BILL ANALYSIS �
SENATE HUMAN
SERVICES COMMITTEE
Senator Jim Beall, Chair
BILL NO: AB 1703
A
AUTHOR: Hall
B
VERSION: May 23, 2014
HEARING DATE: July 24, 2014
1
FISCAL: Yes
7
0
CONSULTANT: Sara Rogers
3
SUBJECT
In-home supportive services: reading services for blind and
visually impaired recipients
SUMMARY
This bill would include assistance in reading and
completing financial and other documents which are
essential to activities of daily living for a recipient of
the In Home Supportive Services Program (IHSS) who is blind
or visually impaired, or who has another disability that
significantly impairs his or her ability to read.
ABSTRACT
Existing Law:
1.Establishes the In-Home Supportive Services (IHSS)
program to provide in-home domestic supportive and
personal care services for aged, blind or disabled
individuals living at or below the poverty level for the
purpose of enabling IHSS consumers to avoid
Continued---
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institutionalization and remain safely in their homes
with supportive services. (WIC 12300 et seq.)
2.Defines the scope of supportive services available under
the IHSS program to include heavy cleaning, personal care
services, accompaniment by a provider when needed during
necessary travel to health-related appointments or to
alternative resource sites, yard hazard abatement,
protective supervision, teaching and demonstration
directed at reducing the need for other supportive
services, and paramedical services which make it possible
for the recipient to establish and maintain an
independent living arrangement.
3.Defines the scope of personal care services available
under the IHSS program to include:
Assistance with ambulation.
Bathing, oral hygiene, and grooming.
Dressing.
Care and assistance with prosthetic devices.
Bowel, bladder, and menstrual care.
Repositioning, skin care, range of motion
exercises, and transfers.
Feeding and assurance of adequate fluid intake.
Respiration.
Assistance with self-administration of
medications.
1.Requires CDSS, in consultation with county welfare
departments to establish and implement statewide hourly
task guidelines and instructions to provide counties with
a standard tool for consistently and accurately assessing
service needs and authorizing service hours to meet those
needs. (WIC 12301.2)
2.Permits certain IHSS recipients with high care needs, as
specified, to receive up to 283 hours of IHSS services
per month. (WIC 12303.4(b))
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3.Requires county welfare agencies to provide eligible
visually impaired or blind IHSS recipients information
and referral to non-profit services that provide reading
services. (WIC 12304.6)
4.Pursuant to federal law, defines legal blindness as
persons with central visual acuity of 20/200 or less in
the stronger eye, while wearing a correcting lens or
glasses; or a limitation in the field of vision in the
better eye, so that:
There is contraction of peripheral visual
fields to 10 degrees from the point of fixation, or
The widest diameter of the visual field
subtends an angle no greater than 20 degrees, or
There is a contraction of peripheral visual
fields to 20 percent or less visual field efficiency
(Title XVI of the Social Security Act Sec. 1614 (42
U.S.C. 1382c))
This bill:
1.Adds to the scope of personal care services provided
within the IHSS program assistance in reading and
completing financial and other documents essential for
completing activities of daily living for a recipient who
is blind or visually impaired, or who has another
disability that significantly impairs his or her ability
to read.
2.Requires the Director of Health Care Services to seek any
federal approvals necessary to ensure that Medicaid funds
may be used in implementing the amendments to this
section made by the act adding this subdivision.
FISCAL IMPACT
An Assembly Appropriations Committee analysis projected
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that if 50 percent of the approximately 10,000 visually
impaired or blind individuals receiving IHSS services were
authorized for this service and required about 1.5 hours
per month in reading assistance, the cost would be about
$900,000 in additional wages annually.
Additionally, the analysis cites unknown costs to provide
reading services to IHSS recipients who have "another
disability that affects his or her ability to read" as well
as unknown, but likely minor, costs to counties for social
workers to add eligibility determination for reading
services to the IHSS in-home assessment.
BACKGROUND AND DISCUSSION
According to the author, about 2 percent of IHSS consumers
are legally blind, however reading and document completion
assistance is not a covered service under IHSS. Reading
assistance is critical for consumers who need to know about
notices that may affect their ability to live
independently, including insurance coverage, prescription
drug labels, housing notifications or other time-sensitive
information that may require action.
According to the sponsor, the California Council for the
Blind, "without access to the many types of written
documents, including financial documents, notices from
public programs and more, it is almost impossible to
effectively handle many of the important decisions that a
person faces in his/her daily lives." Additionally the
sponsor states that blind and visually impaired individuals
cannot, by themselves, access their daily mail and other
written materials that they receive, and that because they
are on a fixed incomes they do not have the excess income
necessary to hire someone to perform the services of
reading their mail and completing documents for them.
In Home Supportive Services Program (IHSS)
The IHSS program was established in 1973 as an innovative
alternative to institutional care, and evolved in the
context of a growing "independent living" civil rights
STAFF ANALYSIS OF ASSEMBLY BILL 1703 (Hall)
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movement led by persons with disabilities.<1> The program
has experienced continuous growth following the U.S.
Supreme Court decision Olmstead v. L.C. in 1999 which
established the rights of people with disabilities to
receive services in the most integrated setting possible to
"provide individuals with disabilities opportunities to
live their lives like individuals without disabilities"<2>
under the American with Disabilities Act.
The IHSS program is operated as benefit under the Medi-Cal
program, providing in-home services to more than 460,000
qualified low-income individuals who are aged, blind, or
disabled. Currently, of approximately 464,402 IHSS
recipients, approximately two percent of consumers are
visually impaired or blind (10,153 consumers). County
welfare agencies administer the program under CDSS
oversight and county social workers determine eligibility
and assess eligible consumer to determine the allowable
services and number of allotted hours following a
standardized in home assessment.
Scope of Services
The scope of supportive services provided through IHSS is
defined in statute to include "domestic and related
services, heavy cleaning, personal care services,
accompaniment to health-related appointments or to
alternative resource sites, yard hazard abatement,
protective supervision, teaching and demonstration directed
at reducing the need for other supportive services, and
paramedical services which make it possible for the
recipient to establish and maintain an independent living
arrangement." (WIC Section 12300)
-------------------------
<1> http://www.cicaihss.org/ihss-public-authority-history
<2> Statement of the Department of Justice on Enforcement
of the Integration Mandate of Title II of the Americans
with Disabilities Act and Olmstead v. L.C. June 22 2011.
http://www.ada.gov/olmstead/q&a_olmstead
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Personal care services are further defined to include
assistance with ambulation i.e. walking; bathing, oral
hygiene, and grooming; dressing; care and assistance with
prosthetic devices; bowel, bladder, and menstrual care;
repositioning, skin care, range of motion exercises, and
transfers; feeding and assurance of adequate fluid intake;
respiration and assistance with self-administration of
medications.
Welfare and Institutions Code allows IHSS providers to
perform paramedical services that are ordered by a licensed
health care professional, which consumers could provide for
themselves but for their functional limitations.
Paramedical services include the administration of
medications, puncturing the skin or inserting a medical
device into a body orifice, activities requiring sterile
procedures, or other activities requiring judgment based on
training given by a licensed health care professional.
The current program provides recipients the right to
"self-direct" their care, although not all recipients are
cognitively able to do so. Among IHSS recipients, there is
wide range in the functional needs and level of
independence, making a one-size fits all model of care
impractical. Some recipients may have a physical or
cognitive impairment, but are not otherwise medically
needy. Such recipients rely on IHSS for assistance with
activities of daily living that enable a typical lifestyle
including employment, social and community activities, and
an otherwise fully independent living arrangement. Other
recipients may be medically needy, but are cognitively
independent and capable of managing their own care under
the direction of an aide. An increasing number of
recipients are aging seniors who may have substantial
cognitive and physical impairments combined with medical
conditions that make care management particularly relevant.
The functional index is measured on a 0-5 (or sometime 0-6)
scale as established in Welfare & Institutions Code 12309,
as follows:
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------------------------------------------------------------
|Rank 1 |Functioning is independent, and he or she is able |
| |to perform the function without human assistance, |
| |although the recipient may 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. |
|---------+--------------------------------------------------|
|Rank 2 |Able to perform a function, but needs verbal |
| |assistance, such as reminding, guidance, or |
| |encouragement. |
|---------+--------------------------------------------------|
|Rank 3 |Can perform the function with some human |
| |assistance, including, but not limited to, direct |
| |physical assistance from a provider. |
|---------+--------------------------------------------------|
|Rank 4 |Can perform a function, but only with substantial |
| |human assistance. |
|---------+--------------------------------------------------|
|Rank 5 |Cannot perform the function, with or without |
| |human assistance. |
|---------+--------------------------------------------------|
|Rank 6 |Paramedical Services Needed |
------------------------------------------------------------
The "Functional Index Rank" is set for each task when the
social worker evaluates the hours and type of care an IHSS
consumer needs to remain independent. For example, a
consumer can be ranked as a "3" for bathing and as a "4"
for meal preparation. The "Functional Index Score" is the
average of the Functional Index Rankings as determined by
the social worker. As previously mentioned, efforts to
achieve budgetary savings by reducing the functional index
levels that qualified to receive services were enjoined by
the courts on the basis of the ADA and Olmstead.
Counties are required to use statewide hourly task
guidelines, established by CDSS, when conducting
assessments or reassessments in order to consistently
assess and authorize service hours in a standard way. (WIC
12301.2) The guidelines specify a range of hours associated
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with each Functional Index level for each task.
State regulations require that the time authorized for
services must be "based on the recipient's individual level
of need necessary to ensure his/her health, safety and
independence based on the scope of tasks identified for
service." Regulations further state that, "in determining
the amount of time per task, the recipient's ability to
perform the tasks based on his/her FI ranking shall be a
contributing factor, but not the sole factor."
Additionally, state law requires recipients to obtain a
certification from a licensed health care professional
declaring that the recipient is unable to perform some
activities of daily living independently, and that without
services to assist him or her with activities of daily
living, the applicant or recipient is at risk of placement
in out-of-home care.
Legal Blindness and the Americans with Disabilities Act
Title 16 of the Social Security Act defines legal blindness
a central visual acuity of 20/200 or less in the stronger
eye, while wearing a correcting lens or glasses; or a
limitation in the field of vision in the better eye, so
that:
There is contraction of peripheral visual fields to
10 degrees from the point of fixation, or
The widest diameter of the visual field subtends an
angle no greater than 20 degrees, or
There is a contraction of peripheral visual fields
to 20 percent or less visual field efficiency (Title
XVI of the Social Security Act Sec. 1614 (42 U.S.C.
1382c))<3>
Titles II and III of the Americans with Disabilities Act
(ADA) mandate that government and private sector
-------------------------
<3> Title XVI of the Social Security Act Sec. 1614 (42
U.S.C. 1382c)) "Meaning of Terms"
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organizations must provide print materials in an
alternative format for people with visual impairment.
Specifically, Section 36.303, Title III of the ADA
provides, "A public accommodation shall furnish appropriate
auxiliary aids and services where necessary to ensure
effective communication with individuals with
disabilities." These print materials can include, but not
limited to, billing statements, financial statements,
personnel manuals and business cards. According to the
United States Department of Justice, Civil Rights Division,
in practice this means that the ADA requires that effective
communication not exclude people with disabilities -- which
in the case of visually impaired or blind persons may
require businesses and government to provide information
verbally or in braille.<4> However, it states the law does
not require any measure that would cause an undue financial
or administrative burden.
Braille and visual aid technologies
The National Braille Press states that braille literacy
rates for school-age blind children have declined from
greater than 50 percent (40 years ago) to only 12 percent
today.<5> This may be compared to a 50% literacy rate among
blind individuals in the 1960s. Academic research on
braille literacy suggests that:
"One of the greatest reasons for this decline in
Braille literacy has been the controversy of whether
or not to teach Braille when a blind child has some
residual vision, in which case it has become more
popular to rely on magnification equipment or large
print. Children with some residual vision account for
approximately 85% of blind children because they are
blind by the legal definition (i.e., vision is worse
than 20/200 and cannot be improved with corrective
----------------------
<4> United States Department of Justice, Civil Rights
Division. "Myths and Facts about the Americans with
Disabilities Act." http://www.ada.gov/archive/mythfact.htm
<5> National Braille Press.
http://www.nbp.org/ic/nbp/braille/needforbraille.html
STAFF ANALYSIS OF ASSEMBLY BILL 1703 (Hall)
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lenses) but have some vision remaining.
Certain degenerative conditions, such as glaucoma and
degenerative myopia, have an onset early in childhood
with vision worsening over time. Low-vision students,
in particular those with degenerative visual
impairments, are at risk for not receiving appropriate
braille instruction while some level of sight
remains.<6>
An ADA handbook published by the University of California
notes that not all blind people read Braille and that
"typically, people who have lost their vision later in life
tend to rely on speech output as their access strategy."
The handbook notes alternative adaptive equipment that may
be useful including:
Magnified display of computer screen though software
and hardware that presents images with character size
increased approximately 2-16X.
Keyboard aids with adhesive-backed large, bold
letters applied to the standard keyboard.
Copy machine with enlarging and reducing capability
to magnify print or narrowly restrict the field of
vision.
Screen reader software to direct the screen contents
to a speech synthesizer allowing the individual to
listen to the information appearing on the screen.
Braille input devices including portable note-taking
systems that can generate a file to be transferred to
the PC, but also to other devices designed to be
connected to the PC in place of the standard keyboard
to provide for a braille input mechanism. In addition,
there are software packages available that will
configure a standard keyboard so it can be used for
Braille input.
Braille note-taker, a small, portable device that
allows braille code entry for note taking, editing and
storage of information.
Refreshable Braille, a device with a row of braille
------------------------
<6> K.To`ussaint and J.Tiger. Teaching Early Braille
Literacy Skills within a Stimulus Equivalence Paradigm to
Children with Degenerative Visual Impairments J Appl Behav
Anal. 2010 Summer; 43(2): 181-194.
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cells that change to reflect what is being presented on
the computer screen. The individual reads the screen
contents using the dynamically changing braille
display.
Optical character recognition (OCR) allowing printed
documents to be scanned and converted to speech output
or written to a PC by use of an OCR configured to
support use by a visually impaired person.
Speech Recognition through speech input systems
allowing voice commands and/or mouse movements instead
of using the keystroke equivalents.
Such technology may be costly and inaccessible for
low-income individuals with visual impairments or
blindness, particularly among individuals whose sole source
of income is SSI/SSP.
Prior Legislation:
AB 238 (Beall) 2007 was substantially similar to this bill
and was vetoed by the Governor. The Governor is his veto
message of AB 238 stated:
I strongly support the In-Home Supportive Services (IHSS)
program which provides services to low-income aged, blind
or disabled persons so they can remain safely in homes. My
Administration has worked hard to secure more than 1.7
billion in federal funds to protect these important
services. However, I cannot support expanding the program's
scope to include reading services. This expansion would add
more than one million dollars in new costs at a time of
ongoing budget challenges. We must balance our need for
important program services with our fiscal reality. For
these reasons, I am returning AB 238 without my signature.
COMMENTS
In response to a prior version of this bill AB 238 (Beall)
2007, CDSS reported a concern that the bill "could create a
fiduciary relationship between the IHSS provider and the
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recipient, and may increase the risk for potential
financial fraud as an IHSS provider would be in control of
what is communicated on the IHSS recipient's financial
documents."
Staff notes that the nature of a caregiver / consumer
relationship may inherently expose the consumer to
potential fraud, theft and abuse, and for that and other
reasons, the state requires criminal background checks to
be conducted on prospective caregivers. Staff notes that
the only mention of fraud in existing statute pertains to
fraud against the state. However, given the department's
concern with the wellbeing of blind consumers, should the
bill move forward, the author may wish to consider an
amendment clarifying that the state is not legally
responsible should the provider commit an illegal act in
connection with this service.
PRIOR VOTES
Assembly Floor 71 - 2
Assembly Appropriations 14 - 0
Assembly Human Services 6 - 0
POSITIONS
Support: California Association of Public Authorities
for IHSS-
(Co-sponsor)
UWD and AFSCME Local 3930 (Co-sponsor)
AFSCME
California Commission on Aging
California Council of the Blind
California Senior Legislature
Coalition of California Welfare Rights
Organizations
Public Authority for In-Home Supportive
Services-
In Alameda County
SEIU California
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State Independent Living Council
Oppose: None received.
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