ON SITE ASSESSMENT TOOL
Assessment Date:__________ Time:______ Nurse I.D:________ Policy #___________
PERSONAL INFORMATION
CLAIMANT INFORMATION
Name:_____________________________________
SS#_____________________
Street Address___________________________________________________________
City:________________________________________ State:___ Zip:________
Telephone:(__)______________
Please ask for government picture identification
Date of Birth ___________ Sex: ____M
____F
Other than insured who is present at assessment?__________________________________
CONTACT INFORMATION
Name: _________________________________
Relationship______________________
Mailing Address: _________________________________________________________
Telephone:
________________________________
Is this person present at the assessment? Yes
No
Relationship to Insured?_________________________________________
Does this person hold POA? Yes
No
If no, who has Power of Attorney? ___________________________________________
Address:________________________________________________________________
Telephone:_______________________________________________________________
There is no Power of Attorney
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ON SITE ASSESSMENT TOOL
GENERAL INFORMATION
General physical appearance: _______________________________________________
Height ____________
Weight ___________
Actual
Stated
Identify if problems with/devices used for:
Vision: ______________ Hearing:_____________ Speech/Communication:_______________
What is insured’s primary language?
English
Single
Married
Insured’s marital status:
Divorced (when__________)
Children:
Yes
Spanish
Other________
Widowed (when__________)
No
Are children involved in Insureds care? __________________________________________
CURRENT LIVING ARRANGEMENTS
Does client live alone? Yes
No
Who lives with insured? Name _______________________________ Relationship
Name _______________________________ Relationship
Place of Assessment:
Private home
If a private home, is it:
Your own home
Assisted Living
Skilled Facility
Assisted Living
Skilled Facility
Other:
The home of another individual
Other:______________________________
Name of facility? _______________________________admit date:_________________
Reason Admitted?______________________________________________________
Address (if different from above):____________________________________________
Phone (include area code)_______________________ Fax: ______________________________
If in a facility, please obtain a copy of Current License and MDS / Resident Assessment
Contract
Insureds location before admit to facility______________________________________
Do you have a discharge date?
No
If no: Date of discharge unknown
Plans to stay long term
Yes
If yes: Anticipated date of discharge: ________
When were you last living at home? __________________________________________
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ON SITE ASSESSMENT TOOL
Is the bed state licensed? (NOT necessarily Medicare licensed)
Yes
No
How is the insured’s bed specifically licensed?
Nursing home……………
Assisted Living Facility…
Dementia Unit…………..
Other (be specific):
If the insured is on a Dementia Unit, is it secured?
Unsecured
Door Alarms Only
Secured (describe)___________________________________________________
Can the insured leave the facility unattended
Yes
No
Name of person who gave you above information: ______________________________________
Administrator
DON
LTC Claims Advisory Committee Guide 2007
Other (describe) _____________________________
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ON SITE ASSESSMENT TOOL
MEDICAL HISTORY
MEDICAL INFORMATION:
The insured was generally healthy until (date?) _______________________________________
What happened at that time? ______________________________________________________
Did insured have home care assistance since the onset of current illness/injury? No___
Yes ___
If yes: Name of Home Care Agency__________________________________________
Dates: Start date_____________
End date______________ Frequency________________
Have family members assisted with care since onset of current illness/injury?
No___ Yes ___ Frequency _______________________________________________
Reason(s) for initiating claim:
____________________________________________________________________________________
____________________________________________________________________________________
_______________________________________________________________
Information received from: ___ Insured ___ Family Member ___Chart ___ Other___________
List physicians currently involved in insured's care:
Primary Physician: ______________________________________Specialty:________________
Address: ______________________________________________________________________
Phone: ______________________________ Date, last visit: ______________ Reason: ________
Physician: ______________________________________Specialty:_______________________
Address: ______________________________________________________________________
Phone: ______________________________ Date, last visit: ______________ Reason: ________
Physician: ____________________________________ Specialty: _______________________
Address: ______________________________________________________________________
Phone: _______________________________ Date, last visit: ______________Reason:________
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ON SITE ASSESSMENT TOOL
List hospitalizations within the past year:
Name of hospital: ________________________________________Dates:__________________
City and state of hospital: _________________________________________________________
Reason for admission: ___________________________________________________________
Name of hospital: ________________________________________Dates:__________________
City and state of hospital: _________________________________________________________
Reason for admission: ___________________________________________________________
List services insured received within the past year: (please list provider if possible)
Skilled Nursing Facility____________________________
Dates_____________________
Address:______________________________________
Phone:____________________
Reason for Services:___________________________________________________________
Assisted Living Facility___________________________ _
Dates_____________________
Address:______________________________________
Phone:____________________
Reason for Services:___________________________________________________________
Rehabilitation Unit_______________________________
Dates_____________________
Address:______________________________________
Phone:____________________
Reason for Services:____________________________________________________________
Transitional Unit________________________________
Dates_____________________
Address:______________________________________
Phone:____________________
Reason for Services:____________________________________________________________
Home Health Care______________________________
Dates_____________________
Address:______________________________________
Phone:____________________
Reason for Services:____________________________________________________________
Adult Day Care_________________________________
Dates_____________________
Address:______________________________________
Phone:____________________
Reason for Services:____________________________________________________________
OT, PT or ST __________________________________
Dates_____________________
Address:______________________________________
Phone:____________________
Reason for Services:_____________________________________________________________
Hospice Program________________________________
Dates_____________________
Address:______________________________________
Phone:____________________
Reason for Services:_____________________________________________________________
Other(e.g.spouse, private caregiver)_______________________Dates_____________________
Address:______________________________________ ______Phone:____________________
Reason for Services:_____________________________________________________________
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ON SITE ASSESSMENT TOOL
COORDINATION OF BENEFITS
Are any Medicare (includes Medicare HMO or Fee for Service plans) services being received?
__ No __Yes
Name of insurer ________________________________________________
Describe services _______________________________________________
Are any commercial health insurance benefits being provided? __ No __Yes (name of insurer/describe
services) ______________________________________________________
Are other LTC policies benefits being received? __No __ Yes (name of insurer/describe services)
_________________________________________________________________________________
Are you currently receiving any other Government assistance? (E.g. SSDI, Medicaid, Veteran benefits)
__No _Yes Please list the program and services provided:
_________________________________________________________________________________
MEDICATION LIST (list all current medications)
Ask insured to show all of their prescription bottles and containers as well as
over-the-counter medications, vitamins, and supplements that they currently use.
If insured is in a facility, you may attach a copy of their current medication list. If
there are any medications for which there was no diagnosis listed, update the
diagnosis list.
Medication
Dosage
Frequency
Reason
Prescribing
Physician
Check most appropriate response:
___ Able to take medications without assistance or supervision from another person.
___ Needs occasional assistance or supervision from another person to administer med. to self.
___ Needs cueing, reminding or setting up of mediations by another person to take meds.
Check the activities the insured CANNOT do by him/her self:
___ measure proper amounts of medications
___ remove caps from medications containers
___ read labels clearly
___ understand times to take medications
___physically swallow pills
___ apply ointments of inject medications
Notes:
____________________________________________________________________________________
_________________________________________________________________
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ON SITE ASSESSMENT TOOL
HEALTH
Does insured currently use oxygen? ___ No ___ Yes
If yes, frequency ___ Continuous ___ At night only ___ Other ___________________
Does insured smoke? ___No ___ Yes
If yes, Amount per day? ____________
___ Cigarettes ___ Cigar ___ Other ___________
Does insured drink alcoholic beverages: ___ No ___ Yes
If yes, a. Amount per day? ____ per week?____ per month?___ b. Type: ________________
Has insured lost more than 10 pounds in the last six months without trying? ___ No ___ Yes
a. If yes, how many? ________ lbs.
Does Insured follow a special diet or take nutritional supplements (e.g. ensure) ___ No ___Yes
a. If yes, type:_____________________________________________________________
Does insured have paralysis in any part of body? ___No ___ Yes
a. If yes, check all that apply: ___R Arm ___ R Leg ___ L arm ___ L leg
___ Other (describe) _____________________________
Has insured had an amputation of any type? ___No ___ Yes
___ R Arm ___ R Leg ___ L arm ___ L leg ___ Other _________________________
Does insured have a prosthesis? ___ No ___ Yes If yes, what kind? ______________________
Is insured wearing a cast? ___ No ___ Yes
If yes, a. Reason: ___________________________________________________________
b. Duration: ___________________________________________________________
c. Location: ____________________________________________________________
Does the insured have any type of open wound or sore on their body? ___ No ___ Yes
If yes: a. Is it being treated? ___ No ___ Yes
b. Describe treatment: ______________________________________________________
c. Location: ______________________________________________________________
d. Type of wound/sore? _____________________________________________________
Does the insured have any pain? ___ No ___ Yes
If yes: a. Where is the pain? _______________________________________________________
b. What is the severity? (on a scale from 1 -10, 1 – least & 10 – most severe): __________
c. How often does it occur? _________________________________________________
d. What causes the pain?
_______________________________________________
e. What relieves the pain? _________________________________________________
f. What make the pain worse? _______________________________________________
Has the Insured received Physical Therapy or Occupational Therapy within the past ninety days?
___ No ___ Yes
If yes,
a. Date(s): ______________________________________________________________
b. Reason: _______________________________________________________________
c. Location: ___Home
___ Outpatient
___ Rehab Facility
___ Hospital
Does the insured currently perform any type of exercise? ___No ___ Yes
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ON SITE ASSESSMENT TOOL
If yes, describe_______________________________________________________________
Have there been other medical problems since the onset of current illness/injury? ___ No ___ Yes
Please list: ______________________________________________________________________
Is the insured bed bound?
Yes___ No ___
Can the insured follow simple directions? Yes ___ No ___
Has the insured tripped or fallen in the past year? ___ No ___ Yes
If yes,
a. Number of falls: ______________
b. Dates: __________________________________
c. Reason for fall(s)? _________________________________________________________
d. Was the physician notified? __________________________________________________
If the insured has fallen in the past year please complete the Fall Risk
Assessment.
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ON SITE ASSESSMENT TOOL
ADL ASSESSMENT INSTRUCTIONS
Activities of Daily Living
Complete the "Current" column for all functions noted by observing the insured. Examples of such observation
are noted below under Considerations in Performing Assessment. Please note that while this assessment tool
is similar to the OASIS, it is not the same. Please read each section carefully and mark most appropriate
response.
When completing the “Prior” column when care will be provided in the home mark the level of care needed that
corresponds to the insured’s self reported level of function for the given task approximately 14 days prior to the
condition or event which resulted in the insured’s request/need for care. If the policyholder is in an assisted
living or skilled nursing facility, the assessor must review the medical record kept by the facility staff to identify
what was documented as the functional capacity prior to the current need for care. If there is no information
regarding “Prior” functional levels then mark Unknown, for the “Priors.”
Considerations in Performing an Assessment:
Prior to assessing range of motion (ROM), a visual observation of the bathroom must be performed to
determine actual range of motion required based on the individual’s bathroom facilities, e.g.. toilet riser, grab
bars, walk in shower versus step up tub.
Ask the insured to ambulate to the bathroom to show you how they would perform toileting, getting in and out
of a seated position, reaching, range of motion, and balance. Document observations of insured getting in and
put of a seated position, reaching, upper/lower extremity strength, fine motor skills, ROM, balance.
Ask the insured to show you how they handle the supplies or equipment and related hygiene. Document
observations of insured managing continence such as strength, fine motor skills, ROM, balance. Also
document appropriate use of assistive devices.
Ask the insured to show you how they would bathe, and observe ROM, balance, reaching back and feet, drying
body off. Document observations of insured’s upper/lower extremity strength, fine motor skills, ROM, balance,
reaching.
Ask the insured to put on a sweater or shirt. Document observations of insured’s upper extremity strength, fine
motor skills, ROM, balance. Document what type of assistive devices might help the insured complete the task
such as a device for buttoning.
Definitions to consider:
Verbal cueing: Unable to initiate or complete task without verbal instructions
Stand-by assistance: Requires the presence of another person within arm’s reach for contact guard to
prevent injury by physical intervention to complete the task if needed.
Hands-on assistance: Requires physical assistance from another person to perform the activity.
NOTE
Send the completed assessment directly to the requesting company. DO NOT provide any part of the
assessment to the Insured. If the Insured or their legal representative requests a copy of the
assessment or any portion of the assessment, instruct them to put their request, in writing to their long
term care insurance company.
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ON SITE ASSESSMENT TOOL
ADL ASSESSEMENT
FUNCTIONAL ASSESSMENT
Check the box that most accurately describes the level of assistance required. Provide a brief narrative of
insured’s deficits. Ask to see insured demonstrate whenever possible.
1. Eating - The ability to feed self meals and snacks. Note: This refers only to the process of eating,
chewing, and swallowing It does not include meal prep or getting food to the table.
Observed
Uses adaptive equipment?
yes
Interviewed
no type: _____________________________________________
Prior Current
- Able to independently feed self.
- Able to feed self independently but requires intermittent verbal cuing from another
person.
 - Able to feed self independently but requires stand-by assistance due to swallowing
difficulties or choking risk.
- Unable to feed self and requires hands-on assistance throughout the meal/snack.
- Able to take in nutrients orally and receives supplemental nutrients through a
nasogastric tube or gastrostomy.
- Unable to take in nutrients orally and is fed nutrients through a nasogastric tube or
gastrostomy.
- Unable to take in nutrients orally or by tube feeding.
- Unknown
Explanation/Examples: ________________________________________________________________
__________________________________________________________________________________
Please check when assistance is required:
_____Morning
____Afternoon
____Evening
____Snacks
Would any assistive devices, not already in place, increase the client’s independence with eating?
yes
no
If yes, please indicate the type of device(s) deemed appropriate to increase independence:
__________________________________________________________________________________
__________________________________________________________________________________
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ON SITE ASSESSMENT TOOL
2. DRESSING (Putting on and taking off all items of clothing and any necessary braces, fasteners or
artificial limbs, and selecting clean, weather-appropriate clothing)
Observed
Uses adaptive equipment?
yes
Interviewed
no type: ___________________________________________
Ability to Dress Upper Body (with or without dressing aids) including undergarments, pullovers, front-opening
shirts and blouses, managing zippers, buttons, and snaps:
Prior Current
-
Able to get clothes out of closets and drawers, put them on and remove them from the
upper body without assistance.
Able to dress self without assistance, but requires another to get them out and set them
within arms reach
Able to dress upper body without assistance, but requires verbal cueing to complete
process.
Someone must stand-by to help the patient put on upper body clothing.
Patient requires hands-on assistance from another person to dress the upper body.
Unknown
Ability to Dress Lower Body (with or without dressing aids) including undergarments, slacks, socks or nylons,
shoes:
Prior Current
-
Able to obtain, put on, and remove clothing and shoes without assistance.
Able to dress self without assistance, but requires another to get them out and set them
within arms reach
Able to dress lower body without assistance, but requires verbal cueing to complete
process.
Someone must stand-by the patient to put on undergarments, slacks, socks or nylons,
and shoes.
Patient requires hands-on assistance from another person to dress lower body.
Unknown
Explanation/Examples: ____________________________________________________________
________________________________________________________________________________
Length of time to fully dress:
less than 15 min.
15 - 30 min.
30 – 45 min.
> 45 min.
How often is assistance provided? # times per day:__________; and # times per week:_______________
Who provides assistance? __________________________________________________________
Would any assistive device, not already in place, increase the client’s independence in dressing?
yes
no
If yes, please indicate the type of device(s) deemed appropriate to increase independence:
_________________________________________________________________________________________
___________________________________________________________________________
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ON SITE ASSESSMENT TOOL
3. Transferring - The ability to move from bed to chair, on and off toilet or commode, into and out of tub
or shower, and in and out of wheelchair.
Observed
Uses adaptive equipment?
yes
Interviewed
no type: _____________________________________________
Prior Current
-
Able to independently transfer.
Transfers independently with use of an assistive device.
Someone must stand-by the patient to transfer between stationary items.
Unable to transfer self but is able to bear weight and pivot during the transfer process
with verbal cueing.
Unable to transfer self and requires hands-on assistance from another person to be
transferred between stationary items.
Unknown
Explanation/Examples: _____________________________________________________________
__________________________________________________________________________________
Who provides assistance? ___________________________________________________________
How often is assistance provided? # times per day: ________ and # days per week: _______________
__________________________________________________________________________________
Would any assistive devices, not already in place, increase the client’s independence with transfers?
yes
no
If yes, please indicate the type of device(s) deemed appropriate to increase independence:
__________________________________________________________________________________
__________________________________________________________________________________
4. Mobility/Ambulation (The ability to walk or move from one place to another once in a standing
position with or without the use of a cane or walker, or the use of a wheelchair, once in a seated
position, on a variety of surfaces.) Please have the policyholder demonstrate ambulation to and from
the bathroom or bedroom.
Observed
Uses adaptive equipment?
yes
Interviewed
no type: _______________________________
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ON SITE ASSESSMENT TOOL
Prior Current
-
Able to independently walk on even and uneven surfaces with or without assistive
devices.
Able to independently climb stairs with or without assistive devices.
Requires use of a device (e.g., cane, walker) to walk alone.
Requires verbal cueing to negotiate stairs or steps or uneven surfaces.
Able to walk only with stand-by assistance from another person.
Chairfast, unable to ambulate but is able to wheel self independently.
Unable to ambulate and requires hands-on assistance for all mobility.
Unknown
Explanation/Examples: ______________________________________________________________
__________________________________________________________________________________
Who provides assistance? __________________________________________________________
How often is assistance provided? # times per day: __________ and # days per week: ______________
__________________________________________________________________________________
Would any assistive devices, not already in place, increase the client’s independence with transfers?
yes
no
If yes, please indicate the type of device(s) deemed appropriate to increase independence:
__________________________________________________________________________________
__________________________________________________________________________________
5. TOILETING (Able to get to and from toilet or commode, get on and off toilet or commode and
maintain satisfactory personal hygiene). It does not include the need or use of assistive devices
or adaptive equipment. Request that the insured walk to bathroom and demonstrate ability to
sit/stand from toilet.
Observed
Uses adaptive equipment?
yes
Interviewed
no type: _______________________________
Prior Current
-
Able to get to and from the toilet independently with or without a device.
With verbal cueing by another person is able to get to and from the toilet.
Able to get to and from the toilet with stand-by assistance from another.
Unable to get to and from the toilet but is able to use a bedside commode, bedpan or
urinal independently.
Requires hands-on assistance from another person with all toileting.
Unknown
Explanation/Examples: ___________________________________________________________
_______________________________________________________________________________
Who provides toileting assistance? ____________________________________________________
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ON SITE ASSESSMENT TOOL
How often is assistance provided? # times per day: __________ and # days per week:___________
__________________________________________________________________________________
Does hygiene appear adequate?
Unusual odors noted?:
yes
yes
no
no
If yes, explain: _____________________________________
Would any assistive devices, not already in place, increase the client’s independence with
toileting?
yes
no
If yes, please indicate the type of device(s) deemed appropriate to increase independence:
___________________________________________________________________________________
___________________________________________________________________________________
6. Continence (Ability to voluntarily control bowel and bladder function without the aid of
another person or use an external catheter or other equipment to otherwise maintain a
reasonable level of personal hygiene). It does not include the need or use of assistive devices or
adaptive equipment.
Observed
Uses adaptive equipment?
yes
Interviewed
no type: ___________________________________________
Bladder:
Do you experience any loss of control of your urine?
yes
no
If yes, when did incontinence begin? ______________ Any treatments? ______________________
Is there a noticeable urine odor due to the bladder incontinence?
yes
no
If incontinent, is assistance required with personal hygiene related to the loss of control?
yes
no
Who provides continence assistance?: _________________________________________________
How often does the client experience bladder incontinence (number of times per/day or times per/week –
specify) __________________________________________________________________________
Does hygiene appear adequate?
yes
no
Explanation/Examples: ______________________________________________________________
__________________________________________________________________________________
Would any assistive devices, not already in place, increase the client’s independence with bladder continence?
yes
no
If yes, please indicate the type of device(s) deemed appropriate to increase independence:
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ON SITE ASSESSMENT TOOL
__________________________________________________________________________________
__________________________________________________________________________________
Bowel:
Do you experience any loss of control of your bowels?
yes
no
If yes, when did incontinence begin? ______________ Any treatments? ______________________
Is there a noticeable bowel odor due to the bowel incontinence?
yes
no
If incontinent, is assistance required with personal hygiene related to the loss of control?
yes
no
Who provides continence assistance? _________________________________________________
How often does the client experience bowel incontinence (number of times per/day or times per/week – specify)
___________________________________________________________________________
Does hygiene appear adequate?
yes
no
Explanation/Examples: ______________________________________________________________
__________________________________________________________________________________
Would any assistive devices, not already in place, increase the client’s independence with bowel continence?
yes
no
If yes, please indicate the type of device(s) deemed appropriate to increase independence:
__________________________________________________________________________________
Durable Medical Equipment (DME):
Do you use any durable medical supplies like catheters or ostomy bags?
yes
no
If yes, type of equipment/devices: _____________________________________________________
How long have you had this device? ___________________________________________________
Do you require assistance managing your devices?
yes
no
Would any assistive devices, not already in place, increase the client’s independence with bowel or bladder
continence?
yes
no
If yes, please indicate the type of device(s) deemed appropriate to increase independence:
__________________________________________________________________________________
__________________________________________________________________________________
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ON SITE ASSESSMENT TOOL
7. Bathing (Ability to get in and out of a tub or shower, ability to effectively wash self in a tub, shower,
or by sponge bath, and process of drying off with or without the aid of another person).
Assess insured’s ability to perform each type of bathing, completing all areas noted.
Sponge Bath:
Observed
Interviewed
Uses adaptive equipment?
yes
no type: _________________________________
Prior Current
-
Tub:
Observed
Able to physically bathe self independently.
With the use of devices, is able to sponge bathe independently.
Able to sponge bathe with the assistance of another person: (Check which apply)
with verbal cueing to complete sponge bath, OR
for washing difficult to reach areas.
Participates in bathing self in sponge bathe, but requires stand-by assistance from
another person throughout the bath.
Unable to participate in bathing and requires hands-on assistance from another person
for the bathing process.
Unknown
Interviewed
Uses adaptive equipment?
yes
no type: __________________________________
Prior Current
-
-
Able to physically bathe self independently.
With the use of devices, is able to bathe self in tub independently.
Able to bathe in tub with the assistance of another person: (Check which apply)
with verbal cueing to complete bath OR
to get in and out of the tub, OR
for washing difficult to reach areas.
Participates in bathing self in tub, but requires stand-by assistance from another person
throughout the bath.
Unable to participate in bathing and requires hands-on assistance from another person
for the bathing process.
Unknown
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ON SITE ASSESSMENT TOOL
Shower:
Observed
Interviewed
Uses adaptive equipment?
yes
no type: _______________________________
Prior Current
-
-
Able to physically bathe self independently in the shower
With the use of devices able to bathe self in shower independently.
Able to bathe in shower with the assistance of another person: (Check which apply)
with verbal cueing to complete shower, OR
to get in and out of the shower, OR
for washing difficult to reach areas.
Participates in bathing self in shower, but requires stand-by assistance from another
person throughout the shower.
Unable to participate in bathing and requires hands-on assistance from another person
for bathing in the shower.
Unknown
Other:
- Unable to sponge bathe, or use the shower or tub and is bathed in bed or bedside chair.
General:
If in a facility, it is facility policy to assist with bathing?
Yes
No
Number of baths per week: ______________________________________________________
Who provides bathing assistance: ________________________________________________
Does hygiene appear adequate?
Unusual odors noted?:
No
No
Yes Explain: ________________________________
Yes Explain: ________________________________
Would any assistive devices, not already in place, increase the client’s independence with bathing?
no
yes please indicate the type of device(s) deemed appropriate to increase independence:
_____________________________________________________________________________
_____________________________________________________________________________
Additional Explanation/Examples:
___________________________________________________________________________________
____________________________________________________________________________________
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-
ON SITE ASSESSMENT TOOL
Cognition Section
Please refer to the discussion section included in Introduction to the On Site Assessment
section of the LTC Claims Toolbox to learn more about utilizing cognitive testing and their
application to policy language defining benefit triggers.
This section would include the standardized test chosen by the insurance company to ascertain
the cognitive functional level of the insured. The insurer should also consider including the
scoring scheme by category (see example below) specific to the standardized test used. This will
provide a consistent application of the insurer’s administrative policy on cognitive triggers if the
assessor or a vendor will be performing tax qualified certification on behalf of the insurer.
Normal
Range
#–#
Mild
Impairment
#–#
LTC Claims Advisory Committee Guide 2007
Moderate
Impairment
#–#
Severe
Impairment
#–#
18
ON SITE ASSESSMENT TOOL
BEHAVIORS & EMOTIONS
BEHAVIORS
“Yes” answers should only be recorded if there has been an actual occurrence of the behavior – not just a
concern that it could happen. For every “Yes” answer, please give details and approximate date of the
occurrence(s) in the Comments section.
1. Have there been incidents of wandering? (Wandering is defined as incidents such as the claimant
being found away from the home, moving about without rational propose, or becoming
permanently lost and unable to find their way home from a familiar place.) __No __Yes
If “Yes,” on what dates? ___________________________________
Please describe the incidents. ________________________________________________
_____________________________________________________________________________
___________________________________________________________________
Have these incidents been reported to insured’s physician? __No __Yes If yes name of
physician ______________________________
2. Have there been incidents of behaviors that subject the claimant to significant safety risks? (This
includes activities such as unsafe use of tools or recurring incidents such leaving gas stoves on
while not cooking.) __ No ___Yes If “Yes,” on what dates?
________________________________________________________________________
Please describe the incidents. ________________________________________________
_____________________________________________________________________________
___________________________________________________________________
Have these incidents been reported to insured’s physician? __No __Yes If yes name of
physician ______________________________
3. Have there been incidents that that pose a significant risk to the claimant’s health? (These should
generally be recurrent in nature, such as refusing to eat, refusing to follow medical treatments
without a rational reason, or going outside in clothing that is completely inappropriate for the
weather. They generally would not include using a “pill dispenser” to help take medication
properly or eating (regularly) a diet that others might view as unhealthy but not bizarre.)
Yes ____ No ____ If “Yes,” on what dates? _____________
________________________________________________________________________
Please describe the incidents. ________________________________________________
_____________________________________________________________________________
___________________________________________________________________
Have these incidents been reported to insured’s physician? __No __Yes If yes name of
physician ______________________________
4. Have there been incidents of abusive or violent behavior? (This generally should not include
opinions that the claimant is “grumpy, angry, or cranky” without actual abusive or violent
behavior.) Yes _ No __ If “Yes,” on what dates? ___________________
________________________________________________________________________
Please describe the incidents. ________________________________________________
_____________________________________________________________________________
___________________________________________________________________
Have these incidents been reported to insured’s physician? __No __Yes If yes name of
physician ______________________________
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ON SITE ASSESSMENT TOOL
5. Have there been incidents of poor judgment or uncooperative behaviors that have resulted in the
insured being found/put at risk to harm themselves? Yes __ No __ If “Yes,” on what dates?
___________________________________________________________
Please describe these incidents. ______________________________________________
_____________________________________________________________________________
___________________________________________________________________
Have these incidents been reported to insured’s physician? __No __Yes If yes name of
physician ______________________________
Comments:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
EMOTIONS
Do you often feel sad or blue? __No __Yes If yes, How often _______ How long _________
Do you enjoy life? __No __Yes If no, reason_______________________________________
Circle all that currently apply, as reported by the ___ insured ___ caregiver:
Angry
Anxious
Apathetic
Combative
Depressed
Fearful
Paranoid/Suspicious
Withdrawn
Is the insured unsafe alone? __No __Yes
Explain ______________________________________________________________________
Have you ever been treated for any other of the above mentioned emotional problems? __No __Yes
If yes,
a. Which emotional problem: __________________________________________________________
b. Dates of treatment: ___________________________________________________________
c. Type of treatment: ____________________________________________________________
What precipitated the above mentioned emotions: __________________________
Comments: ___________________________________________________________________
General Affect: Please circle all that apply as observed by the Assessor:
Agitated
Alert
Appropriately dressed
Cheerful
Confused
Cooperative
Disoriented
Flat affect
Lethargic
Nervous
Oriented
Pleasant
Tearful
Well groomed
Comments: ___________________________________________________________________
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ON SITE ASSESSMENT TOOL
IADL ASSESSMENT
Check the appropriate box concerning the insured’s ability to perform their Instrumental Activities of Daily Living
Activity
Insured is
Independent
Insured
requires
Limited
Assistance
Insured
requires
Total
Assistance
Insured
requires
Supervision
Did the
insured ever
do this
Activity?
If alone,
could the
insured do
this Activity?
Do you
expect the
insured to do
this Activity
in the future?
Meal Preparation
Yes
No
Yes
No
Yes
No
Light Meal
Preparation/Reheating
Yes
No
Yes
No
Yes
No
Heavy Housekeeping
Yes
No
Yes
No
Yes
No
Light Housekeeping
Yes
No
Yes
No
Yes
No
Laundry
Yes
No
Yes
No
Yes
No
Telephone Use
Yes
No
Yes
No
Yes
No
Personal Finances
Yes
No
Yes
No
Yes
No
Medication
Management
Yes
No
Yes
No
Yes
No
If the insured is unable to perform
this Activity…..
Who performs
Activity now?
Did the insured ever drive? … Yes … No
Does the insured still drive? … Yes … No Frequency? ________________________________________________________
Was the insured instructed not to continue driving? … Yes … No If yes by who______________________________________
How does the insured get to medical appointments? _____________________________________________________________
Additional information/comments on IADLs ____________________________________________________________________
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Date Started?
ON SITE ASSESSMENT TOOL
FALL ASSESSMENT
Insured Name: _____________________________________________ Date _________
Environment Observed: Home ___ Facility ____
Physical Factors:
Has the insured fallen in the last ____ 30 days ____31-180 days ____181-365 days?
How many times has the insured fallen in the last ____ 30 days ____31-180 days ____181-365 days?
What caused the insured to fall? __________________________________________________
Was the insured injured? ___No ____Yes Describe injuries ___________________
Was the insured seen by an MD?
Yes___ Date ____
No____
MD Name and Address: ________________________________________
________________________________________
Are there any fall precautions in place at this time? No__ Yes__ Describe:____________________
Has the insured complained of dizziness or exhibited unsteadiness in the past 30 days?
Yes___ No___
Orthostatic Blood Pressures (Orthostatic pressures must be done in this order lying, sitting, standing
Two or three minutes must elapse between each position change)
Lying: ________
Sitting: ___________
Standing: _________
Has insured experienced an unplanned weight loss of ten or more pounds in the last year?
No ___Yes___ Explain: _______________________________________________________
Does the insured participate in:
Physical activities ___No ____Yes Describe:_____________________________________________
Social activities
___No ____Yes Describe:_____________________________________________
Is the insured homebound? ___No ____Yes
How long and Why_______________________________________
Environmental Factors Contributing to Fall Risk:
Are stairs used to enter/exit? Yes __ No__
Is sleeping area easily accessible to insured? Yes ___ No __
Are walk areas to rooms used in home cluttered?
Yes ___ No __
Is there poor lighting in rooms or on stairs? Yes ___ No __
Are there electrical cords or phone cords crossing walk areas? Yes ___ No __
Are there throw rugs present with edges not anchored? Yes __ No ___
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ON SITE ASSESSMENT TOOL
Medication Factors:
Check all that apply for each condition:
Condition
History of
Being Treated
(other then meds)
Taking Medication
Anti-Anxiety
Anti-psychotic
Anti-depressant
Anti-hypertensive
Medication Factors:
Is the insured taking any of the following (circle all that apply): Diuretic
Hypnotic
Narcotic
Nurse Signature: _________________________________________________________________
Date: __________________
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ON SITE ASSESSMENT TOOL
HOME HEALTHCARE INFORMATION
Complete This Section For All Paid Caregivers Regardless of Payer Source
Caregiver/Agency
Information
Type of Care
(e.g. HHA,
HM, SN, PT,
ADC, MOW,
ERS, etc)
Amount &
Frequency
(e.g. 2 hrs
6 x wk)
Payer Source
(Medicare,
Private Pay,
etc)
Date
Care
Started
Is Caregiver
from a home
care
agency?
Name: ______________
Address:_____________
Phone: ______________
Yes
No
Name: ______________
Address:_____________
Phone:_______________
Yes
No
Name: ______________
Address:_____________
Phone:_______________
Yes
No
Name: ______________
Address:_____________
Phone:_______________
Yes
No
Name: ______________
Address:_____________
Phone:_______________
Yes
No
Name: ______________
Address:_____________
Phone:_______________
Yes
No
If there are unpaid caregivers providing service to the insured please
complete the following section. If the caregiver is present ask them the
following questions, if not please ask the insured to respond.
Are there any family or unpaid caregivers present?
No
Yes If yes,
Name: ____________________________________ Relationship _______________________
Date you began receiving care? ________________
How long do you expect to need care? _____________
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ON SITE ASSESSMENT TOOL
How many hours a week do you spend providing assistance? _______________________________
What services are you providing to the insured? _________________________________________
Who is your main caregiver or person who helps you the most?
Name: ________________________________________________________
Address:__________________________________________________________
Phone Number (s): Home _________________ Work ____________ Cell _______
Relationship:
Spouse
Child
Sibling
Parent
Friend
Other:
Completed by the Assessor
The insured receives assistance a TOTAL of ___ hours/day ____days per week, including care
provided by family.
Current care is appropriate
Yes
No
Current care is excessive
No Yes
If care is excessive, in your professional opinion, appropriate care would be
2 to 6 hours
Care is inadequate
7 to 11 hours
No
12 to 24 hours
Yes (explain why) ______________________________
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