SELECT patient.Patient_ID, patient.Last_Name_M0040 AS Last_Name, patient.First_Name_M0040 AS First_Name, patient.Middle_Initial_M0040 AS Middle ,patient.Payer_ID ,Employee.Last_Name as LastName,Employee.First_Name as FirstName FROM #Request.prefix_db_agency#.patient LEFT OUTER JOIN #Request.prefix_db_lookup#.Employee on Employee.Employee_ID = patient.Primary_ReferringPhys_ID_M0072 WHERE patient.Patient_Id = '#session.cs.patientid#' AND patient.Agency_Id = '#session.AgencyId#' SELECT patient.First_Name_M0040, patient.Last_Name_M0040, patient.M1100_Living_Situation, Assessment_New.Person_Complete_M0080, Assessment_New.M1028_diagnosis, Assessment_New.M1060_height, Assessment_New.M1060_weight, Assessment_New.Certification_Start, Assessment_New.Certification_End, Assessment_New.Discharged_From_M0175, Assessment_New.Home_Safety_Assess, Assessment_New.Endocrine_Assess, Assessment_New.M0250_Assess, Assessment_New.Start_of_Care_M0030, Assessment_New.Fall_A, Assessment_New.Fall_B, Assessment_New.Fall_C, Assessment_New.Fall_D, Assessment_New.Fall_E, Assessment_New.Fall_F, Assessment_New.Fall_G, Assessment_New.Fall_H, Assessment_New.Fall_I, Assessment_New.Pain1, Assessment_New.Pain2, Assessment_New.Pain3, Assessment_New.Pain4, Assessment_New.Pain5, Assessment_New.Inpatient_Discharge_Date_M0180, Assessment_New.Resump_of_Care_M0032, Assessment_New.Assessment_Completed_M0090, Assessment_New.M0102_Physician_SOC, Assessment_New.M0110, Assessment_New.M0104_Date_of_Referral , Assessment_New.Conditions_Prior_M0220, Assessment_New.Therapies_Home_M0250, Assessment_New.M1032_Frailty, Assessment_New.Rehab_Prognosis_M0270, Assessment_New.High_Risk_Factors_M0290, Assessment_New.Vision_M0390, Assessment_New.Hearing_M0400, Assessment_New.M1220_Verbal_Under , Assessment_New.Speech_M0410, Assessment_New.M1240_Pain_Assess, Assessment_New.Freq_of_Pain_M0420, Assessment_New.M1300_Pressure, Assessment_New.M1302_Pressure, Assessment_New.M1306_Unhealed_Pressure, Assessment_New.M1310_Length, Assessment_New.M1312_Width, Assessment_New.M1314_Depth, Assessment_New.Pressure_Ulcer_b_M0450, Assessment_New.Pressure_Ulcer_c_M0450, Assessment_New.Pressure_Ulcer_d_M0450, Assessment_New.Pressure_Ulcer_e_M0450, Assessment_New.M1308_d_2_Pressure, Assessment_New.M1308_d_3_Pressure, Assessment_New.M1308_a_12_Pressure, Assessment_New.M1308_b_12_Pressure, Assessment_New.M1308_c_12_Pressure, Assessment_New.M1308_d_12_Pressure, Assessment_New.M1308_d_22_Pressure, Assessment_New.M1308_d_32_Pressure, Assessment_New.Pressure_Ulcer_Status_M0464, Assessment_New.Pressure_Ulcer_a_M0450, Assessment_New.Pressure_Ulcer_Stage_M0460, Assessment_New.Stasis_Ulcer_M0468, Assessment_New.Stasis_Ulcer_Num_M0470, Assessment_New.Stasis_Ulcer_Status_M0476, Assessment_New.Surgical_Wound_M0482, Assessment_New.Surgical_Wound_Status_M0488, Assessment_New.Breathing_M0490, Assessment_New.Resp_Treatments_M0500, Assessment_New.M0490_Assess, Assessment_New.M0520_Assess, Assessment_New.UTI_M0510, Assessment_New.Urinary_INcont_when_M0530, Assessment_New.Urinary_INcont_M0520, Assessment_New.M0540_Assess, Assessment_New.Bowel_Incont_M0540, Assessment_New.Ostomy_for_Bowel_M0550, Assessment_New.Cog_Function_M0560, Assessment_New.When_Confused_M0570, Assessment_New.When_Anxious_M0580, Assessment_New.M1730_Depression, Assessment_New.Patient_Behav_Weekly_M0610, Assessment_New.Patient_Behav_freq_M0620, Assessment_New.M0610_Assess, Assessment_New.Psy_Nursing_M0630, Assessment_New.M0650_Assess, Assessment_New.Grooming_M0640, Assessment_New.Dress_Upper_M0650, Assessment_New.Dress_Lower_M0660, Assessment_New.Bathing_M0670, Assessment_New.M1845_Toilet, Assessment_New.Fall_A, Assessment_New.Fall_B, Assessment_New.Transferring_M0690, Assessment_New.Ambulation_M0700, Assessment_New.Eating_M0710, Assessment_New.Meal_Prep_M0720, Assessment_New.Use_Phone_M0770, Assessment_New.M1900a_SelfCare, Assessment_New.M1900b_Amb, Assessment_New.M1900c_Transfer, Assessment_New.M1900d_House, Assessment_New.M2000_Adverse, Assessment_New.M2002_Med_FU, Assessment_New.M2010_Med_Edu, Assessment_New.Oral_Meds_M0780, Assessment_New.Inject_Meds_M0800, Assessment_New.Oral_Meds_M0780p, Assessment_New.Inject_Meds_m0800p, Assessment_New.M1840_Toilet, Assessment_New.M2100a_Equip, Assessment_New.M2100b_Equip, Assessment_New.M2100c_Equip, Assessment_New.M2100d_Equip, Assessment_New.M2100e_Equip, Assessment_New.M2100f_Equip, Assessment_New.M2100g_Equip, Assessment_New.M2110_Assist_Freq, Assessment_New.M1016_DX_NA, Assessment_New.M0826_Ther_Need, Assessment_New.M2250a_PhysNot, Assessment_New.M2250b_Diabetic, Assessment_New.M2250c_FallsPrev, Assessment_New.M2250d_Depress, Assessment_New.M2250e_Pain, Assessment_New.M2250f_PressUlc, Assessment_New.M2250g_PressUlcMoist, Assessment_New.M1730a, Assessment_New.M1730b, Assessment_New.M1350_Other_Wounds, Assessment_New.Braden_1_Sensory, Assessment_New.Braden_2_Moisture, Assessment_New.Braden_3_Activity, Assessment_New.Braden_4_Mobility, Assessment_New.Braden_5_Nutrition, Assessment_New.Braden_6_Friction, Assessment_New.M1910_Fall_Risk, Assessment_New.Record_Created_By, Assessment_New.Assessment_Note, Assessment_New.M0440_Assess 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 = '#Form.Record_Created_By#' SELECT Diagnosis.ICD, Diagnosis.Diagnosis FROM #Request.prefix_db_agency#.Diagnosis WHERE Diagnosis.Assessment_ID='#session.cs.AssessmentId#' AND Diagnosis.M0190_Link IS NOT NULL order by Diagnosis.Dx_Order ASC SELECT Diagnosis.ICD, Diagnosis.Diagnosis FROM #Request.prefix_db_agency#.Diagnosis WHERE Diagnosis.Assessment_ID='#session.cs.AssessmentId#' AND Diagnosis.M1012_Link IS NOT NULL order by Diagnosis.Dx_Order ASC SELECT Diagnosis.ICD, Diagnosis.Diagnosis FROM #Request.prefix_db_agency#.Diagnosis WHERE Diagnosis.Assessment_ID='#session.cs.AssessmentId#' AND Diagnosis.M0210_Link IS NOT NULL order by Diagnosis.Dx_Order ASC 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

Start of Care OASIS Assessment #getP.Last_Name#, #getP.First_Name# #getP.Middle# SOC Date #DateFormat(Form.Start_of_Care_M0030,"mm/dd/yyyy")# #Form.First_Name_M0040# #Form.Last_Name_M0040# Certification #DateFormat(Form.Certification_Start,"mm/dd/yyyy")# To #DateFormat(Form.Certification_End,"mm/dd/yyyy")# 1 - Start of Care Completed by #GetE.First_Name# #GetE.Last_Name# CLINICAL RECORD ITEMS (M0080) Discipline of Person Completing Assessment: #Form.Person_Complete_M0080# (M0090) Date Assessment Completed: #DateFormat(Form.Assessment_Completed_M0090,"mm/dd/yyyy")# (M0102) Date of Physician-ordered Start of Care (Resumption of Care) for specific physician- indicated start of care (resumption) date #DateFormat(Form.M0102_Physician_SOC,"mm/dd/yyyy")# (M0104) Date of Referral: Indicate the date that the written verbal referral for initiation or resumption of care was received by the HHA #DateFormat(Form.M0104_Date_of_Referral,"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? #M0110# PATIENT HISTORY AND DIAGNOSES (M1000) From which of the following Inpatient Facilities was the patient discharged during the past 14 days? #Form.Discharged_From_M0175# (M1005) Inpatient Discharge Date (most recent): #DateFormat(Form.Inpatient_Discharge_Date_M0180,"mm/dd/yyyy")# (M1010) List each Inpatient Diagnosis and ICD -9-CM code at the level of highest specificity for only those conditions treated during an inpatient stay within the last 14 days (no ICD10 Z-Codes): #GetM1010.Diagnosis# (M1012) List each Inpatient Procedure and the associated ICD-9-CM procedure code relevant to the plan of care. #ListElement# Start of Care Page 1

#Form.First_Name_M0040# #Form.Last_Name_M0040# 1 - Start Of Care Date Completed #DateFormat(Form.Assessment_Completed_M0090,"mm/dd/yyyy")# (M1016) Diagnoses Requiring Medical or Treatment Regimen Change Within Past 14 Days: List the patient's Medical Diagnoses and ICD-9-CM codes at the level of highest specificity for those conditions requiring changed medical or treatment regimen within the past 14 days (no surgical, ICD10 Z-Codes): #GetM1016.Diagnosis# (M1018) Conditions Prior to Medical or Treatment Regimen Change or inpatient Stay Within Past 14 Days: If this patient experienced an inpatient facility discharge or change in medical or treatment regimen within the past 14 days, indicate any conditions which existed prior to the inpatient stay or change in medical or treatment regimen #Form.Conditions_Prior_M0220# Home Safety: #Form.Home_Safety_Assess# (M1020/1022/1024) Diagnoses, Symptom Control, and Payment Diagnoses: List each diagnosis for which the patient is receiving home care and enter its ICD-9-CM code at the level of highest specificity (no surgical/procedure codes). #GetM1020.Severity# - #GetM1020.Diagnosis# Endocrine: #Form.Endocrine_Assess# Nutrition: #Form.M0250_Assess# M1028 - Active diagnoses-Comorbidities and Co-Existing Conditions #Form.M1028_diagnosis# (M1030) Therapies the patient receives at home: #Form.Therapies_Home_M0250# (M1032) Risk for Hospitalization: Which of the following signs or symptoms characterize this patient as at risk for hospitalization? #Form.M1032_Frailty# (M1034) Overall Status: Which description best fits the patient's overall status? #Form.Rehab_Prognosis_M0270# Start of Care Page 2

#Form.First_Name_M0040# #Form.Last_Name_M0040# 1 - Start Of Care Date Completed #DateFormat(Form.Assessment_Completed_M0090,"mm/dd/yyyy")# (M1036) Risk Factors, either present or past, likely to affect current health status and/or outcome: #Form.High_Risk_Factors_M0290# M1060 -Height and Weight – While measuring, if the number is X.1 –C.4 round down; X.5 or greater round up a. Height in inches.Record most recent height measure since the most recent SOC/ROC #Form.M1060_height# b. Weight (in pounds).Base weight on most recent measure in last 30 days;measure weight consistently,according to standard agency practice(for example,in after voiding,before meal,with shoes off,etc..) #Form.M1060_weight# LIVING ARRANGEMENTS (M1100) Patient Living Situation: Which of the following best describes the patient's residential circumstance and availability of assistance? #Form.M1100_Living_Situation# SENSORY STATUS (M1200) Vision (with corrective lenses if the patient usually wears them): #Form.Vision_M0390# (M1210) Ability to hear (with hearing aid or hearing appliance if normally used): #Form.Hearing_M0400# ((M1220) Understanding of Verbal Content in patient's own language (with hearing aid or device if used): #Form.M1220_Verbal_Under# ((M1230) Speech and Oral (Verbal) Expression of Language (in patient's own language): #Form.Speech_M0410# (M1240) Has this patient had a formal Pain Assessment using a standardized pain assessment tool (appropriate to the patient's ability to communicate the severity of pain)? #Form.M1240_Pain_Assess# (M1242) Frequency of Pain Interfering with patient's activity or movement: #Form.Freq_of_Pain_M0420# Skin Assessment #Form.M0440_Assess# PAIN SCALE Pain Characteristics #Form.Pain1# Pain threshold #Form.Pain2# RateCurrentpain treatment effectiveness on a scale* of 1 to 10(1=low effectiveness) #Form.Pain3# How long does each treatment work before needing another dose #Form.Pain4# Whats is patient's opinion of the cause of her/his pain? #Form.Pain5# Start of Care Page 3

#Form.First_Name_M0040# #Form.Last_Name_M0040# 1 - Start Of Care Date Completed #DateFormat(Form.Assessment_Completed_M0090,"mm/dd/yyyy")# INTEGUMENTARY STATUS (M1300) Pressure Ulcer Assessment: Was this patient assessed for Risk of Developing Pressure Ulcers? #Form.M1300_Pressure# ((M1302) Does this patient have a Risk of Developing Pressure Ulcers? #Form.M1302_Pressure# (M1306) Does this patient have at least one Unhealed Pressure Ulcer at Stage II or Higher or designated as "unstageable"? #Form.M1306_Unhealed_Pressure# ((M1308) 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 #Form.Pressure_Ulcer_b_M0450# b. Stage III: Full thickness tissue loss. #Form.Pressure_Ulcer_c_M0450# c. Stage IV: Full thickness tissue loss #Form.Pressure_Ulcer_d_M0450# d.1 Unstageable: Known or likely but Lmstageable due to non-removable dressing or device #Form.Pressure_Ulcer_e_M0450# d.2 Unstageabre: Known or likely but unstageable due to coverage of wound bed by slough and/or eschar #Form.M1308_d_2_Pressure# d.3 Unstageable: Suspected deep tissue injury in evolution. #Form.M1308_d_3_Pressure# (M1310) Pressure Ulcer Length: Longest length "head-to-toe"(cm) #Form.M1310_Length# (M1312) Pressure Ulcer Width: Width of the same pressure ulcer; greatest width perpendicular to the length (cm) #Form.M1312_Width# (M1314) Pressure Ulcer Depth: Depth of the same pressure ulcer; from visible surface to the deepest area (cm) #Form.M1314_Depth# (M1320) Status of Most Problematic (Observable) Pressure Ulcer #Form.Pressure_Ulcer_Status_M0464# (M1322) Current Number of Stage I Pressure Ulcers: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. #Form.Pressure_Ulcer_a_M0450# (M1324) Stage of Most Problematic Unhealed (Observable) Pressure Ulcer: #Form.Pressure_Ulcer_Stage_M0460# (M1330) Does this patient have a Stasis Ulcer? #Form.Stasis_Ulcer_M0468# (M1332) Current Number of (Observable) Stasis Ulcer(s): #Form.Stasis_Ulcer_Num_M0470# (M1334) Status of Most Problematic (Observable) Stasis Ulcer: #Form.Stasis_Ulcer_Status_M0476# Start of Care Page 4

#Form.First_Name_M0040# #Form.Last_Name_M0040# 1 - Start Of Care Date Completed #DateFormat(Form.Assessment_Completed_M0090,"mm/dd/yyyy")# (M1340) Does this patient have a Surgical Wound? #Form.Surgical_Wound_M0482# (M1342) Status of Most Problematic (Observable) Surgical Wound: #Form.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? #Form.M1350_Other_Wounds# BRADEN SCALE SENSORY PERCEPTION ability to respond meaningfully to pressure-related discomfort #Form.Braden_1_Sensory# MOISTURE degree to which skin is exposed to moisture #Form.Braden_2_Moisture# ACTIVITY degree of physical activity #Form.Braden_3_Activity# MOBILITY ability to change and control body position #Form.Braden_4_Mobility# NUTRITION usual food intake pattern #Form.Braden_5_Nutrition# FRICTION & SHEAR #Form.Braden_6_Friction# RESPIRATORY STATUS (M1400) When is the patient dyspneic or noticeably Short of Breath? #Form.Breathing_M0490# (M1410) Respiratory Treatments utilized at home: #Form.Resp_Treatments_M0500# Cardio-respiratory: #Form.M0490_Assess# ELIMINATION STATUS (M1600) Has this patient been treated for a Urinary Tract Infection in the past 14 days? #Form.UTI_M0510# (M1610) Urinary Incontinence or Urinary Catheter Presence: #Form.Urinary_INcont_M0520# (M1615) When does Urinary Incontinence occur? #Form.Urinary_INcont_when_M0530# Genito-Urinary: #Form.M0520_Assess# Start of Care Page 5

#Form.First_Name_M0040# #Form.Last_Name_M0040# 1 - Start Of Care Date Completed #DateFormat(Form.Assessment_Completed_M0090,"mm/dd/yyyy")# (M1620) Bowel Incontinence Frequency: #Form.Bowel_Incont_M0540# Gastro-Intestinal: #Form.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? #Form.Ostomy_for_Bowel_M0550# NEURO/EMOTIONAL/BEHAVIORAL STATUS (M1700) Cognitive Functioning: Patient's current (day of assessment) level of bootbox.alertness, orientation, comprehension, concentration, and immediate memory for simple commands. #Form.Cog_Function_M0560# (M1710) When Confused (Reported or Observed Within the Last 14 Days): #Form.When_Confused_M0570# (M1720) When Anxious (Reported or Observed): #Form.When_Anxious_M0580# (M1730) Depression Screening: Has the patient been screened for depression, using a standardized depression screening tool? #Form.M1730_Depression# PHQ-2*: a) Little interest or pleasure in doing things? b) Feeling down, depressed, or hopeless? #Form.M1730a#, #Form.M1730b# (M1740) Cognitive, behavioral, and psychiatric symptoms that are demonstrated at least once a week (Reported or Observed) #Form.Patient_Behav_Weekly_M0610# (M1745) Frequency of Disruptive Behavior Symptoms (Reported or Observed) Any physical, verbal, or other disruptive/dangerous symptoms that are injurious to self or others or jeopardize personal safety. #Form.Patient_Behav_freq_M0620# (M1750) Is this patient receiving Psychiatric Nursing Services at home provided by a qualified psychiatric nurse? #Form.Psy_Nursing_M0630# Neurological: #Form.M0610_Assess# ADLS/IADLS Musculo-Skeletal: #Form.M0650_Assess# (M1800) Grooming: Current ability to tend safety personal hygiene needs (i.e., washing face and hands, hair care, shaving or make up, teeth or denture care, fingernail care). #Form.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: #Form.Dress_Upper_M0650# Start of Care Page 6

#Form.First_Name_M0040# #Form.Last_Name_M0040# 1 - Start Of Care Date Completed #DateFormat(Form.Assessment_Completed_M0090,"mm/dd/yyyy")# (M1820) Current Ability to Dress Lower Body safely (with or without dressing aids) including undergarments, slacks, socks or nylons, shoes: #Form.Dress_Lower_M0660# (M1830) Bathing: Current ability to wash entire body safely. Excludes grooming (washing face, washing hands, and shampooing hair). #Form.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. #Form.M1840_Toilet# (M1845) Toileting Hygiene: Current ability to maintain perineal hygiene safely, adjust clothes and/or incontinence pads before and after using toilet, bedpan, urinal. #Form.M1845_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. #Form.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. #Form.Ambulation_M0700# (M1870) Feeding or Eating: Current ability to feed self meals and snacks safely. Note: This refers only to the process of eating, chewing, and swallowing, not preparing the food to be eaten. #Form.Eating_M0710# (M1880) Current Ability to Plan and Prepare Light Meals (e.g., cereal, sandwich) or reheat delivered meals safely: #Form.Meal_Prep_M0720# (M1890) Ability to Use Telephone: Current ability to answer the phone safely, including dialing numbers, and effectively using the telephone to communicate. #Form.Use_Phone_M0770# (M1900) Prior Functioning ADL/IADL: Indicate the patient's usual ability with everyday activities prior to this current illness, exacerbation, or injury. Check only one box in each row. a. Self-Care (e.g., grooming, dressing, and bathing) #Form.M1900a_SelfCare# b. Ambulation #Form.M1900b_Amb# c. Transfer #Form.M1900c_Transfer# d.Household tasks (e.g., light meal preparation, laundry, shopping ) #Form.M1900d_House# (M1910) Has this patient had a multi-factor Fall Risk Assessment (such as falls history, use of multiple medications, mental impairment, toileting frequency?? #Form.M1910_Fall_Risk# Start of Care Page 7

#Form.First_Name_M0040# #Form.Last_Name_M0040# 1 - Start Of Care Date Completed #DateFormat(Form.Assessment_Completed_M0090,"mm/dd/yyyy")# FALL RISK Level of Consciousness #Form.Fall_A# History of Falls #Form.Fall_B# Ambulation Elimination #Form.Fall_C# Vision #Form.Fall_D# Gait & Balance #Form.Fall_E# Orthostatic Changes #Form.Fall_F# Medications #Form.Fall_G# Medical History #Form.Fall_H# Equipment Issues #Form.Fall_I# MEDICATIONS (M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically significant medication issues, e.g., drug reactions, ineffective drug therapy, side effects, drug interactions, duplicate therapy, omissions, dosage errors, or noncompliance? #Form.M2000_Adverse# (M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calendar day to resolve clinically significant medication issues, including reconciliation? #Form.M2002_Med_FU# (M2010) Patient/Caregiver High Risk Drug Education: h-las the patient/caregiver received instruction on special precautions for all high- risk medications (such as hypoglycemics, anticoagulants, etc.) and how and when to report problems that may occur? #Form.M2010_Med_Edu# (M2020) Management of Oral Medications: Patient's current ability to prepare and take all oral medications reliably and safely, including administration of the correct dosage at the appropriate times/intervals. Excludes injectable and IV medications. #Form.Oral_Meds_M0780# (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.. #Form.Inject_Meds_M0800# (M2040) Prior Medication Management: Indicate the patient's usual ability with managing oral and injectable medications prior to this current illness, exacerbation, or injury. Check only one box in each row. a.Oral medications b.Injectable medications #Form.Oral_Meds_M0780p# #Form.Inject_Meds_m0800p# Start of Care Page 8

#Form.First_Name_M0040# #Form.Last_Name_M0040# 1 - Start Of Care Date Completed #DateFormat(Form.Assessment_Completed_M0090,"mm/dd/yyyy")# CARE MANAGEMENT (M2100) Types and Sources of Assistance: Determine the level of caregiver ability and willingness to provide assistance for the following activities, if assistance is needed. a.ADL assistance; transfer/ ambulation, bathing available b.IADL assistance (e.g., meals, housekeeping) available c.Medication administration #Form.M2100a_Equip# #Form.M2100b_Equip# #Form.M2100c_Equip# d. Medical procedures/ treatments #Form.M2100d_Equip# e. Management of Equipment #Form.M2100e_Equip# f.Supervision and safety #Form.M2100f_Equip# g. Advocacy or facilitation #Form.M2100g_Equip# (M2110) How Often does the patient receive ADL or IADL assistance from any caregiver(s) (other than HHA staff)? #Form.M2110_Assist_Freq# 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? #Form.M0826_Ther_Need# (M2250) Plan of Care Synopsis: Does the physician-ordered plan of care include the following a. Pt-spec parameters for notifying #Form.M2250a_PhysNot# b. Diabetic foot care and education #Form.M2250b_Diabetic# c. Falls prevention interventions #Form.M2250c_FallsPrev# d. Depression intervention(s) #Form.M2250d_Depress# e. Intervention(s) to monitor and mitigate pain #Form.M2250e_Pain# f. Intervention(s) to prevent pressure ulcers #Form.M2250f_PressUlc# g. Pressure ulcer treatment based #Form.M2250g_PressUlcMoist# Assessment Note #Form.Assessment_Note# Start of Care Page 9

#Form.First_Name_M0040# #Form.Last_Name_M0040# 1 - Start Of Care Date Completed #DateFormat(Form.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: ____________________________________________________ Start of Care Page 10