5 - Information Item*Central Records
Ill ~
Memo
TO: Planning Board
FROM: Mary Lovrien
SUBJECT: Planning Board Materials
DATE: February 27, 2001
Attached are additional letters and information for the March 1, 2001 Planning Board meeting.
Attachments
r~
Memo
TO: Planning Board
FROM: Peter Pollock, Planning Director ~~' \~
' David Gehr, Assistant City Attorney
Bob Cole, Director of Project Review/Land Use
SUBJECT: Follow-up from February 22, 2001 Planning Board hearing regarding amendments
to Title 9, Land Use Regulation, of Boulder Revised Code, 1981, concerning new
standards for the siting of overnight, day and emergenecy shelters, transitional
housing, and addiction recovery facilities.
BACKGROUND:
The Planning Board continued the February 22, 2001 hearing item to March 1, 2001. The staff
presentation, public hearing, and substantial portions of the Planning Board deliberation were
completed. There were several items raised by the Planning Board that are clarifications of the
ordinance:
1. Under definitions for emergency shelters and overnight shalters, clarify that the accessory
services are meant for the occupants.
2. In transitional housing, change "overnight accommodation" to "housing."
3. Change the "waiting area" standard under day shelters to be the same as that used for
overnight shetters.
4. Clarify the occupancies that can be granted by conditional use review and those that can
be granted only through use review.
A list of further discussion items was identified. Staff has developed possible policy options and
code amendments for Planning Board consideration.
Include a process for reviewing the management plan and making changes to it over time.
a. Use the process called for in the proposed ordinance which requires that the
original management plan includes methods for future communication with the
neighborhood.
s:\plan\pb-items~cnemos\sheltetpb2-22issues. doc
b. Require an annual meeting to be held to review the status of the management
plan.
c. Require that the management plan be resubmitted periodically for review and
approval by Planning staff.
6. Increase the notice for the Good Neighbor Meeting. In the present code, a 600 foot notice
is required for all discretionary reviews and subdivisibns; co-op housing units require a
300 £oot notice, and accessory dwelling unit (ADin and owner accessory unit (OAU)
applications require notice to adjacent property owners.
a. Use the notice called for in the proposed ordinance which is within 300 feet of the
subject property.
b. Use 600 feet instead.
Use the parking defenal process to lower required parking instead of parking reductions.
a. Use the standards in the proposed ordinance which specify parking requirements
and allow up to a 50% parking xeduction within conditional or use review.
b. Treat these uses like all others in the code and allow up to a 20% parking
reduction, a 90% parking deferral in industrial zones, a 35% parking deferral in
commercial zones, and a 20% parking deferral in all other zones, at staff level.
8. Include an open space standard for emergency, overnight, and day shelters.
a. Use the standards of the cunent code for the particular zone district to set the
required quantity of open space AND specify any particular issues concerning the
quality of the open space for each shelter type, such as waiting areas or outdoor
assembly areas.
b. Reduce the open space requirements for particular shelter types by up to 25% with
standards specified in the code.
9. Either exclude damp shelters near schools or mention this issue specifically in the
requirements for a management plan.
a. Exclude "damp" overnight or day shelters from within a certain distance o£K-8
schools.
b. Require "damp" overnight ar day shelters within a certain distance of K-8 schools
to go through a use review.
c. Include as a required element of a management plan, if a"damp" overnight ar day
shelter is within a certain distance of K-8 schools, that a jointly (school and
shelter) prepared safety plan be included in the management plan.
~
s:\plan\pb-items~nemos\shelterpb2-22issues.doc 2
l0. Should the parking standards far an addiction recovery facility be lower than for medical
clinics?
a. Use the standards of the current code for the particular zone district to set the
required quantity of parking. Use staff level ar site review level parking
reduction/deferral processes to consider fewer parking spaces.
b. Create a lower parking standard for addiction recovery facilities.
1 L What is the appropriate review process for overnight and day shelters in the high dansity
residential zone districts? (HR/I-IZ).
a. Use the standards of the proposed ordinance for the HR/HZ zones that allow
shelters smaller than 75 occnpants and with no occupancy per dwelling unit
increase over four to be considered as conditional uses. Larger shelters and
shelters proposing occupancy per dwelling unit increases would be considered as
a use review.
b. Require all overnight and day sfielters in HR/HZ zones to 6e considered under use
review.
12. Should overnight shelters in TB (transitional business), CB (community business), and
BMS (business main street) zones be reviewed when the subject property is adjacent to
residential zones? What is the appropriate definition of adjacent?
a. Use the standards of the proposed code that define "adjacent" as across property
lines or alleys.
b. Expand the definition of "adjacenY' to include streets of a certain dimension or
less, i.e., 80 feet.
13. How would multiple occupancies from different shelter types included in one facility be
treated relative to the requirement that proposed overnight shelters greater than 75
occupants in high density residential zones go through use review?
a. Include only that portion of the project that qualifies as an ovemight shelter.
b. Include the total number of occupants from all facets of the proposed project,
including emergency and transitional housing, to calculate the total number of
occupants.
ATTACHMENT:
Attachment A. Ordinance and Ordinance Options
s:\plan\pb-items~nemos\shelterpb2-22 issues. doc
ATTACHMENT A
February 27, 2001
Attachment to the Staff Memorandum
Options in the attached ordinance are shown in bold.
ORDINANCE TITLE
A. Atnendment to Yhe title to also note changes to the use review standards
DEFINITIONS
B. Amendment to definitions of emergency shelters and overnight shelters to more clearly
explain the parameters of "personal care" services.
C. Change in the definition of transitional housing to delete "overnight accommodations" and
replace with "housing." ~
OVERNIGHT SHELTERS
D. 9-3.4-25 (a)(3). Notice for the meeting. Options:
1, Proposed by staff - 300 feet - about a city block.
2, Alternative - 600 feet - the site review and use review standard for notice.
E. 9-3.425 (a)(3) Add language thaY allows an applicant to deliver the management plan, rather
than only by mailing it to surrounding property owners.
F. Management plan alternatives. Two options are added at 9-3.4-25(b)(5).
Option: Require new management plan to be submitted every _ years.
Option: Require new neighborhood meeting and managament plan to be submitted
for approval every years
G. Add language clarifying the opening paragraph to 9-3.4-25(~, noting that the provision
applies to the maximum occupancy, unless an increase in occupancy is approved.
H. Add an option that declares that "adjacency" also includes streets that are not designated as
a majar arterial or greater in the TMP to Paragraphs 9-3.4-25(~(2) and (3).
s: \plan\pb-items~memosUn-shelters-3-options-list.wpd
Calculating occupancy far the purpose of determining thresholds. Add a new paragraph 9-
3.5.25( fl(4) to clarify that it is the commutative occupancy when different sheltering uses co-
located together.
J. Alcohol Near Schools. Options.
l. Exclude "damp" overnight or day shelters from within a certain distance of K-8
schools. See option in 9-3.4-25(g)
2. Require "damp" overnight or day shelters within a certain distance of K-8 schools to
go through a use review. See option, new paragraph added to 9-3.4-25(h)(3).
3. Include as a required element of a management.plan, if a"damp" overnight or day
shelter is within a certain distance of K-8 schools, that a jointly (school and shelter)
prepazed safety plan be included in the management plan.
DAYSHELTERS
K. 9-3.4-26(a)(3) Notice for the meeting. Options:
1. Proposed by staff - 300 feet - about a city block.
2. Alternative - 600 feet - the site review and use review standard for notice.
L. 9-3.4-26(d). Waiting areas. Redraft so that the requirement for day shelters is parallel with
overnight shelters. Corrects a typographical error from first draft.
M. Alcohol Near Schools. Options. Add a new section 9-3.4-26(g) to address the issue. Three
options are drafted in that section.
Exclude "damp" overnight or day shelters from within a certain distance of K-8
schools.
2. Require "damp" overnight or day shelters within a certain distance of K-8 schools to
go through a use review.
3. Include as a required element of a management plan, if a"damp" overnight or day
shelter is within a certain distance of K-8 schools, that a jointly (school and shelter)
prepared safety plan be included in the management plan.
EMERGENCY SHELTERS
N. 9-3.4-27(a)(3) Notice for the meeting. Options:
1. Proposed by staff - 300 feet - about a city block.
2. Altemative - 600 feet - the site review and use review standard for notice.
s: \plan\pb-items~nemosUn-shelters-3-options-list.wpd
O. Add language clarifying the opening paragraph to 9-3.4-27(d), noting that the provision
applies to the maximum occupancy, unless an increase in occupancy is approved.
P. Add an option that declares that "adjacency" also includes streets that are not designated as
a major arterial or greater in the TMP to Paragraphs 9-3.4-27(d)(1)(B) and (C).
Q. Calculating Occupancy. For the purpose of determining thresholds. Add a new paragraph
9-3.4-26(d)(4) to clarify that it is the commutative occupancy when different sheltering uses
co-]ocated together.
OPTIONS ARE NOT DRAFTED FOR THE
FOLLOWING ISSUES
THE FOLLOWING ITEMS FROM THE STAFF MEMORANDUM
DO NOT HAVE ANY LANGUAGE PROPOSED BY STAFF.
STAFF WILL DRAFT LANGUAGE AS NEEDED FOLLOWING
THE BOARD DISCUSSION.
7. Use the parking deferral process to lower required parking instead of parking reductions.
A. Use the standards in the proposed ordinance which specifyparking requirements and
allow up to a 50% parking reduction within conditional or use review.
B. Treat these uses like all others in the code and allow up to a 20% parking reduction,
a 90% parking deferral in industrial zones, a 35% parking deferral in commercial
zones, and a 20% parking deferral in all other zones, at staff level.
Include an open space standard far emergency, overnight and day shelters.
A Use the standards of the current code for the particular zone district to set the
required quantity of open space AND specify any particular issues concerning the
quality of the open space for each shelter type, such as waiting areas or outdoor
assembly areas.
B. Reduce the open space requirements for particular shelter types by up to 25% with
standards specified in the code.
10. Should the parking standards for an addiction recovery facility be lower than for medical
clinics?
A. Use the standards of the current code for the particular zone district to set the
required quantity of parking. Use staff level or site review level parking
reduction/deferral processes to consider fewer parking spaces.
B. Create a lower parking standard for addiction recovery facilities.
s:\plan\pb-items~nemos~n-shelters-3-options-list.wpd
11. What is the appropriate review process for overnight and day shelters in the high density
residential zone districts? (HR/I-IZ).
A. Use the standards of the proposed ordinance for the HR/HZ zones that allows shelters
smaller than 75 occupants and with no occupancy per dwelling unit increase over 4
to be considered as conditional uses. Larger shelters and shelters proposing
occupancy per dwelling unit increases would be considered as a use review.
B. Require all overnight and day shelters in HR/HZ zones be considered under use
review.
s:\plan\pb-items~nemos~tn-shelters-3-options-list.wpd
ORDINANCE NO. _
AN ORDINANCE AMENDING TITLE 9, "LAND USE
REGULATIONS," B.R.C. 1981, BY AMENDING THE
STANDARDS FOR USE REVIEWS AND BY THE ADDITION
OF NEW STANDARDS FOR THE REGULATION AND STTING
OF OVEItNIGHT SHELTERS, EMERGENCY SHELTERS,
TRANSTTIONAL HOUSING, DAY SHELTERS AND ADDICTION
RECOVERY FACILTTIES
BE TT ORDAINED BY THE CTTY COUNCIL OF THE CITY OF BOULDER,
COLORADO:
Section *. Section 9-1-3, B.R.C. 1981, is amended by the addition of the following
definitions, to read:
eounseling, avd-transporf~~tont,services, and services to support the personal care of the residents
of the facility including medical care, dental care, and hygiene.
amrtrarispqrtaiipl~ s~r,~Qe~ and services to support the personal care of the residents of the
facility including medical care, dental care, and hygiene.
Section *. Section 9-1-3, B.R.C. 1981, is amended by the repeal of the definition of
"temporary shelter," to read:
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Section *. Section 9-3.1-1(a), B.R.C. 1981, (residential ilistricts) is amended by the
amendment of line 28, the repeal of line 29, "temporary shelters," and the addition of new lines, to
read:
RR-E MR-E MR-D MXR-E MXR-D HR-E MU-X MU-D RMS-X MH-E
RRI-E LR-D MR-3C HR-D
ER-E HR-X
LR-E HZ-E
28. medical or dental clm~cs
or "' U U U * U M U U •
_
o~ces o~`addict'ton reCOVel3? I
~'acilit~es
Y . t ~S t3 ~3 H ~3 ~S ~J ~ I
.. I
'~~1~ oveiYiight;ahelter ~ ~!t ~7 ~ ~ ~ ~ ~ ~ ~ I
32` rlay sheltb~ ,+,~ u ~ ~~ 1~ U I;1 ~ ,~ ~ I
5~+ 4me~@ency°shelEer' ~J ~ ~ ~ ~ ~ C ~ ~ ~ l
S4: 'hanklhona(bousin8 ~ ~ ~' ~ ~ ~ "C ~ ~ ~ I
A: use permitted
C: conditional use ~ - ~ . ~
G: use permitted, provided that It Is located above or below the flrst floor, ~otherwise by use review ~~~~ ~- ~ . ~
M: usepermltledprovidedatleast50percentofthefloorareaisforresldenGaluseandthenon-residentlaluseislessthan7,000.
square feet per building; oiherwise by usa reWew only ~ , ~ ,~ ~ ~~
U: use permitted by use review ~ , ,, -
. use prohibited - . - ~ ~ ~ ~ , -~
ection *. Section 9-3.1-1(b), B.R.C. 1981, (business districts) is amended by the
amendment of line 8 and the addition of new lines, to read:
7'B•E
TB-D BMS-X CB-E
CB-D RB-8 RB-D RB1-E R82-E R83-E R81-X RB2-X RB3-X
8. medical or dental clinics or
ofTices OT~add~Ck9D tRGQvFry
feq,ilitia~ A A A A A G A A A A A
~ik pvtimightsfiel'tee C ~ ~ ~ ~ ~ ~3 ~ C G ~
S?i id'By sheltqr C ~ C;i !ka S~ C C G' C G G
~3 emeigency shelfer C~ ~' d ~ Q !p ~ C C !G C
i9~ fianaiHonal hou&ing C} C ~(; d ~ ~ C C ~ 1C '(~,
Section *. Section 9-3.1-1(c), B.R.C. 1981, (industrial districts) is amended bythe repeal
of line 46, "temporary shelters" and the addition of new lines, to read:
- IS-E
IS-D IG-E
IG-D IM-E
]M-D IMS-X
. F3 ~3 ~3 F3
52. qvemighf~`ahelta~ ~ C C Q
53, dAysfielter t~ C C ~
54. emergeney sfielter C C G C
55. hansiti4nal hqgsing C C. C C
Section *. Subsection 9-3.1-1(d), B.R.C.1981, (public and a~icultural) is amended by the
addition of new lines, to read:
P-E A-8
~~% ~.X~~~lul~lt~' ~ t~
~8~+ ~~@ite~ • ~ ~
~~ X-`~~~nCY`~~~ ~ ~
~k~. ~'8nal~onat fi9u4~i~8 ~ ~
Section *. Chapter 9-3.4, B.R.C. 1981, is amended by the addition of a new section 9-3.4-
25, "Overnight Shelter," B.R.C. 1981, to read:
9-3.4-25 Overnight Shelter.
The following criteria apply to any overnight shelter:
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(5) Amendment of a Mana~ement Plan: Every _ years, no owaer or operator shall
fail to resubmit a management plan that meets the requirements of Subsection
(b) above. The management plan shall address how the facility will address any
additional adverse impacts that have been identified by the city manager.
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(5) AmendmentofaManaEementPlan: Every_years,noowneroroperatorshall
fail to organize, host, and participate in a good neighborhood meeting and
resubmit a management plan that meets the requirements of this section. The
management plan shall address how the facility will address any additional
adverse impacts that Lave been identified by the city manager.
(56)
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~g~~ol~,i~ving unless approved pursuant to an occupancy increase~
]ot area or ppen space onjthe site. An
>rsons per dwellin~ unit`equivalents in
cf the: propert~Y~g npx ~jaceni ta a
t_ . x~~r,
street that is a minor arterial or lesser
(3)
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street that is a minor arterial or Iesser classification on the
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(g) Alcohol Use Prohibited N~ar Schonic,
fac~l~ty t4at is within five hundred feet f om a sc4ool. aForthe purpose of this section,
"school" means a public, parochial; or nonpublic school that provides a basic academic
edacation in compliance with the school attendance laws for students in grades
kindergarten throug4 the eighYh grade. °°Basic academic education" has the same
meaning as set forth ia § 22-33-104(2){b), C.R.S.,
(g) School Safe Plan. Any facility Yhat is within Gve-hundred feet from a school that
proposes to admit clients that may be under the influence of alcohol shall also develop
a safety plan, in consultation with the school, to ensure safety of the school's students.
For the parpose ofthis section,'°school" means a public, parochial, or nonpublic schoo!
thatprovides a basic academic education in compliance with theschool attendance laws
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Calculat~p~~upa~~. The maximum occupancy for a facility shall include
the occupants of facility in addition to the occupants of emergency shelter uses
and traasitional housing uses that are also located on the property.
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a street that is a minor arterial or lesser
(3) Alcohol. Any facility that is within five-hundred feet from a school that
proposes to admit clients that may be under the influence of alcohol will be
required to complete a use review. For the purpose of this section, °°school"
means a public, parochial, or nonpublic school that provides a basic academic
education in compliance with the school attendance laws for students in grades
kindergarten through the eighth grade. "Basic academic education" has the
same meaning as set forth in § 22-33-104(2)(b), C.R.S,r
Section *. Chapter 9-3.4, B.R.C. 1981, is amended by the addition of a new section 9-3.4-
26, "Day Shelter," B.R.C. 1981, to read:
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for students in grades kindergarten through the eighth grade. "Basic academic
education" has the same meaning as set forth in § 22-33-104(2)(b), C.RS.
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potentiai impacts upon;ne~~hb0;ln~ pro~~rties ~(~wners ~nd operators shall implement a
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No person shall allow or permit clients of a facility to queue or otherwise wait for the
facility to open or to be otherwise be admitted into the facility in the public right-of-
way. The facility shall provide an indoor or outdoor waiting area in a size adequate to
prevent the anticipated number of clients from queuing into or otheryvise waiting in the
public right-of-way.
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(g) Alcohol Use Prohibited Near Schools. No person shall admit another person into a
facility that is within five hundred feet from a school. For the purpose of this section,
"school" means a public, parochial, or nonpublic school that provides a basic academic
education in compliance with t6e school attendance laws for students in grades
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kindergarten through the eighth grade. "Basic academic education" has the same
meaning as set forth in § 22-33-104(2)(b), C.R.S:
(g) Review Standards: Uses designated as conditional uses in Section 9-3.1-1, "Schedule
of Permitted uses of Land," B.RC.1981, shall be processed under the provisions of't6is
section, unless the applicant propose to locate a facility within five-hundred feet from
a school that proposes to admit clients that may be under the intluence of alcohol. For
the purpose of this section, "school" means a public, parochial, or nonpublic school that
provides a basic academic education in compliance with the school attendance laws for
students in grades kindergarten through the eighth grade. "Basic academic education"
has the same meaning as set forth in § 22-33-104(2)(b), C.RS. In such a case, the
applicant will also be required to complete the use review process pursuant to Section
9-4-9, "Use Review," B.R.C.1981.
(g) School Safety Plan. Any facility that is within five-hundred feet from a school that
proposes to admit clients that may be under the influence of alcohol shall also develop
a safety plan, in consultation with the school, to ensure safety of the school's students.
For the purpose of this section, f°school" means a public, parochial, or nonpublic school
that provides a basic academic educatiou in compliance with the school attendance laws
for students in grades kindergarten through the eighth grade. "Basic academic
education" has the same meaning as set forth ia § 22-33-104(2)(b), C.R.S.
Section *. Chapter 9-3.4, B.R.C. 1981, is amended by the addition of a new section 9-3.4-
27, B.R.C. 1981, to read:
9-3 4 27?~ ~mergeucy S.h,elter;
'i`lig follow%ng, cnteria appl~'~i~;any_eanergency sheltgr:
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(c)
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(2)
(3) One parkix-g space for eaeli attached dwellttig unitr
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(d) Maximum Oocunanca:`~~To pe}'Son shall pernnrt S~e=maxunum occupanay o~ a: ~ac~l~'~,y_ tg
exoeed the foilowing~unless approved pursuant to an occupancy increase;
(1) For emergenay;shelte~;facilities that operat~ witti sleeping r
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(}3)
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One parlun~{ space foz~~aeh twen~y'ocoupant~; based on the ma~iimwnt oC~~ip,axi~y oE
sleeping roorii~ And tYi~;dorniitory type slgeping areas; aiid
(G~
a~~'~ a street that is a minor arter~al or lesser classificahon on the
Transportatfon Master Plan functional classification ma~ ~~~t
~ine;~o~`~~itlis~`'`~g~,ab e: ~t:~~!v~`~%,fhat~i sharedbetwQ_.:. e w..° "~
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arterial or lesser classifcation on the Transaortation Master Plan
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Section *. Chapter 9-3.4, B.R.C. 1981, is amended by the addition of a new section 9-3.4-
28, B.R.C. 1981, to read:
~ 3 a 28 Transttiti~al Ilpusing
.. . •'£fxi'F ~" Y'-T 6 L t. ~i F G* F#$/~ Y3 ~?~~
The,following entei~a.app~y to ~r-y_~ransit~opa7~~~s~t acil~tya
Ca)
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(c)
Section *. Subsection 9-4-9(d), B.R.C. 1981, is amended to read:
(d) Criteria for Review: No use review application will be approved unless the approving
agency finds all of the following:
(1) Consistency with Zonine and Non-Conformitv: The use is consistent with the
purpose of the zoning district as set forth in Section 9-2-1, "Zoning Districts
Established," B.R.C. 1981, except in the case of a non-conforming use;
(2) Rationale: The use either:
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(4) Calculating Occupancy: The maximum occupancy for a facility shall include
the occupants of facility in addition to the occupants of overnight s6elter uses
and transitional housing uses that are also located on the property.
(A) Provides direct service or convenience to or reduces adverse impacts to the
surrounding uses or neighborhood;
(B) Providesacompatibletransitionbetweenhigherintensityandlowerintensity
uses;
(C) Is necessary to foster a speciSc city policy, as expressed in the Boulder
Valley Comprehensive Plan, including, without limitation, historic
preservation, moderate income housing, residentiai and non-residential mixed
. uses in appropriate locations, and group living arrangements for special
populations; or
(D) Is an existing legal non-conforming use or a change thereto that is permitted
under subsection (e) of this section;
(3)
(4) Infrastructure: As compared to development permitted under Section 9-3.1-1,
"Schedule of Permitted Uses of Land," B.R.C. 1981, in the zone, or as compared to
the existing level of impact of a non-conforming use, the proposed development will
not significantlyadverselyaffect the infrastructure ofthe surrounding area, including,
without limitation, water, wastewater, and storm drainage utilities and streets; and
(5) Character of Area: The use will not change the predominant chazacter of the
surrounding area.
Section *. This ordinance is necessary to protect the public health, safety, and welfare of
the residents of the city, and covers matters of local concern.
Section *. The council deems it appropriate that this ordinance be published by title only and
orders that copies of this ordinance be made available in the office of the city clerk for public
inspection and acquisition.
INTRODUCED, READ ON FIRST READING, AND ORDERED PUBLISHED BY TTf LE
ONLY this day of
S:~P1.AN\P&ITEMS~MEMOSb-aheltma-3-opdone.wpd
2001.
Compatibilitv: The location, size, design, and operating characteristics of the
proposed development or change to an exiating development are such that the use
Attest:
City Clerk on behalf of the
Director of Finance and Record
Mayor
S:~PLAN~P&iTEMSUNEMOSb-aheiters-3-opriona.wpd
.
.
READ ON SECOND READING, PASS$D, ADOPTED, AND ORDERED PUBLISHED
BY TITLE ONLY this day of , 2001.
Mayor
Attest:
City Clerk on behalf of the
Director of Finance and Record
From: "Andrea Ryan" <andrearyan2@hotmail.com>
To: <StraszewskiH@ci.boulder.co.us>
Date: 2/24/01 4:59PM
Subject: Re: Fwd: Ptanning Board Shelter code meeting, 2/22/01
>From: "Heidi Straszewski" <StraszewskiH@ci.boulder.co.us>
>To: <BLDRJET@aol.com>,<Ljourgensen@aol.com>, <revbledsoe@aol.com>,
><scherow2@aol.com>, <dan.corson@chs.state.co.us>, "Brent Bean"
><BeanB@ci.boulder.co.us>, "Mark Beckner" <BECKNERM@ci.boulder.co.us>, "Bob
>Cole" <Cole6@ci.boulder.co.us>, <cstout@ci.boulder.co.us>, "David Gehr"
><GehrD@ci.boulder.co.us>, "Loree Greco" <GrecoL@ci.boulder.co.us>, "Terence
>Harmon" <HARMONT@ci.boulder.co.us>, "Peter Pollock"
><PollockP@ci.boulder.co.us>, "Susan Purdy" <PurdyS@ci.boulder.co.us>, "Ron
>SecrisP' <SecristR@ci.boulder.co.us>, "Heidi Straszewski"
><StraszewskiH@ci.boulder.co.us>, <handerson@clarionassociates.com>,
><anthony.goodman@colorado.edu>, <lindakuhn@compuserve.COm>,
><mhcbc_inc@compuserve.com>, <joellenr@eclipseinc.com>,
><tayerville@email.msn.com>, <g.harms@ericsson,com>,
<tess@facilitationprofessionals.com>, <andrearyan2@hotmail.com>,
<anngetches@hotmail.com>, <mruzzin@igc.org>, <bparadis@ix.netcom.com>,
<pastordrott@juno.com>, <rgmann@juno.com>, tohn.mcferran@painewebber.com>,
<vmassingdale@quest.net>, <nolan@rrcassoc.com>, <edpowers@uswest.net>
>Subject: Fwd: Planning Board Shelter code meeting, 2/22/01
>Date: Tue, 20 Feb 2001 16:34:42 -0700
>« message1.txt»
Dear Planning Board Members,
Thank you for the pubfic hearing last Thursday night. I wan to commend
you on your perceptive comments. I especially agree with Peter with regard
to the "muddy" and unclear definitions. To me, and to most of the cities
that were researched, an overnight shelter is very different from an
emergency shelter. An emergency shelter is a facility for folks who are
temporarily dispaced due to situations beyond their control. Often these
folks are related, and they remain at the emergency facility for up to a
year. Therfore they have a vested interest in the neighborhood, whereas at
the overnight shelter the clients change every day and they do not require
identification.
I also felt that Beth's comment about the disparity between the zoning
with overnight and day shelters, is quite true. A use review should be
required for both, in all residential areas, and I am also concerned about
the mixed use as well as the business zones (especially with regard to
Basemar and Tablemesa), please require a use review for overnight shelters
at these locations as well as they are so close to low, medium, and high
residential areas. Thank you for your consideration regarding this
recommendation. I sincerely appreciated the opportunity to contribute to
this work group, and i wanted to thank you for all of your hard work.
.~
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Yage 1 oi 1
Mary Lovrien - Shelter hearing
From: <Fap464@aol.com>
To: <]ovrienm@ci.boulder.co.us>
Date: 02/22/2001 4:52 PM
Subject: Shelter hearing
As I am unable b at[end tonighYs planning board mee[ing, 1 would like to
use this means m express some thoughts.
In my opinion, there should always be a public hearing when any type of
shelter is proposed. People affected by these decisions need ways to voice
opinions in a public forum.
Also, shelters should not be located in any case within 500 Ceet of a school.
There
are too many unknowns conected with such facili[ies.
Fai[h A. Peterson
763 16th St.
Boulder, Co 8030
file://C:\WINDOWS\TEMP\GW}OOOlO.HTM 02/23/2001
Page 1 of 1
Mary Lovrien - Homeless Shelters
From: <Adsboulder@aol.com>
To: <lovrienm@ci.boulder.co.us>
Date: 02/22/2001 5:02 PM
Subject: Homeless Shelters
Please require that public hearings for homeless shelters sitings be held in
all zones. Please also write inro the code Ihat shclters may not bc locared
within 500 feet of a school or children's park.
Thanks.
Amanda Steinhardt
Bouider
file://C:\WIlVDOWS\TEMP\GW } 00009.HTM 02/23/2001
Page 1 of i
Mary Lovrien - Shelter Land Use Code
From: runner runner <mmm~ner@go.com>
To: <lovrienm@ci.boulder.co.us>
Date: 02/22/2001 5:10 PM
Subject: Shelter Land Use Code
As Mr. Nolan so poignantly said "We'have a right m public process and Use Review for facilities in our areas. You must establish a process with ground
rules that are fair and objective to all parties imolved."
Shelters of all types must require and be classified as USE REVIEW in HRE and MAE areas.
I attended a few of the Land Use Code Working Group meetings for the Shelter guidelines. I was dismayed at the composition of the working group:
overwheimingly biased towards Ihe Shelter. Any outcome of the proposal is a resul[ of bias for which
I do no[ support Shel[ers of any [ype on a stree[ which already has an exis[ing'affordable housing project.' Nor do 1 support an ovemight She~~er nex[ to a
school. Smaller Shel~ers are be[ter.
Wha[ steps will the Ciry of Boulder taking with regards to Faith Based grants from Ihe US govemment? Has the Ciry of Boulder taken tlie broad view
approach and entered the Faith Dased gran[s into i[s equation?
MN Runner
Get Your Free, Pnvate E-mail at http;//mail_gg.cpm
file://C:\WINDOWS\TEMP\GW } 00010.HTM 02/23/2001
~~
From: "Andrea Ryan" <andrearyan2@hotmail.com>
To: <StraszewskiH@ci.boulder.co.us>
Date: 2I24I01 4:59PM
Subject: Re: Fwd: Planning Board Shelter code meeting, 2122/01
>From: "Heidi Straszewski" <StraszewskiH@ci.boulder.co.us>
>To: ~BLDRJET@aol.com>,<Ljourgensen@aol.com>, <revbledsoe@aol.com>,
><scherow2@aol.com>, <dan.corson@chs.state.co.us>, "Brent Bean"
><Bean6@~i.boulder.co.us>, "Mark Beckner" <BECKNERM@ci.boulder.co.us>, "Bob
>Cole" <ColeB@ci.boulder.co.us>, <cstout@ci.boulder.co.us>, "David Gehr"
><GehrD@ci.boulder.co.us>, "Loree Greco" <GrecoL@ci.boulder.co.us>, "Terence
>Harmon" <HARMONT@ci.bouider.co.us>, "Peter Poilock"
><PollockP@ci.boulder.co.us>, "Susan Purdy" <PurdyS@ci.boulder.co.us>, "Ron
>SecrisY' <SecristR@ci.boulder.co.us>, "Heidi Straszewski"
><StraszewskiH@ci.boulder.co.us>, <handerson@clarionassociates.com>,
><anthony.goodman@colorado.edu>, <lindakuhn@compuserve.com>,
><mhcbc_inc@compuserve.com>, <joellenr@eclipseinc.com>,
><tayerville@email.msn.com>, <g.harms@ericsson.com>,
<tess@facilitationprofessionals.com>, <andrearyan2@hotmail.com~,
<anngetches@hotmail.com>, <mruzzin@igc.org>, <bparadis@ix.netcom.com>,
<pastordrott@juno.com>, <rgmann@juno.com>, <john.mcferran@painewebber.com>,
<vmassingdale@quest.net>, <nolan@rrcassoc.com>, <edpowers@uswest.net>
>Subject: Fwd: Planning Board Shelter code meeting, 2/22/01
>Date: Tue, 20 Feb 2001 1634:42 -0700
>
>« messagel.txt»
Dear Planning Board Members,
Thank you for the public hearing last Thursday night. I wan to commend
you on your perceptive comments. I especially agree with Peter with regard
to the "muddy" and unclear definitions. To me, and to most of the cities
that were researched, an overnight sheiter is very different from an
emergency shelter. An emergency shelter is a facility for folks who are
temporarily dispaced due to situations beyond their control. Often these
folks are related, and they remain at the emergency facility for up to a
year. Thertore they have a vested interest in the neighborhood, whereas at
the overnight shelter the clients change every day and they do not require
identification.
I also felt that 8eth's cqmment about the disparity between the zoning
with overnight and day shelters, is quite true. A use review should be
required for both, in all residential areas, and I am also concerned about
the mixed use as we)1 as the business zones (especially with regard to
Basemar and Tabiemesa), please require a use review for overnight shelters
at these locations as well as they are so close to low, medium, and high
residential areas. Thank you for your consideration regarding this
recommendation. I sincerely appreciated the opportunity to contribute to
this work group, and I wanted to thank you for ali of your hard work.
"~~~~~~+~ MJJIJ llVl+
City of Boulder Planning Board
PO Box 791
Boulder, CO 80306
February 26, 2001
VIA FAX & US MAIL
Dear Pldnning Board Members:
I'HVt eIL
As the owner of property at 2601 Spruce St, In Boulder I am wHtlnq to formally object to any
consideratlon of a thange to the Boulder Valley Comprehensive Plan Land Use Deslgnation on my
property, The property is currently the home of a long-time Ioca- business, Toledo GIaSS. A letter
just reccived from the City Planning staff spaifi~ally points out the reason why we have taken
this position when It states: "..., to the eztent that community expectations are ~tablished In the
Comprehensive Plan, future zoniny -egulation5 may be chanyed bo tx conslstent with those
expectations." Further the let~er goes on to say, " the amount and kind of development on
properties may be affected (in the future) by zonin9 regulations that are enacted to reflect
Comprchen5lve Plan land use dasiqnaUons."
There has ony been supe~cial wntact by the City staff with individual affected property owners.
City planners stnd us a letter within about 30 days of a hearing, proviQe warnings of future
actions, but no specifics of what will foliow sdid hearing in the way of noniny chang~, or even
what is the pu~pose of the proposed Changes. This is not the'public process'that the City seerrs
to always tout as how it does business.
An `open house' where people are urged to "drop In anytime" is a poor excuse for a pu6lic
process. The map published in the paper does little justlte to the mapnitude of the proposed
BVCP map changes since, as I undersland it, over 600 property owners have been notified.
You should halt thls projett now, yo back and start a true puhlic process, allowing property
owners sufficient time to fully understand the proposais and their future impiications, and require
that the City Planner's fully dtscuss this information wltfi us, Useful public hearings cannot
happen until and unless we are bold clea~ly what this means to our propertles, both now, and in
the future.
C: Ed Toledo
City Council
Vincent J. PorreCa
V tr ~~y~v,ur~5, ~
f2d RU~i'~EII - ~~
Cb$bel Hill, North Carolina
Facility/Definitions:
Shelter: A building or group of buildings otvned or operated by a non-profit organization
intended to be used solely for temporary occupancy by not more than 25 homeless persons, with
on-site supervision during all hours of operation, with or without boazd for the occupants and
staff of the shelter.
White Plains, New York
7. No Ovemight Shelter for the Homeless may accommodate more than 19 persons.
Gainesville, Florida
Restrictions (Narrative): ~
1. Fifteen total beds can be provided in a residence for destitute people that is accessory to a
~~ p ace of religious assembly.
San Diego, California
6. No Emergency Shelter may accommodate more than 19 persons.
_ _ _. . . ... _..,,
_ Santa Monica, California
Permitted uses
Any shelter with less than 55 beds in the DC (downtown commercial), HC (highway
commercial), and CP (commercial professional), IC (industrial conservation), LM (light
manufacturing), and S (studio).
DENVER'CODE
(i) Large residential carc use: In the RS-2, RS-4, R-0, F-1, R-X, R-2 and R-2-A zone
districts, large residential care uses, other thar, a community corrections facility or a
shelter for the homeless, shall be located only in a structure existing on May 24, 1993,
and shall be limited to a maximum number of twenty (20) residents. Such structure
shall not be enlarged as long as it is u'sed for a large res~ ential care use. In the R-3,
R-3-}: and R-4 zone districts, large residential care uses, other than a cornmunity
corrections facility or a shelter for the homeless, shall be limited to a maximum of forty
(40) resiilents.
New HaveniConnecticut
Fair Share Housing Provision:
The City of New Haven finds that Emergency and Transition Housing needs must be met in a
neighborhood context, where there is a variety of housing stock available, a mix of income
ranges exist, social and medical services are available, and adequate public transportation is
offered.
In order to aintain a balanced community that properly functions, no neighborhood should be
ired to absorb more than a faic shaze of Tzansition and Emetgency Housing facilities.
_--_.- -----------~--- _._----_..__ .
-~- _,._~--
Madison, Wisconsin
• Bear in mind the City's general intent to accommodafe commututy living arrangements.
• Exercise caze to avoid over-concentration of community living azrangements which could
create an institutional setting and seriously strain the existing social structure of a
community. Considerations relevant for this determination aze:
o The distance separating the proposed co~nunity living arrangement from other such
facilities. '
Zoning Districts: Ralei~6, North Carolina
~ Overnight And Inclement Weather Emergenev Shelters. The zoning for this type shelter is
restricted to Business and Office and Institutional only, with no permitted usage in Residential.
Emer~encv Shelters For Specialized Tazqet Groups. The zoning for this type shelter depends on
the target groups to which it is directed. There aze two types of target groups:
St. Paul, Miunesota
Emergency Housing Facilities in multi-family and business districts
Overnight Shelter in central business district and industrial districts
Transitional Housing in any residential districts - depending on size (see restrictions below)
Restrictions (Narrative)r Portland, OreSOn
There is a sepazate county certification process for shelters. Certification requires a"good
neighbor" plan that includes loitering and litter control policies and an agreement to work~
neighborhood or community groups on crime prevention. Annual recertification is required.~C,~
Shelter operators that go through certification eam a streamlined wning process. Those who opt
not to be certified must apply for a conditional use permit and go through public hearings.
~; ~ 8. ~ To r ote the disaer~jng_of facilities_aad.beds for special populations thereby
\~~-~ ° ~ preventing.individuals from being forced into neighborhoods with concentratior.s
~E' '
~\L~ [~ of treatment facilities and beds and thus perpetuating isolation resulting from
iY ~ institutionalization. ~
Subj: Proposed Land Uae Code for Day Sheltering
Date: 2/27l01 6;40:30 AMI First Booti
From: JUDYGREENA
To: Planning Board Members c/o Mary Lourien and Peter Pollack
Dear Planning Board Members:
On behalf of the START Homeless Day Resource Center, I would like to express our concems rega~ding the Proposed
Land Use Code for Day Sheltering.
START is in iPs fourth successful season of serving Boulders Homeless men and women in the downtown area. We are
currentty housed at 1301 Arapahoe in the SOS Building from 2:30-5:30 PM six days a week. Our season and hours are
limited to October 1 through April 30 due t0 facility restrictions. Once again this summer we will be looking for a temporary
summer home to meet the needs of our clients. We a~erage 35-40 quests per day. We ha~e been assured that we can be at
this location from October 1, 2001, through April 30, 2002. Howe~er, beyond next season our location is tenuous due to flood
plane restrictions and the city's plans, hence we are currently looking for a pemianent home elsewhere. Our goal would be to
operete all day, year round. In order to adequately proHde this senice for Boulder START needs to continue to be within the
usual trdtfic pattems of homeless people, which tend to concentrate in the downtown Boulder area. Homeless people
graNtate toward public areas such as the park, the library and the Peal Street Mall. In order to best sene this population and
minimize the impact on these public areas we need to be where they are.
Although the current proposal opens the downtown commercial areas to day shelters with a conditional reNew there is ~ery
Iittle property in the adjacent residential areas that would be zoned for day shelter use at all or without a site plan review.
WE ARE FORMALLY REQUESTiNG THE PLANNING BOARD CHANGE 7HE DESIGNATION OF THIS
RESIDENTIAL AREA TO CONDI110NAL USE ESPECIALLY FROM EAST OF BROADWAY BETWEEN SPRUCE AND
MAPLETON OVER t0 FOLSOM. OUR RAl10NALE IS AS FOLI~OWS:
1. In our 4 seasons of operation we ha~e had no complaints from the surrounding nelghborhood.
2. We protide no oremight impact.
3. The criteria required for Conditional Use includes a Good Neighbor Meeting and Plan, a Management Plan, On-site
Staffing, and Waiting Areas so that the neighborhood would be ~ery inwl~ed without haHng to haee a public hearing.
We feel it could be handled much more efiicientiy and expeditiously this way while the neighborhood would still be oery
inwl~ed in the process.
4. The ideal facility for our program would be a large house close to downtown. One of aur hallmarks of our success is the
sense of community that we provide for homeless people. The enNronment is wartn and fiendly unlike a commercial facility it
is inviting to our clients - so they would choose being at the Day Center o~er hanging out at the library etc.
5. We are getting increasing support from the downtown churches. It is quite possible that a church wiil donate a site on
their property or in an adjunct building for use as a day shelter. We are pleased that a day sheiter shall be allowed as an
accessory use to a religious institution; howe~er, we aannot affob to restrict any other faith community possibiAties.
We consider START to be paR of Boulder's solution to homelessness. STARTs mission is to provide a stable supporti~e
community for homeless men and women. We meet immediate suMval needs and pro~ide resources that lead to
employment, housing ,personal stability and healing. By prouding a Day Resource Center and a meal during the day at the
~ery least we bring homeless men and women to us who will othervvise be hanging out on the Peari Street Mall, Lib~ary, bus
station, past office and other public areas. Whether we like it or not our clients are Boulder residents as this is where they
reside. Unless we are located downtown where they are we are of limited service to our clients and our community as a whole.
We need your help to continue to meet this need for our community.
Thank you for your time and consideration of this ~,ery diflicult issue. We would be happy to tour you through our facility at
your cornenience. If you ha~e any questions or would like a tour please 6eel free to contact me via email at
JudyGreena~aoLoom or call me at 3031194~725.
Sincerely,
Judith Greenan
President
START Homeless Day Resource Center
Tueatl~y,FaMUeryS7,R007 AmeAc~Onllna:JUDYOREENA Pepe:1
Control of T~ Among Homeless Persons -- Recommendations of the ACE" Page 1 of ] Cr
~>~1~:
`~~ April 17, 1992 / 41(RR-5);001
Prevention and Control of Tuberculosis Among
Homeless Persons Recommendations of the
Advisory Council for the Elimination of
Tuberculosis
SUGGESTED CITATION: Centers for Disease Control. Prevention and control of tuberculosis in
U.S. communities with at-risk minority populations: recommendations of the Advisory Counci] for
the Elimination of Tuberculosis and Prevention and control of tuberculosis among homeless persons:
recommendations of the Advisory Council for the Elimination of Tuberculosis. MMWR 1992;41
(RR-5):(inclusive page numbers).
CIO RESPONSIBLE FOR TH1S PUBLICATION: National Cenier for Prevention Services
Summary
Because tubercuiosis (TB) is a major problem among home[ess persons, the Advisory Council for the
Elimination of Tuberculosis has developed recommendations to assist health-care providers, health
departments, shelter operators and workers, social service agencies, and homeless persons prevent
and control TB in this population. TB should be suspected in any homeless person with a fever and a
productive cough of more than 1-3 weeks' duration, and appropriate diagnostic studies should be
undertaken. Confirmed or suspected TB in a homeless person should be immediately reported to the
health department so that a treatment plan can be decided upon and potentially exposed persons
located and examined. Patients with TB should be counseled and voluntarily tested for human
immunodeficiency virus (HIV) infection because TB treatment recommendations are different for
HIV-seropositive and HIV-seronegative persons (]). TB therapy should be directly observed
whenever possible. This may require the establishment of special shelters or other long-term-care
arrangements far homeless persons with TB. For eac~ person with an infectious case, an
investigation should be conducted to identify exposed persons, and those found to be infected should
be considered for preventive therapy. Shelter staff should recerve a tuberculin skin test when they
start work and every 6-12 months thereafter. Those with positive skin test results should be
considered for preventive therapy according to current guidelines. Shelters for the homeless should
be adequately ventilated. The installation of ultraviolet lamps also may be useful to further reduce
the risk of TB transmission.
INTRODUCTtON
Since the early 1900s (2), tuberculosis (TB) has been recognized as an important health problem
among homeiess persons and among residents of inexpensive lodging houses, night shelters, single-
room occupancy hotels, and common hostels. Subsequent reports have continued to call attention to
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Controi of TB Amone Homeless Persons -- Recommendations of the ACC"I Yage 2 of ( G
this problem, especially in the United Kin~dom (3-] 1). With the increase in homelessness in the
United States during the 1980s. TB amone homeless persons became a subject of heightened interest
and concern (12-24).
There is no universally agreed-upon definition of homelessness; in general, however, the homeless
can be defined as persons who do not have customary and regular access to a conventional dwelling
or residence (25). The exact number of homeless persons at any given time is not known, and
reported estimates have varied widely. According to the Urban lnstitute, there may have been more
than 1 million persons in the United States who were homeless at some time durin~ ] 987 (26).
From a national perspective, the overall incidence of active TB and the prevalence of latent
tuberculous infection among the homeless are unknown. Based on screening at selected clinics and
shelters, the prevalence of clinically active disease ranges from 1.6% to 6.8% and the prevalence of
latent TB infection ranges from 18% to 51% (12,13,15-]7). Clinical data from the National Health
Care for the Homeless project indicated a point prevalence of active TB of 968/100,000 homeless
adults (27). However, because of the selective nature of these screening activrties, it is not
appropriate to e~rapolate these reported prevalence rates nationwide or to "special populations,"
such as single-parent families or runaway children (28).
Although shelters and other inexpensive housing for the homeless are vita] to the survival of these
persons, there is substantial potential for TB transmission in such facilities (18), especially in the
winter when shelters are ]ikely to be more crowded and ventilation from the outside may be
diminished.
The recommendations in this document are intended for the entire medical communiry and the
public, but are particularly targeted to health department TB-control programs and to those who
provide health care and other services to homeless persons. Health departments and shelter operators
are encouraged to implement these recommendations whenever applicable.
ASSE5SMENT OF THE MAGNITUDE OF THE PROBLEM
Communities should assess the nature and magnitude of the TB problem in their area, specifically,
the incidence and prevalence of TB among persons who are homeless. All patients with TB should
be speci6cally asked whether they are homeless or ]ive at a single-room occupancy hotel, shelter, or
lodgin~ house since they may not volunteer such information. Health departments should maintain,
and regu]arly update, listings of single-room occupancy hotels and homeless shelters so that patients'
addresses can be checked against these ]istings. Shelters should be encouraged.to maintain lists of
names of persons staying there. This will facilitate health department searches for patients in need of
diagnostic or therapeutic services.
PWORITIES FOR TB SERVICES
Priorities for TB prevention and control activities among homeless persons have been established on
the basis of their ciinica] and public health importance and their cost-effectiveness (see box).
Priorities for Tuberculosis Prevention and Control Activities Among Homeless Persons
l. The highest priority should be given to a) detection,
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evaluaUon. and reporting ofhomeless persons who have current svmptoms of active TB and bj
completion of an appropriate course of treatment by those diagnosed with active TB.
2. The second priority should be screening and preventive therapy for homeless persons who have, or
are suspected of having, human immunodeticiency virus ( HiV) infection.
3. The third priority should be the eaamination and appropriate treatment of persons with recent TB
that has Ueen inadequately treated.
4. The fourth priority should be screening and appropriate treatment of persons exposed to an
infectious (sputum-positive) case of TB. Because contacts are difficult to define in a shelter
population, it is usually necessary to screen all residents of a shelter when an infectious case is
identi~ed.
5. The fifth priority should be screening and preventive therapy for homeless persons with known
medical conditions that increase the risk of TB, e.g., diabetes mellitus (29).
CASE FINDING
Educational materials on TB should be developed for shelter clients, shelter employees, and
volunteers. This material should address the mode of spread, the common signs and symptoms, and
methods for treatment and prevention. Infonnation on local resources for TB care should be made
available to shelter staff and guests.
TB case finding should be part of the re~ular health care provided to homeless persons. Shelter staff
and others providing services can assist in case finding by identifying persons with a persistent cough
and ensuring that suspected cases are quickly evaluated by a health-care provider. If this evaluation
cannot be done at the shelter, immediate transportation to a health-care facility should be provided.
If the clinical evaluation of a symptomatic person is consistent with TB, appropriate diagnostic tests
(e.g.; sputum smears and cultures and chest radiographs) should be done as yuickly as possible. A
homeless patient will usually need to be hospitalized at least until the diagnostic evaluation is
complete and effective therapy instituted.
Routine tuberculin skin test screening of asymptomatic homeless persons for TB is not an efficient
way to find new cases. ChesY radiographic screening of homeless persons may be useful during
outbreak investigations. ,
CASE REPORTING
The diagnosis of TB in a homeless patient may occur during diagnosis and treatment of an unrelated
problem or during incarceration in a jail or prison. When a homeless person is suspected of or
diagnosed as having TB, the health department should be notified promptly so that appropriate
follow-up can be arranged. Delay or failure to notify the health department of a case of confirmed or
suspected TB may result in the patient's being lost to foilow-up, a failure to initiate appropriate
treatment, and continuing transmission of tuberculosis in the community.
CASE MANAGEMENT
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Homeless patients with ne~~~ly diagnosed infectious TB should be appropriatel}~ housed to allo~~
initial therapy to be fully supervised and to preclude continuing transmission of TB in the
community. Ideally, homeless persons with active TB should be housed in a special shelter, halfwa~~
house, or other long-tenn treatment facility until therapy is complete or.more permanent housin~ is
identified. It is also important that ancillary services, such as substance abuse treatment and
evaluation and treatment ofHN disease, be offered in these facilities.
A health department staff inember should visit a homeless person with suspected or confirmed TB, in
the hospital or elsewhere, as soon as possible afrer the diagnosis is suspected or made. The health
department worker should make an assessment of the likelihood of adherence to therapy, if treatment
is to be given on an outpatient basis. During the initial visit, the treatment plan should be discussed
and the patient's cooperation elicited.
Arrangements for the patient's first visit to the clinic or other place of intended outpatient care should
be made before the patrent is discharged from the hospital. Details about personai activities, friends,
and favorite gathering places, which may assist in locating the patient in the field, should be included
in the chart. A physical description of the patient should also be inciuded in the chart to assist field
workers in locating the person. It is essential that rapport between the patient and the health
department staff be established and maintained.
The homeless person with TB may not view TB as the highest priority concern. Other concerns --
e.g., shelter, food, and saf'ety -- are likely to be of greater priority. Thus, the involvement of social
workers on the treatment team to assist in solving these other problems is important for achievine
successfu] treatment of TB.
Treatment must be carefully monitored. Failure of patients to take TB medications as prescribed can
result in relapses, drug resistance, further transmission of TB, and death. For most patients, it is
desirable that a health-care worker or other responsible adult directly observe ingestion of
medication. This allows careful monitoring for adherence to therapy and drug side effects. In
addition, carrying medications may be dangerous for homeless persons; if others believe the
medications are addictive or valuable, the homeless person may be robbed or assaulted.
Whenever possible, TB clinics should be located close to shelters or other places (e.g., soup kitchens)
where homeless persons receive services. If this is not possible, transportation to the clinics should
be provided. The clinic schedule should include hours that facilitate patient attendance. lncentives
and enablers to encourage adherence should be used (20-22,30). These might include items such as
food or food vouchers, cash, special lodging, transportation vouchers or tokens, articles of clothing,
priority in food lines, and assistance in filing for benefits. In many communities, successful programs
represent a cooperative community activity in which local merchants or American Lung Association
affiliates provide the incentives.
Treatment outcomes are likely to be optimal if homeless patients have a reliable source of food and
shelter throughout the course of therapy. Some communities have successfully used halfway houses
and special shelters for this purpose. In areas lacking these alternatives, a longer period of
hospitalization in an acute-care facility may be necessary. Long-term institutionalization may be
essentia] for the management of inentally ill or seriously uncooperative patients. If, despite the
efforts of health-care providers, any infectious patient (regardless of residential status) refuses
treatment, temporary enforced isolation should be instituted in accordance with state and local public
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.. •~uw~~VII.~VI lll~!-l~Ll rtjj:~,'Uf ~~.
health la~n~s and regulations. This option should be used when necessary afier due 7ega1 process,
Medicaid rei~nbursement for these services should be available in all states.
TREATMENT
A responsible person (e.g., physician, nurse, outreach worker) should observe the patient ingest
medications to prevent treatment failure, the emergence of drug-resistant organisms, and continued
transmission of infection (31). Provided there is adequate medical supervision, treatment can be
given and observed by designated persons at the shelter or other location. Ali TB treatments of
homeless persons should be free of charge to the patient.
Treatment should stress the use of intensive multidrug bactericidal regimens for aU eligible patients
(29). Outpatient treatment should be a regimen that includes isoniazid and rifampin in addition to
pyrazinamide and ethambutol for the first 2 months of therapy. Drug susceptibility tests should be
initially obtained on positive cuitures from ali patients. If the organisms are susceptible to both
isoniazid and rifampin, ethambuto] can be discontinued and the second phase of therapy completed
with an additiona] 4 months (if patient is HN negative) or 7 months (if patient is HIV positive) of
treatment with isoniazid and rifampin. Treatment can be given daily for the first 2 weeks to 2 months
and either daily or twice weekly thereafter, or it can be given three times weekly from the beginning
(32). Baseline labaratory tests should be done to detect conditions contraindicating certain drugs and
to better assess any subsequent adverse drug reactions (29).
For patients with active pulmonary TB, sputum smears and cultures should be obtained at 2- to 4-
week intervals until cultures become negative. Patients should be monitored for possible adverse
drug effects by asking them about signs and symptoms. Appropriate laboratory studies should be
obtained when indicated. Hospitalized patients who are initially found to have positive sputum
smears or cultures can return to the shelter when there is bacteriologic and clinical evidence of a
response to therapy, i.e., three consecutive daily negative sputum smears and asymptomatic status.
PREVENTION
Early case finding and effective treatment of persons with active TB are the most impoRant measures
for preventing spread of TB in the community. A thorough contact investigation should be done
around every case (33). Although such investigations are difficult in shelters because of the transient
nature of the population, they should always be attempted.
Contact investigations are usually based upon screening with the tuberculin skin test, followed by
chest radiographs for those with skin test reactions greater than or equal to 5 mm. Because of the
high prevalence af TB among some homeless populations and because of the possibility of false-
negative tuberculin skin test reactions due to disease or other factors, it may be useful to screen
homeless populations with chest radiographs during an outbreak investigation.
Severa) factors in the shelter environment influence the likelihood of TB transmission. The absolute
number and population density of persons sharing the same breathing space is an important
transmission factor in shelters. If a11 other factors are constant, the size of the shelter population is
direcUy proportional to the likelihood that someone with infectious TB will be present and that
someone else wil] become infected (34). Conversely, the smaller and less crowded the shelter, the
lower the risk.
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Control of TB Among Hmneiess Persons -- Recommendations of the ACET Pa;~e 6 of 1(~
The probabilitv of transmission is affected by building ventilation. Ventilation should be at or above
25 cubic feet of outside air per minute per person. Recirculated air ma~- contribute to transmission
within a shelter. During periods of peak occupanc~~, it may be difficult to provide ventilation at
adequate levels. Air quality consultants can determine the adequacy of'ventilation and recommend
improvements where necessary.
Because even optimal ventilation does not preclude TB transmission, supplemental upper room
gennicidal ultraviolet (UV) air disinfection may be useful to further reduce the chance of
transmission (35). UV lamps may be useful when ongoing transmission of infection is demonstrated
by the continuing occurrence of cases or skin test conversions. For safery and efficacy reasons, UV
fixtures should be planned, installed, and monitored after installation by an experienced consultant.
To avoid acute eye and skin injury, shelter staff and workers should be advised not to look at the
tubes in UV fixtures, and exposure at eye level must be no greater than 0.2 microwatts per square
centimeter over 8 hours. Nonreflective paint should be used in rooms where iJV lamps are located.
Tuberculin skin test screening and isoniazid preventive therapy programs among homeless persons
have been generally unproductive because of poor patient adherence to follow-up visits and
treatment regimens (36). Screening should be undertaken only if there is a reasonable possibility that
most infected persons identified will complete preventive treatment. Priorities for preventive therapy
among TB-infected persons have been established (see box) (29).
Priorities for Preventive Therapy Among TB-infected Persons
1. Persons with HIV infection
2. Recent contacts of persons with infectious TB
3. Persons with recent skin test conversions
4. Persons with recent TB disease who have been inadequately
treated
5. Persons with negative sputum cultures and stable fibrotic lesions on chest radiographs consistent
with inactive TB
6. Persons with medical conditions that increase the risk of TB (29)
lncentives may also be used to improve adherence to preventive treatment. Twice-weekly directly
observed isoniazid preventive therapy, given in a dose of 15 mg/kg, should be considered if the
person cannot or will not comply with daily self-administered therapy. Although the efficacy of this
regimen has not been proven in preventive therapy trials, extrapolation from clinical therapy trials
suggests it would be effective (37).
Staff and regular volunteers in shelters for the homeless shouid receive a Mantoux tuberculin skin
test when they start work and every 6 to 12 months thereafter. The two-step method of testing is
generally recommended (38). Persons with positive reactions should be evaluated and considered for
preventive therapy according to current American Thoracic Society / CDC guidelines (29). The
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results of staff and volunteer skin tests should be maintained in a central confidential file.
Clinical data on homeless clients (guests) should be maintained and shared bet~a~een shelters.
HIV INFECTION AND TB
HIV infection is a major risk factor for the development of TB (39). An association between TB,
HIV infection, and homelessness has been documented (21,22,24).
Persons with TB and HTV infection appear to respond to standard anti-TB drugs (40-42), Uut data on
clinical and bacteriologic response among these patients are limited. When HN infection is known
or suspected, the recommended initial treatment regimen is the same as for non-HlV-infected
persons. Patients treated with rifampin who are on methadone should have the methadone dosage
increased to avoid withdrawal symptoms resulting from the interaction between the two drugs (43).
If the patient has drug-susceptible organisms, the continuation phase need include only isoniazid and
rifampin. lf resistance to any of the drugs in the regimen is found, the treatment regimen should be
appropriately revised in consultation witH a specialist. Treatment should be continued for a minimum
of 9 months and for at least 6 months beyond documented culture conversion as evidenced by three
negative cultures. If either isoniazid or rifampin is not or cannot be included in the regimen, therapy
should continue at least 18 months and for at least 12 months after culture conversion.
All patients diagnosed with TB should be offered couriseling and HIV-antibody testing, Previously
published guidelines for counseling and testing and notification of sex partners and those who share
needles with HIV-infected persons should be followed (44). Particular emphasis should be placed on
offering counseling and HIV-antibody testing to persons with extrapulmonary TB and persons with
TB in the age groups in which most HN infections occw (i.e., those ages 25-44 years). Because
homelessness may be a sequela of injecting drug use or HIV disease, information on behaviors *
associated with an increased risk or prevalence of HIV infection should be routinely sought from
homeless persons. If HIV infection is considered a possibility, counseling and HIV-antibody testing
should be strongly encouraged. Because HIV infection is one of the strongest known risk factors for
the progression of latent tuberculous infection to TB (39), the presence of HIV infection in a person
with a positive tuberculin skin test (i.e., greater than or equal to 5 mm induration) is an indication for
preventive therapy regardless of that person's age. The recommended therapy is isoniazid, 300 mg
daily or 15 mg/kg twice weekly for 12 months. Preventive therapy should be started only afrer
excluding active pulmonary or extrapulmonary TB.
HIV-infected persons, with or without acquired immunodeficiency syndrome (A1DS) or other HN-
related disease, should be given a Mantoux skin test consisting of 5 tuberculin units ofpurified
protein derivative. Although false-negative results may result in these persons because of HIV-
indaced immunosuppression, positive Yuberculin reactions are clinically meaningful. Persons with
clinical AIDS or other HIV-related disease should receive a chest radiograph and be examined for
evidence of extrapulmonary TB, regardless of the skin test reaction. If abnormalities are noted,
additiona] diagnostic studies for TB should be undertaken.
ROLE OF THE HEALTH DEPARTMENT
Health departments must ensure the provision of essential TB supplies and services for homeless
persons regardless of their ability to pay. Care should be readily accessible to homeless persons; this
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provided bv trained ouTreach workers~tivith the same cultura1, ethnic; and linguistic background as tl~e ~
homeless population being served.
Health depanments should also ensure that e;cperi TB medical consultation is avai]aUle to the
clinicians and nurses who provide health-care services to homeless persons.
State and local health departments should provide TB training to those ~~~ho provide health-care
services to homeless persons. (CDC has made training materials available to state health departments
to assist in this training.)
There is a nationa] network of primary health-care programs for the homeless as a result of the
McKinney Homeless Assistance Act. The 109 communiry programs supported by the Bureau of
Health Care Delivery and Assistance of the Health Resources and Services Administration are
appropriate partners for ]ocal health agencies in controlling TB among the homeless.
ROLE OF THE U.S. PUBLIC HEALTH SERVICE
The U.S. Public Health Service (PHS) should promote coliaboration between health departments and
those who provide health care to the homeless so that they can plan and implement TB prevention
and control activities. The PHS should require documentation of such collaboration as part of
applications from states and cities for federally funded grants and cooperative agreements. ln
addition, as part of routine site visits, PHS staff should review state and local TB activities and make
recommendations for more effective coilaborative programs.
CONCLUSIONS
Homeless persons suffer disproportionately from a variety of health problems, including TB.
Detecting, treating; and preventing TB in this special population benefit not only persons who are
homeless, but society at large. The goal of prevention and control of TB among the homeless is
difficult and challenging, but it can be achieved.
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Prehein LC. Short-course chemotherapy for pulmonary infection due to Mycobacterium bovis. Arch
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S. Exogenous reinfection with tuberculosis in a shelter for the homeless. N Engl J Med
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Barr H, Saeed AM, Risser DR. An outbreak of tuberculosis in a shelter for homeless men. Am Rev
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RA, Mani S, Altholz J, Brickner PW. Human immunodeficiency virus infection among homeless
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1990;46(4):49-64. 28. Marin P. Helping and hating the homeless. The struggle at the margins of
America. Harper's Magazine 1987(January):39-49. 29. American Thoracic Society / CDC. Treatment
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issues related to the treatment of tuberculosis. Chest 1985(suppl);87(2):IZSS-7S. 32. Hong Kong
Chest Service, British Medical Research Council. Controlled trial of 4 three-times-weekly regimens
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to 24 months. Tubercle 1982;63:89-98. 33. American Thoracic Society/CDC. Control of
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Page 1 U of 1 C
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UV air disinfection. Am Rev Respir Dis 1989: ] 39:1286-94. 36. CDC. Tuberculosis among residents
of shelters for the homeless -- Ohio, 1990. MMWR 1991;40:869-71, 877. 37. Committee on
lsoniazid Preventive Treatment, .4merican College of Chest Physicians. Preventive treatment of
tuberculosis. Chest 1985(suppl);87(2):128S-32S. 38. American Thoracic Society / CDC. Diagnostic
standards and classification of tuberculosis. Am Rev Respir Dis 1990;142:725-35. 39. Sehvyn PA;
Hartel D, Lewis VA, et al. A prospective study of the risk of tuberculosis among intravenous drug
users with human immunodeficiency virus infection. N Engl J Med 1989;320:545-50. 40. Sundennan
G, McDonald RJ, Maniatis T, Oleske J, Kapila R, Reichman LB. Tuberculosis as a manifestation of
the acquired immunodeficiency syndrome (AIDS). JAMA 1986;256:362-6. 41. Pitchenik AE, Cole
C, Russel] BW, Fischl MA, Spira TJ, Snider DE Jr. Tuberculosis, atypical mycobacteriosis, and the
acquired immunodeficiency syndrome among Haitian and non-Haitian patients in South Florida. Ann
Intern Med 1985;101:641-5. 42. Louie E, Rice LB, Holzman RS. Tuberculosis in non-Haitian
patients with acquired immunodeficiency syndrome. Chest 1986;90:542-5. 43. Kreek MJ, Garfield
JW, Gutjahr CL, Giusti LM. Rifampin-induced methadone withdrawal. N Engl J Med
1976;294:1104-6. 44. CDC. Public Health Service guidelines for counseling and antibody testing to
prevent H]V infection and AIDS. MMWR 1987;36:509-15.
. The Advisory Council for the Elimination of Tuberculosis recognizes that a variety of terms
are used and preferred by different groups to describe race and ethnicity. Racial and ethnic
terms used throughout the document reflect the way data are collected and reported by official
health agencies.
Based on seroprevalence studies, behaviors that place a person at risk for HIV infection
include injecting drug use and male homosexua] contact. Other factors that increase the risk
for HIV infection among adults include having received bfood or clotting factor concentrate
between 1978 and 1985 and having had sexual relations at any time since 1978 with a) a
person known to be infected with HN or to have AIDS, b) a man who has had sexual contact
with another man, c) prostitutes, d) injecting drug users, or e) persons born in countries where
most transmission of HIV is thought to occur through heterosexual sexual contact. Risk factors
for HIV infection among infants and children include a) parents, especially the mother, with
HIV infection or any of the adult risk factors, and b) receipt of blood or clotting factor
concentrates between 1978 and 1985.
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