If the facility does not close, law enforcement (not the state licensure offices) fines the illegal operation $50 for the first offense and $500 for each additional offense. difference is that some personal care homes accept Medicaid to Failing to promptly report resident deaths, including more than one instance of leaving a dead body in the facility or back yard. In the District of Columbia, an ombudsman reported that they were involved in collaborative efforts with University Legal Services, Department of Mental Health, Department of Accountability and other groups, such as APS. 4600, Primary Home Care and Community Attendant Services - Texas According to SMEs and key informants, the following factors are likely drivers of the demand for unlicensed care homes in their communities or states: The policies that licensed care homes have against admitting residents who exhibit behavior problems and those who have substance use disorders, or to discharge residents who develop these problems. Preventing residents from using the bathrooms after a certain time at night and providing buckets for residents to use rather than toilets. A 2010 report from the Pennsylvania BHSL noted that enforcement actions against illegal personal care homes had increased from four homes in 2009 to 27 in 2010 (most were located in the Philadelphia area). or home health care. Medicare is more often used to pay for a skilled nursing facility Such practices violate residents' rights, and the profit-enhancing practices of the operators, such as limiting the availability of food, water, and other basic needs, endanger residents' lives and well-being. We heard stories from SMEs and site visit informants of operators recruiting vulnerable individuals from psychiatric wards of hospitals, from acute care hospitals through the hospital discharge planners, from homeless shelters, and directly from the street, similar to those we found in media reports (see Appendix B for details). Targeted searches of media reports in states with the lowest percentages (New Jersey, Mississippi, Indiana, Florida, and Michigan) did not yield a higher number of reports on unlicensed care facilities than those with the highest spending rates for HCBS (Arizona, Vermont, Alaska, Minnesota, and Oregon). Each interview began with a general question to ascertain what the interviewee knew about unlicensed care homes. These are Alaska, Arizona, Arkansas, Connecticut, Florida, Hawaii, Idaho, Indiana, Kansas, Kentucky, Massachusetts, Michigan, Minnesota, Montana, Nebraska, Nevada, New Hampshire, New York, North Dakota, Ohio, Oregon, South Dakota, Texas, Utah, Virginia, West Virginia, Wisconsin, and Wyoming. 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. Submit all required documents. Because of the potential for a large loss of life from fires in these places, comprehensive emergency management planning and practices are reported to be needed to proactively protect those at risk (Tobia, 2014). Potential SMEs were included in the initial listing based on their familiarity with residential care regulations, experience in and research about residential care, experience working with the potential target populations of unlicensed care homes, and knowledge of Medicare and Medicaid payment policies and home and community-based services (HCBS) waiver programs. PDF Medication Aide / Technician Categories By State This results in different payment streams and different regulatory agencies that have responsibility for different residents in the same residence. This lack of knowledge contributes to the need for the government and policy makers to have a better understanding of unlicensed care homes. One key informant explained how North Carolina regulations restrict ombudsman activity in unlicensed care homes, stating "our structure is pretty clear as far as the accountability," implying that the regulations make ombudsmen unaccountable for residents in unlicensed care homes. Almost all SMEs and key informants recommended more proactive strategies to identify unlicensed care homes. what type of license they have; Type A or B - large or small. It is worth noting that this research activity would require developing an operational definition of "unlicensed residential care home," since definitions vary considerably across and sometimes within states, as some focus on services offered, some on size, and some on the characteristics of the residents. Neglected to death, part 3: Inspectors find violations at Lauderhill ALFs. Key informants described the way the teams function. Based on the information gathered, we determined key criteria for site visit location selection, including having good leads/contacts for identifying key informants in the state, and having geographic variation across states. One of the SMEs shared comments from ombudsmen that the numbers of unlicensed homes in some states are increasing, while in other states, they reported that they had not heard about unlicensed care homes. 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. These include tapping into fire/EMS databases to identify addresses of care homes that could be unlicensed, and tracking multiple SSI payments that go to a single representative payee at the same address. 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. There were no reports of varying frequencies of unlicensed facilities between urban and rural areas. State inspection staff, already overwhelmed with large caseloads, are required to obtain warrants to execute searches, a time-consuming process, when trying to follow up on reports of unlicensed homes and determine whether the home is illegal. Multiple key informants expressed concern about other state policies related to reductions in funding for mental health services and supports as potential contributors to a gap that illegally unlicensed personal care homes can fill. In Pennsylvania and Georgia, key informants indicated ombudsmen are permitted to make site visits to unlicensed care homes if complaints are received, although access can be denied by the operator. Key informants described both state and local infrastructure issues related to the prevalence of unlicensed care homes in the state. In Durham County we interviewed key informants from APS, Group Care Monitoring Services, a local hospital discharge planner, a local ombudsman, and one local law enforcement official, who also serves on a crisis intervention task force. Interview results indicate that the majority of unlicensed care homes investigated by state officials and local APS agencies involve situations in which residents are not being cared for properly. or home health care. One interviewee, who interacts with residents of unlicensed care homes on a daily basis, estimated that for every licensed personal care home in Georgia there is one unlicensed care home. 5. One key informant suggested that lists of available housing maintained by a local homeless housing assistance program may include illegally unlicensed personal care homes. The agencies do not typically get complaints from residents inside the home, although if the home is bringing in services such as home health or hospice nurses, those outside agency staff could file reports that result in the identification of an illegally unlicensed personal care home. One key informant provided additional information, stating that hospitals in Allegheny County use placement agencies to help find residential settings for discharges, and that illegally unlicensed personal care homes are used as an option. 3.5.4. There is often confusion about the roles of unlicensed caregivers in the home. 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. Texas Health & Human Services Commission. One Florida media report estimated there were hundreds of congregate living facilities across the state that escaped state oversight because no agency regulates them (Savchuk, 2013). Several states (California, Pennsylvania, Maryland, and Mississippi) publish notices of how and where to report unlicensed care facilities, which implies that these states may be experiencing problems with unlicensed homes. 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). Therefore, it's always a good idea to ask Assisted Living Facility - Texas Health and Human Services Estimates of the prevalence of unlicensed residential care homes are lacking for most states. If residents are able to self-determine and choose where they want to live, they may choose to go with the operator to a new residence. Like the SME interviews, each key informant interview began with a general question to ascertain what the interviewee knew about unlicensed care homes. Referral and Placement Agencies and Discharge Planners. 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. Many low-income individuals cannot afford the cost of licensed residential care homes, and some residents exhaust their private funds in licensed facilities and are discharged with no options other than lower cost care homes, some of which may be unlicensed. Failed Legislative Efforts to Improve Oversight. Oversight was spread across several agencies and depicted as convoluted and overstretched. Advocates reported a growing number of unlicensed facilities and difficulties distinguishing them from boarding homes or other types of RCFs. In Georgia, they advertised themselves as licensed and admitted residents to the licensed facility and then shifted residents to their illegally unlicensed homes. Allegheny County was specifically chosen as the site visit community because of their currently active PCRR team, which continues to address illegally unlicensed personal care homes. example, if your mother requires skilled care, Medicare will cover We conducted nine total interviews with ten key informants, including state licensure officials and staff from the North Carolina NAMI in Raleigh. This American life, episode 554: Not it! The biggest difference is that some personal care homes accept Medicaid to help cover the costs of residency. Some key informants noted that EMS personnel are a better source than firefighters to learn about unlicensed care homes in a community because EMS personnel respond to all emergency calls while firefighters do not. 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. Indiana: An Indianapolis news article stated that the area had far more unlicensed than licensed facilities. Several states have taken steps in improve oversight of unlicensed facilities, often as a result of newspaper exposs on unlicensed residential care homes. UAPs also provide bedside careincluding basic nursing proceduresall under the supervision of a registered nurse, licensed practical nurse or other health care professional. However, SSI payments are low, and most states supplement these payments with a State Supplementary Payment (SSP). 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. Retrieved from http://www.dads.state.tx.us/providers/alf/howto.html. 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. Another concern expressed by some of the individuals interviewed was that even those unlicensed homes that were clean or free of neglect and abuse, commonly have safety hazards and do not meet the fire safety codes required of licensed facilities. Obtaining licensure would require operators to pay the costs of additional and qualified staff and service provision. might not do well with the larger assisted living facilities. This Given their direct linkage to unlicensed care homes, these three sources (hospitals, homeless shelters, and licensed personal care homes) are potential sources of information for identifying unlicensed care homes. These complaints may be made to the police, APS, ombudsmen, and the Department of Community Health, HFR Division. Medicaid Supplemental Payment & Directed Payment Programs, Click here for news, information letters (ILs) & provider letters (PLs), Contact Information for Eligibility Operations Provider Contract Management (PDF), Community Services Regional Contacts for your region, Texas Administrative Code, Title 40, Part 1, Chapter 46: Contracting to Provide Assisted Living and Residential Care Services, Texas Administrative Code, Title 40, Part 1, Chapter 49: Contracting for Community Services, United States Code, Title 42, Chapter 7, Subchapter XIX, 1396, United States Code, Title 42, Chapter 7, Subchapter XX, 1397-1397f, List of Excluded Individuals and Entities, Medicaid for the Elderly and People with Disabilities, HHSC Publishes IL 2022-33 Records Retention and Contact Information After Contract Termination, HHSC Publishes Payment Rates for Residential Care Personal Attendant Services (IL 2022-06), Quality in Long-Term Care 2021 Conference Available Free On Demand, HHSC Publishes Acceptable Documentation for a Criminal History Check for Contractors (IL 2021-48), COVID-19 Vaccine Status Not a Requirement for Services, 2022 Cost Report and 2022 or 2023 Accountability Report Training Information, Contract and Fiscal Compliance Monitoring Implementation of Enhanced Monitoring, Records Retention and Contact Information After Contract Termination, Payment Rates for Residential Care Attendant Services, 2021 Cost Report and 2021 or 2022 Accountability Report Training Information, Acceptable Documentation for a Criminal History Check, Handling of Sensitive Personal Information and Breach Notification, Cost/Accountability Report and 2021 Accountability Report Training Information, 2019 Cost Report and 2020 Accountability Report Training Information, Supervision of/assistance with or direct administration of medication, Information regarding eligibility criteria: contact, Nursing or other services: contact one of the. Complaints can also be received by fax, letter, or email. Personal care homes offer a more home-like setting than nursing homes. All rights reserved. Because of licensure standard variations, for example, homes that were legally unlicensed in Texas (e.g., adult foster care homes with five or fewer beds) were required to be licensed in California and Oregon. The AAA office, APS, Disability Rights Network, and state or regional licensure offices can receive complaints concerning resident care that may lead to the discovery of illegally unlicensed personal care homes. No Legally Unlicensed Residential Care Homes Are Allowed in Some States. PubMed and other database searches yielded very little literature related to unlicensed RCFs. Provision of housing plus one or more personal services requires a personal care home (or other licensed facility) permit. 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. Findings from the interviews suggest that the majority of unlicensed care home residents in the metro Atlanta area have severe and persistent mental illness and are highly vulnerable to exploitation. Available at http://www.ncjrs.gov/pdffiles1/nij/grants/229299.pdf. 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 quality and safety and the policies that influence the supply of and demand for these homes. Absent assistance from the ombudsman or other support in finding affordable licensed care options, unlicensed care homes may be the only option these individuals have. For example, one ombudsman report from Florida noted the difficulty in identifying an unlicensed care home due to the quantity and quality of evidence needed to obtain a search warrant in order to enter the home and positively identify a place as providing unlicensed care or housing residents who must be cared for in a licensed facility. 3.2.3. If an illegally unlicensed personal care home continues to operate, the state regulatory agency has the authority to take out a warrant on the operator ordering her to cease operations. They are a leading provider of top-notch senior care and assisted living solutions. Per one report, the Department of Public Welfare lacks the legal authority to inspect, require plans of correction, or fine these facilities; however, APS can act on referrals of abuse (Pennsylvania Health Law Project & North Penn Legal Services, 2007). 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. In Georgia, the number of complaints about unlicensed facilities rose from 253 in fiscal year 2013 to 293 in fiscal year 2014, with at least one-third of claims being substantiated. Illegally Unlicensed Residential Care Homes, 6.3. However, even if the home continues to operate, the fines are rarely enforced or collected. (2013). 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. Three-bed residential care homes are lawfully allowed in at least one state. 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. 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.
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