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Seniors for Sale

Investigating adult family care centers

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The pitch is seductive: Live in a cozy residential home in a familiar neighborhood with more freedom and superior care. Why settle for a big-box nursing home when you can live with a handful of people served by dedicated caregivers?

It's no wonder that residential care is among the fastest growing segment of senior care. It is also among the least regulated.

The industry has many names: adult family homes (AFH) in Washington, residential care facilities for the elderly (RCFEs) in California, and adult foster care homes (AFCH) in Arizona. You may also hear them referred to as board and care homes, senior family homes, and personal care homes.

In general, homeowners receive state licenses to provide room and board for up to six older adults (Federal law permits up to eight elders per home, but some states, like Arizona, limit that number to four). Adult home owners set monthly rates for private pay seniors – an average of $3,500 in Washington. The state establishes rates for Medicaid patients, at far lower levels than those paid to nursing homes.

This cost-saving motive can encourage state agencies to steer poor and vulnerable adults to residential homes, then turn a blind eye to problems.

While nursing homes are bound by strict federal laws, adult family homes are typically governed by weak state standards or none at all. Adult home owners aren't required to own life-saving equipment like a defibrillator. There are no minimum nurse staffing standards because they aren't required to hire a registered nurse.

Such feeble standards and lack of oversight has taken a steep toll. In my six-part Seattle Times series "," I found that thousands of vulnerable elderly adults had been abused, neglected or exploited for profit in many of Washington's more than 2,800 adult family homes. I also discovered a potential cause: Caseworkers trying to meet quotas were transferring nursing home residents into the homes to reduce the state's Medicaid costs and save money.

Unraveling the system – the owners

Imagine that you want to open an adult family home. Could it be as easy as filling out an application, paying a few hundred dollars for a license, passing a home inspection and claiming that you have some rudimentary experience working with seniors? Yes – although in some states you might need to take two days' worth of classes.

To investigate the residential care facilities in your state, deconstruct the adult family home process. Follow the paper. Track the myriad of state forms and records collected and generated. Build a roadmap of the process. And scour state law, so you know the rules of the game.

* Now it's time to crack open a spreadsheet program like Excel. It's an essential journalistic tool. If you don't know how to use it, learn. Otherwise, you're blind to reams of public information.

* Obtain a list of licensed adult family homes for the last decade (ask for a computer file) from the agency in your state that regulates them. These vary from state to state. In Washington state, for example, it's the Department of Social and Health Services (DSHS), but in neighboring California, it's the Department of Social Services. Thousands of miles away, in Florida, the Agency for Health Care Administration oversees adult family care homes and residential treatment facilities.

* Import the list into a spreadsheet, which should include name of home; date license; status; date closed; owner name; and so on.

With this basic information you can:

Determine the churn rate. How many open and close? In Washington, three homes closed for every four homes opened. This is a flag for a troubled and chaotic system. Look for owners with multiple properties. One person might own 10 homes with 60 boarders – larger than the population of some nursing homes but without the oversight. Find the heaviest clusters of homes. Adult family homes are protected by the federal Fair Housing Act, which prohibits discrimination against the disabled. What this means is that cities are required to accept adult family homes in every residential and commercial district. Some municipal governments have tried to push back.

Scrutinize homes that have closed. Find out why. Financial ruin? Problems with care? Examine real estate listings for owners who are trying to unload adult homes. In Washington, some owners touted their homes as get-rich investments. In some cases, seniors were listed for sale.

Next, track health and safety violations. Some states make this information readily available. If not, collect state press releases and news clips to track enforcement actions. Yes, you may need to hand-code these violations into your spreadsheet.

Here's a tip to crafting a unique story: break down paper investigative files into a spreadsheet. Every discrete piece of information goes into a column. Was the home cited? How many patients were involved? Was this a case of undetected bedsores? Which homes failed to provide adequate heat or food? Were patients forced to soil themselves because there was no night attendant? The more columns you create, the more powerful and precise the story.

That's how I knew exactly how many elderly victims were imprisoned in their rooms, roped into their beds at night, strapped to chairs during the day so they wouldn't wander off, drugged into submission or left without proper medical treatment for weeks.

The goal is quantification. Don't use qualifiers like some or many.

Seek out the good homes. Responsible owners, often dismayed by those who are trying to make a quick buck, can be great sources.

How do you dig out information from a recalcitrant state agency? File a public record request for every database manual related to adult homes – a blueprint to every piece of information, down to the last period.

The profiteers

As America ages, legions of entrepreneurs seek to cash in.

Senior placement agencies represent a virtual Wild West of the senior care landscape where web-based brokers promise to find perfect long-term care matches, raking in lavish commissions paid by adult home owners who are desperate to fill empty beds.

Look around your region. You'll find dozens of services, including national companies like A Place for Mom, a multimillion dollar enterprise based in Seattle.

The average commission equals one month of rent. Adult home owners say they need to fill 3-4 beds just to break even on expenses. That's why they sometimes panic and will pay almost anything to fill a bed.

Most placement companies advertise their service as free to families. The question is whether a placement service recommended a home because it was the best match or one that paid the highest commission.

Compare the placement service's recommended homes to the state's list of violations. In Washington, one service touted an adult home that had been cited with more violations than any home in state history, including a case of negligent death.

Look at the caregivers, too. Most states have web-based search tools to determine if a health provider has a valid license. Unfortunately, you are likely to find – as I did – that adult homes in your state are refuges for convicted felons and nurses with revoked licenses, including substance abusers.

For many of us, finding long-term care for a loved one will be a difficult and emotional decision. It often happens without warning – a stroke or heart attack – and a choice must be made in days. Who do you turn to for help?

Help your readers answer this vital question.

-- Michael Berens has been an investigative reporter for The Seattle Times since 2004. He previously worked for seven years on the investigative team at the Chicago Tribune and for 13 years at the Columbus Dispatch. While still attending Ohio State University, he began his newspaper career as a copy boy. He has won dozens of national and regional awards, and has twice been a finalist for the Pulitzer (investigative and beat reporting). He won the 2010 Worth Bingham Prize for Investigative Journalism for his series "Seniors for Sale," along with the National Press Club's Consumer Journalism Award, the Investigative Reporters and Editors award, and first place awards from the Association of Health Care Journalists and the American Society of Business Editors. He is a former adjunct professor for Northwestern's Medill School of Journalism graduate program, and has been a trainer and panelist for IRE, the Associated Press Media Editors (News Train) and the University of Southern California's Annenberg School of Communication & Journalism and Center for Health Journalism Digital.

Photo Credit: Dreamstime

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