Sunrise Application for Host Home Providers

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.

1. The name, address, telephone number, and organizational affiliation of the person(s) designated to represent the applicant.

Julie Reiskin

Colorado Cross Disability Coalition

1385 South Colorado Blvd Suite 610 A
Denver, CO 80222

1. What is the occupational group for which the applicant is seeking regulation? 

Host Home Residential Provider

1. Identify the associations, organizations and other groups representing the practitioners. Please provide contact information for each organization.

• Alliance represents the companies that contract with host home providers
  Contact: Josh Rael, Executive Director at jrael@alliancecolorado.org or 303.832.1618 Ext. 11
• SEIU represents or seeks to represent the direct care workers.
  Contact: Stephanie Felix at 970-545-1019 or sfelix@seiu105.0rg

1. Please estimate the number of Colorado practitioners in each group.

There are approximately 3,500 providers or eligible providers in Colorado.

1. Describe the functions performed by members of this occupational group. Note which functions are unsupervised or supervised and by whom. In addition, indicate functions which are similar to those performed by other groups and identify those groups. How do the functions performed by this group vary from the other groups’ functions?

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.

1. Describe the client group(s) with which this occupational group deals.

Host Home Providers serve people with severe intellectual disabilities.

• In Colorado, they must have a cognitive impairment with an IQ or adaptive IQ (https://www.aaidd.org/intellectual-disability/definition) under 70.
• Clients will require a lifelong suite of services.
• Their impairment must have appeared before the client was age 22.
• Host Homes are a Medicaid service. To receive this high level of service in the most expensive of the Medicaid waiver programs, one must also demonstrate the need for 24 hour services and be unable to function in a less restrictive/intense service environment.
• Clients may have additional medical and behavioral needs.

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..

1. Describe and provide examples of typical work settings of this group.

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.

1. Does the applicant propose licensure, certification, registration, or another type of regulation? Why? (Under licensure, it is illegal for anyone to engage in an occupation without a license, and only persons who possess certain qualifications are licensed. Certification protects specific occupational titles of persons who have met certain educational and experiential standards. Only persons certified in that occupation may use the protected title, although anyone may practice the occupation. Under registration, any person may engage in an occupation, but he or she is required to submit information concerning the location, nature, and operation of the practice.)

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.

Safety

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.

Professionalism

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.

1. What would be the impact of the proposed regulation on the supply of practitioners in the occupation, including the degree to which existing practitioners would be precluded from practice?

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.

 

1. Describe any anticipated disqualifications on an applicant for licensure, certification, re-licensure, or recertification based on criminal history and how the disqualifications serve public safety or commercial or consumer protection interests.

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.

1. To what degree would the proposed regulation either directly or indirectly affect the cost of goods or services provided by the occupational group? Specify those costs as they exist now and as they would change after the imposition of regulation.

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.

1. What is the applicant seeking to gain through regulation of the occupational group? Indicate how the public would be protected by regulation of this occupational group?

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.

1. Within the usual practice of this occupation, document the physical, emotional or financial harm to clients resulting from failure to provide appropriate service, or erroneous or incompetent service. Give specific, verifiable examples.

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:

• Clients have setbacks (medical, physical, emotional) due to plans not being followed
• Clients end up in the hospital (some of which have died) due to medications or treatments not given
• Clients have injured themselves, intentionally or unintentionally, because of lack of supervision
• One client ended died in a fire, with her death being preventable
• Clients have been isolated from family and friends.
• Clients have been financially exploited through loss of personal property without replacement
• Clients’ rights have been restricted without proper approval through the Human Rights Committee
• Clients have received care from untrained respite providers
• Clients have been locked in home without access to a key
• Retaliation against family members and clients when they speak up about abuse or neglect
• Intimidation of vulnerable clients to pressure them to say what the provider wants
• Client deaths due to lack of adequate water being given by host homes

Do clients have access to this occupational group directly, or are they referred by members of another occupational group?

• They are referred by the PASAs who are referred by the Community Centered Boards, which are designated in statute

1. Does the current lack of regulation of this group make its practitioners ineligible for third party insurance payments or federal grants?

Unsure.because Medicaid is the only real funder of host homes.   There is no private insurance that pays for this type of service.

1. Describe the minimum competencies necessary to enter this occupation.

PASA can impose other requirements.

• First Aid/CPR; medication administration; safety care/behavioral training (created by the agency); GED or diploma required; 18+
• Trade name registered; proof of auto, home and/or renters insurance; professional liability insurance
• Home qualifications. Environmental inspection (determined by agency); at minimum, meet HUD Section 8 standards; rooms must be adequate (min 80 square feet); fire extinguishers; background check for everyone 18+; computer & internet access. As far as we know these qualifications have not yet been implemented.
  • Maximum of 2 (must have private bedroom and bathroom), but a third bedroom can also serve as respite care for a third person periodically or a home can receive a waiver if all 3 want to be roommates
  • Ownership/rentals. The provider can apply with an intent to move; no identified state requirement for housing stability
  • Lease terms. Not specified.
• MVR/DMV check (you do not have to have a DL if another person in the home does) and current vehicle inspection; set comprehensive minimum auto coverage.

Other qualifications.

• I/DD-specific training is set by the agency and is supposed to be tailored to the individual. We have experienced people in homes and the host home provider says that they have not had any training about the individual.
• Communication/language. No specific requirements, though agencies are expected to train in assistive technology. Our experience is that when someone has assistive technology it is not used or supported because providers do not know how to support it.
• Personal care training. Training is likely provided by the agency, but not directed by the state. Our experience is that providers do not know how to do this, for example, Becky’s provider does not seem able to wash her hair.

1. List institutions, program titles and contact information for such programs offering accredited and nonaccredited programs in Colorado to prepare practitioners for entry into this occupation. What is the cost of completing these programs? If programs are not available in Colorado, what is the cost of out-of-state programs?

None

1. If no formal training or education is required, how does the practitioner learn the occupation? 

They are “trained” by the PASA.

1. Is there an examination currently used to measure qualifications for entry? If so, who constructs and administers the examination? Please submit documentation on the validity and reliability of such exams.

No

1. Is this occupational group affiliated with an association which sets and enforces standards? If so, please explain the process and standards.

No

1. What federal, Colorado state, county, or local laws currently apply to the practice of this occupational group? Please provide copies of the relevant statutes, ordinances and rules.  See attachment 1.
2. What type of private credentialing is or could be available as an alternative to government regulation?

We are not aware of any.

1. If the occupational group has been deregulated (sunsetted) by the General Assembly, and the applicant is requesting re-regulation, the applicant should provide documentation on harm to consumers since deregulation that necessitates re-regulation by the state.

N/A

1. If the occupational group is a former applicant re-submitting a sunrise application, please include updated information that will substantiate the request for regulation. 

NA

1. Is mandatory continuing education part of the proposed regulation? If yes, you must complete an application for mandatory continuing education, which is available from the Office of Policy, Research and Regulatory Reform.

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.

 

1. In how many other states is the occupation regulated? Please complete the following table. See attachment 1.

State Regulation       Comments    Yes      No

Alabama

Alaska

Arizona

Arkansas

California

Colorado

Connecticut

Delaware

Florida

Georgia

Hawaii

Idaho

Illinois

Indiana

Iowa

Kansas

Kentucky

Louisiana

Maine

Maryland

Massachusetts

Michigan

Minnesota

Mississippi

Missouri

Montana

Nebraska

Nevada

New Hampshire

New Jersey

New Mexico

New York

North Carolina

North Dakota

Ohio

Oklahoma

Oregon

Pennsylvania

Rhode Island

South Carolina

South Dakota

Tennessee

Texas

Utah

Vermont

Virginia

Washington

West Virginia

Wisconsin

Wyoming

 

 

 

 

We the undersigned support the regulation of host home providers as described above.

1. Julie Reiskin 303-667-4216 jreiskin@ccdconline.org  representing advocacy organization
2. Lloyd Lewis 720-206-7047 llewis@arcthrift.com  employer and advocate for individual harmed by lack of regulation
3. Mary Young 970-381-5056  Concerned citizen and family member of adult with IDD (who is not in a host home due to past harms)
4. JoyAnn Ruscha 970-397-4911 jruscha@arcthrift.com  concerned citizen
5. Darla Stuartdstuart@thearcofaurora.org 720-318-2467 representing Arc of Aurora
6. Denver Fox dnvrfox@aol.com 303-358-5578 (son killed due to dehydration/neglect
7. Carrie Gagnon Guardian for Rebekka who has been harmed by lack of regulation 719-231-1391
8.  Rebekka Gagnon incapacitated adult who relies on host homes
9. Suzanne Wanamaker sw57431@gmail.com 281-620-3656 c representing her sister who has been harmed
10. Kari Easterly 720-634-6886 keasterly@arcadams.org and DeAnn M dmajor@arcadams.org  representing four families and the Arc of Adams County.
11. Robin Bolduc robinbolduc@msn.com  concerned citizen