Several experts in senior care say that Maryland officials need to take action to prevent a dangerous underground network of unlicensed assisted living facilities from expanding.Susy Elder Murphy is the director of care management at Aging Well Eldercare, which is based in Silver Spring and provides senior case management in the Washington, D.C., metro area. She said unlicensed facilities are taking advantage of a broken senior-care system.
“Unfortunately, I foresee even more people being forced into choosing some place that’s unlicensed because they don’t have any other options,” Murphy, a Maryland-based member of the National Board of Directors of the Aging Life Care Association, told Spotlight on Maryland. “I think they’re preying on people who are at their most vulnerable, either seniors who don’t have any family or families who don’t have any other option.”
Kevin Heffner, the president and CEO of Columbia-based LifeSpan Network, which represents more than 250 senior care provider organizations in Maryland and Washington, D.C., described the issue of “underground facilities” as a “public health crisis.” Heffner emphasized that this crisis comes at a challenging time for Maryland amid a budget deficit and an increasingly disproportionately large senior population.
“The older adult population that’s being served in the broader senior care landscape is more frail and has more complex medical issues than at any point in the past,” Heffner told Spotlight on Maryland.
“You also have the dynamic of, in Maryland, for the first time ever in 2030, there will be more people over the age of 65 and under the age of 18, so the challenge is exacerbated not just from a payer standpoint, but from an available direct care worker standpoint. There just aren’t enough workers entering the field to be able to care for all of the older adults who need it.”
‘See where the money’s going’
Anne Montgomery, a senior long-term care policy expert at the National Committee to Preserve Social Security and Medicare in Washington, D.C., said the first step for Maryland officials in improving senior care is ensuring they have good data to act on.
“We ought to look at cost report data and see where the money’s going. You look at these four things: staffing, ownership, the safety record and the cost report analysis. If you can do that, you really can see who the bad actors are and who the good actors are. And yet we are not really doing that at either the federal level or at the state level in a comprehensive way,” said Montgomery, who worked as a senior policy advisor for the U.S. Senate Special Committee on Aging from 2007 to 2013.
“As the population grows of people who are living in those settings, we must do a much better job, a much more comprehensive oversight than we have in the past, or we’re going to see continued deterioration and people running into serious abuse and harm,” Montgomery continued.
MDH denied a public information request from Spotlight on Maryland for all assisted living complaints over the past two years, citing a “medical review committee” exemption.
‘We have to figure it out somehow’
Heffner said the Maryland state government needs to boost its oversight of senior facilities before tragedy strikes.
“Until the other shoe drops, nothing really happens, no change happens. We’re in the midst of the other shoe dropping, where you’ve got unlicensed homes that are popping up all over the place that put already vulnerable, poor, frail older adults at risk of medication errors or falls; other kinds of safety issues that we can’t even imagine,” he told Spotlight on Maryland. “We’re one high-profile death or terrible story away from this becoming a national news kind of situation, and nobody wants that attention for Maryland. We have to figure it out somehow.”
When Spotlight on Maryland launched its senior housing series on Nov. 11, the Office of Health Care Quality (OHCQ) — MDH’s agency that monitors health care facilities — had only issued one referral for prosecution to shut down an unlicensed senior facility despite receiving hundreds of complaints since October 2023. Five days after the investigative report, OHCQ issued a second criminal referral to Maryland Attorney General Anthony Brown, marking the first referral of the year. There have been zero prosecutions since 2023.
Senior care experts said prosecution is a necessary part of reform that must also include more staffing to help identify potentially abusive senior facilities.
“There aren’t enough people to ensure quality in licensed facilities, which we represent, much less the ones who are unlicensed that have to follow up on complaints in order to shut them down,” Heffner told Spotlight on Maryland. “If someone makes a medication mistake, sometimes people die. And so that’s what’s at stake.”
‘We can’t take care of our seniors’
Another issue cited by experts is Maryland’s backlog of applications to the Medicaid Long Term Services and Supports program, which covers housing and assistance for seniors in need of medical and financial support.
Murphy, who also serves as the co-chair of programming for the American Geriatric Society in the Washington, D.C., metro area, said state officials need to address the backlog of Medicaid long-term services applications so that vulnerable seniors can avoid living in unlicensed facilities.
“Literally nobody knows how many of those people are even still alive, let alone still needing a slot,” Murphy said of the state’s backlog. “We’re supposedly one of the richer states in the union, and we can’t take care of our seniors.”
Spotlight on Maryland asked MDH to provide updated data on its backlog of Medicaid long-term services applicants. The department did not provide the data by deadline.
Montgomery said one solution to this backlog is to allocate Medicaid long-term service funds toward more affordable, accessible group home environments. However, she said this requires better oversight of those facilities, which often struggle to follow state requirements, especially in cases of unlicensed homes.
“If you monitor appropriately and you hold individual facilities accountable who are not providing good enough care, then you can clean up the system. That has not been done, generally speaking,” Montgomery told Spotlight on Maryland. “We can look at cost reports and see who’s doing a good job, who’s doing a terrible job, and basically focus on those that are not doing a good job: make it uncomfortable for them in various ways.”
“We don’t need lowball operators to continue being in our systems that are taxpayer financed,” she continued. “We want good quality mission-driven providers, but we have to insist on it.”