1 welcome ellen bloom, mph health educator indiana state department of health indiana lead and...

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WELCOME

Ellen Bloom, MPHHealth EducatorIndiana State Department of HealthIndiana Lead and Healthy Homes Program

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LEAD RULE410 IAC 29

REPORTING, MONITORING, AND PREVENTIVE PROCEDURES FOR LEAD POISONING

Indiana State Dept of Health

Indiana Lead and Healthy Homes Program (ILHHP)

http://www.in.gov/isdh/19124.htm

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Overview of Statutory Background

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From a Statute . . .

Statutes aka Public Laws, Codes, Acts● Come from Indiana Legislature and start as Bills

● Statutes may grant a State Agency the power to adopt rules

● Senate Bill 538 (passed by the General Assembly) Public Law 135-2005 (signed by the Governor) IC 16-41-39.4

Indiana Code 16-41-39.4● Granted ISDH statutory authority to adopt rules for case

management of a child with lead poisoning – Title 410

● http://www.in.gov/legislative/ic/code/

● Health – Title 16

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To a Rule

Rules aka Administrative Codes, Regulations

● Promulgated by State Agencies based on authority granted by the Legislature in a statute

● Have the force and effect of law

Indiana Administrative Code (Rule by ISDH) Rule 410 IAC 29-2-1:“Local health officers shall ensure the provision of case management to all children under seven (7) years of age in their jurisdiction.”

● http://www.in.gov/legislative/iac/

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LHD Authority and Responsibility

Rule 410 IAC 29-4-1Simply restates this already existent power to inspect:

● Local health officers may enter upon and inspect private property, at proper times (think “reasonable”) after due notice (owner and residents), in regard to the possible presence, source, and cause of lead poisoning and lead hazards.

● Local health officers may order what is reasonable and necessary to prevent lead poisoning or remediate lead hazards.

● Remediation shall be followed by a clearance examination.

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LHD Enforcement Powers

Issue an Order to Abate* (IC 16-20-1-25)● Specify conditions in writing● Name shortest reasonable time for abatement● Enforceable by injunction in local court by county attorney

Eliminating an unlawful condition – not necessarily abatement as defined in lead hazard control laws

Dwelling Unfit for Human Habitation (IC 16-41-20-1)

(1) – Want of repair and/or(4) – Unsanitary conditions

● Order to Vacate in 5-15 days (IC 16-41-20-4)● Declare a Public Nuisance (IC 16-41-20-6)● Order repair (IC 16-41-20-7)● Serve on tenant and owner

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LHD Enforcement Powers

Nuisance Law (IC 32-30-6) (6-6) Whatever is injurious to health (6-7) County OR City attorney may bring a civil

action to abate or enjoin a nuisance

Other tools: Municipal Laws, County Ordinances, Local Building Codes, IKE Model Code

Build relationships with County/City Attorneys and Local Judges

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Alternate Option

Local Health Departments may submit cases to Attorney General by providing the following documentation:

● Risk assessment;

● Statement about children living in home OR lead poisoned children

who used to live in the home;

● Copy of notice provided to property owner requesting lead hazard

remediation within reasonable time period;

● Referral letter stating that a property owner has failed to take steps

to remediate;

And

● Authorization for the AG to take action on behalf of the LHD.

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Overview of Case Management

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Who is our target population?

At-risk Child (410 IAC 29-1-2) is one who:• lives in or regularly visits a house or other structure

built before 1978• has a sibling or playmate who has been lead poisoned• has frequent contact with an adult who works in an

industry or has a hobby that uses lead• is an immigrant, refugee, or has recently lived abroad• is a member of a minority group• is a Medicaid recipient• uses medicines or cosmetics containing lead• lives in a geographic area that increases the child’s

probability of exposure to lead

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The Team Approach

The case management team (in ideal cases) includes:

Case managerChild’s caregiverHealth educatorNutritionistEnvironmentalistChild’s primary care provider

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Definitions

Case management - the process of providing, overseeing, and coordinating lead poisoning services (410 IAC 29-1-4).

Case manager - a person authorized by a health department and trained by the ISDH to perform case management protocols (410 IAC 29-1-5).

Case managers must be trained within 6 months of hire

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Case Management (410 IAC 29-2-1)

Child case management includes:

Outreach and identification of EBLL children• Service planning and resource identification• Service implementation and coordination• Retesting• Monitoring of child case management service

delivery, program advocacy, and program evaluation

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One step further

Effective case management includes:

Ongoing communication with the caregivers and other providers.

A cooperative approach to solving any problems that may arise.

Eliminate lead hazards in the child’s environment.

Efforts to decrease the child’s BLL.

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Where Do We Begin?

• Timeframe for action varies according to the child’s blood lead levelA case manager should schedule an appointment with the child’s caregiver as soon as possible after being assigned the case.

• Higher levels require a quicker responseWhere feasible, priority should be given to children with the highest BLLs and those less than two (2) years of age.

• Highest levels treated as medical emergenciesSee case management chart (rainbow chart)

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What is a Confirmed EBLL?

An elevated blood lead level is confirmed in the following situations:The initial test was a venous testThe initial test was a capillary test, and was

followed by a venous (preferred) or a capillary test within the recommended time frames (see rainbow chart)

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Action levels defined

….for confirmed blood lead levels between zero (0) and nine and nine-tenths (9.9) g/dL….

● Notify primary medical provider within 10 working days of receipt of test results by the local health officer.

● Provide educational materials to the parents or family of the child regarding prevention of lead poisoning.

● Any additional actions the local health officer believes will assist the family in preventing the child’s blood lead level from increasing.

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10-14.9 µg/dL…

● Begin case management services within 10 working daysBegin case management services within 10 working days

● Notify the primary medical provider within Notify the primary medical provider within 5 working days5 working days

● Arrange testing of children under 7 years old in the home Arrange testing of children under 7 years old in the home

● Conduct an initial home visit Conduct an initial home visit

● Initiate an environmental inspectionInitiate an environmental inspection

● Provide written notice to property ownerProvide written notice to property owner

● Ensure coordination of long-term services and retestingEnsure coordination of long-term services and retesting

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15-19.9 µg/dL…

● Begin case management services within Begin case management services within 5 working days5 working days

● Notify the primary medical provider within 5 working days Notify the primary medical provider within 5 working days






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20- 44.9 µg/dL…

● Begin case management services within 5 working daysBegin case management services within 5 working days

● Notify the primary medical provider Notify the primary medical provider immediatelyimmediately






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45 – 69.9 µg/dL…

● Begin case management services within Begin case management services within 24 hours24 hours

● Notify the primary medical provider immediatelyNotify the primary medical provider immediately



● Initiate an environmental inspection within Initiate an environmental inspection within 2 working days2 working days if the if the structure was built before 1978structure was built before 1978


● Ensure Ensure coordination of chelation therapycoordination of chelation therapy, long-term services and , long-term services and retestingretesting

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70 µg/dL or greater…

● Begin case management services within Begin case management services within 24 hours24 hours

● Notify the primary medical provider immediatelyNotify the primary medical provider immediately

● Initiate a home visit and environmental inspection within Initiate a home visit and environmental inspection within 24 24 hourshours for pre-1978 dwellings for pre-1978 dwellings

● Treat child’s condition as a Treat child’s condition as a medical emergencymedical emergency● Admit child to hospital for chelation therapyAdmit child to hospital for chelation therapy● Obtain venous blood test 1 month after completion of therapyObtain venous blood test 1 month after completion of therapy




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Local Health Officer shall…ensure the provision of case management (410 IAC 29-1-6)

1. Notify child’s primary medical provider Assist in setting appointment, if necessary

2. Visit child’s residence (and other sites where the child spends significant amounts of time)

Provide educational materials to parents and caregivers

Assess factors that may impact the child’s BLL (including sources of lead, nutrition, access to services, family interaction and caregiver understanding)

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Remember. . .

It is VERY important that EBLL history be included as part of the permanent medical problem list on a child’s medical chart!

Why?Family may change providersAlerts schools of the need to provide more

intensive monitoring of the child

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Conduct home visit to include:

Medical, developmental, behavioral history Lead education, including medical effects and

environmental sources A determination of potential household exposures Evaluated risk for other family members, including

pregnant women Nutrition assessment or referral Developmental assessment or referral Referral to other social services as appropriate

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Referral Examples

First StepsWICEarly Head Start/Head StartParents as TeachersYMCA programsFSSA (Medicaid, Food Stamps, TANF)Other local agencies

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Initial Home Visit From Receipt Of BLL Test Result

BLL (µg/dL) Time frame for home visit

10 – 14.9 Within 10 working days

15 – 19.9 Within 5 working days20 – 44.9 Within 5 working days45 – 69.9 Within 24 hours>70 Immediately

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How Do I Notify Child’s Guardian?

● Attempt to visit child’s primary residence ● Telephone call to child’s parent/guardian

What if the caregiver does not have a telephone, nor are they at home to receive initial notification and education?

● Leave information at door● Mail (certified) letter to parent or guardian

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3. Implement child case management services

● Develop a written plan for intervention

The plan is based on the needs assessment determined through communication with primary healthcare provider, environmental investigation, home visits (including developmental and social evaluations), and parental involvement.

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How to Create a Written Plan

Work with the caregiver Identify priorities Short-term goals

Exposure reductionCaregiver educationReferralsFollowup for siblings or pregnant women in the

home

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How to Create a Written Plan

Work with the caregiverLong-term goals

Housing remediationEnforcement actionsDevelopmental and early intervention followup

Ensure the plan is relevant to the family’s needs and contains realistic goals

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How Long is a Child in Case Management?

Baseline Lead Time for 50% to reach <10 µg/dL

10-14 µg/dL 9 months




Roberts, J. R., Reigart, J. R., Ebeling, M., Hulsey, T. C. (2001) Time required for blood lead levels to decline in nonchelated children. Journal of Toxicology, Clinical Toxicology, 39, 153-160.

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● Provide an environmental inspection* to include (410 IAC 29-1-14):

Risk assessment of child’s primary and secondary addresses

Environmental investigation

*Although environmental services may be provided by the case manager, environmental inspector, or other program staff;

the case manager is responsible for ensuring that

a child receives services in a timely fashion!

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Environmental Inspection from Receipt of BLL Test Result

CEBLL (µg/dL) Time frame for environmental

inspection:*10 – 14.9 Within 10 working days15 – 19.9 Within 5 working days20 – 44.9 Within 5 working days45 – 69.9 Within 2 working days>70 Within 24 hours

* For CEBLL child at or above ten, with a pre-1978 primary or secondary residence, case management must include an Environmental Inspection.

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4. Provide written notice, including risk assessment, to property owner of lead hazards present and required remediation options (per 410 IAC 29-1-22).

5. Ensure retesting (per 410 IAC 29-1-21).● Arrange testing for other children under age

seven at same residence.

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6. Provide continuing child case management services until case closure

Coordinate the activities of the case management team

Evaluate compliance and success of the plan Ensure that needed care is provided Follow up on referrals or other problems identified

during the child’s care

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Case Closure (410 IAC 29-2-2)

1. “Case complete”

● The child has at least 2 consecutive confirmed tests less than 10 μg/dL in a six (6) month period, AND

● environmental lead hazards have been remediated and passed a dust clearance test, …AND…

● Referrals have been made for long term medical, developmental, environmental and follow-up.

…OR…

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Case Closure continued

2. “Administratively closed”

• the child moves to another state (referral)• the child moves to another county in Indiana (referral)• child reaches his or her seventh birthday (referral)• case management is blocked for religious or legal

reasons• death of the child • the child can no longer be located (5 attempts – next slide)

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“Administratively Closed”

Five attempts to locate the child:At least one telephone call to parent or

guardianAt least one letter to parent or guardian Certified letter to parent or guardian Home visit attempt to last known residence

…AND…Any repeat (2nd attempt) of the above

- shows due diligence

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State Responsibilities

● Oversight for county case management activities

● Notify counties via EBLL Manifest

● Provide guidance, support, and resources to local health departments, parents of lead poisoned children, physicians, health clinics and general public

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Environmental Inspection(410 IAC 29-1-14)

The local health officer shall enter upon and inspectprivate property of the primary and secondary addressesoccupied by all lead poisoned children (CEBLL), if thestructure was built before 1978, to include:

● Risk Assessment (410 IAC 29-1-22)● Identifies specific lead hazards from structural sources of

exposure● Includes more information such as and history of dwelling,

occupancy by children under age 6, visual inspection, limited environmental sampling

● Environmental Investigation (410 IAC 29-1-15)● Presentation of results of the nonstructural sources of lead

hazards identified, including recommendations for reducing or eliminating exposure

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Risk Assessment(410 IAC 29-1-22)

● Conducted by a trained, licensed risk assessor, according to “documented methodologies” established by law (326 IAC 23-4-2).

● Report given to the family and the owner (if the family does not own the home) including range of recommendations to mitigate identified lead hazards within 5 business days.

● Written notice of the required remediation options to be completed within 180 days. A clearance examination is conducted to establish the efficacy of remediation.

● Education of the family and owner on lead hazards in the home and temporary and permanent measures to protect children from further poisoning.

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• Visual examination, underlying causes

• Exterior testing of deteriorated paint

• Soil testing of bare soil • Interior testing of deteriorated

paint• Water samples when called for• Dust samples and testing

“Documented Methodologies”

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Local Health Officer may…order what is reasonable and necessary (410 IAC 29-4-1)

Risk Assessment Report

Remediation = actions that constitute either:

1. Abatement“Lead-free home”

2. Interim control of a lead hazard (326 IAC 23)

“Lead-safe home”

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Lead Hazard Example

Remediation Options*:1. Remove and replace entire window with aluminum,

vinyl, or wood painted with lead free paint.2. Wet sand sill to bare wood, repaint with non-lead

based paint.3. Remove loose paint and repaint.

* All of these must be done using lead safe work practices.* All of these must be done using lead safe work practices.

Lead based paint deteriorated on a window sill

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Lead Safe Work Practices(IC 13-17-14-12)

• Find the causes of the problem• Prioritize work • Separate work and occupied spaces• Isolate high dust areas• Wet dust/sand, low temp heat guns• Correct causes of the problem (friction, impact, or substrate

deterioration)• Dispose of waste safely• Educate occupants about risks

from lead based paint

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Remediation shall be followed by dust clearance examination (410 IAC 29-4-1)

• Licensed clearance examiner or risk assessor

• Required for all remediation• Visual examination of the

area• Dust sample testing for lead

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Risk Assessor Training

• Environmental Management Institute (EMI) in Indianapolis

• ILHHP maintains waiting list for the training

• Scholarships available for LHD staff

• Within the limits of the ILHHP budget, ISDH will cover the cost of the training classes. LHDs will have to pay for the travel expenses.

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Resources

• 247 licensed risk assessors in Indiana. • About half of them are private environmental.• Price generally between $400 and $700. • 31 LHDs have licensed risk assessors on staff*,

many have more than one.

*LHD counties with licensed risk assessors: Allen, Bartholomew, Boone, Dearborn, Decatur, Delaware, Elkhart, Fayette, Floyd, Grant, Hamilton, Hancock, Hendricks, Howard, Jackson, La Porte, Lake, Lawrence, Madison, Marion, Marshall, Miami, Monroe, Morgan, St Joseph, Tippecanoe, Vanderburgh, Vigo, Wayne, Wells, Whitley

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Resources

• Indiana Community Action Agency (CAA) network has 37 licensed risk assessors in their service areas around the state

• Other service entities (cities, non-profits, housing authorities, state agencies) have risk assessors

• Indiana Public Licensing Agency (IPLA) maintains the current list of licensed Risk Assessors, Lead Inspectors and Lead Contractors at:

Website:

http://www.in.gov/pla/

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Indiana Lead and Healthy Homes Program

State Responsibilities include:

● Oversight for county case management activities

● Notify counties via EBLL Manifest

● Provide guidance, support, and resources to local health departments, parents of lead poisoned children, physicians, health clinics and general public

Child case management includes:

Outreach and identificationof EBLL children

• Service planning and resource identification

• Service implementationand coordination

• Retesting• Monitoring of child case

management service delivery, program advocacy, and program evaluation

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Contact Information

Ellen Bloom, MPHHealth EducatorIndiana Lead and Healthy Homes ProgramIndiana State Department of Health2 N. Meridian Street, 5th floorIndianapolis, IN 46204317.233.1290317.233.1630 [email protected]

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ANY QUESTIONS?ANY QUESTIONS?

1 welcome ellen bloom, mph health educator indiana state department of health indiana lead and...

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