The Colorado Cross-Disability Coalition, with the support of other advocacy organizations and individuals, filed a request to have Host Homes evaluated for regulation. This is called a Sunrise Review and is conducted by an office inside of the Division of Regulatory Agencies or DORA. There are three levels of regulation which are registration, certification, and licensure. We did not specify the level of regulation but asked DORA to make a recommendation. The Colorado Office of Policy, Research and Regulatory Reform which is inside of DORA is currently conducting a sunrise review of Host Home Residential Providers. An analysis is performed to determine if regulation of Host Home Residential Providers is necessary to protect the public. If you have experienced or witnessed harm please share your experience using this link. To provide input on this review, please visit COPRRR’s website.
Please respond to the following questions in the order provided.
Colorado Cross Disability Coalition
1385 South Colorado Blvd Suite 610 A
Denver, CO 80222
Host Home Residential Provider
There are approximately 3,500 providers or eligible providers in Colorado.
A Host Home Provider (“HHP”) is an independent contractor providing caregiving services and supports in their personal home for up to three adults with intellectual and developmental (“IDD”). It is sometimes called adult foster care.
HHPs provide care and oversight to people with intellectual and developmental disabilities so severe that the state has determined they require 24/7 care and supervision. Out of almost 100,000 clients in Long Term Services and Supports (LTSS), only 25% are eligible for this highest level of care.
Duties of a Provider include: implementing medical treatment, behavioral plans, managing transportation, coordinating with day programs and other providers, communicating with team members, assuring client rights, providing food, shelter, assisting with bathing, dressing, and all activities of daily living.
Most adults with IDD in residential services live in Host Homes.
HHPs are not employees of any agency – they are independent contractors who make upwards of $18,000-60,000+ per year per person. And unlike nursing homes, these private homes have no regulation or oversight by the state. This is not comparable to any other industry except maybe assisted living but those are facilities not individual providers. They are also highly regulated. Host home providers are expected to do much more than an assisted living facility.
Host Home Providers serve people with severe intellectual disabilities.
Our organization has assisted clients who were subject of abuse or mistreatment in these homes. Arc Chapters around Colorado have also assisted many more clients who have been abused, neglected or exploited by these providers. Below are two examples.
Becky, age 21
Becky is 21 years old and has low muscle tone, seizures, schizophrenia, autism, intellectual disability, speech impairment, severe constipation (multiple hospitalizations), and a trauma history.
She was severely abused in a cult for the first five years of her life before being adopted into a loving and stable home. Despite this fresh start, she carries the scars of her traumatic past. These scars cause attachment and testing behaviors that can be severe – especially when her caretakers are not following proper protocols.
Becky requires help with grooming, including “line of sight supervision” with teeth brushing. She requires someone to wash her hair and clip her nails. She can shower and dress with support. She can walk, but has coordination issues. She cannot use public transportation, even Access a Ride, without someone to supervise and accompany her.
Becky requires structure and consistent behavioral support. She requires line of sight supervision with medication and diet. She needs to have things to do during the day and a fair amount of “down time” after activities.
When she does not have her needs met, she communicates this through self-harm, excessive 911 calls, and asking to go to the hospital. She has a loving family, but cannot live with them because she is not safe with little children over long periods of time (due to past abuse) and has siblings who are young.
She has been in 9 host homes since she turned 18. The last one was substantiated for neglect. The provider lied about the fact that a little girl lived there, in addition to failing to take her to her medical appointments. Becky has endured inappropriate sexual behavior, sudden rejection, and other traumatic experiences at other placements.
Lori, age 52
Lori is a 52 year old female with severe Cerebral Palsy. Because of trauma from her father passing away, she has been experiencing mental health issues such as severe depression and unstable Schizophrenia.
Lori has been in a wheelchair all of her life and requires full physical assistance with bathing and toileting tasks. A two-person lift is required to transfer her to a bed. She has very limited range of motion with her arms and hands, and most of the time, requires assistance to feed herself. Lori must be monitored at all times and cannot be left alone when bathing or eating. She becomes impatient and verbally aggressive if she does not get what she wants.
Because of her advanced age, Lori’s mother is unable to care for her, which resulted in her being placed in a host home. Over the past three years, Lori has been in over seven host homes due to difficulties in finding adequate and compassionate care. Most concerning was a host home who retained a psychologist who dramatically overmedicated Lori, who then became frightened and experienced hallucinations and psychotic episodes. When her employer became concerned and got involved, the host home and PASA threatened to institutionalize her as a clear punishment for her complaining..
The services are provided in the home of the provider, who is asked to engage with the client and include them as “part of the family.” Theoretically, the setting would also include family outings including participating in faith communities, recreation, shopping, etc.
Unfortunately, this does not always happen. For example, we have seen cases where clients are left to watch TV for hours on end while providers swap clients for “respite” (the state is billed for respite care).
The provider is also supposed to accompany the client to medical appointments and therapy, but clients often fail to receive these services. Some are also forced to take medications, generally antipsychotics, that can cause drowsiness and excessive sleepiness but not necessarily be medically appropriate.
The provider is responsible for some transportation and may drive the client in their personal vehicle and are required to carry liability insurance. They may also subcontract that to any other person. The state does track these subcontractors. Becky, the client mentioned above, would arrive at therapy in a van full of children. When her mother/guardian asked who was driving her, she was told that it was not her business.
We are asking DORA to evaluate the situation and use their resources to assess the current state of regulations, or lack thereof.
Transparency & Oversight
Host Homes are not inspected by an independent licensing authority. Unlike Group Homes, the Colorado Department of Public Health and Environment (CDPHE) does not inspect Host Homes because they are Individual Residential Services or Supports (IRSS) programs. The word individual is misleading as many host homes have 3 clients (not counting “respite” beds.
Of Colorado’s 336 Program Approved Services Agencies (PASAs) providing residential services for people with IDD, 303 are IRSS-designated. They independently contract with hundreds of HHPs statewide, serving thousands of people with IDD.
PASAs do have some oversight responsibilities, but they do not license or supervise the host home provider.
Unless a client is able to find us, we do not even know who is providing these services because they are run through Program Approved Service Agencies (PASAs). There is no state database (unlike the state of Hawaii, which maintains a public database of all providers, similar to looking up a teaching or medical license).
One host home provider can work for more than one PASA. And if someone is dismissed from a PASA for poor service, they can just sign up with another. It is even possible to have clients from more than one PASA.
Sometimes the legal name of the provider is concealed from the guardian.
While the PASA may need to run background checks to hire a host home provider, they are permitted to hire irrespective of the results. The APS 2020 Audit Report stated on p.31:
“The risk of an employer being unaware of an employee’s substantiated mistreatment of an at-risk adult may be higher in some circumstances than others. For example, it may be more difficult for an agency overseeing host homes to monitor whether there are investigations of employees at the individual host homes than it would be for a small nursing home. Currently, neither the counties nor the Department notify employers when a county substantiates that an employee has mistreated an at-risk adult, unless (1) the employer initiates a CAPS check on that employee, or (2) after the employer’s CAPS check, the employee is substantiated for mistreatment, in which case the Department would contact the employer, confirm the perpetrator still works there, and notify the employer of the subsequent substantiation.
We identified 152 perpetrators in CAPS, who were substantiated for mistreatment after July 1, 2018, and were professionals working with at-risk adults but have not undergone a CAPS check, which indicates that they have not changed employment since July 2018. In the event that an employer requested a CAPS check on these individuals, the employers would be informed of the finding. However, without initiating a check, agencies that employ these 152 perpetrators may be unaware that they have employees who have harmed at-risk adults.”
Originally, host home providers were allowed to have two clients. Then three were allowed in emergency situations. But we are finding that three is the norm-and some have three and take in more clients on a temporary basis to offer respite care for other host home providers.
Host Home Providers are asked to use a lot of judgement, implement complex behavioral interventions, and follow medical orders. As such, we also seek to professionalize the workforce, including mandatory training that would be provided by the state, minimum standards for background checks and qualifications, and transparency in a licensure or certification process.
There is a national workforce shortage, with this field included. Some parts of the state have no providers available. Regulations are not likely to affect this, unless regulations weed out practitioners who are not providing safe services.
Some will be able to provide better services because of the training and professional development opportunities. We believe that professionalizing the industry and providing additional support to the providers would reduce burnout and improve care.
Finally, the payments providers receive is tax-free income of up to $60,000 a year per client. We do believe this financial incentive is meaningful for those entering the field and believe it will continue to be so after regulations are implemented. Daily rates are contingent on the care and support needs of the individual living in the home and range from $66.31 to $230.17. The annual range is approximately $24,203 to $84,012 per year per person. Please note that most providers have three clients This is non taxed income for the Host Home Provider.
We would like to see people barred for barrier crimes. If they have been dismissed by more than 2 PASAs for quality problems they should not be allowed to provide services until they have remedied the problems. We believe that having oversight alone will increase safety. They should be able to demonstrate competencies in following individualized plans. If they have had substantiated neglect charges from Adult Protection they should at the very least have heightened oversight. Surprise visits by guardians and advocates must be allowed and encouraged.
This should not affect the cost of services. There would be a small cost to provide training, but that cost could be absorbed by HCPF using ARPA funds, and, in the long-term, be absorbed into the state budget. Comparatively speaking, other professionals (medical, finance, teaching, law, etc.) pay for their own education, exams, and continuing education requirements.
Host Home Providers aren’t certified or licensed, putting adults with intellectual and developmental disabilities at high risk for exploitation and abuse.
The Colorado Department of Regulatory Agencies (DORA) regulates more than 130 professions (such as barbers who must complete a training program of at least 1,500 hours before being certified), but Host Home Providers are not under their purview. In comparison, all youth foster care providers must obtain a license and receive training from their county.
Adults with IDD are four to ten times more likely to be abused than peers without disabilities. Unfortunately, paid or family caregivers perpetrate the majority of these offenses.
There is no independent complaint or grievance process for Host Home Providers, leaving the most vulnerable clients at risk. We ask for Increased professionalism of this occupation to ensure the safety and security of Coloradans with intellectual and developmental disabilities who live in these homes.
Colorado Adult Protective Services Performance Audit May, 2020, page 41:
“A host home provider waiting 4 hours to call poison control and 911 after an at-risk adult consumed another adult’s medication, resulting in the at-risk adult overdosing and suffering multiple organ failure. The appellant claimed the delay in calling 911 occurred because they did not know that the adult consumed the medication. However, the case file in CAPS showed that the appellant’s employer, a police detective, and a county caseworker believed the act was deliberate, particularly since the appellant first called poison control instead of 911.”
Additionally, we have observed:
Do clients have access to this occupational group directly, or are they referred by members of another occupational group?
Unsure.because Medicaid is the only real funder of host homes. There is no private insurance that pays for this type of service.
PASA can impose other requirements.
They are “trained” by the PASA.
We are not aware of any.
Not at this time but we are eager to hear the professional assessment of DORA. Our experience with other disability programs is that mandatory training is not always productive but we do think something needs to be done.
State Regulation Comments Yes No
We the undersigned support the regulation of host home providers as described above.