IHSS: Protective Supervision and Paramedical Services
For most children, the bulk of IHSS hours awarded will be to those who are eligible for protective supervision and/or paramedical services. Both services require physician certification and documentation of need. We break them both down for you here.
Protective supervision is an IHSS service for recipients who require 24/7 supervision to prevent injury to themselves or others due to severely impaired judgment, orientation, and/or memory (their words). IHSS does not provide funding for 24/7 supervision, but it does award a block of hours to cover a portion of this need. Severely impaired recipients will receive protective supervision hours on top of their other hours, up to a maximum of 283 hours per month. Non-severely impaired recipients will receive their monthly hours plus 195 protective supervision hours.
Your child’s doctor will need to fill out the SOC 821 form to confirm eligibility for this service. It may be useful to provide your doctor with a log of your child’s potentially hazardous behavior in terms of judgment, orientation, and/or memory so they have a sense of how to fill out the form. You might even ask your doctor if they would like you to fill out a copy of the form as a guide and then provide them with a blank copy to fill out themselves.
Disability Rights CA’s publication on protective supervision offers the following advice regarding the specific categories listed on the SOC 821 form:
“Many times, the county will grant protective supervision if a recipient’s doctor marks the “yes” boxes in questions one and two of the SOC 821 form and marks the “severe” boxes in all areas of functioning, and will deny protective supervision to everyone else. However, the county is supposed to use the SOC 821 form in conjunction with other pertinent information to assess the need for protective supervision. The (SOC 821) form alone shall not be used to show eligibility for protective supervision. (Welfare and Institution Code § 12301.21 and MPP 30-757.173(a)(2) and (3)).”
Protective supervision is awarded for recipients who are non-self-directing and whose risk of harm to self or others is due to their severe cognitive impairment. Non-self-direction is defined as “an inability, due to a mental impairment/mental illness, for individuals to assess danger and the risk of harm, and therefore, the individuals would most likely engage in potentially dangerous activities that may cause self-harm.”
Protective supervision will NOT be awarded for:
🚫 Monitoring in anticipation of medical emergencies as opposed to accidental injury. (However, you may seek paramedical service hours for intermittent monitoring, such as to track blood sugar or check pulse oximetry, particularly if the recipient’s communication deficits impair their ability to relay symptoms to their provider.)
🚫Intentionally self-injurious or aggressive behavior. A recipient cannot receive protective supervision to prevent intentional self-harm or deliberate violence.
🚫Damage to property as opposed to physical harm to others.
Along with the SOC 821 form, you can also submit other documentation to IHSS, including hazardous behavior logs, a letter from your child’s Regional Center outlining their cognitive impairments relative to judgment, orientation, and/or memory, a copy of your child’s ABA assessments, or other documentation that demonstrates an elevated need for close and constant supervision due to non-self-direction.
Protective supervision for children under five
It is difficult, but not impossible, to receive protective supervision for young children (those under five years old). This is especially the case for toddlers, because small children generally require very close supervision. However, age cannot be the sole deciding factor in denying protective supervision. Your documentation, including logs of injuries and prevented injuries, will be key to securing this service. (See Disability Rights California’s publication “In Home Supportive Services Protective Supervision” for further reading, as well as a guide to creating a hazard log.)
You must be able to demonstrate that your child requires closer supervision than what would be required for a typically developing child of the same age.
Special considerations for medical emergencies caused by non-self-directing behavior
Counties will generally argue that a person who requires monitoring for medical reasons is not eligible for protective supervision. However, there is a difference between supervision for an anticipated medical emergency (such as a seizure or high/low blood pressure) and supervision to prevent a medical emergency directly caused by the recipient’s non-self-directing behavior.
While protective supervision is not available in anticipation of a spontaneous medical emergency due to a known medical condition, supervision may be awarded if the recipient requires constant supervision to prevent the removal of life-sustaining devices because the recipient doesn’t understand the consequences of their actions. (See the CDSS training document with hypothetical recipient Karen, who relies on a wheelchair for mobility, but who pulls out her IVs as a non-self-directing behavior. Answer #9 indicates that this constitutes a dangerous behavior sufficient to warrant protective supervision. Note the statement that “it is the CDSS position that it is not a reasonable measure to use arm restraints to prevent Karen from pulling out the intravenous tubes.”
If a child is on oxygen, a ventilator, an intravenous port, a feeding tube, or similar life-sustaining medical technology and frequently removes, disconnects, or otherwise interferes with the function of the medical device in a way that is potentially dangerous because they don’t understand the danger and can’t be taught to stop interfering, this may be sufficient to demonstrate a need for protective supervision.
This potential avenue of self-injury may be particularly crucial to consider for medically complex children who are non-ambulatory, as counties will frequently argue that a child who isn’t mobile can’t get into trouble and hurt themselves. Documentation is key, both from the doctor and in terms of tracking incidents, whether in the hospital or at home.
The 24-hour care plan
In addition to the physician certification form, you may also be asked to fill out SOC 825, the 24-hour care plan for protective supervision. This form does not require great detail; it is simply meant to ensure that arrangements have been made for 24-hour coverage for a child who requires 24-hour supervision. A sample response might read, “8:00 a.m. to 3:00 p.m. at school with 1:1 aide. I provide all supervision outside of school hours.”
Paramedical services are services ordered and directed by the child’s physician or other licensed medical provider. Examples include, but are not limited to:
Preparation and administration of medications
Home therapy programs
Stoma and wound care
Monitoring of vital signs
Monitoring for as-needed medical interventions (such as assessing for need of rescue inhalers)
Related tasks requiring judgment based on training given by a licensed healthcare professional (see Disability Rights California’s publication “IHSS Program Covers Paramedical Services,” for further reading)
Breathing treatments, suctioning, and oxygen administration should also be included on the paramedical services form, although the hours may be allocated in their own category under “respiration” if the service provided is limited to assistance in self-administration.
Completing the paramedical services form
Sometimes, doctors will request assistance from parents in filling out the paramedical services form (SOC 321). If there are a lot of services, it is often helpful to provide your doctor with a spreadsheet of each paramedical service they have ordered, about how long it takes you to perform the task, and how frequently it occurs. The calculation of time should be from start to finish, including the time it takes to prepare, complete, and clean up after any task. It is easy to underestimate time spent on these services, so it may be useful to keep a detailed activity log for a week or two. If your child’s needs extend the amount of time required for a task, that should also be included in the calculation and you should make a note of it in the spreadsheet. For example, a child may have difficulty sitting still for a breathing treatment or venting of a g-tube, which makes it take longer. A child’s inability to communicate symptoms may necessitate more frequent monitoring of measures like blood sugar, pulse oximetry, and assessment for other ongoing symptoms of known medical conditions.
The doctor should review your spreadsheet for appropriateness, and can either translate the spreadsheet to the paramedical services form or write “see attached spreadsheet” on the form and then sign both the paramedical services form and the spreadsheet.
Tip: If your child’s PT/OT/speech therapy provider has given you a home plan to follow for reinforcement of skills outside of sessions, you should ensure that the plan includes specific instructions on frequency (how often) and duration (for how long) for each task or activity. On your paramedical services form, have your child’s doctor write, “Home therapy plan as directed by PT/OT/SLP” (depending on the service), and attach a copy of the home plan.
IHSS Protective Supervision and Paramedical Forms
Paramedical services (SOC 321) : https://www.cdss.ca.gov/cdssweb/entres/forms/English/SOC321.pdf
Protective supervision (SOC 821): https://www.cdss.ca.gov/cdssweb/entres/forms/english/soc821.pdf
You can also request that your caseworker provide you with copies of these forms during your initial home assessment, but if you anticipate that you will be requesting these services, you may wish to have them filled out ahead of the in-home visit.
Your doctor may complete and submit forms directly to IHSS or may provide you with the signed forms to submit yourself.
Tip: Keep copies of all documents completed by your child’s doctor in case IHSS misplaces them, and confirm receipt of all forms by IHSS.