Form 1515a Home Health Functional Assessment Instrument: Module A

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

Date

A2. Date of Birth/Age: A3. Sex
M

A13. ICD-9-CM

Surgical Procedure

Date

A14. ICD-9-CM

Other Pertinent
Diagnoses

Date

Provider Medicare ID:
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

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

Form CMS-1515A (11/05) EF 10/2005

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.