Unscrupulous care providers are unlikely to obtain the proper licensing and hire qualified staff due to the cost. Many key informants regarded the closing of Mayview State Psychiatric Hospital in 2008, which was located in Allegheny County, as an important factor contributing to the gap of services and affordable housing available for individuals with mental health diagnoses. In the first half of 2013, 37 other unlicensed homes had been identified. One key informant reported that during the investigation of this home, it also was discovered that the operator was taking the residents' food stamps. Two key informants noted that they only see the worst cases of illegally unlicensed personal care homes, so they could not offer examples of adequate or good care that may occur in those they do not investigate. States with concerns about the prevalence of unlicensed care homes may wish to examine their licensure regulations, as these may influence the supply of and demand for unlicensed care homes, either because the complexity of some regulations makes them hard for operators to understand, or because they might contain loopholes that operators can easily exploit. Areas for Future Research and Potential Data Sources. Interviews with key informants also indicate that many residents are poor and receive Supplemental Security Income (SSI) benefits from the U.S. Social Security Administration (SSA); the SSI program pays benefits to disabled adults and children who have limited income and resources. The closure of large mental health institutions and concomitant transition of previously-institutionalized individuals with severe and persistent mental issues to community-based care settings, such as legally unlicensed care homes. States have a variety of options for reducing the prevalence of both legally and illegally unlicensed residential care homes, such as changing regulations and coordinating across agencies to address these homes. The Room and Board Coalitions primary purpose is to provide access to healthy, safe housing that is either owner occupied or with an on-site house manager.. Retrieved from https://www.socialsecurity.gov/ssi/text-benefits-ussi.htm. The environmental scan and SME interviews informed state selection for site visits. The Assistant Secretary for Planning and Evaluation (ASPE) is the principal advisor to the Secretary of the U.S. Department of Health and Human Services on policy development, and is responsible for major activities in policy coordination, legislation development, strategic planning, policy research, evaluation, and economic analysis. Informants expressed other specific concerns about unlicensed care homes, including improper management of residents' medications; unsafe, unsanitary, and uncomfortable living environments; theft of utilities from neighbors; and fraudulent collection of government payments (e.g., not reporting residents' deaths and continuing to collect their SSI payments). Concerns remain that agencies do not have the resources needed to monitor and follow through with the appropriate actions to cope with unlicensed care homes (e.g., finding emergency placements for residents, prosecuting violators, ensuring that the illegally unlicensed residential care home remains closed and has not reopened in another location). They capture key variables such as the name and any aliases of the illegally unlicensed care home; the owner's name and whether they own more than one unlicensed care home; the licensure status (formerly licensed, never licensed, operating illegally); and any relevant information about the complaint (e.g., investigation dates, or dates any residents were moved/relocated). During interviews, informants talked about situations in which the operators of unlicensed care homes continue to be the representative payee and continue collecting the SSI checks of residents even after the resident moved out of home. As discussed earlier, Pennsylvania is a state that legally allows unlicensed residential care homes, if they serve three or fewer individuals. NBC News 4, Washington D.C. Retrieved from http://www.nbcwashington.com/news/local/Caretaker-Accused-of-Abusing-and-Neglecting-Kamara-Zanaib-268343912.html. 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). Retrieved August 6, 2015 from http://www.medicaid.gov/medicaid-chip-program-information/by-topics/long-term-services-and-supports/home-and-community-based-services/downloads/requirements-for-home-and-community-settings.pdf. In Georgia, efforts are now under way to provide workshops for law enforcement that clarify the new laws about unlicensed care homes and how law enforcement and agencies, such as aging and licensure can work together to identify and investigate crimes against at-risk adults and prepare the necessary components for successful prosecutions. Florida publishes a listing but it does not correspond with the media reports of the number of unlicensed care homes identified by state inspectors. reported by the California Department of Justice. Lax enforcement in personal care homes. Key informants noted that it is important to know the history of Pennsylvania's personal care home regulation changes in order to understand why and how the state has addressed illegally unlicensed personal care homes. Pennsylvania begins licensure with four beds, but the state has locally certified domiciliary care (Dom Care) homes that serve 1-3 residents. Assistant Secretary for Planning and Evaluation, Room 415F Further details on findings from the environmental scan can be found in Appendix B. Per the California Registry (California Registry, 2017), "Residential Care facilities operate under the supervision of Community Care Licensing, a sub agency of the California Department of Social Services. However, this likely is not a viable method for detecting the population of illegally unlicensed residential care homes. As a resident of a licensed residential care or unlicensed room and board facility, you have all the rights guaranteed by the Constitution of the United States and by the State of California. These include tapping into fire/EMS databases to identify addresses of care homes that could be unlicensed, and tracking multiple SSI payments that go to a single representative payee at the same address. Failing to consistently provide running water and electricity, or having unsafe or illegal electrical wiring. This conflicted with other media reports that describe Arizona citizens calling for closing the loopholes in state laws to prevent "imposter" senior living facilities that use false advertising (Azmfairall, 2013). Anecdotal examples of residents wandering outside of their home and onto neighbor's property, which typically generates a complaint call from the neighboring homeowner, were also provided. Since 1983, California Advocates for Nursing Home Reform has been fighting for the rights of long-term care . Medicaid fraud reports, 2009-2013. Retrieved from http://www.thisamericanlife.org/radio-archives/episode/554/not-it. Many key informants and SMEs suggested that discharge planners face difficulty placing residents in licensed care homes because these homes often do not accept patients who only have SSI (or otherwise have little money), and they often will not accept individuals with a history of mental illness, substance abuse, or those who are homeless. Most of the literature we found referenced problems in and the prevalence of unlicensed residential care homes prior to 2009, or addressed abuse and exploitation of adults living in licensed facilities. Information from interviews with key informants also revealed incidents of emotional and physical abuse, including intimidation, and threats. If the tenant refuses to leave the premises after the three days expire, the landlord may file an unlawful detainer action with the California Superior Court to evict the tenant. Providing unsafe housing conditions, including overcrowding of resident rooms, housing many more residents in bedrooms than is allowed by state licensure regulations, housing residents in storage sheds, basements, and attics that were unsafe, unsanitary, and made egress difficult for frail or disabled residents. Fraud reports have been filed with the U.S Department of Housing and Urban Development for the misuse of funds to send users from Puerto Rico to unlicensed rehabilitation centers in the United States. Texas Department of Aging and Disability Services. Strategies for Identifying Unlicensed Care Homes, 5.4. One key informant noted that the state or the LME-MCO can conduct follow-up to assess whether a facility that received a cease and desist letter does, in fact, close down. If the illegally unlicensed personal care home can be deemed unsafe, code enforcement has the authority to condemn the building and shut the illegal operation down. Abuse, Neglect, and Financial Exploitation, 3.4. Examples of financial exploitation described by key informants include the operator becoming a resident's representative payee and then withholding a resident's money, and pocketing profits while providing inadequate care and services or no services at all. Audio podcast. One interviewee, who interacts with residents of unlicensed care homes on a daily basis, estimated that for every licensed personal care home in Georgia there is one unlicensed care home. (2004). Education: Statewide or Interagency. (2013). Pennsylvania's BHSL is currently working on an amendment to create a graduated fine system for those operators who continue their illegally unlicensed care homes after they have been ordered to cease operations. In one state, the AG only received nine cases in the entire year; in another state they handled only 2-3 cases a year. Theft of government benefit checks (e.g., SSI, Social Security, food stamps, Medicaid, veteran's checks) was common, with one case in which operators diverted more than $790,000 to themselves. Using information from a HHS Administration on Aging report, provided by the National Ombudsman Reporting System (2009-2013), we identified reports regarding unlicensed facilities in five states: Maryland, Michigan, Nevada, Florida, and Georgia, as well as the District of Columbia. According to several key informants in the state, including APS and law enforcement officials, the property, which they referred to as a boarding home, was being rented by the operator, members of the church served as the representative payees for the residents, and the money was then pooled together and given to the operator. (2011). Operators forcing the resident to name the operator as the representative payee for government payments, such as SSI, and controlling the use of that money. Another interviewee suggested that it is becoming more difficult to recruit individuals to be Dom Care operators because of the competing demands on their time. Most state licensure offices, county offices, or advocacy agencies use a complaint system to identify unlicensed care homes. If you suspect that a facility is not licensed or in violation of its license, call 1-844- LET US NO (1-844-538-8766) to file a complaint with the Department of Social Services. One provider in San Bernardino County was housing residents with psychiatric disabilities in chicken coops which had been converted into barracks-style housing. One Florida media report estimated there were hundreds of congregate living facilities across the state that escaped state oversight because no agency regulates them (Savchuk, 2013). They do not necessarily reflect the views of the Department of Health and Human Services, the contractor or any other funding organization. This is a link to a form you can use to file an advertising complaint with CSLB. To accomplish this we conducted an environmental scan, including a review of the peer-reviewed and grey literature and interviews with SMEs. 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. No positive literature was found, which, as noted earlier, may be reflective of the fact that nothing is published about these places unless they are discovered because they are being investigated for poor care or resident exploitation or abuse. County and District Attorney referralsdeclined from 29 in 2010 to six in 2014. The key informant likened these networked operations to organized crime: "The other thing we are seeing too is that people [operators] are well networked, and within a day or two people are identified and going back, herding them up againthey are well networked so we look at them as organized crime organizations.". Although they did not know about exiting listings, several informants suggested potential ways to develop a list of unlicensed care homes. Section 1750.1 is the statute governing the duties that unlicensed dental assistants are allowed to perform. The regional and state licensure offices are closely involved in this process. They noted that the following may have heightened the demand for unlicensed care homes: The admission and discharge policies of licensed care homes. State and Local Policies Related to the Supply of and Demand for Illegally Unlicensed Care Homes. The PCRR teams in Pennsylvania are similar, and are based at the local level working in coordination with state licensure offices. Some interviewees reported that unlicensed care home operators sometimes run homes in more than one state, across state borders to avoid arrest, and may be trafficking residents across state borders as well. Medicaid in residential care. In California, many types of facilities offer room and board, including hotels, universities, residential care facilities and privately owned residences. Key informants recommended several tactics to address poor quality in unlicensed care homes, but the overall strategy consistently discussed was to shut down these homes. Oversight was spread across several agencies and depicted as convoluted and overstretched. Atlanta Journal-Constitution. As with health and safety concerns, the environmental scan and interviews conducted with SMEs and key informants revealed myriad concerns about abuse, neglect and financial exploitation. The fact that four people should have been receiving personal care services made the home eligible for licensure as a residential care home--not the fact that three people were receiving the services (which would make it under the legal limit).