COURT COUNTY OFDEPARTMENT OF HEALTH AND HUMAN SERVICESFORM APPROVEDCENTERS FOR MEDICARE & MEDICAID SERVICESOMB NO. 0938-. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Patient HI Claim No.HOME HEALTH FUNCTIONAL ASSESSMENT:::::::Index No.MODULE C: HOME VISIT(For Q. C1-C3, clarify discrepancies between information contained in the clinical record and what you observe in the home.) DateSURVEYOR NOTES FAMILY SITUATIONCalendar No.C1. Living Arrangement:AloneWith SpouseWith OtherUnknownJUDICIAL SUBPOENAPlaintiff(s) -against-Defendant(s)C2. Primary Caregiver:SelfSpouseChildFriendOtherNoneOther VolunteerOther RelativePaid AttendantC3. Primary informal caregiver is able to receive instructions and provide care? Please giveexample.YesNoUnknownNot ApplicableMEDICAL 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.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .THE PEOPLE OF THE STATE OF NEW YORK TONO UNKNOWNYESYESYESPATIENT/CAREGIVER IS ABLE TO:PatientCaregiverBothC4. Describe reason for admission to HHA C5. Describe how HHA care relates to patientsGREETINGS:medical, nursing and/or rehabilitative needs C6. Report change(s) in patients condition (nature ofWE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before Court at the the Honorablechange(s)) C7. Identify medications prescribed for treatment,,located at County ofand their administration C8. Describe the therapeutic diet (if appropriate)o'clock in the day of, on the, 20, at or adjourned date, to testify and give evidence as a witness in this action on the part of thenoon, and at any recessed in roomC9. Answer questions about the patients rightsC10. 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,Your 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.determine patients 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 ofModule B.BetterorseW, one of the Justices of theC12. Through observation of and/or conversation with the patient/caregiver, if appropriate,Court in Witness, Honorableday of, 20 County,determine patients ability to perform the Instrumental Activities of Daily Living (IADLs). Determine level of deficit and record on IADL section of Module B.BetterWorse(Attorney must sign above and type name below)ENVIRONMENTAL PROBE C13. Through conversation and observation, determine if there is anything in the patients livingenvironment 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).Attorney(s) forBEHAVIORAL/MENTAL PROBE C14. Through conversation and observation, determine whether patient exhibits any behavioral orOffice and P.O. Addressmental problems that could influence the following: patients response to instructions about the patients 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:Telephone No.: Facsimile No.: E-Mail Address: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.Mobile Tel. No.:Form CMS-1515C (06/90)American LegalNet, Inc. www.USCourtForms.com
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