# Presentation: 176019

## USING LAW FORHEALTHY HOMES

- Priscilla Keith, JD
- Dana Reed Wise
- Health and Hospital Corporation of Marion county
- Indianapolis, Indiana

##    Environmental Justice

- “Environmental justice is the fair treatment and meaningful involvement of all people regardless of race, color, national origin, or income with respect to the development, implementation, and enforcement of environmental laws, regulations, and policies.”
-      EPA Policy statement

##  Selected Indiana statutes

**IC 12-15-12-20  Child lead poisoning screening****    **
**IC 16-41-39.4 Childhood Lead Poisoning**** **
**IC 13-17-14 Lead-Based Paint Activities**** **
**IC 13-14-10 General Emergency Procedures**** **

**Notes:**
IC 12-15-12-20 Requires developing a way to evaluate a Medicaid managed care screening of children under six years old; these evaluations must be maintained in written form, and provides for an incentive program for Medicaid managed care screening organizations.
IC 16-41-39.4 grants ISDH broad powers to provide education and coordination to screeners, local health departments, social service organizations, and consumers.
IC 13-17-14 establishes safe practices for anyone involved in lead based paint activities in targeted housing, especially when children are six years old.  Also establishes inspections of targeted housing, licensing and training of contractors, and license revocation.
IC 13-14-10 General Emergency Procedures allows the Governor to declare an emergency when contamination threatens the health and safety of persons in an area.

## Proposed changes to Chapter Ten of HHC Ordinance

- An “approved water supply” may not contain hazardous levels of copper and lead.
- Defines and adopts standards for determining:
- Lead in dust contamination
- Lead in soil and water contamination
- Defines and adopts lead-safe work practices.
- Requires replacement of all pipes constructed or contains lead compounds.
- Requires interior of housing, exterior walls and soil be free from lead and lead dust hazards.

## Proposed State Legislation

- Protecting Children from Lead Hazards
- Restrictions on Retailers of Children’s Jewelry
- Restrictions on Paint Retailers

**Notes:**
Protecting Children from Lead Hazards includes jewelry designed, sized, or marketed for use by children may present a danger to children.
Restrictions on Retailers of Children’s Jewelry includes prohibiting retailers from selling children’s jewelry unless it contains a lead content of less than .06 percent by weight or the retailer provides written documentation that the product is safe.
Restrictions on Paint Retailers would require paint retailers to conspicuously offer to customers copies of the EPA pamphlet “Protect Your Family” and paint retailers must offer for sale a dead dust kit for determining the presence of lead.

## Medicaid Reimbursement Amount

- Reimbursements for the following:
- Blood tests to determine levels of lead
- Allocation between laboratory and corporation
- Case management and inspections

## Code Enforcement Procedures

- Ordinance authorizes health officers to conduct housing inspections.
- Generally, the inspectors must first obtain consent from the owner or occupant.
- The health officer may make both a lead-based paint inspection and risk assessment

**Notes:**
The exception to consent occurs with a serious health risk that may become greater through delay and the corporation may seek an administrative search warrant in cases where consent is denied.
 An inspection is a surface by surface investigation to determine the presence of lead based paint.
A risk assessment includes investigation of the entire property.
For example, one inspection and risk assessment in 2005 listed nineteen violations, including chipped or peeling lead-based paint on exterior doors and frames, exterior window frames, sashes and sills, and the exterior door of an accessory building.  Additional violations included deteriorated eaves with lead-based paint on an accessory building and lead-based paint chips on the ground.

## Code Enforcement Procedures

- After finding a violation, a health officer will issue an administrative notice of violation to the persons responsible.
- The written notice will include the reasons for which it is issued.
- The notice will also contain an outline of remedial action to achieve compliance.

**Notes:**
In one case from Marion County, an inspector found a bathtub that contained hazardous levels of lead-based paint.  The inspector issued an NOV thirteen days after the inspection.
Service of the notice may be to the person responsible or that person’s agent.
In Marion County, service was given to the apartment’s owner.

## Code Enforcement Procedures

- The notice will allow a reasonable time for the performance of any act it requires.
- The person who receives the notice may request an administrative hearing.
- The administrative law judge shall issue a final order within 15 days of the hearing.

**Notes:**
In the Marion County case, the bathtub required reglazing or replacement.  The property owner was given three weeks to comply.
The NOV also included safe practices for the owner to follow.
Additionally, the notice included recommendations for visual inspections by the owner annually, after damage, or during a period of vacancy.
The request for an administrative hearing must be made within ten business days and must be in writing. After request, the ALJ will send notice of date and procedures to all parties involved in the hearing.
If either party wants a transcript of the hearing, that party must request that the hearing be recorded.

## Code Enforcement Procedures

- Either party may appeal the final order in court.
- HHC may issue a bill to the property owner to recover costs incurred in bringing the property into compliance.
- HHC may also bring a civil action to enforce an ordinance violation
- Any person found in violation may be fined up to $2,500 for each offense.

## Lead Hazard Control Grant Update

- 141 units under contract to receive remediation:  74 units completed, and $600,000 collected from property owners
- An additional 76 units are enrolled, but not under contract
- 17 contractors working in Marion Co. have been trained in lead-safe work practices
- Grant ends October 31, 2008

**Notes:**
Just as as reminder, we were awarded a $3million Lead Hazard Control Grant from HUD.  The grant doesn’t end until October 31, 2008 but we are way ahead of schedule.  Since we received our grant, 2 other counties in Indiana have received Lead Hazard Control grants (Fort Wayne and South Bend).  Additionally, we partnered with Indiana Black Expo to receive a Lead Outreach Grant.  Indiana Black Expo services the entire state of Indiana, because our program has been recognized as a leader in its efforts to eliminate lead hazards our assistance was requested in the organization’s “get out the lead” campaign. 

## Systematic Code Enforcement

- Original purpose  - to focus on holistically improving the housing stock, one neighborhood at a time
- The team consisted of a social worker, community resource liaison, nurse, and health educator
- The team worked to assist families in bringing their properties into compliance

**Notes:**
The systematic in Systematic Code Enforcement meant that we were systematically going neighborhood by neighborhood inspecting each residence, and  issuing housing and sanitation orders where needed, and to assess the overall needs of the families to perhaps connect them with the services they needed so they could address the code violations.  
In addition to the sw, crl, nurse and health educator, there was and environmental health specialist that worked with this team, as our EHS are assigned by census tract.  So depending on the neighborhood being inspected, the EHS would change. 
However, there was community backlash against this approach not only from the neighborhoods, but also from the Mayor’s office.  The neighborhoods felt like they were being singled out and targeted as not necessarily poor, but “bad” neighborhoods and did not want to be perceived that way.  And it didn’t help that the neighborhoods selected were part of the city’s New Approach to Anti-crime Program grant activities.  The idea was part of the broken window theory, where there is a concentration of substandard or dilapidated housing, poor sanitation, there is a higher incidence of crime.
We also started running into the issue of “degree” of violation, e.g. peeling paint, vs. boarded windows.  Issue all or only the most egregious?

## Systematic Code Enforcement

- Current team consists of only social worker and community resource liaison
- No longer working on specific neighborhoods, but county-wide
- Referrals from adult protective services, child protective services, community development corporations

**Notes:**
So the programs was scaled back, and now we only have a social worker and a community resource liaison working full time on this effort.
They work county wide and not only receive referrals from Env health specialists, but from many social service agencies throughout the county.  Their job is difficult as many agencies call us for help, when in the past we would call on them for help.  Their case load stands at about 75, and although that doesn’t sound like a lot, there are so many more that could be referred to them, but due to the lack of resources and the amount of time each case takes, they really can’t handle many more.
I need to back up a little bit, it’s been mentioned (if it has) that MCHD is one if not the only health departments in the county where housing code inspection is part of the health department instead of city government, we do participate in neighborhood sweeps with city law enforcement and zoning.

## SCE – Healthy Homes Initiative

- Staff from the National Center for Healthy Housing provided training for MCHD staff
*Essentials for Healthy Homes Practitioners *course was very well received
- Before training, recognized the need that the program needed to be enhanced

**Notes:**
So given the challenges with the current program, we are in the initial phases of turning the program into our Healthy Homes program, or H2 for short, and it really is an initiative right now.  We recently held and internal meeting, and made a few external calls to make sure we could partner with others n the community that would be interested n working on this effort.  
We were fortunate to be able to offer the Essentials for Healthy Homes Practitioners course for housing staff, public health nurses, lead program inspectors, and a few participants from the community.  Tom Neltner was one of the trainers and the training was very well received by staff from the health department, and I’ve already received a request to bring the training back for our community based nurses.  
Before the training was conducted in September of this year, we recognized that the program could be used for so much more.  In fact, I received a little seed money from the director that I have been holding onto because I want to make sure I can get a lot of the dollars. 

## SCE-Healthy Homes Initiative

- National Center for Healthy Housing provided a detailed report with recommendations after the training
- Goals of the program:
- To implement a multi-disciplinary approach for inspecting homes
- Provide cross-training for staff in environmental health and population health bureaus

**Notes:**
The report completed by the National Center for Healthy Homes was very extensive and offered many new ideas to make our program more comprehensive, and others we had considered on our own, but it reinforced out thinking that we were on the right track.  In a second I will mention a few of the initial goals of our H2 initiative, but one that I have not put in the slide, that I plan to tease out further with Priscilla and her staff is eliminating retaliation by landlords against their tenants.  In perhaps a couple of our lead abatement projects, and many of our code violation cases dealing with issues other than lead, the owners have retaliated against tenants that have legitimate housing complaints.  The report mentioned the adoption of a rule of prohibiting retaliation.  
The basic premise or goal of our initiative remains to improve the housing in neighborhoods, but basically we are taking it one step further and also concentrating on the health environment of the home and the people living in it.  So in addition to the structure, we are of course looking for lead hazards, mold, safety issues/injury prevention, pests, sanitary maintenance, and again the health of occupants, physically and mentally.
This speaks to our desire to implement a multi-disciplinary approach for inspecting homes, where we would have public health nurses, environmental health specialists, health educators, social workers, staff from our healthy families program, having the ability to at least recognize issues out of their normal course of work activities, and where necessary could conduct joint inspections.
We will need to provide cross training for our staff, because we don’t want to overwhelm the homeowners with so many inspectors swooping down on their property.  In the beginning, the program will only be for owner occupied homes. 

## Healthy Homes Initiative

- Goals continued:
- Implement a team approach for EHS and nurses based on census tract or assigned health district
- Develop a list of resources and funding opportunities
- Immediately add another team consisting of a social worker and community resource liaison

**Notes:**
During the training, we learned that there was a stong desire for the enEHS and the public health nurses to be able to conduct joint inspections.  This will not only assist the nurses in being able to address obvious violations they see when making home visits, but will help to dispel the “bad guy” image of the housing inspectors (may use EHS and housing inspector interchangeably).  Home owners and landlords often feel like they are being picked on by the inspectors.
Developing a list of resources is an on-going project,  Many reliable resources have disappeared and often we don’t here about other programs until it’s too late.  We also need to know the eligibility requirements.  Staff are often told or resources or programs that we an refer homeowners too, but the requirements often make it difficult for our customers to qualify.  
The last goal is one that I have already put into place, as I received to vacant positions where the job descriptions are being redone so that we can post these positions when I return form this trip.  The goal is to reduce to workload on the current team, and to also have bodies to assist in restructuring the program. 

## Healthy Homes Initiative Conclusions

- Lead hazard control and elimination plays a large role in the initiative
- Plan to purchase moisture meters for inspectors
- Plan to construct a database for the homes that may need to be re-inspected
- Support has been given by the MCHD director

**Notes:**
I haven’t mentioned lead abatement, but our childhood lead poisoning prevention program was the impetus for our improving the program.  We learned about the moisture meters from  during the training conducted by Tom and we plan to purchase at least 15 of them.  We have 41 EHS, and 4 lead inspectors (4 screeners, and 4 liaisons). 
We currently have a database of homes that have lead hazards, those that have been abated and those that haven’t.  We’ve learned that some abatement activities may only last 5 years, so we are going improve our database to re-inspect some of the homes to determine the current condition. 
Finally, as I mentioned earlier, I have been given a small pot of money to get this initiative started and we have briefly discussed this idea with our public health board, so I will be excited to come back and give you an update on the program.  Our hope is that we will able to qualify for additional funding that we can put back into the community as we are doing with the Lead Hazard control grant .  Thank you for your attention.