Pediatric Environmental Home Assessment - Background on General Housing Characteristics

Special Note on Rent-to-Own: Many low income residents enter into agreements with the owner to rent the property with a portion of the "rental" payment going to the purchase of the property. These situations are essentially a contract to purchase the home and a rental agreement. The guidance on rental housing below applies but, generally, the resident is more responsible for maintenance and repairs. The arrangement is potentially subject to abuse by the owner/landlord. Advise the resident to get legal assistance.

Owner-Occupied Housing: If the resident owns the home, the resident has control of the property and can make the repairs. Most of the repairs can be made with only a small investment. When repairs are extensive - such as for major moisture or structural damage - the resident may not have the financial ability to make it work. Some key resources that might be available:

Weatherization Assistance: Local agencies - usually called Community Action Agencies or Community Action Programs - make homes of low income residents more energy efficient. These improvements typically involve insulation and sealing but may also include replacement furnaces and refrigerators. Where the solution to a health concern overlaps with a energy efficiency upgrade, weatherization may help. The U.S. Department of Energy provides funds for the weatherization. Funds are limited to low-income residents but the limits are less restrictive that many programs.
HUD-funded Lead-Hazard Control or Healthy Homes Grants: Many communities receive funds from the U.S. Department of Housing and Urban Development to make homes lead-safe and healthier. This is a competitive grant program so each program is different and your community may not have a grant.
Resident-funded: The resident may be eligible for a home equity line of credit from a local bank. The resident should check with resident's bank for options.
Other local programs: Some communities provide additional assistance to low-income residents. Check with your local department of housing and neighborhood development.

Rental Housing: If the resident is a renter, responsibility is split between the owner/landlord and the resident. Generally, the landlord is responsible for structural and major maintenance issues and the resident is responsible for housekeeping. Rent-to-Own situations are especially complicated. There are three steps to determine responsibilities:

Lease: Start with the lease signed by the landlord and renter. While it may be boilerplate language, look at the section headings to make it more digestible. While you may not be comfortable interpreting the terms of the lease, the resident will probably benefit from the shared reading. Some residents may not have read the lease or understood their responsibilities for housekeeping, cleaning, and maintenance.
Housing Code: The housing code is a local ordinance that sets minimum standards for the conditions of the house to protect the safety and health of residents. No matter what the lease says, the housing code must be met. The lease can only say who is responsible for ensuring compliance with the code. Housing codes are usually tailored to the community. Unfortunately, many smaller communities do not have housing codes and many of the existing housing codes do not reflect the latest science on the threats to health such as asthma triggers, carbon monoxide, and lead-based paint dust.
- Find your local code. Go to www.municode.com. This website is on-line versions of local ordinances for thousands of communities. There is no cost to look up the ordinance for a single community. Search for housing or a particular hazard such as "rat" or "rodent". This service is limited for large cities. Some do not use the service often putting it on their own website. And large cities may adopt the housing code as regulations adopted by an agency not by the city council. These may not be on-line at www.municode.com.
- Model Code. More than 500 communities and three states - New York, Virginia and Oklahoma - have adopted the International Property Maintenance Code (IPMC) as their housing code. Go to www.iccsafe.org/government/adoption.html to see if your community or state has adopted it. Make sure you follow the links to see how your community adopted the code. Some communities pick and choose provisions of the IPMC to adopt. To get a copy of the IPMC and other model codes, go to www.iccsafe.org. NCHH has developed a summary of the healthy homes-related provisions of the IPMC and some background on the IPMC.
Landlord-Tenant Law: Most states and many communities have adopted laws defining the responsibilities of landlords and tenants. Usually these laws define the turnover of property and return of deposits. But they may set minimum standards for rental housing and give residents rights to withhold rent until repairs are made. You may want to advise residents to consult with an attorney if it reaches this level.

Special Federal Regulations: In some cases, Congress has authorized the federal government to establish special rules to protect citizens. These standards benefit residents who rent or who own their home. But .

Lead-Based Paint: Generally applies to housing built before 1978. Deals with abatement, disclosure at lease or sale, pre-renovation notification, and federally-subsidized housing.
Asbestos: Generally applies to housing with more than four units. Extensive requirements in place.
Disability: Protects residents who are disabled from discrimination.
Federally-Subsidized Housing: When the U.S. Department of Housing and Urban Development (HUD) provides assistance to the resident, HUD imposes detailed standards on the property. Two common programs are public housing and Section 8. NCHH has developed a summary of the Housing Quality Standards for Section 8 property with some supporting information.

Shelter: Shelters are complicated. The shelter provides an essential service for the community. But they are often operated on limited funding. It is best to work directly with the non-profit or agency running the shelter to resolve problems.

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Age of Home

The age of the home is important to know because it helps housing professionals you work with better understand the potential problems in a home. It is usually the first question they will ask.

It is also a special area of concern since a home built before 1978 may contain lead-based paint. According to the 2005 American Housing Survey, 65.5% of all homes were built before 1980. Deteriorated lead-based paint can poison children. Homes built before 1950 are much more likely to have lead-based paint on the interior and exterior, especially on the windows. After 1950, lead-based paint began to be phased out of interior use. In 1978, Congress banned use of lead-based paint in residences. The table below describes the situation around 2000. If a resident doesn't know the age of the home, presume it was built before 1978. See the lead paint hazards section of indoor pollutants for more information.

Action Steps for "Age of Home": If a nurse is working with a resident of a home built before 1978, the nurse should

Look for deteriorated paint - paint that is peeling, flaking, chipping, cracking or chalking. If the paint is deteriorated and it contains lead, then the lead dust hazards may be in the home and the floor should be tested.
Ask resident if:
- Child less than six years old is regularly in the home. If so, arrange for child to get blood lead test.
- Resident got a lead-based paint warning and specific disclosures about lead-based paint in the home when buying or leasing property as required by law. If the resident did not get the warnings, the resident may have legal rights that can fix potential problems.
- Paint was disturbed that might have made lead dust or released paint chips.
- If paint was disturbed, did a contractor or landlord do the work. If more than 2 square feet of paint was disturbed, the resident was entitled to special notice under federal law and should have signed a form. If the resident did not get the warnings, the resident may have legal rights that can fix potential problems.
- If resident is already working with state or local Childhood Lead Poisoning Prevention Program. If not, ask for permission to contact the local CLPPP program for them.
Get more information about lead testing at www.epa.gov/lead/ and provide to family.
Educate the residents as follows:
- Home is likely to have lead paint.
- Lead hazards can be harmful to young children's health and development.
- Any children regularly in the home should have their blood tested for lead.
Review items in “Family To Do” column with family.
- If your child is less than six years old, contact the childhood lead poisoning prevention program (CLPPP) at your state and local departments of health.
- Consider getting a lead paint inspection or risk assessment to determine whether there are lead hazards in your home.
- If there are hazards, repair them based on state and local regulations and requirements. Consult with state CLPPP.

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Structural Foundation

Type of structural foundation is not an area of concern. However, it is a crucial factor in determining what problems might be present. It is also a question that housing professionals that you may call on will ask.

Basement: A basement is a helpful asset in a home. According to the 2005 American Housing Survey, 30.9% of all single-family homes have a full or partial basement. However, it can be a problem.

Moisture can get into the the basement from the foundation, especially if the groundwater is shallow. Damp indoor spaces attract rodents and roaches and helps mold grow. See Institute of Medicine report on damp indoor spaces (page 2)
Radon may have a better chance of getting into the home from the outside soil.
Basement may serve as a storage place for boxes and other items that can serve as a home for rodents and insects.
Messes can accumulate since it is out-of-sight.

Slab on Grade: A house set on a concrete on the ground is a "slab on grade" home. According to the 2005 American Housing Survey, 21.1% of all single-family homes have a home on a slab. This type of foundation is common where there is a shallow groundwater that makes a basement too difficult to keep dry. A slab avoids many of the problems with basements. However because concrete is porous to water, it can have moisture problems. Also homes on slab often have wall-to-wall carpeting to avoid the cold floor. Wall-to-wall carpeting can result in serious problems with cleaning and moisture that lead to asthma triggers. Also cracks can allow radon and insects to enter the home.

Crawlspace: A crawlspace is the area under a home that you must crawl into to access. According to the 2005 American Housing Survey, 17.5% of all single-family homes have a home on a slab. Some homes are raised above the ground - often to avoid floods - and the crawlspace is the area under the floor. In other situations, the area under the floor is excavated. Crawlspaces share many of the same problems as basements.

The ground is moist. The moisture can get into homes, especially in humid areas or where the crawlspace is poorly ventilated. It is difficult to isolate that air in the crawlspace from the air in the home Damp indoor spaces attract rodents and roaches and helps mold grow. See Institute of Medicine report on damp indoor spaces (page 2)
Home for pests. A crawlspace can become a home for rodents and insects because they are less likely to be disturbed and the area is moist.
Messes can accumulate since it is out-of-sight.

Crawlspaces should be sealed and made part of the home because it is too difficult to keep the air in the home isolated from the air in the crawlspace. See Keep It Dry - Slide 25. They do not need to be heated or air-conditioned.

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Floors Lived In

The number of floors lived in is not an area of concern. However, it is a factor in identifying safety hazards. if the home has more than one floor, the stairs may pose a safety hazard and may limit mobility for the disabled. In addition, upstairs windows may pose a falling hazard.

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Heating - Fuel Used

The fuel used to heat the home may present a danger to residents if equipment is damaged. Anything that burns a fuel is going to produce carbon monoxide and nitrogen oxides. Carbon monoxide is an invisible, tasteless, odorless gas that can - and does - kill. The residents fall asleep and die because the carbon monoxide is more easily absorbed by the blood than oxygen. Nitrogen oxides are an irritant to the respiratory system. A smoldering burn or yellow flame produces more carbon monoxide. A hot or blue flame produces nitrogen oxides - but not usually at levels of concern in a home.

Natural Gas/Liquid Propane Gas: Used in furnaces, stoves, water heaters, and space heaters. Devices burning gas should always be vent outside. If there is a gas leak, you will smell it. Producers add a stenching agent that smells like rotteneggs. Call the supplier and fire department immediately if you smell this stenching agent.

Oil: Used in furnaces, water heaters, and space heaters. There is usually a storage tank in the basement. Oil burning equipment must be vent outside

Electric: Electric heat does not produce carbon monoxide or nitrogen oxides in the home.

Wood: Used in furnaces, water heaters, and fireplaces. Wood burning equipment can produce high levels of carbon monoxide. They must be vented outside.

Action Steps for Fuel Used:

Counsel family about the dangers of such heating sources in terms of fire safety and indoor air quality.
Get more information about indoor air quality and combustion sources in the home at www.epa.gov/iaq/combust.html and provide to family.
Review items in “Family To Do” column with family
Make sure kerosene heaters are vented to the outdoors or not used.
Make sure space heaters are at least 3 feet from anything flammable.
When necessary, use only 12 or 14 gauge extension cords (the lower the better).
Ensure that there is a good seal on fireplace screen or woodstove doors.

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Heating - Sources in Home

If the home is heated by a space heater or an appliance such as the stove or oven, the resident is at serious risk of carbon monoxide poisoning. Counsel the resident to stop using the space heater or appliance until they are sure it is safe. If there are problems with the furnace, they need to get it fixed.

Beyond concerns with the space heater, it is helpful to know whether the home is heated with a radiator or forced hot air system.

Forced Warm Air System: Homes use a forced air system where air in the home is pulled by a fan through ductwork to a furnace. According to the 2005 American Housing Survey, 62.7% of all homes use a forced air furnace. The air is heated by a heat exchanger in a central furnace. The heat exchanger is a metal device that is heated by combustion of oil or gas one side of the metal. The hot metal warms the air passing over it. The warmed air sent by separate ductwork throughout the home. A furnace has a filter to remove dust that can clog the heat exchange or cause respiratory problems for residents. The forced air furnace is often located in the attic in the South and in basements where there is a basement.

Radiators: A radiator uses hot water or oil to heat the home. You typically see them in older homes. The radiators are usually located on the exterior walls of the home. You may also see electric baseboard heaters to supplement the radiators. The oil or water is typically heated in a central heater and distributed by pipes. The major concerns with radiators is localized hot and cold spots. Some radiators are put in boxes with fans to reduce the problem.

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Heating - Filters Changed

In a forced warm air system and on radiators with fans, filters are used to keep the heat exchanger clean. If the heat exchange gets dirty, it will not transfer the heat was effectively. If high enough quality filter is used, the filter can also removed fine dust that can irritate the respiratory system and exacerbate asthma. Filters are rated on a system called MERV - Minimum Efficiency Rating Value. The higher the number, the more effective it is at removing particles. NCHH recommends a MERV 10 or higher. Click here for more information and photos of various filters.

The nurse should counsel family to:

Change filters quarterly.
Use filters which are rated MERV 10.

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Heating - Control

A home should be comfortable. According to the 2005 American Housing Survey, 7.3% of all homes were uncomfortable cold for 24 hours or more the previous winter. Most housing codes set a minimum temperature in a home - usually around 65F. If it cannot maintain this temperature, the ventilation may be poorly designed or maintained. It needs to be repaired.

In high-rises apartments or condominiums, the ventilation may be poorly designed so that some residents are hot. They must open windows. This is a waste of energy and may create unhealthful conditions.

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Cooling

It is helpful to understand how the home is cooled. Air conditioning removes humidity from the air and then cools the air. Window air conditioners can cause water damage in the walls if not properly installed. Central air conditioning can also cause water damage if poorly installed or maintained.

In some cases, especially humid areas, the cool interior may cause water too form in the wall cavities of exterior walls. This moisture can result in mold.

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Ventilation

Each bathroom and the stove should have a fan that exhausts outside. The fan removes moisture, smells, and other contaminants. If the bathroom has a shower or bath or the stove/oven is not electric, the fan is essential.