Form SOC 864 In-home Supportive Services (Ihss) Program Individualized Back-Up Plan and Risk Assessment - California

Form SOC864 or the "In-home Supportive Services (ihss) Program Individualized Back-up Plan And Risk Assessment" is a form issued by the California Department of Social Services.

The form was last revised in March 1, 2011 and is available for digital filing. Download an up-to-date fillable Form SOC864 in PDF-format down below or look it up on the California Department of Social Services Forms website.

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCIES
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
IN-HOME SUPPORTIVE SERVICES (IHSS) PROGRAM
INDIVIDUALIZED BACK-UP PLAN AND RISK ASSESSMENT
SECTION 1 – RECIPIENT’S INFORMATION
RECIPIENT’S NAME:
CASE NUMBER:
INDIVIDUALIZED BACK-UP PLAN
SECTION 2 – SUPPORT CONTACTS
If you need non-emergency assistance, and/or your IHSS care provider has not arrived as scheduled,
call:
Name
Phone
Family Member:
Friend/Neighbor:
County Social Services Worker:
County IHSS Social Services Office:
Public Authority:
Other:
Other important numbers available to you, if needed:
Doctor’s Office:
Advocacy Group(s):
Police Department:
Fire Department:
Other:
If you need to report abuse, fraud and/or neglect, call:
Adult Protective Services:
Child Protective Services:
Deaf or Hard of Hearing Resource Hotline:
(916) 558-5670
Fraud & Elder Abuse Hotline:
(800) 722-0432
Medi-Cal Fraud Hotline:
(800) 822-6222
Social Security Administration Fraud Hotline:
(800) 269-0271
If you have an emergency, call: 911
An emergency is an immediate threat to your
health, welfare and/or safety.
Distribution:
Original/Case File
Copy/Recipient
Page 1 of 4
SOC 864 (3/11)
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCIES
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
IN-HOME SUPPORTIVE SERVICES (IHSS) PROGRAM
INDIVIDUALIZED BACK-UP PLAN AND RISK ASSESSMENT
SECTION 1 – RECIPIENT’S INFORMATION
RECIPIENT’S NAME:
CASE NUMBER:
INDIVIDUALIZED BACK-UP PLAN
SECTION 2 – SUPPORT CONTACTS
If you need non-emergency assistance, and/or your IHSS care provider has not arrived as scheduled,
call:
Name
Phone
Family Member:
Friend/Neighbor:
County Social Services Worker:
County IHSS Social Services Office:
Public Authority:
Other:
Other important numbers available to you, if needed:
Doctor’s Office:
Advocacy Group(s):
Police Department:
Fire Department:
Other:
If you need to report abuse, fraud and/or neglect, call:
Adult Protective Services:
Child Protective Services:
Deaf or Hard of Hearing Resource Hotline:
(916) 558-5670
Fraud & Elder Abuse Hotline:
(800) 722-0432
Medi-Cal Fraud Hotline:
(800) 822-6222
Social Security Administration Fraud Hotline:
(800) 269-0271
If you have an emergency, call: 911
An emergency is an immediate threat to your
health, welfare and/or safety.
Distribution:
Original/Case File
Copy/Recipient
Page 1 of 4
SOC 864 (3/11)
IN-HOME SUPPORTIVE SERVICES (IHSS) PROGRAM
INDIVIDUALIZED BACK-UP PLAN AND RISK ASSESSMENT
RECIPIENT’S NAME:
CASE NUMBER:
RISK ASSESSMENT
SECTION 3 – GENERAL RISK ASSESSMENT
A. IHSS Assessment
During this IHSS assessment process, you and your social worker identified risks based on those personal
care and domestic and related services for which you may need assistance. Assistance may be met through
IHSS or with other formal or informal services.
B. Additional Risk Areas
The following are additional risk areas that you and your social worker discussed that may be outside the
scope of the IHSS program (check all that apply):
Comments
B1.Living Arrangements
■ ■
Lives with others who may assist
■ ■
Lives alone, relatives/friends nearby who may assist
■ ■
Lives alone, no relatives/friends nearby
B2.Evacuation/Environmental Factors
■ ■
Can evacuate independently
■ ■
Can evacuate, but only with supervision/verbal direction
■ ■
Needs physical assistance to evacuate home in an
emergency
■ ■
Able to access food/water independently
■ ■
Aware of emergency or crisis numbers/contacts
■ ■
Able to control lights, heat, cooling or other utilities
B3. Communication
■ ■
Communicates without difficulty
■ ■
Hearing impairment, communication limited
■ ■
Speech impairment, communication limited
■ ■
Can speak or hear with the use of assistive device(s)
Assistive device(s):
______________________
■ ■
Able to place and receive calls independently
■ ■
Can use telephone only with assistive device(s)
Assistive device(s):
_____________________
SECTION 4 – DISASTER PREPAREDNESS
In preparation for a disaster, such as hot and cold weather emergencies, fires, floods, and earthquakes, you and
your social worker discussed the following:
Your individual health needs that will be listed in the County’s Disaster Preparedness Assessment Plan
(if utilized by your county).
Distribution:
Original/Case File
Copy/Recipient
Page 2 of 4
SOC 864 (3/11)
IN-HOME SUPPORTIVE SERVICES (IHSS) PROGRAM
INDIVIDUALIZED BACK-UP PLAN AND RISK ASSESSMENT
RECIPIENT’S NAME:
CASE NUMBER:
AGREEMENT AND SIGNATURES
SECTION 5 – AGREEMENT AND SIGNATURES
By signing below, you, your social worker, and any other individual(s) you have chosen to be involved in
this process, are confirming you discussed and agree with the information contained in this Individualized
Back-Up Plan and Risk Assessment.
Recipient
Signature:
Date:
______________________________________________________
____________________
County Staff
Signature:
Date:
______________________________________________________
____________________
Print Name and Title:_________________________________________________________________________
Authorized Representative
Signature:_________________________________________________ Date:__________________
Print Name and Relationship:__________________________________________________________
Other
Signature:_________________________________________________ Date:__________________
Print Name and Relationship:__________________________________________________________
In the event there have been no changes in the Individualized Back-Up Plan and Risk Assessment from the prior
year, the Recipient/Social Worker can sign below confirming no change.
Recipient /Authorized Representative
Signature:_________________________________________________ Date:__________________
County Staff
Signature:_________________________________________________ Date:_
___________________
Print Name and Title:
______________________________________________________________________
Distribution:
Copy/Recipient
Original/Case File
Page 3 of 4
SOC 864 (3/11)
IN-HOME SUPPORTIVE SERVICES (IHSS) PROGRAM
INDIVIDUALIZED BACK-UP PLAN AND RISK ASSESSMENT
RECIPIENT’S NAME:
CASE NUMBER:
INSTRUCTIONS
Use this form to work with the recipient to allow him/her independence and choice in decisions related to his/her
Individualized Back-Up Plan and Risk Assessment.
Ensure that discussion and negotiation occurs between the social worker, the recipient, and any others whom the
recipient wants involved while working through this process. After completion, a copy of the Individualized
Back-Up Plan and Risk Assessment shall be provided to the recipient. The original form shall be filed
in the recipient’s case file. Social worker shall encourage the recipient to post page 1 in an easily
accessible area.
SECTION 1: Fill in the recipient’s name, and case number. This information will need to be added to each page
until CMIPS II can auto-fill.
SECTION 2: Through discussion with the recipient/others involved in the development of this plan, fill in the
recipient’s choices and preferences of back-up contacts, as well as other important numbers identified, if needed.
Discuss abuse, fraud and neglect with the recipient, the process to report abuse, fraud and neglect, and include
the local APS/CPS numbers in their area. Reinforce with the recipient to call 911 if he/she has an emergency.
SECTION 3A: If assistance will be met through other formal or informal services, complete the SOC 450,
Voluntary Services Certification, as needed. Identified risks may be mitigated through the authorization of hours
in the service plan. If the recipient refuses any service, clearly document the service refused and the identified
risks, and that the recipient elects to assume the risks associated with not receiving the service.
SECTION 3B: Also, discuss with the recipient additional risk areas that could be mitigated or improved through
discussion and planning (Back-Up Plan).
SECTION 4: Discuss disaster preparedness with the recipient/others involved in the development of the plan.
Include a discussion of how individual health needs may be addressed in the event of a disaster.
Section 5: With the recipient’s/others’ participation, review all sections verifying that each area was discussed
during the process. Ensure that all appropriate individuals sign the form to confirm agreement with the
information on the form.
Comments/Notes:
Distribution:
Original/Case File
Copy/Recipient
Page 4 of 4
SOC 864 (3/11)

Download Form SOC 864 In-home Supportive Services (Ihss) Program Individualized Back-Up Plan and Risk Assessment - California

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