Paramedical Services through the IHSS Program
Paramedical Services through the IHSS Program
What are paramedical service? Where can I find the law on paramedical services? How do I know whether what I need is a “Paramedical Service”...find answers to these questions and more.
What are Paramedical Services?
Paramedical services are a category of services available under the In-Home Supportive Services (IHSS) program. Paramedical services are skilled tasks which are necessary to maintain the IHSS recipient’s health.1 Paramedical services are activities which a person would normally perform for themselves but for their functional limitations.2 In the IHSS program paramedical services are provided by IHSS care providers trained to provide paramedical services or tasks.
IHSS rules describe paramedical tasks as:
- Administration of medications,
- Puncturing the skin,
- Inserting a medical device into an opening in the body,
- Activities requiring sterile procedures, or
- Other activities requiring judgement based on training given by a licensed health care professional.3 Please see below for examples of these activities.
Paramedical services will not be provided unless they are ordered by a licensed health care professional using the SOC 321 Form. Paramedical services must be provided at the licensed health care professional’s direction.4 The licensed health care professional must determine the time needed to perform the service.5 Licensed health care professionals include doctors and other licensed health care professionals whose license permits them to order the paramedical service, such as a registered nurse, physical therapists, and/or occupational therapists.
In order to receive paramedical services, a recipient must give informed consent.6 Consent means you must give permission to receive paramedical services ordered by the licensed medical professional. The IHSS recipient also has the right to choose the licensed health care professional who completes the Paramedical order.7
Note: the current SOC 321 Form (discussed further below) limits who can authorize paramedical services to a “Physician/Surgeon,” “Podiatrist” and “Dentist.” Limiting authorization to just these four categories of licensed healthcare professionals does not comport with the IHSS Statute. DRC is advocating with CDSS to revise this form to accurately reflect the law.
Examples of Paramedical Services
The IHSS rules provide specific examples of paramedical services, including:
- Administration of medications such as crushing pills and putting medications into a recipient’s food, liquid, or in their mouth8 This does not include help with self-administration of medication - see below.
- Nasal-gastric tube or G-Tube feedings & care of stoma site. If a person receives tube feeding for all nutrients, the individual will be ranked as a “1” in meal preparation/meal cleanup and eating because tube feeding is a paramedical service.10
- Tracheostomy care and suctioning through a tracheotomy or through the nose and mouth including tracheal (deep) suctioning. This includes monitoring. If all the help that is needed includes tracheostomy care and suctioning, the recipient should be ranked a "1" for respiration assistance because the care is a paramedical service rather than respiration.11
- Skin and wound care needed to treat and care for decubitus ulcers such as a bed or pressure sore, or a diabetes related wound. If the person has a history of pressure sores or ulcers, checking the body for “hot spots” that could turn into decubitus ulcers.12
- Catheter insertion, catheter changes, emptying urinary drainage bag and recording contents, assisting with emptying bladder.13
- Colostomy/ostomy irrigation. If an individual can eliminate without help and uses a catheter to urinate, the individual is ranked a 1 in bowel, bladder and menstrual care.14
- Digital stimulation as part of a bowel program and digital stool disposal.15
- Insertion of suppositories or administration of an enema.16
- Range of Motion (ROM) exercises include exercises an individual cannot do for themselves because of their functional limitations, and other home therapy programs ordered by a healthcare professional. ROM and other therapy program must be provided by an IHSS provider trained by a health care professional to use judgment in order to provide the IHSS service. The controlling issue is the level of skill involved.17
Other examples of tasks which DRC believes can be Paramedical Services include:
- Pulmonary toileting (pounding lung areas of back and chest to loosen secretions).
- Monitoring and help provided on an as needed basis with the use of a ventilator, C-PAP, or BiPAP machine or help with breathing or nebulizer treatments. Help can include connecting tubing and ventilator, machine adjustment, cleaning equipment, and putting on a mask, or ensuring a mask stays on.
- Monitoring to determine need for an intervention including medications that are given on an as-needed basis rather than on a schedule.
- Application of medicated creams necessary to treat broken skin, rash, infections, or fungus.
- Brushing skin to treat autism.
- Putting someone who has paralysis into a standing frame.
How do I know if a task is a “Paramedical Service”?
The following questions can help you determine if a task is a paramedical service:
- Is the service ordered by a licensed health care professional?
- Is the paramedical task something you would do for yourself if not for functional limitations?
- Is the task necessary to maintain your health because of a physical or mental condition?
- Does the task involve:
- Administration of medications,
- Puncturing the skin,
- Sticking a medical device into a body opening,
- Require sterile procedures or
- The use of judgement (this means to understand something and decide what to do) based on training or direction from a recipient’s treatment team or from a medical professional.18
Tip: If the requested service does not require special training by a health care professional in order to be provided by an IHSS caregiver, consider if the task may be covered as a personal care service.
If you answer yes to these questions, the task may be a paramedical service.
What IHSS tasks can be either Paramedical or Personal Care Services?
There are some tasks in IHSS rules that can be either a paramedical or personal care service. These tasks are:
1. Administration of medications:
Help with self-administration of medications.19 This means the recipient can take the medication with help. This can consist of reminding an IHSS recipient to take prescribed and/or over-the-counter medications and setting up Medi-sets or cutting pills in half.20
Putting medications in the recipient’s mouth or crushing them and putting in food; for medications to be given on an as-needed basis, determining when needed; administering medication through suppository, nebulizer, application of salve on a wound or through G-tube or N-G tube - all would be covered under paramedical services.
Supervision and help with ROM exercises or maintenance therapy taught to a recipient to do on their own by a health care professional to restore mobility restricted because of injury, not using, or disease. Maintenance therapy program exercises include repetitive exercises required to maintain function, improve gait, maintain strength, or endurance; passive exercises to maintain range of motion in paralyzed extremities; and assistive walking.21 The recipient should be able to do exercises safely on their own and do not require that the caregiver receive special training in order to provide help. These types of exercises can be provided both inside and outside the home with the help or supervision of an IHSS care provider. If the exercises are provided outside the home, travel time cannot be authorized. However, time to help the recipient in and out of a car can be authorized if needed.22 The exercises should help an individual keep limbs flexible and minimize contractures or muscles from tightening up.
ROM or other home therapy programs ordered by a healthcare professional and provided by an IHSS caregiver trained, by a healthcare professional, to use judgement in order to provide the ROM or therapy exercises can be covered as paramedical services.
3. Repositioning and Rubbing Skin:
Help with repositioning and rubbing skin includes rubbing a person’s skin to promote circulation and/or prevent skin breakdown.23 This could include rubbing medicated or non-medicated cream on an individual’s skin when training by a medical professional and judgment is not required to provide the service.
Help with care of broken skin, infections, wound care, pressure sores or decubitus ulcers and the assessment of skin to identify “hot spots” that may be precursors to skin breakdown would be covered under paramedical services.
Personal Care Service
Help with using a nebulizer, oxygen, preparing and cleaning an intermittent positive pressure breathing (IPPB) or continuous positive airway pressure (CPAP) machine when special training and/or monitoring is not required.24
Help with using oxygen or other breathing machines, ordered by your doctor, that your care provider must receive training from a health care professional on how to use judgement in order to provide you with the IHSS service. For example, monitoring and providing medication with the use of a nebulizer on an as needed basis.
5. Fingernail/Toenail Care:
Personal Care Service
Help with caring for fingernails and toenails is covered by IHSS under grooming when the service is not provided as a paramedical service, but does not cover nail clipping.25
Help with cutting fingernail/toenail care may be provided as a paramedical service if the licensed health care professional determines it is necessary.
Can I get paramedical services if I have a spouse or parent provider?
Yes, if you have a spouse or parent provider you can still get paramedical services. A spouse can provide paramedical services.26 Parent providers can also provide paramedical services.27 You can review our publications about how to become eligible to be a parent provider here: https://www.disabilityrightsca.org/publications/ihss-self-assessment-and-fair-hearing-guide and here: https://www.disabilityrightsca.org/publications/in-home-supportive-services-ihss-advocates-manual.
How do I Complete and Submit the Paramedical Services Form?
A licensed health care professional must complete and sign an IHSS Request for Order and Consent – Paramedical Services form before the paramedical services you need can be approved. You can get the IHSS Request for Order and Consent – Paramedical Services form here: https://www.cdss.ca.gov/cdssweb/entres/forms/English/SOC321.pdf. The form can be completed online and printed out. If there is not enough space on the form, your doctor should check the box that says, “IF CONTINUED ON ANOTHER SHEET, CHECK HERE” at the bottom of the “additional comments” section of the SOC 321 form and provide additional notes on another piece of paper. You or your authorized representative must also sign the form giving consent for the paramedical task to be performed by an IHSS provider trained to do so.
Before the SOC 321 form is completed, you should speak to your provider about your functional limitations which prevent you from doing paramedical tasks for yourself and explain why you need help. You should explain to your provider that the county will not give you the paramedical services you need without the doctor completing an SOC 321 form. You should talk to your provider about what information needs to go into the form. For example:
- Your disability and functional limitations which prevent you from performing the paramedical service yourself;
- Name of the service(s)
- Time needed to complete the service. Depending on the paramedical task, the time could include taking out equipment or materials, washing hands, putting on gloves, sterilizing, or cleaning the body site for the procedure, such as where the injection will be given. At the end of the task, additional time may be needed for cleaning a device, removing gloves, following universal precautions in disposing of any bodily fluids or materials soiled with bodily fluids, cleaning the area, washing hands, putting things away including locking up medications. Sometimes tasks also involving keeping records such as writing down when as-needed medications are given and why, glucose testing results, time injections are given, etc.
- It is important for the time needed to be set forth very specifically by the licensed health care professional.
- How often the service is to be provided. For example, daily or twice daily.
- How long the service should be provided, such as 6 months or indefinitely.
Note: IHSS rules do not require that the county worker complete and/or provide the form to the doctor. You have the right to have a licensed health care professional fill out the form and to provide the completed form to the county yourself. You can also have a licensed health care professional complete the form ahead of time so that you can give it to the county worker at your next in-home assessment. You or your provider’s office can send the form directly to the county. Remember to make yourself a copy of the completed SOC 321 form before you give it to the county.
Because the time authorized for paramedical services is determined by a licensed health care professional the county cannot overrule what paramedical services the licensed health care professional has ordered in the SOC 321 form.28 Sometimes a county worker may call your provider directly to discuss time frames for services and paramedical tasks. Your provider’s office can choose not to respond to the county IHSS worker or ask they put questions in writing.
Is a Paramedical Services form required annually?
A new paramedical form is not required annually.31 However, IHSS social workers may ask for a new paramedical form at the time of reassessment. This most commonly should occur if the previous paramedical services form states an end date to the paramedical service.
What if I am denied paramedical services or my paramedical services are reduced or terminated?
If you disagree with the county’s decision about your IHSS benefits, you have the right to ask for a state fair hearing. There are two deadlines that you must know about when asking for a hearing.
90 Day Deadline for Requesting a Hearing
You only have 90 days from the date of the IHSS notice of action (“NOA”) to ask for a hearing to dispute a county action or inaction with which you disagree. Here you can find more information about asking for a hearing: https://www.cdss.ca.gov/hearing-requests. If you believe you need a Home Hearing, you may want to review our publication entitled Right to Request a Home Hearing for more information about how to get a home hearing at: https://www.disabilityrightsca.org/publications/right-to-request-a-home-hearing.
Aid Paid Pending your Hearing
Aid Paid Pending is a rule which prevents your IHSS NOA from taking effect while your hearing is pending. If you ask for a hearing before the change in your IHSS NOA is supposed to happen, your IHSS services will continue at the same level until the outcome of your hearing.32 Aid Paid Pending IHSS services are not considered an overpayment even if you lose your IHSS hearing.33 For example, if you get an IHSS NOA reducing or terminating your IHSS benefits and you ask for a hearing before the change in the IHSS NOA is supposed to happen, your IHSS benefits will not change pending your hearing. But if you do not ask for a hearing before the change is supposed to happen, then the IHSS NOA will take effect.
How to Get More Information About Your Rights
If you have a question about your legal rights:
- Call DRC’s intake line at: 1-800-776-5746.
- Call DRC’s Office of Clients’ Rights Advocacy (OCRA) at:
- Northern California 1-800-390-7032 (TTY 877-669-6023)
- Southern California 1-866-833-6712 (TTY 877-669-6023)
IHSS Self Advocacy Resources
DRC IHSS Self-Advocacy Publications:
In-Home Supportive Services (IHSS): A Guide for Advocates:
Disclaimer: This publication is legal information only and is not legal advice about your individual situation. It is current as of the date posted. We try to update our materials regularly. However, laws are regularly changing. If you want to make sure the law has not changed, contact DRC or another legal office.
- 1. MPP § 30-757.191(b).
- 2. MPP § 30-757.191(a).
- 3. MPP §§ 30-757.19, 30-780.1(a)(9), California Welfare and Institutions Code § 12300.1, and California Code of Regulations, Title 22 § 51183(a)(9)
- 4. MPP § 30-757.193
- 5. MPP § 30-757.194
- 6. MPP §§ 30-757.196
- 7. MPP § 30-757.192
- 8. MPP § 30-757.191(c), California Welfare and Institutions Code § 12300.1, and All County Letter (ACL) 08-18, Question 17.
- 9. MPP §§ 30-757.19(c), 30-780.1(a)(9), California Welfare and Institutions Code § 12300.1, and California Code of Regulations, Title 22 § 51183(a)(9)
- 10. MPP § 30-756.41. To learn more about how IHSS services are ranked, please see Disability Rights California’s IHSS Self-Assessment and Fair Hearing Guide at https://www.disabilityrightsca.org/publications/ihss-self-assessment-and-fair-hearing-guide.
- 11. MPP § 30-756.42
- 12. MPP § 30-780.1(a)(5)(A), California Code of Regulations, Title 22 §§ 51183(a)(5)(A) and 51350(h)(1)
- 13. MPP § 30-757.14(a)(1), California Code of Regulations, Title 22 § 51350(g), and ACL 08-18, Question 12 and Question 18.
- 14. Id.
- 15. Id.
- 16. Id.
- 17. MPP §§ 30-757.19(c), 30-780.1(a)(9), ACL 08-18, Question 21, California Welfare and Institutions Code § 12300.1, and California Code of Regulations, Title 22 § 51183(a)(9).
- 18. MPP §§ 30-757.19, 30-780.1(a)(9), California Welfare and Institutions Code § 12300.1, and California Code of Regulations, Title 22 § 51183(a)(9)
- 19. MPP § 30-757.14(i)
- 20. MPP § 30-757.14(i)(1), and California Code of Regulations, Title 22 § 51183(a)(7)
- 21. MPP § 30-757(g) and California Code of Regulations, Title 22 §§ 51183(a)(5)(A), (B), 51350(h)(2), and ACL 08-18, Question 21
- 22. ACL 08-18, Question 20
- 23. MPP § 30-757.14(g), and California Code of Regulations, Title 22 § 51350(h)(1)
- 24. MPP § 30-757.14(b), and California Code of Regulations, Title 22 § 51183(a)(8)
- 25. MPP § 30-757.14(e)(3), California Code of Regulations, Title 22 §§ 51183(a)(2) and 51350(f)
- 26. MPP § 30-763.415(b)
- 27. MPP § 30-763.456(e)
- 28. MPP § 30-757.194
- 29. MPP § 30-757.197
- 30. MPP § 30-763.351
- 31. ACL 08-18, Question 14
- 32. MPP § 22-072.5
- 33. MPP § 30-768.111