COURT DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE &OF COUNTY MEDICAID SERVICES Date ...................................................... HOME HEALTH FUNCTIONAL ASSESSMENT No. : Index FORM APPROVED OMB NO. 0938-0355 Patient HI Claim No. MODULE C: HOME VISIT (For Q. C1-C3, clarify discrepancies between information contained:in the clinical Calendar record and what you observe in the home.) FAMILY SITUATION C1. Living Arrangement: Alone C2. Primary Caregiver: Self None With Other With Spouse : Unknown Child Other Relative Friend Other : Paid Attendant Plaintiff(s) Spouse -againstOther Volunteer SURVEYOR NOTES No. JUDICIAL SUBPOENA : C3. Primary informal caregiver is able to receive instructions and provide care? Please give example. Yes No Unknown Not Applicable : MEDICAL CONDITION PROBE Defendant(s) : Through conversation with the patient and/or informal caregiver (or observation), determine the ...................................................... influence the HHA has had in helping patient/caregiver in the following review areas. ASKING SIMPLE YES OR NO QUESTIONS IS NOT SATISFACTORY. ANSWERS IN THIS SECTION ARE BASED ON YOUR IMPRESSIONS/BEST JUDGEMENT. THE PEOPLE OF THE STATE OF NEW YORK PATIENT/CAREGIVER IS ABLE TO: TO YES YES YES Patient Caregiver NO UNKNOWN Both C4. Describe reason for admission to HHA C5. Describe how HHA care relates to patient’s medical, nursing and/or rehabilitative needs GREETINGS: C6. Report change(s) in patient’s condition (nature of change(s)) WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , at the Court located at County of C8. Describe the therapeutic diet (if appropriate) in room , on the day of , 20 , at o'clock in the noon, and at any recessed or questions about the patient’sand give evidence as a witness in this action on the part of the adjourned date, to testify rights C9. Answer C7. Identify medications prescribed for treatment, the Honorable and their administration C10. Describe the availability of the State hotline, and knows the hotline telephone number Your failure to (Refer with this subpoena is punishable as a contempt of court and will make you liable to FUNCTIONAL CAPACITY PROBEcomply to Module B for information.) C11. Through observationwhose behalf this subpoena was issued for a if appropriate, the party on of and/or conversation with the patient/caregiver, maximum penalty determine patient’s ability to perform the Activities of Daily Living (ADLs). result of your failure to comply. Determine level of deficit (e.g., needs help, unable to do) and record on ADL section of Worse Module B. Better Witness, Honorable of $50 and all damages sustained as a , one of the Justices of the C12. Through observation of and/or County, conversation with the patient/caregiver, if appropriate, Court in day of , 20 determine patient’s ability to perform the Instrumental Activities of Daily Living (IADLs). Determine level of deficit and record on IADL section of Module B. Better Worse (Attorney must sign above and type name below) ENVIRONMENTAL PROBE C13. Through conversation and observation, determine if there is anything in the patient’s living environment that could influence the plan of care and/or progress toward outcomes (e.g., general habitability of home, uneven floors, etc.). Determine if these influences have Attorney(s) for been discussed with the patient/caregiver by staff and recorded in clinical record (if appropriate). BEHAVIORAL/MENTAL PROBE C14. Through conversation and observation, determine whether patient exhibits any behavioral or mental problems that could influence the following: Office and P.O. • patient’s response to instructions about the patient’s rights; and • course of care and/or progress. Problems may include, but are not limited to the following: disoriented/wandering, agitated, forgetful, depressed, anxious, disruptive, assaultive. Explain: Telephone No.: Address Facsimile No.: 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 E-Mail Address: 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. No.: Mobile Tel. Form CMS-1515C (06/90) American LegalNet, Inc. www.USCourtForms.com