Form SOC2306 "Exemption From Workweek Limits for Extraordinary Circumstances Referral Justification - in-Home Supportive Services (Ihss) Program" - California

What Is Form SOC2306?

This is a legal form that was released by the California Department of Social Services - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 1, 2018;
  • The latest edition provided by the California Department of Social Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a fillable version of Form SOC2306 by clicking the link below or browse more documents and templates provided by the California Department of Social Services.

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Download Form SOC2306 "Exemption From Workweek Limits for Extraordinary Circumstances Referral Justification - in-Home Supportive Services (Ihss) Program" - California

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State of California – Health and Human Services Agency
California Department of Social Services
IN-HOME SUPPORTIVE SERVICES (IHSS) PROGRAM
EXEMPTION FROM WORKWEEK LIMITS FOR EXTRAORDINARY
CIRCUMSTANCES REFERRAL JUSTIFICATION
Information completed on this form to be entered in the provider’s case note section in CMIPS.
County to retain a signed copy for quality assurance confirmation.
Initial
Renewal (Must be same provider, recipients, and criteria as the initial exemption.)
County Name:
Provider Name:
Provider Number:
The following referral condition(s) should be completed for all recipients in which the
exemption is being applied: (Check all that apply)
RECIPIENT 1: Name:____________________________
Case #:__________________________
A: Complex Medical/Behavioral Needs
B: Rural/Remote
C: Language/Communication
RECIPIENT 2: Name:____________________________
Case #:__________________________
A: Complex Medical/Behavioral Needs
B: Rural/Remote
C: Language/Communication
RECIPIENT 3: Name:____________________________
Case #:__________________________
A: Complex Medical/Behavioral Needs
B: Rural/Remote
C: Language/Communication
RECIPIENT 4: Name:____________________________
Case #:__________________________
A: Complex Medical/Behavioral Needs
B: Rural/Remote
C: Language/Communication
Note: If there are additional recipients included under the exemption request, please ensure
to add the name, case #, and criteria selection of each additional recipient to the referral
justification.
Is the provider an authorized representative for all recipients?
Yes
No, if not please provide
explanation below.
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
FOR RENEWAL ONLY
Have any circumstances changed since the initial referral justification?
Yes
No
SOC 2306 (1/18)
Page 1 of 5
State of California – Health and Human Services Agency
California Department of Social Services
IN-HOME SUPPORTIVE SERVICES (IHSS) PROGRAM
EXEMPTION FROM WORKWEEK LIMITS FOR EXTRAORDINARY
CIRCUMSTANCES REFERRAL JUSTIFICATION
Information completed on this form to be entered in the provider’s case note section in CMIPS.
County to retain a signed copy for quality assurance confirmation.
Initial
Renewal (Must be same provider, recipients, and criteria as the initial exemption.)
County Name:
Provider Name:
Provider Number:
The following referral condition(s) should be completed for all recipients in which the
exemption is being applied: (Check all that apply)
RECIPIENT 1: Name:____________________________
Case #:__________________________
A: Complex Medical/Behavioral Needs
B: Rural/Remote
C: Language/Communication
RECIPIENT 2: Name:____________________________
Case #:__________________________
A: Complex Medical/Behavioral Needs
B: Rural/Remote
C: Language/Communication
RECIPIENT 3: Name:____________________________
Case #:__________________________
A: Complex Medical/Behavioral Needs
B: Rural/Remote
C: Language/Communication
RECIPIENT 4: Name:____________________________
Case #:__________________________
A: Complex Medical/Behavioral Needs
B: Rural/Remote
C: Language/Communication
Note: If there are additional recipients included under the exemption request, please ensure
to add the name, case #, and criteria selection of each additional recipient to the referral
justification.
Is the provider an authorized representative for all recipients?
Yes
No, if not please provide
explanation below.
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
FOR RENEWAL ONLY
Have any circumstances changed since the initial referral justification?
Yes
No
SOC 2306 (1/18)
Page 1 of 5
State of California – Health and Human Services Agency
California Department of Social Services
GENERAL QUESTIONS
1. Has the county inquired whether other adults living in the home would be able and willing
to be a paid provider for any of the recipients?
Yes
No
No Other Adults in Home
If YES, explain why this is not a viable option. If NO, explain why the county has not
explored this option.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
2. Has the county inquired whether an IHSS recipient in the home would be eligible to be a
provider? (Note: An IHSS recipient can be an IHSS provider as long as they are not providing the
Yes
No
same services they are authorized.)
If YES, explain why this is not a viable option. If NO, explain why the county has not
explored this option.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
3. Has the county inquired whether relatives, friends, or neighbors living outside the home
would be able and willing to provide services for any of the recipients?
Yes
No
If YES, explain why this is not a viable option. Include names of individuals contacted and
outcome of discussions. If NO, explain why the county has not explored this option.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
4. Are there currently other providers on the case(s)?
Yes
No
If YES, explain why the active provider(s) cannot rearrange work hours so that the 66-hour
workweek limit is not exceeded.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
5. Have there been other providers on the case(s) in the past?
Yes
No
If YES, explain why there are no longer a viable option.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
SOC 2306 (1/18)
Page 2 of 5
State of California – Health and Human Services Agency
California Department of Social Services
6. Has the county explored hiring another provider to provide non-personal care services
(e.g. domestic, related, protective supervision, etc.)?
Yes
No
If YES, explain why this is not a viable option. Include names of individuals contacted
and the outcome of the discussions. If NO, explain why the county has not explored this
option.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
7. Has outreach been made to the Provider Registry/Public Authority to inquire about
individuals willing to be a provider for any of the recipients?
Yes
No
If YES, explain why this is not a viable option. Include names of individuals contacted
and the outcome of the discussions. If NO, explain why the county has not explored this
option.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
8. Do the recipients for whom the provider works have authorized hours totaling more than
360 per month?
Yes
No
a. If YES, explain what arrangements have been made to hire an additional provider(s)
to work those hours in excess of the 360 per month limit (if an exemption is granted)
so that all of the recipients’ authorized monthly hours are provided. (NOTE: Counties
must assist in finding an additional provider to ensure that all authorized hours are provided.
Volunteering hours can result in a reduction of the recipients’ authorized IHSS hours.)
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
b. Explain why the additional provider(s) being hired to work in excess of 360 cannot work
all of the hours that exceed the 66-hour workweek limit so that an exemption would not
be necessary.
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
FOR RECIPIENTS WHO MEET THE FOLLOWING
COMPLETE QUESTIONS IN:
REFERRAL CRITERIA
Criteria A: Complex Medical/Behavioral Needs
Section A & D
Criteria B: Rural/Remote
Section B & D
Criteria C: Language/Communication
Section C & D
Note: If multiple criteria apply, complete the appropriate section for each criterion.
SOC 2306 (1/18)
Page 3 of 5
State of California – Health and Human Services Agency
California Department of Social Services
SECTION A (Criteria A)
1. Has the county verified that the provider lives in the same home as all recipient(s) applying
under Criteria A?
Yes
No
2. Explain why having another provider would place the recipients in the home at serious risk
of placement in out of home care and how this has been determined and confirmed.
Note: Please do not solely list the recipient’s medical/behavioral conditions or authorized services
(i.e., protective supervision, etc.), but the impact that having another provider would have on them
and how this has been confirmed).
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
SECTION B (Criteria B)
1. Does the county consider the location where the recipient resides to be rural and/or
remote?
Yes
No
If YES, please provide justification. Note: Include the population of the recipient’s city, town etc.,
any information describing the remote location and difficulties encountered when attempting to
find/hire providers.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
2. Have Provider Registries/Public Authorities in neighboring counties been contacted to find
providers who are willing and able to travel to be a provider for both or either recipient(s)?
Yes
No
If YES, explain why this is not a viable option. Include names of individuals contacted
and the outcome of the discussions. If NO, explain why the county has not explored this
option.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
SECTION C (Criteria C)
1. Explain why the recipient(s) would be at risk of out-of-home care if authorized services are
provided by a provider who does not speak their language.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
SOC 2306 (1/18)
Page 4 of 5
State of California – Health and Human Services Agency
California Department of Social Services
2. Explain why the recipient(s) cannot have their services provided by another provider with
initial interpretation assistance given by someone who speaks the recipients’ language.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
SECTION D
COMPLETED BY:
Name:
Date:
Title:
Telephone #:
E-Mail Address:
SOC 2306 (1/18)
Page 5 of 5