Request for Information
Documenting Patient’s Functional Limitations

(Form Attached)

Your patient applied for, or is a recipient of, In-Home Supportive Services (IHSS). The IHSS program provides attendant care services in the home for people who cannot perform certain tasks (i.e. activities of daily living) for themselves so that the individual can continue to live at home. The services that can be authorized under the IHSS program are listed in the California Department of Social Services Manual of Policies and Procedures (MPP) beginning at section 30-757.

The IHSS program needs to know what your patient’s functional limitations are, and how your patient’s limitations impact his or her ability to perform activities of daily living, to determine how many hours per month can be authorized for attendant care services. For example (Cannot do housework because of inability to walk, use arms, and wrists.)

Please complete the following form to document your patient’s functional limitations.

Beneficiary Name:

DOB:

Diagnosis:

Prognosis:

Date Patient Last Seen By You:

Functional Limitations

Please list your patient’s functional limitations. (For example: breathing, seeing, hearing, walking, standing, bending, reaching, grasping, carrying, sitting, turning, weakness in arms or legs, loss of use of limbs, endurance, fatigue, etc.):

Functional Limitations Assessment

Please check appropriate box

(No more than 1 box for each task)

(Domestic) Housework: MPP § 30-757.11

Sweeping, vacuuming, and washing floors; washing kitchen counters and sinks; cleaning the bathroom; storing food and supplies; taking out garbage; dusting and picking up; cleaning oven and stove; cleaning and defrosting refrigerator; bringing in fuel for heating or cooking purposes from a fuel bin in the yard; changing bed linen.

• Independent: Able to perform domestic chores without a risk to health or safety.

• Able to perform tasks but needs directions or encouragement from another person.

• Requires physical assistance from another person for some chores; e.g., has a limited endurance or limitations in bending, stooping, reaching, etc.

• Although able to perform a few chores (e.g., dust furniture or wipe counters) help from another person is needed for most chores.

• Totally dependent upon others for all domestic chores.

Please briefly describe how your patient’s functional limitations limit your patient’s ability to do housework:

Laundry: MPP § 30-757.134

Gaining access to machines, sorting, manipulating soap containers, reaching into machines, handling wet laundry, operating machine controls, hanging laundry to dry, folding and sorting. Ability to iron non-wash-and-wear garments is ranked as part of this function only if this is required because of the individual’s condition; e.g., to prevent pressure sores or for employed recipients who do not own a wash-and-wear wardrobe.

• Independent: able to perform all chores.

• Requires assistance with most tasks. May be able to do some laundry tasks; e.g., hand wash underwear, fold and/or store clothing by self or under supervision.

• Cannot perform any task. Is totally dependent on assistance from another person.

Please briefly describe how your patient’s functional limitations limit your patient’s ability to do laundry:

Shopping & Errands: MPP § 30-757.135

Compile shopping list, bending, reaching, and lifting, managing cart or basket, identifying items needed, transferring items to home, putting items away, phoning in and picking up prescriptions, and buying clothing.

• Independent: Can perform all tasks without assistance.

• Requires the assistance of another person for some tasks; e.g., help with major shopping needed, but consumer can go to nearby store for small items or needs direction or guidance.

• Unable to perform any tasks for self.

Please briefly describe how your patient’s functional limitations limit your patient’s ability to shop and do errands:

Meal Preparation and Cleanup: MPP §§ 30-757.131 & 30-757.132

Planning menus. Washing, peeling, slicing vegetables, opening packages, cans and bags, mixing ingredients, lifting pots and pans, reheating food, cooking, safely operating stove, setting the table, serving the meal, cutting food into bite-sized pieces. Washing and drying dishes, and putting them away.

• Independent: Can plan, prepare, serve and clean up meals.

• Needs only reminding or guidance in menu planning, meal preparation and/or cleanup.

• Requires another person to prepare and cleanup main meal(s) on less than a daily basis; e.g., can reheat food prepared by someone else, can prepare simple meals and/or needs help with cleanup on a less than daily basis.

• Requires another person to prepare and cleanup main meal(s) on a daily basis.

• Totally dependent on another person to prepare and cleanup all meals.

• Is tube-fed. (Please complete paramedical services evaluation form) *

Please briefly describe how your patient’s functional limitations limit your patient’s ability to do meal preparation and cleanup:

(Ambulation) Mobility Inside: MPP § 30-757.14(k)

Walking or moving around inside the house, changing locations in a room, moving from room to room. Can respond adequately if (s) he stumbles or trips. Can step over or maneuver around pets or obstacles, including uneven floor surfaces. Climbing or descending stairs if stairs are inside dwelling. Does not refer to transfers, to abilities or needs once destination is reached, to ability to come into or go out of the house, or to moving around outside.

• Independent: Requires no physical assistance though consumer may experience some difficulty or discomfort. Completion of the task poses no risk to his/her safety.

• Can move independently with only reminding or encouragement. For example, needs reminding to lock a brace, unlock a wheelchair or to use a cane or walker.

• Requires physical assistance from another person for specific maneuvers; e.g., pushing wheelchair around sharp corner, negotiating stairs or moving on certain surfaces.

• Requires assistance from another person most of the time. At risk if unassisted.

• Totally dependent upon others for movement. Must be carried, lifted or pushed in a wheelchair or gurney at all times.

Please briefly describe how your patient’s functional limitations limit your patient’s mobility:

Bathing, Oral Hygiene and Grooming, Routine Bed Baths:
MPP §§ 30-757.14 (d) & 30-757.14 (e)

Bathing means cleaning the body using a tub, shower or sponge bath, including getting a basin of water, managing faucets, getting in and out of a tub, reaching head and body parts for soaping, rinsing, and drying. Grooming includes hair combing and brushing, shampooing, oral hygiene, shaving and fingernail and toenail care (unless toenail care is medically contraindicated and therefore is evaluated as a Paramedical Service). NOTE: Getting to and from the bathroom is evaluated as Mobility Inside.

• Independent: Able to bathe and groom self safely without help from another person.

• Able to bathe and groom self with direction or intermittent monitoring. May need reminding to maintain personal hygiene.

• 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 can sponge bathe but another person must bring water, soap, towel, etc.

• Requires direct assistance with most aspects of bathing and grooming. Would be at risk left alone.

• Totally dependent on others for bathing and grooming.

Please briefly describe how your patient’s functional limitations limit your patient’s ability to bathe, maintain oral hygiene and grooming:

Dressing: MPP § 30-757.14 (f)

Putting on and taking off, fastening and unfastening garments and undergarments, special devices such as back or leg braces, corsets, elastic stockings/garments and artificial limbs or splints.

• Independent: Able to put on, fasten and remove all clothing and devices without assistance. Clothes self appropriately for health and safety.

• Able to dress self, but requires reminding or direction with clothing selection.

• Unable to dress self completely, without the help of another person; e.g., tying shoes, buttoning, zipping, putting on hose or brace, etc.

• Unable to put on most clothing items by self. Without assistance would be inappropriate or inadequate clothed.

• Unable to dress self at all. Requires complete assistance from another.

Please briefly describe how your patient’s functional limitations limit your patient’s ability to dress:

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

Assisting person to and from, on and off toilet or commode and emptying commode, managing clothing and wiping and cleaning body after toileting, assistance with using and emptying bedpans, ostomy and/or catheter receptacles and urinals, application of diapers and disposable barrier pads. Menstrual care limited to external application of sanitary napkin and cleaning. (NOTE:  Catheter insertion, ostomy irrigation and bowel program are evaluated as Paramedical Services.* Getting to and from bathroom is evaluated as Mobility Inside.)

• Independent: Able to manage bowel, bladder and menstrual care with no assistance from another person.

• Requires reminding or direction only.

• Requires minimal assistance with some activities but the constant presence of the provider is not necessary.

• Unable to carry out most activities without assistance.

• Requires physical assistance in all areas of care.

Please briefly describe how your patient’s functional limitations limit your patient’s ability manage bowel, bladder and menstrual care:

Transfer: MPP § 30-757.14(h)

Moving from one sitting or lying position to another sitting or lying position; e.g., from bed to and from a wheelchair, or sofa, coming to a standing position and/or repositioning to prevent skin breakdown. (NOTE:  If pressure sores have developed, the need for care of them is evaluated as a Paramedical Service.)

• Independent: Able to do all transfers safely without assistance from another person.

• Able to transfer but needs encouragement or direction.

• Requires some help from another person; e.g., routinely requires a boost or assistance with positioning.

• Unable to complete most transfers without physical assistance. Would be at risk if unassisted.

• Totally dependent upon another person for all transfers. Must be lifted or mechanically transferred.

Please briefly describe how your patient’s functional limitations limit your patient’s ability to transfer:

Feeding: MPP § 30-757.14(c)

Reaching for, picking up, grasping utensil and cup; getting food on utensil, bringing food, utensil, cup to mouth, chewing, swallowing food and liquids, manipulating food on plate. Cleaning face and hands as necessary following a meal.

• Independent: Able to feed self.

• Able to feed self, but needs verbal assistance such as reminding or encouragement to eat.

• Assistance needed during the meal e.g., to apply assistive device, fetch beverage or push more food within reach, etc., but constant presence of another person not required.

• Able to feed self some foods, but cannot hold utensils, cups, glasses, etc., and requires constant presence of another person.

• Unable to feed self at all and is totally dependent upon assistance from another person.

• Is tube fed. All aspects of tube feeding are evaluated as a Paramedical Service.*

Please briefly describe how your patient’s functional limitations limit your patient’s ability to feed herself/himself:

Respiration: MPP § 30-757.14(b)

Respiration is limited to non-medical services such as assistance with self-administration of oxygen and cleaning oxygen equipment and IPPB machines.

• Does not use respirator or other oxygen equipment or able to use and clean independently.

• Needs help with self-administration and/or cleaning.

• Needs Paramedical Service such as suctioning.*

Please briefly describe how your patient’s functional limitations limit your patient’s ability to respire:

Mental Functioning Assessment

Please check appropriate box

(No more than 1 box for each mental functional limitation)

Memory: Recalling learned behaviors and information from distant and recent past.

• No problem: Memory is clear; consumer is able to give you accurate information about his/her medical history; is able to talk appropriately about comments made earlier in the conversation; has good recall of past events.

• Memory loss is moderate or intermittent: Consumer shows evidence of some memory impairment, but not to the extent where (s)he is at risk; consumer needs occasional reminding to do routine tasks or help recalling past events.

• Severe memory deficit: Consumer forgets to start or finish activities of daily living which are important to his/her health and/or safety. Cannot maintain much continuity of thought in conversation with you.

Please briefly describe how your patient’s memory limitations limit his/her ability to complete ADL:

Orientation: Awareness of time, place, self and other individuals in one’s environment.

• No problem: Orientation is clear. Consumer is aware of where (s)he is and can give you reliable information when questioned about activities of daily living, family, etc.; is aware of passage of time during the day.

• Occasional disorientation and confusion apparent but does not put self at risk: Consumer has general awareness of time of day; is able to provide limited information about family, friends, daily routine, etc.

• Severe disorientation which puts consumer at risk: wanders off; lacks awareness or concern for safety or well-being; unable to identify significant others or relate safely to environment or situation; no sense of time of day.

Please briefly describe how your patient’s orientation limitations limit his/her ability to complete ADL:

Judgment: Making decisions so as not to put self or property in danger; safety around stove. Capacity to respond to changes in the environment, e.g., fire, cold house. Understands alternatives and risks involved and accepts consequences of decisions.

• Judgment unimpaired: Able to evaluate environmental cues and respond appropriately.

• Judgment mildly impaired: shows lack of ability to plan for self; has difficulty deciding between alternatives but is amenable to advice; social judgment is poor.

• Judgment severely impaired: fails to make decisions or makes decisions without regard to safety or well-being.

Please briefly describe how your patient’s judgment limitations limit his/her ability to complete ADL:

Signature of Professional:

_________

Print Name:

Date:

Medical specialty:

Address:

License No.:

City: State:

Telephone: