1515e Home Health Function and Care Summary: Module E

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

Survey Dates
SERVICE AREA
Rural
Urban
Rural and Urban

FORM APPROVED
OMB NO. 0938-0355

HOME HEALTH FUNCTION AND CARE SUMMARY: MODULE E

HHA NAME
Provider Medicare ID

SURVEYOR NOTES:
Number of records reviewed with home visits:
Number of records reviewed, no home visits:
Number of home visits with no record review:
Total records reviewed:
Total home visits:

SUMMARY OBSERVATION (Check One in Each Category)

REVIEW AREA

FAVORABLE
FOR MOST
PATIENTS

FAVORABLE
FOR SOME
PATIENTS

UNFAVORABLE
FOR MOST PATIENTS

Appropriateness of assessments
Appropriateness of care plans
and services
Adherence to plan of care
Coordination of services between
disciplines
Completeness of documentation
Treatment contributed to meeting
patients’ medical, nursing, and
rehabilitative needs

SURVEYOR SUMMARY: Based on the reviews of the patients from this HHA, including all information
surveyed in the standard survey and using the Functional Assessment Instrument (FAI), this HHA:
1. Provides care that promotes a high potential for reaching the highest attainable levels of
functioning for its patients. There is no evidence of need for a partial extended or extended survey.
2. Provides care that promotes a moderate potential for reaching the highest level of functioning
for some but not all of its patients. There are standard level deficiencies and need for a partial
extended survey. If no Conditions of Participation are out of compliance, a Plan of Correction
will be requested for the standard level of deficiencies.
3. Provides substandard care. There are condition level deficiencies in one or more Conditions
of Participation. There is an immediate need for an extended survey.
Name of Surveyor(s)

FORM CMS-1515E (06/90)

Date

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