Personal board and care homes: A hidden population in Anne Arundel County. We also heard suggestions from some SMEs and state stakeholders for improving safety and quality. In this study we sought to identify: Characteristics of unlicensed care homes and the residents they serve. Pennsylvania Department of Public Welfare. There is a critical challenge of providing housing and supportive services for particularly vulnerable groups, including individuals: who have severe and persistent mental illness or other disabilities, were formerly homeless, or older adults who have limited financial resources. These parts include: Not surprisingly, fees vary by location, provider, the type of services provided and the amount of care the resident receives. For example, one SME from a state licensure office reported that their database does not include information on whether the call pertains to a licensed or unlicensed care home. While we visited only three communities, the concerns articulated by the case study respondents were echoed by SMEs from other areas of the country and are consistent with the literature and media reports in the environmental scan. Using the 2012 annual Medicaid LTSS expenditures report produced by Truven, we identified the ten states that spent the highest percentage of their LTSS expenditures on HCBS and the ten that spent the least. Multiple key informants described unlicensed care homes as primarily serving persons with mental illness. Unlicensed assisted living facilities. Almost all SMEs and key informants we interviewed offered strategies to identify, monitor, or close unlicensed care homes. Overall, key informants were able to provide little information about the prevalence of illegally unlicensed care homes (henceforth referred to as unlicensed care homes); informants we spoke with at both the state, local licensure office and APS reported that they do not currently systematically monitor or track unlicensed care homes. The remainder of this section summarizes findings from interviews with SMEs and site visit key informants, and also includes additional information from the environmental scan. Using the 2012 annual Medicaid LTSS expenditures report produced by Truven, we identified ten states that spent the highest percentage of their LTSS expenditures on HCBS and those that spent the least. Their services focus on medical care more than most assisted living facilities. One state key informant told us that the state licensure office is currently working on an amendment to add a graduated fine system which would increase fines overtime for those operators who are repeat offenders which could potentially serve as a deterrent to continuing illegal operations. In Georgia, all unlicensed personal care homes are illegal, and thus to remain in operation they try to avoid being identified. The regional and state licensure offices are closely involved in this process. Although the majority of key informants described unlicensed care homes as unsafe environments where residents are abused, neglected, or exploited, it also was noted that some unlicensed care homes may provide quality care in safe and clean environments. Pennsylvania Department of Public Welfare. Key informants mentioned that state funding and regulatory mechanisms specific to Pennsylvania had a direct influence on the state's capacity to address illegally unlicensed personal care homes. In 2012, the Secretary of the Department of Public Welfare noted that the state continues to struggle with illegal operators and asked all Pennsylvanians to join in the fight and report any unlicensed homes or activities because "unlicensed care is deadly" (Pennsylvania Department of Public Welfare, 2012). The latest thing with hospitals, not only discharging to substandard places, the hospital is paying for the first month because it's cheaper than an expensive hospital bed.". After completing the vetting calls, we emailed an introductory letter explaining the purpose and goals of the research to the potential interviewees. Most of the literature and media reports reviewed focused on the pitfalls of unlicensed care homes and the poor quality and safety provided in these settings. According to one key informant, this illegally unlicensed care home had recently housed a mix of residents and family members, including four related family members (two children and two adults), two persons under the care of a local hospice, and one individual who was receiving methadone treatment. For example, in Georgia it recently became a misdemeanor to operate an unlicensed care home,therefore we aimed to speak with law enforcement officials who had been involved in the process of investigating unlicensed care homes. In Durham County we interviewed key informants from APS, Group Care Monitoring Services, a local hospital discharge planner, a local ombudsman, and one local law enforcement official, who also serves on a crisis intervention task force. Care homes provide care 24 hours a day, 365 days of the year. State informants did not provide information on the services provided in 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. Per state regulations, residential settings providing room, board and personal assistance with three or fewer residents who have at least one personal care need do not meet the requirements for licensure as a personal care home and are legally unlicensed. He also noted that they were not currently using the system in this way, and that it is mostly used to note unsafe locations (e.g., places known for drug trafficking and drug use, or for having dangerous dogs). Further, receipt of a complaint was the most commonly cited method to spur identification of an unlicensed care home. To find out if you are, your local authority will need to prepare a support and care plan. Findings also indicate that conditions in some unlicensed care homes are unsafe, abusive, financially exploitative, and neglectful of residents' basic needs. Residential care homes that serve three or fewer residents are legally unlicensed in this state. In addition, SMEs noted variability across states in the availability of resident advocacy and protection through such agencies as the ombudsman program. NBC News 4, Washington D.C. Retrieved from http://www.nbcwashington.com/news/local/Caretaker-Accused-of-Abusing-and-Neglecting-Kamara-Zanaib-268343912.html. A separate search of a few state Attorney General (AG) reports of unlicensed RCFs identified six cases of successful prosecutions in New York, Nevada, Florida, and California for operating an RCF without a license--and, in several cases, for gross neglect. What concerns are there about the quality of care and safety in unlicensed care homes? Some illegally unlicensed facilities deny services are being provided. Despite this lack of information about prevalence, we heard about many strategies for addressing the existence of unlicensed care homes and the conditions in them. In contrast, in Pennsylvania, the BHSL has the authority to execute a warrant to investigate a suspected illegally unlicensed care home. In Georgia, the number of complaints about unlicensed facilities rose from 253 in fiscal year 2013 to 293 in fiscal year 2014, with at least one-third of claims being substantiated. Based on the findings from this exploratory study, illegally unlicensed care homes appear to be a problem for at least some states; the residents of these homes are extremely vulnerable, and while some are elderly and physically disabled, many have severe and persistent mental illness. Lack of clarity in licensure regulations regarding minimum bed size required by licensure also exists in a few states. Several key informants discussed the role hospitals and hospital discharge planners potentially play in referring patients to unlicensed care homes. The financial pressure hospitals feel to free up hospital beds sometimes results in discharges to unlicensed care homes, both unintentionally and for expediency. Her e-mail addresses is: Emily.Rosenoff@hhs.gov. Some of these homes also serve mixed populations (e.g., elderly residents as well as individuals with severe and persistent mental illness). County and District Attorney referralsdeclined from 29 in 2010 to six in 2014. However, there were many reports of poor conditions in legally unlicensed care homes. And APS often plays a critical role in relocating residents with an illegally unlicensed home is closed. The state made bridge funding available to those group homes impacted by this funding change, but one key informant said that according to a recent report, very few group homes accessed this bridge funding. We focused on a range of questions, including: How do agencies handle specific complaints about unlicensed care homes? The agencies do not typically get complaints from residents inside the home, although if the home is bringing in services such as home health or hospice nurses, those outside agency staff could file reports that result in the identification of an illegally unlicensed personal care home. Owners of current small licensed personal care homes are also potential sources of information; they will be able to fully describe the monetary costs associated with licensure, and these costs appear to be one reason why some people choose to operate illegally. Similarly, by nature of their jobs, many of our interview participants, including APS staff, ombudsmen, police, and fire department personnel, typically hear about care homes when there are complaints or emergencies. At the local level, one key informant estimated that members of the Allegheny PCRR, along with the state licensing office, have investigated approximately five illegally unlicensed personal care homes in their specific geographic region over the past two years. We hypothesized that states that do not have well-funded HCBS programs may have a higher incidence of illegally unlicensed homes than states with more robust HCBS programs. Pennsylvania lists the number of enforcement actions taken against illegally unlicensed residential care homes in their annual report on personal care homes, but this information may not be representative of how many complaints about unlicensed care homes are made (see the state summaries in Appendix A for more details). According to the regulations, some states also allow residential care homes to be legally unlicensed if they have 1-2 beds. 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