BOARD AND CARE

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OFFICE OF INSPECTOR GENERAL 
OFFICE OF EVALUATION AND INSPECTIONS 
MARCH 1990  BOARD AND CARE

Richard P. Kuserow 
INSPECTOR GENERAL 
OEI-02-89-0186  MARCH 1990
 .......... ...... ................ ."....... ...............  .......  ...... .... ... 
.................................. ........ ................................................ ................ ........ ............. . .......... 
TABLE OF CONTENTS 
EXECUTIVE SUMMARY 
NTRO DU CTIO N .... ................................................. .................................8............8..... 1

PU R P~S E ............. .................................................................................................... 1

B AC KGROUND ................................................................................................. .."8... 1

..................."..................... 3

M ETHO DOLOG Y ......................... ...8................................ 
......................................................... 4

FI N DI NGS. ................ .... ..... 
Although State Standards Adequately Address Certain Basic Safety

and Service Requirements, Weaknesses Exist in

......... 4

Other Important Areas  ...11.... 
While States Conduct Basic Enforcement Activities,

Serious Weaknesses Exist .......................................................................11.... 10

Care........................... 

The DHHS Plays a Limited Role in Board and 
R ECOM MEN DATION  II...... II. .11..... 17

Co mments ..... ...... II......... ..11............ ..... ...... .......... ....... .11.............................. ..11.... 

APPENDIX A:  818 LIOG RAPHY  ................................ .... A -

APPENDIX B: COMMENTS ON THE DRAFT REPORT ........................... B -1

APPENDIX C:  CHARTS................... .................................... ................. ........ ...... C -1
 EXECUTIVE SUMMARY 
PURPOSE 
The purose of ths inspection is to assess existig State board and care reguations and 
enforcement activity. 
BACKGROUND 
Board and car refers to nonmedcal community-based living argements providig shelter 
foo, and protective oversight to a dependent elderly and disabled population. Over one 
milon elderly and disabled individuals reside in boar and care facilties nationwide, and 
ar 
their numbers  increasing. 
As an outgrowth of abuses in board and car facilties, the Congrss enacted the Keys 
Amendment (Section 1616 (e) of the Social Securty Act) in 1976. It requis States to set 
stadads that assur that Supplementa Securty Income (SSI) recipients do not reside in 
substadad facilties. The Offce of Human Development Servces (OHDS) has the Federa 
responsibilty for adminsterig the Keys Amendment and assurg that States have these 
stadads in place. 
The American Bar Association (ABA) developed "A Model Act Reguatig Board and Car 
grt 
Homes: Guidelies for States" under an OHDS  to help States develop standads to 
improve conditions in the homes. 
METHODOLOGY 
Ths inspection included the followig activities: intervews with Federa offcials involved 
with board and car; discussions with 70 State offcials in 50 States and the Disctrcet rotf g 
progrs 
Columbia (DC) representig 72 State  involved with licensing and/or 
board and car facilties; analysis of curent stadads for each of the 72 progrs; and onsite 
visits to seven locations involvig intervews with 26 providers, 15 provider or resident 
advocates and several State offcials. 
FINDINGS 
Although Stale Standards Adequately Address Certin Basic Safety And Servce 
Requirements, Weaknesses Exist In Other Importnt Areas. 
Alost al  stadas  strctue, 
State  addrss personal car servces, fIre safety, physical 
sanitation and licensing. Only limited attntion is given to level of care needs of residents, 
tring, 
dealing with unlicensed facilties, complaits and coordnation among responsible 
agencies, providers and consumers.  Alost th-quarers of State respondents and more than the-quarers (80 percent) of 
providers and advocates recommend a common set of national minimum standas. These 
shoultdr ingclu,d e basic safety and servce requirments, ways to deal with unlicensed facilties, 
sta 
reuirments for dierent levels of care and coordination among responsible 
agencies, providers and consumers. They feel that such stadads would create greater 
unonnity and effectiveness in reguation and enforcement 
While States Conduct Basic Enforcement Activities, Serious Weaknsses Exist. 
Alost al  Only about one-third 
States conduct inspections and issue con-ective action plans. 
stadas  moneta penalties 
of State  provide intennediate sanctions such as assessing civi 
adssion of new residents to homes under citation. According to some 
and prohibitig 
respondents, the absence of these sanctions restrcts States' enforcement capacity. 
Whe most States have the abilty to revoke or deny licenses, less than hal actually did so in 
stada 
1988. Mor than one-thd of State  provide for closing homes and removing 
residents, but only 11 States actualy tok these actions or imposed any penalties or sanctions. 
car. 
There ar a number of enforcement concerns which exist with regard to board and 
Unlicensed homes ar one such enforcement concern. Ambivalence exists as to how these 
homes should be penalzed Over the-quarers of State respondents cite consttnts to 
effective enforcement. These include liited sta, a lengty legal process, insuffcient 
fmancial resources, the absence of legal authority for sanctions and the lack of alternative 
placement Close to hal felt their States assigned board and car a low priority. A majority 
felt the Keys Amendment could not be enforced 
The DHHS Plays A Limited Role In Board And Care And Limited Coordinatin Exists. 
Activities afectig boar and care facilties and residents ar liited with HHS. The Offce 
of Human Development Servces is responsible for adinisterig the Keys Amendment. The 
noti 
States must  the Social Securty Administration (SSA) of violations of the Keys 
identig 
Amendment and SSA provides inonnation to States to assist in  unlicensed homes. 
The Adminstrtion of Developmenta Disabilties (ADD) and the National Institute of Menta 
(NI)  progrs 
Health  both have protection and advocacy  administered by State agencies 
or organations which may include residents of boar and car facilties. The Administrtion 
Progr 
on Agig (AoA) has an Ombudsman  which advocates the rights of the 
institutional elderly includig residents in board and car facilties. The Health Care 
progr 
Financing Admstrtion (HCFA) has a home and communty based waiver  which 
gives States the option to broaden the definition of "medcal assistace" under Medcaid if 
cert 
States  compliance with Keys Amendment  may include 
reuirements. These waivers 
servces to board and care residents. The Assistat Sectar for Planning and Evaluation 
(ASPE) has severa board and car initiatives curntly underway.  IlS 
involved with board and 
There is limited contact between these varous agencies within 
care; each unit functions independently and has litte awareness of relevant activities occunng 
Deparent 
elsewhere in the 
RECOMMENDATIONS 
States should 
Re-evaluate their board and care standas especially in the areas of level of care, 
facilties. 
traiing, coordination and unlicensed 
Improve their abilty to identiy and deal with unlicensed facilties and provide 
incentives for facilties to become licensed. 
Use such sanctions as civil moneta penalties, restrctions on new admssions and 
closing of homes. 
Assure that existing procedurs for resolvig complaits are sufficiently publicized 
to the attention of the proper authorities. 
so that complaits ar brought 
' efforts in implementing the above recommendations, OHDS should 
To support Stats
designate a unit  will 
for board and care which 
Dissemiate information on such matters as operational efficiencies, effective 
enforcement techniques, researh and States' best practices. 
Prmote more effective use of the Model Act 
Prvide technical assistance to States, parcularly to support the standads and 
enforcement concerns highlighted in ths report 
Coordinate deparental activities relative to board and care. 
COMMENTS 
Comments on the draf report were received from HCFA, ASPE, AoA, PHS, SSA and OHDS 
and were generaly supportve of our findings and recommendations. While support was 
expressed for our recommendation that there be a Deparental coordinating unit, the 
question of fundig was raised by OHDS (See Appendi B). We continue to believe the

wart 
problems addrssed in this report are suffciently important to  the relatively small

expenditu necessar to support a coordinating u  it.
 INTRODUCTION

PURPOSE 
The purose of this inspection is to assess existig State board and care regulations and 
enforcement activity. 
BACKGROUND 
History 
Board and car refers to nonmedical community-based living argements providig shelter, 
food and protective oversight to a dependent population of elderly and disabled. These 
facilties var widely in defInition, size, resident populations, fundig sources and servces 
provided. The termnology for board and car facilities encompasses a broad range of titles 
such as residential car, personal care, adult foster care, sheltered car, domicilar care, 
famy homes, adult homes, group homes and assisted living. Board and care residents have a 
wide range of demographic characteristics and needs; they include the elderly, 
developmentay disabled and mentay impaid. 
All States have regulations relatig to board and care. However, States use a varety 
defInitions and a wide rage of size crteria to identiy these homes for licensing. The 
defmition is usually based on the services provided rather than the anticipated needs of the 
home may be defined by a State as "a publicly or privately 
residents. A board and care 
operated residence that provides meals, lodgig and personal assistace to two or more adults 
who ar unrlated to the licensee or admistrator." In contrast, a nursing home provides 
24- hour medcal care. 
State regulations requir that al facilities which fit their definition of a board and car home 
be licensed or certed. The license is issued to a specific licensee for a specifc facility and 
cannot be trsfen-ed to a different licensee or facilty. The licensee is the person(s) who holds 
requirements 
the license to operate the facilty and is responsible for seeing that the licensing 
for the facilty ar met The licensee may operate and maintain the home or delegate those 
functions to an admnistrator or manager. 
Within some States more than one agency has 
Oversight and enforcement also var. 
responsibilty for board and care, differig usually with the tye of resident, size of the facility 
and kids of services provided to the residents. The most prevalent agencies involved are the 
Deparent of Social Servces, Deparent of Public Health and Deparent of Mental 
Health and Retardation. 
According to the House Subcommttee on Health and Long-tenn Car report, over one millon 
elderly and disabled individuals reside in board and car facilties nationwide. Their numbers 
are increasing due primarly to thre factors. The first is the deinstitutionalization of the  mentaly il in the 1960s which resulted in many of these people being placed in board and 
the enactment 
care homes because they continued to require a sheltered environment. Second, 
progr 
in 1972 created a guarantee of payment 
of the Supplementa Securty Income (SSI) 
for owners and operators of these facilties. Lastly, a shortge of nursing home beds and other 
long-term car services has resulted in more admssions to board and care homes. 
Legislative Highlights 
Securty Act) as an 
The Keys Amendment was enacted in 1976 (Section 1616 (e) of the Social 
outgrowth of abuses in board and care facilties in the mid-1970' s. It requires States to 
establish, maitai and insur the enforcement of standads" for residences where " 
significant number" of SSI recipients reside or are liely to reside. It also has a penalty 
s SSI payments if he or she resides in a facilty not 
provision which reduces a reipient 
meetig State standards. This reuction is applied to that porton of the payment that is a 
State supplement and only by the amount of the supplement that is used for medical or 
concern of Congress that Federal SSI 
remedial care. The legislative history reflects the 
benefits not be used to support substadad living facilities. 
The Omnbus Budget Reconcilation Act of 1987 is likely to impact on board and care. 
, 1990) the Medicaid distiction between skilled nursing facilities 
elinates (by October 1
(SNFs) and intermediate car facilties (ICFs) and combines them into a single level, called 
nursing facilty," under Medicaid. Some ICFs that cannot meet the more sttngent 
requirements for nuring facilties wil be downgrded to a lower level such as board and care. 
nuring facilty car and 
As a result, residents presently in ICFs may no longer be eligible for 
may become board and care residents. 
HHS Role 
A number of HHS components have responsibilty for board and car homes or their residents. 
The Offce of Huma Development Services (OHDS) has the Federal responsibilty for 
The 
managing the Keys Amendment and seeing that it is implemented at the State level. 
Admnisttation on Developmental Disabilties (ADD), the Admnistrtion on Aging (AoA) 
(NIM)  grts to States to operate 
and the National Institute of Mental Health  each provide 
an Ombudsman or a protection and advocacy program for their respective client groups. To 
help States locate board and car facilties, the Social Securty Admitshtr tion (SSA) provides 
where  or more SSI recipients 
State Data Exchange (SDX) tapes which identiy addresses 
reside. The Health Care Financing Admnistrtion (HCFA) issues waivers to broaden the 
progr if 
defmition of "medical assistance" under the Medicaid  the Keys statute and 
regulations ar met. 
Prior Activities 
Concerns about the quality and services in board and care homes were highlighted in a prior 
Offce of Inspector General (OIG) study (1982) and, more recently, in both a General  Accountig Offce (GAO) study and a report issued by the House Select Commttee on 
Aging s Subcommttee on Health and Long-term Care (March 1989). 
The American Bar Association (ABA) developed "A Model Act Regulating Board and Care 
Homes: Guidelies for States" under an OHDS grant in 1984. This was intended as a 
resoure document to help States develop and revise standads to improve conditions in the 
homes. Fire and safety  also developed by an HHS interagency task force and 
gudelies were 
shared with the States. These guidelines were the result of a ten year effort and have been 
Curently, 
incorporated in the Life Safety Code by the National Fire Protection Association. 
there is a large evaluation being conducted of this system which is being jointly funded by six 
Federa agencies. 
METHODOLOGY 
This inspection was conducted in thee par. Firt, Federa offcials with some responsibility 
for board and care were intervewed to determe the level of activity within HHS. 
Distrct of 
Second, 70 discussions with State offcials were conducted in 50 States and the 
Columbia (DC). They represented 72 State program involved with licensing and/or 
certyig board and care facilties (one person in 33 States, two each in 15 States and thre 
each in 3 States; in 2 States one respondent spoke for two program). An effort was made to 
for this function. Information was 
identiy al agencies in each State with responsibilty 
licensing, certfication and enforcement activities, and perceptions were 
obtaied regarding 
gathered regarding board and car regulations and their enforcement. Copies of curent 
standads and licensing requirements for each of the 50 States and DC were obtaied and 
analyzed agaist the Model Act, each other and exemplar State standads for commonalties 
and varations.

th 
Durg the  par, on site visits were made to seven locations (California, DC, Georgia, 
Michigan, Missour, New Jersey, and New York) selected on the basis of geographical 
distrbution, recommendations from State and industr respondents and prior analyses. 
Members of the team included a physical therapist and a registered nurse. Interviews were 
held at 26 homes selected for severa reasons, including whether they cared for SSI recipients 
or parcipated in demonstration program. The 26 homes represent a mix of diferent sizes, 
services and types of residents served. Also interviewed were 15 advocates of providers or 
residents and severa State officials involved with board and care. The interviews included 
industr. 
discussions of State standads, enforcement and problems in the  ............................................................................
. .. .. . . .. . . . . .. .. . .. . . . .. . .. . . . . 
FINDINGS

ALTHOUGH STATE STANDARDS ADEQUATELY ADDRESS CERTAIN BASIC 
SAFETY AND SERVICE REQUIREMENTS, WEAKNESSES EXIST IN OTHER 
IMPORTANT AREAS.

carng 
States have made progress in  out their responsibilties in board and care facilties 
over the past few year. Alost all State stadads include basic safety and service 
requiements such as personal car services, fIre safety, physical strctue, sanitation and 
lited 
licensing. However, only  attention is given to the level of care needs of residents; 
trning; dealg with uncensed facilties; a complaints procedur requirement; and 
coordiation among responsible agencies, providers and consumers. State standads were 
compar to the Model Act to determe States' conformty to key areas in the Act (Figue I). 
See a State by State comparson to the Model Act in Appendi A. 
FIGURE I

State Conformance With Model Act Provisions

80" .
11 
88" 
100" 88" 88" 82"
88ft  88". 
.7ft........................... 
A - Definition of Board & Care  H - Residents' Rights 
B - Physical Structure  I - Size Criteria 
C - Admissions Criteria  J - Training Requirements for Staff

D - Administrator /Staff Qualifications  K - Variance and Waivers

E - Licensing Requirements  L - Complaints Procedures

F - Enforcement Programs  M - Board & Care Plan

G - Sanctions  N - Unlicsed Facilties
 percent) include personal care services, fire safety,
Almost all State standads (over  95 
physical strcture, sanitation and licensing. 
stadas 
Vinally all State  presently reuire the provision of minimal personal 
car servces. Most commonly, these include assistance with daily living activities 
(94 percent), help with medications (96 percent), diet (96 percent), and supportive 
foo 
servces (86 percent). All the standads addss sanitation, including 
Alost  strctue 
handling, laundr, water and sewerage.  all address the physical 
buildig, includig the  safety. Most also deal 
of the  architectual plans and fie 
with residents' rights (85 percent) and record-keeping (92 percent), although 
usually in a lited way. 
State standards do not adquately adress residnts' needs. 
According to almost half of the respondents, standads do not clearly distinguish 
the level of care needed. They cited this problem most frequently. Respondents 
report that while the original "Mom and Pop" facilities served a fairly 
self-sufficient population, the medical and health needs of many residents are 
increasing. One respondent stated, "The standards are not responsive to the change 
in residents ' needs. " Another said, "We need to be more realistic with regard to 
who lives in the homes. Homes with SSI and developmentaly disabled residents 
ar very dierent than those with private-pay elderly." While most respondents 
cited this need for increased level of car, many mentioned diffculty in providing 
these addtional servces due to the limited financial resources of board and care 
residents who have only SSI benefits as income. 
State standads do not meet the needs of the changing population in board and care 
homes. Most stadads (68 percent) restrct the adssion of residents to homes if 
they are physically or mentaly unable to evacuate the premises independently. 
curnt 
However, respondents report that some  residents do not meet this criterion. 
Additionally, team onsite visits to homes showed residents who were wheelchair-or 
bed-bound and others who cognitively would not be able to leave the home 
independently. Also, alost hal of the State stadads do not restrct admitting 
residents to homes without adequate resources to car for them. Thus, residents 
with grater car needs may potentially be placed in facilties where their needs 
cannot be met 
Almost two-thirds of the State standads do not specifcally mention a board and 
car plan, although thee-quarers require physician certcation upon admssion. 
Such a plan is one way of planning and providing for different levels of car. Of 
those standads which do addrss car plans, the great majority do not specify how 
often the plan should be updated.  Simiarly, case management (someone monitoring the needs of each resident) is 
noted in only 38 percent of the stadads, generaly with the developmentally 
disabled and mentaly impaied as opposed to the aged. The Model Act provides 
that each resident should have a board and care plan which is reviewed quarerly 
and which describes the abilty of residents to fuction in the home. One provider 
stated: "We need regulations which watch for the changing condition of the 
elderly patients and not just nitpickig of easy envionmenta issues. 
Over one-thd of State stadads do not addrss nursing services. Of those that do, 
over hal prohibit them. One respondent, representig a view often heard, said, 
There is no flexibilty for residents that requir acute car to remain in the home. 
In contrt, some felt that nursing servces were inappropriate for this level of car. 
One State is instituting a demonstration project that will enable residents who 
requi ongoing nursing car, such as catheter and colostomy car or insulin 
therapy, to live in board and car facilties. 
Resident level of car nees are rarly specifed in State definitions. A board and 
car facilty is usualy defmed based on the servces provided rather than the 
anticipated needs of the residents. Some State officials suggested that the 
the nees of the resident and the servces provided.
defmition should include  both 
Limited attention is given to staff training. 
Accordig to State respondents, staf trainig is the second most frequently cited 
problem. Both State and provider respondents often mentioned the changing needs 
of residents as a reason traiing is essential. Accordig to one State respondent, 
sta tring 
the lack of control of  is a "vuerable area." Many also noted that 
limited resoures and insufficient staff at the State level often constrain 
implementing existing trainig requirements. 
stada 
One-thd of State  do not addrss traig. The Model Act provides for 
traig 
specifc areas of  for both admnistrtors and staf and suggests that the 
the 
operator have training before being issued a license (which  States curently 
require). It also suggests that if a facilty is found to be out of compliance, the 
operator and staf should be given traiing in the areas where violations exist. 
Of the two-thirds of State stadards which do addess trning, thee-quarers do 
not specify the tye or hour of trning reuired. Generally, traiing requirments 
ar specified as being "in-servce" or "on-the-job." Much of the trning is limited 
fi 
to first aid coures, genera orientation,  safety and foo handlng. 
Although most States give limited attention to training, six States reported 
innovative training programs. These include medication aide training, special  progrs for working with the mentally retaded, seminars in different aspects of 
care by experts in relevant fields, and special training prior to being issued a 
license. One State uses the money derived from licensing to hold traiing 
progrs. 
Alost al States (93 percent) addrss qualcations and requirments of the 
staf. However, the requirements for both are extrmely limited 
adnistrator and 
In many cases, the 
and were cited as a problem area by numerous respondents. 
operator is required to be at least 18 years of age, have a high school diploma and 
be of "goo mora character." A few States, however, are begining to require a 
bachelor s degree for the admnistrator and nurse s aide traiing for staff. Many 
say it is difficult to requir adequate qualfications for board and care staff since the 
pay is low and it is diffcult to recrit and keep employees. 
State standards do not usually adess unlicensed/acilites and complants. 
Seventy-four percent of State stadads do not mention unlicensed facilties so they 
do not include a penalty provision for failure to comply with licensing 
requirements. Some respondents volunteered faiur to addrss these homes as a 
problem with their standads. 
Only 51 percent of State stadads require a complaints proedur, although almost 
having such a procedure in place. 
al States report 
(The above two areas are discussed in more detail in the enforcement section of this report. 
Coordinaton rarely occurs. 
Accordig to State respondents, coordnation was the thd most frequently cited 
problem area. Although almost two-thds of State respondents felt coordination 
between State agencies was adequate, only one-third of providers agred. Some 
providers said duplication of effort often occurs, with several agencies doing the 
same thing, such as investigatig complaints. One provider said, "People 
comig in al the tie. provider respondents recommended the 
" Both State and 
establishing coordnation units and strngthening communication. 
No State standads address coordation among responsible agencies, providers 
and consumers. The Model Act suggests a coordnating council, to include 
advocates, residents and providers, as a mechanism to assur coordination among 
the multiple State agencies responsible for regulating facilties and providing 
An analysis of State regulations conducted 
services to residents of these facilties. 
by Boston University in 1980 identified 77 agencies nationally that were 
care facilties. Our study revealed 72 agencies; 10 States had 
monitorig board and  reuced their number of agencies and two States are combining two monitorig 
agencies into one. Five States have added agencies. 
A majority of States, providers and advocates felt coordination between States and 
the Federa government was lackig. Most stated that coordination did not exist. 
Most respondents advocate a common set of minimum standards 
for every State. 
Accordig to alost the-quarers (72 percent) of State respondents, a common set 
of miimum stadads should be federay mandated. Some felt that since some 
States were less active in board and car than others, minimum standards would 
crate grater uniformty in regulation and enforcement. Others mentioned that
mium 
stadads would alow for common expectations of safety and care in the 
boar and care industr. One respondent said that "every disabled and frail elderly 
person in this countr has a right to minimum standads, despite where they live. 
Numerous respondents, includig those in favor of minimum standads, said that 
mium 
were  stadads to be developed, States should be given the flexibilty to 
adapt and add to the standads to meet their parcular needs. 
Twenty-eight percent of State respondents did not favor a mandatory set of
mium 
stadads for States. Most felt that States should be alowed to establish 
their own regulations to alow for regional and local differences. One argued that 
stada 
since most State  have aleady been tred and found to work, only 
suggestions concerng possible new topics and ideas should be 
gudelies and 
mium 
provided. Some felt that  stadards would only add another level of 
unnecessar governent buraucracy to the board and care industr; one stated 
that "people are monitored enough without someone else coming in." Another felt 
that minimum standads would not assure quality of care in these homes any more 
than State stadads would. 
Eighty percent of providers and advocates agreed that minimum standards should 
be mandated for every State for many of the same reasons given by State offcials. 
industr 
They mentioned that national standads might serve to professionalize the 
and provide helpful guidelines to operators when settig up homes. A number 
expressed concern that minimum standas might become maximum standads in 
that States might choose not to elaborate upon them. Minimum standards might 
thus "give permssion" to States to do only the minimum requird. 
The majority of all respondents also felt that common definitions should be used in 
every State. Many believed it would be an impottt prerequisite to the 
development of minimum stadads.  ........................................-.........................................................................................................
. . . . . . . . . . . . . . . . . . . . . . 
Respondents generay agree on key areas where miimum standas should be 
developed. These include basic safety and service areas and some aras not 
presently addressed, such as unlicensed facilties, trning and board and care plans 
(Figu II). However, the maner in which they are addressed vares from State to 
State. Supportg ths was the respondents ' frequently cited concern about faiure 
cert 
to adess  key aras in greater depth and with more clarty. 
FIGURE II

THREE KEY AREAS NOT SUFFICIENTLY ADDRESSED ARE RECOMMENDED

FOR INCLUSION IN NATIONAL MINIMUM STANDARDS

Training 
Board and Care Plan	
109 	 18099  .............................................
. Hi. 
 81S..' . . . .
89 ....................... .88". . . . . . . . . . . . . . . . 	
89.''''''''.'.''''''''''

80.. ......................

79 ......................

811 ......................
 80.. ....

ISO" ......................
 ISO" ....

411 .... 
S9 .... 
29 ....
20.. ....

19 ....	 19 .... 
State 
Standards  State  Providerl  Standars  Providerl 
Recommendations  Advocte  Recommendations Advocate 
Recmmendations  Recommendations 
Unlicensed Facilities 
109 
8I ........................................ ' 88""". 
89 ....................................... 
70.. .......................................

89 .......................................

1S9.""'.'."'"''''''''

49 ......................

29 ....

19 ....

Standars  State  Providerl 
Recommendations  Advocate 
Recommendations 
. Percentage of current State standards which address each area.  Model Act discusses key areas not adressed in State standards. 
The Model Act provides alternatives to States in those areas which respondents 
identify as being a problem with their standards, such as level of car, training, 
uncensed facilties and coordination. 
A majority of State respondents (51 percent) were unawar of the Model Act. A 
few respondents expressed keen interest when informed of it and asked where to 
obta a copy. 
Of those who heard of the Model Act, 35 percent used portons of it as a guide 
when preparg or updatig their individual State standads; 24 percent continue to 
use it as a reference tool. 
WHILE STATES CONDUCT BASIC ENFORCEMENT ACTIVITIES, SERIOUS 
WEAKNESSES EXIST. 
Almost al State standas address inspections and corrctive action plans and States are 
implementing these standads. However, problems exist in enforcement, both with unlicensed 
facilties and facilties found out of compliance. 
Almost all State standards adress  percent) and corrective action plans (82
inspections  (94 
percent). 
As par of their licensing process, thee-quarrs of States inspect al homes at least 
once a year, some even more frquently. The frquency is often determned by the 
avaiabilty of sta and resources. 
A majority of States report at least some unanounced inspections. In hal these 
States all inspections are unannounced, whie in others they are conducted only 
just over hal requir that licensing inspections 
when deemed necessar. However, 
be unannounced. Many ar doing more than their stadards mandate, thus 
indicating that they perceive unanounced inspections as an effective enforcement 
tool. Most States (80 percent) also use spot checks as par of their enforcement 
activity. An analysis showed that unannounced inspections were conducted by 
States that have both strngths and weakesses in enforcement. 
Alost al States with standads for corrective action plans actually requird such 
plans for the majority of their licensed homes in 1988. Many reported that few 
homes were ever without any deficiency. In most cases, the operators came into 
compliance after successfully implementing the plan. The violations ranged from 
the minimal, such as improperly storing a head of lettuce or missing a light bulb, 
sprier 
to the more serious, such as lacking a  system. However, the deficiencies  noted in most of the corrective action plans were primarly non-life-thatening. In 
a few States, deficiencies are grded for their degree of seriousness, thus 
monitorig of homes with more significant problems. 
faciltating close 
Almost all States report havig a complaints proedur in effect, although State 
stadads do not always address the requirement for such a procedure. In most 
cases the licensing agency itself receives complaints; only one-quarer of States 
report that the Ombudsman also receives them. Most States conduct onsite 
investigations in response to complaits; they investigate the more serious 
allegations alost imediately. As par of their proedures for resolving 
complaints, almost one-hal (47 percent) report having a resident hotline. The 
range, from poor foo and an unsanitar physical
tyes of complaits cover a wide 

envinment to inadequate care and abuse or neglect. A number of providers 
asserted that their State s complaint procedure was always biased in favor of the 
consumer and offered the operators no recourse for their own grevances against 
residents. 
Enforcement activity is limited. 
th 
Respondents cited  major factors to explain why constrints to enforcement 
resources inhibit the States' abilty to actively enforce 
exist. Firt, lack of State 
their curnt stadads. Second, no statutory authority exists in many States to 
impose both intermedate and severe sanctions. Finally, the lack of alternative 
placement for boar and car residents makes it difficult to close homes and 
penalize unlcensed homes even when those sanctions ar avaiable. 
While most States (86 percent) are able to revoke or deny licenses, under half 
actualy did so in 1988. The average number of revocations or denials was 20. 
The problem was seen as not being with the avaiabilty of the sanction but with its 
use; one provider voiced a common concern that "States are reluctant to use what is 
available. 
Fort percent of States imposed no penalties or sanctions on board and car homes 
in 1988. Of those which did, 15 imposed fines, 7 issued provisional licenses, 4 
issued citations, 4 limited or suspended admssion to homes, 2 used receiverships, 
crmial charges against a provider and 1 cancelled a service contract. 
1 initiated 
Closing homes and removing residents, the most severe penalty, was reported by 
only 11 States. One of these States with a separate enforcement unit reported 
closing 53 homes. However, the remaining 10 States closed from one to eight. 
number of respondents mentioned that they were often complacent in their 
enforcement activities and would wait for a situation to significantly deteriorate 
before takng action.  ................ ..... ................. .... .... ......... ............... ............ ........ ..- .."...." ..."......".......".......".. ...."...... ."........"......"..  ....'...'..'..'..  ......... ..... .. .......... .." .."....".. ..... ......... ...... ..... ...-....... ............ ............ .-...........
...........................................................................................................................................................  ...-........... .... .....-. ........,.. ..- ..-..  .......
Enforcement options are limited. 
Slightly more than one-third of State standards alow for the intermediate sanction 
of civil monetar penalties, whie less than one-third prohibit admtting new 
residents to homes under citation. Just over one-thd of State standads allow for 
the more severe sanction of closing homes and removing residents (Figue III). 
Most States which do allow civil moneta penalties consider them very 
instrmental in minimzig substadard facilties and essential to the success of 
their enforcement efforts. Fines usualy go into the genera treasur, although 
car 
few States use them for board and  activities. 
FIGURE III

ENFORCEMENT OPTIONS ARE LIMITED

100 
................ 37

.. GO,' 

1 O 
Civil  Closing Homes  Restrictng  Addresing 
Monetar  & Removing  Admission of  Unlicensed 
Penalties  Residents  New Residents  Facilities 
Many respondents stated that the legal process required to revoke licenses was 
often lengty and cumbersome. Thus, the absence of intermediate sanctions such 
moneta penalties was seen as restrcting the enforcement capabilties of 
as civil 
some States. Some respondents believed that prohibiting the admssion of new 
residents into homes while the legal proess is occurng would prevent placing 
more individuals into homes where conditions ar questionable. Only 17 percent 
of State stadads requir a criminal check for providers as par of their licensing 
procedure; even fewer require such a check for staff members.  Over th-quarers of State respondents felt that constraints limited effective 
enforcement. Most frequently cited were limited staf, insufficient financial 
resources, a lengty legal process, and the absence of legal authority for 
intermediate sanctions. Since in most States board and care is not a separate 
budget item, it is not possible to determne the level of resources devoted to 
enforcement Two States report having separte enforcement units. Drastic 
measurs ar rarely used because inadequate funds frequently preclude expensive 
actions. A number of respondents mentioned that enforcement efforts were often 
hampered by political considerations. For example, local judges and law 
to act against neighborhoo providers. 
enforcement offcers might be reluctat 
Respondents did not agr on the most effective enforcement techniques. 
Recommendations included imposing civi monetar penalties, increasing State 
resources, improvig the strength of legal options and categorizing diferent levels 
of violations. Some see fmes as a deterrnt to non-compliance; others see them as 
a means of tang funds away frm where they ar most needed-to improve the 
home. Some provider responses reflect this dilemm. One stated, "it hurt when 
the pocketbook is hit" Others complained that fines were too excessive for minor 
problems which caused no dict har to the resident. When a license is revoked 
in some States, the home is allowed to continue operating as a boarding home and 
the residents may remai in the facilty. In other States, the home is closed and the 
residents always removed to other licensed locations. However, the lack of 
alternative facilties for placement is a problem as there is sometimes no other 
avaiable licensed home for residents to move to. Respondents mention residents 
rights as a consideration: residents may wish to stay in the home, even if it is 
determned to be unsafe and becomes unlicensed. 
Unlicensed homes are a key enforcement concern. 
State efforts to deal with unlicensed facilties are restrcted by lack of resources and 
diculty in locating the homes. Most State offcials felt that their resources were 
not sufficient to deal with unlicensed as well as licensed homes. Respondents also 
had difficulty in estimating the number of unlicensed facilties in their States which 
should be licensed accordig to their definition of a board and car home. 
Ambivalence exists among respondents as to whether and how unlicensed facilties 
should be penalzed. Some States feel they should be immediately penalized while 
others feel the operators of these homes should first be given the opportnity to 
acquir a license. However, a majority of providers and advocates favored 
ar 
penalizing these operators. Some States  reluctant to take action against 
unlicensed facilties because of a lack of alternative placement for the residents in 
these homes.  " "
Avaiable SSA tapes are seldom used and ar not found useful. Only 41 percent of 
State respondents knew of the tapes, and very few (17 percent) reported using them 
Respondents generally felt that the tapes were of 
to locate unlicensed facilties. 
wart 
lited use and did not  additional allocation of staff and resources. 
An analysis of existig enforcement techniques and how they are implemented 
corrlation between the enforcement technique and the presence 
showed no diect 
or absence of unlcensed facilties. 
Concerns were expressed about the adequacy of enforcement. 
Two-thirds of providers and advocates felt that some problem with enforcement 
existed in their State. The majority felt enforcement was slow, inadequate, 
inconsistent and ignored. One provider, expressing a prevaiing view, said he 
would "like to see more emphasis on education and less on mechanical 
enforcement of stadads--ducation should be used in addition to fines." A 
number felt their State was not strgent enough with unlicensed facilties and that 
operators of these facilties should always be fmed. Some providers and advocates 
complaied that the lengty proess for penalizing providers could potentially put 
residents at risk. Most agrd, neverteless, that such a process was essential. 
Half of the providers and advocates felt that the inspection process does not 
adequately ensure that standads are maitaed. They often caled it a paper 
proess in which evaluation was limited to checking off items on a list. A few 
State respondents mentioned a recent requirement for a resident interview during 
the inspection. However, one provider said that in practice this means that 
residents are asked over a loudspeaker to come and speak to the inspector if they 
want to. Many providers and advocates voiced concern about the inconsistency of 
how different inspectors interpreted regulations. State respondents also mentioned 
this as being a problem when inspections were delegated to county authorities. 
Close to hal of the State respondents felt that their States assign board and care a 
low priority in tenns of overal health care. An even greater number of providers 
progrs 
thirds) agred. Most argued that other  in the 
and advocates (two-
long-tenn care continuum, such as nursing homes, were regarded as more 
important As a result, resources allocated were not always adequate. 
A majority of State respondents felt the Keys Amendment could not be enforced. 
Only 17 percent clai to have reported substandard facilties to the Federal 
government as the Keys Amendment requires. Most felt that the penalty clause 
which reduces the benefits of SSI recipients was unenforceable. Some suggestions 
included: "Junk it and sta over again,  penalize the owners-not the residents,  board and care 
and "(requi) mandatory registrtion of SSI recipients residing in 
facilties. " 
THE DHHS CURRENTLY PLAYS A LIMITED ROLE IN BOARD AND CARE AND 
LITTLE COORDINATION EXISTS. 
llS 
Activities afNectIig  boar and care facilties and residents ar limted within  in OHDS, 
SSA, AoA  and HCFA, with litte coordation among these agencies. 
Board and care activites are limited within HHS components. 
Within OHDS only one person is responsible for managing the Keys Amendment 
and collectig the requied inonnation from the States. A yearly OHDS 
memorandum remids States that they must certy annually that they comply with 
the Keys Amendment and includes inonnation on the  SSNSDX 
Model Act and 
tapes. Approximtely 30 States responded in 1988 with brief letters saying, in 
effect: "Ths is to inonn you that (State s name) is in compliance with the Keys 
Amendment. "

No SSA procedurs are in place to implement the penalty provision of the Keys 
Amendment. While the Keys Amendment has a penalty provision which reduces a 
recipient s SSI payments if he or she resides in a substadard facilty, the 
prevailing opinion among people in the field is that deductig money from the SSI 
recipient s payment does not assure that conditions wil improve in the facilty. 
Due to lack of resources, the Admnistrtion on Developmental Disabilties (ADD) 
does not systematically monitor al developmentay disabled individuals who 
reside in board and car homes. However, ADD does have a protection and 
advocacy program for the developmentay disabled which may extend in pan to 
residents of board and care homes. 
Although board and car is now included in the AoA Ombudsman Program, no 
additional funds have been appropriated for this addtional responsibility. The 
extent to which local and State Ombudsmen become involved in board and care 
vares from State to State. The AoA has been diected to study the impact of the 
Ombudsman Program on residents of boar and car facilities, to develop 
recommendations for expanding and improving Ombudsman servces, and to study 
the effectiveness of recruiting, supervsing and retaiing volunteer Ombudsmen. 
This report wil be available by December 31, 1989. 
NI 
The major pan of the  protection and advocacy program is to advocate for 
residents of public 24-hour care facilties. In 1988 only 6 percent of the program  clients were in facilties outside of public institutions. Some of these were board 
and care homes. 
Few States have taen advantage of the available SSA State data exchange tapes 
and many were not even aware that such tapes existed. A number of respondents 
obta 
requested informtion on how to  these tapes after learng about them. 
As of August 1989, HCFA had approved 125 waiver programs in 47 States. 
HCFA is unable to identify how many of these waivers include servces for board 
progr 
and care residents. However, they do clai to ensur that each  which 
indicates that it serves such recipients makes explicit provision for the welfar of 
these clients. HCFA also reports to have investigated and taken necessar action 
where there has been any indication brought to their attention that health and 
welfare has been compromised. 
On the positive side The Assistat Secretar for Planing and Evaluation (ASPE) 
is curently fudig a study entitled "Analysis and Comparson of State Board and 
Car Reguations and Their Effect on the Qualty of Care in Board and Care 
wi 
Homes." Ths study  attempt to determne the extent to which care in 
unlicensed homes difers from the care provided in licensed homes. They also 
futu. 
anticipate doing a boar and care census in the 
Little coordination exits within HHS among the agencies involved with board and care. 
lited 
There appears to be  contact between the varous agencies within HHS 
involved with boar and car; each unit fuctions independently and has little 
occurg  Deparent. 
awareness of relevant activities  elsewhere in the 
While the Keys Amendment specifies that the State must notify the SSA of any 
violations in board and car homes, it is not requird that OHDS be so notied, and 
the SSA does not share any such information with OHDS. 
No unit is designated within HHS for coordnating the activities of different 
agencies and disseminating information between them. Such a unit previously 
existed in the Deparent but has since been disbanded. 
Some coordiation does exist, however, between the different agencies involved 
with protection and advocacy programs for the mentally il, developmentally 
disabled and aged residig in board and car homes. These agencies will be 
meeting regularly to inform each other of their activities and to coordinate their 
efforts.  RECOMMENDATIONS 
States should 
Re-evaluate their board and care standads (using the Model Act as a reference) to 
assure they include and adequately address 
level of car,

traing,

coordination, and

unlcensed facilties.

Improve their abilty to deal with unlcensed facilties such as 
tagetig ways to identify them and

providig incentives for facilties to become licensed.

Use such sanctions as 
civi moneta penalties,

restrctions on new admssions, and

closing of homes.

Assure that existing proedurs for resolvig complaints are sufficiently publicized 
so that complaints ar brought to the attention of the proper authorities. 
To support States' efforts in implementing the above recommendations, OHDS should 
designate a unit  will 
for board and care which 
Disseminate information on such matters as 
operational effciencies

effective enforcement techniques 
research and

States ' best practices.

Promote more effective use of the Model Act  Provide technical assistace to States, parcularly to support the concerns relating 
to the stadads and enforcement highlighted in this report. This might include 
convening a workgroup of States and other pares to discuss developing minimum 
stadads. 
Coordiate deparental activities relative to board and care. 
COMMENTS 
drt 
Comments of the  report were received from HCFA, ASPE, AOA, PHS, SSA and OHDS 
and were generay supportve of our fidigs and recommendations. While support was 
expressed for our recommendation that there be a Deparenta coordinating unit, the 
question of fundig was raised by OHDS. (See Appendix B). We continue to believe the 
wart 
problems addrssed in this report are suffciently importt to  the relatively small 
expenditu necessar to support a coordinating unit.  APPENDIX A 
BIBLIOGRAPHY 
American Association of Retied Persons (AARP). Selected papers from the conference on 
board and car. December, 1978. 
Plans and State
Boston University, School of Social Work.  Preliminary Analysis of Title  XX 
Residential Facilities in 50 States and the District of Columbia.
Regulations for  574 
Februar, 1980.

Commssion on Calorna State Governent  Community 
Organization and Economy. 
Residential Care in California: Community  December, 
Care As A Long Term Care Service. 
1983. 
Commssion on Calorn State Governent  The Little Hoover 
Organization and Economy. 
Commission  Januar, 1989 
s Report on Community Residential Care For the Elderly. 
Board and Care: Insuffcient Assurances that Residents
General Accounting Offce (GAO). 
Februar, 1989

Needs are Identified and Met. 
Institute for Health and  Residential Care Facilities: Understanding Their Role and 
Agig. 
Improving Their Effectiveness. 1988. 
Offce of Inspector General (OIG), Deparnt of Health and Human Servces (DHHS). 
Board and Care Homes: A Stu of Federal and State Actions to Safeguard the Health and 
Apri, 1982.
Safety of Board and Care Residents. 
Service Delivery Assessment, Deparent of  Boarding 
Health, Education and Welfare. 
Homes Assessment.  June, 1979. 
Subcommttee on Health and Long-term Car, Report to the House Select Commttee on 
Board and Care Homes in America: A National  Marh, 1989. 
Agig.  Tragedy. 
The American Bar Association, Commssion on Legal Problems of The Elderly and 
A Model Act Regulating Board and Care Homes
Commssion on the Mentaly Disabled. 

Guidelinesfor States.  October, 1982.
 ...
APPENDIX B

COMMENTS ON THE DRAFT REPORT 
Comments received from HCFA, ASPE, AoA, PHS, SSA and OHDS were generally 
supportve of our fidigs and recommendations. Suggestions for changes in the wording and 
most par been incorporated into the fmal report. 
clarfications in the text have for the 
Deparental 
Among the comments that were supportve of our recommendation that a 
coordiatig unit for board and care be designated were the following: The Assistant 
'Tugh 
Secretar for Health noted that: ' technical assistace and dissemiation activities, 
ths unit would have the potential to greatly improve the qualty of care and lie of individuals 
Secta 
" Simarly, the Assistat  for Human Development Servces stated "that the 
and supportve of State actions given the real advances 
functions might be tiely, appropriate, 
in State performce over the past severa year and the Federal government s new federasm 
relationship with States." The OHDS adde that "such a unit might help meet Congrssional 
concern that the Deparent addss identied abuses. 
Deparenta 
The ASPE specifcaly recommended that OHDS be designated as the 
activities. We concur and have moded our report by 
coordiating unt for boar and care 
specifically addressing our reommendation to OHDS. 
While as noted above OHDS expressed concerns about inadequate CUIent stang and 
fundig, OHDS supports the idea of a coordiatig unit. We recognize that a coordiatig 
unit would requir realocation of very scarce resources. However, in view of the importance 
of this area we feel that such reallocation is necessar. 
In addition, OHDS note that the Deparent fuds very litte researh, has little information 
to dissemiate and possesses no parcular expertse to offer technical assistace to the States. 
We might offer, in response, that ths coordatig unit would be expected to disseminate not 
only the Deparent s researh but also research conducted by other soures; would gather 
and shar ideas and best practices frm the States; and would hopefully utiize the knowledge 
of expert in the field in offering technical assistace. 
The OHDS had some question about the substace of the proposed coordination role. Our 
vision is that ths unit would be the focal point for board and car activities within the 
Deparent. In doing so, it would serve as a refeITal source for outside requests, periodcaly 
evaluate the effectiveness of Deparenta progrs and make recommendations to improve 
them. 
In conclusion, we strongly encourage having a Deparental coordinating unit as essential to 
supportg and encouraging the States' efforts to assure the safety and well-being of the board 
and car population. We believe OHDS should be given this role. 
The actual comments received ar on the following pages.  &. 
Office of

DEPARTME  T OF HEALTH  Ht:MA  SER\"ICES	 Human Development Services 
Assistant Secretary 
Washington DC 20201 
FEB I  199 
::0 :	 Richard P. Kusserow 
Inspector General 
FROM:  Assistant Secretary 
for Human Development Services 
Report: -
SUBJ ECT :	 Office of Inspector General Draft  Bogrd and
Care,  89-l860 
. OAI-
Thank you for the opportunity to review and comment on the 
draft Office of Inspector General (OIG) report on -Board and 
Care.  Over  ll, the report is timely, and we believe its 
issue. It 
findings will inform future discussion on this 
contains information that will be helpful to this office in 
carrying out its responsibilities under the Keys Amendment. 
addi tion, we appreciate the briefing and the addi t4io.n al views 
and information provided by OIG staff on January  However, 
we do have serious concerns regarding the recommendation that 
the 
the Secretary designate a unit for board and care in 
Department. We also have some general suggestions for
strengthening the report. 
Addi tional contextual information should be added to the 
report 
We suggest that the report incl ude the posi t i 
observations and other excellent points made by OIG staff 
at the January 4 briefing, e. g., that care being provided 
is much better than the pUblic s perception of such care 
and that states are trying and, for the most part, are 
this 
succeeding in carrying out their responsibili ties in 
area, particularly given the changing needs of the board
and care population. 
Also, as additional 
background, we suggest that a brief 
description of the range and types of homes and facilities 
included under the category of board and care be added, as 
well as a brief description of the various types of persons 
being served in these homes. We believe it is particularly 
important to emphasize that there is no common definition 
or description of a board and care facility and that board 
wide range of demographic

and care residents have 

character istics and a wide range of needs.
 page 2 - Richard P. Kusserow

Recommendations for state action

Generally, we support the four recommendations for State

action. We believe OIG has identified areas that would

benefit board and care residents and allow for better State

oversight and enforcement.

Recommendation that the Secretary should designate a uni t

in the Department for board and care

out
We agree that the functions recommended to be carried
by a designated board and care uni t might be timely, 
real
appropriate, and supportive of state actions given the 
advances in State performance over the past several years 
and thset aFetedesr.a l government' s new federalism relationship 
Also, such a uni t might help meet 
wi th 
congressional concern that the Department address
identified abuses. 
However, it is unclear how the specific 
recommendations for Federal research, technical assistance, 
and other acti vi ties could be implemented gi ven the cur rent 
lack of staff and funding for such activities in the

Department.  follows: 
Our specific comments are as 
a. The report stated that one function of the unit would be

to disseminate information on matters such as

operational efficiencies, effecti'v be eesntf oprrcaecmetinct
es. 
techniques, 
research, and States
fact, the Department funds very little research and has 
almost no information to disseminate on the other
objectives. 
b. A second function of the board and care uni t would be to 
Although 
promote more effective use of the Model Act. 
the report used the Model Act exclusively against which 
to measure state standards, there are other model 
standards and regulations which could or should be
considered by States, e. g., model regulations developed 
by Boston Uni versi ty and a Model Act on Zoning for board 
and care residences developed by the Administration on 
Developmental Disabilities. 
" would be 
c. A thi 
rd function of the board and care unit
As noted
provide technical assistance to States.

earlier, the Department has no particular expertise in

this area and the Office of Human Development Services

(HDS), for example, would need additional staff and

ry out such acti vi ties. 
fund ing to car  Page 3 - Richard P. Kusserow

board and care uni t would be 
c. The fourth function of the 
to coordinate Departmental board and care acti vi ties. 
In reali ty, however, the Department carries out few

this area. 
meaningful activities in  Three agenci s make 
grants to States to carry out advocacy and ombudsman 
services on behalf of board and care residents and
others.  rarely 
The Social Security Administration is 
that do 
involved as states chose to deal with facilities 
not meet standards by enforcement methods other than

reduction of an individual' s Supplemental Securi 
payment. 
Income (SSI)  The Health Care Financing 
Administration, by statute, must verify that Keys 
Amendment and other standards are met in order to grant 
state 8communi ty based  wai verso We administer 
compliance with Section 16l6(e) of the Social Security
Act. 
The Office of the Assistant Secretary for Planning 
and Evaluation has been involved in various long term 
has 
care research and evaluation efforts and recently 
funded a project to further study board and care

issues. It is 
unclear what the substance of the

be.

coordination is or should 
Finally, we agree it is important for the Department to

respond to congressional concern on the board and care

issue. As opposed to recommendations that would require

additional staff and funding resources, we suggest that

the OIG consider exi sting mechanisms, such as cur rent 
promotion work

Departmental long term care and health 
functions. 
groups, as a way to carry out sOme of these 
Other points of clarification

In addition to the marked-up copy (attached), we have the

follo 
ing suggestions:

unlicensed
a. Clarify that the report uses the term 8I s standard for
refer to homes that fall under a state 

licensure, not those that are exempt. (See page' 13. 
national 
b. clarify that, while respondents recommended 8
8 they also recommended State 
minimum standards, 
standards. 
flexibility in meeting or developing such 
(See page 8. 
c. It is stated tha
 8 A ma8jo rIit  ty felt the Keys Amendment
would be preferable to say
could not be enforced. 

that standards developed under the Keys Amendment could

not be enforced. 
(See page ii.
 Page 4 - Richard P. Kusserow

d. It is stated that .state regulations require that all 
or certified.  This is 
board and care homes be licensed 
ncor rect. (See page 1. 
e. Clarify that although the Keys Amendment also included 
SSI 
statutory amendments to the Social Security and 
programs, historical usage and this report refer to 
Section l6l6(e) of the Social Security Act as the Keys
Amendment. 
f. It is stated that .Fire and safety guidelines were also

developed by an HHS interagency task force and shared 
wi th the States.  This needs further explanation. The 
fire and safety guidelines were the result of a ten year 
effort. A .Fire-Safety Evaluation System for Board and 
Care Homes. was incorporated in the Life Safety Code by 
represents 
the National Fire Protection Association. It 
a major development in the technology of providing board 
and care services. Cur rently, there is a large 
evaluation being conducted of this system which is being 
agencies. 
(See page 3. 
jointly funded by six Federal 
attached copy of 
We believe the marginal notes and edits on the 
explanatory. If 
you have any 
the draft report are pelf 
70 7. 
questions, please call Janet Hartnett on 245-
Attachment  :) .
 \ :...... "'". . ."'":,"" ' '" 
..,l
//Ib 
VIC" 
DEPARTMENT OF HEALTH 8L HUMAN SERVICES  Office of the Secretary
/I
;.,z; 
It '1 ; . Washington, D.C. 20201 
E l:;' 
...., DIG 

AIG.
rgSD  ". 0v.  "
I'
JlMORAUK  AIG
AIG. 
Richard P. Kusserow  ADM 
OGC/IG 
Inspector General 
I I  EX SEC 
DATE SENT 
FROM  Arnold R. To  ns tary 
Acting Assi  for Planning and Evaluation 
SUBJECT:  OIG Draft Report:  "Board and Care" , OAI-02-89-01860 
We have reviewed the above report and conditionally concur based 
observations: 
on consideration of the following 
study, 
Al though ASPE worked closely with the OIG during this 
no mention is made of the board and care initiatives 
ASPE. 
currently underway in  The report should cite the ASPE 
board and care initiatives which include the current quality 
of care study and the design work for a board and care
census. 
These activities demonstrate that the Department is 
issues. 
more than just a passive observer of board and care 
The report points out, and rightly so, that very little

coordination exists within HHS among the agencies involved

wi th board and care. However, as a result of the ASPE 
initiatives cited above, information sharing and 
improved. 
coordination among agencies has 
The tone of the report implies that all Unlicensed board and 
care homes are operating outside of the law and that if 
licensing was required of them, the system would somehow be 
much better. First, it should be made clear that not all 
unlicensed homes are operating illegally (some States have
very limited licensing requirements). 
Second, although the 
quality of care provided in some unlicensed homes is

suspect, there are many unlicensed homes that provide care 
homes. In 
equal too or better than that found in licensed 
some communities, unlicensed homes are an important part of 
the community-based care system. The issue is to determine 
the extent to which care in unlicensed homes differs from 
the care provided in licensed homes. The ASPE quality study 
issue. 
will attempt to address this 
References to the Keys Amendment of the Social Security Act 
should be clarified to explain that reductions to an S5I
recipient I s payment can only be applied to that portion of 
the payment that is a State supplement and only by the 
amount of the supplement that is used for medical or 
remedial care. This adds to the intractable nature of 
Keys. 
employing the penalty provision of  Page 2 - Richard P. Kusserow

Several references are made to the' SDX tapes and the 
feasibility of having states use them to locate unlicensed
homes. 
These references need to be placed in a context that 
informs the casual reader of what the SDX tapes are, what 
their potential is for addressing the unlicensed homes issue 
and what problems are associated with use of the tapes. 
Again, the ASPE quality of care study will test the 
feasibility of using the tapes to locate unlicensed homes. 
One of the maj or recommendations of the study is that the

Secretary designate a unit .for board and care. We concur 
with this recommendation. The next step, ifu onthietr.s  Iatl so

occurs 
concur, is to choose the location of such a 
to us that SSA' s invol vement is essentially as a check

writing agency, HCFA's interest is centered around the 2176

Waivers, and ASPE is not a program office. On the other

hand, OHDS includes AoA, which has responsibility for the

ombudsman program and the aged constituency, which makes up

the bulk of board and care residents, and ADD which

administers programs for the developmentally disabled.

Hence, our initial reaction is that the unit be located in

OHDS. We would be interested in exploring this issue

furter. 
Historv
, it is 
On page 1, in the third paragraph under 

implied that all state regulations require the licensing of
board and care homes. This 
is not true. 
HHS Role  The first sentence should be 
mOn paoge d2, iufndiere d by adding "
or their residents" to the end of the 
sentence. 
On page 15, the ADD means the Administration 2R

Developmental Disabilities.
 j) 
.. . //..  ... 
.. .  "': . .. ' ':!"" : "".... -'?;.\..
,k./
'b  -'7L 
bel-
,t4 
YmO
/ OficetO th Seetary

DEPARTMENT OF HEALTH II HUMAN SERVICES 
(1
Wasington. D.C. 20201 
8-. "'"
Administration on Aging	
I.... l  ;. vL' 
1 . ;
. ,. L.. 

1990 JAN I 0 

2: 25 
JAN	 1r 
8 19 

TO:	 Richard P. Kusserow

Inspector Gener 

FROM:  Acting Commissioner on Aging 
Board 
SUBJECT:	 Comments on Draft Inspection Report Entitled " 
and Care 
8, 198  memorandum to Mary

This is in response to your December 
Buman Development Services,

Sheila Gall. Assistant Secretary for 
draft inspection report

requesting review and comment on the

entitled "Board and Care. 
he draft report and concur with its findings

We have reviewed 
 suggest only the following changes and

and recommendations. We 
additions: 
p. ii  , should be changed to 
, 7th line from the bottom
read  Ombudsman Program w  ch advocates the rights 
elderly including....  (The 
institutionalized 
of the 

Older Amer cans Act requires the State Office of the

or on

ombudsman to investigate complaints made by

facilities, not

behalf of residents of long term care 

all elderly.

page 2, line 5 under BBS Role, should be changed to

administered by

read  NIMH ) havet piroogra ms 	 which.... (Neither,
State agencies or organiz

ADD, AoA, nor NIMH dIrectly operate their respective

protectio 
and advocacy programs. 
funded. by the 
The report should mention a study  (ASPE)
Assistant Secretary for Planning and Evaluation
entitled "
Analysis and Comparison of State Board and 
Care Regulations and Their Effect on the Quality of
" which is currently

Care in Board and Care Bomes.

d by Research Tr iangle Institute. This 
being conduct 
is a major Department initiative involving board and 
should be mentioned on page 15

care regulation. ASPE 
DIG

AIG

AIG-AI

AIG

ADM

. OGCIIG  ~~~
Page 2 - Richard P. Kusserow

and elsewhere, and reference to the study should be 
the report. 
made at appropriate places in 
on the draft
We appreciate the opportunity to review and comment

report.  .' :"
Health Ca'

DEPART;\E  T OF HEALTH &. Ht..\\AS SERVICES  FinanCing Ac"" " , 
Memorandum
"."410  i i
Date 
From  ::S 2 
:S 
Acting Admini

Subject OIG Draft Report - Board and Care, OAI-02-89-01860 
The Inspector General

Office of the Secretary

Thank you for the opportunity to review your draft report

which assesses existing State board and care regulations and

enforcement activities.

The report states that HCFA is unable to identify how many 
of the approved waiver programs include services for board and 
care residents. While this is true, HCFA does ensure that each 
program which indicates that it serves such recipients makes 
explicit provision for the welfare of these clients. HCFA has 
also investigated and taken necessary action where there has 
been any indication that health and welfare has been 
compromised. We want to ensure that OIG is aware of the 
aims. 
following HCFA initiatives that help accomplish these 
Since the inception of the waiver program in 1981, 
States have been required to provide assurances that

the health and welfare of clients will be protected

during their participation in the program. 
The States 
are also required to back up these assurances with 
anual reports 
copies of written provider standards and 
on the satisfaction of these requirements. 
In our 1985 final regulations, we specifically required

that states providing waiver services to individuals

who were residents of board and care facilities ensure

compliance with section 1616(e) of the Social Security

Act 
(Keys Amendment) and supply a copy of the required 
review. In 
standards to us for  addition, our 
regulations authorized the withholding of Federal

matching funds for wai  r services during periods of

l th 
noncompliance with the Keys Amendment or other he 
and safety standards.  Page 2 - The Inspector General

investigations 
HCPA has conducted intensive regional office 
of several programs in which allegations were made that 
recipient health and welfare were being compromised while
residential waiver providers. 
In West Virginia, HCFA used 
the results of this inquiry to deny the state' s application 
program. In 
for renewal of its waiver  Pennsylvania and 
Oregon, corrective action was promptly initiated by the
states. 
report, "nurs ing
I would also note that on page 2 of the 
facili ty. 
applies only to Medicaid, not Medicare. 
Than 
you for the opportunity to review the above draft
report.  ::,.:..:	:: .....'.:. ,..', .  : "
aAW	
(,1\ 
N tJ.. 

DEPARTMENT OF HEALTH Sa HUMAN SERVICES	 7z/7  Public Health Service
Memorandum 
JA 2 
Date  2 199 
From	 Assistant Secretary for Health 
and Acting Surgeon General 
Subject	 OIG Analysis and Inspections Draft Report "Board and Care 
2-89-01860 
OAI -0 
Inspector General, OS

We are in agreement with the overall content of the subject

OIG draft report and concur with the report s recommendation

that the Secretary, RUS, should designate a board and care

unit to support the States' efforts in implementing the

recommended improvements. Through technical assistance and

dissemination activities, this unit would have the potential

uality of care and life of individuals

to greatly improve the 

residing at boarding homes.

Jame  . Mason, M.D., Dr. 
DIG 
AIG-A 
AlG-AI  "':1 
AIG-l 
ADM 
OGCIIG 
EX SEC 

DATE SENT  ~~~
. -'-- &. =-  (..:.' .. , -) .,.  .:-
U1b ')d
UUJART.'\UNT 01. HEALTH 	 HlIMAN SERVICES 
 "uV?  I  Social Security Administration
4-'	
Memorandum 
Refer to
Date: 
From: 
Report, " Board and Care 
ff ce of Inspector General Draft 
Subject:	
OA -02-89-01860) --INFORMTION 
usserow 
To:  Mr. Richard P. 	
Inspector General

report.

If we can be of

Attached is our response to the draft 
know.

further assistance, please let us 
Attachment: 
Tab I - SSA response

v =

IG 
PDIG  =- V 
DIG-AS 
DIG-EI 

DIG-OI 

AIG.	 r''l .
c-J '
OG/IG 
NT  How to use these separators 
Look for your reference letter. The far left column designated "TAB" will indicate 
proper tab position for that number or letter. Cut off and discard all tabs except the one 
you wish to retain. Example: Position number " 10" would be found behind the fourth 
tab. Position letter "C" would be found behind the third tab. 
TAB  (CHOOSE YOUR TAB) 
FIRST

SECOND

THIRD

FOURTH

FIFTH

SIXTH

r-
SEVENTH 
TAB  (CHOOSE YOUR TAB) 
FI RST  98 91 84 77 70 63 56 49 42 35 28 21 
SECOND  99 92 85 78 71 64 57 50 43 36 29 22 15 
THIRD  100 93 86 79 72 65 58 51 44 37 30 23 
FOURTH  94 87 80 73 66 59 52 45 38 31 24 17 
FIFTH  95 88 81 74 67 60 53 46 39 32 25 18 11 
SIXTH  96 89 82 75 68 61 54 47 40 33 26 19 12 
SEVENTH  97 90 83 76 69 62 55 48 41 34 27 20 13 
TABBED SEPARATOR SHEET 
Form SSA-69 (10- 791  COMMENTS OF THE SOCIAL SECURITY ADMINISTRATION ON THE OFFICE OF 
INSPECTOR GENERAL DRAFT REPORT, " BOARD AND CARE" OAI-02-8901860 
General 
(OIG) 
In this inspection, the Office of Inspector 
assessed existing State board and care regulations and 
enforcement activities. The inspectors found serious weaknesses 
in existing State standards and enforcement practices and found 
standards. 
support for the establishment of national minimum 
They also found that the Department of Health and Human Services

board and care.
plays a limited role  in 
OIG' s recommendations were directed to the States and to the
Secretary.  were: that States 
Among those for the States 
reevaluate their board and care standards, and improve their 
facilities. The 
ability to identify and deal with unlicensed 
inspectors recommended that the Secretary should designate a 
uni t for board and care which will disseminate information and 
provide technical assistance. to .States, promote more effective 
use of the Model Act for Regulating Board and Care Homes and 
are. 
coordinate Departmenta1 activities relative to board and 

Al though none of OIG' s recommendations are directed toward the 
Social Security Admnistration 
(SSA), we appreciate the 
the report. 
opportunity to revie 
Technical Comments

We have the following general comments to offer concerning

Security:

certain sections of the report dealing with Social 
First, on Page 15 of th  report OIG notes that "No SSA

procedures are in place to implement the Keys Amendment"

This statement is inaccurate since procedures have been

he Keys Amendment and may be found 
120. 
promulgated to implement 
 These 
in our Program Operations Manual System, GN 00502. 
procedures provide that substandard facilities be reported

to SSA' s Regional Offices. The Regional Offices are

responsible for disseminating the lists of substandard

facilities to SSA field offices to be screened as part of the 
representative payee selection process to ensure benefits are 
facilities. 
not inappropriately directed to these 
We assume that the statement in the report that SSA has no

procedures to implement the Keys Amendment is related to the

lack of SSA procedures to implement the penalty provision of

the Keys Amendment, contained in section 1616 (e) (4) of the

Social Security Act. This is true, primarily because the

penal ty provision is basically inoperable because of a flaw

in its construction. The law states that when a Supplemental

Security Income (SSI) recipient resides in a substandard

facility the individual' s title XVI payments should be
 any State 
reduced by an amount equal to the amount of 
payment which 
supplementary payment or other State or local 
is made for or onf aacccioluintyt .o f any medical or remedial care 
provided by the  States do not include money for 
medical. or remedial care in their supplementary payments or, 
as we understand it, in other payments. In addition, board 
the provision 
and care homes ordinarily are not involved in 
Thus, 
of the type of care specified in section 1616 (e) (4). 
is virtually impossible to

it seems fair to say that 
 sanction.  it
implement this 
Furthermore, the provision is not workable because it hurts 
indirectly at
bthee srte.c ipient directly and the operator only 
benefit, the 
Conceivably, if SSA reduced the SSI 
recipient and get 
operator could get less, or could evict the  latter. 
a new resident. Chances are it would do the 
a minor technical point found on

OPura segcoend  ob1se rvaotifon  
 the executivei s  summary. Paragraph 2, line 3 under

Background" should read .Supplemental Security Income

I) . . . R . 
( SS 
observations have

Other miscellaneous technical comments and 
provided to OIG

been made on a mark-up copy of the report and 
staff under separate cover.
 APPENDIX C

CHARTS

C - 1
 L 
A
NK 
MIC
E
RIH
CC
D  D 
E E
NS S
S
ES E
CER
LIMD
NOD
UHA
N 
T O
CI
IS
RS
TMI
S
 
 ED
I RA
T
E S 
E
S
OM
LO
CH
Y 
RY 
A
T
TL
L NEA
I N
VO
CIMPE
Y 
N
E
D
E/E 
KS
  N
O
E VE
C
E
I
RL
C
D 
R
E
T
CS 
O EE
PM
SO
N
F IH
  E 
. V
I
T
ECN  S 
RO E
RTI  Y
OC -
CA y
a  S 
bi D
STATE  Alabama/1 Alabama1 Alaska  Arizona Arkansas  California  Colorado/1 Colorado/2 Connecicut Delaware  District of Colum Florida Georgia  Hawaii Idaho Ilinois  Indianal1 Indiana1  lowa/1  lowa/2  lowa/3 Kansas/1 Kansasl2  Kentuckv/1 Kentuckvl2 Louisiana  Maine  Marvland/1  Marvland/2  Marvland/3 Massachusetts  Michiaan/1  Michiganl2 Minnesota  STANDARS. IN E. ENFORCED   
s
n
o L 
A
ti NK 
p
O MIEC
  RIH
t CC
n
e
m
e D  D 
orc ENSES ESSE
nf CER
E LIMD
NOD
UHA
N 
CT IO e. 
RISS ak
TMI o t
RESAD ority t
h
ut
a
y 
E S  utor
SE at
OM st
LO er 
CH h
ot
Y  ve 
RY  ha
A
T
L NETAL may 
VION
CIMPE s. States 
al
ci
Y  ff
o
N e 
E at
D St
E/E  h 
KNS wit
VOE ns 
RELIC ssio
u
c
s
di
D  & 
E s 
T d
CS  ar
EE nd
PM a
NSO e st
IH at
St
g 
VE  stin
I xi
T e
RRECTION  alyzing 
OC n
a
CA n 
o
d 
e
s
a
b
s 
n i
o
ati
STATE  Mississicci  Missouri  Montana Nebraska Nevada  New Hamcshire  New Jersev/1  New Jersevl2  New Mexico  New York  North Carolina  North Dakota  Ohio/1  Ohio/2 Oklahoma Oreaon/1 Oreaonl2 Pennsvlvania  Rhode Island  South Carolina  South Dakotal1
 South Dakota1  T ennessee/1 Tennesseel2 Texas  Utah/1  Utah/2  Utah/3  Vermont/1  Vermontl2  Virginial1 Virginia1  Washinaton/1  Washinatonl2  West Virginial1  West Virainia1 Wisconsin Wvomina  . The above inform  
s  
s
d ct
a
S
r
s 
a nt
ai
pl
  m
o
n C
s 
n
o
a ct
e
p
s
n
t I
  e 
c
. n
a
  ar
V
t ed 
s
c nlicenomes 
UH
 
g 
n
l si
n
c
U
e
g 
n
ni
ai
Tr
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Fir
 
h
h 
t alt
e
i H
e 
r
u
ct
r
St
 
i
t
  u
c Q
n
a nt 
l ResideRiahts 
n 
o
si
s
mi
d
A
   
f & lan
 P
d 
n orare
BC
o
e 
z
Si
  n 
o
e niti
efi
t D   o 
ta State  Alabamal1 Alabamal2 Alaska Arizona Arkansas California  Coloradol1 Coloradol2 Connecticut Delaware  Florida Georaia  Hawaii  Idaho  Ilinois  Indianal1  Indianal2  lowal1  lowal2  lowal3 Kansas/1 Kansas/2  Kentuckv/1  Kentuckv/2  Louisiana  Maine  Marvlandl1  Marvlandl2 MattMarylandl3 Michiaanl1  Michiaanl2  Minnesota  . = yes
empty box = n s 
  n
s o
d cti
r n
a a
d S
Stan plaints 
m
t  o
c C
A s 
n
  o
el cti
d pe
o ns
M I
h  e 
c
t n
wi aria
  V
e
c d 
n se
ma nlicenomes 
r UH
o
nf g 
o sin
C n
e
y  Lic
c
n
e g 
n
g ni
A ai
  Tr
e
t
a
t
S
e 
Fir
h 
alt
e
H
e 
r
u
ct
r
St
 
i
t
i
f
i
u
Q
nt 
ResideRiahts 
E 
n
o
si
s
mi
d
A
 
n
& la
Board Care P
e 
z
Si
n 
o
niti
efi
D
State  MississiDoi  Missouri  . Montana  . Nebraska  Nevada  Hamosil New  New Jersey/1  New Jersey/2  New Mexico  New York  Nort Carlina
 Dakota Nort  Ohiol1  Ohiol2 Oklahoma  Oreaon/1 Oreaon/2 Pennsvlvania  Rhode Island So Carina  s. Dakotal1
 S. Dakotal2 Tennesseel1 Tennesseel2 Texas  Utah1 Utah2 Utah3  VermonV1  VermonV2  Virainial1  Virainial2  Washinaton/1 Washinaton1  W. Virainial1  W. Virainial2
Wiscnsin
 Wyomina  = yes empty box = no  :::::::::.:.::.:.:.::.:.:.:::.;:::,::.:,:....... ....,:::.:...::.:.:.:..:::::::::':::'::::;;:::":::"::'::::::::"":":: """... .;:::;::::';:'::'::"::":::"::":"::::::::;::"::'::':':::':;;"::::'::::::::::::;:;':::'::':;:':'::::::::':::"::::::::':::'::'::::":;::':::::::'::$':'::'':':::':::":::.:::::.:::.:::::::::::-::~:.:~:~::~~.~:~:::~:~:~~::~:.~~:~:;~:;~:~~:~::.~~:~::~::~~~:~~~':~~~:~:~;:::::::::::::::::::::::
1 1J  l H 
KEY OF MULTIPLE LICENSING AGENCIES 
u aUHH

Alabama/1  Dept. of Health 
Alabama/2  Dept. of Menta Retardation 
ilil 
Colorado/1  Dept. of Health 
Colorado/2  Dept. of Social Services  II1I
Indiana/1  Dept. of Health 
Indiana/2  Dept. of Menta Health 
1111 
lowa/1  Dept. of Human Services 
lowa/2 Dept. of Human Services 
lowa/  1111 
Dept. of Inspections and Appeals 
Kansas/1  Dept. of Health and Environment  ilf!l 
Kansas/2  Dept. of Social Services and Rehabiltation 
Kentucky/1  Cabinet for Human Resources 
Kentucky/2  Cabinet for Human Resources 
Maryland/1  Dept. of Human Resources 
Maryland/2  Ofice on Aging

Maryland/3  Dept. of Health 
Michigan/1  Dept. of Social Services 
Michigan/2  Dept. of Public Health 
New Jersey/1  Dept. of Community Affairs 
New Jersey/2  Dept. of Health 
Ohio/1  Dept. of Human Services 
Ohio/2  Dept. of Housing 
iii 
Oregon/1  Dept. of Human Resources, Senior Services Div. 
Oregon/2  Dept. of Human Resources, Mental Health Div. 
Tennessee/1  Dept. of Menta Health and Mental Retardation 
Tennessee/2  Dept. of Health and Environment 
Utah/1  Dept. of Social Services 
Utah/2  Dept. of Social Services, Div. of Aging & Adult Servo 
Utah/3  Dept. of Health 
Vermont/1  Dept. of Health 
Vermont/2  Dept. of Human Services 
Virginia/1  Dept. of Social Services, 4 or more Residents 
Virginia/2  Dept. of Social Services, 1-3 Residents 
Washington/1  Dept. of Social and Health Services 
Washington/2  Dept. of Health 
iil 
West Virginia/1  Dept. of Social Services 
West Virginia/2  Dept. of Health 
IIII 
::::::::;::::X:::::;:::::  ::::::x:  x;::";:.:x*:*:.:;x