DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES Survey Date: FORM APPROVED OMB NO. 0938-0355 HOME HEALTH FUNCTIONAL ASSESSMENT INSTRUMENT: MODULE A PATIENT INFORMATION CONDITION/PROBLEM A.20 A1. Patient Name A12. ICD-9-CM Principal Diagnosis A13. ICD-9-CM Surgical Procedure Date A14. ICD-9-CM Other Pertinent Diagnoses Date Patient HI Claim No: Anticipated patient care outcomes related to medical, nursing, and rehabilitative services. Patient and condition specific outcomes should be measureable and quantifiable. Include date outcome was defined and/or revised. Review the plan of care; other parts of the clinical records. Level of Achievement for Patient Care Outcome Completely Partially Not At All Surveyor Comments Date A2. Date of Birth/Age: A3. Sex M Provider Medicare ID: 1. F A4. Referral Date Hospital D/C Date 2. A5. Start of Care (SOC) Date 3. A15. Impairments A6. Admitted From Home Nursing Home Hospital Other A7. Patient Risk Factors related to medical diagnoses Alcoholism Obesity Heavy Smoking Drug Dependency Speech Hearing No. of medications ordered None Known Contraindications Alone With Spouse Unknown None A16. Review medication orders. Check for notations in the record of the following situations: (Do Not list out medications) Chronic Conditions A8. Family Situation/Living Arrangement Vision Psychotropic mood altering drugs HHA awareness 5. of drug sensitivity/ allergies with specific and visible warnings on patient record. 6. Other (Specify) Other More than 6 outcomes? Yes (Continue on back of module) A9. Primary Informal Caregiver(s) Self Spouse Other Relative Friend None Paid Attendant Child Other Volunteer A10. Informal caregiver(s) is (are) able to receive instructions and provide care? Yes No N/A Not Known A11. Is there information that the patient’s living environment might detract from HHA’s ability to implement or complete the plan of care? Yes 4. No A17. Prognosis (at start of care) Poor Guarded Fair Excellent Good A18. Medical Condition at Review (as compared to time of admission) Deteriorated Improved Unchanged Unknown A19. Review plan of care and interim orders for type, duration, and frequency of services ordered. Use the calendar worksheet to ensure that services were delivered as required in the plan of care. Were services delivered as ordered? Yes No No Is there evidence of planning toward discharge? Yes No Does record contain progress notes that describe the level of achievement for anticipated outcomes? Yes Some No Not Appropriate SURVEYOR NOTES: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0355. The time required to complete this information collection is estimated to average 1 hour 10 minutes per response, including the time to review instructions, searching existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, Attn: PRA Reports Clearance Officer, 7500 Security Boulevard, Baltimore, Maryland 21244-1850. Form CMS-1515A (11/05) EF 10/2005 American LegalNet, Inc. www.USCourtForms.com