What is Protective Supervision?

Protective supervision is a service under the In-Home Supportive Services (IHSS) program. It provides monitoring for “nonself-directing” IHSS recipients with cognitive impairments, mental health conditions, or other conditions to ensure that they do not accidentally hurt themselves.1 An IHSS provider can be paid to supervise the recipient, help prevent injuries or accidents and offer verbal redirection or other interventions as needed.2

Protective supervision services are difficult to get and require you to clearly document the need for the service. This publication will help you understand the eligibility criteria for protective supervision, the maximum number of hours available, and how to document a need for protective supervision.

Why is Protective Supervision Important?

Protective supervision provides constant monitoring for individuals with disabilities who cannot safely live alone, helping them stay in their homes and communities instead of being placed in a facility. Recipients eligible for protective supervision may be authorized for up to 283 hours per month of total IHSS services.

What is the Maximum Number of Hours a Person Eligible for Protective Supervision Can Receive?

The amount of protective supervision IHSS hours a recipient can receive is based on the following:

1. Funding subprogram, and
2. Whether the recipient is “severely impaired” or “non-severely impaired.”

We will discuss later how to determine if an IHSS recipient is considered “severely impaired.”

IHSS Funding Subprograms

There are four IHSS funding subprograms:

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

You can find out the subprogram by looking at the IHSS Approval Notice of Action or by asking the IHSS social worker.

The following chart lists the four IHSS funding subprograms and maximum monthly IHSS hours available to people who get protective supervision under each program:

Subprogram	If you are considered Severely Impaired (SI) – up to:	If you are considered Non- Severely Impaired (NSI) – up to:	Citation/source of information
PCSP – No Parent/Spouse Allowed	283 hrs/mo	283 hrs/mo (195 hours of PS, plus other hours of need)	All County Letter (ACL) No. 93-21 ACL 99-86
CFCO	283 hrs/mo	Up to 283 hrs/mo (195 hours of PS, plus other hours of need)	ACL 14-60
IPO	283 hrs/mo	195 hrs/mo	ACL 11-19
IHSS-R	283 hrs/mo	195 hrs/mo	Welf. & Inst. Code § 12303.4

How to Qualify as Severely Impaired?

To qualify as “severely impaired” an individual must need twenty or more hours per week in the areas of non-medical personal services, meal preparation, meal clean-up when the preparation of meals and feeding is required, and paramedical services.3

To qualify as “severely impaired”, an IHSS recipient must have a “total assessed need” of 20 or more hours per week in:

• Meal Preparation and Meal Clean-Up (if feeding is required)
• Respiration Assistance
• Bowel and Bladder Care
• Feeding
• Routine Bed Bath
• Dressing
• Menstrual Care
• Ambulation
• Transferring
• Bathing
• Oral Hygiene
• Grooming
• Rubbing Skin
• Repositioning
• Help with Prosthesis (artificial limb, Visual Hearing Aid), Setting up Medications
• Paramedical Services

How to Calculate the “Total Assessed Need”

To calculate your “Total Assessed Need”, add up the time in the IHSS Notice of Action in the column marked “Total Amount of Service Needed” for each of the above listed services. If proration has been applied for meal preparation and meal clean-up, include the prorated amount. Prorated time for meal preparation and meal clean-up includes only the time the recipient needs for those services. The result of all time added up in the column is the “Total Assessed Need.”

• If the “Total Assessed Need” is 20 hours or more per week, then the recipient is considered “severely impaired.”
• If the “Total Assessed Need” is less than 20 hours per week, then the recipient is “non-severely impaired.”

Who can get Protective Supervision?

Individuals living with Autism, Alzheimer’s and other dementias, intellectual disabilities or other mental health disabilities may be more likely to have impairments that require protective supervision. However, having one of these disabilities alone does not automatically qualify an IHSS recipient for protective supervision.

To be eligible for protective supervision, individuals must have:

1. A “cognitive impairment,” “mental health condition” or “other condition” such as a mental impairment or illness, that causes functional limitations in:
   • Memory (e.g. forgetting things, people, places, to start or finish a task, etc.)
   • Orientation (e.g. inability to recognize and adapt to time, people, places, environment, surroundings etc., needed to live and complete tasks.)
   • Judgment (e.g. making decisions which put the individual’s health and/or safety at risk),4

• And

2. Be “nonself-directing.”
   Nonself-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.5 For example, an IHSS recipient may not understand what is safe behavior and could get hurt trying to do something they should not do without help.
3. Require 24-hours a day supervision to remain safely at home.6 For example, a recipient with unpredictable, dangerous or hazardous behaviors that occur at any time during the day or night needs 24 hour supervision.

Additional Protective Supervision Eligibility Criteria for Children

A child (under age 18) can get protective supervision if they meet the eligibility criteria listed above, but there is an additional requirement they must meet: the child must require more supervision than a child of the same age without disabilities. A child cannot get protective supervision for routine childcare required by all children of the same age.7

County staff must assess all children’s mental functioning on an individualized basis and provide protective supervision based on individualized need.

Children should not be denied protective supervision based on:

• Age alone,
• Because the child has not had a recent injury,
• Because the parent leaves the child alone for a short, fixed period of time, like 5 minutes.

The county must provide information to the child’s parent or guardian about the availability and eligibility for protective supervision as part of the assessment process.

When the IHSS worker assesses a child for protective supervision, the IHSS worker may ask for information like medical records, school reports (Individualized Education Plans or IEPs) or regional center records (Individualized Program Plans or IPPs) to help the worker determine if a child needs protective supervision.

When Can Protective Supervision Be Requested?

IHSS workers are required to assess individuals for all IHSS services they may need as part of the IHSS application and annual reassessment processes. This includes assessing the need for protective supervision.

An IHSS recipient or family member can ask for protective supervision services as soon as the need for protective supervision is discovered. This includes making a request during the application or reassessment process or between reassessments. A request for protective supervision can also be made over the phone, email, or mail.

Documenting Protective Supervision Eligibility

To receive protective supervision, you will need to provide the county with documentation showing that the IHSS recipient has a cognitive impairment or mental condition or other condition which prevents the IHSS recipient from being able to cognitively assess danger and the risk of harm. You also need to show that the recipient is at risk of injury, hazard or accident if left alone at any time during a 24-hour day.

The documentation must provide examples of the things a recipient will do that can cause them to accidentally hurt themselves or put themselves in danger if left alone.

If you do not show that the recipient has dangerous behaviors that put them at risk when unsupervised, protective supervision may be denied.

Be sure to keep a copy of all the documentation you submit to the county for your records.

1. Create a Hazard/Injury Log Showing Recipient’s Dangerous Behaviors

The best way to show eligibility for protective supervision is by creating a list or log documenting every accident/injury or near accident/injury the recipient had, within the past six (6) months.

At the end of this publication, there is a sample Daily Hazard / Injury Log and form you can use to keep track of dangerous behaviors.

The log or list you make should describe every action the recipient has taken that might cause injury or has put the recipient at risk of injury or harm, and how often it happens.

Some examples of dangerous behaviors include: leaving lit cigarettes throughout the home, using unsafe products such as bleach to bathe and clean themself, wandering out of the house and getting lost, letting strangers into the home, turning the stove on and forgetting to turn it off, lighting fires around the home, leaving water running, turning water to scalding temperatures, eating dangerous products, eating unsafe foods or food out of the trash can, headbanging, self-biting and scratching, picking at skin or open wounds, using knives or other unsafe household objects, playing with toilet bowl water or feces, climbing onto a high places and jumping off, hiding in the refrigerator, sticking fingers in light bulb socket to see if electricity works, wandering into the street without regard for oncoming traffic, jumping into a swimming pool without knowing how to swim, putting things into an electrical outlet, putting a phone charger or wire that is plugged into the wall into mouth, trying to move furniture when the individual lacks needed balance and strength, trying to get out of bed when the individual lacks needed ability to use or control muscles, trying to walk unassisted when the individual has strength and balance limitations, performing any task beyond the individual’s mental or physical ability that would cause injury or harm to the recipient.

If the recipient has not had an accident or put himself/herself in a dangerous situation recently, explain why. For example, there may have been no incidents because the individual is watched 24 hours a day by the IHSS caregiver and family members to prevent accidents.

Explain the actions such as verbal redirection or other interventions caregivers and family members have had to take to prevent injury or accidents.

In the hazard/injury log, you should note the reasons that the recipient’s home cannot be modified or made entirely safe and/or the alternative way in which the individual is watched when the IHSS recipient must be left alone for a brief, fixed period of time (if applicable). For example, the recipient can open cabinets despite using child safety locks or the recipient may be left alone twice a month for the family member to go shopping for no longer than 1 hour and the recipient is watched by receiving a phone call at home every 20 minutes.

2. Submit an “Assessment of Need for Protective Supervision for IHSS Program” (SOC 821) Form to the County

The Assessment of Need for Protective Supervision for the In-Home Supportive Services Program form (SOC 821) should be completed by the IHSS recipient’s doctor or a medical professional with specialty or practice in the areas of memory, orientation, and/or judgment.8 The SOC 821 form is used to determine if protective supervision is needed along with other information collected by the county about the need for protective supervision.9 It is helpful to provide the doctor or medical professional completing the SOC 821 form with a copy of the IHSS recipient’s Hazard or Injury Log. You should also ask that the doctor include examples of the IHSS recipient’s hazardous nonself-directing behavior and explain why the behavior is due to a cognitive impairment, mental health or other condition. For example, the doctor could explain that a recipient’s attempts to walk unassisted and falling is because of a cognitive impairment, mental health or other condition, that the individual does not intend to hurt themselves; and that they do not understand they have physical limitations which causes them to unknowingly put themselves at risk of harm or injury.

IHSS rules do not require an IHSS worker to complete and/or provide the SOC 821 form directly to the doctor or medical professional. IHSS recipients or family members have the right to have the doctor complete the SOC 821 form and provide it to the county. If the form is not returned to the county or is incomplete, the county will determine the need for protective supervision based on the information it has.10 The county may deny protective supervision if it does not have all the information it needs to determine eligibility.

Remember to keep a copy of all documents submitted to the county for your records.

3. Obtain a Letter from a Doctor or Medical Professional Documenting the Need for Protective Supervision

In addition to the SOC 821, you should obtain a letter from the recipient’s doctor or a medical professional documenting the recipient’s cognitive impairment or mental health condition or other condition, functioning level, age, and describing how the impairment or conditions causes poor memory, disorientation, or judgment. The letter should explain that the individual is unable to cognitively assess danger and risk of harm, and why the individual is at risk of injury, hazard or accident, if left alone.

The letter should provide examples of hazardous behaviors and explain how the behavior is related to a cognitive impairment or mental health condition or other condition. The doctor or medical professional should also explain why the individual must be watched 24 hours a day to remain safe at home.

The doctor or medical professional writing the letter must have some knowledge of the individual’s behaviors and whether they have the physical and mental ability to put themself in dangerous situations. You should provide the recipient’s doctor or medical professional with a copy of your hazard/injury log to help the doctor or medical professional better understand what kind of dangerous behaviors the recipient has that prevents them from being left alone at any time during a 24-hour day.

At the end of this publication, there is a Protective Supervision Sample Doctor’s Letter which can be completed by the recipient’s doctor or a medical professional to provide IHSS with more detailed information about the need for protective supervision services.

4. Obtain Other Letters of Support Showing a Need for Protective Supervision

You should also obtain other letters about the recipient’s need for protective supervision from providers who work with the recipient regularly such as from the regional center day program, childcare provider, Applied Behavior Analysis (ABA) therapy provider or physical therapy provider. The letters should contain the following information:

• The recipient’s age and how long the provider has known them,
• The recipient’s disabilities and diagnoses to show that they have a cognitive impairment(s), mental health or other condition,
• Information about the individual’s functional limitations in memory, orientation, and judgement caused by cognitive impairment(s) and/or mental health or other condition and the severity,
• Information about whether the individual is nonself-directing. Nonself-directing means an individual is (1) unable to cognitively assess danger and the risk of harm and (2) at risk of injury, hazard or accident because of a cognitive impairment/ or mental health condition or other condition,
• Information about whether the individual needs to be observed and monitored to keep them safe and why (e.g. the recipient must be closely watched because the individual does things which are unsafe due to a cognitive impairment and may accidentally hurt themselves or place themselves in hazardous situations),
• Provide examples of unsafe behaviors the individual engages in and how often they occur.

5. Obtain Other Documentation of the Need for Protective Supervision

You can also gather other documentation, including recent psychological assessments; behavioral health assessments; treatment plans and reports; IEPs and any amendments; Regional Center Individual IPPs; and other documents showing the recipient’s functional limitations, cognitive impairments, mental health conditions and other health conditions, and nonself-directing (i.e. dangerous) behaviors. You can also collect police reports documenting incidents when the IHSS recipient has eloped from the home and gotten lost or was found wandering in the streets.

6. Complete A Protective Supervision 24-Hour A Day Coverage Plan (SOC 825) Form

The county may request the completion of a Protective Supervision 24-Hour A Day Coverage Plan (SOC 825). The county is required to collect information about how 24-hour supervision will be provided. This is because IHSS does not pay for 24 hours of services per day due to the 283 hour per month limit, even though an individual eligible for protective supervision still needs to be observed 24-hours a day. This form asks the provider to share information about how the IHSS recipient will be watched when IHSS hours are not available during a 24-hour day.

When is Protective Supervision Not Approved?

Protective supervision cannot be provided for:

• Friendly visiting or social activities (e.g. Watching a recipient so they can go to church or attend Bingo games).
• A need caused by a medical condition and a person needs medical supervision (e.g. Watching a recipient with impaired swallowing for choking and providing suctioning to prevent asphyxiation).
• A need due to anticipation of a medical emergency (e.g. Watching a recipient because they may have a heart attack, stroke, seizure or asthma attack and need medical assistance).
• A need to prevent or control anti-social or aggressive recipient behavior (e.g. Watching a recipient because they may hit or injure someone or destroy property).
• A need to guard against deliberate (intentional) self-destructive behavior, like suicide, or when an individual knowingly tries to harm himself/herself.11

Other Reasons Protective Supervision May Be Denied

• The individual is physically unable to hurt themselves.
• The individual does not have a “cognitive impairment” or “mental health condition” or “other condition.”
• The individual is self-directing because they know when things are dangerous and can stop themselves from doing harmful things. (e.g. An elderly person who understands they have physical limitations which prevent them from being able to walk safely without help. This individual can choose when to wait for help with walking and at other times after weighing the risk of falling can choose to try to walk unassisted such as when trying to escape a fire).
• If a child does not need more supervision than a child of the same age without disabilities. The need to be watched must be related to the functional limitations (e.g. memory, orientation and judgement) of the child and not the age of the child.
• Environmental modifications eliminate the need for protective supervision. For example, removing stove knobs or adding safety latches.
• The behaviors are predictable and the need for supervision is only at certain times of the day.12

Requesting a Hearing to Challenge IHSS Decisions

If you disagree with the county’s decision about your IHSS benefits, including the county’s decision to terminate or deny protective supervision, you have the right to ask for a hearing to challenge the decision. There are two important deadlines that you must know about to ask for a hearing.

1. 90-Day Deadline to Request a Hearing

A recipient only has 90 days to ask for a hearing from the date of the IHSS Notice of Action (NOA) or inaction with which the individual disagrees (e.g. verbal denial of protective supervision). Here is where you can find more information about asking for a hearing: https://www.cdss.ca.gov/hearing-requests.

2. Aid Paid Pending

Aid Paid Pending is a rule which prevents an IHSS NOA from taking effect while a hearing is pending. This means that your benefits will continue at the current level until a hearing decision is released. If a hearing is requested before the change in the IHSS NOA is effective, IHSS services will continue at the same level until the hearing decision is released.13 Aid Paid Pending IHSS services are not considered an overpayment, even if the recipient loses at their IHSS hearing, the benefits will not need to be repayed.14

You can visit the California Department of Social Services website to request a hearing online and for more information about State Hearings Requests.

For more information about preparing for a hearing, see DRC’s publication IHSS Fair Hearings Guide: How to Prepare for IHSS Terminations or Reductions in Hours.

For information about how to advocate for additional IHSS services such as the ones listed above, please review DRC’s publication: IHSS In-Home and Self-Assessment Guide

To learn more about how IHSS hours are calculated, please see DRC’s publication: Understanding the Maximum Amount of Hours Available & Calculating Hours

Responses To Common Reasons A County Denies Protective Supervision

Counties have many common reasons for telling someone they are not eligible for protective supervision. Below is a list of common county justifications and some possible responses.

Is there a severe mental impairment?

County Justification for Denial:

Severe mental impairments not observed on home visit.

Response:

• The wrong standard is being used to determine a need for protective supervision. A severe impairment is not required. Recipient must have an inability to assess danger and risk of harm based on a cognitive impairment, mental health condition or other condition (such as a mental impairment or illness) and be at risk or injury, hazard or accident because of disability and impairments.
• The IHSS home visit was too short to observe the common dangerous behavior.
• Evidence that contradicts the county’s assessment: i.e. Recipient’s daily log, doctor's statement, psychological assessment documenting a cognitive impairment, mental health condition or other condition (such as a mental impairment or illness) and risk of accidental harm because of dangerous behaviors.
• Dementia patients show only “good days” to visitors.

County Justification for Denial:

Needs protective supervision because of physical impairment, not mental impairment.

Response:

• A recipient is not requesting protective supervision in response to medical or other emergencies caused by physical impairments. For example, they are not requesting to administer insulin during diabetic attack or asthma or heart attack.
• Instead, a cognitive impairment, mental health condition or other condition (such as a mental impairment or illness) causes a risk of injury. The need to be watched is related to a cognitive impairment, mental health condition or other condition (such as a mental impairment or illness).
• The recipient ‘s cognitive impairment, mental condition or other condition (such as a mental health impairment or illness) prevents the individual from understanding physical impairments or limitations. Recipient does not understand or appreciate consequences of actions (e.g., tries to get up or walk without assistance when cannot do so without risk of injury, will eat sweets even though risks injury because of diabetes, will try to remove ventilator tubing or brace because it hurts or is irritating,etc.)

Is there dangerous behavior at home?

County Justification for Denial:

Formal diagnosis of cognitive impairment, mental condition or other condition (such as a mental health impairment or illness) doesn't prove need.

Response:

• SOC 821 and a doctor or medical professional's statement shows the recipient does not have an inability to assess danger and risk of harm based on a cognitive impairment, mental health condition or other condition (such as a mental impairment or illness) and is at risk or injury, hazard or accident because of disability and impairments.

County Justification for Denial:

No injuries in the recent past.

Response:

• Recipient is supervised constantly and the provider intervenes or redirects as needed to prevent harm.

County Justification for Denial:

No evidence of dangerous behavior during county worker's home visit.

Response:

• The behaviors are unpredictable and vary from day to day.
• Share a hazard/injury log that captures the dangerous behaviors when IHSS worker was not present.

County Justification for Denial:

The recipient does not have the physical ability to place themselves in dangerous situations or hurt themself.

Response:

• The recipient has the ability to pull out their catheter, G-tube, etc. and doesn’t understand the behavior is dangerous.

County Justification for Denial:

The recipient’s behaviors are predictable and based on triggers.

Response:

• Even if a dangerous behavior is consistently brought on by a particular trigger (i.e. when recipient is frustrated or upset), it is difficult, if not impossible at times, to reasonably predict when, where, and how the recipient will become triggered and harm themself.
• Without constant supervision and vigilance, the harm cannot be reliably prevented.

County Justification for Denial:

The recipient’s self-injurious behaviors are not severe enough to warrant protective supervision.

Response:

• Degree of self-injury is not the standard.
• The recipient does not have to “suffer actual injury” to be eligible for Protective Supervision. Rather, they must show a “history of a propensity for placing him/herself in danger”.

Sample Daily Hazard/Injury Log

Sample Hazard/Injury Log Form

Click here for the Sample Hazard Injury Log Form (pdf)

Beneficiary: _________________________________________________

Case Number: _________________________________________________

If you chose not to keep a daily log as shown above, you can use this form to help you document a beneficiary’s behaviors that puts the recipient in danger or creates a risk of injury. This chart may not contain all examples of a recipient’s dangerous behaviors. You should modify this chart to reflect the recipient’s behaviors.

Dangerous Behavior

• Wanders out of the house and gets lost.
  Would behavior happen if the recipient is not watched 24/7? (Yes/No)
  Date of each occurrence:
  Description:
  ___________________________________________________________
  ___________________________________________________________
  ___________________________________________________________
• Allows strangers to enter the home.
  Would behavior happen if the recipient is not watched 24/7? (Yes/No)
  Date of each occurrence:
  Description:
  ___________________________________________________________
  ___________________________________________________________
  ___________________________________________________________
• Unaware of the danger of strangers.
  Would behavior happen if the recipient is not watched 24/7? (Yes/No)
  Date of each occurrence:
  Description:
  ___________________________________________________________
  ___________________________________________________________
  ___________________________________________________________
• Turns the stove on and forgets to turn off.
  Would behavior happen if the recipient is not watched 24/7? (Yes/No)
  Date of each occurrence:
  Description:
  ___________________________________________________________
  ___________________________________________________________
  ___________________________________________________________
• Places hands or other body parts or other inappropriate items near or on the stove.
  Would behavior happen if the recipient is not watched 24/7? (Yes/No)
  Date of each occurrence:
  Description:
  ___________________________________________________________
  ___________________________________________________________
  ___________________________________________________________
• Starts fires in the microwave or around the house.
  Would behavior happen if the recipient is not watched 24/7? (Yes/No)
  Date of each occurrence:
  Description:
  ___________________________________________________________
  ___________________________________________________________
  ___________________________________________________________
• Eats dangerous products, or unhealthy foods (for example soap).
  Would behavior happen if the recipient is not watched 24/7 (Yes/No)
  Date of each occurrence:
  Description:
  ___________________________________________________________
  ___________________________________________________________
  ___________________________________________________________
• Eat foods inappropriate for medical conditions (e.g., unlimited sugary sodas if diabetic).
  Would behavior happen if the recipient is not watched 24/7 (Yes/No)
  Date of each occurrence:
  Description:
  ___________________________________________________________
  ___________________________________________________________
  ___________________________________________________________
• Inserts dangerous objects into throat/ears/nose.
  Would behavior happen if the recipient is not watched 24/7? (Yes/No)
  Date of each occurrence:
  Description:
  ___________________________________________________________
  ___________________________________________________________
  ___________________________________________________________
• Does not properly chew food or drinks or chokes when eating or drinking.
  Would behavior happen if the recipient is not watched 24/7? (Yes/No)
  Date of each occurrence:
  Description:
  ___________________________________________________________
  ___________________________________________________________
  ___________________________________________________________
• Hits their head, mouth or chin, or bites or scratches themself
  Would behavior happen if the recipient is not watched 24/7? (Yes/No)
  Date of each occurrence:
  Description:
  ___________________________________________________________
  ___________________________________________________________
  ___________________________________________________________
• Uses knives or other household items in an unsafe manner.
  Would behavior happen if the recipient is not watched 24/7? (Yes/No)
  Date of each occurrence:
  Description:
  ___________________________________________________________
  ___________________________________________________________
  ___________________________________________________________
• Climbs or jumps from high places or at risk of falling and/or hitting head.
  Would behavior happen if the recipient is not watched 24/7? (Yes/No)
  Date of each occurrence:
  Description:
  ___________________________________________________________
  ___________________________________________________________
  ___________________________________________________________
• Hides in dangerous areas (e.g., refrigerator, oven).
  Would behavior happen if the recipient is not watched 24/7? (Yes/No)
  Date of each occurrence:
  Description:
  ___________________________________________________________
  ___________________________________________________________
  ___________________________________________________________
• Puts objects into electrical outlets or fixtures.
  Would behavior happen if the recipient is not watched 24/7? (Yes/No)
  Date of each occurrence:
  Description:
  ___________________________________________________________
  ___________________________________________________________
  ___________________________________________________________
• Puts hands in unhygienic areas (e.g., toilet bowl, trash, dirty diapers).
  Would behavior happen if the recipient is not watched 24/7? (Yes/No)
  Date of each occurrence:
  Description:
  ___________________________________________________________
  ___________________________________________________________
  ___________________________________________________________
• Wanders around streets or parking lots without regard for traffic/cars.
  Would behavior happen if the recipient is not watched 24/7? (Yes/No)
  Date of each occurrence:
  Description:
  ___________________________________________________________
  ___________________________________________________________
  ___________________________________________________________
• Jumps into the pool without knowing how to swim.
  Would behavior happen if the recipient is not watched 24/7? (Yes/No)
  Date of each occurrence:
  Description:
  ___________________________________________________________
  ___________________________________________________________
  ___________________________________________________________
• Walks when it is not safe to do so without assistance.
  Would behavior happen if the recipient is not watched 24/7? (Yes/No)
  Date of each occurrence:
  Description:
  ___________________________________________________________
  ___________________________________________________________
  ___________________________________________________________
• Moves heavy, dangerous or delicate objects without strength/balance.
  Would behavior happen if the recipient is not watched 24/7? (Yes/No)
  Date of each occurrence:
  Description:
  ___________________________________________________________
  ___________________________________________________________
  ___________________________________________________________
• Hides if has a need to urinate or defecate.
  Would behavior happen if the recipient is not watched 24/7? (Yes/No)
  Date of each occurrence:
  Description:
  ___________________________________________________________
  ___________________________________________________________
  ___________________________________________________________
• Plays with feces.
  Would behavior happen if the recipient is not watched 24/7? (Yes/No)
  Date of each occurrence:
  Description:
  ___________________________________________________________
  ___________________________________________________________
  ___________________________________________________________
• Hits glass, mirrors, televisions, etc.
  Would behavior happen if the recipient is not watched 24/7? (Yes/No)
  Date of each occurrence:
  Description:
  ___________________________________________________________
  ___________________________________________________________
  ___________________________________________________________
• Stands or sits on glass tables.
  Would behavior happen if the recipient is not watched 24/7? (Yes/No)
  Date of each occurrence:
  Description:
  ___________________________________________________________
  ___________________________________________________________
  ___________________________________________________________
• Wakes up in the middle of the night/needs to be supervised during the night to prevent elopement or hurting self in the home.
  Would behavior happen if the recipient is not watched 24/7? (Yes/No)
  Date of each occurrence:
  Description:
  ___________________________________________________________
  ___________________________________________________________
  ___________________________________________________________

Sample Doctor’s Letter

To be completed by a medical professional only.

Click here for the Sample Doctor’s Letter (pdf)

You should provide the doctor or medication professional completing the form with a copy of the IHSS recipient’s Hazard / Injury Log so the doctor will have a better understanding of the recipient’s behaviors at home.

To show that an IHSS recipient is eligible for protective supervision an IHSS recipient must obtain proof (in the form of a doctor’s or medical professional’s letter) about their need for the service.

The letter should describe the individual’s disabilities (diagnoses) and functional impairments (memory, orientation and judgement). The letter should also describe how the disabilities cause poor judgment, confusion, poor memory, or disorientation and provide examples of the dangerous behaviors the individual engages in without an awareness of the potential for harm.

The letter should also explain that the individual has the physical ability to put themselves in harm’s way or in hazardous situations. The letter should explain that the individual needs to be watched 24-hours a day to remain safe at home because of dangerous behaviors caused by cognitive impairment, mental health condition or other condition (mental impairment or illness).

Beneficiary: _________________________________________________

Case Number: _________________________________________________

1. Does the individual have a cognitive impairment, mental health condition or other conditions?
   
   Please check the appropriate answer: (Yes/No)
2. Does the cognitive impairment, mental health condition or other condition cause functional limitations in memory, orientation or judgement?
   
   Please check the appropriate answer: (Yes/No)
3. Is the individual able to assess danger and the risk of harm?
   
   Please check the appropriate answer: (Yes/No)
4. Is the individual’s inability to assess danger and risk of harm related to a cognitive impairment, mental health condition or other condition?
   
   Please check the appropriate answer: (Yes/No)
5. Is the individual at risk for injury, hazard or accident because of a cognitive impairment, mental health condition or other condition?
   
   Please check the appropriate answer: (Yes/No)
6. Does the cognitive impairment, mental health condition or other condition prevent the individual from being left alone during a 24-hour day?
   
   Please check the appropriate answer: (Yes/No)
7. Are the behaviors described in the individuals Hazard and Injury Log consistent with the individual’s cognitive impairment, mental health condition or other condition?
   
   Please check the appropriate answer: (Yes/No)
8. Can the individual’s cognitive impairment, mental condition or other condition be expected to cause the kind of behaviors caused in the Hazard and Injury Log?
   
   Please check the appropriate answer: (Yes/No)
9. Please provide a brief description of the individual’s dangerous behaviors and their causes, including any cognitive impairment, mental health condition or other condition, and limitations in memory, orientation or judgement. Explain how these behaviors prevent the individual from recognizing danger and staying safe at home without 24-hour supervision:
   ___________________________________________________________
   ___________________________________________________________

I have provided the above information to the best of my knowledge.

Signed by: _________________________________________________

Date: _________________________________________________

• 1. Manual of Policy and Procedures (MPP) 30-701(n)(3) and MPP 30-757.17
• 2. MPP 30-757.17 and MPP 30-757.171
• 3. MPP 30-701(s)(1)
• 4. MPP 30-756.372
• 5. MPP 30-701(n)(3)
• 6. 30-757.17 and 30-757.173(a)
• 7. ACL 15-25
• 8. MPP 30-757.173(a)(1) and MPP 30-757.173(a)(1)(A)
• 9. MPP 30-757.173(a)(1)-(3)
• 10. MPP 30-757(a)(4)
• 11. MPP 30-757.172
• 12. ACL 15-25 and All County Information Notice (ACIN) I-76-21
• 13. MPP 22-072.5.
• 14. MPP 30-768.111.