The killing of a caretaker this month at an Owings Mills group home for the mentally ill -- the latest in a series of violent incidents at assisted-living centers -- has renewed concerns about the state's ability to regulate such facilities.
In several incidents this year, a state review uncovered serious problems, including inadequate staff training and supervision.
And though state officials acknowledge that as many as 1,000 unlicensed group homes may be in operation, there are no inspectors dedicated to finding them.
"Something's got to be done," said Del. Richard C. D'Amato, an Anne Arundel County Democrat who pushed unsuccessfully this year for a study of how well the state regulates assisted living centers.
"There's an enforcement issue and a standard-of-care issue here."
But finding solutions to violence and other long-standing problems associated with assisted-living homes -- whether they are licensed or, as in the Owings Mills case, unlicensed -- will not come quickly.
Politicians and health care advocates say meaningful reform could be months or even years away.
Baltimore County police entered the Owings Mills group home the morning of July 10 and found the body of a 33-year-old woman lying in a pool of blood. One of the mentally ill men she cared for was pacing back and forth in the room.
Within hours, detectives charged the man with fatally stabbing Valerie L. Johnson, his caregiver.
There have been other serious problems at Maryland group homes. Among them:
In May, state health officials revoked the license of an Eastern Shore group home for teen-age boys after two residents were charged with raping other teens -- one a resident at the home and another a student at a nearby middle school.
In March, officials shut down a Randallstown assisted-living facility after learning that a worker with a prior murder conviction was accused of using an ax handle to attack a resident.
In February, state officials cited a group home for developmentally disabled youths in Joppatowne for a series of health violations after a resident threatened to kill a counselor and blow up the home.
The state's Office of Health Care Quality has shut down A Touch of Love Assisted Living Service Inc., which was running the group home in the Briarwood Apartment complex where Johnson was killed. Residents have been moved to other homes.
The Randallstown-based service had been operating five group homes in the area, state officials said.
It had been caring for 24 men and women with varying degrees of mental illness and physical disabilities, some of whose relatives did not know the company was unlicensed.
Residents at the Briarwood complex lived in luxury apartments, sharing two-bedroom units with lofts and fireplaces. There is a clubhouse and a swimming pool nearby. A security system kept entrances locked. A Touch of Love provided vans to take residents to jobs or day care programs.
A trained caretaker was supposed to be with them at night, though Johnson's family said she had received no training.
By the state's own conservative estimates, there are at least 2,000 homes for the mentally ill, the physically disabled and the elderly in Maryland. About half operate without licenses.
"There's a whole underground network of unlicensed assisted living providers," said Carol Benner, director of Maryland's Office on Health Care Quality. "This is a national issue, not just a local problem."
A staff of 175 is responsible for performing annual inspections at more than 5,000 health care facilities across Maryland, including group and nursing homes, birthing and adult day care centers.
That's in addition to those applying for licenses for the first time, making it impossible for the office to search out unlicensed providers, Benner said.
Instead, the staff responds to complaints -- or as in the Owings Mills case, a tragedy.
"We're spending most of our time in assisted living doing technical assistance and enforcement," Benner said.
"With so many providers out there -- many of them unprepared for licensure -- we have to do a lot of hand-holding, even helping them fill out forms."
Politicians, health care advocates and health officials charged with overseeing group homes, agree more inspectors must be hired.
The Office of Health Care Quality recently received permission to hire six more surveyors, Benner said.
But efforts to step up oversight of assisted-living centers have gone nowhere.
A proposal by D'Amato, the Anne Arundel legislator, to include such centers in a state study on nursing home regulation didn't make it out of committee.
Several proposals to toughen penalties for operating unlicensed assisted living facilities and to strengthen current regulations also failed in the General Assembly in recent years.
"The issue here is money," said Kate Farinholt, who heads the Metropolitan Baltimore chapter of the National Alliance for the Mentally Ill.