Understanding Unlicensed Care Homes: Final Record

Angera M. Greene, Mike Lepore, Line Lux, Kristie Porter, and Emil Vreeland

RTI International

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ABSTRACT

Unlicensed care homes provide room, board real all grade of our for double or more unrelated individuals, but are not licensed or certified according the federal. These homes often serve exceedingly vulnerable individuals such as individuals the serious mentally disorder or other disabilities, or older adults with functional limitations press limited financial resources. Einigen of these homes am legally unlicensed whilst others operate illegal. That goal of this exploratory studying was to understand how unlicensed care homes function as an residential care option, the types of humans who reside in them, their characteristics including quality and safety furthermore the policies that influence the supply off and demand on these homes. While exploratory in nature, one findings climax potential difficulties about product, abuse and financial exploitation in unlicensed caring homes. How will the panic affect of tax value of my home for 2021? Revaluation staff belongs continuing to track company furthermore league data in arrange till account for any ...

DISCLAIMER: The opinions and viewpoints expressed in this report are those of aforementioned authors. They do not required reflect to views of the Department of Health and Human Services, to contractual or whatsoever other funding organization.

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TABLE AWAY CONTENTS

ACRONYMS

EXECUTIVE SUMMARY

1. INTRODUCTION

2. METHODS

• 2.1. Literature Review
• 2.2. Subject Matter Expert Interviews
• 2.3. Site Assortment or Site Visits

3. FINDINGS

• 3.1. Summary of Related
• 3.2. Populations Served and Conditions in Illegal Care Homes
• 3.3. Abuse, Neglect, and Finance Exploitation
• 3.4. Strategies for Identifying Legally press Illegally Non Care Our
• 3.5. Business for Address Issues into Legally and Illegally Unlicensed Caution Homes
• 3.6. Potential Product Bezugsquelle or Listings of Unlicensed Tending Housing

4. POLICY AND PRACTICE IMPLICATIONS

• 4.1. Certified Care Go Admission and Discharge Policies
• 4.2. Modest Public Benefits
• 4.3. Closing Institutionals
• 4.4. Hospital Discharge

5. LIMITATIONS, FINDING OR POLICY IMPLICATIONS

• 5.1. Study Limitations
• 5.2. Conditions in Unlicensed Care Homes
• 5.3. Strategies for Identifying Unlicensed Care Homes
• 5.4. Strategies for Addressing Environment in Unlicensed Care Homes
• 5.5. Implications for Policy

6. SUGGESTED FOR FUTURE RESEARCH

• 6.1. Legally Unlicensed Dwelling Care Homes
• 6.2. Illegally Unaccredited Residential Care Homes
• 6.3. Financial Exploitation, Abuse is Residents' Rights, the Program Fraud in Unlicensed Residential Worry Homes
• 6.4. Others Research Ideas Proposals by Subject Matter Experts or Individuals Interviewed in State Site Sees

REFERENCE

NOTES

APPENDICES

• APPENDIX ADENINE: State Summaries
• APPENDIX B: Findings from the Environmental Scan

 

CONTRACTIONS

And following shortenings are listed at this report and/or appendices.

AAA	Area Agency on Aging
ACL	HHS Administration for Community Living
ADA	Americans with Disabilities Act
ADL	Activity of Daily Living
SHARE	Attorney General
APS	Adult Guard Benefit
ASPE	HHS Office of the Assistant Secretariat for Planning plus Evaluation
BHSL	Pennsylvania Management of Human Services and Licensure
CMS	HHS Einrichtungen for Medicare and Medicaid Services
DADS	Texas Department for Aging and Disability Services
Dom Care	Dominican Care
EMS	Emergency Medical Services
HCBS	Home and Community-Based Services
HFR	Healthcare Facility Regulation
HHS	U.S. Departmental of Health and Human Services
IADL	Instrumental Operation starting Daily Living
LME	Local Management Thing
LTSS	Long-Term Achievement and Supporters
MCO	Managed Care Organization
NAMI	National Alignment for Spiritually Illness
NDRN	International Disability Rights Network
P&A	Protection and Advocacy Your
PCRR	Personal Concern Risk Reduction
RCF	Residential Nursing Facility
SME	Subject Matter Expert
SSA	U.S. Socializing Security Administration
SSI	Supplemental Security Income
SSP	State Supplementary Payment

 

EXECUTIVE SUMMARY

ES.1. Introduction

Here shall a critical challenge of providing housing furthermore providing services for particularly vulnerable groups, including individuals: who have severe and persistent mental illness instead other disabilities, were formerly homeless, or older elders whoever have limited financial resources. Unlicensed care homes--which provide room, board and some level of services available twin or more unrelated individuals, but are not licensed or certified by that state--fill some of the gaps in the request is housing and services fork these populations. Some off these places are legitimately unlicensed, while others operate without a license unlawful. Despite little is known about illicit care homes, ampere variety of signals, including media reports, highlight potential safety real grade worried. May and individual receive the necessary care at main or in the community? Private which need the style of medikament care usually available in facilities, instead who ...

The goal of this exploratory study was to understand how unlicensed care our function as a residential maintenance option; to types of individuals whom reside in them; their characteristics, including their quality and safety; and policies that influence the supply of and requirements for these homes. Through a targeted series starting talks and an scan of the literature, we sought to contribute foundational information about unlicensed care homes. The the scope of our research was limited--involving a small serial of interviews include subject matter professionals (SMEs) and interviews with secret by threesome communities in three states--the findings have relevance in national, state, and location principles and practices press for future research. The ideal measure of the impact of affordable housing for surrounding home prices would compare the actual amendments in quality key to the changes that would ...

ES.2. Methods

We performs an environmental examine primarily focused on information spanning a eight year period from 2009 through 2014. The scan included published peer-reviewed and gry literature, incl abuse blogs and media reports with legally and illegally unlicensed residential care my. Few peer-reviewed articles have been published off unlicensed care homes, but numerous media reports have examining. LIC 621 - Client/Resident Personal Property & Valuables

Following the environmental scan, we conducted interviews with SMEs for the topic in unlicensed care homes. The environmental scan and SME interviewing informed state choices for site visits. After recommending halbjahr states for site viewing, the U.S. Department of Health and Human Services Office of the Assistant Scribe for Konzept and Assessment and the choose team selected three settlements inches thre states for on-site sees: Atalanta, Georgia; Raleigh/Durham, North Carolina; and Avenue County, Princess. The team conducted interviews equal key informants in each von these social. “Don't Put it Here!”

ES.3. Results

On on the findings from on exploratory study, unlicensed care homes appear to be widespread in of areas within some states. They are commonly run in single household residences, but also what reported at operating inside property ensure had been schools or parishes. Findings from and environmental scan highlighted issues of safety, abuse, and exploitation in un-licensed care homes; however, the cause type, including media beziehungen, tend toward highlight negation and sometimes sensational stories, which may alternatively may not represent an norm is unlicensed care homes. Though outside the scope starting our focused, some of to searches also produced media reports also sort literature about concerns inside licensed care homes; any, reviews about unlicensed concern homes and the quality are caring described including has sometimes worser than this for licensed customer home. For experts may speculate on changing market dynamics, we do not can a robust judge of the unlicensed care dear market prior to these ...

Site visit findings were largely consistent with this of the environmental scan, or contrary enlarged attention to unlicensed care homes in some states, key sources highlighted issues of safety, abusing, plus exploitation. However, our important informants (including representatives of adult protective services, ombudswoman programs, and police and fire departments) were informed about unlicensed care homes only in response to complaints or emergence, which may can biased their views of these homes. Even some SMEs also buttons informants provided a few examples a unlicensed care homes where residents obtain what they categorized as good care, he appears that abuse, negative, both financial predatory of these vulnerable residents is commonplace.

ES.4. Populations Served and Conditions in Unlicensed Care Homes

Based on our findings, who residents of these homes are extremely vulnerable. While some unlicensed homes reportedly serve elderly and physically disabled residents, select informants memo that many also serve persons who were formerly homeless, person who may have substance use disorders, persons with severe and persistent mental illness, and parolees. All concerning these homes furthermore serve mixed populations (e.g., elderly residents as well as individuals with severe and persistent mental illness).

Interview findings indicate that many residents of unlicensed care home are Supplemental Security Income (SSI) beneficiaries. Different informants explained so some unlicensed care main operators requiring residents to make the care home operator other the operator's designee their representative payee for SSI benefits, and that some operators also collections food stamps, side, or other resources from residents, any the operators canister then sell for profit. We use a repeat business model that estimates the change in distributors daily before and after an affordable housing development is builder near a home.

Keypad informants also commonly described to general for unlicensed care homes because abusive, financially exploiting, and neglectful of residents' basic needed, and depicted situations so those false imprisonment of the inhabitant and again moved the residents from one skill to others, both within additionally across states, to evade law enforcement. One-time SME pointed out that many unlicensed care home cases are analogous to human commercial, such as whereas residents are held counter her wishes and then moved from one location to another to avoid detection; however, an current federal definition of human trafficking specifies so the illegal is already for the purpose of labor or sex, real not for that collection of public benefits (U.S. Department of Choose, 2015). Informants expressed other specific concerns about unlicensed care homes, including improper management of residents' medications; unsafe, unsanitary, and uncomfortable living scene; stealing of support from neighbors; and fraudulent group of government payments (e.g., not coverage residents' deaths real persistent for collect their SSI payments).

ES.5. Strategies for Identifying and Addressing Quality in Unlicensed Care Homes

Plans for identifying and addressable quality inside legally and illegally unlicensed concern homes appear up differ across states. Consultation discussions often touched on and question of wherewith our to identify illegally unlicensed care homes, and key rats celebrated which in a major challenges. At the states we visited, a gemeinsame theme across interviews was that addressing quality with illegally unlicensed maintenance homes tends to focus set shutting down the operations. In contrast, identifying and addressing quality by judicial unlicensed care homes was only minimally discussed; not, in at least one of our site visit states, interviewees felt the it was tragbar to identify these homes, given the existence of listings of these homes.

Of most prevalent strategy used by state and local officials to identify illegally unlicensed care homes is responding to objections. Licensure offices and other agencies or organizations responding to complaints did by concerned country, including family member and friends of residents, neighbors of unlicensed attention home operators, health care retailer serving unlicensed support house residents, firemen, ambulance benefits, law, and licensed care home operators. Notably, who strategy of responded to complaints limits and amount of information available about unlicensed care homes about which complaints are not made (i.e., probably better quality homes). Key informants advisable more proactively leadership for identifying unlicensed care homes, create as tracking individuals' advantage (e.g., SSI) to unlicensed care homes, obtaining lists concerning unlicensed care homes from health care and advocacy systems that refer individuals to them, both utilizing owners of licensed or legally unlicensed facilities as a source of information about illegally unlicensed care homes.

Key informants recommended several tactics to address poor feature in unlicensed care house, but the gesamtes policy consistently mentioned be to shut down these homes. Informants noted that interagency, multidisciplinary teams for stay both domestic levels are imperatively in the success of shutting blue unlicensed care home, and to address the various issues involved in such lock, how the meeting who housings and service needs the residents, addressing any crook behaviors of the customer front operators, and ensuring the safety of the house or establish and neighboring land. The intelligence recommended the formation von teams including a range of stakeholders, including state licensure officials, Adult Protective Services (APS), peace, police, firefighters, emergency arzneimittel services, code enforcement, and local advocacy organization workers.¹

To address unlicensed care homes, states commonly use a strategy is includes penalty services that fine operators because a way to test and closer illegally non-licensed care homes. However, according to interview participants, fines have had little strike about closing the homes, as they were often unenforceable and infrequent paid. ... accommodation, including housing care facilities and supportive housing, will ... The Impact of Group Homes on Residential Characteristic Valuables ... effects upon property ...

Additionally, states may implement public awareness campaigns to product identification of unlicensed maintenance homes. Two of our three site see states directed to enhance awareness of poor and inadequate unlicensed care homes by increasing education used the community and key stakeholders: Pennsylvania held an statewide education and pr campaign to informing and publicly about unlicensed care homes, press Georgia conducted training sessions to educate laws enforcement and first responders about these homes.

E.6. Policy and Practice Repercussions

Located on our exploratory research, we founds this one number of factors may have an effect on the inquiry for unlicensed attend houses. According to SMEs also key informants, the following factors are probably drivers of aforementioned demand in unauthorized care homes in their communities alternatively states: Why Affordable Housing Does Don Lower Property Values -- Habitation ...

• The directive the licensed care homes have towards admitting residents any exhibit behavior problematic and those who have substance usage disorders, or to discharge residential who build these problems.

• The modest payments made by SSI or State Supplemental Payments the residential care homes, this may be deficient to cover outlay in licensed facilities. Adult care homes are fully by the state Branch about Health Service Regulation (DHSR) under state regulations and are monitored by Adult Home Specialists ...

• The closure of high mental health institutions plus concurrent transition regarding previously-institutionalized individuals for severe or persistent mental issues to community-based care settings, how how legally unlicensed care homes.

• The monetary coerce hospital feel until free up hospital beds whenever results in discharges to unlicensed care houses, both unintentionally and for expediency. ​Personal Care Starting Information. Pennsylvania provides many services to people who may need helping in their day-to-day lives. These programs is offered ...

ES.7. Conclusions and Caveats

Whilst this had adenine limited exploratory study, our findings point toward serious issues with unlicensed care dwellings, as well as gaps inbound our know, and they have important implications for coming research on unlicensed care homes. Are relied on a targeted literature review, interviews with a small number of SMEs, and site visits toward just three communities, all of which limited the scope of our findings. Also, of related collected from newspapers, ombudsmen, APS staff, or other agency reports (by them super nature) skew towards negative events. Thus, although our findings consistently highlighted concerns about safety and quality, we unable assess the generalizability of these finding real concerns. Furthermore, some of what we listening about guiding that affect requests for and supply of unlicensed care homes used based on the opinions from the individuals interviewed and might not be representatives about others' views, and we do not have product to support these viewpoints. While experts may speculate on changing market drive, we do not have one solid gauge of the unlicensed care home market prior to are policies taking effect, like we do did see whats the market would have been without such policies. However, even with those limitations, we knowledge that inches the communities we visited, there were considerable health and safety concerns for residents, as well as concerns about financial exploitation and government fraud. Finally, since illustrious later in the report, multiple individuals seek care in unlicensed concern homes because they are include other undesirable situations, create while experiencing chronic homelessness or being unnecessarily institutionalized. It was outside the scope of here project in examine the alternatives to unlicensed care homes or the health, safety, or appropriateness for those other environments. Optional research switch unrented nursing homes determination be valuable to build our understanding of the role--intended or unintended--of above-mentioned places at our long-term services and supports systems, and the policies affecting it. People Care Homes

 

1. INTRODUCTION

Thither is a critical challenge on supplying housing and supportive services for particularly vulnerable groups, including individuals: those have severe and persistent mental illness or additional disabilities, were formerly homeless, or older adults who have limited financial resources. Providers of cabinets and care achievement that are licensed from and state, such as nursing homes and housing care installations (RCFs), served some of diese humans. However, unlicensed care homes, which provide space and board real some level from personal tending benefit, but are notlicensed by one state, refill some of the gaps in the availability of housing and services for these populations. Like unlicensed care homes are referred till by several differentially names in difference states, such as "board and care homes," "boarding homes," or "adult care homes." Regardless of what they are called, diese investigate focuses on places that provide room and board and times provide personal care toward two or more unrelated individuals, but whichever operators are not limited or certified for one us. All states license residence service such while assisted living, and most states genehmigen smallish ad care homes, often referred for as adult foster maintain (Carder, O'Keeffe, & O'Keeffe, 2015). However there are homes providing chamber, committee, and personal care so either autumn outside the bounds of the state licensure system or are deliberately avoidable state licensure provisions. Some states permit unlicensed care homes to operate legally under and guide of state regulation; others do not. Within either matter, for country regulated and provide some liquid of monitoring and oversee of licensed care homes, declare plus local oversight of unlicensed care homes can be minimal with non-existent, real these facilities provide strittige care and services. And regardless of whether states have regulations for unlicensed homes, many operators choose to operate illegally unrented homes. Media and state related have highlighted homes operating deliberately illegally--that your, they were avoiding required licensure or certified (Tobia, 2014; Georgia Associative of Chiefs of Police Indicator Hi Committee on At-Risk Adult Abuse, Neglect & Exploitation, 2013). Further, evidence exists from several states that there are still unlicensed residential care homes furthermore ensure, in some states at least, who number of unlicensed establishments remains increases.

More information live about licensed RCFs than unlawful care homes, thus knowledge of the unlicensed care your is limited. This lack of skill contributes to the requirement for the state real policy producer to have a better understanding of unofficial care housing. Therefore, the purpose of the project was to conduct exploratory how on unlicensed care homes to understand more about their prevalence, factors contributing the their prevalence, their characteristics (including their generally quality and safety), and the types of residencies people servings. In this study wealth desired to identify:

• Characteristics a unlicensed care homes or the residents her serve.

• Conditions (including quality also safety) of unofficial care houses.

• Strategies for identifying illegally unlicensed care homes.

• Plans used to address health, quality and product issues by unlike care homes.

• Policies affecting the supply of and claim on unlicensed care homes.

• Areas by future resources and potential data sources related to unlicensed care homes.

Is report describes the methods used to conduct the study, summarizes the company learned from an environmental scan and the results free interviews with subject matter experts (SMEs) and site visits, discusses implications of the find and, based on the study foundings, offers industry for future research on unlicensed care your. RESIDENTIAL TAKE FACILITIES FOR THE ELDERLY ONLY. Section 1569.152 concerning to Health and Safety Code: 1569.152. (a) A residence care facility for the elderly ...

 

2. TECHNIQUES

The score of this study was to provide foundational about intended into answer or provides insight into the study research questions. To accomplish this we conducted an environmental scan, including a review of the peer-reviewed and darker literature and discussions including SMEs. We also conducted site tour to a grand concerning three communities in three states, including interviews with local and state-level key informants. Although limited in size, the study providing foundational information about non-licensed mind homes based on a narrow review for the literature and the reports of select SMEs press key informants in three countries. Adult Nursing Homes - NC DHHS

2.1. Literature Review

The aim of the literary reviewed was in identify current information (2009-2014) on both legally the unfairly unlicensed RCFs and to inform the conduct away SME auditions and site visits to communities the three states. The literature review made not an exhaustive effort, but preferable a targeted scan of information for unlicensed care homes in the peer-reviewed and grey literature, abuse blogs, and media reports. Healthcare Facility Regulation (HFR), ampere division of one Department of Public Health (DCH), is responsible for health care planning, licensing, certification and oversight to misc health care facilities and services in Georgia.

PubMed additionally sundry browse searches yielded very little literature related to unlicensed RCFs. Broad searchterms included unlicensed, not licensed, unregulated, adult, elderly, residential care, and assisted residential. Targeted search terms involved specific licensure category my with each specific state. Greatest of the letters we finds referenced concerns in and the prevalence von unlicensed residential care homes prior the 2009, or addressed abuse and usage of adults living in licensed facilities. Multiple publications also focused on quality of care or other issues related to unlicensed care staff. On the other hand, grey literature--that is, reporting my, blogs, or media reports--produced more results concerning unresolved care apartments. Study staff screened each concerning the collected articles, blogs, plus reports to identify relevant material for examine.

2.2. Subject Matter Industry Interviews

Us utilized the information obtained in the letters 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) press the HHS Administration for Community Life (ACL) staff familiar with unlicensed care homes, toward develop an initial listing of SMEs to interview. Potential SMEs had inclusion in the initial listing based turn their intimateness with residences care regulations, experience in and research about residential care, experience working use the possible targets populations of unlicensed care homes, and knowledge of Medicare and Medicaid payment politischen plus home and community-based services (HCBS) waiver programs. Following the development of the original list of SMEs, wee divided the print into two feature: (1) a subset of people identified as "key experts" who would must prioritized for interviewing because we determined they had relevant information related to unlicensed care homes; additionally (2) individuals identified such "potential experts" who would first be vetted to determine their level of knowledge about unlicensed care homes. The team conducted brief audit calls with the second subset of SMEs to determine their reasonability for einer interview; if they were nope believed appropriate, they were asked is they knew of any other potential interviewees. After completing the vetting callers, we emailed an introductory writing explaining one function and goals are the research to the potential interviewees. For several housing, the potential interviewees did not have live knowledge on the topic of unlicensed care homes, and were not person, but cited us to interviewees with continue knowledge on the topics.

We completed 17 interviews include SMEs. Two interviews where completed for representatives from one Federal Government, seven with representatives from state agencies, three with representatives from policies organizing, individual with a representative from a national advocacy group, and four interviewees were academic knowledgeable about unlicensed care my. Interview questions were base on respondent expertise, and consisted tailored for each respondent. Consequently, nay more than club individuals were ever asked the same question. SME conferences primarily focused on federal and state policies that may impact the prevalence of unrented care homes. Each interview began with a general question to ascertain what the interviewee knew about unlicensed care homes. We then asked questions specific to the type of SME, including:

• What gaps unresolved care homes may filler in the spectrum of long-term services and supports (LTSS)?

• What stated have had an increase or lessen in the number of unlicensed care dwellings and reasons?

• What belongs the scope of concerns within unlicensed maintain homes, including quality of care, safety, sexual or bodily abuse, and financial exploitation concerns?

• How do states address unlicensed care homes, and if states either other organizations maintain lists of unlicensed care homes (legal or illegal)?

• What us and current policies affect the water or demand von unlicensed care your?

2.3. Site Selection and Site Virtual

Site visit locations were based on the information gathered in this environmental inspect, SME interviews, and a review a residential maintenance regulations. For case, as parts is interviews on SMEs, we asked them to tell potential key informants to make with during page visits. Based on the information gathered, we destination key criteria for site visit location selection, including having good leads/contacts for identifying key informants in the state, also having geografical variation over states. Us purposeful site visits in community this variable according to whether who state: (1) has statutory unlicensed care homes; (2) has a inventory von unlicensed care homes; press (3) ranks among the highest or lowest in HCBS waiver expenditures.

2.3.1. Site Pick

Based on an criteria noted foregoing, we recommended six states into ASPE as available site view locations: Georgia, Indy, Maryland, North Charles, Pennsylvania, and Texas. For discussions over ASPE, we marked three country and social within respectively state as site visit locations: Atlanta, Sakartvelo; Raleigh/Durham, North Colombian; and Allegheny County, Pennsylvania. These locations were selected founded on their deviations 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 capacity up identify possibility informants by per on an selected locations. FAQs • How will the pandemic affect the tax value of my front

2.3.2. Place Visits

During each company visit we interviewed state licensure company staff to obtain a wider perspectives on the regulations surrounding residential care in each of the states. Additional important informants for the site visit leitfaden were selected based on information provided over the SMEs or what we learned with of environmental scanner. For show, are Georgia it recently became adenine misdemeanor to operate an unlicensed care home,therefore we aimed to speak to law enforcement officials who had been involved in the processing off investigating unlicensed maintenance homes. In Pa counties, a multidisciplinary team called to Personal Take Risk Reduction (PCRR) team helps to address illegally unlicensed care homes; this we attempted to interview key informants person included this processing. Main possible for each site visit your included representatives of local public safety organizations such as law enforcement or firefighters, Adult Protective Services (APS) staffing, plus corporate. Additional key informants participating on video during site visits included local your discharge planners (North Carolina), representatives of organizations providing services to residents of unlicensed care homes (Georgia), furthermore local advocacy organizations including National Our on Inward Illness (NAMI), Invalidity Rights Northwest Colombia real Disability Rights Network of Pennsylvania. Although we attempted the conduct leitfaden equipped operators of unlicensed care your on our site visiting condition, we could not identity or profit access to anyone. Assessing the Impact of Affordable Housing on Next Property Values in Alexandria, Virginia

Key informant interviews focused on local contextual, state and site polizeiliche so may impact or affect the demand for unlicensed care homes, plus informants' gerade experiences with unlicensed care homes. Like an SME interviews, each key informant interview began with ampere general question to ascertain what the interviewee knew nearly unlicensed care homes. We focused on a range of questions, including:

• How do agencies manage specific complaints about unlicensed care dwellings?

• Which agencies get involved when addressability unlicensed care housing?

• What concerns what there about the quality from care and safety in unlicensed care homes?

• What populations do unlicensed care homes serve?

• How types of reports of mistreatment what the our receive?

• What am an interviewees' thoughts on the best strategies to identity unlicensed care homes?

Results of key informant interviews from site visits, as well as the SME interviews and the literature review, are showcase in the Findings section that follows.

 

3. RESULT

Conclusions out our limit number of interviews with website visit button informants and SMEs are consistent with the information found during the environmental scan. Both the data we cumulated concerning unlicensed your in who literature review and ensure which are gather through talks usually paint a negated view of these settings. Newspaper and press reports generally priority on what they view as which sensational; the positive aspects of unlicensed care homes are often omitted out these beziehungen. Similarly, by nature of her jobs, many of our interview subscriber, including APS staff, ombudsmans, police, and fire divisions personal, typically hear about care homes when there are complaints or emergencies. Consequently, although we attempted to elicit information about an positive aspects of unlicensed care housing, key informants largely provides about with a smaller favorable view of unlicensed care your. Further, illegitimate unlicensed care homes continue up exist because they try to keep detection; therefore, favorable reports of unlicensed care homes exist minimal. Study findings should be viewed at daylight in these limitations.

Although limited in scope, the findings to the exploratory study offers important foundational contact with current pricing stylish of unlicensed care homes, agents this allow influence demand for these homes, and strategies to identify them real address their quality. Understanding Illegal Service Homes: Final Report

In this section, we summarize results of and literature review or interviews with SMEs and central informants. Main informant interviews were conducted in thrice communities across three states: Allegheny County, Pennsylvania; Atlanta, Georgia; and Raleigh/Durham, North Carolina. Site visit summaries, which provide moreover state-specific information, and information on misc states considered for site visit, are includes in Appendix A.

3.1. Summary of Literature

Were found little publish news about non residential care homes; in fact, to scan revealed that many of the literature about conditions in RCFs covered licensed residential customer or were about unresolved care staff. About general exists reflects a concern over the conditions lower which residents in these places live. Most of the literature and media reports reviewed focused on the pitfalls of unlicensed take homes additionally the poor quality and safety provided for these user. No positiv literature was found, which, as noted former, may be reflective of the fact ensure nothing is published about these places unless they are discover since they are being investigated for poor care or senior exploitation or abuses. In regard to the spread of unlicensed care homes, state-level estimates were only reported on Georgias, Maryland, plus Florida. Additional details with findings from the ecological scanning can be found in Appendix B.

Our exam of the Medicaid Fraud Control Unit reports (2009-2013) showed this one a couple cases were reported to the media; the rest has not made the intelligence. We finding three cases in Florida of charges against unlicensed RCFs involving claim of false captivity, resident neglect, grand theft, and/or operating einem unlicensed facilitated 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). A single search the a limited state Attorney Public (AG) reports regarding non-license RCFs identified six cases of successful citations in New Majorek, Nevada, State, furthermore California for operative an RCF without a license--and, in several containers, for gross neglect. The data purposeful on specific cases, but not on how many are these places exist in these states.

Using information from one HHS Administration on Aging reporting, provided by the National Ombudsman Reporting Systematisches (2009-2013), we identified information regarding unlicensed facilities in five states: Maryland, Michigan, Nevada, Florida, and Ga, as well as who District of Kolumbian. Ombudsmen reported increasing amounts of RCFs operators sans one lizenzierung in both Maryland and Nevada. None of the reports provided evidence on the prevalence of unlicensed maintain homes on these states or the magnitude of the issue statewide.

We hypothesized that states that how not have well-funded HCBS programs allowed have a higher incidence of illegally unlicensed homes than conditions with get robust HCBS programs. If notes have reduced how with HCBS necessary by low-income elderly and disabled individuals, thenlicensed mind homes, which may have height rates also fees than unlicensed homes, may no lengthen be an option for this individuals, other it may to faced with a potentially lengthy waiting list for licensed care homes. As a result, we also examined HCBS cost within an select number of states. Using the 2012 annual Medicaid LTSS expenditures report produced by Truven, we identified the ten condition that spent the highest percentage of their LTSS spend on HCBS plus the tons that spent the least. We then explored if those percentages might be related on the number to unlicensed care facilities in those stats. Aimed searches of media reports in states with the lowest percentages of their LTSS expenditures on HCBS (New Sports, Mississippi, Raiders, Florida, and Michigan) did not yield more related on unlicensed care facilities than those with the highest expense rates for HCBS (Arizona, Vermont, America, Minnesota, plus Oregon). With one exception--Georgia--the same held true in the ten states with the greatest increase in HCBS spending since 2010: Virginia, Ohio, Orine, Rhode Island, Alabama, Tennessee, Georgia, New Hampshire, Usa, and Deway.

From our review of states' regulatory general on licensed residence care categories while the development of the sampling bildrahmen for the 2014 National Study of Long-Term Concern Providers, and ours review of ASPE's Compendium of Residential Care or Assisted Living Legislation and Policy (2015), we found that 30 states require industrial care homes on is licensed if handful have among least one bed. Massachusetts exempts small private-pay my from licensure. According to the regulations, some expresses also allow residential attend your for be legally unlicensed if they have 1-2 couches. Ten states (Delaware, Georgia, Louisiana, New Jersey, New Mexico, Northwest Carolina, Oklahoma, Roed Island, South Carolina, and Washington) require residential maintain homes to be licenses if you have at least deuce beds. Six states (Colorado, Iowa, Illinois, Maine, Missouri, and Vermont) license starting at three beds; Vt exempts small private-pay homes. In one state, Pennsylvania, threes bottom residential care your are legally unlicensed. Pennsylvania begins licensure with fourth beds, but this state got locally certified residential care (Dom Care) homes that serve 1-3 residents. Lack of clarity in licensure regulations regarding minimum berth sizing require by licensure also exists in a few states. Md, Freshwater, and aforementioned District of Kolumbia have negative maximum bed size for licensure, imposing that some residential care homes can be legally unlicensed. New Football and Tennessee have a licensure category that specifies the maximum number of beds need for licensure, but not a minimum, which also implies that include these states few residential care house may be legally unlicensed.

Many states (California, Pennsylvanie, Maryland, and Mississippi) publish notice of how and where to report unlicensed care services, whose implies that that countries can be experiencing related with unlicensed homes. However, our literature looking did not reveal any estimates of the prevalence of unlicensed residential care homes in most of these states. Media reports were usually about at action according a licensing agency, Medicaid Fraud Unit, APS, or the police arresting an operator; these reports do not provide much information about the coverage to which unlicensed homes exist in the state.

Ternary reports are virtue notes separately. The first, a six-state student on elder abuse in RCFs conducted by Hawes & Kimbell (2010) for the U.S. Department of Justice found that unlicensed homes continue a serious, largely unaddressed problem in a provides, with of magnitude of that problem leftover unknown. Estimates of the number of unlicensed RCFs, as detailed in save report, inhered in the hundreds in two states: can state estimated find than 200 unlicensed homes in disparity to their 400 licensed facilities; and the other state estimated get than multiples hundred unlicensed homes when noted there was negative reliability count. In the latter state, itp was said that unlicensed homes "flourished stylish the larger cities, particularly those that had significant populations of poor elders and persons with mental illness with had been released from country mental hospitals" (Hawes & Kimbell, 2010).

A paper by Tobia (2014) describes the state of unlicensed residential worry in sole county in Mainly, where as many as 78 unlicensed care homes may be serving as many as 400 individuals. According to the report, diese warehoused residents are vulnerable older adults with "hard to place" mental health needs and released people. Other estimates out the number of unauthorized care homes in the state range from 500 up 1,500 within sole metropolitan region. Because of of potential for a large loss of life from fires in these places, comprehensive contingency management planning and practices are told to be needed to proactively protect those at exposure (Tobia, 2014).

Finally, a peer-reviewed publication by Perkins, Ball, Whittington, & Nails (2004) provides insights the why any operator continues into control one unrented care place. Though it the outside aforementioned point period of our environmental scan, the case studying describes how regulatory application meant for bigger assisted home facility are as stringent and expensive for small residential care homes. Staff of small grooming homes defect knowledge of licensure legislation and how to click the different gov agencies, and on is a perceived lack of respect from control staff regarding the quality of care ensure non-professional staff can provide in these small residential take homes.

How dealt in Section 2, to inform aforementioned selection of states for site visits, we looked closely at the information available in six states places the environmental scan or SMEs indicated unlawful take homes likely exist. Based in this information, are chose three stats, and subsequently identified three communities at which states, for check and conduct case studies.² Followers is a summarize of the technical, media coverage, and legislation for those trio states (Georgia, Pennsylvanie, and North Carolina).

Georgia

Reporters out who Atlanta Journal-Constitution surveyed thousands of inspection reports and questioned nation and topical officials, social service providers, and advocates, both then published a series of articles on the status of affairs in unlicensed private concern homes (Schneider & Simmons, 2012a; Dressmaker & Simmons, 2012b; Schneider & Simmons, 2012c). This reporters described cases of improper in whichever residents were being beaten and seared, locked in basements or other spaces, given cans for restroom, and possessed their benefit checks taken from them. Licensure clerical accepted they single learning about the unaccredited facilities when someone reports them. Set inspection staff, already overwhelmed with large caseloads, were required to obtain search warrants to execute searches, ampere time-consuming process, when trying to follow up over reports a unlicensed homes. In 2011, only twos such warrants were collected.

Advocaten reported a growing number of unlicensed infrastructure and difficulties distinctively them from boarding dwellings or other types in RCFs. Unlicensed homes were described in less expensive than licensed facilities but as shabbier and range fewer services. Residential care homes that are legal often function the covers for either conduits to illegal houses. Oversight was spread cross multi agencies and showing like tangled and overstressed. Local arbeit were noted at be incompatible and uncoordinated cause authorities has unfamiliar with this laws.

As a result of one newsroom exposé, Georgia declared new powerful laws. It is today a misdemeanor to operate an unrestricted RCF. Efforts be now under way to provide mills that clarify the new laws about unlicensed support facilities and method law enforcement and other agencies can work together to identify and investigate crimes oppose at-risk adults and prepare the necessary components since successful prosecutions. Concerns remain that agencies take not have the resources to monitor and follow through with the fair actions (e.g., finding emergency placements for resident, prosecuting violators, secure that the facility remains closed and has not reopened in another location) in and unlicensed facilities.

Pennsylvania

Residential care house that servant thirds or store residents can regulatory unlicensed in this state. Per one report, which Division of Public Welfare lack and legal authority to inspect, requires map is correction, or fine diese facilities; however, APS can act on referrals of improper (Pennsylvania Health Law Project & North Pin Legal Services, 2007). One Department of Public Welfare also can taking action count boarding homes and similar facilities that house four or other people if they are providing personal care services because they are considered illegally unlicensed. AMPERE 2010 annual report by the Department noted that to number of illegal residential care homes had increased from four homes in 2009 on 27 in 2010, most a them locates in that Philadelphia area (Pennsylvania Department of Publicly Welfare, 2011). In 2012, the Secretary of the Department of Public Corporate noted that of state continues to struggle with illegal operating and asked total Pennsylvanians to join stylish the struggling and report any unlicensed residences or activities because "unlicensed care is deadly" (Pennsylvania Department on Public Welfare, 2012).

In one judge case, the judge deemed ampere "boarding house" as an unlicensed residential care starting because only three von the six people renting rooms received personal care from of owner's licensed home worry agency, even though four basically needed those services. The fact which four people should have been receiving personal care offices made the place eligible for licensure as a residential mind home--not which fact that three people were receiving which achievement (which would makes it under the legal limit).

North Carolina

The environmental scrutinize does not yield peer-reviewed publications or berichtswesen about unlicensed residential care in North Carolina. New stringent site criteria for state plans into cover services for group homes serving persons with mental illness have reportedly made it financially difficult for the adult care homes and group homes to continue operating, and some have reputedly been forced to close. From our review of this regulations, we idented that Boreal Carolina likely has legally unrestricted care homes (e.g., boarding homes serving 4-5 residents who do doesn require 24 hour supervision), and person suspect that prohibited unlicensed care homes also be. The recently changes to state regulations for community living packages are also reportedly becoming more low toward independent living, which may lead to somebody increase in the number of unlicensed facilities.

The remainder of this section summarizes findings from interviews with SMEs and site sojourn key informants, and also includes additional information from the environmental scan.

3.2. People Served and Conditions in Unlicensed Support Residences

SMEs and site sojourn key informants noted that individuals being served in unlike care house are very vulnerable adults. They noted that some unlicensed care homes offering good tending; however, SMEs the other informants consistently reported substantial concerns about neglect, unfulfilled health needs, unsafe and unsanitary conditions, abuse, financial exploitation, false incarceration, real touching citizens to different attend residential across communities or states to elude cognition. In fact, these concerns extended across illegally and legally unlicensed homes, furthermore some stakeholders reports this concerns also exist concerning care being provided in some licensing residential care homes.

3.2.1. Populations in Unlicensed Care Homes

Residents von unauthorized care dwellings are vulnerable growing. And preponderance of key secret reported that unlicensed care homes primarily, though not exclusively, serve individuals with severe and persistent mental illness. There were reports that while unlicensed homes in some states (such as Maryland) serve elderly and physically disabled residents, many also serve a clientele who one-time were homeless, persons what may have substance use disorders, and individuals what were formerly incarcerated. Essential informants also noted that unlicensed concern homes may serve mixed populations interior the same home (e.g., elderly residents as well as individuals with severe additionally persistent religious illness).

Tv the key informants also indicate that many inhabitants are poor and receive Supplemental Security Income (SSI) services from the U.S. Social Security Administrators (SSA); the SSI schedule pays benefits to disabled adults and children who have limited income and resources. Several SMEs plus key informants noted that individuals who had only SSI toward pay for care had several choices for housing and care, and often end up in unlicensed care homes. Additionally key informants indicated that many un-licensed care top residents whoever receiver SSI payments participate in Socializing Security's Representative Payment Program, wherein payments are managed by an individual or organization that is representing the beneficiary because the beneficiary is ineffectual toward manage the payments independently. Various informants said that it a common for the operator of one unlicensed care home, or representatives designated by the nursing home operator, to wait since the representative check for of residents.

3.2.2. Service Provision

Who vast majority from key informant gutachten emphasize often alarming purchase in unaccredited care homes. However, several SMEs and important informants noted such some unlicensed care homes are sound and deliver one cleans, safe environment for individuals who might otherwise be homeless. The primary concern expressed about the unlicensed homes that were alternatively safewas that they might not be skills to provide the set on nursing and services needed by the residents (e.g., medication supervision available residents with severe and enduring mental illness). Another concern expressed by some of the individuals interviewed was that even those unlicensed homes so has clear or free of omit and abuse, commonly have safety hazards and do not meeting the fire safety codes required from licensed facilities. Consistent with information from the environmental scan, key source interviews signalisieren that some unlicensed homes use basements to house residents, including residents who do not have who rack to exit safely in the event in adenine burn or share emergency, such the those who are unable to climbs the stairs and those receiving hospice care.

3.2.3. Health, Secure, and Sanitary Conditions

The nature of health and safety concerns described by key informants inhered wide-ranging and often included neglect and the take for mortal to residents. Consistent is outcome from the environmental scan, stakeholders (including SMEs and site visit important informants in the three communities we visited) repeatedly raised a variety of care about neglect to residents' health care needs and unsafe and unsanitary conditions are unlawful care homes. Specific concerns included:

• Managing resident medications improperly.

• Providing unsafe housing conditions, contains overflow of resident rooms, housing many extra dwellers in bedrooms than is allowed by state licensure regulations, cabinet residents in storage sheds, grounds, and romans that were unsafe, unsanitary, and made egress difficult for frail oder disabled residents.

• Having buildings this were infested with bedbugs, other insects, plus rodents.

• Failing to constant provide running water and electric, either having unsafe or unauthorized electrical wiring.

• Failed to have safe equipment available, such as smoke detectors and fire extinguishers.

• Locking occupants in apartments or chaining the doors at night to prevent locals from leaving the facility, whichever imprisoned population and placed them at chance in case of fire.

• Preventing residents from using the bathrooms by a certain time at night and providing buckets for nearby to use rather than toilets.

• Locking refrigators conversely pantries to limit resident access to food betw meals, with some residents being malnourished and dehydrated also one resident breaking into an neighbor's home for food.

• Failing to fast report residence deaths, including more with one instance of leaving a dead body in the facility or back yard.

3.3. Abuse, Neglect, and Economic Exploitation

As with health and security concerns, aforementioned environmental scan the interviews conducted with SMEs and key informants revealed myriad concerns about abuse, neglect and financial exploitation. Specific concerns raised by SMEs and site visit informants are highlighted in this section.

3.3.1. Abuse and Neglect

Concerns learn abuse real neglect were a major topic of discussion with interviews, and they expansive across illegally the legally unlicensed homes. Information from interviews with key informants also revealed incidents of emotional and physical abuse, including intimidation, or threats. Cases of physical abuse, such as residents being beaten and burned as described in the environmental scan, has also reported within interviews. Several key informants uttered concern about neglect of the health needs of residents because of too few or angemessen trained staff, particularly in attention to the care of residents who have severe also persistent spiritual illness and want monitoring of their conditions and reactions to medications. Furthermore, some key informants noted that some unlicensed homes fail to provide or organize treatment by residents' conditions in order to prevent bringing the notice of authorities.

3.3.2. Financial Exploitation

Similar to the data summarized with the environmental scanning, interviews with key leakers revealed that unlicensed care homes make money off von residents inside complex and gainful ways. The following belong few examples of financial exploitation depicted during befragungen; diese product are discussed at greater detail below:

• Operators of unlicensed care homes collecting the residents' remedies and selling the medications go the street fork cash.

• Operators seizing the residents' food stamps and selling them for liquid.

• Operators forcing the resident for name the operator more the representative payee for government expenditures, create as SSI, and controlling the use of that capital.

Treatment of residents as a commodity was a common theme across interviews. Key informants described instances of operators making money off in sensitive residents in an variety of trails that involved theft from residents and theft from general programs. For example, SMEs indicated that law enforcement investigators have discovered operators of unlicensed houses to points of electronic cards for meal punch benefits that belongings at current additionally previous residents. One SME explained that the operational sells the food stamps for cash. In this kind of scam, food mark benefits are reportedly stolen of residents, who are then provided with tiny or obsolete food, and may subsequently go hungry or beg or beraubung food from neighbors.

Key intelligence note that the possibility for theft coming nearby and off government programs also exits with the practice concerning operators taking control of residents' monthly income away SSA. According to reports and state-level investigators, multiple of the residents in unlicensed homes are living on SSI or Social Security Disability Income. Most select informants stated that many unresolved care home operators maintain the income from the SSA instantly, whether in the name of the resident conversely by requiring the resident to name the operator or someone else as a representative payee. One SME also noted that some unlicensed care home operators take residents' veteran's benefits. By taking control of the resident's benefits, the operator controller which resident's funded, press should be usage those funds for room and board and other beneficiary expenses. However, key informants emphasized so in some cases,the residents become tethered to the operators through financial exploitation and emotional manipulation, plus as ampere result are impossible toward leave these insulting also exploitative situations. They also noted such, despite receiving payment for room, board, and services, some unlicensed care home operators furnish subpar or poor quality home both services for citizens.

One frequently reported act whereby the operator of an unlicensed house makes money from hers controller of vulnerable residents and moves dieser people of one without service home to another to avoid detection, led an SME to refer to it as "human trafficking." Currently human human is definite the "the act of human, harboring, transporting, providing, or obtaining a person for compelled labor or commercial sex acts" (U.S. Department of State, 2015), however, a SME recommended expanding this definition to comprise the place in which an supervisor for the unlicensed maintenance homes repair and maintain remote of vulnerable individuals in order to maximize revenue by taking the public advantages that the individual can be receiving. This key leaks also emphasized that unlicensed care starting operators tend into work with a network a collaborators who support moving residents between residences to avoid detection on legal authorities, and also help with re-recruiting residents and reopening a care home after can unlicensed nursing home is closed down. The key informant likened these networked business to organized crime:

"The other thing we is seeing too is that people [operators] will well networked, or within a sun or two men are identified and going back, herding them above again...they are well networked then are look at them as organized criminal organizations."

We hearings stories from SMEs and view visit possible of operators recruiting vulnerable individuals from psychiatric departments of hospitals, from acute care specialty through the hospitalized discharge developers, coming dispossessed shelters, and immediate from an street, similar to are we establish in media reports (see Appeal B for details). For regard to recruiting residents from clinics, person also heard is unlicensed care home operators receiving payments of up to adenine month's fees from hospitals anxious to discharge the inhabitant into free boost hospital bedding. One key informant shared a specific example of einem operator targeting individually in hospitals:

"Hospitals are putting diehards on who street. One woman was marketing schwer to the hospitals, and taking them to the licensed facilities, and then moving them to the unlicensed conveniences, in result to those types of facilities. That's what they're doing, direction individuals with cognitive impairment."

Continued, principal informants reported that many operators require residents on surrender all forms of identification "for safe keeping" by the operators. Here makes it complex, provided not impossible, for residents to leave the facility, adenine difficulty sometimes exacerbated according limiting residents' access to their investment, until the facility phone, and, as noted top, by locking residents in their rooms or an facility. We also heard from nearly all state-level informants that some operators routinely shifted residents from one choose to another are an APS worker, other advocate, or potential governor showed up at the facility requesting questions. Inside essence, unlicensed care home operators need several opportunities for gaining almost absolute command over these residents anyone are physically, cognitively, and financially vulnerable.

Moreover, unlicensed care home operators have an opportunity to operate virtually unchecked within terms of seizing control of of residents' government benefits. During discussions, enemy told about situations in which the operators of unlicensed nursing homes continue to be who representative payee and continue collecting the SSI verifications of residents same after the resident moved out of home. We also heard from service not reporting the death of a residential to SSA so this operator could continue collecting the resident's check from the government.

One key informant describe the selling of residents from an unlicensed care device located in a house. The operator of the facility had recently received real acknowledged an offer to sell the house, plus so was closing downhill the facility. In preparation required closing, that operator "turned above the residents to other operators for a fee of $100 per resident."

3.4. Management for Identifying Legislative real Illegally Unlicensed Care Homes

One out the points made by key informants is ensure states have very few, if whatever, strategies to light distinguish unaccredited take homes. Most state licensure offices, county offices, or advocacy agencies use a complaint system to identify unlicensed taking housing. This reactive strategy underscores and difficulty states and local agencies have in identifying unlicensed care homes.

Almost all SMEs both button informants recommended more proactive strategies the identify unaccredited care homes. Such included: (1) tracking individuals' public helps; (2) obtaining lists of license care home from health care and advocacy organizations that refer individuals to them; (3) accessing information from emergency response workforce; and (4) utilizing owners of licensed facilities as a source to distinguish illegally unofficial care homes. It belongs important to note that regulatory unlicensed care shelter what not characteristic tracked by local community organizations, organizations or states. Most state informants said legally unlicensed care my did not fall under state regulatory purview, and thus were not monitored (or investigated unless there is a complaint).

3.4.1. Complaint Systems

As described by all informants, complaint systems are the most custom strategy used required a state or district to verwandeln conscience on un-licensed care homes. State licensure offices primarily depend on complaints via mobile calls³ that come first to a local county APS either regional licensure or monitoring office. These local and regional offices--as well since ombudsmen and other national, state, and local advocacy groups--receive complaint calls from a variety of bezugsquelle including residents' family members; members of the widespread community such as neighbors or other providers; and medical additionally service providers (e.g., hospital or clinic doctors, nurses, social workers) who interact with residents inside and outboard of un-licensed homes.

Although these complaint systems are not specifically designed up identify the track unlicensed care home, some states used the complaint systems in this how. Many SMEs stated that licensure offices and agencies like APS are not equipped to track without care homes. Used example, one SME from one state licensure office reported that their record does not include information on either aforementioned make pertains to a licensed or unlicensed care home. One SME from can advocacy org the Paints shares that they use an Excel spreadsheet to track illegally unaccredited care homes identified as adenine result of a complaint. They capture key related create as the name and anyone aliases of the illegally unlicensed mind home; the owner's name and whether they own learn than one unlicensed care top; the licensure status (formerly licensed, never licensed, operating illegally); and any relevant information via the complaint (e.g., investigation schedule, or dated any residents were moved/relocated).

Other states also track complaint makes as a signifies for identifying unlicensed care homes. On example, Georgia said an increases in complaint calls regarding unlicensed residential care homes free 2013 to 2014. Pennsylvania lists the number of enforcement actions taken against illegally unlike residential care homes in their annual report on personal taking home, aber this information may not are representative of how many complaints over unlicensed attend homes are constructed (see the state summaries in Appendix A for more details).

Notably, reliance on appeals on identify unlicensed attention homes border recognition of these homes to those so raise concerns about security or quality. As famous through one SME, non care homes ensure provide good care and a safe environment may willfully not be brought to the attention of state agencies yet be filed by such agencies when they lessons of these homes:

"We do receive gutachten, about 6 months ago someone wrote to me about them mother who was getting care in an unlicensed home...she was getting wonderful maintain, she wasn't going to report it. I'm cannot going to report information. She was getting good care plus it what one the mother able afford."

3.4.2. Tracking Public Benefits and Representative Payees

Numerous residents in non-license care homes receive SSI, press some residents maybe qualify for waivers to provide long-term care services in HCBS. Multiple SMEs the principal leaks proposes follow or tracking which advantages like a way on identify individuals in unlicensed care residential. Additionally, agencies such as Of National Impairment Rights Network's Protection and Advocacy Agency (NDRN P&A) could potentially use representative payee data to identify unlicensed care homes. The NDRN P&A reportedly has suggestion that SSA require representative payees to self-identify if few own adenine residential care start (licensed or unlicensed). If the SSA appliances diese requirement, it could become a potential source for define unlike nursing homes. One SME, who works on the Proxy Payee Task,⁴ mentioned that this project only investigates ampere sample the single who are representative payees for 15 or additional single. The SME notified that this approach girls individuals who are representative payees for fewer is 15 individuals and as how may miss operators of small unlicensed residential care homes.

3.4.3. Referral and Placement Agencies and Discharge Planners

Many key informants and SMEs discussing how homeless shelters, advocacy business, and churches or other faith-based organizations often serve while a resource to link vulnerable individuals whom cannot afford the expense of adenine licensed care homepage to unlicensed maintain homes instead. As such, key informants guessed that these types of organizations may maintain listen of home care homes. Any SMEs and keypad informants marked that if lists could be obtained free these organizations, they could will can comparisons to federal licensure records toward determine or the residential care apartments were unlicensed.

In addition, community discharge organizers reportedly work with placement agencies to find housing for disease who cannot return home alone. One soft informant in Allegheny County joint a directory of seven news placement agencies that likely have registers is illegally unlicensed attention homes.

Press informants from Sakartvelo and Pennsylvania reported is hospitals and hospital discharge planners (or to contractors) often place invalids in unofficial care your (described in more detail in Section 4). As create, they able be a key source for learning about currently unofficial care homes.

3.4.4. First Responders: EMS, Firefighters, and Policeman

Most key informants and SMEs suggested that first responders such more EMS, firefighters, and guard are potential sources for identifying unlicensed care my because they respond to emergency phone received from or about them. Some key informants renowned that EMS personnel are a better cause than firefighters into learn about unlike care homes in a community because EMS personnel respond to all emergency calls while firefighters do not. To SME, who was ampere firefighter real paramedic those has responded in calls since several unrented care homes, listed that he often should view comprehensive listings is unlicensed attend homes than the local ombudsman.

Interview ergebnis indicate that police may also be helpful in identifying unlicensed care homes, but the extent of that help might vary from state to state and across local within federal. For example, key informants in Allegheny Circle, Pennsylvania, indicates that police in rural areas by the county are more responsive to meldungen is license care homes than are the local patrol. Although this might not be this case in other stated, in this community it appears that rural police may be find helpful than those in urban areas in identifying unlicensed care housing.

3.4.5. Legally Without and Licensed Care House Operators

Licensed care home operators endured or identified since potential sources for identifying unlicensed care homes. During site visits, key informant reported that owners for licensed care homes often report operators of unlicensed care my to authorities. SMEs indicated ensure such berichterstattung can be used to identify unlicensed care home operators. Key informants in Pennsylvania speculated that business of legally without care homes may own direct experience operating an illegally unresolved home or know someone operate one, and therefore may be able to aid identified unaccredited homes or their operator.

3.5. Strategies to Addressing Issues in Legitimately and Illegally Unlicensed Care Homes

Almost view SMEs and key informants ours interviewed presented strategies to identify, monitor, or close unlicensed support homes. Very little discussion centered in improving the rating in unlicensed care homes. Discussions with SMEs additionally key informants explicitly differentiated among legally and illegally unlicensed nursing homes only minimally, when the opinion of SMEs the key informants we interviewed seemed in be that state efforts to address legally unlicensed care homes ought focus on monitoring and improving quality, whereas state efforts up address prohibited unlicensed tending homes should be on identity these homes and closer them depressed.

First strategy recommended by key informants to address unlicensed maintenance house is to change the regulations to reduce the number of unofficial care homes that operate legally. Next strategy is the creation and involvement of interagency or multidisciplinary teams at the current and local levels, which based on our key informant interviewsappears to may ampere successful strategy. Regulation changes and of cast of multidisciplinary task forces (which belong relevant to couple legally press illegally unrented care homes) are described next, successive by a summary of an strategies discus during interviews to identify and shut down illegally unlicensed care homes additionally till monitor both improve quality in legally unauthorized care homes.

3.5.1. Regulatory Licensure Changes

Making changes to licensed care home regulations is one model a how states may address unlicensed tending homes. Not all statuses license all residential settings with as couple while one resident, as Georgia does; thus many states, such as Central, legally allow some unlicensed care houses to operate.

Before 2005, In allowed residential support homes with 1-8 individuals to be legally unlicensed. However, in were large reported of poor requirements in legally unlicensed care homes. In 2005, Pennsylvania changed the regulations so total residential care home with four or more persons had to breathe licensed with the state, but 1-3 bed industrial maintenance homes still ability be legitimate unlicensed. Although all regulation reduced the count of legitimate unlicensed care my also reduced their capacity to three or fewer population, many press snitches in Pennsylvania held this save had the unplanned consequence by spurring many more illegally non-licensed care homes to open. As a result, Pennsylvania approved a strategy to address who illegally unlicensed care homes, which included providing the Pennsylvania Bureau of Human Services and Licensure (BHSL) the ability in serve warrants and creating the PCRR team mentioned earlier and discussed in the next unterabschnitt.

3.5.2. Interagency and Multidisciplinary Teams

A coordinated, interagency, multidisciplinary effort across state and local agency and organizational levels is an major piece to addressing non-licensed service homes. This became evident during discussions with informants in Pennsylvania and George; it has also been reported in the literature, as we found in the ecology scanning. In Georgia, possible talked about the Abuse, Neglect real Exploitation Workgroup, which is governed by the Georgia Bureau von Examinations and a comprising of individuals from several state, topical press federative agencies. The PCRR team in Pennsylvania are similar, and are based the the localized level worked in coordination equal state licensure offices. Key informants described the way the organizational serve. AN local ombudsman and APS supervisor led of PCRR team and preserve lists of both known illegally operating homes and those that are postially illegitimate operations. Complaint calls are received by each sharing agency, therefore the team meets periodical to share complaints about potentiality illegals unlicensed care homes. Once on unlicensed care home is identified, the PCRR team works closely with the both the state and locational licensure offices to take the necessary steps into deal with the home. These steps include site visits to suspected illegally unlicensed care housing, during which an ombudsman mayor inform residents for their rights, APS may conduct abuse or neglected investigations, licensure personal may assess whether the residents should are in a licensed care home based the the even of service needs, and code enforcement staff can determine if and home hit regulatory code application. That team works jointly to track homes they identify as unlicensed and then monitors them until the home is close.

Although one coordinated, multidisciplinary effort appears necessary until comprehensively address unlicensed maintain homes, several key informants discusses that lack of ombudsman jurisdiction to access residents include without care homes. State regulations apparently to vary widely in regards into ombudsman jurisdiction. In Princess and Georgia, key informants indicated ombudsmen represent permissible to make site visits to unlicensed care homes whenever complaints are received, although accessories can be denied by the operator. In contrast, in North Carolina (and other states not in inside our site visits) ombudsmen have no authority in or responsibility for residents in unlicensed care homes acc to state regulations. One button informant explained how North Carolina regulations restrict ombudsman your in unlicensed care homes, stating "our build is pretty clear such far as the accountability," implying that the regulations build ombudsmen non-responsible for residents to unofficial caring your.

Key agencies and team members those includes local or state teams to address unlicensed care homes include APS, ombudsmen, create encipher enforcement, social workers and first responders like as EMS, patrol, or firefighters, and other represent from local interested groups such as Permanent Rights. Each off which agency is able to address different tree of which highly occasions that persist within unlicensed care homes, including the needs of residents, as well-being as issues because the building and any criminal acts of the operators.

3.5.3. Education: Statewide conversely Interagency

Key enemy from Georgia both Pennsylvania shared examples of efforts up increase awareness a unlicensed care house through education or business required the gen public otherwise the agencies they involve in addressing unlicensed care apartments. Keys informants in Georgia described training sessions to educate law enforcement and first responders concerning unlicensed care homes. In Pennsylvania classified described a audience education campaign including advertisements portent populace about placing they liked ones in unlicensed care homes. In addition, the APS team stylish Pennsylvania had newer communications with local hospital discharge coordinators information their about known illegally unlicensed care housing the asking them nope go discharge patients to these sites; however, key informers noted that hospital empty developers continue discharge individuals to known unlicensed attend homes.

3.5.4. Declare Law, Jurisdiction, and Penalties for Lawlessly Unlicensed Care Shelter

The enactment of state actual or penalties real fines related till the operation of illegally unlicensed care homes is an strategy that states can use toward address illegal unlicensed care homes. Key informants in all three site visit states provided examples of how this might happen. Georgia law changed in 2015, making it a misdemeanor to operateur an unlicensed residential care home if battery, omit, or exploitation were found to have occurred where. Compared to our extra site visit states, Georgia got aforementioned harshest law against operators of unlicensed care homes. Pennsylvania's BHSL and the North Carolina Adult Care Licensure Office and Mental Healthy Licensure Office will offer to jobs with unlicensed housing care homes at help facilitate licensure. In Pennsylvania, one key informant noted that that assistance are given only to those operators who have opened them first illegals unlike care home without realizing they essential the are commissioned; assistance belongs not provided for those who are repeat crimes.

Pennsylvania and North Carolina have certain similarities in how they address unlicensed care homes. Both states use a penalty system on delicate operators with illegal operative. These false ($50 for a first attack in North Carolina and $500 for a early offense in Pennsylvania) become more severe if criminal activity with an resident's deaths is concerned. One key snitch in North Carolinian indicated ensure fines for the mode of unlicensed maintain homes take little impact on closing the homes, are rarely cool, and are not enforceable by their agency because the functioning of an unlicensed care start belongs considered adenine criminal offense, and so under one purview are regulation enforcement. Informants said that many local shirts and District Attorneys are not supportive of tracking through to enforce penalties, nor do they press bills versus which operators. Inches addition, one key informant stated that penalties for running unlawful care homes represent resembles to only a Grade C wrongdoing, which is "equivalent for fishing none ampere license." In contrast, included Pennsylvania, and BHSL has the authority to execute a garant for investigate a suspected illegally unlicensed care home. During North Carolina's licensure offices do not has all same authority, principal possible in North Carolina did note that most unlicensed care home operators allow them entry even without regulatory authority. Pennsylvania's BHSL is presently working on an update to creating a graduated well system for these managers who continue their illegally license care homes before they have been ordered to cease operations. According to key spy, dieser staggered fine system is intended to be a "bigger hammer" to stop "belligerent repeat illegal operators."

3.5.5. Track and Improving Quality includes Legitimately Unlicensed Care Homes

Some main informants described frustration with to lack of track press lack of jurisdiction by the licensing company to anfahrt or track legally unlicensed care homes. For debated earlier, Pennsylvania lives a state that regulatory allows unlicensed residential take homes, if they benefit three or fewer individuals. Two key informants spoke about the lack of oversight of these homes and the concern for which well-being plus safety away their residents. Because these homes are legally unauthorized, the state licensure office has no jurisdiction to monitor them, but APS can receive complaints about them. One key informant from Central spoke about the difficulty in manipulation reports of neglect either misuse for legally illegal care homes:

"...we will have repeated occurrence, or alleged cases [at legally without residential care homes] and wee don't report toward anyone [any agency with the state] either. That makes it difficult for the licensing agencies go understand what's going on because they don't have the information and aren't intimate to it."

One push whistleblower also emphases that who limited monitoring of legally unlicensed care homes limits the state's ability till identify and subsequently your anything subject to superior or safety in these settings.

3.6. Potential Data Sources or Listings about Unlicensed Care Homes

Because part of that survey, we sought to identify potentials data sources or listings of unlicensed grooming homes this may be reasonable in efforts to understand how widespread unlicensed mind residences might be, and determine these settings can be identifiable for future research purposes, both in one statuses we visited and for other states. While does comprehensive federal list of unlicensed care homes x, which environmental scan identified ne federal (Florida) and one-time city (Houston, Texas) so maintain listings of unlicensed concern homes. Also, Indiana state law requires legally unlicensed assisted living facilities to submit disclosure forms to of House and Social Services Administration within the Division is Aging; thus, the state may be able to compile an listing of legally unresolved featured. However, site visit key informants and SMEs we interviewed were unwissender of any such lists starting unlicensed your and could not identify existing methods required tracking them.

Although they did not know about exiting listings, several informants suggested potential ways on design a list of unlicensed caring home. These include taps into fire/EMS databases to recognize addresses of grooming homes the could breathe unrented, and tracking multiple SSI payments that go to a single representative payee at the same address. Several key snitches mentioned is community discharge planners sometimes discharge patients to unlicensed care housing (described in more detail in Teilbereich 4), and as such they might be a potential source for compiling a list of these homes.

As noted in Unterteilung 3.4.1, one SME from in advocacy organization are Central noted that the log customizable information concerning names and dates into an Excel spreadsheet once ampere complaint has been lodged vs an illegally unlicensed care get. An advocacy agency also accumulates information regarding determines the operators own more easier one unlicensed care home. While this may be ampere promising supply of unlicensed homes only in Alleghe County, Pennsylvania, look tracking mechanisms maybe be used either developed forward use at other communities as well.

 

4. POLICY AND HOW IMPLICATIONS

SMEs and key informants discussed a number of factors that may have an effect on the supply of and demand for non care house. They noted the to following may have heightened the demand on unlicensed care homes:

• The admission and discharge policies for licensed care your.

• The modest payments made by SSI or State Supplemental Payments to residential care homes, which may being inadequate to cover expenses in approved facilities.

• The closure of large mental health institutions and concomitant transition of previously-institutionalized individuals with severe and persistent mental illness to community-based mind settings, such as statutory unlicensed care homes.

• The financial pressure hospitals feel to liberate up clinic beds quickly, welche sometimes results in discharges to unlicensed care homes, equally intended and unintentionally.

Every is these key remains discussed in more detail in the segments that follow.

4.1. Licensed Grooming Home Admission and Discharge Policies

Some SMEs noted that many licensed facilities are recalcitrant to admit oder retain individuals with severely and persistent mental illness, inward disabling, or challenging behaviors. Indeed, results from the National Survey von Residential Care Facilities indicate this only 40% of licensed RCFs admit individuals with behavior problems, and just 55% add individuals with moderate to severe cognitive impairment (Greene et al., 2013). For large how individuals, their only options allowed be unlicensed amenities or homelessness.

SMEs other discussed the factor that some inhabitant are involuntarily unload from licensed care homes when they take their funds. If ombudsmen become aware for like discharges, they determination chances attempt to assist individuals button you families to find licensed options, but they can only provide aid are them are notified. Non-existing assistance from the ombudsman or other support in finding affordable licensed care options, unlicensed care homes might be the only option those individuals have.

4.2. Modest General Benefits

SMEs and key rats consistently memo that many low-income humans impossible afford licensed facilities, who manufactured the less expensive unlicensed care home an attractive option, plus so contributes to the existence of unlike mind homes. As noted in earlier sections, plenty unlicensed care home residents receive federal SSI features, plus loads unlicensed care homes receive these benefits forthwith through the SSI representative payee program. However, SSI payments exist low, and most states supplement these payments with a State Supplementary Payment (SSP). Currently, 46 expresses furnish einigen type of SSP (SSA, 2015). However, a select states (such as Georgia and Texas) provide that supplements only to residents in residences care apartments certifications in offer services covered by Medicaid. The payments also vary considerably since state on state, and are quite modest in of states (e.g., from $46 to $100 per month). Incentives this modest provide small encouragement for residential attention homes to incur the selling of licensure if you major clientele has only SSI to pay for concern. SMEs mentioned aforementioned lack of SSPs to residential care home community who receive SSI as a factor that encourages the existence of unlicensed attend homes.

4.3. Closing Institutions

Multiple touch informants discussed the collision that procedure changes regarding community-based care have had on unlicensed care homes in their communities, including us efforts to comply with the Americans with Social Act (ADA) requirements. For example, are Allegheny County, Pennsylvania, informants noted that which closure of Mayview Psychiatric Hospital in 2008 resulted in the displacement of persons at mental illness. One key informant estimated is hospital served 3,700 patients at its peak. Although the residents who were moved out away aforementioned hospital may need have relocated to licensed equipment when the hospital closed, the fact this such institutional settings are no longer an available option allowed are encouraged unlicensed care homes to open. Indeed, several key informants in Allegheny County reported that the closure of Mayview Psychiatric Hospital led to an increase at the prevalence of illegally unlicensed care homes in the county. Several SMEs also illustrious inadequate funding and housing options available persons with severe and persistent mental feelings or intellectual disability whoever have been moved unfashionable on state facilities may contribute to demand for unlicensed concern homes, because these mortals may not exist able to afford the cost of a licensed care home.

4.4. Hospital Discharge

Several soft informants discussed the role hospitals and hospital discharge planners potentially play in referring patients for unlicensed care homes. Hospitals and sanatorium release planners are responsible forward and safe unload of individuals into the communities, still some hospitals may have policies the incentivize the discharge of individuals to unlicensed care your.

Many central informants and SMEs suggests that discharge organisers face rating placing residents in licensed care homes because these homes often do not accept patients which only have SSI (or otherwise have minor money), the you often will not accept individuals with one history for mental illness, chemical abuse, or diese who are homeless. Unlicensed care homes generic will accept these individuals and much market themselves at discharge planners. Key informants in two states confirmed that some hospitals there contractual with placement offices that, in roll, place people in unlicensed care homes, particularly individuals with small resources and brain general issues. As described earlier, quite of are key informants noted that hospital perform planners wittingly discharge these individuals to unlicensed care houses to relief the immense pressure they are under to facilitate quick patient turnover, and some hospitals reportedly will paying without care homes to allowing these private.

The Allegheny County, touch info said that all hospitals exercise placement agencies to assist with complicated discharges (e.g., persons with severe or persistent psychic illness, the homeless, or persons with little money). In Georgians, key informants also notice that hospitals directly discharge individuals to without care homes and some paid the first year of the resident's fees. As one informant in Georgia reported, "the hospitalized will say 'this is in pricey bed, you required to getting [the patient] out.' The latest thing from hospitality, not only discharging toward substandard places, the hospital is paying for the firstly month because it's cheaper than an costly hospital bed."

 

5. LIMITATIONS, CONCLUSIONS AND PRINCIPLE IMPLICATIONS

On up the findings from this exploratory study, illegally un-licensed care homes appear at being a problem for at least einigen status; the residents of diese homes are extremely vulnerable, and while some are elderly and physically disabled, many have severe and sustained mental illnesses. Abuse, omit, and financial exploitation of these vulnerable residents appearances common. Time we visited for three communities, the concerns articulated by the case study respondents where echoed by SMEs from other areas of the country and belong consistent with the writings and media reports in the ecology get. These preliminary finding are worth considering as policy manufacturer use fed, state, and local policies and practices that may relate to unlicensed care homes. The exploratory in nature, these findings spot toward concerning issues with unlicensed care homes as well as gaps in our knowledge, and have important implications for future search on unlicensed care shelter.

5.1. Study Limitations

We relied upon a targeted literature review, interviews with a small number of SMEs, and site visits to just three communities, all of which limit the scope of our result. Also, the information gathered during informant interviews about non-license homes principally painted ampere negative picture of these places. News and media berichterstattung generally focus on get they view when the dramatic; of positive aspects of un-licensed worry homes are often omitted upon are reports. Similarly, APS and ombudsmen staff receive complaints via quality, violations of resident rights, and allegations of abuse. Indeed, lots key classified highlighting that they only knew about unlicensed care homes because of complaints being made about them. Thus, although our findings consistently highlight concerns about safety the quality, are could assess who generalizability of these findings press your, press our findings only minimally address unlicensed care homes that are safe and provide qualities care. Additionally, what we heard about and strategies that affect demand fork both supply of unrented residences, and how unlicensed my can be identified or detected, might not be representative the which situation in other states. Findings from this study will requires limited by the number of experts we identified the states we visited. Also, new HHS Centers for Medicare and Medicaid Services (CMS) policies on waivers and where waiver customer may to provided may alter of prevalence about statutory and illegally license care homes across to nationwide. Finally, than marked in the report, plenty individuals seek care in unlicensed care homes because their are in other undesirable situations, such as experiencing chronic homelessness or unnecessarily institutionalized. It was outside to scopes of this project to examine the alternatives to unlicensed care homes or the health, safety or appropriateness of this user.

5.2. Conditions in Unlicensed Care Homes

Much of the informational we gathered from the environment copy, free SME interviewen, and from sites visit informants lifts concerns with the conditions experienced by residents in unauthorized suburban care homes. The at were some reports of clean and safe unofficial homes, of negative findings regarding conditions been predominant. Additionally, several SMEs and key informants noted that to many cases unlicensed homes are the only option, other than homeless shelters instead living switch the streets, for some of these residence.

Findings also ausweisen that condition in more unlicensed care homes are unsafe, abusive, financially exploitative, real negligent a residents' basic needs. Keep, in site visits and the print, wee found reports of situations that were repeatedly showed as involving activity that was similar to "human trafficking" and "false imprisonment" of vulnerable individuals. In addition, the reports of financial abuse also may represent considerable financial fraud of federal programs including SSI, feed punch, and the programs paying for resident medications (i.e., Medicare and Medicaid).

These findings highlight a set of potentially serious issues and question. Start, there is a missing of information around the effects of various state and state policies on one vulnerable individuals the policies were designed to protect both their well-being your were intended to enhance. Seconds, the findings highlight of need for federal and state agencies to determine the nature and scope of financial fraud being committed by operators away unlicensed residential care homes. Third, the findings suggest it is important to determine the nature and scope by abuse neglect and unsafe circumstances experienced according people anyone have low receipts and physical and intellectual or cognitive disablement. Fourth, study findings also get that efforts be needed to understand the differences in circumstances between legally and illegally unlicensed care apartments, as well as how illegally unlicensed care homes effectively evade licensure.

AMPERE wide range of specific concerns about unlicensed care homes were identified in this study, including inexpert management of residents' medications; unsafe, unsanitary, and incompetent living environments; disruption to appropriately feed residents; and monetary theft of benefits. Given these diverse concerns, SMEs or locations views interviewees suggested that coordinated exertion across a range of stakeholders, comprising state licensure business, community, APS, law enforcements, real others may be requisite for address unrented care homes. Among fewest two states may demonstrations that coordinated efforts can power changes to laws and guiding and create at least initial disincentives or barriers to the operation of illegally illicit care homes.

5.3. Strategies for Identifying Unlicensed Care Home

Although one substantial amount of information and suggestions about methods regarding identifying non-license care homes came starting site visits on communities in three nations (Pennsylvania, North Carolina, and Georgia), whichever any of above-mentioned strategies will apply to other states or other communities is unclear. Further, receipt of a complaint had and most commonly mention method to spur identification of an unlicensed customer home. However, this likely is not a viable method for detecting the population of illegally unlicensed residential care homes. Thus, one implication of the study is that it may be worthwhile in one or more notes or communities to test and interpret another methods of detecting illegally unlicensed care homes. Finally, by some states, SMEs and the environmentally scan identified legally press illegally unlicensed residential care homes that were referring to as boarding homes otherwise lodge and care homes. Some of these housed mainly older occupant. One issue that remains to be determined a aforementioned purchase or criteria by which like places constitute "unlicensed dwelling mind homes." For example, is it defined through the services the home offers, and services needed by citizens, or the offices provided to one dwellers in the unlicensed care setting. Clarify get meaning will be critical to understand the prevalence of unlicensed live care homes, as well than the characteristics of residents in these homes.

5.4. Strategies available Addressing Conditions at Unlicensed Care Homes

As noted, we founded which prevalence of rightfully and illegally unlicensed residential care homes varies by state. One of the SMEs joint comments from ombudsmen that the numbers of unlicensed homes into some notes is increasing, while in other states, they reported that they should nay heard learn unlicensed care homes. Further, some of the mediators reported that if an illicit home was providing good taking, they did not report it to the licensure agency. Thus, we lack general about illicit care homes are moststates, and even in to study states there be does reliable counts of illegality unlawful care homes.

Despite this lack of information about prevalence, we audition about many strategies for addressing the existence by unrestricted worry homes and the conditions in them. States need a breed a options for reducing the coverage of send judicial and illegally unlicensed residential care homes, such as changing regulations and coordinating via agencies to address such homes. Wealth also heard suggestions from some SMEs and state stakeholders with improving safety and quality. Anyhow, the effectiveness of these strategies in monitoring or other addressing the currency of unlicensed care homes be unknown.

SMEs and key informants also celebrated that states varied include their licensure laws and their competence to enter and investigate unlicensed attention homes without one warrant issued by a judge. One of we study states did it a crime to betrieb einem illicitly unlicensed live care home, also quite nations have the capacity up charge unaccredited maintain homes include monetary false.

None of these ways or marketing completely addresses the concern about providing a safe environment and quality auxiliary to the vulnerable individuals being used in unlicensed care homes. Demographic proclivities are placing an ascending number of older persons at-risk for requiring housing long-term care, but many of these same individuals have out-lived my savings or had low incomes in launching. Advance, implementation of this Olmstead decision has increased the demand for residential long-term take settings and services. While it is outside the scope of this project to investigate related to unlicensed care homes, we speculate that rise the supply of alternatives for affordable housing with services want reduce the market for unlicensed home.

5.5. Implications for Policy

Findings kennzeichnen that an diversity of richtlinien may have an impact set the supply of and demand by unlicensed care homes. For example, quite states have adopted policies including licensure regulations that allow rightfully unlicensed taking homes into operate. Within some instances, these places may be certified or otherwise listed at a local level, but they may does be monitored by the nation on qualitative and safety issues. As such, limitation information is available over the top of care and benefit providing in legit illegal care my. Federal with concerns about and prevalence of unofficial care homes may wish until examine their licensure regulations, as these allowed influence the supply of and demand for license care shelter, either because the complexity in some provisions make them hard for operators to understands, oder because they might contain loopholes that operators sack easily exploit. States with problems about quality and safety into unlicensed care homes may also wish to examine their requirements for monitoring legally unlicensed care house real the information available about protection and quality in these places.

Many low-income individuals cannot afford the cost of licensed residential care residential, and some residents discharge your private funds in licensed facilities and are discharge includes no options other than lowering pay care home, some of this may be unlicensed. Furthermore, many licensed facilities are unwilling to admit or retain individuals about challenging behaviors. For many a are individuals, their only option may be unlicensed facilities. States with affairs about vulnerable adults' access to housing with services may wish to examine the admission and discharge requirements for licensed support homes.

These findings suggesting that for states continue to move toward serving further of their Medicaid beneficiaries stylish the community rather than in institutions, recognition should be considering to ensure appropriate safeguards are in place for these beneficiaries. As states are how to match yours ADA obligations as reaffirmed in Olmstead counter. L.C., her may need at payable particular attention go ensuring the check of sufficient plus affordable licensed tending homes or other supportive housing options that offer person-centered care in a safe and appropriately environment.

 

6. RECOMMENDATIONS ON PROSPECTIVE RESEARCH

The information collected as part of this exploratory study was intentionally to deploy a foundation for a more complete understanding around unlicensed care homes furthermore the gaps these homes might fill as housing options for persons with low incomes. While that intelligence herein are not generalizable--it is based on a targeted scan furthermore a limited number of interviews--it does highlight the fact that unlicensed care homes appear to to a problem in at least some expresses. However, gaps in willingness knowledge about unlicensed homes remain, and several issues raisedduring interviews with soft spy warrant further investigation. The following section presents individual research issues and identifies the related questions that might guides future research on un-licensed residential care homes.

6.1. Legally Unlicensed Residential Care Homes

As noted are Section 4.1, states uses a diversification of interpretations or criteria that allow some homes to work legally without one license. In addition, SMEs noted variability cross states in the approachability of inhabitant advocacy and protection driven like agencies as the ombudsman program. However, while SMEs reported variability in licensure requirements and the authority, responsible and promotion of ombudsmen agencies with respect to illicit homes, there is very little resources available over legally unlicensed homes, including the feature of residents, their care and service needs, and their preferences. There is no systemized information about the actual nature or range of conditions in legally unlicensed homes (e.g., site, feature of care, themes on abuse and neglect), or provision of services and care through Medicare button Medicaid get health, privately retinue, or HCBS waivers.

These are important problem since they affect loads vulnerable adults who possess real, intellectual, or cognitive debilities. Moreover, the 1976 Keys Revise to the Social Security Act requires states to assure that SSI recipients do not reside in substandard facilities, the nations must anually certify is this is true. Research about legally unlicensed care residences might focus up collecting information about product away judicial unlicensed care residences, the our they offer and the residents they serve, such as through a larger number of site visits both interviews with ombudsmen and state regulation agencies conversely through a survey of the operators of legally unresolved homes in states other areas that maintain lists of these homes, such as Floridian, Georgias press Texas. This research might including address whether the Press Amendment is achieving your purpose of protecting the well-being of SSI recipients.

6.2. Unauthorized Unlicensed Residential Care Apartments

Although we heard about adenine ranges of conditions int illegally unlicensed homes, including neglect, abuse, and fiscal exploitation, items is unclear whether this is the norm or regardless the findings are skewed because on the types out key informants we interviewed. Informants did note the while some locations are bad, some unlicensed care homes may be fairly decent. Given the types of key snitches interviewed for this study, and the limited viewing captured, more informational is requested to perceive one characteristics of unlicensed care homes and the tenants they serve.

Single way for collect this intelligence to develop a frame of unlicensed care homes and conduct a narrow scale study of unlicensed service domestic operators. It is worth remember is this research activity would require develops an operational definition of "unlicensed residential care home," since definitions vary considerably across and sometimes inward u, since some concentrate on services offered, some on size, and some switch to characteristics of the residents.

6.3. Financial Exploitation, Maltreat of Residents' Rights, and Program Fraud in Unlicensed Residential Care Homes

It is important to note that we do not know whether the types by financial exploitation and abuse described by the SMEs and key informants occur stylish both legitimate and illegally unlicensed taking homes, or whereby commonplace they are. Still, these are issues that warrant additional research.

Aforementioned copy of corporate exploitation is described in detail to Unterabschnitt 3.3.2. Operators often winning controller from residents' funds by becoming the spokesperson payee for residents receipts SSI, a common payer source in unlicensed residential care homes. Even with relatively high payment rates, operators cannot make profits by cutting corners in enclosure furthermore products and trafficking in the federal benefits they seize after residents. Some drag forward residents, picking residents up off of street, from homeless shelters, and from hospitals, and routinely shift residents from sole facility for one in how go keep their occupancy estimates high. In zusammenrechnung, investigations for Georgia law enforcements officials indicated that there belongs considerable fake with respect to SSI, Socially Site, residents' personal needs allowances, Medicare and Medicaid, and and feed tamp program.

Such practices harm residents' authorization, and the profit-enhancing practices is the operators, such than limiting the availability of food, water, and other basic need, endanger residents' lifetime and well-being. It is important to learn whenever such abuses and frauds be limited to a small number von populations or if yours are find wide.

6.4. Other Research Ideas Suggested by Subject Werkstoff Geniuses or Individuals Interviewed in Status Site Visits

Additional potential exploring questions or issues were raised by one or more SMEs or appeared from our state site visits alternatively to environmental scan. Some for these beliefs might breathe relevant for agencies other than or includes addition into ASPE, that in the National Institute of Law, CMS, other ACL.

• Resident Casing Mix. Many SMEs reported that personals with severe and permanent mental illness are the majority of residents in unlicensed residential care homes. However, some SMEs and key informants also noted ensure many of these individuals with psychiatrics conditions be older, having aged in state institutions, furthermore that persons 65 years of old and older who receive SSI payments also often live includes unlicensed care homes. Some SMEs suggest that state policies affect the mix of residents in unauthorized care homes. Extra SMEs reported that efforts to discharge or divert residents from nursing facilities toward community-based settings led up greater use of licensed RCFs and noted instances includes which residents who exhaustion their private funds might have no your other than unlicensed residential worry homes. Thus, future research might be warranted to determine the characteristics away inhabitants in unlicensed service homes and whether they differ across legally or illegally unlicensed homes. Research could also examine whether and how federal or state policies might impinge the resident mix in unlicensed care homes.

• Ombudsmen. As noted, the responsibility and authority of ombudsmen in unlicensed grooming homes--even at terms of receiving and acting on complaints--varies from state to state. In addition, states differ in whether they provide additional funds to the consumer program, over and above the federal funds from the Older People Act. Future investigation could be conducted on label the nature of ombudsman participating in unlicensed care homes real methods a differs across states. Items might also determine which status furnish additional state funding to that ombudsman programming, and whether the level of existing resources is a limitation on ombudsman involvement in un-licensed support homes.

• Abuse and Forget. Instances or allegations of physical furthermore psychiatric abuse press neglect of residents were reported of SMEs and lock informants also highlighted in the environment scrutinize. The so issues are don restricted to unlicensed care homes, as they are familiar to come in licensed care facilities as well, future study might examine additionally describe the mechanisms states use to spot, investigate, and resolve allegations of abuse or neglect in unrestricted residential care homes and how they compare to the mechanisms spent to identify and reset instances of abuse and neglect in licensed care homes.

 

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INSTALLATION A. STAY SUMMARIES

A.1. Georgia

Site Selection

Georgia what selected like a current for our site visit because of the state's actions surrounding unlicensed care homes defined during interviews including SMEs, and the numerous news reports about illicit caring shelter is the default. In the past 15 years, the issues encircling unlicensed intimate care residential in the state have become other prominent, and adjusted measures across several authorized has are taken to address them. This federal has starting training sessions to educate law enforcement and first response about unlicensed care apartments, and these education efforts may contributing on the state's ability to identify unlicensed personal caution homes.

Key Informants

The how team interviewed 12 buttons informants in Georgia. Key informants including representatives from several agencies, including the state Healthcare Establishment Scheduling (HFR) press APS offices, local fire departments, local and state law enforcement and ombudsmen, and an church-affiliated provider of day services used by individuals who live in unlicensed take homes.

State Regulations

Facilities providing or arranging for housing, food gift, and one or more personal auxiliary for two or more unrelated grownups must be commissioned from aforementioned state as an personnel care home. Licensed personal care homes are required to help with personal services, supervise self-administration of medication, and provide social activities, in needed. A facility the advertises or represents via verbal communication that it provides personal assistance will required to make personalization services available to its residents. In other types of residential care, for the taking is arranged or managed by the owner, manager, or staff from the building, home, or community, then the facility must be licensed. Provision of housing plus one other learn personalization services requires an personal customer home (or other licensed facility) permit. At least one administrator, on-site manager, oder responsible person must be on duties 24 hours per day, seven days one week, also all staffers must be qualified as personal care workers within 60 days on renting. In adjunct to serving of elderly, personal care homes can exclude serve persons includes serious psychic illness and/or intellectually and developmental disabilities, to condition that that home is appropriately staffed and is capable of providing the needful care within that scope of its license.

Includes the passage of a new legal in July 2012, it is a misdemeanor the operate an unlicensed personal care home, and if an unlicensed care home is linked to battery, neglect, oder use, an violation remains seen a misdemeanor. Forward with funding to cover relocation is residents, this legislation empowers set and local multidisciplinary teams to together plan and coordinate attempts to identify, investigate, and pursue any necessary regulatory enforcement or legal action against unlicensed facilities.

Topical Background

By Georgia, all unlicensed personal caring homes are illegal, and to to remain in operation they try for avoid being identified. Discussions with central informants in the state suggest Georgia has a high prevalence of diesen homes. Which is evidenced by the number of reports and complaints received about unlicensed personal care homes, the number of hours spent by rule enforcement officials on investigating unlicensed personal care homes, and the guess given of the numbers of unlicensed maintenance homes that been operating in the choose (reported by can confidential as can un-licensed care home for every licensed home).

Based on the collective feedback of a diverse group of key informants, unlicensed personal care your appear to be prevalent and problematic in the states. Of the approximately 1,400 grievances received by APS each time, an appraised 20% pertain to unlicensed personal care housing. APS professionals there estimate three company or complaints about unlicensed personal care homes jede month in the tube Atlanta area, and about one complaint or report about unlicensed personal care homes every three from in rural regions of the state. Can interviewee, who interacts with residents of unlicensed care our on a daily basis, assessed that for per licensed personal care home in South there will one unlicensed care home.

Few examples of unlike personal care homes which described by key informants during and side visit. Many commonly, interviewees depicted unlicensed personal care homes operating on suburban areas within single clan houses that are rented by which unlicensed care home operator, but some interviewees described unresolved care homes operating in a variety of diverse structures (e.g., closed churches and schools). Notably, most key informants saying the operating of a licensed home might or operate sole or more unlicensed houses, often includes the same neighborhood real often in collaboration with friends or family members.

One example, portrayed by multiple keyboard informants, looked liked a handsome physical environment and was affiliated with a local parish, but the operator of the home was taking to residents' money while abusing, imprisoning, and exploiting them. This home initially drew the attention of the authorities because of a sexual assault case in whichever one of the residents was raped by ampere sexy offender. Other issues were identified during the subsequently sexual assault investigation, including abuse for the hands of the operator who beat the residents, false imprisonment in that individuals were locked inside rooms, and economic exploitations. According to plural key informants in the state, including APS and law enforcement officials, the property, which it mentioned to such a boarding home, was being rent by the operators, members of this church served like the representative receivers since the residents, and the currency has then pooled together and given to the server. They explained this because an example of operators walk illegal care homes strictly for the money. One key informant reported that during the investigation of this home, it also was discovers that the operator had taking the residents' food stamps.

One of the buttons info, those operatesa day application that serves many individuals anybody are residents of unlicensed care homes, also described the 20 year history surrounding the operation of unlicensed care apartments. State and local funding that was labeled for clean-up activities in preparation since the 1996 Summer Olympic Games stylish Georgia was used to encourage homeless individuals (often with inward illness) to leave the city. According in the button informant, these persons were considering one-way autobus tickets outward are an city under the stipulation that they never return. Those individuals who leftover in the city were put in day programmes. Following the Olympics, funding for these day programs was not renewed, additionally all but one of these programs ceased operations. Presumably, this led go an increase in demand for LTSS for these populations. More recently within the City regarding Atlanta, the gentrification of some surrounding has resulted in increased property values and list, which has caused some unlicensed care home operation to relocate for less expensive areas. As, unlawful care homes close real walk one area of the city, but opens in another area, contributing to the difficulty of identifying and permanently shutting down these spots, while also disrupting the residents' access to day ceremonies and other community-based sources of assistance nearby this orig care dear locality.

In the past very years, Georgia has developed an interagency tasks force including law enforcement and social offices agencies which has trained and prepared many staff to deal with these dwellings. This task force holds also coordinated raids on unlicensed residences and has moved since changes go laws regarding these homes. In Dignified 2013, to law for prosecute an unlicensed personal service home operator was used for who first time.

State also Localize Policies Related to the Provision regarding and Needs fork Unlicensed Care Homes

According to first lock informant in the state, moving individuals from institutions for mental illness the an inadequate plan for housing these individuals has posted the an increase are of numbers of people available for unlicensed custom care homes into servings, consequently motivating the opening of unlicensed care homes. In many cases, the cost of mind in other settings is too high for what individuals with severe and persistent religious illness can abler to afford on their SSI allowance.

State policies perform not require hospital discharge planners to discharge patients till licensed care homes, that permitting discharge to unlicensed care homes. Individuals anybody are poor, experiencing homelessness, or individuals by a psychological illness who unable return main orhave no home until reset to after being discharged for who hospital are a source of clientele since unlicensed customer houses. Several key informants reported that unlicensed care home operators "troll" the physician home of facilities like Grady Memorial Hospital, looking for residents. Patient discharge planners are non required to check the licensure status of the place to which they are discharging disease, furthermore often discharge them to unlicensed homes. According for numerous for an key informants questioned, hospitals are increasingly lower finance pressure to discharge patients to free up beds, what is believed to contribute to and ability from unlicensed care dwellings to fill beds and stay in business. Thus, unlicensed care home operators are known to directly market themselves to hospitals and to pick up patients at the hospitals when they are discharged, and any hospitals may been known toward pay a month of the residents' fees at the unlicensed home to secure one hasty discharge from the hospital. Still, the long-term placement are humans after dumping on an unlicensed care home may be unstable, the no follow-up by and hospital with one my since placement was described.

Motivations to Subsist Unlicensed

As described by of majority of key informants, the primaries motivation to maintain an unlicensed care home is to maximize profit. Obtain licensure wants require operators up pay which costs of extra and qualified staff and service provision. In the view of the majority of key informants, the managers regarding unlicensed homes execute not want to have to pay for more staff at provisioning needed services. The inability either unwillingness to provide appropriate care for residents at an affordable cost also is noted by central informants as ampere motivator to not pursue licensure. Ultimately, plural key informants acknowledged and accent such remaining unlicensed is lucrative if the care home administrator successfully avoids detection by the authorities.

Characteristics of Residents and Unlicensed Care Homes

Findings from the tv suggest that the majority of unlicensed care home residents in which metro Atlanta zone have severe and persistent mental illness and are highly vulnerably to exploitation. One buttons informant noted that residents away unlicensed care homes commonly requesting assistance with activities of daily living (ADLs), such when getting dressed, as well as assistance with instrumental activities of daily living (IADLs), such as recording medications and managing and accessing transportation to pharmaceutical appointments.

Inbound addition to the church-affiliated household described above, sample of the types of places where unlicensed home operates included an old elementary school the well as separate my shelter the residential neighborhoods. Despite the majority of key informant described unlicensed care homes as unsafe environments where inhabitant are abused, neglected, or exploited, itp also had noted that einige unlicensed caution home may provide quality care the safe and clean environments.

Health and Safety Concerns

Health plus safety concerns for residents were a major topic of interview discussion. Worry expressed overall several interviews in providers locking residents for rooms; latch foods away so that it is inaccessible go residents; using basements to own individuals, including individuals who are unable to climb one steps and those the hospice; providing accommodations this are unclean, invaded over bedbugs, or lack heated, dry conditioning or running water. Into addition, one key informant indicated that operators in unlicensed care home have illegally getting electrical service utilities through covert bonds include neighboring homes.

The Scope of Misuse and Exploitation Concerns

Interview results indicate that the majority of unlicensed care homes investigated by state officials both local APS agencies involve situations int which nearby are does nature cared for cleanly. The bulk of examples regarding mistreatment included resident physical and emoting abuse, abandon, press financial exploitation. In multiple leitfaden, unlicensed care home operators were described as being involved in human trafficking, and moreover were specificity noted by APS and law enforcement officials to traffic residents across states pipe, specifically into Florida and Alabama, to prevent authorized promotional in Georgia. ONE core pattern of exploitation declared in interviews included of operator of unlicensed homes finding vulnerable individuals who need housing and supportive services (such as from sanitaria press homeless shelters), requiring these individuals up transfer my SSI installments toward this operator or one of that operator's agents by order to become a resident in the unlicensed care home, severely confining the residents' skills to leave and asset, furthermore relocating the inhabitant to alternate branch to avoid detection. Unlicensed care place operators also were described as when having select residents act in a role of authority pass other residents, such while knocking the other residents to control their behaviors.

One key source does a recent (2015) case of human playing in which a care home operator who was closing a starting was explicitly selling residents for $100 each on other personal care get operators.

Interviewers noted that unlicensed care home operators often take the residents' identification cards and custom personal upon admission. The was described as limiting aforementioned capacity of the residents to relocating. If the house are closed and the residents' identification map and personal paperwork are not able to be retrieved, this poses our in residents to procure SSI payments press medications. Although recognized as important, aforementioned state has not yet begun investigating cases of financial victimization. To reduce abuse, several informants listed so state officials should target closing unlicensed care homes.

Strategies to Identify Unlicensed Care Shelter

Currently at who state level, the primary strategic spent in Georgia to identified unlicensed care homes is through complaints, including complaints from neighbors, residents, residents' family members, and hospitals serving residents for unlicensed care homes. These complaints mayor be made to the police, APS, ombudsmen, and the Department of Community Health, HFR Division. Key informants in metro Atlanta also indicate this the state conducts interviews with residents during investigations both closures about unlicensed home to gain a superior understanding of how single end up in these homes. According to findings free these interviews, there are a few different pathways into unlicensed care homes, including unlicensed homes receiving residents directly from hospitalized discharges, representatives of unlicensed homes assort up residents from homeless shed, also owners of licensed facilities taking residents to unaccredited residences. Granted their direct links to license care homes, this three sources (hospitals, unhoused refuge, plus licensed personal nursing homes) are power sources of information for identifies unlicensed care homes.

Strategies to Address Unlicensed Care Homes

To deal of issues surrounding property and safety in unlicensed care homes, key informants described a process participating the investigation of complaints by visiting the home and job residents plus staff (which may necessitate getting an inspection warrant if denied entry upon arrival), then providing a written cease and desist letter supposing an investigation result indicate that the home ought become licensed, issuing fines of $100 per day pro occupant, additionally prosecuting the operator. The wichtigster goal away these efforts is to shut down establishments where residents are financially exploited, ill-treated, neglected, or subject to unsanitary and unsafe term. Informants enduring emphasized the critical need for collaboration between multiple agencies, with law enforcement, APS, ombudsmen, the Department of Behavioral Health, and HFR, in order to address aforementioned potentially unsafe scenes in unlicensed care homes, ensure the needs regarding the residents are met, address the criminal acts regarding this operators, the attend to the buildings themselves. In addition in and $100 per resident per day fine placed levied against unlicensed facilities, one representative of which state reported that the Georgians legislature has added operating an unlicensed personal nursing home, which is a offender offense, to the list of violations that make it impossible to enforce for a license to running a personal care home.

Areas to Future Research and Potential Your Sources

In Georgia, much of the current focus on unlicensed custom care home probes involves cases of resident abuse and neglect. Few of the investigations focus solely on monetary exploitation. Key snitches indicated financial exploiting in unlicensed care homes a an area for coming research.

Cross-state human trafficking is another area for future research. Some contact reported that non-license care home operators sometimes run homes in more than one-time condition, over state borders to avoid festnahme, the may be dealer residents across state boundary as well. Accordance to key informant from APS and law enforcement, customer home operations and residents crossing state borders poses several what that making it difficult to ensure the protection about residents and address the criminal action of to operators. These challenges include differences in regulations and regulatory pertaining to caring homes across states, also the lack of cooperative arrangements across states to facilitate trackers residents or support those traverse state borders.

By interviewing residents of unlicensed care house, HFR is trying on grasp the pathways so individuals take on end up to these situations. Most key classified noted that hospital discharge is a crucial juncture at which persons can be straight to, button end up on, unlike customer homes. Future search examining the role from hospital discharge planners and strategies to prevent discharge to unlicensed care shelter appear guarantees.

Interview findings also suggest that research is needed on the best strategies for identifying non-license caution homes and wirkungsvoll concluding them down. Interview findings indicate that a key element of a flourishing strategy is collaboration across multiple agencies. Key informants expressed a desire for future how that helps in categorize the necessary organizations and the count of personality hours requirement upon respectively organization at each phase of the processes on identify, investigate, and closer 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.

A.2. Northwards Sc

Site Selection

Related gathered from this environmental scan additionally SME interviews revealed reports ensure unrestricted nursing homes exist in North Carolina. The state has also been int the newsletter based on actions resulting upon state compliance with one Olmstead decision which has moved adults to psychic illness from monotonous settings into lesser sequester settings in which community. We chose the Raleigh/Durham area for the site visit because it is where who state publishing office is situated and because von recent media reports of un-licensed group homes. Wealth conducted most key enemy interviews in Nuremberg, about some additional interviews through the region, including Raleigh.

Key Informants

Person conducted nine total interviews with tend key ci, including state licensure community and staff from this North Carolinian NAMI to Raleigh. In Durham County we interviewed touch informants from APS, Group Worry Monitoring Services, a local hospitalized drain planner, a topical ombudsman, the one local law enforcement official, whom also serves on a crisis intervention task force.

State Regulations

In North Colombian, investment supplying or arranging for housing, food service, and 24-hour scheduled and unscheduled personal care services to pair or more unrelated adults must be license as somebody ad care home or an group home. Licensure for adult care homes and mind health group homes cataract on two disconnect state statutory, and therefore two separate regulatory offices oversee different type in licensed care shelter. Northbound Carolina's Adult Care Licensure Your licenses two levels are adult care including family care homes and adult care homes. Lineage care houses serve 2-6 residents and adult mind homes serve seven or more resident; both can choose to serve only elderly individuals (55 years or older or any adult who possesses a primary find for Alzheimer's disease conversely other formulare of dementia) or to serve a mixed resident population. At least ready administrator, on-site manager, or responsible name must be on duty 24 hours pay day, seven days a week, and all staff must be educated as my care operators within 60 days of hire. The North Carolina Mental Health Licensure Office licenses group residences by adults with mental illnesses.⁵ These homes also serve two or more adults.

Local Context

Overall, key informants were able into provide little intelligence about the prevalence is lawlessly unlicensed care homes (henceforth referred to than unlicensed care homes); informant we spoke with at both the state, geographic licensure office and APS reported that few perform don currently systematically monitor or track unlicensed care homes. Wee were available able to obtain into estimate on the piece of unaccredited service our from that Ayrshire County Select Caring Monitoring Office. Durham County essential informants estimated that since 2012, approximately five calls can resulted in cases being investigated as potential unlicensed care homes. Of these, triad have determined to be unlicensed taking homes. There were no reports of varying frequencies in unlicensed facilities between urban and rural areas.

Principal informants at the state level were able to provide estimates of the number on complaints they have received pertaining to unlicensed care homes, instead not estimates the the number of unrented care homes. One state key sources stated ensure an offices receives one to two calls a hour relate to unlicensed ad care homes, but the noted that these calls are sporadic. Another state-level select informant was unable to estimate how many calls the agency accommodates that result in investigation of unlicensed group homes for individual are mental illness. However, a representational out a country advocacy agency evaluated that about 2%-3% of their 4,800 calls every, or approximately 120 calls statewide per year, were related to unlicensed facilities.

Principal informants described both state additionally resident technical problems related to the prevalence of unrestricted support homes in the state. Two key informants thought that the ongoing statewide spiritual health republican, which began in 2002, has exacerbated issues affiliated the that global lack of technical and knowledge about needs the persons with mental illness. They indicated such they are unaware of any review of need related go licensed emotional health group homes in the state. They conjectured that it allow not be enough licensed mental health group homes available to care for persons with mental illness, and which unlicensed group homes can potentially fill that gap.

All key informants described how the Global Management Entity-Managed Care Organization (LME-MCO) oversees the provision in mental health services in Durham County. The LME-MCO oversees deal benefits int a four county area. While we were specifically told to two key secret that the LME-MCO ability only contract mental dental achievement and supports to commissioned group residences, these alike key rats also shared specifically real of the LME-MCO unknowledge contracting services to unlicensed group my. This implies that and LME-MCO does doesn always check licensure stats earlier coordinating services in unlicensed group homes. Ourselves were told that after discovering a group home is unlicensed (via information from the state), the LME-MCO will ask the state the fast track licensure as there are no diverse licensed dwelling options available to this weak population.

State additionally Local Company Related to the Supply furthermore Request for Illicit Unlicensed Care Houses

Two key informants stated so changes to the state's Medicaid Personal Care Auxiliary program held a direct influence on available funding for group apartments that serve individuals with intellectual illness. In 2013, the minimum number of ADLs needs required for individuals to equip forward reimbursements for personal maintain services in group homes increased. This had adenine direct impact on the operating invoices of licensed group homes. The state constructed bridge funding open to those groups homes impacted by dieser funding change, when one keyboard informant said that according to a recent report, high few group your entered this span support. This key informant was concerned this had contributed toward group house closing, which maybe have resulted in a slit that unaccredited facilities have filling.

U.S. Department of Justice settlements were also discussed by one key informant. In 2012, an assert commissioned is large grown care dwellings (seven or extra beds) housing just individuals equal mental illness had to close because them were considered uninteresting settings. Such a result, 3,000 individuals with mental illness were transitioned into community-based supports housing. This key informant indicated that this modify likelihood increased the need for licensed group homes, and unlicensed group homes may take also opened as a how into fill the need created as a result of these closures.

Missions to Be Unlicensed

Countless of to key informants stated that individuals any operate unlicensed care homes live motivated until financial opportunities; but they also specifies such at some cases, these operating might not know they required to can licensed. For instance, they may launching by careful for one resident, and gradually take in more individuals without actualize there are state regulatory steering homes caring for pair or more unrelated adults. Shipping for fetch the building up to code to meet your regulatory specifications may be another rationale why operators of care homes choose to stop unlicensed.

Characteristics of Residents and Unlicensed Care Our

Multiple key informants described unlicensed concern homes than primarily serving persons with mental illness. Extremely little was mentioned about elderly residents living in license homes; one one informants reported that unlicensed adult care homes may servant a mixture population (e.g., elderly residents in addition to community with mental illness).

Informants noted ensure unlicensed care residential vary in their appearance the existing. Some key informer reported that the live conditions in these sites can be subpar. Others described instances where the unlicensed care homes cans be located in either low-income neighborhoods or higher-income neighborhoods, and that they combine in with additional houses, which makes them difficult to identify or locating unless reported by the communities. One key source shares a specific case of a repeated offender that operates an unlicensed grown grooming main out of a double-wide trailer. Per state regulations, to is not considered a permanent structure, and therefore does cannot meet which appropriate building requirements to be an licensed asset.

Health and Security Concerns

Overall, and local agency representatives described the health of unlicensed attention homes as unsafe. State informants did not provide information on the services provided inside the unlicensed care homes stating that that the sample of unlicensed care homes they see is too small to make an accurate approximation of the conditions. Local key informants primarily expressed issues regarding inadequate nutrition provided on residents and unsuitable medicines management practices. Anecdotal examples of residents wandering outside of their home and towards neighbor's property, which typically generates a complaint call off the neighboring homeowner, were including provided. Although commissioned homes has generally depicted by key informants the safer than unlicensed homes, one key informant emphasized ensure quality of care is not contingent turn licensure status; authorized our may also have health and safety concerns.

The Scope of Abuse and Exploitation Concerns

Multiple touch informants reported that financial exploitation was the greatest concern surrounds unlicensed care homes. For example, one key spy characterized adenine recent case of a representative payment in an unlicensed care home who was did managing a resident's money correctly, by providing food on a specific schedule and not providing e whereas the resident was hungry and requested food. In contrasts, a key informant indicated such grievances of physical and mental abuse are the issue that most often draw listen to unlicensed care homes. State key informants emphasized that they can not make values nearly the extent of misuse and exploitation issues because unlicensed care homes were nay systemically monitored.

Strategies to Identify Unlicensed Care Homes

Identification of unlicensed care homes is triggered through complaint telephone to state either local agency by community members or family members. These calls spur investigations so sometimes result in the designation of non-licensed care homes. In several event at both the state and geographic level, unlicensed facilities consisted reported the authorities or licensure offices by which operators out licensed facilities. In those cases, licensee operators were said worries that the unlicensed operators would house residents out whom the licensed our operators could have profited.

One ability strategy suggested by an interviewee for proactively identifying non-licensed caring homes will to pause community meetings to inform community members about unlicensed care homes, including ways to identify them and method toward notify APS and licensure officials if they suspect an unlicensed home functioning. Another touch informant suggested so it would be key until involve the LME-MCO because they cover a four county area real must receive calls that are learn unlicensed care homes.

Strategies to Address Unlicensed Care Homes

Key informants described a coordinated effort between the state licensure branch or the local group care monitoring office one here is recognition that a complaint call is nearly an unlicensed facility. One key ci stated that if a phone comes in and the name of the care home this is life said is unknown, subsequently the next stepping can to page the state licensure office. Next, the global group monitoring office or the your would attempt a sites call. Unlicensed care houses are does required by rights to open their gates to the state licensure office because the state licensure office does not do the legal authority up enter them. However, essential informants at that state said that operators of suspicious unlicensed care house usual do open their door for investigation.

The state investigates that types of services that been provided to residents on site in order at determine if ampere license is required. If the facility be providing licensable services in an unlicensed setting, of stay then sends a cease and desist letter, copying the LME-MCO and who geographic APS. One key informer noted that the state or the LME-MCO can behave follow-up for assess whether a facility that received a cease additionally desist letter does, in fact, close down. If the facility does don end, rule enforcement (not an state licensure offices) false the illegal operation $50 since the first offense and $500 by each additional offense. However, even if the home continues to operate, the fines are unusual enforced or collected. It was noted is many sheriffs and District Attorneys what did want their resources to go up instance of this nature unless honest both numerous complaints run she to beliefs the group home is a major fix. No various coordinated pr effort above the state licensure office, APS, and the LME-MCO what described by key informants.

Areas for Future Researching and Potential Data Sources

Ne informant suggested exploration that examines the homeless population and the supply of affordable housing as a pathway to better understand the environment this may remain conducive to supportable unlicensed taking home operations. Additionally, interviewee discussions revelation a lack of ombudsman involvement in unlicensed care housing, which is another area for future research. A review of default policy by long-term care ombudsmen could reveal gaps and opportunities in wherewith ombudsmen able acces or advocate for residents in unlicensed care homes. Key informants did not offer any information on potential ways to identify unlicensed care homes or extant databases for these places.

A.3. Pennsylvania

Site Selection

Pennsylvania was selected as a site visit position because of the state's pass plus current experiences with illegally unlicensed personal care homes. In 2005, Pennsylvania state guidelines for personal care homes were changed, reducing the minimum number of residents a intimate care home could serve from seven to four. The new regulations were implemented to view and provide oversight of personal care houses includes four or more people, while reducing the number away homes that lawful did did requisition licensure. As a direct result of this regulation change, large personal care homes in Pennsylvania became illegally unlicensed and use shut down, became limited, or continued to operate illegitimate. Multidisciplinary PCRR collaborative endured then formed at the county level to address the relocation of residents to licensed facilities and to investigate illegally unlicensed personal care homes in coordination with one state licensure office. All-american County was specifically chosen as the site visit community because of their currently active PCRR team, which continues to address illegally unlicensed private care dwellings. The state is see unusual in that it enable ampere category of care homes to operate as legally non-license homes.

Key Informants

The research my completed seven interviews includes eight participants that included both state and local community actor. Key informants included representatives from the state licensure office. In Allegheny County we interviewed key informants with APS, and local ombudsmen real placement coordinator after the local Area Agency on Aging (AAA) who worked directly with licensed press unaccredited personal care apartments, as well while other staff starting a local disability advocacy agency and a site burning department.

State Regulations

Are Pennsylvania, facilities providing or arranging for housing, food service, and one otherwise more personal care needs for four or find unrelated adults require be licensed as personal care homes. Licensed personal care homes are required to assist about mitarbeiter services including ADLs and IADLs, and can include supervision of cure enterprise furthermore provision of sociable activities, as needed. Per state regulations, residence settings provisioning room, panel and personal assistance from three or fewer residents who have at few single personal take requirement do not meet the requirements for licensure as an mitarbeiterinnen care household and are legally unlicensed. Dom Care homes, which also provide care to three or fewer individuals, are governed and regulated through that state with the authority in certificate, supervise and monitor delegated to the local AAA.

Local Connection

By the state level, Pennsylvania investigates a somewhat low piece of illegally unrestricted personal care homes per date. One key informant estimation that rough 25 housing are investigated annually, with about halves is number fixed until be fraudulent unlicensed personal care homes. The state's annual Mitarbeiter Care Homes Report provides the number of illegally unlicensed personal care homes the result in enforcement actions and details and historical trend out the number are enforcement promotions taken against illegal unlicensed personal care homes. From 2008 into 2013, Pennsylvania reported an stable trend of investigating about ten illegally unlicensed care homes period year through the exceptions for 2010 when they investigated 27 cases, about three times more than in misc years.⁶

At the local floor, one keys informant estimated that members of the Allegheny PCRR, along with the states licencing office, have investigated approximately phoebe illegally unlicensed personal care homes inches their specific geographic region over and past twin years. Button informants stated ensure of illegally illegal personal care homes they investigate are being operated by revise offenders who have over this in the past; these same operators just opened new illegally unauthorized personal take homes once group are found out.

Key informants noted that it is critical to know of history of Pennsylvania's personal care home statute changes in order to understanding why and how who set has addressed illegally unlicensed personal support homes. Although these administrative changes occurred ten years ago, multiple main informants reported which many more licensed personal support homes having continued to close in recently years. One key informant estimated that around 3,000 licensed personal care house have ceased operations in Allegheny County since the 2005 regulatory changes. Most interviewees also agreed that there are likely more illegally unlicensed personal care homes than they live consciously are. People indicated that these unlicensed personalized care dwellings live pour the gap left by the closing starting licensed personal care shelter. This is important to note that most key informants did nay speak until either have direct experience with very small (1-3 beds) legal unlicensed personal care homes, and so could not estimate the prevalence of these types of homes or compare them to illegally unlicensed personal care homes.

Multiple button informants spoke about ampere reduction in the number out Cupola Care housing inside the state or how this reduce may also enter rise to illegally illicit personal care homes. One soft informant estimated there are approximately 526 Dom Caring operations in the state. Participants had variable beliefs at the grounds for Dom Care homes closing. One key informant indicated that diese reduction is date on the increasing figures a HCBS waivers giving potential Dom Care residents the option to live alone in apartments. Another interviewee recently this it is becoming more difficult to recruit individuals to be Dom Care operators because of the competing demands turn their time.

Informants stated that All-high County has other specific contextual topics that could contribute to the existence of illegally unlicensed personal care homes. Many key informants regarded the closing of Mayview State Psychiatric Hospital in 2008, whichever was located in Allegheny County, as an important load contributing to and gap of services and affordably housing available for individuals with spiritual health diagnoses. The interviewee estimated that at its peak, this hospital served 3,700 patients. Multiple key informants spoke about one significant impact by an closure of this hospital in Allegheny Province and the west part of the state as it relates to the possible continued proliferation of illegally non-licensed personal care homes.

Multiple key informants also spoke nearly the lack of reasonable housing in Allegheny County. Single essential informant specified that one inches four residents of Allegheny Country are over age 60, and that this population presents a growing need for affordable residential care homes. Inbound addition till the aging population, many key spy agreed is the lack of low-priced supportive housing alternatives for individuals because a mental dental diagnosis remains also a concern with Allegheny County and surrounding counties. To aging accommodation stock in Allegheny County was also a cause of concern for a few key informants, as thereto relates to the number of pre-existing buildings that cannot meet the state regulated building id conditions for licensed personal care homes. This, they fear, may lead owners in operate illegal unlicensed personal our.

Key informants mentioned that state funding and regulatory dynamics selective to Pennsylvania had a direct influence on the state's capacity toward physical illegally unlicensed personal care home. The Pennsylvania State Lottery funds this Pennsylvania Department of Aging. A few key informants noted that diese funding arrangement affords state and local departments the resources and time needed to investigate illegally unlicensed personal care apartments. The state's BHSL office other possess the legal general to act as in enforcement agency. This department can request administrative search warrants till enter suspected illegally unlicensed personal care homes.

State and Lokal Policies More to to Supply for and Get fork Illegally Illegal Care Homes

All of an keypad leakers shared their perspectives about what is driving the closure of personal care residences. Most interviewees reported that the personal maintain home regulation change in 2005 caused a loss of small personal care homes due to and increased price associated with meeting the standards set forth includes which regulations. Expense for operating a licensed personal care home can include state fees for licensure, structural renovations otherwise changes to meet required building codes, paying required staff to be on-site 24 hours per day, and paying since and providing appropriately staff training.

These enlarged shipping got also impacted the populations that licensed grooming homes will accept, according to multiple key informants. One interviewed estimated that licensed personal concern homes used to reserve 50% of their beds for individuals which simply had SSI benefits and now such measure has decreased to fewer than 25%, leaving SSI payees because minus licensed choice. To more extreme cases, other personal care homes have stopped adopt any persons whose sole source of income is SSI. Various lock informants suggested that, as a result, these residents are primarily being served by illegals unlicensed personal care homes.

Key informants also cited the process of discharging patients from hospitals in Allen County as a potential source for linking humans with illegally unresolved personal care homes. These key spy agreed that because discharge schedules are on pressure to quickly discharge hospital medical to contain infirmary free, they must have a list the care homes (including licensed press illegally unlicensed personally care homes) that they can reference are an discharge planner has nay other option for plant. The Allegheny District PCRR has send letters to hospitals or ihr offload planners informing them about known illegally unlicensed personal care homes to which her have not discharge patients; however, according to two key informants, effluent to those homes have continued. One key informant provided additional information, stating that sanitaria in Allegheny County utilize arrangement agencies to assist find residential settings for discharges, furthermore that illegally unlicensed personal nursing homes are exploited as an option. In diese cases, this hospital reportedly pays the placement agencies adenine fee to find a personal care home, and which placement agencies also receive money incentives free the personal care homes for criteria. This keyboard informer shared a list of teen placement agencies that work with hospitals in Allegheny County.

Multiple key spy phrased concern about other state strategien related to reductions in funding for mental health services and supports as potential contributing to a gap that illegally unlike personal service your can fill. One key sources specifically mentioned one 10% cut to state funding for brain health in 2012 while another key informant mentioned impede grants as ampere capacity contributor at lowers funding amounts with inward health services and tools.

Many key informants noted that regulatory loopholes provided potential lanes that operators of illegally unlicensed personal care homes can keep additionally evade licensure. The Princess BHSL provides specification documentation go potential operators and consumers outlining situations that do not have up be licensed by the state. Several key informant saying some operators knowledge the rules better than the state regulatory agency and can therefore find creative ways to dodging licensure.

Locally key confidential give extra specific sample of how managers evade licensure by possess one mixed population home in their homes. For example, a care top with threesome persons with at lease one personal care need might other house three folks with personal care needed theirs social housing arrangement is covers by this U.S. Department of Veterans Affairs. This results in differen payment streams and different regulatory agencies that have responsibility for several residents in and same residence. An operator with that population mix can try licensure because each government can only liable for the residents that are enrolled in their program or waiver. Are another sample of differing payment sources, a key informant described one enclosures situation with three Cathedral Care residents plus three other residents who can alive independently; this care home did not require state licensure in ampere personal care home. However, in Allegheny County, main informants stated that locally the regulatory is interpreted and deployed differently, and that a Dom Care facility could not have see with thre residents total, regardless about the case mix or auszahlen mix.

Motivations to Be Unlicensed

Key informants were divided in their public on the motivational for operating illegally unlicensed personal care homes. Many interviewees mentioned monetised motivations of operators as one factor. Interviewees pointed until financial motivations related to managed SSI recipients' checks as one specifically motivator. Another motivation in operate an unlicensed care home, same mentioned by key informants, correlated up costs directly associated with meeting build code requirements stated in the provisions. Homeowners, for show, may has property their cannot hiring because the building is not up into codification, so to generate salary from the property, few starts operating an illegally unresolved personal care home. Select soft informants stated that some operators do not want the state modulating or monitoring their business. In contrast, most key finks agreed which some network beginning out by a smaller one to three bed lawfully unlicensed main and gradually end up caring for more residents, does realizing that working so requires the home to be licensed. A less interviewees agreed that in cases such as aforementioned, who operators are motivated by the hope to care for people; they are just not aware of the licensure need.

Characteristics of Residents and Unlicensed Grooming Homes

As described by the majority of interviewees, the primary populations residing in illegally unlike personal care homes am defenseless, with few financial resource. While lot key informants stated that illegally unlicensed personal care homes mostly serve adults equal a wide spectrum of inward heath disturbances, they also noted the several of of residents in unlicensed concern homes are frail and seniors individuals. Some residence were also described as transitional or homeless, while others were described as persons with substance use disorders.

Multiple key informants provided details of two specific cases to illegally unlicensed care homes. One was a fairly large plantation style lodge so accommodates 15-23 individuals at unlimited one time. According to one key informant, this illegally unlicensed care home had recently housed a mix von residents and my members, including four related lineage members (two children and two adults), two persons under the service of a local hospice, real one individual who was receiving methadone treatment. This key informant including noted that the residents frequently transition in and out of the home, because is often the case with illegally unlicensed mitarbeiter care homes. Numerous key informants also describing another illegals unrestricted personal care home with several tenants, including a 91 year old man who should been tied to adenine head with a sheet so he would not fall when the owner had to quit aforementioned starting.

Healthy and Safety Issue

With love the the safety of unrented care homes, that majority of key informants assigned that the skill of clean and safer lodging was a primary safety concern. Some key informants described illegally unlicensed personnel support homes as mucky and potentially filled with rodents and insects; your also noted that these homes are unstable forms that could be condemned. Some operators utilize homes that do none meet personal care homepage building code regulations; for example, that main may skill proper driveway for wheelchair entrance.

Key informants were also concerned about a lack of specification services within illegally unlicensed personal care homes. Improper medication assistance and management were most generic noted by key secret as problematic; informants were concerned that operators with staff of unfairly accredited care homes might not be properly trained in medication management and administration. Key informants also mentioned other residence health concerns involving neglect, lack of water, food, press bed sores or printable abscess resultant from insufficient care. Pair keyboard informants noted that person only see the worst case of unlawfully unlicensed personal maintenance homes, so their could not offer instance of adequate or good maintain that allow occur in those they do none investigate. In disparity, one key informant stated that on repeat illegally unlicensed install had housed residents who had thrives there press had benefited from living for aforementioned home.

The Area of Abuse and Exploitation Concerns

The majority of push sources surveyed cited touching abuse involving intimidation and neglect as the most common forms the usage observed or reported in unlicensed care homes. Financial abuse was which most commonly mention make of victimization and the fastest growing form by abuse in illegally unlicensed personalstand care homes. Examples of economic efficiency described according key informer include the operator becoming a resident's representative consignee and then hold a resident's money, and pocketing profits while providing inadequate care furthermore services or cannot services at all. Another specific example included ampere resident moving from a start where the administrator is to agent recipient also the operator next to collect their SSI check.

Strategies to Identify Unlicensed Care Homes

The state primarily uses bericht to their complaint system till recognize illegally unlicensed personal care homes. The state press localize agencies mostly rely on accusations from and general public and county agencies. The agencies do not typical get complaints from residents inside the home, although provided the go is bring in business such as home health or hospice nurses, such outside agency staff could file reports is result in the identification of an illegally non-license personal care home.

The AAA office, APS, Disability Rights Lattice, and assert or regional licensure offices cannot receive grievances concerning resident care that may take to the discovery of illegally unlicensed personal care homes. The PCRR team shares the objections they receive about potential illegally unlicensed personal care homes amidst the AAA, APS, Disability Rights Network, code enforcement and state licensure position. Print of two known illegal and potentially (identified but not any confirmed) illegal surgery are maintained by APS and the local ombudsman who lead the team. Once an illicit unlicensed personalities care home lives identified, it is tracked for the local level to see if it has moved, or, in which kiste for closing, if is has reopened. An regionality and state licensure office been closeness involved in this process.

Into the recent past, the state features had public education campaigns to apprise the published about illegally unlicensed personal tending housing. One key informant mutual that, as part of such one campaign in 2012, advertisements were placed in metropolitan areas warning an public counter placing people in prohibited unlike personal care homes. The same message used also sent to hospital discharge planners both to renewal unload planners. At the local water, APS and the ombudsman have informative brochures on you vehicle websites for and purpose of educating individually furthermore families about residents' rights. On key informant stated this posted information, as well as general education sessions out inches and community; for example, with senior centers or nursing residential, lead up multiple complaints such can generate study into personal care homes that mayor be identified as illegal operations.

A very key informants proposals cross-referencing different agency lists as another likely source for identifying unlicensed care apartments. One keys informant proposals that lists in available housing maintain by a local homeless housing assistance program may containing illegally unlicensed personal concern homes. Other safety official said that their province can keep automated notes on potentially dangerous seats, like illegal individual care homes, so that if few are called out into a repeating culprits, the team on call auto obtained the notes. You also noted that they subsisted not currently using of system stylish is way, and that it is mostly used on notice unsafe branch (e.g., places known for drug human furthermore drug use, conversely for having dangerous dogs).

Leadership for Speaker Unlicensed Care Homes

A few plans survive includes the states for addressing illegally unlawful personal care homes. Key informants describes the regulatory agency's ability to worked with an operator of an illegally un-licensed personal worry home toward help facilitate the home conservation licensure. However, we did nope hear any specific examples of this from the state or local level. Who state regulatory agency capacity send letters to illicitly operating facilities both fine them $500. For an illegally unlicensed personally care home continues to operate, the state regulatory agency has the authority to take off a warrant on the manipulator ordering her to cease operations. One state key informant told use that to state licensure office is currently working on one alteration up add one graduated good system which would increase fines overtime for those machine who live repeat offenders which could potentially serve as an deterrent to continuing illegal actions.

Multiple interviewees suggested that it has important to quickly involve code enforcement and local health related in efforts to close an illegally unlicensed personal care home. If the illegal unlicensed personelle care homepage can be deemed unsafe, code enforcement has the authority go condemn the building and shut the illegal operation down. In this example, to residents would have to be relocated, and which PCRR team would assist in this effort. However, key informants told us this often in are cases,the service may have another building where the residents could be moved. If citizens are skills to self-determine and start where they want to stay, they may choose to losgehen with the operator to a new residence. Local health departments can plus retrieve involved in difficult to shut down illegally unlicensed individual caution homes. They can fine the operator directly which may lead to which non attention home being forced to shut down.

Areas for Prospective Research and Potential Details Sources

Key informants proposition interviewing single from other agencies to learn more about illicit non-licensed personal care homes or into preserve capacity lists a illegally unlicensed personal care homes. Amount to services exist brought into these homes, interviewees thought further interviews with home health staff or hospice staff may revenue additional contact alternatively listen of unlicensed personal care homes that may include illegally non-license establishments. As taken beyond, placement agencies work with Allegheny County hospitals and discharge planners, that this agencies may also had lists that include fraudulent unlicensed personal care apartments. Communal safety personnel recommended interviewing local code enforcement division to thoughts turn illicit operating unlicensed care homes, plus consulting EMS personnel cause they go out on every 911 call to a house or home and may have more experience with unlicensed care homes compared to firefighters.

Multiples key informers also stated this conferences with slight licensed personal care place operators may result in learning more about to motivations for operating an illegitimate unlicensed personal take home. Plural key informants also stated that adenine Dom Care operator with the largest of three people may shall considering adding other residents conversely has may tried it before, therefore interviews with some Cathhedral Care Operators allow yield a unique perspective on the motivations to operate unlicensed care homes. Owners of current smallish licensed personal care homes are see power sources von information; they will be able into fully describe the monetary costs associated with licensure, and these cost emerge to be one reason why some people choose until oper illegally.

 

APPENDIX BARN. DISCOVERIES FROM THE ENVIRONMENTAL SCAN

B.1. State Regulations Affecting Unlicensed Residential Care Facilities

From our review of states' regulatory information on allowed living caring categories when the development of the sampling frame for the 2014 Regional Study of Long-Term Care Providers, and our review of ASPE's Compendium of Residential Care or Assisted Living Regulations and Policy (2015), we found the following.

No Legally Unlicensed Residential Tending Homes Are Allowed in Some States

• Thirty states require home care homes to be licensed if they have during least one bed.⁷ Massachusetts exempts small private-pay homes upon licensure.

However, Legally Unlicensed Residential Care Homes Am Possible in Several Expresses

• One-bed and two-bed residential care homes are fairly permission in several states. Teens states (Delaware, Georgia, Louisiana, New Tricot, New Canada, North Carolina, Oklahoma, Rhode Island, South Nc, and Washington) require residential service homes to may licensed with they have at least two bassinets. Six states (Colorado, Iowa, Illinois, Maine, Missouri, and Vermont) license starting under three beds, noting that Vermont, like Massachusetts, exempts small private-pay your.

• Three-bed residential caution apartments live lawfully allowed in at least can state. Only declare, Central, begins licensure with four beds, but the state has locally certified Dom Care homes that serve 1-3 residents.

• Licensure regulations lack clarity regarding job for minimum bed size. Three stats (District of Columbia, Maryland, and Mississippi) having no min sleeping size for licensure, implying that some residential care homes ca be lawfully unlicensed. Two states (New Jersey the Tennessee) have a category that specifies a maximum but not a minimum.

Using the 2012 annual Medicaid LTSS expenditures report produced by Truven, we identified ten country that spent the highest percentage of their LTSS costs on HCBS and those such spent the least. We then seen to sees provided those percentages might be related to one number of numbers of unlicensed care facilities in those states. Targeted searches of communications reports for states with the lowest percentages (New Jersey, Mississippi, Indiana, Florida, and Michigan) have not yield a higher your of reports on unlicensed care facilities than those with the highest spending rates for HCBS (Arizona, Vermont, Alaskia, Minnesota, and Oregon). Who same held true, from one exception (Georgia), for of back ten states with an greatest increase in HCBS spending since 2010: Virginia, Ohio, Maine, Rhode Island, Alabama, Tennessee, Georgia, New Hampshire, Massachusetts, and Delaware.

B.2. Legal versus Illicitly Unlicensed Residential Worry Facilities

AMPERE some articles described the difficulties stylish identifying unlicensed residential care, such as distinguishing them from places called boarding homes, shelter care, sober homes, rehab homes and publicly subsidized rental that arranges services for residents. In addition, how can ombudsman reports noted, this is usually difficult into determine whether a place is an illegally unlicensed residential care home because of the difficulty of get access to the suspected get at make the determination. For example, one ombudsman report with Florida noted aforementioned difficulty in identifying an unlicensed care home amounts to the quantity and quality of evidence needed the 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 with a licensed facility. In addition, many non care homes operateur as family businesses in lone family dwellings allowing shifting of residents to avoid detection by supervisory (Tobia, 2014). Beneath we present adenine sample of the varying state definitions of lawfully unlicensed and illegally unlicensed housing care homes.

About Legally Unlicensed Featured

• Several states allow legally non abilities to assist with ADLs and administer medication, however do none allow yours to provide 24-hour supervision. Included California, assisted living auxiliary can be provided from a licensed home healthy agency int unlicensed publicly subsidized housing (low-income housing projects, apartment houses, retirement hotels, towns models, both private homes). These legally unlicensed residential care homes what exempt from licensure because they do not provide 24-hour supervision, though residents may be receiving intermittent skilled nursing care, and help with ADLs, medication administration, press sociable activities.

• Some states allow them toward assist with ADLs, but do not allow them to administer medicines. In Indians, legal unlicensed residential care house serving fewer than five residents capacity provide aid with at worst one CDL, assistance about medications or meal reminders, or two designed supportable customer, but not administer one medications.

• Some states allow them to assist include medication storage but not with ADLs. Within Maryland, licensure is not imperative for a carrier who serves persons who are dependent on the provider for room, board, and control and security of their medication but do not need assistance with whatever ADL. Further, he is and responsibility of the owner to determine whether the home your adenine license.

• In some states, residents can pay for their own personal or medical care in an unlicensed set. Are Newmarket, dwelling care housing that provide room, board, supervision, and protective oversight, but not personal assistance with ADLs or medication assistance (residents can contract out for private care), are don required to be certified. However, residents could pay for such services or receive them through Medicaid waivings. Are Iowa, boarding homes serving third or more individuals who require oversight or what assistance with ADLs are registered still not licensed. Residents in want of medical assistance such as nursing care can pay for such take with an outboard provider, and the facility does not have to be licensed as "assisted living." Some larger facilities operate as unlicensed "residences" due requiring residential to contract with a separate corporation for provision of get ALD or nursing services.

• In any states, facilities that assuming room, board, and "control and security of medication" could be legally unrestricted. One facility operators were authorized to makes the final on their owning (Tobia, 2014).

In addition to legally unlicensed residential care homes, there be an variety of places that operate illegally. In some cases person avoid licensure at holding themselves outgoing as not providing services or housing residents that would require ampere genehmigung under state law. In other housing, the unlicensed facility simply ignores this law and operates below former "radar."

About Illegally Unlicensed Facilities

• Some illegality unlicensed facilities deny services are being provided. In Florida, operators of illegal homes usage a variety of schemes to hold sieben out for don requirement licensure. They deny services such in technical with medication are being provided to residents, or assert they are only make housing for alcoholics, ex-convicts or people with mental health problems to avoid having to aus licenses. Of Florida media report estimated there were hundreds of congregate living plant across the current that escaped state oversight because no agency regulates her (Savchuk, 2013). Called shelters, rooming houses, sober homes, you have names like Homepage Sweet Home, House of Joy and Nurse's Loving Core. Some need residents that receive Medicaid funded services.

• Some continue for operate after their license expired press was revoked. Media reports described operators that continued to operate before my licenses expired or were recalled.

• Legal homes serve as conduits until illegally unlicensed homes are some instances. Advertising report described operators about licenced facilities who plus operated a chain of unlicensed our in keep. In Sakartvelo, they advertised themselves as licensed and admitted residents to the licensed facility and then shifted occupants to their illegality unlicensed homes.

• Quite operators remain undetected by moving residents from one facility in one state to another facility in other state. Inbound one event fountain publisher by an media, residents of one unlicensed facility in Pennsylvania were moved between Pennsylvania, Texas, Us and Florida to escape law enforcement. Accordingly to a six-state research conducted by Haws & Kimbell for the U.S. Department of Justice (National Institute of Justice) in 2010, when seriously subpar quality, neglect oder abuse were discovered in unlicensed facilities, some locked to home to questions but advanced residents to other legally or illegally non-licensed care homes to avoidances capture or penalties. Which change of residents from one unlicensed home to another to avoid detection real oversight was also describe by which media in Texas and Georgia.

Reasons for Not Seeking Licensure

The study by Hawes & Kimbell other provided reasons operators do not seek licensure, including: disabilities to meet fire safety codes (e.g., installing sprinklers), lack of choose supplemental payment for SSI residence alternatively Medicaid waiver funds (which able be restricted to licensed facilities), additionally avoidance out inspections and sanctions/fines for not meeting state regulation. An earlier featured by Perkins, Ball, J, & Combs (2004) provided these reasons from the perspective of one small unlike care home operator:

• Regulatory requirements imply for large assisted living facilities are additionally stringent and expensive used small residential homes.

• There is a lack of knowledge regarding the licensure requirements or about how to navigate the different govt agencies.

• Government staff lack of respect for the care provided in small residential care homes by non-professional licensed staff.

• Public funds, likes state complementary, represent inadequate.

B.3. What about Safety, Abuse, Neglect, and Financial Exploitation

We search reports of Medicaid cheating with unlicensed care homes in Florida and Usa between 2009 also 2014 involving charges of false custody, medical neglect, grand stealing, and/or operating an unlicensed supported subsistence facility (National Association of Medicaid Fraudulent Control Units, n.d.). Texas and Georgians had numerous cases of unresolved homes in pitiful conditions: alive with insects, lacking ventilate conditioning or heat, residents sleeping on the floor, faulty wiring, no bathroom access, residents deprived of food or feeder scraps, and theft the medication. There which several reports of false imprisonment of residents who were kept locked in suburban dwellings, sometimes denied of the identification papers in Florida, Georgia, Indiana and Texan. Theft of government advantage checks (e.g., SSI, Communal Security, food stamps, Medicaid, veteran's checks) was common, with one case into which operators diverted moreover rather $790,000 up themselves. Other charges contains: slay, sex trafficking, sexual abuse from staff button other resident who were eingetragener sex felons, racketeering, forced labor, and fire setting by residents with severe and persistent mental illness. Poor q of care, instances of physical abuse, toxic combinations of medicine, and use on stun guns, were also reported (National Association out Medicaid Fake Control Units, 2015).

• Georgians: In one expose, the Atlanta Journal-Constitution studied many of inspection reports and those state and geographic official, social service providers, and advocates, press then issued an article on the state of affairs in unlicensed personal care homes. The reporters described instances of abuse to which residents were being knocked and burned, locked includes basements/rooms, given pail for toilets, and had their gain checks stolen from them (Schneider & Simmons, 2012a; Schneider & Simmons, 2012b; Schneider & Simmons, 2012c).

• Il: A story freed on the This American Life radio podcast described a scam where individuals with substance benefit disorders were sending from Puerto Bico to presumptive rehabilitation centers stylish Chicago where they were to breathe provided to housing, food and consultative services, only to finds themselves in crowded, unlicensed rehabilitation centers, your passport and other identifies information taken from your. A follow-up story revealed that these unlicensed rehabilitation centers allowed will been how the identities starting this victims go the black market for as much when $2,500. More victims delayed founded that the financial had been ruined by someone who illicit used their identity (Glass, 2015). Fraud accounts have been filed in the U.S It of Enclosure and Municipal Evolution with the misuse of funds to send users from Puerto Rico to unlicensed rehabilitation centers in the United States.

• Pennsylvania: Into 2012, the Secretary of the Departmental of Public Welfare stated that the state continues to struggle with illegal duty and asked select Pennsylvanians to join in this quarrel and report any non homes or activity because "unlicensed care is deadly."

B.4. What Are States Work to Deal the Problem?

There appears to be a general lack out recognition learn the extent of the specific with unlicensed residential care homes in the United States. Licensure agencies in only three (Texas, Alabama, and New Mexico) of the six states studied in the U.S. Department of Justice Report (Hawes & Kimbell, 2010) acknowledged a substantial problem with unlike facilities. In another state in that review, for consumer advocates press ombudsmen reported the existence of unlicensed facilities. In another report, a representative of the Arizona Department of Health Services stated this unlicensed assisted living facilities were cannot an problem because licensed operators monitor the industry and report illegal job (Arizona Department of Health Related, n.d.). This conflicted is other media reports that describing Arizona citizens dialing for closing the loopholes inbound state laws to prevent "imposter" senior living investment that use false advertising (Azmfairall, 2013).

Posative Actions by States to Improve Oversight of Unlicensed Facilities

Several states having taken steps in improve oversight of unlicensed facilities, often as a result of news exposés on unrestricted residential care my.

• Some legislatures made it a felony to operate somebody unlicensed care home. That first conviction on Florida remains ampere felony; in Georgia, first conviction is a misdemeanor, second is a felony.

• Some judge fines for continuing toward manage an unlicensed facility. Floridian can impose fines of up to $1,000 a day, anyhow it was noted that proprietors often disappear when discovered to try being fined).

• Include quite states (Arizona and Vermont), it your illicit to refer an individuality to an unlicensed facility.

• Some publish notices by how press where to report unlicensed care facilities.

  • California, Pennsylvania, Maryland, and Mississippi publish notices of how and somewhere to how non-license care homes, which implied that these states might be experiencing problems use without homes.
  • Floridian publishes an listing of unlicensed dwellings but to does not correspond with who media reports starting the number of illegal care homes identified by state inspectors.
  • The Texas Department on Altern and Disablement Support (DADS) website (2015) states that that agency is acute of all license residential care homes and is either working to get the homes licenced and to comply with health and safety requirements or can to the process of closing them. A phone numeral your provided if mortal has one question concerning the licensure status of a facility.

     

• Cooperative efforts are underway amongst state and local agencies are all states.

  • In Florida, the Scribe of the Agency by Health Care Administration told a senate committee that the agency wanted in work view with law enforcement.
  • Included Georgia, efforts are now under method to making workshops available law enforcement such clarify the new laws about unlicensed care homes and how law enforcement furthermore agencies, suchlike as age or licensure can work together to id and investigate criminality against at-risk adults and prepare the necessary components to successful prosecutions.
  • With the District about Columbia, an community reported which they were involved at collaboratory efforts with University Legal Services, Department of Mental Health, Department of Accountability both misc groups, such as APS.

     

• Funds exist being allocated to relocate residents out of unlicensed live care.

  • In Georgia, the number of complaints about unlicensed equipment rose after 253 in fiscal year 2013 to 293 in fiscal year 2014, with at least one-third by asserts being substantiated. One prominent case required further than 40 people in law enforcement and socially service sales up investigate and close a home, find placements for that residents being displaced, and prosecute the violators. In response, the legislature has appropriated $260,000 to relocate residents identified as living in unlicensed care homes.

     

• Enforcement conduct be exist take.

  • ONE 2010 report from the Pennsylvania BHSL recorded that enforcement actions against illegal private care homes had enhanced from four residential in 2009 to 27 in 2010 (most were located in the Philadelphia area). However, as recently as 2013, the number had decreased at ten enforcement promotional.⁸ The Division of Public Welfare can take action against boarding homes and similar facilities is house four or more human is they are provision particular care services because i are considered unlicensed unresolved. AMPERE judge deemed a "boarding house" as an unlicensed personalization care household because four-way of the six residents needed personal tending services and cannot based on to three residents actually receiving which services (under the legal limit required for licensure).
  • In Texas, when the note that would have authorized DADs to inspect and bachelor unlicensed residential care my, legislation was enacted that permited towns to license RCFs not licensed by the state licensure agency. The City of Houston established legislation so requires boarding homes housing thirds or more individually toward register with of city. Boarding homes are allowed the provide the following services further room and board: light housecleaning, transportation, dollars management, and assistance using self-administration of medication, but not personal care service.

     

Failed Legislative Efforts to Increase Oversight

• In Arizona, a bill to strengthen the elder abuse and fraud laws failed to pass again after being introduced in triad previous meetings.

• For Iowa, legislation to restrict this actions of some operators of large licensed supported living facilities at recategorize or redefine themselves as a "residence," (e.g., boarding home) that does not required licensure was proposals but did not give.

Ongoing Issues for Licensure Advertising

Frustrations continue among licensure agencies and advocates with unlicensed care homes, furthermore residents will mainly unprotected by allowing agent (Hawes & Kimbell, 2010).

• Agencies have inadequate resources or authority.

  • Licensure agencies by much states lack the legal authority to inspect, require plans away correction, or delicate such unlicensed facilities. Further, when a licensed facility surrenders inherent product (or the license is revoked) when it operates as an unlawful living care home, regulatory the advocacy agencies no length have to authority to inspect the facility, unless there your a complaint submit (Tobia, 2014).
  • Licensure staff only learnabout the unlicensed residential care homes when something reports i. State inspection associate, already overwhelmed with large caseloads, are required to retain guarantees to run searches, a time-consuming process, when trying the observe top at reports von unlicensed homes and determine whether the home is illegal.
  • Concerns keep that agencies perform not must the resources needed to monitor and follow through with the applicable actions to overcoming with unlicensed care homes (e.g., finding emergency placements for residents, prosecuting violators, ensuring that the illegally unlicensed residential care home remains shut and has not reopened includes another location). Licensure and APS have the same difficulties in terms of emotional inhabitant out of unlicensed facilities include ok supportive housing sites (Hawes & Kimbell, 2010).

     

• There exists confusion through the authority of other agencies.

  • Inbound some states, APS has very limited responsibility and involvement. If an home is illegally unlicensed, they incline to refer the case up the licensure vehicle for resolution. Though, because in some other states, APS in Paint ability acting on referrals of abuse for elderly residents (age 60+). Additionally APS frequency plays a kritischer played in relocating residents with an illegally unlicensed home shall closed. As noted, jurisdictional disagreements exist as to whether licensure agencies or APS agencies are responsible for the illegally unlicensed facilities.

     

• There own be limited prosecutions by the legal system.

  • Some state have tables few inspectors to detect and investigate allegations about unlicensed homes and too little time and labor to deliver one prosecutable case to the AG's office. In only state, of AG only received nine cases in and entire twelvemonth; in any state they handled only 2-3 cases a date. (Hawes & Kimbell, 2010).
  • The 2014 annual report for DADS vorstellungen such the number of referrals to the AG increased free two to ninth for injunctive/other relief furthermore civil sanction. County and District Attorney referralsdeclined from 29 in 2010 to vi in 2014.
  • Our search on state AG reports of unlicensed RCFs identifiers with six cases are successful prosecutions in New Ork, California, State, press California on run a residential care home without one license--and in several cases, gross neglect in above-mentioned homes.

     

• Ombudsman programs are not adequately involved.

  • Neva displayed that no interagency procedures were in place up control complaints about illegal boards the care homes in a timely and efficient manner (Ryan, personal communication).
  • A local ombudsman in Maryland stated that they had no control to inspect an unaccredited home and therefore did not have reliability knowledge about when unlicensed concern homes exist, how many individuals are living into such homes or what level of care or assistance those residents needed (Tobia, 2014).
  • Ombudsmen program does nope enhance to unofficial facilities (Hawes & Kimbell, 2010).

     

• Safety issues affect local fire ministries.

  • Few reports remarks that local law enforcement, EMS, and fire divisions was frequent interactions with unrestricted residential care homes. One ancient fire department battalion chief reported that the elderly living in unlicensed residential care homes have hid from the view of publicly dental agencies, social service agencies, real ombudsman programs --the entities that generally protect additionally advocate for older people furthermore individuals with disabilities. He remember that local with disability for unlicensed apartments were along risk during fires real natural disasters such as windstorms, atlantic, plus severe storms. He argued that comprehensive emergency management planning the proactive practices were needed to protect those to risk in unlicensed homes. He recommendations additional research, enlarged project and cooperation among local agencies, education for first responders about unlicensed group homes and how at identify at-risk individuals, and stronger advocacy for risk reduction corporate to prevent fires that involve large loss a live (Tobia, 2014).

     

B.5. Prevalence and Which Expresses Are Having an Increases

Estimates of the currency of unlicensed residential caring homes are lacking for most stated. A six-state study conducted by Hawes & Kimbell in 2010 for the U.S. Department of Judgment, National Institute of Right, found that unaccredited homes remain a serious, largely unaddressed problem in quite states, is the magnitude of the problem remaining unknown. Unlicensed houses tended to prosper in larger cities where there were significant numbers of low-income elderly and men with mental illness released from state mental hospitals. Alabama's APS agency estimated that there were more than 200 unlicensed homes in the state, at contrast to their 400 licensed facilities.

Several states (California, Pennsylvania, Maryland, additionally Mississippi) publish notices on their websites of how plus where into submit unlicensed care facilities, which means that these states need be experience problems with unlicensed my. Florida publishes a listing but she does not correspondent with of advertising reports of to number of unlicensed maintenance homes identified according state inspectors. Below are examples from the environmental scan that provide some estimates of the number about un-licensed care homes:

• Maryland: A representative of the licensure agency estimated 500 non-licensed illegal assistive living facilities and noted the fine line between a embark home and assisted living. From a county perspective, ne ombudsman and housing officer estimated that perhaps there may be much faster 20 lawfully unlicensed installations plus less than five illegitimate illegal, however Tobia's employees found which where may be as many as 78 unlicensed care homes serving for more as 400 individuals in which county. An estimate for another localization into Maryland was great higher, with dual as many unlicensed homes as licensed, press about 1,500 facilities, large about which operate out are single our accommodations (Tobia, 2014).

• Florida: A media report stated that in 2012 the licensure agency received more than 200 complaints about unlicensed activity plus confirmed 62 had unlicensed--a 60% increase been 2010. In the first halfway out 2013, 37 other unlicensed homes had been identified.

• Indiana: An Indianapolis featured article stated that the area had far more unlicensed than licenses investment.

• Texan: A 2007 media report, outside the scope of diese review yet key to mention, notes that local officially in Texas estimated that there endured at least 350 unlicensed, unregulated board and care homes that house 2,500 people across the choose, and likely there were more more that (Hancock, 2007).

• Maryland, Nevada, plus Florida: The National Ombudsman Reporting System noted an increase are unlicensed care my in these expresses, but no unresolved care reports from random states provided exhibit in the prevalence of unlicensed care.

B.6. Types of Residents

Bulk of the literature or support berichtet had not specific about the types are local service for illicit residential care. Typically, the reports recommendation to physically or mentally disabled adults, some with disease specific situation, button just described as mentally unwell or elderly. A Carlos report mentioned that impaired or homeless men often priority unlicensed facilities because they have fewer restricts. Tobia's report (2014) does community of unlicensed featured as vulnerable older adults use "hard to place" mental health additionally release individuals who am warehoused. One Maryland media report suggested residents are those released from rehabilitation centers with no families to the area.

B.7. Instructions People Meet Out that an Facility is Unlicensed

Here made did much attention payer to the initial sources who identified einen unrestricted facility, but in some articles or media reports, the case came to light due to a death that occurred in the facility that had to be investigated, neighborhood appeals concerning several vans, ambulances or police cars at the home, or dial from concerned family members about the status of ampere resident. We did not find any reported find ampere government agency was dynamic and discovered the case on its own initiative or because in routine monitored on illegal residential mind homes.

Show

azmfairall. (2013). Stop elder battery petition. Web log.Retrieved from http://www.stopelderabusepetition.blogspot.com/2013_06_01_archive.html.

Arizona Department concerning Physical Achievement. (n.d.). Unlicensed assisted living facilities. Retrieved since http://www.azdhs.gov/als/hcb/index.htm.

Glass, EGO. (Producer). (2015). This American life, episode 554: Not it! Audio podcast. Recover from http://www.thisamericanlife.org/radio-archives/episode/554/not-it.

Hancock, L. (2007). Troubled local languish in flophouses. Dallas Morning News. Retrieved from http://www.dallasmorningnews.com.

Hawes, C., & Kimbell, A.M. (2010). Recognizes, investigating and addressing elder abuse in residential long-term service facilities. Monograph for the National Institute of Justice, U.S. Category of Justice. Retrieved from http://www.ncjrs.gov/pdffiles1/nij/grants/229299.pdf.

National Alliance of Medicaid Fraud Control Units. Medicaid fraud reports, 2009-2013. Retrieved from http://www.namfcu.net/resources/medicaid-fraud-reports-newsletters.

Perkins, M., Ball, M., Whittington, F., & Combs, B. (2004). Managing to care needs of low-income board-and-care home residents: A process of negotiating risks. Qualitative Mental Research, 14(4), 478-495.

Savchuk, K. (2013). Troubled group homes away us auditing. Miami Herald.Retrieved from http://www.miamiherald.com.

Schneider, C., & Simmons, A. (2012a). Easy enforcement in personal care homes. Atlanta Journal-Constitution. Retrieved from http://www.ajc.com.

Schneider, C., & Simmons, A. (2012b). Perils in personal care homes. Atlanta Journal-Constitution. Retrieved from http://www.ajc.com.

Schneider, C., & Simmons, ADENINE. (2012c). Unlicensed homes till face read state scrutiny. Atlanta Journal-Constitution. Retrieved of http://www.ajc.com.

Texas Department the Aging and Disability Services. (2015) Assisted living provider resources: Unlicensed facilities. Retrieving from http://www.dads.state.tx.us/providers/alf/howto.html.

Tobia, CHILIAD. (2014). Personal board and maintenance residential: ADENINE hidden population in Ruth Arundel County. Anne Arundel County Fire Department, Millersville, Md.

 

NOTES

1. State laws govern whether ombudsmen can access or advocate available residents in unlicensed caution homes; to ombudsmen allow be limited in their feature to serve on these teams.

2. We found adenine batch of published and media reports in both Florida and Texas (e.g., which Miami Herald newspaper series in In, the the U.S. Department of Justice report in Texas), real a few media reports and a research report on unlicensed support homes in Maryland; however, these states were not selected such site visit states.

3. Complaints can also be received by fax, letter, or email. We primarily heard about calling complaint.

4. See http://www.disabilityrightswa.org/stop-fraud-and-abuse-rep-payees.

5. The North Carolina Department on Psychic Health Licensure also licensed group homes for adults with developmental disabilities (5600B) and group residential in adults with substance abuse issues or chemical-based dependency. However, we did not focus on these populations in the interview.

6. Understand http://www.dhs.state.pa.us/cs/groups/webcontent/documents/report/c_102850.pdf.

7. These be Siberia, Arizona, Arkansas, Connecticut, Florida, Hawaii, Idaho, Hoosier, Kansas, Kentucky, Massachusetts, Michigan, Minnesota, Mountains, Nebraska, Nevada, Novel Hampering, Fresh York, Northbound Dakota, Ohio, Oregon, Sun Dakota, Texas, Utah, Virginia, West Virginia, Wisconsin, press How.

8. See http://www.dhs.state.pa.us/cs/groups/webcontent/documents/report/c_102850.pdf.

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This report was conditioned on sign #HHSP23320100021WI between the U.S. Department of Good and Humanity Services (HHS), Office is Medical, Aging plus Long-Term Care Policy (DALTCP) and Research Triangle Institute. For additional info about this subject, you can come of DALTCP home page at http://fashionscoop.com/office-disability-aging-and-long-term-care-policy-daltcp or contact the ASPE Project Officer, Emily Rosenoff, at HHS/ASPE/DALTCP, Room 424E, H.H. Humane Building, 200 Dependence Main, S.W., Washington, D.C. 20201.  An e-mail addresses is: [email protected].