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TITLE 410 INDIANA DEPARTMENT OF HEALTH

Emergency Rule
LSA Document #22-290(E)

DIGEST

Temporarily amends 410 IAC 29 to update definitions and to lower the standard for an elevated blood lead level. Statutory authority: IC 16-41-39.4. Effective September 28, 2022.


SECTION 1. (a) This SECTION supersedes 410 IAC 29-1-2.

(b) "At-risk" means a child is at-risk if that child:
(1) lives in or regularly visits a house or other structure built before 1978;
(2) has a sibling or playmate who has an elevated blood lead level;
(3) has frequent contact with an adult who:
(A) works in an industry; or
(B) has a hobby;
that uses lead;
(4) is an immigrant or refugee or has recently lived abroad;
(5) is a member of a minority group;
(6) is a Medicaid recipient or eligible for Medicaid;
(7) uses medicines, cosmetics, toys, foods, or other items containing lead; or
(8) lives in a geographic area that increases the child's probability of exposure to lead.

SECTION 2. (a) This SECTION supersedes 410 IAC 29-1-4.

(b) "Case management" means the process of providing, overseeing, and coordinating lead poisoning services for an elevated blood lead level, including, but not limited to, the following:
(1) Outreach and identification of children with EBLLs.
(2) Child case management service planning and resource identification.
(3) Child case management service implementation and coordination.
(4) Monitoring of child case management service delivery, program advocacy, and program evaluation.

SECTION 3. (a) This SECTION supersedes 410 IAC 29-1-6.

(b) "Child case management service implementation and coordination" means the following:
(1) For blood lead levels between zero (0) and three and four-tenths (3.4) μg/dL, the following:
(A) Notifying the child's primary medical provider within ten (10) working days of receipt of test results by the local health officer.
(B) Any additional actions the local health officer believes will assist the family in preventing the child's blood lead level from increasing.
(2) For confirmed blood lead levels between three and five-tenths (3.5) and four and nine-tenths (4.9) μg/dL, the following:
(A) Notifying the child's primary medical provider within five (5) working days of receipt of test results by the local health officer.
(B) Arranging for testing of all children less than seven (7) years of age living in the home.
(C) Providing educational materials to the parents, guardians, or other adults living with the child regarding prevention of an elevated blood lead level.
(D) Any additional actions the local health officer believes will assist in reducing the child's blood lead level.
(3) For confirmed elevated blood lead levels between five (5) and nineteen and nine-tenths (19.9) μg/dL, beginning child case management services within five (5) working days after receipt of test results, including the following:
(A) Notifying the child's primary medical provider within five (5) working days of receipt of test results and ensuring coordination of long term services and retesting.
(B) Arranging for testing of all children less than seven (7) years of age living in the home.
(C) Conducting an initial home visit to include the following:
(i) A medical, developmental, and behavioral history.
(ii) Lead education, including medical effects and environmental sources.
(iii) A determination of potential household exposures.
(iv) An evaluation of the risk to other members of the household, including pregnant women.
(v) A nutrition assessment or referral for nutrition assessment.
(vi) A developmental assessment or referral for developmental assessment.
(vii) Referrals to other social services as appropriate.
(D) Providing an environmental inspection to include the following:
(i) A risk assessment of the child's primary and secondary addresses within ten (10) working days after receipt of test results if the structure was built before 1978, to include the following:
(AA) A complete risk assessment, including recommendations to mitigate identified lead hazards.
(BB) A written report to the family and the property owner if the family does not own the home.
(CC) Education of the family and the owner on lead hazards in the home and measures to protect the child from further poisoning.
(ii) An environmental investigation, including the following:
(AA) Identification and evaluation of nonstructural exposure sources within the child's environment.
(BB) Presentation of results of the environmental investigation, including recommendations for reducing or eliminating exposure.
(CC) Education of the family on hazards found and education on temporary and permanent measures to protect the child from further exposure.
(E) If the risk assessment finds lead hazards, immediately providing written notice to the property owner of the lead hazards and required remediation options in accordance with 410 IAC 29-4. The notice shall include the risk assessment. The property owner shall be given a reasonable time to implement recommendations for remediating lead hazards within one hundred eighty (180) days. The property owner shall have a clearance examination performed by a properly licensed individual to establish the efficacy of remediation.
(F) Providing continuing child case management services until case closure as appropriate to the child's case and not less frequently than one (1) contact every three (3) months, to include the following:
(i) Monitoring blood lead levels by retesting according to SECTION 8 of this document and notification of the primary medical provider of the results and ensuring blood lead testing of other children and pregnant women residing in the home.
(ii) Monitoring and evaluation of other aspects of the child's case, including, but not limited to, the following:
(AA) Additional home visits to monitor the child's progress and to identify needs that may arise from changes in primary and secondary addresses, housing condition, family composition, occupations of family members, the child's activities, the child's development, medical condition, nutrition, and use of nonprescription medications or household goods.
(BB) Contacts with other service providers to monitor and evaluate service delivery, appropriateness, and efficacy.
(4) For confirmed elevated blood lead levels between twenty (20) and forty-four and nine-tenths (44.9) μg/dL, initiating child case management services within five (5) working days after receipt of test results and all actions as in subdivision (3) with the following changes:
(A) Notifying the child's primary medical provider immediately and ensuring coordination of long term services and follow-up testing.
(B) Initiating risk assessment of the child's primary and secondary addresses within five (5) working days after receipt of test results if the structure was built before 1978.
(5) For confirmed elevated blood lead levels between forty-five (45) and sixty-nine and nine-tenths (69.9) μg/dL, initiating child case management services within twenty-four (24) hours after receipt of test results and all actions as in subdivision (3) with the following changes:
(A) Notifying the child's primary medical provider immediately and ensuring coordination of long term services and follow-up testing.
(B) Initiating a risk assessment of the child's primary and secondary addresses within two (2) working days after receipt of test results if the structure was built before 1978.
(C) Chelation therapy followed by a venous blood lead test one (1) month after completion of therapy as follows:
(i) Chelation therapy may be conducted at the child's home if the home does not have any lead hazards.
(ii) If the home has lead hazards, the child must be admitted to a hospital and chelation therapy performed at the hospital.
(6) For a confirmed elevated blood lead level greater than or equal to seventy (70) μg/dL, initiating child case management services immediately after receipt of test results and all actions as in subdivision (3) with the following changes:
(A) Notifying the child's primary medical provider immediately and ensuring coordination of long term services and follow-up testing.
(B) Initiating a risk assessment of the child's primary and secondary addresses within twenty-four (24) hours after receipt of test results if the structure was built before 1978.
(C) Treatment of the child's EBLL as a medical emergency.
(D) Admission of the child to a hospital for chelation therapy.
(E) Obtaining a venous blood lead test one (1) month after completion of therapy.

SECTION 4. (a) This SECTION supersedes 410 IAC 29-1-9.

(b) "Confirmatory testing" means conducting additional blood lead level tests on children with initial capillary blood lead tests as follows:
(1) Initial blood lead level zero (0) to three and four-tenths (3.4) μg/dL requires no confirmatory test.
(2) Confirming initial blood lead levels of:
(A) three and five-tenths (3.5) to nine and nine-tenths (9.9) μg/dL within three (3) months;
(B) ten (10) to nineteen and nine-tenths (19.9) μg/dL within one (1) month;
(C) twenty (20) to forty-four and nine-tenths (44.9) μg/dL within two (2) weeks;
(D) forty-five (45) to fifty-nine and nine-tenths (59.9) μg/dL within forty-eight (48) hours;
(E) sixty (60) to sixty-nine and nine-tenths (69.9) μg/dL within twenty-four (24) hours; and
(F) seventy (70) μg/dL and higher immediately;
after receiving initial test results.
(3) Initial blood lead levels of seventy (70) μg/dL and higher shall be confirmed immediately with an emergency lab test and shall be considered a medical emergency.

SECTION 5. (a) This SECTION supersedes 410 IAC 29-1-11.

(b) "Confirmed elevated blood lead level" means a blood lead level of three and five-tenths (3.5) μg/dL or higher that has been verified by a confirmed blood lead test.

SECTION 6. (a) This SECTION supersedes 410 IAC 29-1-13.

(b) "Elevated blood lead level" or "EBLL" means a blood lead level of three and five-tenths (3.5) μg/dL or higher.

SECTION 7. (a) This SECTION supersedes 410 IAC 29-1-19.

(b) "Outreach and identification" means the following:
(1) The promotion of awareness of the health effects of lead, techniques for preventing an elevated blood lead level, and techniques for treating an elevated blood lead level and providing lead hazard education in the local health officer's jurisdiction through activities including, but not limited to, training staff on issues relevant to the effects of an elevated blood lead level, prevention, and treatment, including, but not limited to, the following:
(A) Housing.
(B) Environment.
(C) Testing.
(2) Raising awareness in the community of lead hazards for those included in at-risk categories.
(3) Providing consultation and education to the local medical community.
(4) Providing consumer alerts and consumer education regarding lead hazards, including products for purchase in the community.
(5) Determining the magnitude of children with an elevated blood lead level in the local health officer's jurisdictions through activities including, but not limited to, the following:
(A) Ensuring blood lead testing of children at risk for an elevated blood lead level.
(B) Partnering with:
(i) children's and maternal nutrition and health programs;
(ii) education programs and institutions;
(iii) community action agencies;
(iv) housing authorities and housing agencies;
(v) physicians and other health care providers; and
(vi) other partners, such as schools and community and faith-based organizations;
involved in the care of children to ensure screening and testing of all at-risk children.
(C) Partnering with local officials to determine high-risk geographic areas in order to target testing of children at risk for an elevated blood lead level.

SECTION 8. (a) This SECTION supersedes 410 IAC 29-1-21.

(b) "Retesting" means additional testing to monitor a child's blood lead level over time in accordance with the following schedule, unless a primary care physician or local health department determines retesting should occur within shorter intervals:
(1) Within twelve (12) months for results between zero (0) and three and four-tenths (3.4) μg/dL.
(2) Within three (3) to six (6) months for results between three and five-tenths (3.5) and nine and nine-tenths (9.9) μg/dL.
(3) Within one (1) to three (3) months for results between ten (10) and nineteen and nine-tenths (19.9) μg/dL.
(4) Within two (2) weeks to one (1) month for results between twenty (20) and forty-four and nine-tenths (44.9) μg/dL.
(5) By the venous method within one (1) month after completion of chelation therapy for results greater than forty-five (45) μg/dL.

SECTION 9. (a) This SECTION supersedes 410 IAC 29-1-22.

(b) "Risk assessment" means an assessment of lead hazards from any structural source, and adjacent impacted residential soil, by a licensed risk assessor consistent with 410 IAC 32 to include the following:
(1) A complete risk assessment, including recommendations to mitigate identified lead hazards.
(2) A written report to the family and the property owner if the family does not own the home.
(3) Education of the family and the property owner on the following:
(A) Lead hazards in the home.
(B) Measures to protect children from further poisoning.

SECTION 10. (a) This SECTION supersedes 410 IAC 29-2-2.

(b) The department or local health officer may close cases under either of the following conditions:
(1) A case may be designated "case complete" if:
(A) referrals have been made to individuals and agencies for long term developmental, environmental, and medical follow-up; and
(B) the child has two (2) consecutive confirmed blood lead tests at least sixty (60) days apart for which the blood lead level is less than five (5) μg/dL, and environmental lead hazards have been remediated and passed a clearance test.
(2) A case may be designated "administratively closed" for any of the following reasons:
(A) The child moves to another state or territory of the United States and a case referral has been made to the appropriate state elevated blood lead level prevention program. This referral must be made not later than ten (10) working days after the case manager learns of the move, and the department shall keep the case open until the case is confirmed as received by the state to which it has been transferred.
(B) The child moves to another county in Indiana and a case referral has been made to the appropriate local health department. This referral must be made not later than ten (10) working days after the case manager learns of the move, and the department shall keep the case open until the case is confirmed as received by the local health department to which it has been transferred.
(C) The child reaches seven (7) years of age and referrals have been made to individuals and agencies for long term developmental, environmental, and medical follow-up.
(D) The child can no longer be located or contacted and five (5) attempts have been made to contact the child during a twenty-six (26) week closure window according to the following action periods:
(i) At least one (1) telephone call to the parent or guardian after the first four (4) weeks of the twenty-six (26) week closure window.
(ii) At least one (1) letter to the parent or guardian between nine (9) and thirteen (13) weeks into the twenty-six (26) week closure window.
(iii) At least one (1) certified letter to the parent or guardian between thirteen (13) and twenty-one (21) weeks into the twenty-six (26) week closure window.
(iv) At least one (1) attempted home visit to the child's last known address after twenty-four (24) weeks into the twenty-six (26) week closure window.
Actions completed later than the action period shall be recorded against the twenty-six (26) week closure window in the week in which they were performed.
(E) Case management is blocked for religious or other legally recognized reasons, and documentation of these reasons is on file.
(F) The death of the child.

SECTION 11. (a) This SECTION supersedes 410 IAC 29-3-1.

(b) A person that examines the blood of an individual for the presence of lead must report to the department the results of the examination not later than one (1) week after completing the examination. In addition to the information required to be submitted under IC 16-41-39.4-3, the report to the department must include at least the following:
(1) With respect to the individual whose blood is examined, the following:
(A) Full address, including street address, city, and zip code.
(B) County of residence.
(C) Race and ethnicity.
(D) Parent's or guardian's name and phone number, where applicable.
(E) Any other information that is required to be included to qualify to receive federal funding.
(2) With respect to the examination, the following:
(A) The date collected.
(B) The name, address, and telephone number of the person examining the blood.

SECTION 12. (a) This SECTION supersedes 410 IAC 29-3-2.

(b) Local health officers shall ensure that case information is reported to the department for children less than seven (7) years of age who have an elevated blood lead level.

(c) Case management activities shall be reported electronically using the forms designated by the department.

(d) Case closure activities shall be reported electronically using the forms designated by the department.

SECTION 13. (a) This SECTION supersedes 410 IAC 29-4-1.

(b) Local health officers may do the following:
(1) Enter upon and inspect private property, at proper times after due notice, in regard to the possible presence, source, and cause of an elevated blood lead level and lead hazards.
(2) Order what is reasonable and necessary to prevent an elevated blood lead level or remediate lead hazards.
Remediation shall be followed by clearance examination.

SECTION 14. (a) This SECTION supersedes 410 IAC 29-5-3.

(b) If the department seizes items under IC 16-41-39.4-7, the items seized shall be:
(1) held for a period of not less than thirty (30) days;
(2) stored at the owner's expense; and
(3) destroyed as of the date stated in the notice.

SECTION 15. This document expires on the earlier of:
(1) The effective date of LSA Document #22-119(F); or
(2) December 27, 2022.

LSA Document #22-290(E)
Filed with Publisher: September 21, 2022, 8:50 a.m.

Posted: 09/28/2022 by Legislative Services Agency

DIN: 20220928-IR-410220290ERA
Composed: Nov 27,2022 9:26:13AM EST
A PDF version of this document.