1

In-Home Supportive Services Assessment Criteria Worksheet

Name of IHSS consumer: ______________________________________________

The IHSS Assessment

The amount of IHSS you get depends on how many hours you need. A county social worker calculates your hours

of need after doing a “functional assessment.” This is an assessment of your limitations in doing activities of daily

living.

After the social worker does the functional assessment and calculates your hours of need, the social worker

county social workers use when determining your hours of need for IHSS. This worksheet will also help you prorate

hours, if necessary.

NOTE: CDSS updated the format for the HTGs in December 2017 to match the format of the CDSS case

management system. The update is explained in All County Information Notice (ACIN) No. I-82-17 (December 5,

2017), available here. This means that the new, updated format differs slightly from the MPP sections we reference.

The MPP shows the HTGs in a decimal format in 10ths of an hour and looks like this example: 1.50 hours for 1 ½

hours or 1 hour and 30 minutes. See Appendix A for information on how to convert your times to 10ths of an hour.

2

Limitations) to this worksheet (Worksheet #4, IHSS Assessment Criteria Worksheet). Your doctor gave you

a rank for each task, and you need to complete this worksheet to match those same rankings.

2. Transfer the information from Worksheet #3 (IHSS Self-Assessment Worksheet) to this worksheet

(Worksheet #4, IHSS Assessment Criteria Worksheet). Worksheet #3 (IHSS Self-Assessment Worksheet)

helped you calculate the total hours of need for each task. This is the actual hours of need. The need for

domestic services (housework) is based on hours per month. The need for other services is based on

hours per week.

3. Compare the total hours of need with the hourly task guideline (HTG). If the total hours of need fall outside

the range of hours in the guideline, explain why you need an exception.

4. Prorate the hours, where appropriate, if there are other people living in your household who do not get

3

1. Domestic Services (Housework);

2. Laundry;

3. Shopping and Errands;

4. Meal Preparation/Meal Cleanup;

5. Ambulation (formerly Mobility Inside);

6. Bathing, Oral Hygiene and Grooming/Routine Bed Bath (Bathing and Grooming);

7. Dressing/Prosthetic Devices (Dressing);

8. Bowel, Bladder and Menstrual Care;

9. Transfer (Repositioning);

10. Eating;

4

Here are the general standards for ranking functional limitations, taken from the state IHSS regulations at MPP sec.

30-756.1:

have difficulty in performing the function, but the completion of the function, with or without a device or

mobility aid, poses no substantial risk to his or her safety. A recipient who ranks a "1" in any function

shall not be authorized the correlated service activity.

encouragement.

physical assistance from a provider.

impacts his/her functioning in the 11 physical functions listed [above] is ranked in each of those

5

respiration. If these are the only respiration services you need, respiration should be ranked as 1. See, MPP sec.

30-756.4.

functioning on recurring bad days. It is not based solely on a “worst” day scenario. (E.g., if you have arthritis, you

may have days when pain is significant and days when pain is mild. The social worker would determine your

functional index ranks based on the recurring days on which you have significant pain.) MPP sec. 30-757.1(a)(1).

to perform tasks based on your functional index rankings is a contributing factor but not the sole factor. Other

factors include your living environment and variations in your functional capacity. MPP sec. 30-757.1(a)(1).

made when necessary to enable you to establish and maintain an independent living arrangement and/or remain

6

linen; changing light bulbs; and wheelchair cleaning and charging/recharging wheelchair batteries.

☐ Rank 1 - Independent: Able to perform all domestic chores without a risk to health or safety. Recipient can

do all chores though s/he might have to do a few things every day so s/he doesn’t overexert her/himself.

• Social Worker Observation: Observe if the home is neat and tidy. Observe if the recipient’s movement is

unimpaired.

• For Example: Recipient with no signs of impairment moves easily about a neat room, bending to pick up

items and reaching to take items from shelves.

• Question social worker may ask: Are you able to do all the household chores yourself, including taking out

the garbage?

☐ Rank 2 - Able to perform tasks but needs direction or encouragement from another person. Recipient can

7

• Question social worker may ask: How do you keep your apartment clean? Has anyone been helping you

up to this time?

☐ Rank 3 - Requires physical assistance from another person for some chores (e.g., has a limited endurance

or limitations in bending, stooping, reaching, etc.).

• Social Worker Observation: Observe if the recipient has some movement problems as described above;

has limited endurance; is easily fatigued; or has severely limited eyesight. Observe if the home is generally

tidy, but needs a good cleaning; if it is apparent that the recipient has tried to clean it, but could not.

• Example: Small frail woman answers apartment door. Apartment has some debris scattered on carpet and

quite-full trashcan is sitting in kitchen area. The remainder of apartment is neat.

• Questions social worker may ask: Have you been doing the housework yourself? What have you been

8

your activities?

☐ Rank 5 - Totally dependent upon others for all domestic chores.

• Social Worker Observation: Observe if dust/debris is apparent; if there is garbage can odor; if the

bathroom needs scouring; if household chores have obviously been unattended for some time. Observe if

the recipient has obviously very limited mobility or mental capacity.

• Examples: Bed-bound recipient can respond to questions and has no movement in arms or legs. Frail

elderly man is recovering from heart surgery and forbidden by doctor to perform any household chores.

• Questions social worker may ask: Are there any household tasks you can perform? What is limiting your

activities? Who has been helping you to this point?

9

Services)

Hours per month: ____

Rank 2

Rank 3

Rank 4

Rank 5

6:00 hours per month per household

Exceptions to Hourly Task Guidelines needed? Yes ☐ No ☐

Reasons for exceptions:

16

• Social Worker Observation: Observe if the recipient’s movement is impaired; if s/he has poor strength and

endurance or severely limited eyesight; if s/he appears adequately nourished and hydrated.

• Example: Recipient can reheat meals, make a sandwich, and get snacks from the package. Recipient's

arthritis impairs her/his grasp; s/he cannot wash dishes because s/he cannot hold on to dishes.

• Question social worker may ask: What type of meals are you able to prepare for yourself? Can you lift

like fruit and cold drinks, can get cereal, or make toast for breakfast, etc.

• Question social worker may ask: Can you stand long enough to operate your stove, wash, dry, and put

away dishes and/or load/unload the dishwasher?

☐ Rank 5 -Totally dependent on another person to prepare and cleanup all meals.

• Social Worker Observation: Observe if the recipient has severe movement problems or is totally

disoriented and unsafe around the stove.

17

• Example: Recipient has schizophrenia. Recipient believes that when s/he gets wet the water has the

power to enable people to read her/his mind. Provider cuts up food in bite-sized portions and carries tray to

bed-bound recipient.

(hours per week)

18

Rank 2 3:01 to 7:00

Rank 3 3:30 to 7:00

Rank 5 7:00 to 7:00

Meal Cleanup: MPP sec. 30-757.132

Hours per week: ____

Rank 2 1:10 to 3:30

Rank 3 1:45 to 3:30

19

bathroom; climbing or descending stairs; moving and retrieving assistive devices, such as a cane, walker,

☐ Rank 1 – Independent: Requires no physical assistance though recipient may experience some difficulty

or discomfort. Completion of the task poses no risk to his/her safety.

• Social Worker Observation: Observe if the recipient is steady on feet, able to maneuver around furniture,

home and observe ambulation.

• Questions social worker may ask: Do you ever have any difficulty moving around? Have you ever had to

use a cane or walker? Do you feel safe walking alone in your home?

☐ Rank 2 – Can move independently with only reminding or encouragement (e.g., needs reminding to lock a

brace, unlock a wheelchair or to use a cane or walker).

• Social Worker Observation: Observe if the recipient can use his/her walker or cane of his/her own volition;

20

• Questions social worker may ask: Do you ever have trouble handling your device? Are there times when

you forget and get somewhere and need help getting back or do not wish to use your device? What

☐ Rank 3 - Requires physical assistance from another person for specific maneuvers (e.g., pushing

enough to handle the device; if there are architectural barriers in the home.

• Questions social worker may ask: Are there times when you need to rely on someone else to help you get

around the house? What kind of help do you need and when? What happens when there is no one to help

you? Are there certain times of day or night when movement is more difficult for you? Are all areas of your

home accessible to you?

☐ Rank 4 – Requires assistance from another person most of the time. Is at risk if unassisted.

• Social Worker Observation: Observe if the recipient can answer the door; get back safely to his/her seat; if

there is clutter on the floor, scattered rugs, or stairs; if there is obvious fatigue or labored breathing; if there

are bruises, scabs, bumps, or burns (signs of falls) on the recipient.

• Questions social worker may ask: Is there someone in the home helping you now? If so, what is the level

21

• Social Worker Observation: Observe if the recipient appears to be immobile; if s/he appears to be

uncomfortable or in pain; if s/he has any fears related to being moved; if s/he makes needs known.

to make you more comfortable?

(Before Hourly Task (HTG) Guideline Comparison) Functional Index Rank

Hourly Task Guideline (HTG) Comparison (hours per week)

Hours per week: ____

2 0:35 to 1:45

3 1:00 to 2:06

4 1:45 to 3:30

5 1:45 to 3:30

Exceptions to Hourly Task Guidelines needed? Yes ☐ No ☐

22

washing/drying hands.

Grooming includes combing/brushing hair; hair trimming when the recipient cannot get to the barber/salon;

shampooing, applying conditioner, and drying hair; shaving; fingernail/toenail care when these services are

not assessed as Paramedical services for the recipient; and washing/drying hands.

Note: Bathing, Oral Hygiene, and Grooming does not include getting to/from the bathroom. These tasks are

assessed as mobility under Ambulation services.

away; obtaining water and supplies; washing, rinsing, and drying body; applying lotion, powder, and

deodorant; and washing/drying hands before and after bathing.

☐ Rank 1 - Independent: Able to bathe, brush teeth, and groom self safely without help from another person.

23

• Social Worker Observation: Observe if the recipient’s mobility is unimpaired; if the recipient is clean and

well groomed; if there is assistive equipment in the bathroom.

• Questions social worker may ask: Are there times when you forget to bathe, brush your teeth, and groom

yourself, or it seems just too much bother? Does anyone help you organize your bath or shower?

☐ Rank 3 - Generally able to bathe and groom self, but needs assistance with some areas of body care (e.g.,

getting in and out of shower or tub, shampooing hair, or brushing teeth).

• Social Worker Observation: Observe if the recipient has weakness or pain in limbs or joints; difficulty raising

arms over head, frailty, general weakness, unsteady gait indicating a safety risk; if the bathroom is not set

up to meet the recipient’s safety needs (e.g., grab bars, tub bench); if recipient’s grooming indicates an

unaddressed need.

• Example: Recipient has fear associated with lack of movement.

• Questions social worker may ask: Are there areas of bathing, oral hygiene, or grooming you feel you need

24

accessible and modified the bathroom is to meet the recipient’s needs.

• Questions social worker may ask: How much help do you need in taking a bath and washing your hair? If

there were no one to help you, what would be left undone? Do you experience any loss of sensation to

your body? Do you have any fears related to bathing? Have you fallen when getting into or out of the tub

or shower? What would you do if you did fall?

☐ Rank 5 - Totally dependent on others for bathing, oral hygiene, and grooming.

• Social Worker Observation: Observe if there is any voluntary movement and where; if the recipient exhibits

good skin color, healthy, clean skin and hair; if bathing schedules/activities are appropriate for the

recipient’s specific disability/limitations.

routines? Does anything frighten or scare you when you are bathed?

25

Comparison

(hours per week)

Bathing, Oral Hygiene And Grooming: MPP sec. 30-757.14 (d)

Hours per week: ____

Rank 2 0:30 to 1:55

Rank 3 1:16 to 3:09

Rank 4 2:21 to 4:05

Rank 5 3:00 to 5:06

32

• Social Worker Observation: Observe the severity of the recipient’s movement problems; if the recipient

cannot transfer unassisted; the recipient’s or provider’s statement as to the quantity or frequency of daily

laundry and any indication that “hand” laundry is done daily. Observe if there is a large amount of

Bowel, Bladder, and Menstrual Care: MPP sections 30-757.14(a) & 30-757.14(j)

(Before Hourly Task (HTG)

Guideline Comparison

Bowel and Bladder Care: MPP sections 30-757.14(a)

Hours per week: ____

Rank 2 0:35 to 2:00

33

Transfer (Repositioning): MPP sec. 30-757.14(h)

Transfer: Assisting from standing, sitting, or prone position to another position and/or from one piece of equipment

or furniture to another. This includes transfer from a bed, chair, couch, wheelchair, walker, or other assistive device

generally occurring within the same room.

34

☐ Rank 1 - Independent: Able to do all transfers safely without assistance from another person though

recipient may experience some difficulty or discomfort. Completion of task poses no risk to his/her safety.

chair unassisted when s/he shows you the house; if s/he shifts weight while sitting.

the recipient comes to door; if the recipient asks you for a boost when s/he gets up to get medications, or is

shaky when using assistive device; if the recipient is obese and has a great deal of difficulty getting up.

• Questions social worker may ask: Do you always have difficulty getting out of a chair? Who helps you?

How? How often? Do you also have trouble getting out of bed? What kind of help do you need?

35

☐ Rank 4 - Unable to complete most transfers without physical assistance. Would be at risk if unassisted.

• Social Worker Observation: Observe if the recipient uses an assistive device for mobility; if the recipient’s

joints are deformed from arthritis or some other disease; if the recipient is wearing a cast or brace; if

someone in house assists the recipient to get up if s/he uses a walker or is in a wheelchair; if there are

bruises, scabs, or bumps or burns on the recipient.

Functional Index Rank

Comparison

36

Transfer

Hours per week: ____

Rank 2 0:30 to 1:10

Rank 3 0:35 to 1:24

Rank 4 1:06 to 2:20

Rank 5 1:10 to 3:30

Exceptions to Hourly Task Guidelines needed? Yes ☐ No ☐

Reasons for exceptions:

37

o Such exercises include carrying out of maintenance programs (e.g., the performance of repetitive exercises

required to maintain function, improve gait, maintain strength, or endurance; passive exercises to maintain

a range of motion in paralyzed extremities; and assistive walking).

Note: “Repositioning and rubbing skin” does not include:

• Care of pressure sores (skin and wound care). This is assessed as part of “paramedical” specified at MPP 30-

757.19.

• Ultraviolet treatment (set up and monitor equipment) for pressure sores and/or application of medicated

creams to skin. These tasks are assessed as part of “assistance with prosthetic devices” at MPP 30-757.14(i).

Exceptions to Hourly Task Guidelines needed? Yes ☐ No ☐

38

Feeding: MPP sec. 30-757.14(c)

Assisting with consumption of food and assurance of adequate fluid intake consisting of eating or related assistance

to recipients who cannot feed themselves or who require other assistance with special devices in order to feed

themselves or to drink adequate liquids. Eating task includes assistance with reaching for, picking up, and grasping

utensils and cup; cleaning face and hands; and washing/drying provider’s hands.

Note: This does not include cutting food into bite-sized pieces or puréeing food, as these tasks are assessed in

Meal Preparation services.

Note: Tube feeding. If all of the recipient’s ingestion of nutrients occurs with tube feeding, the recipient shall be

• Questions social worker may ask: Do you need any help eating? (Since deterioration usually occurs in a

hierarchical manner and feeding oneself is the last function to lose, questions may not be necessary if the

39

☐ Rank 2 - Able to feed self, but needs verbal assistance such as reminding or encouragement to eat.

• Social Worker Observation: Observe if the recipient appears depressed, despondent, or disoriented; if the

recipient’s clothes seem large for the recipient, indicating possible recent weight loss; if there is rotten food,

no food in refrigerator, or a stockpile of Twinkies®, only; if there are not any signs of cooking.

it sometimes seem like it takes too much effort to eat? Do you have trouble deciding what to eat?

limited eyesight.

utensils to feed yourself? Do you feel you get enough to eat? Do you have difficulty reaching food on your

plate or reaching your glass?

☐ Rank 4 - Able to feed self some foods, but cannot hold utensils, cups, glasses, etc., and requires constant

presence of another person.

• Social Worker Observation: Food stains on clothing; shakiness of hands; deformity of hands with limitation

40

• Questions social worker may ask: Does someone help you eat? How? How often? Do you eat with the

rest of the family? Can you feed yourself finger foods? Are you able to use a fork or spoon? Do you have

difficulty chewing or swallowing? If so, how do you deal with the problem?

towels, bibs, etc., near the recipient.

Guideline Comparison)

Hours per week: ____

Rank 2 0:42 to 2:18

Rank 3 1:10 to 3:30

Rank 4 3:30 to 7:00

Rank 5 5:15 to 9:20

Exceptions to Hourly Task Guidelines needed? Yes ☐ No ☐

41

48

• Questions social worker may ask: What is your name? Where do you live? What is the date today? What

year is it? Where are you? Where are you going? If the recipient cannot respond or responds

49

of poor nutritional value; if the recipient cannot recognize there are alternatives or unable to select between

them and cannot plan or foresee consequences of decisions. Observe if the recipient is not capable of

making decisions without advice from another, is able to understand options when explained, makes

correct choices; knows enough to turn stove and heat on and off.

• Example: Recipient wastes money on useless items while allowing needed repairs to go unattended. The

recipient “makes do” with the condition of home even if it is inconvenient for the recipient. The recipient

appears to be a “collector,” has difficulty throwing anything out even though access through home is limited.

The recipient can’t decide which provider s/he wants. The grocery list to provider contains mostly junk

food. The recipient stopped homebound meals when s/he decided they weren’t tasty rather than add salt.

S/he refuses to use walker or cane.

as if your heater did not work?

50

unattended. In the past year, the recipient has recurrently started dinner and fell asleep and awoke to a

smoke-filled kitchen.

needed to get to the doctor what would you do? Ask Housemate: What happens when __ is left alone?

Can s/he recognize situations that would lead to danger? Is s/he capable of making rational decisions?

Task Area

Hours Per Week

Accompaniment to Medical Appointment: Indicate number of medical appointments per week, driving distance, and

wait time (providers can get paid for accompanying a consumer at a medical appointment if the worker is “on duty” –

meaning the provider is required to remain because at any moment the provider will help the consumer return to

home. For more information, see our IHSS Provider Wait and Travel Times publication, available here).

51

Paramedical (SOC 321 completed by physician & client required): Explanation of time needed for completion of

service and frequency.

Average Time Needed: Click or tap here to enter text.

Average Time Needed: Click or tap here to enter text.

Yard Hazard Abatement/ Snow Removal (services are limited. See, MPP sec. 30-757.16)

Average Time Needed: Click or tap here to enter text.

52

Has the county identified someone or an agency or entity willing to provide IHSS services for free?

Circle answer below ↓

If YES: the county is required to get a signed statement (SOC 450) from the provider saying the provider knows

about the right to be paid by IHSS but voluntarily chooses not to accept pay. See, MPP sec. 30-757.176. The

county may not reduce hours because of an alternative resource until a SOC 450 has been completed and placed in