Fillable Home Health Agency Update Form Peoples Health (Page 2 of 2) in pdf

Occupational Therapy:

Have goals on 485/486 been met? ___Yes ___No; if “no,” list goals that have not been met: _______________________

__________________________________________________________________________________________________

Speech Therapy:

Have goals on 485/486 been met? ___Yes ___No; if “no,” list goals that have not been met: _______________________

__________________________________________________________________________________________________

Home Health Aide:

What level of care is needed for ADL or personal hygiene? Check all that apply:

__ Minimum assistance to ambulate or transfer

__ Maximum assistance, total care needed, non-ambulatory

__ Moderate assistance to ambulate or transfer

__ Incontinent (bowel, bladder or both)

Please list member’s illness or injury that makes home health aide services reasonable and necessary:

__________________________________________________________________________________________________

Homebound Status:

!n individual shall be considered “confined to the home” (homebound) if the following two criteria are met (select all

that apply):

Criteria One—check all that apply:

__ Because of illness or injury, need the aid of supportive devices such as crutches, canes, wheelchairs, and walkers; the

use of special transportation; or the assistance of another person in order to leave their place of residence.

On the line below, please indicate which supportive device is needed (crutches, cane, wheelchair, walker); the use of

special transportation (wheelchair van or ambulance); or the reason the member requires the assistance of another

person to leave their place of residence.

__________________________________________________________________________________________________

__Client has a condition such that leaving his or her home is medically contraindicated

Criteria Two:

__There is normal inability to leave home safely, AND leaving the home requires a considerable and taxing effort due to

the following conditions—check all that apply:

__ Bedbound

__ Becomes fatigued and must rest after ambulation

__ Chair fast

__ Experiences pain that impacts ability to leave home safely

__ Blind

__ Experiences weakness that impacts ability to leave home safely

__ Senile or confused

__ Unable to navigate stairs safely

__ Dyspneic at rest

__ Ambulation is unsteady and unsafe

__ Dyspneic with minimal exertion

__ Psychiatric illness manifested by refusal to leave home (even if no physical limitations)

__ Psychiatric illness of the extent it is unsafe to leave home unattended (even if no physical limitations)

If recertification is anticipated, Peoples Health must receive notification, accompanied by supporting clinical

information and a physician’s order, two weeks prior to the end of the current certification period. If the

recertification request is not received within that time frame, the authorization will be closed.

Home Health Agency Update Form Peoples Health Page 2