Notes

Assessment Date: 9/12/2023. Assessment Type: Annual HV/Reassessment
Time Limited Service: No
Interpreter services were not needed.
Other persons present at the assessment were: None
If recipient has an authorized representative, were there any changes? No
ENVIRONMENTAL DESCRIPTION/IMPACTS
Living arrangement: Recipient Living Alone
Please describe the living arrangement: Client is widowed. Her husband passed away in 2019. Client lives in an apartment on the 3rd floor. Home consists of 2 bedrooms, 1 bathroom, 1 living room and 1 kitchen. 1st floor is garage and the 2nd floor is occupied by landlord's family. They do not share any rooms. No washer/dryer on site.
Home Appearance/ Safety Hazards & other information: The home was organized and clean. Pathways were clear. No odors in the home.
Is the recipient a minor? No.
Provider(s) Status/Issue(s):
Is there an assigned provider? Yes.
Nui Xau Diep, sister
Is the applicant/recipient satisfied with the provider?
Explain: Yes, client is satisfied with the provider.
MODE: IP
MEDICAL INFORMATION
Recipient's self-reporting of health information: Client has SOB, pain in hips, back, shoulder and both knees. She has DM, HLD and HTN. Client has poor sleep due to older daughter passed away in 2015 and husband passed away in 2019. She had a fall on the street in 2/2023 and had a hard time getting up, no serious injuries. Client reported dizziness, fatigue and weakness and she is unable to walk/stand for prolonged time. Client has sensitive digestive system and slight incontinences due to diarrhea. She is not using diapers. Client had a MRI, showing complications in her liver, need further diagnoses. Client has difficulty reaching, lifting and bending. She has on/off leg cramp and Goiter.
New Medical/Health information from Recipient's Physician/Health Care Provider: no new reports
Any hospitalization(s)/leave in the last year? None reported.
Prior relevant Medical History (e.g. SOC 873 diagnoses): Per SOC 873, bilateral shoulder pain, rheumatoid arthritis, SOB on exertion and unsteady gait. Per previous assessment report, client's R breast cancer tumor removed in 2006. She completed cancer treatment and caused R arm pain and limited ROM. Client had cataract surgery on both eyes in 2021. A surgery to remove nasal polyp many years ago.
List of current Medications: Client takes 8 medications, once a day.
SOCIAL WORKER OBSERVATIONS
Social Worker's observations of applicant/recipient's appearance, behavior, abilities and limitations: Client dressed appropriately for the weather. She looked clean. No concern of hygiene. Client was friendly and responsive. She was able to sign all document. Client understood the purpose of the assessment.
Risk/Safety Issues Observed: None reported/observed.
Mental Abilities/Limitations: Client appeared clear of mind at the HV. She was oriented with coherent response. She was able to answer all SW questions and recall her medical history.
Justification for ranking regarding Memory: mild impairment. Client reported being occasionally forgetful and needs reminders for medications.
Justification for ranking regarding Orientation: Orientation is clear. Client was oriented x3.
Justification for ranking regarding Judgement: Judgment unimpaired. Client is able to evaluate environmental cues and respond appropriately.
Durable Medical Equipment (DME):
CANE: ☐ CRUTCHES: ☐ WALKER: ☐ WHEELCHAIR: ☐
BATH SEAT: ☐ BEDPAN/URINAL: ☐ COMMODE: ☐ BOWEL/BLADDER SUPPLIES: ☐ GRAB BAR: ☒ HOSPITAL BED: ☐ RESPIRATORY AIDS: ☐ BRACE: ☐ MED-SET: ☒
OTHER: None.
Is there any DME that is no longer used? None.
SERVICES ASSESSMENT
DOMESTIC SERVICES
Functional Abilities: Client is able to perform light chores such as wiping surfaces and dusting.
Functional Limitations: Client requires substantial assistance with sweeping, mopping, vacuuming, cleaning bathroom, changing bed linen and cleaning stove and refrigerator due to dizziness, fatigue, weakness, pain in hips, back, shoulder and both knees and limitations with walking and standing for prolonged time.
Domestic Services were prorated: N/A
Prorated by None
Explain: Living Alone
RELATED SERVICES
Applicant/Recipient has AC rate: No
IHSS Meal Allowance: No
MEAL PREPARATION/CLEANUP
Meal Preparation:
Functional Abilities: Client is able to plan menus, open packaging, set table, wash vegetables and reheat food in microwave.
Functional Limitations: Client requires some assistance with trimming meat, lifting pots and pans, cooking meals due to dizziness, fatigue, weakness, pain in hips, back, shoulder and both knees and limitations with walking and standing for prolonged time.
Meal Preparation Service Prorated: N/A
Explain: Living Alone
Meal Cleanup:
Functional Abilities: Client is able to put dishes in the sink when done eating, wipe and tidy table, wash/dry hands after meal.
Functional Limitations: Client requires some assistance with cleaning and carrying pots and pans due to dizziness, fatigue, weakness, pain in hips, back, shoulder and both knees and limitations with walking and standing for prolonged time.
Meal Cleanup Service Prorated: N/A
Explain: Living Alone
LAUNDRY
Functional Abilities: Client is able to fold and store clothes on shelves or in drawers.
Functional Limitations: Client has difficulty carrying clothes to the machine, loading and unloading washer and dryer due to dizziness, fatigue, weakness, pain in hips, back, shoulder and both knees and limitations with walking and standing for prolonged time.
Service Prorated: N/A
Explain: Living Alone
SHOPPING FOR FOOD
Functional Abilities: Client is able to make a shopping list for her grocery and travel to stores.
Functional Limitations: Client is unable to lift or carry various items from shelf to cart. She needs help transferring grocery items home due to dizziness, fatigue, weakness, pain in hips, back, shoulder and both knees and limitations with walking and standing for prolonged time.
Service Prorated: N/A
Explain: Living Alone
OTHER SHOPPING/ERRANDS
Functional Abilities: Client is able to make a shopping list for her errands and travel to stores.
Functional Limitations: Client is unable to lift or carry various items from shelf to cart. She needs help transferring grocery items home due to dizziness, fatigue, weakness, pain in hips, back, shoulder and both knees and limitations with walking and standing for prolonged time.
Service Prorated: N/A
Explain: Living Alone
PERSONAL CARE SERVICES
RESPIRATION ASSISTANCE
Functional Abilities: No assessed need.
Functional Limitations: No assessed need.
BOWEL/BLADDER CARE
Functional Abilities: Client is able to wipe and clean, get on/off toilet.
Functional Limitations: Client needs some assistance managing clothing due to dizziness, fatigue, weakness, pain in hips, back, shoulder and both knees and limitations with walking and standing for prolonged time.
FEEDING
Functional Abilities: Able to feed self independently.
Functional Limitations: No functional limitation reported in this task.
ROUTINE BED BATH
Functional Abilities: No assessed need.
Functional Limitations: No assessed need.
DRESSING
Functional Abilities: Client is able to put on/take off shirts and pants one side.
Functional Limitations: Client needs some assistance with putting on/taking off pants on the painful side and socks and shoes due to dizziness, fatigue, weakness, pain in hips, back, shoulder and both knees and limitations with walking and standing for prolonged time.
MENSTRUAL CARE
Functional Abilities: No assessed need.
Functional Limitations: No assessed need.
AMBULATION
Functional Abilities: Client is able to ambulate with a cane inside home.
Functional Limitations: Client needs some assistance with going up/down stairs, to/from front door to car for accompaniment to appts due to dizziness, fatigue, weakness, pain in hips, back, shoulder and both knees and limitations with walking and standing for prolonged time.
TRANSFER
Functional Abilities: Client is able to transfer from sitting with the support of the chair or steady furniture support.
Functional Limitations: Client needs some assistance with physical boost transfer from prone position due to dizziness, fatigue, weakness, pain in hips, back, shoulder and both knees.
BATHING, ORAL HYGIENE AND GROOMING
Functional Abilities: Client is able to brush teeth, clean front torso and face, turn on/ off faucets and get in/out of the bathtub.
Functional Limitations: Client needs some assistance cleaning the back, lower legs, shampooing due to dizziness, fatigue, weakness, pain in hips, back, shoulder and both knees and limitations with walking and standing for prolonged time.
REPOSITIONING AND RUBBING SKIN
Justification: None.
CARE OF AND ASSISTANCE WITH PROSTHETIC DEVICES AND MEDICATIONS
Justification: Client needs reminders for taking meds.
PARAMEDICAL SERVICES: No SOC 321: ☐
ACCOMPANIMENT TO MEDICAL APPOINTMENTS: Yes
KRISTIN WONG (PRIMARY CARE) - 3 Time(s) per year; 0:50 (round trip); Wait Time per trip: 60 Minutes. Total per week: 0:06. Address: 1842 NORIEGA ST Tel: 415-566-8799 Fax: N/A
Explanation: Client need assistant with transfer and ambulation during travel and while at the medical appointment. Round trip determined by google map. Wait time provided by client.
ATTENDING PHYSICIAN (PHYSICAL THERAPIST) - 1 Time(s) per year; 0:50 (round trip); Wait Time per trip: 60 Minutes. Total per week: 0:02. Address: 3222 GEARY ST Tel: N/A Fax: N/A
Explanation: Client need assistant with transfer and ambulation during travel and while at the medical appointment. Round trip determined by google map. Wait time provided by client.
BLOOD TEST (CLINICAL LAB TESTS) - 3 Time(s) per year; 0:50 (round trip); Wait Time per trip: 20 Minutes. Total per week: 0:04. Address: 3838 CALIFORNIA ST #104 Tel: N/A Fax: N/A
Explanation: Client need assistant with transfer and ambulation during travel and while at the medical appointment. Round trip determined by google map. Wait time provided by client.
MAN KIT LEUNG (OTOLARYNGOLOGIST) - 1 Time(s) per year; 1:00 (round trip); Wait Time per trip: 60 Minutes. Total per week: 0:02. Address: 1199 BUSH ST #290 Tel: 415-230-0909 Fax: N/A
Explanation: Client need assistant with transfer and ambulation during travel and while at the medical appointment. Round trip determined by google map. Wait time provided by client.
ATTENDING PHYSCIAN (OPHTHALMOLOGIST) - 1 Time(s) per year; 1:00 (round trip); Wait Time per trip: 60 Minutes. Total per week: 0:02. Address: 925 PACIFIC AVE Tel: N/A Fax: N/A
Explanation: Client need assistant with transfer and ambulation during travel and while at the medical appointment. Round trip determined by google map. Wait time provided by client.
ATTENDING PHYSCIAN (ONCOLOGIST) - 4 Time(s) per year; 1:00 (round trip); Wait Time per trip: 60 Minutes. Total per week: 0:09. Address: 2100 WEBSTER ST Tel: N/A Fax: N/A
Explanation: Client need assistant with transfer and ambulation during travel and while at the medical appointment. Round trip determined by google map. Wait time provided by client.
Total time per week = 25 min.
ACCOMPANIMENT TO ALTERNATIVE RESOURCES: No
Explain: Client does not attend any Alternative Resources.
OTHER SERVICES
HEAVY CLEANING: No Functional Abilities/Limitations: N/A.
YARD HAZARD ABATEMENT: No. Functional Abilities/Limitations: N/A.
REMOVAL OF ICE AND SNOW: No. Functional Abilities/Limitations: N/A.
TEACHING AND DEMONSTRATION: No. Functional Abilities/Limitations: N/A.
PROTECTIVE SUPERVISION (PS)
Recipient is suffering from mental impairment/mental illness:No
Recipient is not self-directing due to mental impairment/mental illness: No
Recipient is likely to engage in potential dangerous activities: No
Alternative resources explored? Yes
DAS Benefits Hub (415) 355-6700.
CRITICAL INCIDENTS
Documented critical incidents: None
Resolution/Follow-up: None
ADDITIONAL INFORMATION
None.
COUNTY AND STATE FORMS DISCUSSED/PROVIDED/RECEIVED:
STATE FORM:
MC 306: ☐ NVRA: ☒ PUB 13: ☒ PUB 104: ☐ SOC 295: ☐
SOC 332: ☐ SOC 426A: ☐ SOC 450: ☐ SOC 821: ☐ SOC 825: ☐ SOC 838: ☐ SOC 839: ☐ SOC 840: ☐ SOC 864: ☒ SOC 873: ☐ SOC 874: ☐ SOC 2256: ☐
TEMP 3000: ☐ Attachment A (Recipient Fact Sheets): ☒
Other: None.
COUNTY FORM:
3008: ☐ 3041: ☒ 3091: ☐ 8014/8015: ☐ 8072 – Language form: ☐
ADA Information/Civil Rights: ☒ BVI: ☒ Home Delivered Grocery Survey: ☒ Other: None.
☒ Social worker discussed the IHSS FLSA rules and regulations, and informed educational materials with the applicant/recipient.
☐ Unmet need addressed (if applicable)
☒ Social worker discussed the IHSS program assessment and authorization process, including how Functional Index rankings and Hourly Task Guidelines are utilized in the assessment process, and informed the applicant/recipient of his/her right to file a state hearing.