This guide is to help you prepare for the county IHSS worker’s initial intake assessment or the annual review. This guide will also help you represent yourself and others in fair hearings when there is a dispute about the number of In-Home Supportive Services (IHSS) hours you need.

This guide will help you prepare for your initial IHSS intake assessment and your annualreview. It provides an overview of the IHSS program and answers commonly asked IHSS questions. The guide also provides information about how to prepare for a fair hearing if there’s a dispute about the services and number of In-Home Supportive Services (IHSS) hours you need.

This guide does not cover everything about IHSS or the fair hearing process. Please see our IHSS Self-Advocacy Resource webpage for more information about other aspects of the IHSS program. You can also Contact Us with questions about other issues this guide does not cover.

This guide will discuss the following:

1. IHSS Assessment Process
2. Authorizing IHSS Services and Hours
3. Conducting an IHSS Self-Assessment
4. Documenting Functional Limitations
5. Reasons Why More IHSS Hours are Needed
6. IHSS for People with Mental Health Disabilities
7. IHSS for Children and Related Issues
8. Parent and Spouse Provider Issues
9. Paramedical Services
10. Protective Supervision
11. State Fair Hearings

IHSS Assessments and Fair Hearings

What is the IHSS assessment process?

An IHSS assessment is when a county IHSS worker comes to your home to assess your physical and mental condition, your living situation, and determine which services you are eligible for as well as how many hours you will get per month. The IHSS worker will use information from you, your family, doctors, schools, the regional center, and your IHSS provider(s). MPP § 30-761.26. This process is commonly referred to as an In-Home assessment.

You will have an In-Home assessment:

• When you first apply for IHSS;
• Once a year for an annual reevaluation; and
• Any time you ask for one. MPP § 30-761.219.
  • If the county denies your request for an IHSS assessment or does not provide you with an assessment within 30 days of your request, you can ask for a state fair hearing. MPP § 30-759.2.

The worker will determine what IHSS services you can receive and how much time you need for those services.

IHSS will pay for services you need:

• Because of your functional impairments.
• To establish and maintain an independent living arrangement and/or
• To remain safely in your own home or where you choose to live. MPP § 30-757.1.

No time will be authorized for IHSS tasks you do not need help with or for services solely foryour “comfort.” The maximum number of IHSS hours you can get in a month is 283.

What happens after the IHSS assessment is completed?

Once the assessment is complete, your IHSS worker will send you an IHSS Notice of Action (NOA). The IHSS NOA will tell you:

• How much time the county will give you for each IHSS task they think you need help with. Your IHSS NOA will give the time in hours and minutes.
• When your IHSS services begin or changes will happen.
• What IHSS rules the county relied on to make its decision.
• Information about your right to ask for a hearing to dispute the county’s decision.

What if I don’t get a Notice of Action or Disagree with my NOA?

You can ask for a hearing if:

• You do not agree with changes to your IHSS services and/or NOA.
• You do not agree with a decision IHSS makes without sending you a NOA.

You only have 90 days from when you get your IHSS NOA or from the action or inaction you disagree with to ask for a hearing.

Authorizing IHSS Services and Hours

How does my IHSS worker decide what services I need and how much time to give me?

Functional Index (FI) Rankings and Hourly Task Guidelines (HTGs) and IHSS Annotated Assessment Criteria are used to determine your functioning when performing certain IHSS tasks and to determine how much time you can get for each tasks. Your IHSS worker is required to give you the time you need to receive each service you need help with. A complete list of IHSS Hourly Task Guidelines is in All County Information Notice (ACIN) I-97-20.

A 2-step process is used to decide what IHSS services are needed and how much time is necessary:

Step One: Determine Functioning

Your IHSS worker will rank your functioning in each of the following IHSS service categories:

• Domestic Services (Housework)
• Laundry
• Shopping and Errands
• Meal Preparation/Meal Cleanup
• Ambulation (formerly Mobility Inside)
• Bathing, Oral Hygiene and Grooming/Routine Bed Bath (Bathing and Grooming)
• Dressing/Prosthetic Devices (Dressing)
• Bowel and Bladder Care
• Transfer (Repositioning)
• Eating
• Respiration
• Memory
• Orientation
• Judgment

Memory, orientation, and judgement are used to determine the need for protective supervision. MPP § 30.756.372

IHSS Functional Index Rankings range from 1 to 6. The rank for each function must be based on physical, cognitive and emotional impairment in functioning. MPP § 30.756.371. The rank is not based on physical limitations alone.

Your functional index rank is based on how much help you need to complete IHSS tasks that must be ranked. IHSS functional index rankings are:

• Rank 1: Independent. You can perform IHSS tasks without help. A recipient who ranks a "1" in anyfunction cannot get time for that service.
• Rank 2: You can perform the IHSS task with verbal help, such as reminders, guidance, or encouragement from an IHSS provider.
• Rank 3: You can perform the IHSS task with some help, including, but not limited to, direct physical help from an IHSS provider.
• Rank 4: You can perform the IHSS task but only with substantial help from an IHSS provider.
• Rank 5: You cannot perform an IHSS task, with or without help from an IHSS provider.
• Rank 6: You need paramedical services.

If your functioning changes throughout the month, your rank for each task should reflect your functioning level most of the time in a week or month. For example, if you have arthritis which causes you stiffness, decreased range in motion and pain with milder symptoms some days and severe symptoms most of the other days, your functional index ranking should be based on your level of functioning during most of the days, when you have more severe arthritis symptoms. MPP § 30-757.1(a)(1) and ACIN I-97-20.

Your IHSS worker can tell you what your functional index rankings are. If you are preparing for a hearing, your functional index rankings should be in the county’s position statement.

Step 2: Use the Hourly Task Guidelines to Determine Time Authorized Based on Functioning

IHSS Hourly Task Guidelines are used to determine the amount of time you can get for each IHSS service you need help with on a weekly basis, except for domestic services. Domestic services are limited to 6 hours per month.

The Hourly Task Guidelines recommend a range in time (low and high) for each IHSS task needed based on functional limitations. For example, if you are a rank “2” in the task ofdressing, the Hourly Task Guidelines say that you can get between 34 minutes to 1 hour and 12 minutes of help per week.

You are allowed to get the amount of time needed to receive help with each IHSS task you cannot do for yourself without help. The Hourly Task Guidelines can only be used if you can receive the IHSS services you need within the recommended range of time. MPP § 30-757.1.

You can get more or less time than what the Hourly Task Guidelines say you can get, if the IHSS worker documents why you need more or less time to complete a task in your IHSS case file.

Examples of exceptions to the IHSS Hourly Task Guideline can be found in California Department of Social Services Manual of Policies and Procedures §§ 30-700 through 30-764.

IHSS Hourly Task Guidelines do not apply to protective supervision or paramedical services.

Conducting an IHSS Self-Assessment

How can I do my own assessment?

An IHSS self-assessment can help you keep track of which IHSS services you need and the time it takes to receive IHSS services so it can be documented in your IHSS file. To complete a self-assessment you can create a daily log of each IHSS task you cannot do for yourself for at least a week.

Your log should include:

• The amount of time it takes to receive help with each IHSS service you need.
• The steps involved in the completion of each service.
• Note how your functional limitations inhibit or limit your ability to receive IHSS services such as muscle spasms, frozen joints, exaggerated reflexes and combative behaviors because of problems with memory, orientation or judgement.

Conducting a self-assessment can help to prevent you from underestimating the amount of time needed daily to receive IHSS services.

Disability Rights California, IHSS Self-Assessment and Fair Hearing Guide also has an IHSS Self-Assessment Worksheet which can be used to document the time you need to receive help for each IHSS service you cannot do for yourself every day of the week. If possible, include the start and stop time for each service. This way you are not guessing or estimating the time you need. At the end of the week add up your daily totals to see how much time you need to receive for each IHSS service in a week.

Once you know which IHSS services you need and how much time you need weekly to receive IHSS services, you can compare the time you need to what the IHSS Hourly Task Guidelines recommend. If you need more time than what the Hourly Task Guidelines suggest, you must explain why more time is needed so the IHSS worker can note it in your IHSS file.

If you need more time that what the Hourly Task Guidelines allow, write down in your daily log or on a separate piece of paper, the reasons (for example, combative behaviors, stiffness in muscles or muscle spasms, incontinence, supervision required to ensure medication is taken, time needed is tracked and documented and the recommended time in the guidelines do not allow for enough time to receive IHSS services) the additional time is needed to receive help with each task. This will help you advocate for and explain why you need more time than what the Hourly Task Guidelines allow.

Further down in this document is a list of reasons why more time for IHSS services may be needed.

How to prepare for an In-Home IHSS Assessment or Fair Hearing?

To get ready for your In-Home Assessment or a Fair Hearing, you can conduct an IHSS Self-Assessment, which we discussed above. When used together, a daily log and the IHSS Self-Assessment worksheet can help you better explain why you need more time than what the Hourly Task Guidelines suggest. Here are some examples of information your self-assessment will help you identify:

• Changes in Functioning - The time needed to complete a task may change each day. It may take twice as long one day to dress a person with spastic quadriplegia cerebral palsy than the day before due to differences in limb flexibility. IHSS bases the time you can get on the average time it takes to get help with the completion of each task. It is important to know how long it takes to complete a task each time during a week so the average time needed each week can be calculated.
• All steps and tasks needed to receive an IHSS service - Sometimes IHSS workers may not always identify exceptions to the Hourly Task Guidelines. You can get more time than what the Hourly Task Guidelines suggest as long as your IHSS worker documents why you additional time is needed in your IHSS file.
  Examples of exceptions can be found in California Department of Social Services Manual of Policies and Procedures §§ 30-700 through 30-764.
  For example, the clean-up time under Bowel and Bladder care is not only about the timefor cleaning but also includes the time it takes to get the cleaning supplies and put them away again. Flush toilet and throw away trash. If bodily fluids or bowel movements are involved, you may need to include the extra time to use universal precautions. Universal precautions include handwashing and using gloves or masking whenever you touch bodily fluids and waste, handle laundry, clothing, or other items soiled with bodily fluids.
• How functional limitations create a need for more time to receive help with IHSS tasks – For example, an elderly person may experience confusion and problems with orientation, stiffness in muscles which cause pain and may have combative behaviors which creates a need for more time to assist them with dressing. For someone who needs help with bowel and bladder care more time may be needed because of frequent bowel or bladder movements, incontinence, morbid obesity, etc.

For more detailed information about your hearing rights and how to prepare for an IHSS Fair Hearing, please see DRC’s publication: IHSS Fair Hearings Guide: How to Prepare for IHSS Terminations or Reductions in Hours.

What to expect during the IHSS In-Home Assessment

The purpose of the IHSS in-home visit is to find out:

• What IHSS tasks you cannot do without help,
• How much time you need to receive help with each IHSS task you cannot do without help.

Your job is to help your IHSS worker:

• Understand all your in-home care needs and
• Understand how much time you need to receive IHSS services.

During your assessment be honest and open. Do not minimize your disability problems andcare needs because you may not get the hours you need. Even though you may feel embarrassed, explain things fully so the county IHSS worker understands your situation.

Before your in-home visit you should review your IHSS NOA to identify which IHSS services you are not receiving enough time for or still need help with so you can ask for them.

During your in-home visit you should have your Daily Log and/or your IHSS Self-Assessment Worksheet to help you explain what services you need and how much time it takes to receive IHSS services.

You can use your IHSS Self-Assessment Worksheet and/or Daily Log to help you explain:

• What IHSS tasks you need or what your provider does for you.
• How you determined the time it takes to complete each task. This is particularly important if there’s differences between what the county authorized before and what you believe you need now.
• Why more IHSS time is needed for a specific task.

Remember, the county will only authorize only what you need and will not allow extra time for “comfort” services. An example of a comfort service is extra dusting to make things look nice.

Documenting Functional Limitations

How can I document my functional limitations?

If you do not agree with the county about your ability to complete IHSS tasks for yourself, get a letter from your doctor explaining your functional limitations and any factors or reasons why more time is needed. Disability Rights California publication, IHSS Fair Hearings Guide: How to Prepare for IHSS Terminations or Reductions in Hours has a form you can use to get information from your doctor about your functional limitations and list factors which cause you to need more time to receive IHSS services.

Your IHSS worker must consider the information your doctor provides when deciding how much time you need to receive IHSS services. For example:

• You may need a dust-free environment that is more frequently or thoroughly cleaned because of allergies or pulmonary/respiratory problems. This could result in a need for more time with domestic services.
• You have incontinence and cannot perform bowel and bladder functions without human assistance such as using urinals, pads or diapers, and managing clothing. You also take medications which increase the time you need to use the restroom. These examples support a need for more time with bowel and bladder care.
• You may need substantial human assistance with laundry and dressing. You may take medications which increase elimination, accidents, odor, and/or perspiration resulting in your need to change soiled bed linens daily and your clothing multiple times throughout the day. These situations support your need for more time with laundry and dressing.

Reasons Why More Time for IHSS Services is Needed

The following is a list of reasons why more time may be needed to complete IHSS tasks.

Domestic Services

Domestic services are limited to 6 hours per month per household unless an exception is needed. MPP § 30-757.11(k)(1). Domestic services may also be prorated. For example, if4 people live in the home, the recipient can only get 1.5 (6 hours / 4 people = 1.5) hours per month. If a recipient’s roommate lives there only as a live-in attendant, domestic services are not pro-rated.

The county should pro-rate hours only for common areas of the home - your own room or bathroom should be authorized separately.

Here are some examples of why an exception to the 6 hours monthly limit in domestic services may be needed:

• Severe asthma or allergies or pulmonary problems cause functional limitation inrespiration (i.e. limitations in breathing) which require the recipient to be in a dust-free environment and a need for more time for frequent dusting and vacuuming.
• Trash needs to be removed daily, or more frequently than twice a month, because of roach, ants or other vermin problems.
• If you spill things, frequent cleaning is required, particularly if there are roach or vermin problems.
• Incontinence results in a need to spot clean floor, furniture, etc., frequently.
• Trash bin is located through two double locked doors at the rear of the building, and it takes 10 minutes to get there and back.
• If you eat in bed, the bed must be vacuumed and remade 3 times a day to remove crumbs. Bed linens must be changed more frequently because of spills.
• If you have incontinence/accidents, bed linens must be changed more often than twice a month (daily, three times a week, once a week, etc.)
• Because of skin fragility and risk of bed sores or decubiti, sheets need to be kept smooth to prevent the development of hot spots; need to ensure that nothing in the bedding rubs or irritates the skin.
• Because you drop things, more picking up is required.
• Since the refrigerator’s seal is worn out, more time is needed for cleaning and defrosting the refrigerator.
• Because you spend most of your time in bed or due to sweating, sheets need to be changed more frequently than twice a month.
• Building-wide roach spraying requires, on a one-time basis, that everything be removed from kitchen and shelves washed and, after spraying, returned. (Time for this is justifiable not only for health and safety reasons, but also for establishing and maintaining an independent living situation since failure to comply may put you at risk of eviction.)

Personal Care Services

Personal care services must be assessed individually. Be sure to count the time for the entire task, from beginning to end. You can get an exception to IHSS Hourly Task Guidelines if you need it to receive IHSS services. Here are some examples of why an exception to personal care services hourly task guidelines may be needed:

Here are If you need more time for personal care services to remain safely at home, the county should allow an exception to the guidelines. For example:

• The bathroom is not wheelchair accessible. Additional time is required to get in and out of the bathroom, to set up the bathroom, gather supplies and for bathing and to complete other personal care/grooming activities such as using medicated shampoos or soaps, application of medicated creams and lotions and powers so you can bathe.
• Accidents in the bathroom require extra clean-up in bowel and bladder care including extra cleaning of commodes or bedpans because of feces and urine being smeared onto them.
• You are sensitive to pain - even combing hair is very painful. Personal care services must be performed slowly and carefully.
• You eat and chew slowly and must be persuaded or your jaw must be manually manipulated. Each meal may take up to 45 minutes for feeding.
• Although you can feed yourself, you need an attendant available to help lift things and because of choking problems.
• You need to be bathed more than twice per week because of spilling, incontinence, or skin problems.
• You have fragile skin and are vulnerable to hot spots which can become bedsores ordecubiti; need to ensure that nothing is rubbing or irritating skin such as clothing or how you are placed in your wheelchair, etc.
• Your hair needs to be shampooed more than once a week due to dandruff or getting food in hair.
• You need extra time to communicate with IHSS provider (as for a person with cerebral palsy, who must use word and alphabet board).
• Susceptible to respiratory infections so hair must be dried after shampoo.

Related Services

Examples of extra time needed for meal preparation and/or menu planning:

• You need a special diet such as a diet excluding salt and sugar or requiring fresh foods.
• You eat fresh hot cooked meals which take more time to cook than sandwiches or bowls of cereal.
• You need to have food cut up or pureed.
• You need between-meal liquids and snacks.
• Your diet and eating patterns differ from the rest of the family so meals are prepared separately.
• You need 2-3 times as much food because of cerebral palsy with spasticity and therefore need more time for meal preparation, menu planning and clean-up,shopping, and feeding.

Example of extra time needed for meal clean-up:

• You need extra time to clean table, wheelchair, and floor due to spilling.

Example of extra time needed for laundry:

• Extra bed linen and clothing changes are necessary due to incontinence, spilling, perfuse sweating due to medications, dry skin and severe dandruff and the need to rinse and hand wash article before placing clothing and linens in the washing machine.
• To comply with universal precautions when bodily fluids are involved (urine, feces, blood, saliva, mucous, vomit) such separating from other laundry, rinsing and hand washing separately before putting into washing machine.
• To stay with laundry during wash and dry because of theft.
• To put clothing through an extra rinse cycle because of skin sensitivity and allergies.

Extra time is needed for shopping and errands, because of:

• Distance to primary market.
• Need to go to market more frequently or go to more than one place because of special diet and a need for fresh food.
• Need to go to the store to purchase incontinence supplies, gloves, medicated creams, vitamins, nonprescription medicated eye wipes, soaps and shampoos.
• Frequent need to get medication due to Medi-Cal limitations on prescription size and/or because all medication needs cannot be met at one place.
• Living in a low-income area, markets are fewer and more crowded, meaning a longer wait in line.
• Need to use public transportation and taxis to shop or run errands.

IHSS for People with Mental Health Disabilities

Can people with mental health disabilities get IHSS?

Yes. IHSS is not just for people with physical or intellectual/developmental disabilities. If you have a mental health disability and you need help to live in your own home or someone else’s home, you may qualify for IHSS services. Your home may include an apartment you share with other people or a hotel room. You cannot get IHSS or personal care services if you live in a board and care or residential facility. However, IHSS services may help you move out of a board and care and into your own apartment or hotel room.

Here are some reasons you may need IHSS to live in your own home or in the home of a relative or friend:

• You need “prompts” to get up in the morning and go through tasks such as bathing, grooming, dressing, taking medication, and/or eating. Prompts and assistance in sequencing are terms used to describe the help people need to start a task and step-by-step to do task. Because of your disability or medication side effects, you may not be able to do that without someone present to guide you through the process.
• You may also need “prompts” to help you go through the tasks leading to going to bed at night.
• You may need help with preparation of meals if you may not be able to do thisconsistently and safely alone.
• You may need reminders to eat and drink water.
• You may need help with shopping, cleaning, laundry, and/or menu planning.
• Some individuals with mental health disabilities may need protective supervision services. Protective supervision is for people that need 24/7 monitoring and intervention because they do dangerous or hazardous things and can accidentally hurt themselves since they don’t understand their actions and behaviors are dangerous.

County IHSS workers who process IHSS applications work mostly with people with physical disabilities (who use a wheelchair or can’t do things due to severe arthritis) or cognitive disabilities (who have intellectual development disability or dementia). They are not as familiar with applications from people with mental health disabilities. That means the IHSS worker will need more help from you and the people helping you to understand why you needattendant care help in your home. To do this, you can get a letter from your psychiatrist, psychologist, social worker at the clinic you go to, case manager, or anyone else who helps you and knows your needs. The letter should explain:

• The things you need help with and the kind of help you need. For example, reminders and prompting.
• Why your mental health disability prevents you from doing IHSS tasks without help. For example, they can explain that your medications plus your disability cause you to have sleepiness, inability to concentrate, stay focused on tasks, confusion, and forgetfulness. Your disability makes it hard for you to get up on time, take your medication on a regular basis and go through the daily self-care routines without help and/or you cannot cook for yourself without accidentally hurting yourself.
• How not getting the help you need could mean you cannot continue living on your own in your own home, hotel room, or apartment.
• How not getting the help you need could make your condition worse because you wouldn’t be able to get up every day, take care of your personal care needs and keep your apartment in order. Your day-to-day life could feel chaotic and lead you into a crisis which could mean a visit to the emergency room.

IHSS For Children and Related Issues

This section will discuss what services a child under 18 years old can get and assessments under the IHSS program as well as common questions.

Can children get IHSS?

Yes. Children under the age of 18 with a disability can get:

• Related services (meal preparation and cleanup, laundry, food shopping, other shopping/errands)
• Personal care services (bathing, toileting, dressing, feeding, assistance with ambulation, etc.)
• Paramedical services (if prescribed by a doctor - injections, catheters, tube feeding, suctioning)
• Protective Supervision (24-hour monitoring and supervision to prevent injury)
  • Not routine childcare or supervision
  • Must show difference between disabled child and other children of the same age.
• Accompaniment when needed to travel to/from:
  • Medical Appointments
  • Alternative Resources

Children cannot get:

• Domestic Services
• Heavy Cleaning
• Yard Hazard Abatement
• Teaching and Demonstration All County Letter (ACL) 23-106

How does IHSS determine a child’s functioning?

IHSS will only provide services based on a child’s functional limitations and need for help instead of age. IHSS uses a Functional Index Ranking Age-Appropriate Guideline Tool for children to help IHSS workers determine a child’s functioning. The guidelines are not regulations. IHSS must still provide services based on individual need. MPP § 30-757.1(a). For example,

• A newborn child can normally respirate (breathe) independently. However, a child with limitations in breathing could receive paramedical services. The child’s need for assistance is based on disability, not age.
• A 5-year-old child is normally expected to be able to ambulate (walk) independently. If a child has limitations with walking, such as problems with balance, strength, or flexibility, their functioning would be ranked between 2-5 and time should be authorized for help with walking based on the child’s functional limitations and level of help.

Most infants and toddlers get IHSS due to a need for paramedical services.

Will a parent’s IHSS earnings affect a minor child’s SSI benefits?

IHSS earnings to a parent of the minor child they are providing IHSS to will not affect that child’s SSI payment amount. However, other income a parent receives, such as IHSS wages from working for an adult sibling, may affect the minor child’s SSI payment amount. POM SI 01320.175. For more information please review Disability Rights California publication, SSI for Children Eligibility Criteria: Spotlight on Parental Deeming.

Can I get IHSS and still get respite from the regional center?

Yes. Respite services from the regional center are different from IHSS. You can receiveIHSS, including protective supervision, without losing any respite hours. ACL 98-53.

Parent and Spouse Provider Issues

What do IHSS rules say about parent providers?

As of February 19, 2024, parents may be paid to provide IHSS services to their minor child, so long as they meet all qualification requirements to be an IHSS provider and complete the IHSS provider enrollment process. ACL 23-106.

What do IHSS rules say about spouse and non-spouse providers?

Able and Available Spouse

IHSS assumes that an IHSS recipient’s spouse is “able and available” to provide certain IHSS services unless the recipient’s spouse provides medical documentation (like a doctor’s note) saying that they cannot. MPP §§ 30-763.411, 30-763.412, and ACL 21-91.

IHSS services a spouse must provide for free

Unless a spouse provides medical documentation (a doctor’s note) that they are unable to perform IHSS tasks, IHSS will require the spouse to provide certain IHSS services for free.

Recipients with an Able and Available Spouse cannot get:

• Domestic Services
• Related Services
• Yard Hazard Abatement Services
• Teaching Demonstration or,
• Heavy Cleaning

For additional information please see MPP § 30-763.413 and ACL 21-91.

IHSS services anyone can provide

Your spouse or anyone else can provide you with non-medical personal services and paramedical services. MPP § 30-763.415.

Non-Medical Personal Services include:

• Respiration Assistance
• Bowel, Bladder Care
• Feeding
• Dressing
• Menstrual Care
• Ambulation
• Transferring
• Bathing, Oral Hygiene, Grooming
• Rubbing Skin, Repositioning
• Help with Prosthesis and/or Setting up Medications

Spouse Provider Eligibility

A spouse can provide protective supervision and transportation if that spouse:

• Leaves full-time employment or is prevented from obtaining full-time employment, and
• There is no other suitable IHSS provider available. MPP § 30-763.416.

Non-Spouse Provider Eligibility

When your spouse is out of the home because they are working, sleeping, meeting the needs of other family members, for health or other unavoidable reasons, a non-spouse IHSS provider can help you with:

• Meal preparation
• Transportation, and
• Protective supervision

If a spouse is unavailable to provide IHSS for more than 24 hours, a non-spouse provider can provide IHSS services during the time your spouse is unavailable (away). MPP § 30-763.414 and ACL 21-91. A spouse may be unavailable because they are institutionalized, military deployment, or are subject to a restraining order.

Paramedical Services

What are paramedical services?

Paramedical services are prescribed by a doctor for your health. Paramedical services require some training and judgment to perform. Common services are injections, colostomy irrigation, catheter insertion/care, suctioning, G-tube and NG tube feeding, ventilator andoxygen care, fecal impaction, range of motion to improve function, wound/decubitus ulcercare, and other services requiring sterile procedures.

Paramedical services are important because people with disabilities who need complexmedical care can stay at home instead of going into nursing homes. Only your doctor candecide what IHSS paramedical services the county must provide and how many hours it mustpay. The county can’t cut service hours ordered by your doctor. Providers don’t need any special license to perform the services.

Paramedical services do not have time limits. You get the time you need for the completion of the service. However, you cannot get more than the maximum 283 monthly hours in combined IHSS services.

When asking for paramedical services, you should ask for enough time to complete the entire service from preparation to clean-up. Recipients sometimes don’t ask for the extra time thatmay be required for record keeping, i.e., diabetes testing and administering injections. You can get time for this too.

Who’s Eligible for Paramedical Services?

To be eligible:

1. The doctor must complete and sign an SOC 321 form which is available online. Your doctor must list what paramedical services you need and how much time you need to get the service. You can give the SOC 321 form to your doctor to complete. Once your doctor has completed the SOC 321 form you can provide it to the county with your request for paramedical services. IHSS rules do not require your IHSS worker to complete and/or provide the form to the doctor.
2. You must be unable to perform the paramedical service for yourself. For example, you have a mental or physical impairment that prevents you from giving yourself aninjection or changing a catheter.
3. You need the service to maintain your health because of your physical or mental condition.
4. The task must involve:
   1. Administration of medications
   2. Puncturing the skin
   3. Sticking a medical device into a body opening
   4. Require sterile procedures or,
   5. Your provider must need training from the doctor or other health professional to provide paramedical services. For example, your provider may need training on what steps to take and how to complete the service. The steps require the provider to carefully observe you to avoid mistakes.

County Actions to Deny or Limit Paramedical Services

Counties may use tactics to deny or limit paramedical services doctors have authorized.

Here are examples and ways to respond:

• The county says some services are not paramedical.
  • Response: Discuss with your doctor the paramedical services you need. Explain that any service billed as skilled nursing under Medi-Cal and Medicare qualifies as paramedical services. Doctors generally know what these services are. When your doctor is completing the SOC 321, ask your doctor to list the paramedical services and write the time you need to receive a service based on your log documenting how long it takes to complete each service.
• The county may send the SOC 321 to your doctor and try to persuade the doctor tochange the SOC 321 order for paramedical services or time.
  • Response: Talk to your doctor before the SOC 321 is completed and get approval of time needed based on your log documenting how long it takes to receive the paramedical service. Discuss your conditions and the need to preserve the doctor-patient relationship from outside interference. Explain to the IHSS worker that the doctor’s decision on the signed SOC 321 form is final, and the county must comply. MPP § 30-757.194.
• A county nurse observes you for one day and determines you need less time for paramedical services. The nurse calls your doctor asking for changes in the time noted in your doctor’s order (SOC 321).
  • Response: Show your doctor your log documenting the time needed to receive paramedical services varies. You should explain that the average time you need is greater than the time you needed on the day the county nurse observed you receiving paramedical services. You should ask your doctor to provide the time needed for you to receive each paramedical service.
• The county says that your receipt of home health care agency services will reduce the amount of IHSS hours you can get.
  • Response: Home health care agency services and other services provided through a Home and Community Based Services (HCBS) waiver are not an alternate resource. HCBS waiver services are provided after IHSS hours have been decided. Home health care agencies can provide services that IHSS does not provide and/or are more than what IHSS can provide, such as nursing, physical or occupational therapy, medical social services, and companion care.
• The county says range of motion is a personal care service and that the county decideseligibility and hours.
  • Response: When the doctor prescribes range of motion to improve and maintain function at the same time, it is a paramedical service if it meets criteria 2 through 4(e) above. You should ask your doctor to include this information on the SOC 321 form.

Where to find more information about Paramedical Services

For more information about paramedical services and eligibility requirements and other useful information, please refer to our Paramedical Services publication found here: Paramedical Services through the IHSS Program.

Protective Supervision

What is protective supervision?

Protective supervision is a service under the In-Home Supportive Services (IHSS) program. It provides monitoring for “non-self-directing” IHSS recipients with cognitive impairments, mental health conditions, or other conditions to ensure that they do not accidentally hurt themselves. MPP § 30-701(n)(3) and MPP § 30-757.17. An IHSS provider can be paid to supervise a recipient to prevent injuries or accidents and offer verbal redirection or other interventions as needed. MPP 30-757.17 and MPP 30-757.171.

The maximum amount of hours an individual can get for protective supervision depends on under which program IHSS services are funded:

• Personal Care Services Program (PCSP),
• Community First Choice Option (CFCO),
• IHSS Plus Option (IPO), and
• IHSS Residual (IHSS-R).

If you qualify as “severely impaired” and get protective supervision, you will receive 283 monthly hours of IHSS. If you are “non-severely impaired” and get protective supervision, then you will receive at least 195 hours per month.

Who is severely impaired?

“Severely impaired” individuals get 20 or more hours per week of the following IHSS services: personal care services, meal preparation and/or clean-up (when feeding is required), and paramedical services. MPP § 30-701(s)(1).

Who is eligible for Protective Supervision?

To get protective supervision a person must:

• Have a “cognitive impairment,” “mental health condition” or “other condition” such as a mental impairment or illness, that causes functional limitations in:
  • Memory
  • Orientation
  • Judgment MPP § 30-756.372
• Be non-self-directing.
  Non-self-directing means the individual is: (1) unable to cognitively assess danger and the risk of harm and (2) at risk for injury, hazard, or accident because of a cognitive impairment or mental health condition or other condition. MPP § 30-701(n)(3).
• Has the physical ability to engage in dangerous behavior.
  If a person is unable to move independently and cannot self-harm, they cannot get protective supervision. An elderly person who forgets or doesn’t understand that they no longer can walk unassisted but tries to walk may be eligible for protective supervision. To be eligible for protective supervision a recipient does not have to actually get injured, only have a history of a propensity for placing themselves in danger. ACL 15-25.
• Requires 24-hour a day supervision to remain safe at home. 30-757.17 and 30-757.173(a)
  The IHSS worker must decide that the recipient needs to be watched 24-hours a dayand can remain safely at home if protective supervision is provided. If the behavior is unpredictable, the person needs to be watched 24 hours a day because the need for supervision is constant. If the behavior is predictable (the behavior only happens at certain times of the day or in certain limited circumstances), protective supervision may be denied because there is no 24-hour-a-day need to be watched. ACL 15-25.

When can Protective Supervision be denied?

Protective supervision will be denied if a person needs protective supervision for:

• Friendly visiting or social activities.
• When the need is caused by a medical condition and the person needs medical supervision.
• In anticipation of a medical emergency. Examples include supervising a person for seizures, strokes, heart or asthma attacks, and providing life saving measures such as measuring the blood sugar levels of a person with diabetes or administering insulin.
• To control anti-social or aggressive recipient behavior. For example, injury to others, property destruction, tantrums and/or fights.
• To guard against deliberate self-destructive behavior, such as suicide or when the individual knowingly intends to self-harm. “Deliberate” means after careful consideration of the effect and consequences. MPP § 30-757.172.

Note: A recipient who is non-self-directing and displays self-destructive behaviors, such as head-banging, as a manifestation of the mental impairment/illness, may be eligible for PS.

A recipient who displays intentional self-destructive behavior, with knowledge that the activity may cause self-harm, would not be Protective supervision eligible. This type of behavior may include tantrums or head-banging as a way to achieve a desired result. In this case, the recipient would be considered self-directing, as there is knowledge that the activity is self-harm; therefore, he/she would be ineligible for Protective Supervision. MPP § 30-757.172(e) and ACL 17-95

What dangerous behaviors may show a need for protective supervision?

Examples of dangerous behaviors can include:

• Wandering out of the house and getting lost
• Letting strangers in the home
• Turning on gas on kitchen stove and leaving it unattended
• Lighting fires
• Leaving water running
• Eating non-food items (soap or dirt)
• Eating wrong foods (foods which trigger allergic reactions or dangerously alter blood sugar levels)
• Taking medications which are not prescribed or appropriate
• Head banging (behavior that is non-self-directing and/or unintentional)
• Self-biting (that is non-self-directing and/or unintentional)
• Self-scratching (that is non-self-directing and/or unintentional)
• Picking at skin (that is non-self-directing and/or unintentional)
• Improperly using knives or other sharp household objects
• Sticking hand in blender or garbage disposal while blades are in motion
• Sticking hand or face near or in hot pan while cooking
• Putting head in hot oven
• Jumping into pools of water and not knowing how to swim

How are children assessed for protective supervision?

The county follows a 4-step process to determine a child’s eligibility for protective supervision. Additional information about the assessment process can be found in All County Letters (ACLs) 15-25 and 98-87. A child can get protective supervision services if the child meets all the following eligibility criteria:

1. The child is non-self-directing due to a mental impairment/mental illness. This means the child cannot assess danger and can accidentally hurt themselves.
2. The child is likely to engage in potentially dangerous activities. This means the child has the physical ability to put themselves in danger. If not, the minor cannot get protective supervision.
3. The child needs “more supervision” than a child of comparable age without a mental impairment or illness. This means a child must be constantly watched and provided with redirection to avoid injury in contrast to a child without a mental impairment or illness who can be safe with routine childcare. For example, a non-disabled child will recognize pain and stop harmful behavior. A mentally disabled child may not recognize pain and will continuously harm themself until redirected. More supervision is needed because there’s a constant need for intense monitoring (i.e., watching the child) and for redirection to avoid injury.
4. The minor must need 24-hours-a-day supervision to remain safe at home. The child must have unpredictable behaviors which require the child to be monitored 24-hours-a-day. Protective supervision will be denied if the child’s behaviors are predictable.

What forms should be completed to apply for protective supervision?

The treating physician must complete an Assessment of Need for Protective Supervision for In-Home Supportive Services Program SOC 821 form for an IHSS recipient to get protective supervision. The county may send the form to the treating doctor to ask for information about the recipient’s mental condition and why that person needs protective supervision. Tell the doctor’s office the county is sending the SOC 821 form and help the doctor complete it. It’s important for the doctor to write examples of dangerous behaviors and explain why the child’s disability prevents them from being alone.

How do I deal with protective supervision denials?

Counties come up with many common excuses for telling someone they are not eligible. Below is a list of common issues and ways to rebut them.

Is there a severe mental impairment?

• County Excuse: Severe mental impairments not observed during home visit.
  • Response: The worker’s home visit was too short; the worker observed behavior and didn’t answer guideline questions. Your daily log, doctor’s statement, ABA therapy evaluation or report, and/or county assessment document show severe mental impairment.
• County Excuse: Needs protective supervision due to physical impairment, not mental impairment.
  • Response: Because of mental impairment, the person does not understand physical impairments, does not understand or appreciate consequences of their actions. Examples include attempts to get up or walk without assistance because a person doesn’t understand they cannot do so without risk of injury.
• County Excuse: Physical impairments cause dangerous behavior because the recipient knows what they are doing.
  • Response: Mental impairments cause the recipient to engage in dangerous behavior or place themselves in harms way. They are unaware or cannot understand that they have physical impairments and/or stop themselves from engaging in dangerous behavior and accidentally hurting themselves.

Is there dangerous behavior at home?

• County Excuse: The recipient has had no recent injuries.
  • Response: Recipients are not required to have injuries to get protective supervision, just a history of a propensity of placing themselves in danger. The recipient is well supervised to prevent injuries.[AK1]
• County Excuse: No evidence of dangerous behavior observed during the IHSS worker’s home visit.
  • Response: Recipient frequently engages in dangerous behavior throughout the day, not hourly; missed day before and after; county cannot generalize from a 1-hour home visit to 24 hours in a day.
• County Excuse: Physical limitations prevents the recipient from doing anything dangerous.
  • Response: The recipient has the physical ability to engage in potentially dangerous behavior such as pulling out catheter, G-tube, ventilator tube, etc. and will engage in dangerous behavior due to cognitive impairment, mental health condition or other condition and may accidentally hurt themselves.
• County Excuse: Ineligible due to exhibiting aggressive and antisocial behavior, i.e., hitting others or destroying property.
  • Response: If a recipient displays self-injurious behavior that would qualify for Protective Supervision and also has aggressive and anti-social behavior, the recipient can get Protective Supervision to prevent dangerous self-injurious behaviors.

Is 24-hour supervision needed and received?

• County Excuse: Needs physical redirection, not just watching or verbal command.
  • Response: Supervision includes redirection and some intervention.
• County Excuse: Family discourages independence and is overprotective of person with mild intellectual disability.
  • Response: More independence caused injuries or near-accidents in the past; others, including regional center and/or doctor, recommend 24-hour supervision.
• County Excuse: The environment can be changed to remove risks or eliminate dangerous behavior. Examples of potential changes include removing kitchen stove’s knobs; locking up tools or cupboards; bracing wheelchair; strapping recipient in wheelchair; removing faucet’s hot water knob; installing higher bed rails to stop night wandering; installing secure keyed locks; bolting down furniture.
  • Response: Environmental modifications are not required. ACL 17-95
• County Excuse: Children always need adult supervision.
  • Response: Due to cognitive impairment, mental health condition or other condition the child needs much more supervision than a same aged child without a cognitive impairment, mental health condition or other condition.
    *Please note that it is harder to establish protective supervision eligibility for younger children. Although there is no age requirement to get protective supervision, a child aged 5 and under will have difficulty qualifying for protective supervision without supporting evidence because younger children usually require close supervision due to their age.
• County Excuse: Attend a behavior parenting class.
  • Response: IHSS rules do not require parenting classes.
• County Excuse: County improperly granted protective supervision; reassessment shows no eligibility.
  • Response: The recipient had no change in SOC 293, Line H, on mental function rankings; no change in recipient's home or their mental condition. The SOC 293 is contained in your IHSS file. You can ask the county to provide you with a copy of this form.

For more information about protective supervision and tips on how to get it, please read DRC’s In-Home Supportive Services Protective Supervision publication: In-Home Supportive Services Protective Supervision.

How can I get the maximum of 283 IHSS monthly hours?

You can get 283 hours per month if:

1. You get protective supervision and are getting IHSS funded through the Personal Care Services Program (PCSP), or
2. You get protective supervision and are “severely impaired,” or
3. You get protective supervision and are in the CFCO program and need additional services, or
4. You need at least 283 hours per month in IHSS services (for example, personal care, related and other services).

You can call your IHSS worker to ask which IHSS program you are receiving services from or look at your IHSS Approval Notice of Action.

Who qualifies as severely impaired?

To qualify as “severely impaired” an individual must get 20 or more hours per week in the following IHSS services: non-medical personal care, meal preparation and meal clean-up when meal preparation and feeding is required, and paramedical. MPP § 30-701(s)(1).

To determine whether you qualify as severely impaired, add up the time in your IHSS NOA for each of the above listed services. If they total 20 hours or more a week, you qualify as severely impaired. You can also call your IHSS worker to ask which program you are in.

How can I qualify as severely impaired?

You can use the Self-Assessment Worksheet for at least a week to log how much time you need in personal care, meal preparation and clean-up (when feeding is required), and paramedical services. Afterwards, add up the time you need in these tasks. These services are labeled with an asterisk (*) on the Self-Assessment Worksheet. If your need in these services are least 20 hours a week, then you can qualify as severely impaired.

If you qualify as severely impaired and you get protective supervision, you will receive 283monthly hours of IHSS. If you are non-severely impaired and you get protective supervision, then you will receive at least 195 hours per month.

Note: If you are not eligible for protective supervision, you will only get 283 hours when your care needs total this amount each month.

The total number of hours you receive will depend on the county assessment and which IHSSprogram you are in.

State Fair Hearings

When do I ask for a hearing?

If you disagree with the IHSS hours listed in your IHSS Notice of Action (NOA) or any other action or inaction IHSS takes, you should appeal by asking for a fair hearing.

You only have 90 days to ask for a hearing from the date listed in the IHSS Notice of Action.

You can appeal up to 180 days after the date on the Notice of Action if you have “good cause” for not requesting a hearing within 90 days. You may have good cause if you had a substantial and compelling reason beyond your control for not requesting a hearing within 90 days.

You should get the county’s position statement at least 2 business days before your IHSS hearing from the appeals officer assigned to represent the county at your IHSS hearing. The position statement should explain why the county made their decision.

Can I keep my IHSS hours from going down or terminating while my hearing is pending?

If the county reduces or ends your IHSS hours, you must request a fair hearing and aid paid pending before the change in your IHSS Notice of Action takes effect. If you ask for a hearing and aid paid pending before the change in your IHSS Notice of Action happens, you will continue receiving all your hours until you receive a written administrative decision. The first page of your IHSS Notice of Action will tell you when the changes in your IHSS services will start, the effective date. If you do not get a Notice of Action or the IHSS Notice of Action takeseffect in less than 10 days from the time you get it, you should immediately ask for a hearingand aid paid pending. When you ask for a hearing, you will need to explain that you did not receive the IHSS Notice of Action or received it late.

How do I ask for a hearing?

You can request a hearing online, by phone, by mail, or by fax.

Request a hearing online:

Click here to request a hearing online.

You have the option of creating an ACMS account to submit your appeal online or submit your appeal without an account.

Request a hearing by phone:

Call the State Hearings Division toll-free (800) 743-8525 or (855) 795-0634

Public Inquiry and Response toll-free (800) 952-5253 or TDD (800) 952-8349

Request a hearing in writing by mail:

Submit your request to the county welfare department at the address on the IHSS Notice of Action or by mail to:

California Department of Social Services
State Hearings Division
P.O. Box 944243, Mail Station 9-21-37
Sacramento, California 94244-2430

Request a hearing by fax:

You can submit your faxed hearing request to (833) 281-0905.

What if I need an interpreter?

If you or someone who will be testifying (such as your IHSS provider) need an interpreter, include that in your request for a hearing. For more information about the hearing process,click here to visit the State Hearings Division website.

If you need additional information about the fair hearing process or how to prepare for a hearing, please review DRC’s publication here: IHSS Fair Hearings Guide: How to Prepare for IHSS Terminations or Reductions in Hours.