After completing the vetting calls, we emailed an introductory letter explaining the purpose and goals of the research to the potential interviewees. Site visit locations were based on the information gathered in the environmental scan, SME interviews, and a review of residential care regulations. States with concerns about the prevalence of unlicensed care homes may wish to examine their licensure regulations, as these may influence the supply of and demand for unlicensed care homes, either because the complexity of some regulations makes them hard for operators to understand, or because they might contain loopholes that operators can easily exploit. The City of Houston established legislation that requires boarding homes housing three or more individuals to register with the city. These unlicensed care homes are referred to by several different names in different states, such as "board and care homes," "boarding homes," and "adult care homes." It is important to learn if such abuses and frauds are limited to a small number of communities or if they are more widespread. Some operators remain undetected by moving residents from one facility in one state to another facility in another state. 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. Indiana: An Indianapolis news article stated that the area had far more unlicensed than licensed facilities. 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. 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. 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. In Texas, when the bill that would have authorized DADs to inspect and license unlicensed residential care homes, legislation was enacted that permitted cities to license RCFs not licensed by the state licensure agency. Some states permit unlicensed care homes to operate legally under the guidance of state regulation; others do not. 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. Qualitative Health Research, 14(4), 478-495. This key informant indicated that this change likely increased the need for licensed group homes, and unlicensed group homes may have also opened as a way to fill the need created as a result of these closures. 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. sleeping hours and must be capable of following directions under 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. In addition to the $100 per resident per day fine placed levied against unlicensed facilities, a representative of the state reported that the Georgia legislature has added operating an unlicensed personal care home, which is a criminal offense, to the list of crimes that make it impossible to apply for a license to operate a personal care home. These locations were selected based on their differences across the selection criteria domains described above, as well as our understanding of the environments surrounding unlicensed care homes in each of the locations, and our ability to identify potential informants in each of the selected locations. Informants did note that while some places are bad, some unlicensed care homes may be fairly decent. the costs of assisted living (personal care homes) or long-term 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. Retrieved from http://www.miamiherald.com. 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). The site is secure. Referral and Placement Agencies and Discharge Planners. A few key informants noted that this funding arrangement affords state and local agencies the resources and time needed to investigate illegally unlicensed personal care homes. Several key informants mentioned that hospital discharge planners sometimes discharge patients to unlicensed care homes (described in more detail in Section 4), and as such they might be a potential source for compiling a list of these homes. 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). Populations in Unlicensed Care Homes. For many such individuals, their only options may be unlicensed facilities or homelessness. 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). Efforts are now under way to provide workshops that clarify the new laws about unlicensed care facilities and how law enforcement and other agencies can work together to identify and investigate crimes against at-risk adults and prepare the necessary components for successful prosecutions. Ultimately, several key informants acknowledged and emphasized that remaining unlicensed is lucrative if the care home operator successfully avoids detection by the authorities. What is the scope of concerns in unlicensed care homes, including quality of care, safety, sexual or physical abuse, and financial exploitation concerns? Personal menus for special diets. The majority of key informants interviewed cited emotional abuse including intimidation and neglect as the most common forms of abuse observed or reported in unlicensed care homes. Maryland, Mississippi, and the District of Columbia have no minimum bed size for licensure, implying that some residential care homes can be legally unlicensed. The remainder of this section summarizes findings from interviews with SMEs and site visit key informants, and also includes additional information from the environmental scan. This results in different payment streams and different regulatory agencies that have responsibility for different residents in the same residence. The .gov means its official. The vast majority of key informant reports emphasize often alarming conditions in unlicensed care homes. A phone number is provided if someone has a question about the licensure status of a facility. However, our key informants (including representatives of adult protective services, ombudsmen programs, and police and fire departments) were informed about unlicensed care homes only in response to complaints or emergencies, which may have biased their views of these homes. One former fire department battalion chief reported that the elderly living in unlicensed residential care homes are hidden from the view of public health agencies, social service agencies, and ombudsman programs --the entities that generally protect and advocate for older people and individuals with disabilities. Provision of housing plus one or more personal services requires a personal care home (or other licensed facility) permit. More recently within the City of Atlanta, the gentrification of some neighborhoods has resulted in increased property values and rents, which has caused some unlicensed care home operations to relocate to less expensive areas. Key informants recommended several tactics to address poor quality in unlicensed care homes, but the overall strategy consistently discussed was to shut down these 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. Pennsylvania Health Law Project and North Penn Legal Services. As described by the majority of interviewees, the primary populations residing in illegally unlicensed personal care homes are vulnerable, with few financial resources. As states are working to meet their ADA obligations as reaffirmed in Olmstead vs. 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. Following the Olympics, funding for these day programs was not renewed, and all but one of these programs ceased operations. Additionally, states may implement public awareness campaigns to support identification of unlicensed care homes. Because these homes are legally unlicensed, the state licensure office has no jurisdiction to monitor them, but APS may receive complaints about them. 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. Retrieved from http://www.dhs.state.pa.us/cs/groups/webcontent/documents/report/p_011015.pdf. One key informant specifically mentioned a 10% cut to state funding for mental health in 2012 while another key informant mentioned block grants as a potential contributor to lower funding amounts for mental health services and supports. But advocates say they see a growing number of unlicensed homes perhaps hundreds around the state operating . Specific concerns included: Managing resident medications improperly. To accomplish this we conducted an environmental scan, including a review of the peer-reviewed and grey literature and interviews with SMEs. Funds are being allocated to relocate residents out of unlicensed residential care. "Caretaker" Accused of Abusing and Neglecting Mentally Challenged Victims. (2009). Hawes, C. & Kimbell, A.M. (2010). In addition, as one ombudsman report noted, it is often difficult to determine whether a place is an illegally unlicensed residential care home because of the difficulty of obtaining access to the suspected home to make the determination. Concerns about abuse and neglect were a major topic of discussion during interviews, and they extended across illegally and legally unlicensed homes. 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). One key informant estimated there are approximately 526 Dom Care operations in the state. Third, the findings suggest it is important to determine the nature and scope of abuse neglect and unsafe conditions experienced by people who have low incomes and physical and intellectual or cognitive disabilities. Most state licensure offices, county offices, or advocacy agencies use a complaint system to identify unlicensed care homes. Multiple key informants described unlicensed care homes as primarily serving persons with mental illness. Traditionally, Medicare does not cover Some of these ideas may be relevant for agencies other than or in addition to ASPE, such as the National Institute of Justice, CMS, or ACL. the types of services needed. for their residents as well as shared rooms. 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. 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. care facilities. Some publish notices of how and where to report unlicensed care facilities. Texas Human Resources Code 42.041(b)(7) refers to an educational facility that is accredited by the Texas Education Agency, the Southern Association of Colleges and Schools, or an accreditation body that is a . 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. They also noted that, despite receiving payment for room, board, and services, some unlicensed care home operators provide subpar or poor quality accommodations and services to residents. Unlicensed Personal Care Homes: What You Should Know The Ombudsman program has seen a sharp increase in complaints about unlicensed personal care homes. When choosing a personal care homes keep in mind that in Texas, they are licensed according to size, type and building safety features so be sure to ask. For example, is it defined by the services the home offers, the services needed by residents, or the services provided to the residents in the unlicensed care setting. In Indiana, legally unlicensed residential care homes serving fewer than five residents can provide assistance with at least one ADL, assistance with medications or meal reminders, or two scheduled supportive services, but cannot administer the medications. resident does not require routine attendance during nighttime Assisted Living Facilities in Indianapolis, Indiana. The new regulations were implemented to monitor and provide oversight of personal care homes with four or more residents, while reducing the number of homes that legally did not require licensure. Characteristics of Residents and Unlicensed Care Homes. Multiple SMEs and key informants suggested following or tracking these benefits as a way to identify individuals in unlicensed care homes.
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