more reports on unlicensed care facilities than those with the highest spending rates for HCBS (Arizona, Vermont, Alaska, Minnesota, and Oregon). The issue of financial exploitation is described in detail in Section 3.3.2. Agencies have inadequate resources or authority. 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. There appears to be a general lack of recognition about the extent of the problems with unlicensed residential care homes in the United States. 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. In Illinois, there are several categories of adult group homes: Shared Housing Establishment (SHE) - Residence for 16 persons, at least 80% of whom are age 55 or older. In response, the legislature has appropriated $260,000 to relocate residents identified as living in unlicensed care homes. Estimates of the prevalence of unlicensed residential care homes are lacking for most states. The recent changes to state regulations for community living arrangements are also reportedly becoming more favorable toward independent living, which may lead to an increase in the number of unlicensed facilities. Key informants in all three site visit states provided examples of how this might happen. 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. Several examples of unlicensed personal care homes were described by key informants during the site visit. The following section presents individual research topics and identifies the related questions that might guide future research on unlicensed residential care homes. Some have residents that receive Medicaid funded services. Assisted Living Facilities in Indianapolis, Indiana. 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. Some of these homes also serve mixed populations (e.g., elderly residents as well as individuals with severe and persistent mental illness). Adult Foster Care In some states, residents can pay for their own personal or medical care in an unlicensed facility. We also heard suggestions from some SMEs and state stakeholders for improving safety and quality. This had a direct impact on the operating budgets of licensed group homes. In Florida, operators of illegal homes use a variety of schemes to hold themselves out as not requiring licensure. See http://www.dhs.state.pa.us/cs/groups/webcontent/documents/report/c_102850.pdf. Glover-Hogan says based on the level of care required in Plummers case, she didnt think that a licensed home was needed. Licensed Care Home Admission and Discharge Policies, http://www.agingavenues.com/topics/assisted-living-facilities-in-indianapolis-indiana, https://aspe.hhs.gov/basic-report/compendium-residential-care-and-assisted-living-regulations-and-policy-2015-edition, http://www.medicaid.gov/medicaid-chip-program-information/by-topics/long-term-services-and-supports/home-and-community-based-services/downloads/requirements-for-home-and-community-settings.pdf, http://www.gachiefs.com/pdfs/White%20Papers_Committee%20Reports/AtRiskAdultAbuseWhitePaper.pdf, https://aspe.hhs.gov/report/medicaid-residential-care, http://www.ncjrs.gov/pdffiles1/nij/grants/229299.pdf, http://www.dhs.state.pa.us/cs/groups/webcontent/documents/report/p_011015.pdf, http://www.bizjournals.com/prnewswire/press_releases/2012/04/17/DC88926, http://www.phlp.org/wp-content/uploads/2011/03/PCH_manual-for-advocates-Feb-20071.pdf, https://www.socialsecurity.gov/ssi/text-benefits-ussi.htm, http://www.nbcwashington.com/news/local/Caretaker-Accused-of-Abusing-and-Neglecting-Kamara-Zanaib-268343912.html, http://www.dads.state.tx.us/providers/alf/howto.html, http://www.state.gov/documents/organization/245365.pdf, APPENDIX B. 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. The closure of large mental health institutions and concomitant transition of previously-institutionalized individuals with severe and persistent mental illness to community-based care settings, such as legally unlicensed care homes. The licensing rules for Adult Foster Care and Home for the Aged facilities provide minimum standards for these regulated facilities. However, this likely is not a viable method for detecting the population of illegally unlicensed residential care homes. One woman was marketing heavy to the hospitals, and taking them to the licensed facilities, and then moving them to the unlicensed facilities, in result to those types of facilities. These preliminary findings are worth considering as policy makers implement federal, state, and local policies and practices that may relate to unlicensed care homes. Cases of physical abuse, such as residents being beaten and burned as described in the environmental scan, were also reported during interviews. 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. Key informant interviews focused on local context, state and local policies that may impact or affect the demand for unlicensed care homes, and informants' direct experiences with unlicensed care homes. 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. None of the reports provided evidence on the prevalence of unlicensed care homes in these states or the magnitude of the issue statewide. 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.). However, according to interview participants, fines have had little impact on closing the homes, as they were often unenforceable and rarely paid. 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. Per state regulations, this is not considered a permanent structure, and therefore does not meet the appropriate building requirements to be a licensed facility. Hancock, L. (2007). There are three ways to file a LARA report with the State of Michigan. Two of our three site visit states aimed to enhance awareness of poor and inadequate unlicensed care homes by increasing education for the public and key stakeholders: Pennsylvania held a statewide education and marketing campaign to inform the public about unlicensed care homes, and Georgia conducted training sessions to educate law enforcement and first responders about these homes. 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. Licensure offices and other agencies or organizations respond to complaints made by concerned citizens, including family members and friends of residents, neighbors of unlicensed care home operators, health care providers serving unlicensed care home residents, firemen, ambulance services, police, and licensed care home operators. Study findings should be viewed in light of these limitations. Which agencies get involved when addressing unlicensed care homes? If you know of a group home that you believe should be licensed, the state wants to hear from you. Strategies for Addressing Unlicensed Care Homes. 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. Fourth, study findings also suggest that efforts are needed to understand the differences in conditions between legally and illegally unlicensed care homes, as well as how illegally unlicensed care homes successfully evade licensure. We would strongly try to encourage the courts and educate the courts on that, to make sure that those guardians and placing agencies are placing them in a proper setting, said Horvath. Specific concerns raised by SMEs and site visit informants are highlighted in this section. The team works together to track homes they identify as unlicensed and then monitors them until the home is closed. Qualitative Health Research, 14(4), 478-495. Dirt was evident over the walls, floor and stairway.. At least one administrator, on-site manager, or responsible person must be on duty 24 hours per day, seven days a week, and all staff must be trained as personal care workers within 60 days of hire. One potential strategy suggested by an interviewee for proactively identifying unlicensed care homes is to hold community meetings to inform community members about unlicensed care homes, including ways to identify them and how to notify APS and licensure officials if they suspect an unlicensed home operation. State officials have touted group homes as a preferred option, citing cost savings that can be used to fund more community care. Failing to consistently provide running water and electricity, or having unsafe or illegal electrical wiring. One-bed and two-bed residential care homes are lawfully allowed in several states. Several key informants reported that unlicensed care home operators "troll" the psychiatric wards of facilities like Grady Memorial Hospital, looking for residents. Government staff lack of respect for the care provided in small residential care homes by non-professional licensed staff. The state's annual Personal Care Homes Report provides the number of illegally unlicensed personal care homes that result in enforcement actions and details the historical trend of the number of enforcement actions taken against illegal unlicensed personal care homes. Detecting, investigating and addressing elder abuse in residential long-term care facilities. However, even if the home continues to operate, the fines are rarely enforced or collected. In addition to the aging population, many key informants agreed that the lack of affordable supportive housing options for individuals with a mental health diagnosis is also a concern for Allegheny County and surrounding counties. 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. Another specific example included a resident moving from a home where the operator was their representative payee and the operator continued to collect their SSI check. % The regional and state licensure offices are closely involved in this process. The primary concern expressed about the unlicensed homes that were otherwise safewas that they might not be able to provide the level of care and services needed by the residents (e.g., medication supervision for residents with severe and persistent mental illness). Multiple key informants suggested that, as a result, these residents are primarily being served by illegally unlicensed personal care homes. For example, as part of interviews with SMEs, we asked them to recommend potential key informants to meet with during site visits. 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. This reactive strategy underscores the difficulty states and local agencies have in identifying unlicensed care homes. Not all states license all residential settings with as few as one resident, as Georgia does; therefore many states, such as Pennsylvania, legally allow some unlicensed care homes to operate. The first conviction in Florida is a felony; in Georgia, first conviction is a misdemeanor, second is a felony. 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. (586) 819-7573. All key informants described how the Local Management Entity-Managed Care Organization (LME-MCO) oversees the provision of mental health services in Durham County. If you prefer to contact the state via mail, please click here. Monograph for the National Institute of Justice, U.S. Department of Justice. 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. "Unfortunately, unlicensed personal care homes are a . It is important to learn if such abuses and frauds are limited to a small number of communities or if they are more widespread. After years of personal and professional experience, I founded The Group Home Connect Academy, where we provide 1:1 Coaching to help entrepreneurs make their business dreams a reality. State Law, Jurisdiction, and Penalties for Illegally Unlicensed Care Homes. 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