1515c Home Health Functional Assessment: Module C

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

Date

FORM APPROVED
OMB NO. 0938-0355

HOME HEALTH FUNCTIONAL ASSESSMENT
MODULE C: HOME VISIT

FAMILY SITUATION

(For Q. C1-C3, clarify discrepancies between information contained in the clinical
record and what you observe in the home.)

C1. Living Arrangement:

Alone

With Spouse

With Other

Unknown

C2. Primary Caregiver:

Self
None

Spouse
Other Volunteer

Child
Other Relative

Friend
Other
Paid Attendant

Patient HI Claim No.

SURVEYOR NOTES

C3. Primary informal caregiver is able to receive instructions and provide care? Please give
example.
Yes
No
Unknown
Not Applicable

MEDICAL CONDITION PROBE
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.

PATIENT/CAREGIVER IS ABLE TO:

YES

YES

YES

Patient

Caregiver

Both

NO UNKNOWN

C4. Describe reason for admission to HHA
C5. Describe how HHA care relates to patient’s
medical, nursing and/or rehabilitative needs
C6. Report change(s) in patient’s condition (nature of
change(s))
C7. Identify medications prescribed for treatment,
and their administration
C8. Describe the therapeutic diet (if appropriate)
C9. Answer questions about the patient’s rights
C10. Describe the availability of the State hotline,
and knows the hotline telephone number

FUNCTIONAL CAPACITY PROBE (Refer to Module B for information.)
C11. Through observation of and/or conversation with the patient/caregiver, if appropriate,
determine patient’s ability to perform the Activities of Daily Living (ADLs).
Determine level of deficit (e.g., needs help, unable to do) and record on ADL section of
Worse
Module B.
Better
C12. Through observation of and/or conversation with the patient/caregiver, if appropriate,
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

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
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:
• 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:
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
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this form, please write to: CMS, Attn: PRA Reports Clearance Officer, 7500 Security Boulevard, Baltimore, Maryland 21244-1850.
Form CMS-1515C (06/90)