IHSS Protective Supervision | Undivided Training Series

Does your child require constant supervision to prevent accidentally hurting themselves? In this training session, Undivided Public Benefits Specialist Lisa Concoff Kronbeck dives into who is eligible for IHSS protective supervision, how many hours your child might get, and important tips to follow when applying.

Here are links to the Undivided articles and other resources included in the training:

• Get the IHSS Protective Supervision & Paramedical Services form and valuable application tips in our article here.

• Don’t have time to create a behavior log? We’ve created a template for you! Check it out here.

See also this Q&A with answers to common questions about protective supervision.

All right, so today we're going to talk about protective supervision. We talked a little bit about it last week, but we'll go into into more detail today. Okay, so protective supervision is one of several different IHS categories of services. Protective supervision hours are awarded to people who need 24/7 supervision in order to prevent injury to themselves or others due to severely impaired judgment, orientation and or memory, their actions need to be non self directing, and the risk of harm to self or others must be due to their severe cognitive impairment. And I self directing can mean a couple different things in different settings. There's there's a clinical definition for the purpose of IHS non self direction is defined as an inability due to a mental impairment or mental illness for individuals to assess danger and the risk of harm, and therefore the individual would be most would most likely engage in potentially dangerous activities that may cause self harm.

So a little, a little note here, it's not it's there's two things. One is that they they have an inability to assess the risk of harm, and two is that they are likely to engage in potentially dangerous activities. So something that comes up sometimes with some of our kids is if they don't walk, meaning they're non ambulatory, but they still require constant supervision. In order to avoid injury, you need to make sure that you're prepared to answer specific questions about how your child could potentially injure themselves, even though they don't walk. And this is something that especially with kids who have medical devices that they pull on or remove, as well as kids who have enough mobility to sort of get themselves into a dangerous position, but not the mobility to get themselves out of it. So they think about that. If you have a child who who is non ambulatory but has still been able to injure themselves due to their impairments. So talk for a minute about what is not protective supervision. First of all, protective supervision cannot be awarded for monitoring and anticipation of spontaneous medical emergencies. The example they always give is seizures, but like if somebody has a heart condition, you can't monitor them in case they they have a heart cardiac episode, it's for accidental injury because of their cognitive impairments.

But there are sort of two caveats to that. One is, even if you can't get monitoring for protective supervision or potential medical emergencies, there may be situations where you need paramedical service hours for intermittent monitoring, especially if the person is not able to communicate their symptoms because of their communication impairments. For example. If you have a child who's diabetic and they're not able to communicate with you how they're feeling, how their how their body is feeling, and whether they're having symptoms, that may necessitate checking their blood sugar more often. If you have a child who has respiratory issues, you might need to check their their their pulse oximetry more often, just if they're not able to communicate, and they have a chronic issue that that fluctuates, you may need to do certain measurements. You may need to take certain measurements more often, and you should account for that in your paramedical services. The other, the other issue that sometimes comes up is that sometimes the the emergency that you're monitoring it for is because of their cognitive impairments.

For example, if a child has a G Tube or oxygen or a trait and they're, you know, constantly playing with it because they don't understand what it's for. Or, you know, if you have, you have a child or a recipient who has, like, a central line, or a thick line, again, a G Tube, anything like that, where it's a life sustaining medical device, and they're taking it off because they don't understand the consequences of taking it off. That is potentially grounds for protective supervision in itself, because the injury, the medical emergency, that is being caused by their cognitive impairment. Protective supervision can also not be awarded for intentional self injury or aggressive behavior that they also say, sometimes aggressive or anti social behavior. You cannot receive protective supervision to prevent intentional harm to self or others. Now, one of the things that, one of the issues that often arises here, is that we have a tendency to like, use words colloquially. So like, we'll we'll say, Oh, they have aggressive behavior, um, meaning they lash out and hit people. But if, if it's not intentional, then I would be careful about using the word aggression, because the way that IHS perceives aggression as is intentional. They they lash out with the intent to hurt somebody else. Whereas a lot of our kids can have sensory issues and meltdowns, and they might be sort of flailing or lashing out, but their intention is not to hit somebody. They're they're they're not regulating their body movements, and so be careful about the words that you use and make sure that the words that you use actually describe your child's behavior.

And the last issue is you cannot get protective supervision for damage to property, as opposed to physical harm to self or others. But there's a question here about, what if your child is damaging property on a routine basis? The question is, could they be injured by that if they're, you know, breaking glass or knocking over furniture, the issue isn't, you know they, you know they, they broke my object. The issue is, if the child doesn't understand that they need to avoid broken glass and they're breaking glass, there's the potential for injury there. So if you're talking about situations where the child is breaking things, the question to ask yourself is, could this, could the child be injured by the thing that they broke? And do, would they understand that they need to be careful around it, and if not, then you want to make sure that you're including that in your behavior log, which we will talk about. So you can open up the app and add the protective supervision goal into your roadmap. It includes a sort of sample behavior log, and we'll go over that in a little while. Let's look at the protective supervision form, though, first, you should talk to your doctor about this form before you have them fill it out, because it can be a little confusing for doctors in terms of how to describe impaired memory, orientation and judgment in a child you know. So when you talk to your doctor, you want to remind them that this is relative to a typically developing child of the same age.

So as far as orientation, for example, what does a typically developing child of the same age know. Do they know what day it is? Do they know what time it is? Do they know what city they live in? Do they know what time like, what what like, what the weather is outside? Do they know their parents names like it like? Do they know their their place in time and space relative to a typically developing child at the same age, and the same would be true about judgment or memory. I mean, four year olds generally don't have the best judgment. But if a doctor can think about the other four year olds that they see, how does that vary? How does your child differ from those children in terms of. Their judgment in terms of their memory. So have that conversation with the doctor ahead of time, because sometimes doctors can be a little bit wary about filling out these forms if they if they haven't thought about what those terms mean, because they might be thinking in terms of adults, and it's like, well, they don't have that kind of judgment relative to an adult. Now it's relative to a typically developing child of the same age, and we're going to talk about the behavior log in a minute, but generally speaking, most advocates recommend that you prepare a log of your child's potentially dangerous behaviors, partially for the doctor and partially for the IHS caseworker, and when you do this, you should make an entry not just every time your child actually gets injured, but every time you have to intervene on a behavior that could have gotten them injured if you hadn't stepped in.

And again, we're gonna we're gonna look at a sample log, but you might want to make a note that this log is non exhaustive and not every single incident is included. You just can't write everything down. I mean, we we spend our whole day looking after our children, and if we spent the whole if we wrote down every single thing, when would we get a break? Right? So just make sure that you make a note that like this is a sampling of the kind of behaviors that we see, and this is pretty indicative of what we see on a regular basis, and just a reminder that you cannot get protective supervision for intentional self harm, intentional aggression or property damage.

Some people have asked, like, does it matter if all of the boxes are marked severe? Because there's there's sort of like no deficit, there's moderate or intermittent, and then they're severe. Generally speaking, they're looking for for at least one of them to be marked as severe, but they're not supposed to just use this form and say, well, if it's not all marked severe, then they're not going to get it. On disability rights, California has a publication where they talk about this, and they say the county is supposed to use this in conjunction with other evidence, like if you submit letters, if you submit you know the behavior log that's supposed to it's supposed to be considered in conjunction with that. People also ask a lot of times, is it okay if I submit documentation from school? Yeah, it can definitely be helpful to submit documentation from school, letter from the teacher, the IEP, to show that your child needs a one to one in the school setting. But you should still make sure that you're providing concrete examples from home, because the main question for IHS is whether the individual needs 24/7 supervision to remain safely in their home.

So you need to, if you're submitting the IEP, still need to make sure that you have examples that happen at home. So let's look at a sample behavior log. I'm not giving sample behaviors, but I the way that I like to do things is because you like, if your child is doing something constantly, you don't. It's hard to write it down every time, so you might want to have your behavior log be like, Okay, this is a non exhaustive list. This is not everything. There's things that are left out, but this is a sampling the kind of the kind of issues we deal with around the clock. Here's some examples of things that we see every single day. Here's a few examples of things that we see at least a few times a week. Here's an example of, you know, maybe bigger incidents that happen at least once a week at unpredictable times. We don't need, you know, there. One of the things they're looking for is to see that issues are happening. 24 the child needs 24/7 supervision. If there's one incident that only happens at three o'clock every day, then they're going to say what happens at predictable times. So think about things that are happening throughout the day. If your child gets up a lot at night, make sure that you're including that as well.

So include those things, and then include a list. Be like, well, I kept track of some additional behaviors over this period of time. And here's a list of these behaviors. And this is, this is pretty representative of what we see on on on a regular basis. And you can find this sample in your in your roadmap. So let's talk about the SOC, 825, which is, which is the 24 hour coverage plan. This. This is not the protective supervision form that was on the previous slides. That's the form your doctor is going to sign. This is a really, really basic form that just shows that, because you're saying that your child needs 24/7 care, you're showing that you have coverage 24/7 they're not going to give you hours for 24/7 care, but they want to make sure that if a child needs it that you're making sure that you have 24/7, coverage, whether or not those hours are being covered by IHS. This can be really, really basic. This is like, you know, from x time to x time the child's in school with a one to one aid, from x like y time to Z time they're at home and the parent is providing supervision. You know. Of our one of our specialists, right? 180 days per year, the child is in school from x time to y time, and the rest of the time the parent provides supervision. It's that basic. You do not want to put a lot of details here. This is super, super basic.

So again, if you don't have time to create a behavior log. You can go back to that concept of, like, here's a bunch of things that we deal with every day, here's a bunch of things that we deal with every week. Here's, you know, here's, here's some other major incidents that have happened and this, this is a good way to approach things. If you know your your meeting is next week and you haven't had time to create, to like, actually write down every single thing that's happened, make a list, put think, put as many things you can think of, of things that that have been happening consistently, and make sure that you note that it's only partial, because one of the things that we've seen come up is you may have the you may submit a behavior log, and then you may talk about other behaviors that your child engages in. And then at the hearing, the judge might say, well, I don't see that behavior in the behavior log, so they must not be doing it that often. Like, no, it's you just, there's no way that you can write every single thing down, you know, um, so, yeah, I'm just trying to think, if there's anything, just make sure that you're giving examples.

Because if you just say, I have to watch my child all the time, what you're going to get back from the caseworker is, so does every other parent, but the more they can see the kind of behaviors that your child is exhibiting, the more they'll be able to sort of differentiate every child needs supervision, and that's parent responsibility from okay, this this child needs more supervision than even a typically developing child of the same Age. So protective supervision is is one of those areas that is really your application is going to be really, really tailored to your child.