Bet Tzedek Legal Services is a non-profit public interest law center that provides free legal services to low-income residents of Los Angeles County. Bet Tzedek means “House of Justice” in Hebrew. Bet Tzedek serves persons of all racial, religious and ethnic backgrounds.
This booklet was written by Kim Selfon and edited by Janet Morris and Dipti Singh from Bet Tzedek. Kirsty Burkhart from Bet Tzedek, Charles Bean from California In-Home Supportive Services Consumer Alliance, Jody Spiegel and Julie Pollock from California Advocates for Nursing Home Reform, Kevin Aslanian from Coalition of California Welfare Rights Organizations and Kristine Loomis provided us with valuable consumer and professional comments and suggestions. We hope the information will help guide consumers, providers and advocates for IHSS.
This guide is not a substitute for the independent judgment and skills of an attorney or other professional. If you require legal or other expert advice, please consult a competent professional in your geographic area to supplement and verify the information contained in this guide, as this guide is directed at services offered in Los Angeles County.
The authors and publisher have done everything possible to make this booklet accurate, up-to-date, and in accord with accepted standards at the time of publication. The authors, editors, and publisher are not responsible for errors or omissions or for consequences from application of the book, and make no warranty, express or implied, in regard to the content of the booklet.
Table of Contents
What are In-Home Supportive Services (IHSS)? ———————————2
How do I qualify for IHSS? ———————————2
How do I apply for IHSS ———————————3
How do I enroll in Medi-Cal? ———————————3
How do I apply for Medi-Cal? ———————————3
How do I find an IHSS home care provider? ———————————3
What services does IHSS provide? ———————————5
How can I get the most IHSS hours? ———————————7
How can I increase my IHSS hours? ———————————9
My condition has gotten worse. Can I get more IHSS hours? ———————————9
What is protective supervision? ———————————10
What are paramedical services? ———————————13
Can my spouse be my IHSS provider ———————————13
Can I be the IHSS provider for my minor child? ———————————14
IHSS reduced my hours. What should I do? ———————————15
How do I ask for a hearing? ———————————15
What happens when I ask for a hearing? ———————————16
What is a conditional withdrawal agreement? ———————————16
What happens at an IHSS hearing? ———————————18
Sample IHSS problem: Sue needs more IHSS time ———————————19
What could she do to increase her IHSS time?
How can I find more information ———————————20
about IHSS services and advocacy?
What other programs pay for home care? ———————————21
IHSS Assessment Worksheet ———————————22
In-Home Supportive Services, or IHSS, are part of the Medi-Cal program. IHSS pays for home care services in your home or workplace so that you can safely stay in your home or continue working. IHSS pays a parent, spouse, family member, friend or other provider to help you with the services needed. IHSS pays up to 283 hours a month for home care services.
You must have Medi-al to qualify for IHSS. You must live in your own home which could be an apartment, a house or another person’s home. You may get IHSS if you are homeless. You cannot get IHSS if you live in an assisted living, board and care, or nursing home.
You must need in-home care to help you stay safely in your home. Your doctor or licensed medical professional must complete an “IHSS Health Care Certification Form” stating:
To apply in Los Angeles County, call 888-944-4477 or 213-744-4477 or contact your local Department of Public Social Services office.
Medi-Cal is a health insurance program for people who have low incomes. For some Medi-Cal programs, you must also have low assets. Medi-Cal pays for medical treatments, medications, adult day healthcare, hospitalization, skilled nursing care, home care and durable medical equipment. You may be enrolled in both Medicare and Medi-Cal.
If you are approved for Medi-Cal but are unable to pay the monthly deductible (called the share of cost), you may be eligible for other less costly Medi-Cal programs.
If you are denied Medi-Cal, there may be ways to adjust your income or savings to qualify for Medi-Cal.
Medi-Cal eligibility rules are complicated. For assistance finding the best Medi-Cal program for you or help with Medi-Cal denials, contact the Health Consumer Alliance, www.healthconsumer.org or call 888-804-3536.
You can apply online at www.CoveredCA.com. You can also apply in person at your local Department of Social Services office or by calling 800-300-1506.
You must find your own provider. The provider can be a family member, friend or private provider. Give yourself time to find a qualified individual. Review their experience level, talk to references and discuss your home care needs and whether the provider is willing and able to help with them.
You are considered the employer for the IHSS program. It is your responsibility to find a home care provider, train the provider, supervise the provider, and, if necessary, fire the provider.
IHSS will send you time sheets that you must complete and sign. IHSS processes the time sheets then pays the provider. All providers—even family members and friends—must pass a criminal background check and complete an IHSS provider orientation before they start working as an IHSS provider.
In Los Angeles County, the Personal Assistance Services Council (877- 565-4477) has a home care registry of qualified IHSS home care providers. If you have a severe disability, they also offer temporary replacement providers if your regular IHSS provider is not available. In other counties, contact your local IHSS Public Authority for a local provider registry. To find your local Public Authority contact www.capaihss.org; or 916-492-9111.
How does IHSS decide how many home care hours I get? IHSS will send an eligibility worker to your home to evaluate your home care needs. IHSS calls the eligibility workers “social workers.” You may need to educate the social worker about your disability and how your disability affects your activities of daily living. The social worker will ask you questions about your daily care needs. Based on her observations and the information you provide, the social worker will determine your monthly IHSS hours. IHSS pays for up to 283 hours of home care per month depending on your individual needs. The average number of hours is 105 hours a month. The IHSS social worker will come to your home once a year to reassess your needs.
After the social worker completes your assessment, she will mail you a Notice of Action. The Notice of Action lists all of the IHSS service hours assessed and the time you receive for each service area.
IHSS pays for specific services as outlined by state law. Below are general service areas IHSS covers. A more specific list may be found online in the California Department of Social Services (CDSS) Manual of Policies and Procedures Division 30, Chapter 30-757 at www.dss.cahwnet.gov/ord/ entres/getinfo/pdf/ssman2.pdf.
Domestic services: sweeping, vacuuming, cleaning kitchen and bathroom, taking out garbage, dusting, changing the bed linens, cleaning wheelchair and recharging wheelchair batteries.
Meal preparation: preparing and cooking meals, pureeing food
Meal cleanup: loading and unloading dishwasher, washing dishes
Laundry: washing and drying laundry, folding and putting away clothes
Shopping for food: making grocery list, travel to and from store, shopping, loading, unloading and storing food
Other shopping errands: personal errands, making shopping list, travel to and from store, shopping, loading and unloading, storing supplies
Respiration: help with suctioning, oxygen, nebulizer or other breathing machines or devices
Bowel and bladder care: help with toileting, including use and cleaning of bed pans/bedside commodes and diapers and time for washing the provider’s and consumer’s hands
Feeding: assistance with eating or drinking including verbal prompting for feeding
Routine bed bath: help with baths in bed or sponge baths
Dressing: help dressing and undressing
Menstrual care: help with managing menstrual pads
Ambulation: help with walking or moving inside the home and workplace
Transfer: help moving from one position to another
Bathing: help with bathing in a tub or shower; helping in/out of shower; drying body; help with lotions, deodorant and powder
Oral hygiene: help with applying toothpaste, brushing teeth, caring for dentures, flossing
Grooming: help with combing/brushing hair, cutting nails, shaving
Repositioning/rubbing skin: help turning in bed or moving in chair, rubbing skin to promote circulation and/or prevent skin breakdown
Range of motion exercises: help with range of motion and strengthening exercises, help with assisted walking to strengthen muscles and gait
Care and assistance with prosthetic devices: help with prosthetic devices including braces, compression stockings, vision/hearing aids
Help with medications: help taking medications, including time for crushing pills and filling weekly pill box
Accompaniment to/from medical appointments: transportation to and from a medical professional’s office, including dental, chiropractic, and physical therapy among others. This may include provider wait time at the doctor’s office
Accompaniment to other places you get services in place of IHSS: transportation to adult day healthcare, senior lunch programs, day centers or other service providers
Protective supervision: monitor people who cannot be left alone because of a cognitive or mental impairment such as dementia, autism, intellectual or developmental disability, mental illness or any other mental impairment that limits the individual’s ability to properly assess dangerous situations.
Paramedical services: help with any care that is invasive in the body, such as checking blood sugar, giving injections, catheter care, or GI tube feedings. Your doctor or health care professional must train your provider to safely perform the paramedical services. The doctor must complete a paramedical services form in order for you to get this service.
Prepare for your IHSS assessment to get the most hours possible. Review the above service areas and see how much time you need for each area. You can complete the IHSS assessment worksheet on pages 22–25 and review it with the IHSS social worker at your assessment. You can give a copy of the completed worksheet to your IHSS social worker.
Be honest with the IHSS social worker about your needs. Although it may be uncomfortable to share personal information, the social worker needs this information to perform a good assessment. You can have a family member, friend or your provider with you at the assessment to help you explain your needs and offer support.
IHSS understands everyone’s condition changes. Explain to your social worker what happens when you have a bad day. If you are able to walk when the social worker visits but on bad days you can’t walk, be sure to give the social worker this information. If you do not share this information with the IHSS social worker, she will assume you are always able to walk.
Domestic and related service hours, like cleaning, meal preparation, meal clean up, laundry, shopping and errands, are usually divided by the number of people in the household. The more people in your household, the lower your hours in these categories will be. Make sure to tell your social worker if someone moves out or if your household members do not share meals or others domestic or related services.
After the IHSS social worker assesses you, she will mail you a Notice of Action. The Notice of Action tells you how many IHSS hours a month you will receive, when the hours begin (the effective date), and breaks down how many hours you get per week for each IHSS service area,
such as dressing or bathing. The Notice of Action has instructions on filing an appeal if you are denied IHSS or need more hours. You will be sent a Notice of Action whenever your hours are changed and after each annual reassessment. There are deadlines for when you can file an appeal—see the appeals section of this booklet for more information.
Be sure to carefully review the Notice of Action to see if you have enough hours to meet your need in each service area. The hours on the Notice of Action are calculated per week. For example, if you get 3:30 for bathing, that means you get three hours and 30 minutes a week or 30 minutes a day for bathing help. If there is a ‘0’ next to the service area, IHSS gave you no time for this service.
If you think the time IHSS gave you is enough to meet your care needs, great! If it is not enough time, you can ask your social worker to increase the time or ask for a hearing to get more hours.
If I am in the hospital or nursing home and I need to know my IHSS hours before I return home, can I ask for an assessment? Yes, IHSS can assess you in a medical facility and estimate how many hours you will receive when you return home. When you are home, IHSS will come back to your home and do a full assessment. If the IHSS social worker refuses to assess you in a facility, you may need to call
a supervisor to ensure you are assessed in the facility. In Los Angeles County, you may call the IHSS Ombudsman for the name and number of the supervisor. The Ombudsman’s number is 888-678-4477.
The best way to increase your hours is to know how many hours you need in each service area and give this information to your IHSS social worker. Complete the IHSS Assessment Worksheet in this booklet to figure out how much time you need and give it to the IHSS social worker.
Be specific with IHSS. Tell them how many minutes you need for each service area each day or each week. For example, if you need 60 minutes a day for feeding, tell the IHSS social worker you need 60 minutes for someone to feed you. Do this for each service area. This will help IHSS give you the time you need.
Keep track of all your calls to IHSS. Write down the day, time and name of person you called. Be sure to leave a message saying you need more hours. You may also write a letter to IHSS asking for more hours. Keep a copy of the letter for your records.
Any time your condition worsens and your home care needs change, you may call your IHSS social worker and ask for a reassessment. Tell your worker about the change in your condition and ask for more hours. The social worker can assess you over the phone or in your home. You have a right to reassessment if your condition worsens. You do not need to wait for your annual reassessment to ask for more hours.
If the IHSS social worker ignores or denies your request for more time, you can call the supervisor for help. IHSS social workers are often out
of the office, and the supervisor may be more responsive to your request. If the supervisor denies more hours, call the deputy director and ask to file a case complaint. The deputy should review your file and respond to your request.
You may ask for a hearing at any time to increase your hours. If you request a hearing, the county must respond to your hearing request, will discuss your concerns with you and may negotiate with you and resolve the problem so you can avoid going to the hearing. See the section “How do I ask for a hearing” on page 13 for more information.
If the IHSS recipient has dementia, an intellectual or developmental disability, mental health challenge or other mental impairment and cannot be left alone, IHSS has a benefit called protective supervision. IHSS will pay a provider to watch the recipient to keep the recipient safe from harm.
Protective Supervision is a benefit for children and adults. The IHSS recipient must be able to engage in dangerous behavior and must be supervised 24 hours a day. The individual must be nonself-directing. Nonself-directing means the individual cannot understand and assess danger and cannot understand the risk of harm to himself. Because the person cannot understand potential dangers, he may do things which could harm himself.
Some examples of dangerous behaviors include wandering from home and getting lost, cooking and leaving the gas on, or eating soap or other inedible objects. It helps to keep a list of any potentially dangerous behaviors and the date they happened. For example: May 1, Mom tried to leave the house at midnight, I asked her to go back to bed. When IHSS evaluates for protective supervision, give the list to the IHSS social worker.
Be sure to have a doctor complete the “Assessment of Need for Protective Supervision” form, which you can download at www.dss. cahwnet.gov/forms/english/SOC821.PDF. The doctor should note all dangerous behaviors on the form. Review the form carefully. If the information on the form is incorrect, ask your doctor to correct it. After the doctor fills it out, give this form to the IHSS social worker and keep a copy for your records. If your doctor sends the form directly to IHSS, ask the doctor to also send you a copy.
IHSS often denies protective supervision benefits when someone needs this service. You should ask for a hearing if protective supervision benefits are denied but you believe the IHSS recipient needs this service.
If IHSS grants protective supervision, the individual will get at least 195 IHSS hours a month. If IHSS considers the person to be severely impaired and they need protective supervision, the person will get 283 IHSS hours a month. To be severely impaired, the person must have at least 20 IHSS hours a week in non-medical personal services, paramedical services, and meal preparation. If the individual needs help with feeding and meal preparation, IHSS also includes time assessed for meal clean up in the 20 hour a week calculation.
Many people need 24-hour care for personal and medical monitoring. However, protective supervision benefits do not cover personal or medical monitoring needs. Please note, protective supervision will be denied if it is:
For more information on protective supervision, see the “In-Home Supportive Services Protective Supervision” publication from Disability Rights California, www.disabilityrightsca.org/pubs/549301.pdf.
Paramedical services are services that a medical professional usually performs. When your medical provider requests your IHSS provider to perform the service, it is called a paramedical service.
Some examples of paramedical services include checking blood sugar levels, giving injections, wound care, checking blood pressure and catheter care.
IHSS requires your doctor to complete a paramedical services form, called the “Request for Order and Consent—Paramedical Services” before these hours are approved.
You can download the paramedical services form at www.dss.cahwnet. gov/cdssweb/entres/forms/english/soc321.pdf. Give it to your doctor to complete. Be sure to tell the doctor how many minutes it takes for your provider to perform each paramedical task. Review the form carefully. If the information on the form is incorrect, ask your doctor to correct it.
Give a copy of the completed paramedical services form to your IHSS social worker and keep a copy for your records. If your doctor sends the form directly to IHSS, ask them to also send you a copy.
If you are married and receive IHSS, your spouse may be your IHSS provider for nonmedical personal services (like help with dressing and bathing) and paramedical services.
You will not receive IHSS time for domestic and related IHSS services (this includes housekeeping, meal preparation, meal cleanup, laundry, shopping for food and errands), protective supervision and accompaniment to medical appointments if your spouse is able and available to provide these services to you. If your spouse is not able or available to provide these specific services because of employment, health or other unavoidable reasons, then a provider may be paid for meal preparation, accompaniment to medical appointments and protective supervision.
If your spouse has to leave full time employment or is prevented from seeking full time employment because there is no other suitable provider for you, then IHSS may pay your spouse for protective supervision and accompaniment to medical appointments.
A parent may be the IHSS provider for children who are under eighteen years old. IHSS has special rules about parent providers. For more information about these rules, please refer to the IHSS Nuts and Bolts Manual available at www.disabilityrightsca.org; 800-776-5746.
Be aware when your child turns eighteen years old, IHSS evaluates a child as an adult and the IHSS hours will probably increase. Be sure to contact the IHSS social worker to reassess your child’s hours when your child turns eighteen years old.
When IHSS reduces or terminates your hours, they must send you a Notice of Action 10 days before the reduction or termination date. If you ask for a hearing before the reduction or termination date, you will get Aid Paid Pending the hearing (APP). This means your IHSS hours will stay the same and not be reduced or terminated while you wait for the hearing.
When you ask for the hearing, be sure ask for “Aid Paid Pending.” See the following section for information about hearing requests. If you lose at the hearing, you do not have to pay back the hours.
Contact the State Hearings office and tell them you need a hearing
to resolve IHSS problems. Give a short explanation about the problem. For example, “I need more IHSS hours” or “IHSS stopped my benefits.”
There are several ways to contact State Hearings and ask for a hearing:
800-952-5253 (Voice); 800-952-8349 (TDD)
916-651-5210 or 916-651-2789.
State Hearings Division
P.O. Box 944243 Mail Station 9-17-37
Sacramento, California 94244-2430.
Be sure to include the IHSS consumer’s name, address, telephone number and IHSS case number on the hearing request. Keep a copy of the hearing request for your records.
If you make a hearing request by phone, be sure to note the date you called and the name of the person who took your hearing request. DO NOT call your local IHSS office to request a hearing; you must contact the State Hearing office to request a hearing.
You may ask for a telephone hearing and the hearing will be conducted on the telephone. If you cannot go to the court or participate in a telephone hearing, you may request a home hearing and the judge will come to your home. You may ask for an interpreter, and the state will provide one for free. You may also have your own representative or advocate at the hearing. This can be a family member or a professional.
After you request a hearing, the Appeals and State Hearings Office will send you a letter with the name and phone number of the appeals specialist assigned to your case. The appeals specialist represents the IHSS program. The appeals specialist is responsible for reviewing the
appropriateness of IHSS’s action or inaction. The appeals specialist listens to your concerns and speaks to your IHSS social worker about them.
The appeals specialist might offer to resolve the case with a conditional withdrawal agreement instead of going to a hearing.
The appeals specialist may offer a conditional withdrawal agreement to resolve your IHSS problem without a hearing. A conditional withdrawal is a binding agreement between you and IHSS. For example, you asked for a hearing because you need more IHSS hours. The appeals specialist agrees you need more hours and IHSS should reassess you. The appeals specialist will write in the conditional withdrawal form that IHSS must reassess you for more hours.
You may ask IHSS to review hours up to 90 days retroactive from the date of your hearing request. For example, if you ask for a hearing on April 1, you may ask IHSS to evaluate you for more hours retroactive to January
The appeals specialist will mail you the conditional withdrawal form. The form outlines the appeals specialist’s agreement with you. Be sure to read it carefully and make sure it is correct. If it is incorrect, contact the appeals specialist and ask for a revised conditional withdrawal form which correctly states your agreement. Do not sign an incorrect conditional withdrawal. IHSS has 30 days to carry out the conditional withdrawal. For example, if IHSS agrees to reassess you; IHSS has 30 days from the date of the conditional withdrawal to reassess you, and issue a new Notice of Action with the new hours. If IHSS fails to do what the appeals specialist promised, you can reopen your hearing request by contacting the State Hearings office. You have the right to disagree with the new hours on the new Notice of Action. You may request a hearing on the new Notice of Action by contacting the State Hearings office and start the process again. You have the right to refuse the conditional withdrawal agreement and may choose to go to the hearing instead. You may also cancel the hearing at any time.
The appeals specialist is required to write a position statement. The position statement is IHSS’s interpretation of the facts and laws that apply to your case and IHSS’s justification for taking the action it took. The position statement may include a list of witnesses, doctor’s reports, notes from your IHSS social worker and other information about your case. The appeals specialist will give the position statement to the judge.
The appeals specialist must make the position statement available to you two working days before the hearing. You may pick up the position statement at the appeals specialist’s office or the appeals specialist may mail or email it to you. It is important to review the position statement so you are prepared to respond to all issues raised by IHSS. If you do not receive the position statement two days before your hearing, you may call State Hearings and ask for a postponement.
You may also write your own position statement to give to the judge. Your facts may be different than IHSS’s facts. You may include doctors’ reports, witness statements, photographs and any other information that supports your case. You may complete the self-assessment worksheet which you can find at page 22–25 of this booklet, and include it with your position statement. The completed worksheet will help the judge understand your IHSS care needs. When you check in for your hearing, give a copy of your position statement to the receptionist. If you have a telephone hearing, fax a copy of the position statement to the State Hearings office before the hearing. Call State Hearings for the local fax number.
An Administrative Law Judge (ALJ) conducts IHSS hearings. In addition to the judge, the appeals specialist will be at the hearing to represent IHSS. The IHSS social worker and IHSS nurse may come too.
The hearing is informal. You can have an advocate represent you but most people do not have advocates.
You can bring witnesses, like your provider. You can also give the judge your position statement, doctors’ reports or pictures which support your case. You can complete the self-assessment worksheet in this book and give a copy to the judge.
Usually, the judge will ask what issues you want to discuss. The judge will ask the appeals specialist how IHSS calculated your time in each category, such as bathing, dressing etc. The specialist will answer based on the IHSS social worker’s assessment and then you can explain your minute- by-minute needs in each category.
Although you may disagree with the IHSS social worker’s assessment of your needs, it helps to be respectful. You may ask the IHSS social worker questions and may disagree with evidence presented by the appeals specialist.
You will have the opportunity to explain in detail how many minutes you need for each IHSS task. You know your own needs better than IHSS. Supporting photos and doctors’ reports describing your home care needs are helpful.
The judge records the hearing and will write a decision. The judge will mail you the decision. The judge must issue the decision within 90 days from the date you requested the hearing. IHSS must comply with the judge’s decision and issue a new Notice of Action with the hours granted by the judge.
If you don’t agree with the decision, you can ask for a rehearing or file a writ. The first page of your hearing decision outlines these options and the deadlines for filing a rehearing or writ.
IHSS assessed Sue six months ago and Sue receives 100 IHSS hours
a month. After the assessment, Sue falls and breaks her hip. Sue needs more help with many activities she used to do herself. She calls her IHSS social worker and asks for more hours but the social worker does not increase her hours.
Sue then completes the IHSS Assessment Worksheet in this booklet and compares the time she needs to the time on her most recent Notice of Action. She realizes she needs more time for bathing, medications and home exercises.
Sue mails the following letter to her IHSS social worker:
The IHSS social worker does not call Sue so she asks for a hearing. State Hearings assigns an appeals specialist to Sue’s case. Sue sends a copy of her letter to the appeals specialist. Sue and the appeals specialist agree IHSS will come to her home to reassess her for more hours. The specialist and Sue sign a conditional withdrawal agreement which states IHSS will reassess her.
The IHSS social worker reassesses Sue. Sue gives the IHSS social worker a copy of the IHSS assessment worksheet which lists the time she needs for bathing, medication and home exercises. IHSS sends Sue a new Notice of Action raising her hours to 125 hours a month.
The Public Authority for In-Home Supportive Services offers provider registries, consumer and provider trainings and education opportunities. Some Public Authorities offer back up provider programs and other innovative programs. The Public Authority services are free of charge. Contact the California Association of Public Authorities for IHSS (CAPA) to find your local Public Authority: www.capaihss.org; 916-492-9111.
The Disability Rights California website offer detailed information about IHSS programs, provider payments, IHSS rules and regulations and their excellent IHSS guide entitled IHSS Nuts & Bolts Manual available at www.disabilityrightsca.org; 800-776-5746.
Legal aid agencies like Bet Tzedek Legal Services and Disability Rights California offer free legal services to people who qualify and may assist with IHSS advocacy and representation. Find a local legal aid
The Medi-Cal Nursing Facility/Acute Hospital Waiver pays for home care. You must need nursing facility level care to qualify for the waiver. The waiver assigns you a monthly budget for home care. You get to choose the home care services you need within the budget. You can choose nursing care, LVN care, attendant care and other services. Most people receive at least 300 hours of attendant care per month on this waiver. This waiver has a waitlist. Call In-Home Operations to apply: 916-552-9105 Sacramento or 213-897-6774 Los Angeles.
Veteran’s benefits are available for veterans who served in the military for 90 days or more, including one day during a time of war. Under the Aid and Attendance and Homebound programs, veterans or their spouses who need home care may receive a stipend to pay for personal care services at home or in a nursing home. The veteran or spouse must provide a doctor’s letter certifying the need for care and must also meet certain low-income and asset criteria. Contact the Department of Veterans Affairs to apply: 800-827-1000
|Do You Need Help with these Activities?||Please Mark the Level of Help Needed|
|Yes or No||Need Verbal Reminder||Can Do but Need Help|
|Shopping for Food|
|Nonmedical Personal Services|
|Breathing Assistance: Oxygen, Nebulizer,
Other Breathing Equipment
|Toileting: On/Off Toilet, Cleaning Up, Diapers|
|Feeding: Eating or Drinking|
|Taking a Bath in Bed or Sponge Bath|
|Menstrual Care: Help with Pads|
|Walking or Moving Around|
|Transferring, Moving In/Out of Bed or Chair|
|Taking a Shower or Bath|
|Brushing Teeth, Dentures, Flossing|
|Repositioning, Turning In Bed|
This assessment form was made possible with the help of the Coalition of California Welfare Rights Organizations.
|How Many Minutes|
|Can Do with Lots of Help||Cannot Do at All||of Help Needed Each Day?|
IHSS ASSESSMENT WORKSHEET CONTINUED
Need Help with these Activities?
|Please Mark the Level of Help Needed|
|Yes or No||Need Verbal Reminder||Can Do but Need Help|
Personal Services cont.
|Range of Motion Exercise, Strengthening Exercise, Assistive Walking Exercise|
|Putting on Braces or Special Equipment, Hearing Aids|
|Setting Up and Taking Medication|
|Going to medical appointments|
|Checking blood sugar levels|
|Other Paramedical Services||Use the space below to describe and detail the other paramedical services needed.|
|Protective Supervision||If a person has a mental impairment and can’t be left alone because of dangerous behaviors, ask for protective supervision.|
This assessment form was made possible with the help of the Coalition of California Welfare Rights Organizations.
|How Many Minutes|
|Can Do with Lots of Help||Cannot Do at All||of Help Needed Each Day?|
|Use the space below to log and describe dangerous activities or behaviors the person did or tried to do. For example, wandering and getting lost, cooking and leaving stove on, eating inedible objects, etc.|