CMS-1515D Home Health Functional Assessment Patient Function and C

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

FORM APPROVED

OMB NO. 0938-0355

HOME HEALTH FUNCTIONAL ASSESSMENT PATIENT
FUNCTION AND CARE SUMMARY: MODULE D

Date
D1. HHA REVIEW AREA

Patient HI Claim No.
SURVEYOR NOTES

HHA PERFORMANCE
(This Patient)
Check ONE Option Where Appropriate
Substantially
Complete

Documentation

Record Completeness
Substantially
Documentation
Record Agrees with In-Home
Observation
Complete
HHA Adherence to Plan
Adherence

Partially
Complete

Substantially
Incomplete

Partially

Not At All

Partial
Adherence

No
Adherence
Check here if no
ADL Plan of Care

Medical Condition
ADL
Patient Condition (Relative
to condition at admission)

Improved

Medical Condition

Unchanged

Deteriorated

Check here if ADL
status and treatment
are not relevant to
this case.

ADL
SUMMARY EVALUATION OF PATIENT’S CARE (Please explain all “no” answers, except
where indicated.)
D2. Were HHA assessments of the patient’s medical, nursing, and rehabilitative needs
appropriate at the start of care and as the care progressed?
NO
YES
D3. Were the types and frequencies of services prescribed in the initial plan of care appropriate,
given the patient’s anticipated outcomes and condition(s) at admission? (Note whether
therapist and other HHA personnel participated in care plan, if appropriate.)
YES

NO

D4. Did you see evidence that the patient’s plan of care was changed appropriately during the
course of care to reflect any changes in the medical, nursing and rehabilitative needs of the
patients?
NO
YES
No Change Required
D5. Did you see evidence of coordination of services between and among the various disciplines
treating this patient?
YES

NO

Not applicable; only one discipline

D6. Did orders for therapy services include the specific procedures and modalities to be used, as
well as the amount, frequency, and duration of services?
YES

NO

Not applicable; no therapy
services ordered

D7. Did your home visit lead you to conclude that the patient's progress (or lack of progress),
was appropriate given the patient’s admitting and current medical and functional status?
YES

NO

D8. Does the evidence from your review of the record, your conversation with HHA nurse, and
your home visit lead you to conclude that the HHA intervened appropriately, and made a
difference in the patient's current medical and functional capacity?
YES

NO

D9. In your opinion, could the HHA have done more to assist this patient in meeting his/her
medical, nursing, and rehabilitative needs within the range of usual HHA practice? If yes,
record specific examples.
YES

NO

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Form CMS-1515D (06/90)