1515b Home Health Functional Assessment Instrument: Module B

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 B

Deteriorated

Unchanged

ACTIVITY

Needs Some
Unable
Needs No Assistance/
to do
Assistance is Helped by
Person

Improved

ACTIVITIES OF DAILY LIVING (as appropriate) ADLs

Patient HI Claim No.

INSTRUMENTAL ACTIVITIES OF DAILY LIVING (as appropriate) IADLs
SURVEYOR INSTRUCTIONS

*
Needs Some
Needs Complete module only if the
Needs No Assistance/ Unable
More Help admitting or secondary
Assistance is Helped by
to do
yes
no diagnosis(es) directly affect the
Person

*

Needs
More Help
yes

B1. Eating
At Admission
Record Review
Home Visit

B2. Transferring
At Admission
Record Review
Home Visit

B3. Dressing
At Admission
Record Review
Home Visit

B4. Bathing
At Admission
Record Review
Home Visit

no ACTIVITY

patient’s potential to meet
his/her ADLs or IADLs, or the
HHA’s planning and care for
the patient.

RR

B7. Prepare Light
Meals

HV

B8. Prepare Full
Meals

HV

RR

SURVEYOR NOTES:

B9. Light
RR
Housekeeping HV
RR

B10. Personal
Laundry

HV

B11. Handling
Money

HV

B12. Using
Telephone

HV

RR= Record Review
HV= Home Visit

(continue on back of module)

RR

RR

*If “yes,” does medical record document planning
to provide additional help? Please explain in
Surveyor Notes.

B13. Behavioral/Mental: Note all conditions documented in record
(e.g., patient disoriented)

B5. Toileting
At Admission
Record Review
Home Visit

B6. Ambulation
At Admission
Record Review
Home Visit

*SURVEYOR NOTE
*If “yes,” does medical record document planning to provide additional
help? Please explain in Surveyor Notes.
Form CMS-1515B(06/90)

B14. Appliance/Aids, Special Equipment Used by Patient
Record
Ambulation Aid, Other
Prosthetic Device
Pacemaker
Hearing Aid
Tub Stool
Glasses/Lenses
Hospital Bed
Special Transferring Equip.
Special Toileting Equip.
Special Dressing Equip.
Colostomy Bag

Home
Visit

Record
Cane
Dentures
Walker
Grab Bar
Commode
Catheter
Oxygen
Wheelchair
Leg Brace
Other

Home
Visit
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
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existing data resources, gather the data needed, and complete
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