s): . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .DEPARTMENT OF HEALTH AND HUMAN SERVICESFORM APPROVEDCENTERS FOR MEDICARE & MEDICAID SERVICESOMB NO. 0938-Survey DatesHOME HEALTH FUNCTION AND CARE SUMMARY: MODULE E HHA NAME Provider Medicare IDSURVEYOR NOTES:THE PEOPLE OF THE STATE OF NEW YORK TONumber 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: Rural UrbanRural and Urban SERVICE AREASUMMARY OBSERVATION (Check One in Each Category)GREETINGS:FAVORABLEFOR MOSTFAVORABLEFOR SOME PATIENTSWE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the HonorableUNFAVORABLE FOR MOST PATIENTS,PATIENTSREVIEW AREAlocated at County ofAppropriateness of assessments, on the, at or adjourned date, to testify and give evidence as a witness in this action on the part of the, 20noon, and at any recessed in roomo'clock in the day ofAppropriateness of care plans and servicesAdherence to plan of careYour failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply.Coordination of services between disciplinesCompleteness of documentation, one of the Justices of theCourt in Witness, Honorable, 20 County,day ofTreatment 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:(Attorney must sign above and type name below)1. Provides care that promotes a high potential for reaching the highest attainable levels ofAttorney(s) forfunctioning 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 functioningOffice and P.O. Addressfor 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 Conditionsof Participation. There is an immediate need for an extended survey.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.Telephone No.: Facsimile No.: E-Mail Address:Name of Surveyor(s)DateMobile Tel. No.:FORM CMS-1515E (06/90)American LegalNet, Inc. www.USCourtForms.com
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