SELECT *, patient.Last_Name_M0040 AS Last_Name, patient.First_Name_M0040 AS First_Name, patient.Middle_Initial_M0040 AS Middle FROM #Request.prefix_db_agency#.Assessment_New INNER JOIN #Request.prefix_db_agency#.patient ON (Assessment_New.Patient_ID=patient.Patient_ID) WHERE Assessment_New.Assessment_ID='#session.cs.AssessmentId#' select Last_Name, First_Name from #Request.prefix_db_lookup#.Employee where Employee_ID = '#recertform.Record_Created_By#' SELECT Diagnosis.ICD, Diagnosis.Diagnosis, Diagnosis.Severity FROM #Request.prefix_db_agency#.Diagnosis WHERE Diagnosis.Assessment_ID='#session.cs.AssessmentId#' AND Diagnosis.M0230_Link IS NOT NULL order by Diagnosis.Dx_Order ASC SELECT * FROM #Request.prefix_db_lookup#.Assessment_Questions_lookup JOIN #Request.prefix_db_lookup#.Assessment_Answer_lookup ON Assessment_Answer_lookup.question_id = Assessment_Questions_lookup.id WHERE Assessment_Answer_lookup.Deleted <> 1 AND Assessment_Questions_lookup.assessment_reason = '4 - Recertification (follow-up) reassessment' AND Assessment_Questions_lookup.questions like 'GG0%' GROUP BY Assessment_Answer_lookup.answer_label ORDER BY Assessment_Questions_lookup.order_id ASC

Recertification OASIS Assessment #recertform.Last_Name#, #recertform.First_Name# #recertform.Middle# SOC Date #DateFormat(recertform.Start_of_Care_M0030,"mm/dd/yyyy")# #recertform.First_Name_M0040# #recertform.Last_Name_M0040# Certification #DateFormat(recertform.Certification_Start,"mm/dd/yyyy")# To #DateFormat(recertform.Certification_End,"mm/dd/yyyy")# 4-Recertification Completed by #GetE.Last_Name# #GetE.First_Name# CLINICAL RECORD ITEMS (M0080)Discipline of Person Completing Assessment: #recertform.Person_Complete_M0080# (M0090) Date Assessment Completed: #DateFormat(recertform.Assessment_Completed_M0090,"mm/dd/yyyy")# (M0110) Episode Timing: Is the medicare home health payment episode for which this assessment will define a case mix group an "early" episode or a "later" episode in the patient's current sequence of adjacent Medicare home health payment episodes? #recertform.M0110# PATIENT HISTORY AND DIAGNOSES Home Safety: #recertform.Home_Safety_Assess# (M1021M1020 /1022/1024) Diagnoses, Symptom Control, and Payment Diagnoses: List each diagnosis for which the patient is receiving home care and enter its IC0-9-C IA code at the level of highest specificity (no surgical/procedure codes). #GetM1020.Severity# - #GetM1020.Diagnosis# Endocrine: #recertform.Endocrine_Assess# Nutrition: #recertform.M0250_Assess# (M1030) Therapies the patient receives at home: #recertform.Therapies_Home_M0250# (M1032/33) Risk for Hospitalization: Which of the following signs or symptoms characterize thispatient as at risk for hospitalization? #recertform.M1032_Frailty# SENSORY STATUS (M1200) Vision (with corrective lenses if the patient usually wears them): #recertform.Vision_M0390# (M1242) Frequency of Pain Interfering with patient's activity or movement: #recertform.Freq_of_Pain_M0420# Recertification Page 1

#recertform.First_Name_M0040# #recertform.Last_Name_M0040# 4-Recertification Date Completed #DateFormat(recertform.Assessment_Completed_M0090,"mm/dd/yyyy")# Pain Assessment #recertform.M0420_Assess# Skin Assessment #recertform.M0440_Assess# INTEGUMENTARY STATUS (M1306) Does this patient have at least one Unhealed Pressure Ulcer at Stage H or Higher or designated as "unstageable"? #recertform.M1306_Unhealed_Pressure# ((M1308)(M1311) Current Number of Unhealed (non-epithelialized) Pressure Ulcers at Each Stage: (Enter "0" if none; excludes Stage I pressure ulcers) a.Stage II: Partial thickness loss of dermis #recertform.Pressure_Ulcer_b_M0450# b. Stage III: Full thickness tissue loss. #recertform.Pressure_Ulcer_c_M0450# c. Stage IV: Full thickness tissue loss #recertform.Pressure_Ulcer_d_M0450# d.1 Unstageable: Known or likely but Lmstageable due to non-removable dressing or device #recertform.Pressure_Ulcer_e_M0450# d.2 Unstageabre: Known or likely but unstageable due to coverage of wound bed by slough arid/or eschar #recertform.M1308_d_2_Pressure# d.3 Unstageable: Suspected deep tissue injury in evolution. #recertform.M1308_d_3_Pressure# (M1322) Current Number of Stage I Pressure Ulcers: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. #recertform.Pressure_Ulcer_a_M0450# (M1324) Stage of Most Problematic Unhealed (Observable) Pressure Ulcer: #recertform.Pressure_Ulcer_Stage_M0460# (M1330) Does this patient have a Stasis Ulcer? #recertform.Stasis_Ulcer_M0468# (M1332) Current Number of (Observable) Stasis Ulcer(s): #recertform.Stasis_Ulcer_Num_M0470# (M1334) Status of Most Problematic (Observable) Stasis Ulcer: #recertform.Stasis_Ulcer_Status_M0476# (M1340) Does this patient have a Surgical Wound? #recertform.Surgical_Wound_M0482# (M1342) Status of Most Problematic (Observable) Surgical Wound: #recertform.Surgical_Wound_Status_M0488# (M1350) Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those described above that is receiving intervention by the home health agency? #recertform.M1350_Other_Wounds# Recertification Page 2

#recertform.First_Name_M0040# #recertform.Last_Name_M0040# 4-Recertification Date Completed #DateFormat(recertform.Assessment_Completed_M0090,"mm/dd/yyyy")# RESPIRATORY STATUS (M1400) When is the patient clyspneic or noticeably Short of Breath? #recertform.Breathing_M0490# Cardio-respiratory: #recertform.M0490_Assess# ELIMINATION STATUS (M1610) Urinary Incontinence or Urinary Catheter Presence: #recertform.Urinary_INcont_M0520# Genito-Urinary: #recertform.M0520_Assess# (M1620) Bowel Incontinence Frequency: #recertform.Bowel_Incont_M0540# Gastro-Intestinal: #recertform.M0540_Assess# (M1630) Ostomy for Bower Elimination: Does this patient have an ostorny for bowel elimination that (within the last 14 days): a) was related to an inpatient facility stay, or b) necessitated a change in medical or treatment regimen? #recertform.Ostomy_for_Bowel_M0550# ADLS/IADLS M1800 Grooming: Current ability to tend to personal hygiene needs (i.e., washing face, hair care, shaving/make up, teeth/dentures... #recertform.Grooming_M0640# (M1810) Current Ability to Dress Upper Body safely (with or without dressing aids) including undergarments, pullovers, front-opening shirts and blouses, managing zippers, buttons, and snaps: #recertform.Dress_Upper_M0650# (M1820) Current Ability to Dress Lower Body safely (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes: #recertform.Dress_Lower_M0660# (M1830) Bathing: Current ability to wash entire body safely. Excludes grooming (washing face, washing hands, and shampooing hair). #recertform.Bathing_M0670# (M1840) Toilet Transferring: Current ability to get to and from the toilet or bedside commode safely and transfer on and off toilet/commode. #recertform.M1840_Toilet# (M1850) Transferring: Current ability to move safely from bed to chair, or ability to turn and position self in bed if patient is bedfast. #recertform.Transferring_M0690# (M1860) Ambulation/Locomotion: Current ability to walk safely, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces. #recertform.Ambulation_M0700# Recertification Page 3

#recertform.First_Name_M0040# #recertform.Last_Name_M0040# 4-Recertification Date Completed #DateFormat(recertform.Assessment_Completed_M0090,"mm/dd/yyyy")# (M2030) Management of Injectable Medications: Patient's current ability to prepare and take all prescribed injectable medications reliably and safely, including administration of correct dosage at the appropriate times/intervals. Excludes IV medications.. #recertform.Inject_Meds_M0800# THERAPY NEED AND PLAN OF CARE (M2200) Therapy Need: In the home health plan of care for the Medicare payment episode, what is total of reasonable and necessary PT, OT, and ST visits combined? #recertform.M0826_Ther_Need# Strengths #recertform.Strengths# Goals #recertform.Goals# Care Preference #recertform.Care_Preference# Risk Factor #recertform.Risk_Factor# Interventions #recertform.Interventions# Assessment Note #recertform.Assessment_Note# Recertification Page 4

#recertform.First_Name_M0040# #recertform.Last_Name_M0040# 4-Recertification Date Completed #DateFormat(recertform.Assessment_Completed_M0090,"mm/dd/yyyy")# #questions# #Evaluate(Variables.cheked_value)# - Recertification Page #page_num#

#recertform.First_Name_M0040# #recertform.Last_Name_M0040# 4-Recertification Date Completed #DateFormat(recertform.Assessment_Completed_M0090,"mm/dd/yyyy")# Signed by patient/legal representative as reviewed: Patient/Representative name ________________________________________________ Date: ________________________ Patient/Representative name printed _______________________________________________________________________ Affiliation to patient (if applicable): _________________________________________________________________________ Physician Signature: ____________________________________________________ Recertification Page #page_num#