*** Effective Date: 9/18/2025   The following required for Bulk Import: |||
2|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; OR (b) Is physically, cognitively, and mentally able to prepare light meals on a regular basis but has not routinely performed light meal preparation in the past (i.e., prior to this home care admission).|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; O|1
3|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and mentally able to perform all housekeeping tasks .|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and menta|1
4|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and mentally able to do laundry and access facilities.|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and menta|1
5|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying packages OR b) Physically, cognitively, and mentally able to take care of shopping, but has not done shopping in the past (i.e., prior to this home care admission).|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying|1
6|0 - Able to bathe self in SHOWER OR TUB independently.|0 - Able to bathe self in SHOWER OR TUB independently.|1
7|0 - Able to dial numbers and answer calls appropriately and as desired.|0 - Able to dial numbers and answer calls appropriately and as desired.|1
8|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body without assistance.|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body|1
9|0 - Able to get to and from the toilet independently with or without a device.|0 - Able to get to and from the toilet independently with or without a device.|1
10|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|1
11|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible public bus.|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible p|1
12|0 - Able to independently feed self.|0 - Able to independently feed self.|1
13|0 - Able to independently take the correct medication and proper dosage at the correct times.|0 - Able to independently take the correct medication and proper dosage at the correct times.|1
14|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct times.|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct ti|1
15|0 - Able to independently transfer.|0 - Able to independently transfer.|1
16|0 - Able to independently walk on even and uneven surfaces and climb stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even and uneven surfaces and climb stairs with or without railings|1
17|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings|1
18|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|1
19|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions independently.|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions indep|1
20|0 - Asymptomatic, no treatment needed at this time|0 - Asymptomatic, no treatment needed at this time|1
21|0 - Caregiver manages all tasks related to equipment completely independently.|0 - Caregiver manages all tasks related to equipment completely independently.|1
22|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations with no observable impairment.|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations w|1
23|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|1
24|0 - Life expectancy is greater than 6 months|0 - Life expectancy is greater than 6 months|1
25|0 - Never|0 - Never|1
26|0 - Never, patient is not short of breath|0 - Never, patient is not short of breath|1
27|0 - No|0 - No|1
28|0 - No emergent care services|0 - No emergent care services|1
29|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage)|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage)|1
30|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and extended or abstract conversation.|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and exte|1
31|0 - No one person|0 - No one person|1
32|0 - None of the time|0 - None of the time|1
33|0 - None, no charge for current services|0 - None, no charge for current services|1
34|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|1
35|0 - Patient does NOT have an ostomy for bowel elimination.|0 - Patient does NOT have an ostomy for bowel elimination.|1
36|0 - Patient has no pain or pain does not interfere with activity or movement|0 - Patient has no pain or pain does not interfere with activity or movement|1
37|0 - Patient manages all tasks related to equipment completely independently.|0 - Patient manages all tasks related to equipment completely independently.|1
38|0 - Poor:  little or no recovery is expected and/or further decline is imminent|0 - Poor:  little or no recovery is expected and/or further decline is imminent|1
39|0 - Timed-voiding defers incontinence|0 - Timed-voiding defers incontinence|1
40|0 - Very rarely or never has bowel incontinence|0 - Very rarely or never has bowel incontinence|1
41|0 - Zero|0 - Zero|1
42|00 - No|00 - No|1
43|01 - Yes|01 - Yes|1
44|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or mental limitations, needs assistance with heavy laundry.|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or|1
45|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the patient.|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the|1
46|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|1
47|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or supervision from another person OR c) a liquid, pureed or ground meat diet.|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or su|1
48|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|1
49|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|1
50|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independently.|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independe|1
51|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only when assisted or accompanied by another person.|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only w|1
52|1 - Able to take injectable medication at correct times if: a) individual syringes are prepared in advance by another person OR b) given daily reminders.|1 - Able to take injectable medication at correct times if: a) individual syringes are prepared in a|1
53|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance by another person OR b) given daily reminders.|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance b|1
54|1 - Able to take medication(s) at the correct times if: a) individual dosages are prepared in advance by another person , OR b) given daily reminders OR c) someone develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if: a) individual dosages are prepared in advanc|1
55|1 - Able to take medication(s) at the correct times if: a) individual dosages are prepared in advance by another person, OR b) given daily reminders OR c) someone develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if: a) individual dosages are prepared in advanc|1
56|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for the deaf) and call essential numbers.|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for t|1
57|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|1
58|1 - American Indian or Alaska Native|1 - American Indian or Alaska Native|1
59|1 - Depressed mood (e.g., feeling sad, tearful)|1 - Depressed mood (e.g., feeling sad, tearful)|1
60|1 - During the night only|1 - During the night only|1
61|1 - Fully granulating|1 - Fully granulating|1
62|1 - Good/Fair:  partial to full recovery is expected|1 - Good/Fair:  partial to full recovery is expected|1
63|1 - Good:  marked improvement in functional status is expected|1 - Good:  marked improvement in functional status is expected|1
64|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|1
65|1 - Heavy smoking|1 - Heavy smoking|1
66|1 - Hospital|1 - Hospital|1
67|1 - Hospital emergency room (includes 23-hour holding)|1 - Hospital emergency room (includes 23-hour holding)|1
68|1 - Hospitalization for EMERGENT (unscheduled) care|1 - Hospitalization for EMERGENT (unscheduled) care|1
69|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepared solutions), patient is able to manage all other aspects of equipment.|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepar|1
70|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|1
71|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|1
72|1 - In new or complex situations only|1 - In new or complex situations only|1
73|1 - Intravenous or infusion therapy (excludes TPN)|1 - Intravenous or infusion therapy (excludes TPN)|1
74|1 - Less often than daily|1 - Less often than daily|1
75|1 - Less than once a month|1 - Less than once a month|1
76|1 - Less than once weekly|1 - Less than once weekly|1
77|1 - Life expectancy is 6 months or fewer|1 - Life expectancy is 6 months or fewer|1
78|1 - Lives alone|1 - Lives alone|1
79|1 - Male|1 - Male|1
80|1 - Medicare (traditional fee-for-service)|1 - Medicare (traditional fee-for-service)|1
81|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of past 24 hours, significant memory loss so that supervision is required|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of pas|1
82|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors in word choice, grammar or speech intelligibility, needs minimal prompting or assistance).|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors i|1
83|1 - No assistance or services received|1 - No assistance or services received|1
84|1 - One|1 - One|1
85|1 - Oxygen (intermittent or continuous)|1 - Oxygen (intermittent or continuous)|1
86|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, and the surrounding layout, can count fingers at arm's length.|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, a|1
87|1 - Patient is incontinent|1 - Patient is incontinent|1
88|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|1
89|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical or treatment regimen.|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical|1
90|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient/couple/significant other)|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient|1
91|1 - Relatives, friends, or neighbors living outside the home|1 - Relatives, friends, or neighbors living outside the home|1
92|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions.|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions|1
93|1 - Requires use of a device (e.g., cane, walker) to walk alone OR requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|1 - Requires use of a device (e.g., cane, walker) to walk alone OR requires human supervision or ass|1
94|1 - Several times during day and night|1 - Several times during day and night|1
95|1 - Spouse or significant other|1 - Spouse or significant other|1
96|1 - Stage 1|1 - Stage 1|1
97|1 - Start of care - further visits planned|1 - Start of care - further visits planned|1
98|1 - Symptoms well controlled with current therapy|1 - Symptoms well controlled with current therapy|1
99|1 - Therapy services|1 - Therapy services|1
100|1 - Transfers with minimal human assistance or with use of an assistive device.|1 - Transfers with minimal human assistance or with use of an assistive device.|1
101|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitations.|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitatio|1
102|1 - Urinary incontinence|1 - Urinary incontinence|1
103|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet.|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet.|1
104|1 - When walking more than 20 feet, climbing stairs|1 - When walking more than 20 feet, climbing stairs|1
105|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary conversation. May need occasional repetition, extra time, or louder voice.|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary c|1
106|1 - With the use of devices, is able to bathe self in shower or tub independently.|1 - With the use of devices, is able to bathe self in shower or tub independently.|1
107|1 - Yes|1 - Yes|1
108|1-RN|1-RN|1
109|10 - Discharge from agency - no visits completed after start/resumption of care assessment|10 - Discharge from agency - no visits completed after start/resumption of care assessment|1
110|10 - Scheduled surgical procedure|10 - Scheduled surgical procedure|1
111|10 - Self-pay|10 - Self-pay|1
112|11 - Other|11 - Other|1
113|11 - Urinary tract infection|11 - Urinary tract infection|1
114|12 - IV catheter-related infection|12 - IV catheter-related infection|1
115|13 - Deep vein thrombosis, pulmonary embolus|13 - Deep vein thrombosis, pulmonary embolus|1
116|14 - Uncontrolled pain|14 - Uncontrolled pain|1
117|15 - Psychotic episode|15 - Psychotic episode|1
118|16 - Other than above reasons|16 - Other than above reasons|1
119|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing calls.|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing|1
120|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another person.|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another pers|1
121|2 - Able to walk only with the supervision or assistance of another person at all times.|2 - Able to walk only with the supervision or assistance of another person at all times.|1
122|2 - Aid: a) for intermittent supervision/encouragement/reminders, OR b) to get in and out of the shower/tub, OR c) for washing difficult to reach areas.|2 - Aid: a) for intermittent supervision/encouragement/reminders, OR b) to get in and out of the sho|1
123|2 - Asian|2 - Asian|1
124|2 - Caregiver requires considerable assistance from another person to manage equipment, but independently completes significant portions of task.|2 - Caregiver requires considerable assistance from another person to manage equipment, but independ|1
125|2 - Daily, but not constantly|2 - Daily, but not constantly|1
126|2 - Daughter or son|2 - Daughter or son|1
127|2 - Doctor's office emergency visit/house call|2 - Doctor's office emergency visit/house call|1
128|2 - During the day and night|2 - During the day and night|1
129|2 - Early/partial granulation|2 - Early/partial granulation|1
130|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors in word choice, organization or speech intelligibility). Speaks in phrases or short sentences.|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors|1
131|2 - Family member's residence|2 - Family member's residence|1
132|2 - Female|2 - Female|1
133|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conversation, needs frequent prompting or assistance.|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conver|1
134|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|1
135|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|1
136|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately stop activities, jeopardizes safety through actions|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately st|1
137|2 - Indwelling/suprapubic catheter|2 - Indwelling/suprapubic catheter|1
138|2 - Injury caused by fall or accident at home|2 - Injury caused by fall or accident at home|1
139|2 - Medicare (HMO/managed care)|2 - Medicare (HMO/managed care)|1
140|2 - Nausea, dehydration, malnutrition, constipation, impaction|2 - Nausea, dehydration, malnutrition, constipation, impaction|1
141|2 - Obesity|2 - Obesity|1
142|2 - On awakening or at night only|2 - On awakening or at night only|1
143|2 - Once a month|2 - Once a month|1
144|2 - One to three times weekly|2 - One to three times weekly|1
145|2 - Parenteral nutrition (TPN or lipids)|2 - Parenteral nutrition (TPN or lipids)|1
146|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic)|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic)|1
147|2 - Patient requires considerable assistance from another person to manage equipment, but independently completes portions of the task.|2 - Patient requires considerable assistance from another person to manage equipment, but independen|1
148|2 - Patient transferred to a noninstitutional hospice|2 - Patient transferred to a noninstitutional hospice|1
149|2 - Person residing in the home (EXCLUDING paid help)|2 - Person residing in the home (EXCLUDING paid help)|1
150|2 - Rehabilitation facility|2 - Rehabilitation facility|1
151|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifting of attention) or consistently requires low stimulus environment due to distractibility.|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifti|1
152|2 - Respite care|2 - Respite care|1
153|2 - Sense of failure or self reproach|2 - Sense of failure or self reproach|1
154|2 - Several times during day|2 - Several times during day|1
155|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonresponsive.|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonrespons|1
156|2 - Someone must assist the patient to groom self.|2 - Someone must assist the patient to groom self.|1
157|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|1
158|2 - Someone must help the patient put on upper body clothing.|2 - Someone must help the patient put on upper body clothing.|1
159|2 - Stage 2|2 - Stage 2|1
160|2 - Start of care - no further visits planned|2 - Start of care - no further visits planned|1
161|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitoring|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitori|1
162|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment regimen.|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment re|1
163|2 - Two|2 - Two|1
164|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistance due to cognitive or mental limitation.|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistanc|1
165|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|1
166|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assistance).|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assis|1
167|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home delivery.|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home deli|1
168|2 - Unable to prepare any light meals or reheat any delivered meals.|2 - Unable to prepare any light meals or reheat any delivered meals.|1
169|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|1
170|2 - UNABLE to take injectable medications unless administered by someone else.|2 - UNABLE to take injectable medications unless administered by someone else.|1
171|2 - UNABLE to take medication unless administered by someone else.|2 - UNABLE to take medication unless administered by someone else.|1
172|2 - UNABLE to transfer self but is able to bear weight and pivot during the transfer process.|2 - UNABLE to transfer self but is able to bear weight and pivot during the transfer process.|1
173|2 - Ventilator (continually or at night)|2 - Ventilator (continually or at night)|1
174|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less than 20 feet)|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less th|1
175|2 - With spouse or significant other|2 - With spouse or significant other|1
176|2 - Yes, assistance or services provided by family or friends|2 - Yes, assistance or services provided by family or friends|1
177|2-PT|2-PT|1
178|3 - Able to answer the telephone only some of the time or is able to carry on only a limited conversation.|3 - Able to answer the telephone only some of the time or is able to carry on only a limited convers|1
179|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube or gastrostomy.|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube|1
180|3 - Alcohol dependency|3 - Alcohol dependency|1
181|3 - All of the time|3 - All of the time|1
182|3 - Black or African-American|3 - Black or African-American|1
183|3 - Boarding home or rented room|3 - Boarding home or rented room|1
184|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment, clean/store/dispose of equipment or supplies).|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment,|1
185|3 - Chairfast, UNABLE to ambulate but is able to wheel self independently.|3 - Chairfast, UNABLE to ambulate but is able to wheel self independently.|1
186|3 - Continuous positive airway pressure|3 - Continuous positive airway pressure|1
187|3 - During the day and evening, but not constantly|3 - During the day and evening, but not constantly|1
188|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the alimentary canal)|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the|1
189|3 - Environmental support (e.g., housing, home maintenance)|3 - Environmental support (e.g., housing, home maintenance)|1
190|3 - Four to six times weekly|3 - Four to six times weekly|1
191|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessing by listener.  Speech limited to single words or short phrases.|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessin|1
192|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires multiple repetitions, restatements, demonstrations, additional time.|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires m|1
193|3 - Hopelessness|3 - Hopelessness|1
194|3 - Hospice care|3 - Hospice care|1
195|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|1
196|3 - Injury caused by fall or accident at home|3 - Injury caused by fall or accident at home|1
197|3 - Intractable pain|3 - Intractable pain|1
198|3 - Medicaid (traditional fee-for-service)|3 - Medicaid (traditional fee-for-service)|1
199|3 - Needs someone to do all shopping and errands.|3 - Needs someone to do all shopping and errands.|1
200|3 - Not healing|3 - Not healing|1
201|3 - Nursing home|3 - Nursing home|1
202|3 - Once daily|3 - Once daily|1
203|3 - Other family member|3 - Other family member|1
204|3 - Outpatient department/clinic emergency (includes urgicenter sites)|3 - Outpatient department/clinic emergency (includes urgicenter sites)|1
205|3 - Paid help|3 - Paid help|1
206|3 - Participates in bathing self in shower or tub, BUT requires presence of another person throughout the bath for assistance or supervision.|3 - Participates in bathing self in shower or tub, BUT requires presence of another person throughou|1
207|3 - Patient depends entirely upon another person to dress lower body.|3 - Patient depends entirely upon another person to dress lower body.|1
208|3 - Patient depends entirely upon another person to dress the upper body.|3 - Patient depends entirely upon another person to dress the upper body.|1
209|3 - Patient depends entirely upon someone else for grooming needs.|3 - Patient depends entirely upon someone else for grooming needs.|1
210|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone else to manage the equipment.|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone|1
211|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable to shift attention and recall directions more than half the time.|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable|1
212|3 - Respiratory problems (SOB, infection, obstruction)|3 - Respiratory problems (SOB, infection, obstruction)|1
213|3 - Resumption of care (after inpatient stay)|3 - Resumption of care (after inpatient stay)|1
214|3 - Several times each month|3 - Several times each month|1
215|3 - Skilled Nursing Facility|3 - Skilled Nursing Facility|1
216|3 - Stage 3|3 - Stage 3|1
217|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|1
218|3 - Three|3 - Three|1
219|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person throughout the process.|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person through|1
220|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal independently.|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal indep|1
221|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person.|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person|1
222|3 - Unknown because patient moved to a geographic location not served by this agency|3 - Unknown because patient moved to a geographic location not served by this agency|1
223|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|1
224|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|1
225|3 - With other family member|3 - With other family member|1
226|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home health services, homemaker assistance, transportation assistance, assisted living, board and care)|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home h|1
227|3-SLP/ST|3-SLP/ST|1
228|4 - At rest (during day or night)|4 - At rest (during day or night)|1
229|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|1
230|4 - Board and care or assisted living facility|4 - Board and care or assisted living facility|1
231|4 - Caregiver is completely dependent on someone else to manage all equipment.|4 - Caregiver is completely dependent on someone else to manage all equipment.|1
232|4 - Chairfast, unable to ambulate and is UNABLE to wheel self.|4 - Chairfast, unable to ambulate and is UNABLE to wheel self.|1
233|4 - Constantly|4 - Constantly|1
234|4 - Drug dependency|4 - Drug dependency|1
235|4 - Four or more|4 - Four or more|1
236|4 - Friend or neighbor or community or church member|4 - Friend or neighbor or community or church member|1
237|4 - Hispanic or Latino|4 - Hispanic or Latino|1
238|4 - Hospice|4 - Hospice|1
239|4 - Impaired decision-making|4 - Impaired decision-making|1
240|4 - Is totally dependent in toileting.|4 - Is totally dependent in toileting.|1
241|4 - Medicaid (HMO/managed care)|4 - Medicaid (HMO/managed care)|1
242|4 - None of the above|4 - None of the above|1
243|4 - Nursing home|4 - Nursing home|1
244|4 - On a daily basis|4 - On a daily basis|1
245|4 - Patient is completely dependent on someone else to manage all equipment.|4 - Patient is completely dependent on someone else to manage all equipment.|1
246|4 - Permanent placement|4 - Permanent placement|1
247|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, punches, dangerous maneuvers w/ wheelchair or other objects)|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, pu|1
248|4 - Psychosocial support (e.g., socialization, companionship, recreation)|4 - Psychosocial support (e.g., socialization, companionship, recreation)|1
249|4 - Recertification (follow-up) reassessment|4 - Recertification (follow-up) reassessment|1
250|4 - Recurrent thoughts of death|4 - Recurrent thoughts of death|1
251|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruction)|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruc|1
252|4 - Several times a week|4 - Several times a week|1
253|4 - Stage 4|4 - Stage 4|1
254|4 - Symptoms poorly controlled, history of rehospitalizations|4 - Symptoms poorly controlled, history of rehospitalizations|1
255|4 - Three or more times per week|4 - Three or more times per week|1
256|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetative state, or delirium.|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetati|1
257|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|1
258|4 - Unable to effectively participate in any housekeeping tasks.|4 - Unable to effectively participate in any housekeeping tasks.|1
259|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or unresponsive (e.g., speech is nonsensical or unintelligible).|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or u|1
260|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonresponsive.|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonr|1
261|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostomy.|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostom|1
262|4 - UNABLE to use the shower or tub and is bathed in BED OR BEDSIDE CHAIR.|4 - UNABLE to use the shower or tub and is bathed in BED OR BEDSIDE CHAIR.|1
263|4 - With a friend|4 - With a friend|1
264|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|1
265|4-OT|4-OT|1
266|5 - Advocates or facilitates patient's participation in appropriate medical care|5 - Advocates or facilitates patient's participation in appropriate medical care|1
267|5 - At least daily|5 - At least daily|1
268|5 - Bedfast, unable to ambulate or be up in a chair.|5 - Bedfast, unable to ambulate or be up in a chair.|1
269|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|1
270|5 - Disruptive or socially inappropriate behavior|5 - Disruptive or socially inappropriate behavior|1
271|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|1
272|5 - Hypo/Hyperglycemia, diabetes out of control|5 - Hypo/Hyperglycemia, diabetes out of control|1
273|5 - More often than once daily|5 - More often than once daily|1
274|5 - Native Hawaiian or Pacific Islander|5 - Native Hawaiian or Pacific Islander|1
275|5 - None of the above|5 - None of the above|1
276|5 - One to two times per week|5 - One to two times per week|1
277|5 - Other|5 - Other|1
278|5 - Other follow-up|5 - Other follow-up|1
279|5 - Paid help|5 - Paid help|1
280|5 - Patient nonresponsive or unable to speak.|5 - Patient nonresponsive or unable to speak.|1
281|5 - Thoughts of suicide|5 - Thoughts of suicide|1
282|5 - Totally unable to use the telephone.|5 - Totally unable to use the telephone.|1
283|5 - Unable to effectively participate in bathing and is totally bathed by another person.|5 - Unable to effectively participate in bathing and is totally bathed by another person.|1
284|5 - Unable to take in nutrients orally or by tube feeding.|5 - Unable to take in nutrients orally or by tube feeding.|1
285|5 - Unsafe for care at home|5 - Unsafe for care at home|1
286|5 - With paid help (other than home care agency staff)|5 - With paid help (other than home care agency staff)|1
287|5 - Workers' compensation|5 - Workers' compensation|1
288|5 - Wound infection, deteriorating wound status, new lesion/ulcer|5 - Wound infection, deteriorating wound status, new lesion/ulcer|1
289|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|1
290|6 - Delusional, hallucinatory, or paranoid behavior|6 - Delusional, hallucinatory, or paranoid behavior|1
291|6 - Financial agent, power of attorney, or conservator of finance|6 - Financial agent, power of attorney, or conservator of finance|1
292|6 - GI bleeding, obstruction|6 - GI bleeding, obstruction|1
293|6 - Less often than weekly|6 - Less often than weekly|1
294|6 - Memory loss to the extent that supervision required|6 - Memory loss to the extent that supervision required|1
295|6 - None of the above feelings observed or reported|6 - None of the above feelings observed or reported|1
296|6 - Other|6 - Other|1
297|6 - Title programs (e.g., Title III, V, or XX)|6 - Title programs (e.g., Title III, V, or XX)|1
298|6 - Transferred to an inpatient facility - patient not discharged from agency|6 - Transferred to an inpatient facility - patient not discharged from agency|1
299|6 - White|6 - White|1
300|6 - With other than above|6 - With other than above|1
301|7 - Exacerbation of CHF, fluid overload, heart failure|7 - Exacerbation of CHF, fluid overload, heart failure|1
302|7 - Health care agent, conservator of person, or medical power of attorney|7 - Health care agent, conservator of person, or medical power of attorney|1
303|7 - Hypo/Hyperglycemia, diabetes out of control|7 - Hypo/Hyperglycemia, diabetes out of control|1
304|7 - None of the above|7 - None of the above|1
305|7 - None of the above behaviors demonstrated|7 - None of the above behaviors demonstrated|1
306|7 - Other government (e.g., CHAMPUS, VA, etc.)|7 - Other government (e.g., CHAMPUS, VA, etc.)|1
307|7 - Transferred to an inpatient facility - patient discharged from agency|7 - Transferred to an inpatient facility - patient discharged from agency|1
308|8 - Death at home|8 - Death at home|1
309|8 - GI bleeding, obstruction|8 - GI bleeding, obstruction|1
310|8 - Myocardial infarction, stroke|8 - Myocardial infarction, stroke|1
311|8 - Private insurance|8 - Private insurance|1
312|9 - Chemotherapy|9 - Chemotherapy|1
313|9 - Discharge from agency|9 - Discharge from agency|1
314|9 - Other than above reasons|9 - Other than above reasons|1
315|9 - Private HMO/managed care|9 - Private HMO/managed care|1
316|NA - No caregiver|NA - No caregiver|1
317|NA - No equipment of this type used in care.|NA - No equipment of this type used in care.|1
318|NA - No inhalant/mist medications prescribed.|NA - No inhalant/mist medications prescribed.|1
319|NA - No injectable medications prescribed.|NA - No injectable medications prescribed.|1
320|NA - No inpatient facility admission|NA - No inpatient facility admission|1
321|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|1
322|NA - No Medicaid|NA - No Medicaid|1
323|NA - No Medicare|NA - No Medicare|1
324|NA - No observable pressure ulcer|NA - No observable pressure ulcer|1
325|NA - No observable stasis ulcer|NA - No observable stasis ulcer|1
326|NA - No observable surgical wound|NA - No observable surgical wound|1
327|NA - No oral medications prescribed.|NA - No oral medications prescribed.|1
328|NA - Not applicable|NA - Not applicable|1
329|NA - Patient does not have a telephone.|NA - Patient does not have a telephone.|1
330|NA - Patient has ostomy for bowel elimination|NA - Patient has ostomy for bowel elimination|1
331|NA - Patient nonresponsive|NA - Patient nonresponsive|1
332|NA - Patient on prophylactic treatment|NA - Patient on prophylactic treatment|1
333|NA - Patient was not discharged from an inpatient facility|NA - Patient was not discharged from an inpatient facility|1
334|UK - Other unknown|UK - Other unknown|1
335|UK - Reason unknown|UK - Reason unknown|1
336|UK - Unknown|UK - Unknown|1
337|UK - Unknown or Not Available|UK - Unknown or Not Available|1
341|01 - Early|01 - Early|1
342|02 - Late|02 - Late|1
343|NA - Not Applicable. No case mix group defined for this assessment.|NA - Not Applicable. No case mix group defined for this assessment.|1
344|NA - No case mix group defined by this assessment.|NA - No case mix group defined by this assessment.|1
47|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or supervision from another person OR c) a liquid, pureed or ground meat diet.|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or su|3
2|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; OR (b) Is physically, cognitively, and mentally able to prepare light meals on a regular basis but has not routinely performed light meal preparation in the past (i.e., prior to this home care admission).|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; O|3
3|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and mentally able to perform all housekeeping tasks .|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and menta|3
4|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and mentally able to do laundry and access facilities.|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and menta|3
5|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying packages OR b) Physically, cognitively, and mentally able to take care of shopping, but has not done shopping in the past (i.e., prior to this home care admission).|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying|3
6|0 - Able to bathe self in SHOWER OR TUB independently.|0 - Able to bathe self in SHOWER OR TUB independently.|3
7|0 - Able to dial numbers and answer calls appropriately and as desired.|0 - Able to dial numbers and answer calls appropriately and as desired.|3
8|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body without assistance.|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body|3
9|0 - Able to get to and from the toilet independently with or without a device.|0 - Able to get to and from the toilet independently with or without a device.|3
10|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|3
11|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible public bus.|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible p|3
12|0 - Able to independently feed self.|0 - Able to independently feed self.|3
13|0 - Able to independently take the correct medication and proper dosage at the correct times.|0 - Able to independently take the correct medication and proper dosage at the correct times.|3
14|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct times.|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct ti|3
15|0 - Able to independently transfer.|0 - Able to independently transfer.|3
16|0 - Able to independently walk on even and uneven surfaces and climb stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even and uneven surfaces and climb stairs with or without railings|3
17|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings|3
18|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|3
19|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions independently.|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions indep|3
20|0 - Asymptomatic, no treatment needed at this time|0 - Asymptomatic, no treatment needed at this time|3
21|0 - Caregiver manages all tasks related to equipment completely independently.|0 - Caregiver manages all tasks related to equipment completely independently.|3
22|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations with no observable impairment.|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations w|3
23|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|3
24|0 - Life expectancy is greater than 6 months|0 - Life expectancy is greater than 6 months|3
25|0 - Never|0 - Never|3
26|0 - Never, patient is not short of breath|0 - Never, patient is not short of breath|3
27|0 - No|0 - No|3
28|0 - No emergent care services|0 - No emergent care services|3
29|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage)|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage)|3
30|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and extended or abstract conversation.|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and exte|3
31|0 - No one person|0 - No one person|3
32|0 - None of the time|0 - None of the time|3
33|0 - None, no charge for current services|0 - None, no charge for current services|3
34|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|3
35|0 - Patient does NOT have an ostomy for bowel elimination.|0 - Patient does NOT have an ostomy for bowel elimination.|3
36|0 - Patient has no pain or pain does not interfere with activity or movement|0 - Patient has no pain or pain does not interfere with activity or movement|3
37|0 - Patient manages all tasks related to equipment completely independently.|0 - Patient manages all tasks related to equipment completely independently.|3
38|0 - Poor:  little or no recovery is expected and/or further decline is imminent|0 - Poor:  little or no recovery is expected and/or further decline is imminent|3
39|0 - Timed-voiding defers incontinence|0 - Timed-voiding defers incontinence|3
40|0 - Very rarely or never has bowel incontinence|0 - Very rarely or never has bowel incontinence|3
41|0 - Zero|0 - Zero|3
42|00 - No|00 - No|3
43|01 - Yes|01 - Yes|3
44|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or mental limitations, needs assistance with heavy laundry.|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or|3
45|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the patient.|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the|3
46|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|3
48|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|3
49|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|3
50|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independently.|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independe|3
51|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only when assisted or accompanied by another person.|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only w|3
52|1 - Able to take injectable medication at correct times if: a) individual syringes are prepared in advance by another person OR b) given daily reminders.|1 - Able to take injectable medication at correct times if: a) individual syringes are prepared in a|3
53|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance by another person OR b) given daily reminders.|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance b|3
54|1 - Able to take medication(s) at the correct times if: a) individual dosages are prepared in advance by another person , OR b) given daily reminders OR c) someone develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if: a) individual dosages are prepared in advanc|3
55|1 - Able to take medication(s) at the correct times if: a) individual dosages are prepared in advance by another person, OR b) given daily reminders OR c) someone develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if: a) individual dosages are prepared in advanc|3
56|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for the deaf) and call essential numbers.|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for t|3
57|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|3
58|1 - American Indian or Alaska Native|1 - American Indian or Alaska Native|3
59|1 - Depressed mood (e.g., feeling sad, tearful)|1 - Depressed mood (e.g., feeling sad, tearful)|3
60|1 - During the night only|1 - During the night only|3
61|1 - Fully granulating|1 - Fully granulating|3
62|1 - Good/Fair:  partial to full recovery is expected|1 - Good/Fair:  partial to full recovery is expected|3
63|1 - Good:  marked improvement in functional status is expected|1 - Good:  marked improvement in functional status is expected|3
64|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|3
65|1 - Heavy smoking|1 - Heavy smoking|3
66|1 - Hospital|1 - Hospital|3
67|1 - Hospital emergency room (includes 23-hour holding)|1 - Hospital emergency room (includes 23-hour holding)|3
68|1 - Hospitalization for EMERGENT (unscheduled) care|1 - Hospitalization for EMERGENT (unscheduled) care|3
69|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepared solutions), patient is able to manage all other aspects of equipment.|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepar|3
70|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|3
71|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|3
72|1 - In new or complex situations only|1 - In new or complex situations only|3
73|1 - Intravenous or infusion therapy (excludes TPN)|1 - Intravenous or infusion therapy (excludes TPN)|3
74|1 - Less often than daily|1 - Less often than daily|3
75|1 - Less than once a month|1 - Less than once a month|3
76|1 - Less than once weekly|1 - Less than once weekly|3
77|1 - Life expectancy is 6 months or fewer|1 - Life expectancy is 6 months or fewer|3
78|1 - Lives alone|1 - Lives alone|3
79|1 - Male|1 - Male|3
80|1 - Medicare (traditional fee-for-service)|1 - Medicare (traditional fee-for-service)|3
81|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of past 24 hours, significant memory loss so that supervision is required|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of pas|3
82|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors in word choice, grammar or speech intelligibility, needs minimal prompting or assistance).|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors i|3
83|1 - No assistance or services received|1 - No assistance or services received|3
84|1 - One|1 - One|3
85|1 - Oxygen (intermittent or continuous)|1 - Oxygen (intermittent or continuous)|3
86|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, and the surrounding layout, can count fingers at arm's length.|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, a|3
87|1 - Patient is incontinent|1 - Patient is incontinent|3
88|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|3
89|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical or treatment regimen.|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical|3
90|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient/couple/significant other)|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient|3
91|1 - Relatives, friends, or neighbors living outside the home|1 - Relatives, friends, or neighbors living outside the home|3
92|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions.|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions|3
93|1 - Requires use of a device (e.g., cane, walker) to walk alone OR requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|1 - Requires use of a device (e.g., cane, walker) to walk alone OR requires human supervision or ass|3
94|1 - Several times during day and night|1 - Several times during day and night|3
95|1 - Spouse or significant other|1 - Spouse or significant other|3
96|1 - Stage 1|1 - Stage 1|3
97|1 - Start of care - further visits planned|1 - Start of care - further visits planned|3
98|1 - Symptoms well controlled with current therapy|1 - Symptoms well controlled with current therapy|3
99|1 - Therapy services|1 - Therapy services|3
100|1 - Transfers with minimal human assistance or with use of an assistive device.|1 - Transfers with minimal human assistance or with use of an assistive device.|3
101|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitations.|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitatio|3
102|1 - Urinary incontinence|1 - Urinary incontinence|3
103|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet.|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet.|3
104|1 - When walking more than 20 feet, climbing stairs|1 - When walking more than 20 feet, climbing stairs|3
105|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary conversation. May need occasional repetition, extra time, or louder voice.|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary c|3
106|1 - With the use of devices, is able to bathe self in shower or tub independently.|1 - With the use of devices, is able to bathe self in shower or tub independently.|3
107|1 - Yes|1 - Yes|3
108|1-RN|1-RN|3
109|10 - Discharge from agency - no visits completed after start/resumption of care assessment|10 - Discharge from agency - no visits completed after start/resumption of care assessment|3
110|10 - Scheduled surgical procedure|10 - Scheduled surgical procedure|3
111|10 - Self-pay|10 - Self-pay|3
112|11 - Other|11 - Other|3
113|11 - Urinary tract infection|11 - Urinary tract infection|3
114|12 - IV catheter-related infection|12 - IV catheter-related infection|3
115|13 - Deep vein thrombosis, pulmonary embolus|13 - Deep vein thrombosis, pulmonary embolus|3
116|14 - Uncontrolled pain|14 - Uncontrolled pain|3
117|15 - Psychotic episode|15 - Psychotic episode|3
118|16 - Other than above reasons|16 - Other than above reasons|3
119|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing calls.|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing|3
120|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another person.|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another pers|3
121|2 - Able to walk only with the supervision or assistance of another person at all times.|2 - Able to walk only with the supervision or assistance of another person at all times.|3
122|2 - Aid: a) for intermittent supervision/encouragement/reminders, OR b) to get in and out of the shower/tub, OR c) for washing difficult to reach areas.|2 - Aid: a) for intermittent supervision/encouragement/reminders, OR b) to get in and out of the sho|3
123|2 - Asian|2 - Asian|3
124|2 - Caregiver requires considerable assistance from another person to manage equipment, but independently completes significant portions of task.|2 - Caregiver requires considerable assistance from another person to manage equipment, but independ|3
125|2 - Daily, but not constantly|2 - Daily, but not constantly|3
126|2 - Daughter or son|2 - Daughter or son|3
127|2 - Doctor's office emergency visit/house call|2 - Doctor's office emergency visit/house call|3
128|2 - During the day and night|2 - During the day and night|3
129|2 - Early/partial granulation|2 - Early/partial granulation|3
130|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors in word choice, organization or speech intelligibility). Speaks in phrases or short sentences.|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors|3
131|2 - Family member's residence|2 - Family member's residence|3
132|2 - Female|2 - Female|3
133|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conversation, needs frequent prompting or assistance.|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conver|3
134|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|3
135|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|3
136|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately stop activities, jeopardizes safety through actions|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately st|3
137|2 - Indwelling/suprapubic catheter|2 - Indwelling/suprapubic catheter|3
138|2 - Injury caused by fall or accident at home|2 - Injury caused by fall or accident at home|3
139|2 - Medicare (HMO/managed care)|2 - Medicare (HMO/managed care)|3
140|2 - Nausea, dehydration, malnutrition, constipation, impaction|2 - Nausea, dehydration, malnutrition, constipation, impaction|3
141|2 - Obesity|2 - Obesity|3
142|2 - On awakening or at night only|2 - On awakening or at night only|3
143|2 - Once a month|2 - Once a month|3
144|2 - One to three times weekly|2 - One to three times weekly|3
145|2 - Parenteral nutrition (TPN or lipids)|2 - Parenteral nutrition (TPN or lipids)|3
146|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic)|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic)|3
147|2 - Patient requires considerable assistance from another person to manage equipment, but independently completes portions of the task.|2 - Patient requires considerable assistance from another person to manage equipment, but independen|3
148|2 - Patient transferred to a noninstitutional hospice|2 - Patient transferred to a noninstitutional hospice|3
149|2 - Person residing in the home (EXCLUDING paid help)|2 - Person residing in the home (EXCLUDING paid help)|3
150|2 - Rehabilitation facility|2 - Rehabilitation facility|3
151|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifting of attention) or consistently requires low stimulus environment due to distractibility.|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifti|3
152|2 - Respite care|2 - Respite care|3
153|2 - Sense of failure or self reproach|2 - Sense of failure or self reproach|3
154|2 - Several times during day|2 - Several times during day|3
155|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonresponsive.|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonrespons|3
156|2 - Someone must assist the patient to groom self.|2 - Someone must assist the patient to groom self.|3
157|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|3
158|2 - Someone must help the patient put on upper body clothing.|2 - Someone must help the patient put on upper body clothing.|3
159|2 - Stage 2|2 - Stage 2|3
160|2 - Start of care - no further visits planned|2 - Start of care - no further visits planned|3
161|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitoring|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitori|3
162|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment regimen.|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment re|3
163|2 - Two|2 - Two|3
164|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistance due to cognitive or mental limitation.|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistanc|3
165|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|3
166|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assistance).|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assis|3
167|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home delivery.|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home deli|3
168|2 - Unable to prepare any light meals or reheat any delivered meals.|2 - Unable to prepare any light meals or reheat any delivered meals.|3
169|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|3
170|2 - UNABLE to take injectable medications unless administered by someone else.|2 - UNABLE to take injectable medications unless administered by someone else.|3
171|2 - UNABLE to take medication unless administered by someone else.|2 - UNABLE to take medication unless administered by someone else.|3
172|2 - UNABLE to transfer self but is able to bear weight and pivot during the transfer process.|2 - UNABLE to transfer self but is able to bear weight and pivot during the transfer process.|3
173|2 - Ventilator (continually or at night)|2 - Ventilator (continually or at night)|3
174|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less than 20 feet)|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less th|3
175|2 - With spouse or significant other|2 - With spouse or significant other|3
176|2 - Yes, assistance or services provided by family or friends|2 - Yes, assistance or services provided by family or friends|3
177|2-PT|2-PT|3
178|3 - Able to answer the telephone only some of the time or is able to carry on only a limited conversation.|3 - Able to answer the telephone only some of the time or is able to carry on only a limited convers|3
179|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube or gastrostomy.|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube|3
180|3 - Alcohol dependency|3 - Alcohol dependency|3
181|3 - All of the time|3 - All of the time|3
182|3 - Black or African-American|3 - Black or African-American|3
183|3 - Boarding home or rented room|3 - Boarding home or rented room|3
184|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment, clean/store/dispose of equipment or supplies).|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment,|3
185|3 - Chairfast, UNABLE to ambulate but is able to wheel self independently.|3 - Chairfast, UNABLE to ambulate but is able to wheel self independently.|3
186|3 - Continuous positive airway pressure|3 - Continuous positive airway pressure|3
187|3 - During the day and evening, but not constantly|3 - During the day and evening, but not constantly|3
188|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the alimentary canal)|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the|3
189|3 - Environmental support (e.g., housing, home maintenance)|3 - Environmental support (e.g., housing, home maintenance)|3
190|3 - Four to six times weekly|3 - Four to six times weekly|3
191|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessing by listener.  Speech limited to single words or short phrases.|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessin|3
192|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires multiple repetitions, restatements, demonstrations, additional time.|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires m|3
193|3 - Hopelessness|3 - Hopelessness|3
194|3 - Hospice care|3 - Hospice care|3
195|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|3
196|3 - Injury caused by fall or accident at home|3 - Injury caused by fall or accident at home|3
197|3 - Intractable pain|3 - Intractable pain|3
198|3 - Medicaid (traditional fee-for-service)|3 - Medicaid (traditional fee-for-service)|3
199|3 - Needs someone to do all shopping and errands.|3 - Needs someone to do all shopping and errands.|3
200|3 - Not healing|3 - Not healing|3
201|3 - Nursing home|3 - Nursing home|3
202|3 - Once daily|3 - Once daily|3
203|3 - Other family member|3 - Other family member|3
204|3 - Outpatient department/clinic emergency (includes urgicenter sites)|3 - Outpatient department/clinic emergency (includes urgicenter sites)|3
205|3 - Paid help|3 - Paid help|3
206|3 - Participates in bathing self in shower or tub, BUT requires presence of another person throughout the bath for assistance or supervision.|3 - Participates in bathing self in shower or tub, BUT requires presence of another person throughou|3
207|3 - Patient depends entirely upon another person to dress lower body.|3 - Patient depends entirely upon another person to dress lower body.|3
208|3 - Patient depends entirely upon another person to dress the upper body.|3 - Patient depends entirely upon another person to dress the upper body.|3
209|3 - Patient depends entirely upon someone else for grooming needs.|3 - Patient depends entirely upon someone else for grooming needs.|3
210|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone else to manage the equipment.|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone|3
211|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable to shift attention and recall directions more than half the time.|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable|3
212|3 - Respiratory problems (SOB, infection, obstruction)|3 - Respiratory problems (SOB, infection, obstruction)|3
213|3 - Resumption of care (after inpatient stay)|3 - Resumption of care (after inpatient stay)|3
214|3 - Several times each month|3 - Several times each month|3
215|3 - Skilled Nursing Facility|3 - Skilled Nursing Facility|3
216|3 - Stage 3|3 - Stage 3|3
217|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|3
218|3 - Three|3 - Three|3
219|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person throughout the process.|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person through|3
220|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal independently.|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal indep|3
221|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person.|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person|3
222|3 - Unknown because patient moved to a geographic location not served by this agency|3 - Unknown because patient moved to a geographic location not served by this agency|3
223|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|3
224|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|3
225|3 - With other family member|3 - With other family member|3
226|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home health services, homemaker assistance, transportation assistance, assisted living, board and care)|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home h|3
227|3-SLP/ST|3-SLP/ST|3
228|4 - At rest (during day or night)|4 - At rest (during day or night)|3
229|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|3
230|4 - Board and care or assisted living facility|4 - Board and care or assisted living facility|3
231|4 - Caregiver is completely dependent on someone else to manage all equipment.|4 - Caregiver is completely dependent on someone else to manage all equipment.|3
232|4 - Chairfast, unable to ambulate and is UNABLE to wheel self.|4 - Chairfast, unable to ambulate and is UNABLE to wheel self.|3
233|4 - Constantly|4 - Constantly|3
234|4 - Drug dependency|4 - Drug dependency|3
235|4 - Four or more|4 - Four or more|3
236|4 - Friend or neighbor or community or church member|4 - Friend or neighbor or community or church member|3
237|4 - Hispanic or Latino|4 - Hispanic or Latino|3
238|4 - Hospice|4 - Hospice|3
239|4 - Impaired decision-making|4 - Impaired decision-making|3
240|4 - Is totally dependent in toileting.|4 - Is totally dependent in toileting.|3
241|4 - Medicaid (HMO/managed care)|4 - Medicaid (HMO/managed care)|3
242|4 - None of the above|4 - None of the above|3
243|4 - Nursing home|4 - Nursing home|3
244|4 - On a daily basis|4 - On a daily basis|3
245|4 - Patient is completely dependent on someone else to manage all equipment.|4 - Patient is completely dependent on someone else to manage all equipment.|3
246|4 - Permanent placement|4 - Permanent placement|3
247|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, punches, dangerous maneuvers w/ wheelchair or other objects)|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, pu|3
248|4 - Psychosocial support (e.g., socialization, companionship, recreation)|4 - Psychosocial support (e.g., socialization, companionship, recreation)|3
249|4 - Recertification (follow-up) reassessment|4 - Recertification (follow-up) reassessment|3
250|4 - Recurrent thoughts of death|4 - Recurrent thoughts of death|3
251|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruction)|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruc|3
252|4 - Several times a week|4 - Several times a week|3
253|4 - Stage 4|4 - Stage 4|3
254|4 - Symptoms poorly controlled, history of rehospitalizations|4 - Symptoms poorly controlled, history of rehospitalizations|3
255|4 - Three or more times per week|4 - Three or more times per week|3
256|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetative state, or delirium.|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetati|3
257|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|3
258|4 - Unable to effectively participate in any housekeeping tasks.|4 - Unable to effectively participate in any housekeeping tasks.|3
259|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or unresponsive (e.g., speech is nonsensical or unintelligible).|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or u|3
260|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonresponsive.|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonr|3
261|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostomy.|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostom|3
262|4 - UNABLE to use the shower or tub and is bathed in BED OR BEDSIDE CHAIR.|4 - UNABLE to use the shower or tub and is bathed in BED OR BEDSIDE CHAIR.|3
263|4 - With a friend|4 - With a friend|3
264|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|3
265|4-OT|4-OT|3
266|5 - Advocates or facilitates patient's participation in appropriate medical care|5 - Advocates or facilitates patient's participation in appropriate medical care|3
267|5 - At least daily|5 - At least daily|3
268|5 - Bedfast, unable to ambulate or be up in a chair.|5 - Bedfast, unable to ambulate or be up in a chair.|3
269|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|3
270|5 - Disruptive or socially inappropriate behavior|5 - Disruptive or socially inappropriate behavior|3
271|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|3
272|5 - Hypo/Hyperglycemia, diabetes out of control|5 - Hypo/Hyperglycemia, diabetes out of control|3
273|5 - More often than once daily|5 - More often than once daily|3
274|5 - Native Hawaiian or Pacific Islander|5 - Native Hawaiian or Pacific Islander|3
275|5 - None of the above|5 - None of the above|3
276|5 - One to two times per week|5 - One to two times per week|3
277|5 - Other|5 - Other|3
278|5 - Other follow-up|5 - Other follow-up|3
279|5 - Paid help|5 - Paid help|3
280|5 - Patient nonresponsive or unable to speak.|5 - Patient nonresponsive or unable to speak.|3
281|5 - Thoughts of suicide|5 - Thoughts of suicide|3
282|5 - Totally unable to use the telephone.|5 - Totally unable to use the telephone.|3
283|5 - Unable to effectively participate in bathing and is totally bathed by another person.|5 - Unable to effectively participate in bathing and is totally bathed by another person.|3
284|5 - Unable to take in nutrients orally or by tube feeding.|5 - Unable to take in nutrients orally or by tube feeding.|3
285|5 - Unsafe for care at home|5 - Unsafe for care at home|3
286|5 - With paid help (other than home care agency staff)|5 - With paid help (other than home care agency staff)|3
287|5 - Workers' compensation|5 - Workers' compensation|3
288|5 - Wound infection, deteriorating wound status, new lesion/ulcer|5 - Wound infection, deteriorating wound status, new lesion/ulcer|3
289|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|3
290|6 - Delusional, hallucinatory, or paranoid behavior|6 - Delusional, hallucinatory, or paranoid behavior|3
291|6 - Financial agent, power of attorney, or conservator of finance|6 - Financial agent, power of attorney, or conservator of finance|3
292|6 - GI bleeding, obstruction|6 - GI bleeding, obstruction|3
293|6 - Less often than weekly|6 - Less often than weekly|3
294|6 - Memory loss to the extent that supervision required|6 - Memory loss to the extent that supervision required|3
295|6 - None of the above feelings observed or reported|6 - None of the above feelings observed or reported|3
296|6 - Other|6 - Other|3
297|6 - Title programs (e.g., Title III, V, or XX)|6 - Title programs (e.g., Title III, V, or XX)|3
298|6 - Transferred to an inpatient facility - patient not discharged from agency|6 - Transferred to an inpatient facility - patient not discharged from agency|3
299|6 - White|6 - White|3
300|6 - With other than above|6 - With other than above|3
301|7 - Exacerbation of CHF, fluid overload, heart failure|7 - Exacerbation of CHF, fluid overload, heart failure|3
302|7 - Health care agent, conservator of person, or medical power of attorney|7 - Health care agent, conservator of person, or medical power of attorney|3
303|7 - Hypo/Hyperglycemia, diabetes out of control|7 - Hypo/Hyperglycemia, diabetes out of control|3
304|7 - None of the above|7 - None of the above|3
305|7 - None of the above behaviors demonstrated|7 - None of the above behaviors demonstrated|3
306|7 - Other government (e.g., CHAMPUS, VA, etc.)|7 - Other government (e.g., CHAMPUS, VA, etc.)|3
307|7 - Transferred to an inpatient facility - patient discharged from agency|7 - Transferred to an inpatient facility - patient discharged from agency|3
308|8 - Death at home|8 - Death at home|3
309|8 - GI bleeding, obstruction|8 - GI bleeding, obstruction|3
310|8 - Myocardial infarction, stroke|8 - Myocardial infarction, stroke|3
311|8 - Private insurance|8 - Private insurance|3
312|9 - Chemotherapy|9 - Chemotherapy|3
313|9 - Discharge from agency|9 - Discharge from agency|3
314|9 - Other than above reasons|9 - Other than above reasons|3
315|9 - Private HMO/managed care|9 - Private HMO/managed care|3
316|NA - No caregiver|NA - No caregiver|3
317|NA - No equipment of this type used in care.|NA - No equipment of this type used in care.|3
318|NA - No inhalant/mist medications prescribed.|NA - No inhalant/mist medications prescribed.|3
319|NA - No injectable medications prescribed.|NA - No injectable medications prescribed.|3
320|NA - No inpatient facility admission|NA - No inpatient facility admission|3
321|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|3
322|NA - No Medicaid|NA - No Medicaid|3
323|NA - No Medicare|NA - No Medicare|3
324|NA - No observable pressure ulcer|NA - No observable pressure ulcer|3
325|NA - No observable stasis ulcer|NA - No observable stasis ulcer|3
326|NA - No observable surgical wound|NA - No observable surgical wound|3
327|NA - No oral medications prescribed.|NA - No oral medications prescribed.|3
328|NA - Not applicable|NA - Not applicable|3
329|NA - Patient does not have a telephone.|NA - Patient does not have a telephone.|3
330|NA - Patient has ostomy for bowel elimination|NA - Patient has ostomy for bowel elimination|3
331|NA - Patient nonresponsive|NA - Patient nonresponsive|3
332|NA - Patient on prophylactic treatment|NA - Patient on prophylactic treatment|3
333|NA - Patient was not discharged from an inpatient facility|NA - Patient was not discharged from an inpatient facility|3
334|UK - Other unknown|UK - Other unknown|3
335|UK - Reason unknown|UK - Reason unknown|3
336|UK - Unknown|UK - Unknown|3
337|UK - Unknown or Not Available|UK - Unknown or Not Available|3
341|01 - Early|01 - Early|3
342|02 - Late|02 - Late|3
343|NA - Not Applicable. No case mix group defined for this assessment.|NA - Not Applicable. No case mix group defined for this assessment.|3
344|NA - No case mix group defined by this assessment.|NA - No case mix group defined by this assessment.|3
2|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; OR (b) Is physically, cognitively, and mentally able to prepare light meals on a regular basis but has not routinely performed light meal preparation in the past (i.e., prior to this home care admission).|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; O|4
3|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and mentally able to perform all housekeeping tasks .|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and menta|4
4|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and mentally able to do laundry and access facilities.|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and menta|4
5|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying packages OR b) Physically, cognitively, and mentally able to take care of shopping, but has not done shopping in the past (i.e., prior to this home care admission).|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying|4
6|0 - Able to bathe self in SHOWER OR TUB independently.|0 - Able to bathe self in SHOWER OR TUB independently.|4
7|0 - Able to dial numbers and answer calls appropriately and as desired.|0 - Able to dial numbers and answer calls appropriately and as desired.|4
8|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body without assistance.|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body|4
9|0 - Able to get to and from the toilet independently with or without a device.|0 - Able to get to and from the toilet independently with or without a device.|4
10|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|4
11|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible public bus.|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible p|4
12|0 - Able to independently feed self.|0 - Able to independently feed self.|4
13|0 - Able to independently take the correct medication and proper dosage at the correct times.|0 - Able to independently take the correct medication and proper dosage at the correct times.|4
14|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct times.|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct ti|4
15|0 - Able to independently transfer.|0 - Able to independently transfer.|4
16|0 - Able to independently walk on even and uneven surfaces and climb stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even and uneven surfaces and climb stairs with or without railings|4
17|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings|4
18|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|4
19|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions independently.|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions indep|4
20|0 - Asymptomatic, no treatment needed at this time|0 - Asymptomatic, no treatment needed at this time|4
21|0 - Caregiver manages all tasks related to equipment completely independently.|0 - Caregiver manages all tasks related to equipment completely independently.|4
22|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations with no observable impairment.|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations w|4
23|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|4
24|0 - Life expectancy is greater than 6 months|0 - Life expectancy is greater than 6 months|4
25|0 - Never|0 - Never|4
26|0 - Never, patient is not short of breath|0 - Never, patient is not short of breath|4
27|0 - No|0 - No|4
28|0 - No emergent care services|0 - No emergent care services|4
29|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage)|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage)|4
30|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and extended or abstract conversation.|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and exte|4
31|0 - No one person|0 - No one person|4
32|0 - None of the time|0 - None of the time|4
33|0 - None, no charge for current services|0 - None, no charge for current services|4
34|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|4
35|0 - Patient does NOT have an ostomy for bowel elimination.|0 - Patient does NOT have an ostomy for bowel elimination.|4
36|0 - Patient has no pain or pain does not interfere with activity or movement|0 - Patient has no pain or pain does not interfere with activity or movement|4
37|0 - Patient manages all tasks related to equipment completely independently.|0 - Patient manages all tasks related to equipment completely independently.|4
38|0 - Poor:  little or no recovery is expected and/or further decline is imminent|0 - Poor:  little or no recovery is expected and/or further decline is imminent|4
39|0 - Timed-voiding defers incontinence|0 - Timed-voiding defers incontinence|4
40|0 - Very rarely or never has bowel incontinence|0 - Very rarely or never has bowel incontinence|4
41|0 - Zero|0 - Zero|4
42|00 - No|00 - No|4
43|01 - Yes|01 - Yes|4
44|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or mental limitations, needs assistance with heavy laundry.|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or|4
45|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the patient.|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the|4
46|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|4
47|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or supervision from another person OR c) a liquid, pureed or ground meat diet.|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or su|4
48|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|4
49|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|4
50|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independently.|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independe|4
51|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only when assisted or accompanied by another person.|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only w|4
52|1 - Able to take injectable medication at correct times if: a) individual syringes are prepared in advance by another person OR b) given daily reminders.|1 - Able to take injectable medication at correct times if: a) individual syringes are prepared in a|4
53|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance by another person OR b) given daily reminders.|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance b|4
54|1 - Able to take medication(s) at the correct times if: a) individual dosages are prepared in advance by another person , OR b) given daily reminders OR c) someone develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if: a) individual dosages are prepared in advanc|4
55|1 - Able to take medication(s) at the correct times if: a) individual dosages are prepared in advance by another person, OR b) given daily reminders OR c) someone develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if: a) individual dosages are prepared in advanc|4
56|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for the deaf) and call essential numbers.|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for t|4
57|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|4
58|1 - American Indian or Alaska Native|1 - American Indian or Alaska Native|4
59|1 - Depressed mood (e.g., feeling sad, tearful)|1 - Depressed mood (e.g., feeling sad, tearful)|4
60|1 - During the night only|1 - During the night only|4
61|1 - Fully granulating|1 - Fully granulating|4
62|1 - Good/Fair:  partial to full recovery is expected|1 - Good/Fair:  partial to full recovery is expected|4
63|1 - Good:  marked improvement in functional status is expected|1 - Good:  marked improvement in functional status is expected|4
64|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|4
65|1 - Heavy smoking|1 - Heavy smoking|4
66|1 - Hospital|1 - Hospital|4
67|1 - Hospital emergency room (includes 23-hour holding)|1 - Hospital emergency room (includes 23-hour holding)|4
68|1 - Hospitalization for EMERGENT (unscheduled) care|1 - Hospitalization for EMERGENT (unscheduled) care|4
69|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepared solutions), patient is able to manage all other aspects of equipment.|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepar|4
70|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|4
71|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|4
72|1 - In new or complex situations only|1 - In new or complex situations only|4
73|1 - Intravenous or infusion therapy (excludes TPN)|1 - Intravenous or infusion therapy (excludes TPN)|4
74|1 - Less often than daily|1 - Less often than daily|4
75|1 - Less than once a month|1 - Less than once a month|4
76|1 - Less than once weekly|1 - Less than once weekly|4
77|1 - Life expectancy is 6 months or fewer|1 - Life expectancy is 6 months or fewer|4
78|1 - Lives alone|1 - Lives alone|4
79|1 - Male|1 - Male|4
80|1 - Medicare (traditional fee-for-service)|1 - Medicare (traditional fee-for-service)|4
81|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of past 24 hours, significant memory loss so that supervision is required|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of pas|4
82|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors in word choice, grammar or speech intelligibility, needs minimal prompting or assistance).|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors i|4
83|1 - No assistance or services received|1 - No assistance or services received|4
84|1 - One|1 - One|4
85|1 - Oxygen (intermittent or continuous)|1 - Oxygen (intermittent or continuous)|4
86|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, and the surrounding layout, can count fingers at arm's length.|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, a|4
87|1 - Patient is incontinent|1 - Patient is incontinent|4
88|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|4
89|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical or treatment regimen.|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical|4
90|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient/couple/significant other)|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient|4
91|1 - Relatives, friends, or neighbors living outside the home|1 - Relatives, friends, or neighbors living outside the home|4
92|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions.|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions|4
93|1 - Requires use of a device (e.g., cane, walker) to walk alone OR requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|1 - Requires use of a device (e.g., cane, walker) to walk alone OR requires human supervision or ass|4
94|1 - Several times during day and night|1 - Several times during day and night|4
95|1 - Spouse or significant other|1 - Spouse or significant other|4
96|1 - Stage 1|1 - Stage 1|4
97|1 - Start of care - further visits planned|1 - Start of care - further visits planned|4
98|1 - Symptoms well controlled with current therapy|1 - Symptoms well controlled with current therapy|4
99|1 - Therapy services|1 - Therapy services|4
100|1 - Transfers with minimal human assistance or with use of an assistive device.|1 - Transfers with minimal human assistance or with use of an assistive device.|4
101|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitations.|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitatio|4
102|1 - Urinary incontinence|1 - Urinary incontinence|4
103|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet.|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet.|4
104|1 - When walking more than 20 feet, climbing stairs|1 - When walking more than 20 feet, climbing stairs|4
105|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary conversation. May need occasional repetition, extra time, or louder voice.|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary c|4
106|1 - With the use of devices, is able to bathe self in shower or tub independently.|1 - With the use of devices, is able to bathe self in shower or tub independently.|4
107|1 - Yes|1 - Yes|4
108|1-RN|1-RN|4
109|10 - Discharge from agency - no visits completed after start/resumption of care assessment|10 - Discharge from agency - no visits completed after start/resumption of care assessment|4
110|10 - Scheduled surgical procedure|10 - Scheduled surgical procedure|4
111|10 - Self-pay|10 - Self-pay|4
112|11 - Other|11 - Other|4
113|11 - Urinary tract infection|11 - Urinary tract infection|4
114|12 - IV catheter-related infection|12 - IV catheter-related infection|4
115|13 - Deep vein thrombosis, pulmonary embolus|13 - Deep vein thrombosis, pulmonary embolus|4
116|14 - Uncontrolled pain|14 - Uncontrolled pain|4
117|15 - Psychotic episode|15 - Psychotic episode|4
118|16 - Other than above reasons|16 - Other than above reasons|4
119|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing calls.|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing|4
120|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another person.|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another pers|4
121|2 - Able to walk only with the supervision or assistance of another person at all times.|2 - Able to walk only with the supervision or assistance of another person at all times.|4
122|2 - Aid: a) for intermittent supervision/encouragement/reminders, OR b) to get in and out of the shower/tub, OR c) for washing difficult to reach areas.|2 - Aid: a) for intermittent supervision/encouragement/reminders, OR b) to get in and out of the sho|4
123|2 - Asian|2 - Asian|4
124|2 - Caregiver requires considerable assistance from another person to manage equipment, but independently completes significant portions of task.|2 - Caregiver requires considerable assistance from another person to manage equipment, but independ|4
125|2 - Daily, but not constantly|2 - Daily, but not constantly|4
126|2 - Daughter or son|2 - Daughter or son|4
127|2 - Doctor's office emergency visit/house call|2 - Doctor's office emergency visit/house call|4
128|2 - During the day and night|2 - During the day and night|4
129|2 - Early/partial granulation|2 - Early/partial granulation|4
130|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors in word choice, organization or speech intelligibility). Speaks in phrases or short sentences.|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors|4
131|2 - Family member's residence|2 - Family member's residence|4
132|2 - Female|2 - Female|4
133|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conversation, needs frequent prompting or assistance.|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conver|4
134|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|4
135|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|4
136|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately stop activities, jeopardizes safety through actions|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately st|4
137|2 - Indwelling/suprapubic catheter|2 - Indwelling/suprapubic catheter|4
138|2 - Injury caused by fall or accident at home|2 - Injury caused by fall or accident at home|4
139|2 - Medicare (HMO/managed care)|2 - Medicare (HMO/managed care)|4
140|2 - Nausea, dehydration, malnutrition, constipation, impaction|2 - Nausea, dehydration, malnutrition, constipation, impaction|4
141|2 - Obesity|2 - Obesity|4
142|2 - On awakening or at night only|2 - On awakening or at night only|4
143|2 - Once a month|2 - Once a month|4
144|2 - One to three times weekly|2 - One to three times weekly|4
145|2 - Parenteral nutrition (TPN or lipids)|2 - Parenteral nutrition (TPN or lipids)|4
146|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic)|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic)|4
147|2 - Patient requires considerable assistance from another person to manage equipment, but independently completes portions of the task.|2 - Patient requires considerable assistance from another person to manage equipment, but independen|4
148|2 - Patient transferred to a noninstitutional hospice|2 - Patient transferred to a noninstitutional hospice|4
149|2 - Person residing in the home (EXCLUDING paid help)|2 - Person residing in the home (EXCLUDING paid help)|4
150|2 - Rehabilitation facility|2 - Rehabilitation facility|4
151|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifting of attention) or consistently requires low stimulus environment due to distractibility.|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifti|4
152|2 - Respite care|2 - Respite care|4
153|2 - Sense of failure or self reproach|2 - Sense of failure or self reproach|4
154|2 - Several times during day|2 - Several times during day|4
155|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonresponsive.|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonrespons|4
156|2 - Someone must assist the patient to groom self.|2 - Someone must assist the patient to groom self.|4
157|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|4
158|2 - Someone must help the patient put on upper body clothing.|2 - Someone must help the patient put on upper body clothing.|4
159|2 - Stage 2|2 - Stage 2|4
160|2 - Start of care - no further visits planned|2 - Start of care - no further visits planned|4
161|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitoring|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitori|4
162|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment regimen.|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment re|4
163|2 - Two|2 - Two|4
164|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistance due to cognitive or mental limitation.|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistanc|4
165|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|4
166|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assistance).|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assis|4
167|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home delivery.|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home deli|4
168|2 - Unable to prepare any light meals or reheat any delivered meals.|2 - Unable to prepare any light meals or reheat any delivered meals.|4
169|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|4
170|2 - UNABLE to take injectable medications unless administered by someone else.|2 - UNABLE to take injectable medications unless administered by someone else.|4
171|2 - UNABLE to take medication unless administered by someone else.|2 - UNABLE to take medication unless administered by someone else.|4
172|2 - UNABLE to transfer self but is able to bear weight and pivot during the transfer process.|2 - UNABLE to transfer self but is able to bear weight and pivot during the transfer process.|4
173|2 - Ventilator (continually or at night)|2 - Ventilator (continually or at night)|4
174|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less than 20 feet)|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less th|4
175|2 - With spouse or significant other|2 - With spouse or significant other|4
176|2 - Yes, assistance or services provided by family or friends|2 - Yes, assistance or services provided by family or friends|4
177|2-PT|2-PT|4
178|3 - Able to answer the telephone only some of the time or is able to carry on only a limited conversation.|3 - Able to answer the telephone only some of the time or is able to carry on only a limited convers|4
179|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube or gastrostomy.|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube|4
180|3 - Alcohol dependency|3 - Alcohol dependency|4
181|3 - All of the time|3 - All of the time|4
182|3 - Black or African-American|3 - Black or African-American|4
183|3 - Boarding home or rented room|3 - Boarding home or rented room|4
184|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment, clean/store/dispose of equipment or supplies).|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment,|4
185|3 - Chairfast, UNABLE to ambulate but is able to wheel self independently.|3 - Chairfast, UNABLE to ambulate but is able to wheel self independently.|4
186|3 - Continuous positive airway pressure|3 - Continuous positive airway pressure|4
187|3 - During the day and evening, but not constantly|3 - During the day and evening, but not constantly|4
188|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the alimentary canal)|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the|4
189|3 - Environmental support (e.g., housing, home maintenance)|3 - Environmental support (e.g., housing, home maintenance)|4
190|3 - Four to six times weekly|3 - Four to six times weekly|4
191|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessing by listener.  Speech limited to single words or short phrases.|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessin|4
192|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires multiple repetitions, restatements, demonstrations, additional time.|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires m|4
193|3 - Hopelessness|3 - Hopelessness|4
194|3 - Hospice care|3 - Hospice care|4
195|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|4
196|3 - Injury caused by fall or accident at home|3 - Injury caused by fall or accident at home|4
197|3 - Intractable pain|3 - Intractable pain|4
198|3 - Medicaid (traditional fee-for-service)|3 - Medicaid (traditional fee-for-service)|4
199|3 - Needs someone to do all shopping and errands.|3 - Needs someone to do all shopping and errands.|4
200|3 - Not healing|3 - Not healing|4
201|3 - Nursing home|3 - Nursing home|4
202|3 - Once daily|3 - Once daily|4
203|3 - Other family member|3 - Other family member|4
204|3 - Outpatient department/clinic emergency (includes urgicenter sites)|3 - Outpatient department/clinic emergency (includes urgicenter sites)|4
205|3 - Paid help|3 - Paid help|4
206|3 - Participates in bathing self in shower or tub, BUT requires presence of another person throughout the bath for assistance or supervision.|3 - Participates in bathing self in shower or tub, BUT requires presence of another person throughou|4
207|3 - Patient depends entirely upon another person to dress lower body.|3 - Patient depends entirely upon another person to dress lower body.|4
208|3 - Patient depends entirely upon another person to dress the upper body.|3 - Patient depends entirely upon another person to dress the upper body.|4
209|3 - Patient depends entirely upon someone else for grooming needs.|3 - Patient depends entirely upon someone else for grooming needs.|4
210|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone else to manage the equipment.|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone|4
211|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable to shift attention and recall directions more than half the time.|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable|4
212|3 - Respiratory problems (SOB, infection, obstruction)|3 - Respiratory problems (SOB, infection, obstruction)|4
213|3 - Resumption of care (after inpatient stay)|3 - Resumption of care (after inpatient stay)|4
214|3 - Several times each month|3 - Several times each month|4
215|3 - Skilled Nursing Facility|3 - Skilled Nursing Facility|4
216|3 - Stage 3|3 - Stage 3|4
217|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|4
218|3 - Three|3 - Three|4
219|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person throughout the process.|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person through|4
220|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal independently.|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal indep|4
221|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person.|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person|4
222|3 - Unknown because patient moved to a geographic location not served by this agency|3 - Unknown because patient moved to a geographic location not served by this agency|4
223|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|4
224|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|4
225|3 - With other family member|3 - With other family member|4
226|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home health services, homemaker assistance, transportation assistance, assisted living, board and care)|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home h|4
227|3-SLP/ST|3-SLP/ST|4
228|4 - At rest (during day or night)|4 - At rest (during day or night)|4
229|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|4
230|4 - Board and care or assisted living facility|4 - Board and care or assisted living facility|4
231|4 - Caregiver is completely dependent on someone else to manage all equipment.|4 - Caregiver is completely dependent on someone else to manage all equipment.|4
232|4 - Chairfast, unable to ambulate and is UNABLE to wheel self.|4 - Chairfast, unable to ambulate and is UNABLE to wheel self.|4
233|4 - Constantly|4 - Constantly|4
234|4 - Drug dependency|4 - Drug dependency|4
235|4 - Four or more|4 - Four or more|4
236|4 - Friend or neighbor or community or church member|4 - Friend or neighbor or community or church member|4
237|4 - Hispanic or Latino|4 - Hispanic or Latino|4
238|4 - Hospice|4 - Hospice|4
239|4 - Impaired decision-making|4 - Impaired decision-making|4
240|4 - Is totally dependent in toileting.|4 - Is totally dependent in toileting.|4
241|4 - Medicaid (HMO/managed care)|4 - Medicaid (HMO/managed care)|4
242|4 - None of the above|4 - None of the above|4
243|4 - Nursing home|4 - Nursing home|4
244|4 - On a daily basis|4 - On a daily basis|4
245|4 - Patient is completely dependent on someone else to manage all equipment.|4 - Patient is completely dependent on someone else to manage all equipment.|4
246|4 - Permanent placement|4 - Permanent placement|4
247|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, punches, dangerous maneuvers w/ wheelchair or other objects)|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, pu|4
248|4 - Psychosocial support (e.g., socialization, companionship, recreation)|4 - Psychosocial support (e.g., socialization, companionship, recreation)|4
249|4 - Recertification (follow-up) reassessment|4 - Recertification (follow-up) reassessment|4
250|4 - Recurrent thoughts of death|4 - Recurrent thoughts of death|4
251|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruction)|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruc|4
252|4 - Several times a week|4 - Several times a week|4
253|4 - Stage 4|4 - Stage 4|4
254|4 - Symptoms poorly controlled, history of rehospitalizations|4 - Symptoms poorly controlled, history of rehospitalizations|4
255|4 - Three or more times per week|4 - Three or more times per week|4
256|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetative state, or delirium.|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetati|4
257|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|4
258|4 - Unable to effectively participate in any housekeeping tasks.|4 - Unable to effectively participate in any housekeeping tasks.|4
259|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or unresponsive (e.g., speech is nonsensical or unintelligible).|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or u|4
260|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonresponsive.|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonr|4
261|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostomy.|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostom|4
262|4 - UNABLE to use the shower or tub and is bathed in BED OR BEDSIDE CHAIR.|4 - UNABLE to use the shower or tub and is bathed in BED OR BEDSIDE CHAIR.|4
263|4 - With a friend|4 - With a friend|4
264|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|4
265|4-OT|4-OT|4
266|5 - Advocates or facilitates patient's participation in appropriate medical care|5 - Advocates or facilitates patient's participation in appropriate medical care|4
267|5 - At least daily|5 - At least daily|4
268|5 - Bedfast, unable to ambulate or be up in a chair.|5 - Bedfast, unable to ambulate or be up in a chair.|4
269|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|4
270|5 - Disruptive or socially inappropriate behavior|5 - Disruptive or socially inappropriate behavior|4
271|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|4
272|5 - Hypo/Hyperglycemia, diabetes out of control|5 - Hypo/Hyperglycemia, diabetes out of control|4
273|5 - More often than once daily|5 - More often than once daily|4
274|5 - Native Hawaiian or Pacific Islander|5 - Native Hawaiian or Pacific Islander|4
275|5 - None of the above|5 - None of the above|4
276|5 - One to two times per week|5 - One to two times per week|4
277|5 - Other|5 - Other|4
278|5 - Other follow-up|5 - Other follow-up|4
279|5 - Paid help|5 - Paid help|4
280|5 - Patient nonresponsive or unable to speak.|5 - Patient nonresponsive or unable to speak.|4
281|5 - Thoughts of suicide|5 - Thoughts of suicide|4
282|5 - Totally unable to use the telephone.|5 - Totally unable to use the telephone.|4
283|5 - Unable to effectively participate in bathing and is totally bathed by another person.|5 - Unable to effectively participate in bathing and is totally bathed by another person.|4
284|5 - Unable to take in nutrients orally or by tube feeding.|5 - Unable to take in nutrients orally or by tube feeding.|4
285|5 - Unsafe for care at home|5 - Unsafe for care at home|4
286|5 - With paid help (other than home care agency staff)|5 - With paid help (other than home care agency staff)|4
287|5 - Workers' compensation|5 - Workers' compensation|4
288|5 - Wound infection, deteriorating wound status, new lesion/ulcer|5 - Wound infection, deteriorating wound status, new lesion/ulcer|4
289|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|4
290|6 - Delusional, hallucinatory, or paranoid behavior|6 - Delusional, hallucinatory, or paranoid behavior|4
291|6 - Financial agent, power of attorney, or conservator of finance|6 - Financial agent, power of attorney, or conservator of finance|4
292|6 - GI bleeding, obstruction|6 - GI bleeding, obstruction|4
293|6 - Less often than weekly|6 - Less often than weekly|4
294|6 - Memory loss to the extent that supervision required|6 - Memory loss to the extent that supervision required|4
295|6 - None of the above feelings observed or reported|6 - None of the above feelings observed or reported|4
296|6 - Other|6 - Other|4
297|6 - Title programs (e.g., Title III, V, or XX)|6 - Title programs (e.g., Title III, V, or XX)|4
298|6 - Transferred to an inpatient facility - patient not discharged from agency|6 - Transferred to an inpatient facility - patient not discharged from agency|4
299|6 - White|6 - White|4
300|6 - With other than above|6 - With other than above|4
301|7 - Exacerbation of CHF, fluid overload, heart failure|7 - Exacerbation of CHF, fluid overload, heart failure|4
302|7 - Health care agent, conservator of person, or medical power of attorney|7 - Health care agent, conservator of person, or medical power of attorney|4
303|7 - Hypo/Hyperglycemia, diabetes out of control|7 - Hypo/Hyperglycemia, diabetes out of control|4
304|7 - None of the above|7 - None of the above|4
305|7 - None of the above behaviors demonstrated|7 - None of the above behaviors demonstrated|4
306|7 - Other government (e.g., CHAMPUS, VA, etc.)|7 - Other government (e.g., CHAMPUS, VA, etc.)|4
307|7 - Transferred to an inpatient facility - patient discharged from agency|7 - Transferred to an inpatient facility - patient discharged from agency|4
308|8 - Death at home|8 - Death at home|4
309|8 - GI bleeding, obstruction|8 - GI bleeding, obstruction|4
310|8 - Myocardial infarction, stroke|8 - Myocardial infarction, stroke|4
311|8 - Private insurance|8 - Private insurance|4
312|9 - Chemotherapy|9 - Chemotherapy|4
313|9 - Discharge from agency|9 - Discharge from agency|4
314|9 - Other than above reasons|9 - Other than above reasons|4
315|9 - Private HMO/managed care|9 - Private HMO/managed care|4
316|NA - No caregiver|NA - No caregiver|4
317|NA - No equipment of this type used in care.|NA - No equipment of this type used in care.|4
318|NA - No inhalant/mist medications prescribed.|NA - No inhalant/mist medications prescribed.|4
319|NA - No injectable medications prescribed.|NA - No injectable medications prescribed.|4
320|NA - No inpatient facility admission|NA - No inpatient facility admission|4
321|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|4
322|NA - No Medicaid|NA - No Medicaid|4
323|NA - No Medicare|NA - No Medicare|4
324|NA - No observable pressure ulcer|NA - No observable pressure ulcer|4
325|NA - No observable stasis ulcer|NA - No observable stasis ulcer|4
326|NA - No observable surgical wound|NA - No observable surgical wound|4
327|NA - No oral medications prescribed.|NA - No oral medications prescribed.|4
328|NA - Not applicable|NA - Not applicable|4
329|NA - Patient does not have a telephone.|NA - Patient does not have a telephone.|4
330|NA - Patient has ostomy for bowel elimination|NA - Patient has ostomy for bowel elimination|4
331|NA - Patient nonresponsive|NA - Patient nonresponsive|4
332|NA - Patient on prophylactic treatment|NA - Patient on prophylactic treatment|4
333|NA - Patient was not discharged from an inpatient facility|NA - Patient was not discharged from an inpatient facility|4
334|UK - Other unknown|UK - Other unknown|4
335|UK - Reason unknown|UK - Reason unknown|4
336|UK - Unknown|UK - Unknown|4
337|UK - Unknown or Not Available|UK - Unknown or Not Available|4
341|01 - Early|01 - Early|4
342|02 - Late|02 - Late|4
343|NA - Not Applicable. No case mix group defined for this assessment.|NA - Not Applicable. No case mix group defined for this assessment.|4
344|NA - No case mix group defined by this assessment.|NA - No case mix group defined by this assessment.|4
2|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; OR (b) Is physically, cognitively, and mentally able to prepare light meals on a regular basis but has not routinely performed light meal preparation in the past (i.e., prior to this home care admission).|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; O|5
3|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and mentally able to perform all housekeeping tasks .|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and menta|5
4|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and mentally able to do laundry and access facilities.|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and menta|5
5|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying packages OR b) Physically, cognitively, and mentally able to take care of shopping, but has not done shopping in the past (i.e., prior to this home care admission).|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying|5
6|0 - Able to bathe self in SHOWER OR TUB independently.|0 - Able to bathe self in SHOWER OR TUB independently.|5
7|0 - Able to dial numbers and answer calls appropriately and as desired.|0 - Able to dial numbers and answer calls appropriately and as desired.|5
8|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body without assistance.|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body|5
9|0 - Able to get to and from the toilet independently with or without a device.|0 - Able to get to and from the toilet independently with or without a device.|5
10|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|5
11|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible public bus.|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible p|5
12|0 - Able to independently feed self.|0 - Able to independently feed self.|5
13|0 - Able to independently take the correct medication and proper dosage at the correct times.|0 - Able to independently take the correct medication and proper dosage at the correct times.|5
14|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct times.|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct ti|5
15|0 - Able to independently transfer.|0 - Able to independently transfer.|5
16|0 - Able to independently walk on even and uneven surfaces and climb stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even and uneven surfaces and climb stairs with or without railings|5
17|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings|5
18|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|5
19|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions independently.|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions indep|5
20|0 - Asymptomatic, no treatment needed at this time|0 - Asymptomatic, no treatment needed at this time|5
21|0 - Caregiver manages all tasks related to equipment completely independently.|0 - Caregiver manages all tasks related to equipment completely independently.|5
22|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations with no observable impairment.|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations w|5
23|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|5
24|0 - Life expectancy is greater than 6 months|0 - Life expectancy is greater than 6 months|5
25|0 - Never|0 - Never|5
26|0 - Never, patient is not short of breath|0 - Never, patient is not short of breath|5
27|0 - No|0 - No|5
28|0 - No emergent care services|0 - No emergent care services|5
29|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage)|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage)|5
30|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and extended or abstract conversation.|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and exte|5
31|0 - No one person|0 - No one person|5
32|0 - None of the time|0 - None of the time|5
33|0 - None, no charge for current services|0 - None, no charge for current services|5
34|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|5
35|0 - Patient does NOT have an ostomy for bowel elimination.|0 - Patient does NOT have an ostomy for bowel elimination.|5
36|0 - Patient has no pain or pain does not interfere with activity or movement|0 - Patient has no pain or pain does not interfere with activity or movement|5
37|0 - Patient manages all tasks related to equipment completely independently.|0 - Patient manages all tasks related to equipment completely independently.|5
38|0 - Poor:  little or no recovery is expected and/or further decline is imminent|0 - Poor:  little or no recovery is expected and/or further decline is imminent|5
39|0 - Timed-voiding defers incontinence|0 - Timed-voiding defers incontinence|5
40|0 - Very rarely or never has bowel incontinence|0 - Very rarely or never has bowel incontinence|5
41|0 - Zero|0 - Zero|5
42|00 - No|00 - No|5
43|01 - Yes|01 - Yes|5
44|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or mental limitations, needs assistance with heavy laundry.|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or|5
45|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the patient.|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the|5
46|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|5
47|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or supervision from another person OR c) a liquid, pureed or ground meat diet.|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or su|5
48|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|5
49|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|5
50|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independently.|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independe|5
51|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only when assisted or accompanied by another person.|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only w|5
52|1 - Able to take injectable medication at correct times if: a) individual syringes are prepared in advance by another person OR b) given daily reminders.|1 - Able to take injectable medication at correct times if: a) individual syringes are prepared in a|5
53|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance by another person OR b) given daily reminders.|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance b|5
54|1 - Able to take medication(s) at the correct times if: a) individual dosages are prepared in advance by another person , OR b) given daily reminders OR c) someone develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if: a) individual dosages are prepared in advanc|5
55|1 - Able to take medication(s) at the correct times if: a) individual dosages are prepared in advance by another person, OR b) given daily reminders OR c) someone develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if: a) individual dosages are prepared in advanc|5
56|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for the deaf) and call essential numbers.|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for t|5
57|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|5
58|1 - American Indian or Alaska Native|1 - American Indian or Alaska Native|5
59|1 - Depressed mood (e.g., feeling sad, tearful)|1 - Depressed mood (e.g., feeling sad, tearful)|5
60|1 - During the night only|1 - During the night only|5
61|1 - Fully granulating|1 - Fully granulating|5
62|1 - Good/Fair:  partial to full recovery is expected|1 - Good/Fair:  partial to full recovery is expected|5
63|1 - Good:  marked improvement in functional status is expected|1 - Good:  marked improvement in functional status is expected|5
64|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|5
65|1 - Heavy smoking|1 - Heavy smoking|5
66|1 - Hospital|1 - Hospital|5
67|1 - Hospital emergency room (includes 23-hour holding)|1 - Hospital emergency room (includes 23-hour holding)|5
68|1 - Hospitalization for EMERGENT (unscheduled) care|1 - Hospitalization for EMERGENT (unscheduled) care|5
69|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepared solutions), patient is able to manage all other aspects of equipment.|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepar|5
70|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|5
71|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|5
72|1 - In new or complex situations only|1 - In new or complex situations only|5
73|1 - Intravenous or infusion therapy (excludes TPN)|1 - Intravenous or infusion therapy (excludes TPN)|5
74|1 - Less often than daily|1 - Less often than daily|5
75|1 - Less than once a month|1 - Less than once a month|5
76|1 - Less than once weekly|1 - Less than once weekly|5
77|1 - Life expectancy is 6 months or fewer|1 - Life expectancy is 6 months or fewer|5
78|1 - Lives alone|1 - Lives alone|5
79|1 - Male|1 - Male|5
80|1 - Medicare (traditional fee-for-service)|1 - Medicare (traditional fee-for-service)|5
81|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of past 24 hours, significant memory loss so that supervision is required|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of pas|5
82|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors in word choice, grammar or speech intelligibility, needs minimal prompting or assistance).|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors i|5
83|1 - No assistance or services received|1 - No assistance or services received|5
84|1 - One|1 - One|5
85|1 - Oxygen (intermittent or continuous)|1 - Oxygen (intermittent or continuous)|5
86|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, and the surrounding layout, can count fingers at arm's length.|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, a|5
87|1 - Patient is incontinent|1 - Patient is incontinent|5
88|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|5
89|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical or treatment regimen.|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical|5
90|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient/couple/significant other)|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient|5
91|1 - Relatives, friends, or neighbors living outside the home|1 - Relatives, friends, or neighbors living outside the home|5
92|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions.|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions|5
93|1 - Requires use of a device (e.g., cane, walker) to walk alone OR requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|1 - Requires use of a device (e.g., cane, walker) to walk alone OR requires human supervision or ass|5
94|1 - Several times during day and night|1 - Several times during day and night|5
95|1 - Spouse or significant other|1 - Spouse or significant other|5
96|1 - Stage 1|1 - Stage 1|5
97|1 - Start of care - further visits planned|1 - Start of care - further visits planned|5
98|1 - Symptoms well controlled with current therapy|1 - Symptoms well controlled with current therapy|5
99|1 - Therapy services|1 - Therapy services|5
100|1 - Transfers with minimal human assistance or with use of an assistive device.|1 - Transfers with minimal human assistance or with use of an assistive device.|5
101|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitations.|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitatio|5
102|1 - Urinary incontinence|1 - Urinary incontinence|5
103|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet.|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet.|5
104|1 - When walking more than 20 feet, climbing stairs|1 - When walking more than 20 feet, climbing stairs|5
105|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary conversation. May need occasional repetition, extra time, or louder voice.|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary c|5
106|1 - With the use of devices, is able to bathe self in shower or tub independently.|1 - With the use of devices, is able to bathe self in shower or tub independently.|5
107|1 - Yes|1 - Yes|5
108|1-RN|1-RN|5
109|10 - Discharge from agency - no visits completed after start/resumption of care assessment|10 - Discharge from agency - no visits completed after start/resumption of care assessment|5
110|10 - Scheduled surgical procedure|10 - Scheduled surgical procedure|5
111|10 - Self-pay|10 - Self-pay|5
112|11 - Other|11 - Other|5
113|11 - Urinary tract infection|11 - Urinary tract infection|5
114|12 - IV catheter-related infection|12 - IV catheter-related infection|5
115|13 - Deep vein thrombosis, pulmonary embolus|13 - Deep vein thrombosis, pulmonary embolus|5
116|14 - Uncontrolled pain|14 - Uncontrolled pain|5
117|15 - Psychotic episode|15 - Psychotic episode|5
118|16 - Other than above reasons|16 - Other than above reasons|5
119|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing calls.|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing|5
120|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another person.|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another pers|5
121|2 - Able to walk only with the supervision or assistance of another person at all times.|2 - Able to walk only with the supervision or assistance of another person at all times.|5
122|2 - Aid: a) for intermittent supervision/encouragement/reminders, OR b) to get in and out of the shower/tub, OR c) for washing difficult to reach areas.|2 - Aid: a) for intermittent supervision/encouragement/reminders, OR b) to get in and out of the sho|5
123|2 - Asian|2 - Asian|5
124|2 - Caregiver requires considerable assistance from another person to manage equipment, but independently completes significant portions of task.|2 - Caregiver requires considerable assistance from another person to manage equipment, but independ|5
125|2 - Daily, but not constantly|2 - Daily, but not constantly|5
126|2 - Daughter or son|2 - Daughter or son|5
127|2 - Doctor's office emergency visit/house call|2 - Doctor's office emergency visit/house call|5
128|2 - During the day and night|2 - During the day and night|5
129|2 - Early/partial granulation|2 - Early/partial granulation|5
130|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors in word choice, organization or speech intelligibility). Speaks in phrases or short sentences.|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors|5
131|2 - Family member's residence|2 - Family member's residence|5
132|2 - Female|2 - Female|5
133|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conversation, needs frequent prompting or assistance.|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conver|5
134|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|5
135|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|5
136|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately stop activities, jeopardizes safety through actions|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately st|5
137|2 - Indwelling/suprapubic catheter|2 - Indwelling/suprapubic catheter|5
138|2 - Injury caused by fall or accident at home|2 - Injury caused by fall or accident at home|5
139|2 - Medicare (HMO/managed care)|2 - Medicare (HMO/managed care)|5
140|2 - Nausea, dehydration, malnutrition, constipation, impaction|2 - Nausea, dehydration, malnutrition, constipation, impaction|5
141|2 - Obesity|2 - Obesity|5
142|2 - On awakening or at night only|2 - On awakening or at night only|5
143|2 - Once a month|2 - Once a month|5
144|2 - One to three times weekly|2 - One to three times weekly|5
145|2 - Parenteral nutrition (TPN or lipids)|2 - Parenteral nutrition (TPN or lipids)|5
146|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic)|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic)|5
147|2 - Patient requires considerable assistance from another person to manage equipment, but independently completes portions of the task.|2 - Patient requires considerable assistance from another person to manage equipment, but independen|5
148|2 - Patient transferred to a noninstitutional hospice|2 - Patient transferred to a noninstitutional hospice|5
149|2 - Person residing in the home (EXCLUDING paid help)|2 - Person residing in the home (EXCLUDING paid help)|5
150|2 - Rehabilitation facility|2 - Rehabilitation facility|5
151|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifting of attention) or consistently requires low stimulus environment due to distractibility.|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifti|5
152|2 - Respite care|2 - Respite care|5
153|2 - Sense of failure or self reproach|2 - Sense of failure or self reproach|5
154|2 - Several times during day|2 - Several times during day|5
155|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonresponsive.|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonrespons|5
156|2 - Someone must assist the patient to groom self.|2 - Someone must assist the patient to groom self.|5
157|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|5
158|2 - Someone must help the patient put on upper body clothing.|2 - Someone must help the patient put on upper body clothing.|5
159|2 - Stage 2|2 - Stage 2|5
160|2 - Start of care - no further visits planned|2 - Start of care - no further visits planned|5
161|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitoring|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitori|5
162|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment regimen.|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment re|5
163|2 - Two|2 - Two|5
164|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistance due to cognitive or mental limitation.|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistanc|5
165|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|5
166|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assistance).|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assis|5
167|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home delivery.|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home deli|5
168|2 - Unable to prepare any light meals or reheat any delivered meals.|2 - Unable to prepare any light meals or reheat any delivered meals.|5
169|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|5
170|2 - UNABLE to take injectable medications unless administered by someone else.|2 - UNABLE to take injectable medications unless administered by someone else.|5
171|2 - UNABLE to take medication unless administered by someone else.|2 - UNABLE to take medication unless administered by someone else.|5
172|2 - UNABLE to transfer self but is able to bear weight and pivot during the transfer process.|2 - UNABLE to transfer self but is able to bear weight and pivot during the transfer process.|5
173|2 - Ventilator (continually or at night)|2 - Ventilator (continually or at night)|5
174|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less than 20 feet)|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less th|5
175|2 - With spouse or significant other|2 - With spouse or significant other|5
176|2 - Yes, assistance or services provided by family or friends|2 - Yes, assistance or services provided by family or friends|5
177|2-PT|2-PT|5
178|3 - Able to answer the telephone only some of the time or is able to carry on only a limited conversation.|3 - Able to answer the telephone only some of the time or is able to carry on only a limited convers|5
179|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube or gastrostomy.|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube|5
180|3 - Alcohol dependency|3 - Alcohol dependency|5
181|3 - All of the time|3 - All of the time|5
182|3 - Black or African-American|3 - Black or African-American|5
183|3 - Boarding home or rented room|3 - Boarding home or rented room|5
184|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment, clean/store/dispose of equipment or supplies).|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment,|5
185|3 - Chairfast, UNABLE to ambulate but is able to wheel self independently.|3 - Chairfast, UNABLE to ambulate but is able to wheel self independently.|5
186|3 - Continuous positive airway pressure|3 - Continuous positive airway pressure|5
187|3 - During the day and evening, but not constantly|3 - During the day and evening, but not constantly|5
188|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the alimentary canal)|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the|5
189|3 - Environmental support (e.g., housing, home maintenance)|3 - Environmental support (e.g., housing, home maintenance)|5
190|3 - Four to six times weekly|3 - Four to six times weekly|5
191|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessing by listener.  Speech limited to single words or short phrases.|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessin|5
192|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires multiple repetitions, restatements, demonstrations, additional time.|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires m|5
193|3 - Hopelessness|3 - Hopelessness|5
194|3 - Hospice care|3 - Hospice care|5
195|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|5
196|3 - Injury caused by fall or accident at home|3 - Injury caused by fall or accident at home|5
197|3 - Intractable pain|3 - Intractable pain|5
198|3 - Medicaid (traditional fee-for-service)|3 - Medicaid (traditional fee-for-service)|5
199|3 - Needs someone to do all shopping and errands.|3 - Needs someone to do all shopping and errands.|5
200|3 - Not healing|3 - Not healing|5
201|3 - Nursing home|3 - Nursing home|5
202|3 - Once daily|3 - Once daily|5
203|3 - Other family member|3 - Other family member|5
204|3 - Outpatient department/clinic emergency (includes urgicenter sites)|3 - Outpatient department/clinic emergency (includes urgicenter sites)|5
205|3 - Paid help|3 - Paid help|5
206|3 - Participates in bathing self in shower or tub, BUT requires presence of another person throughout the bath for assistance or supervision.|3 - Participates in bathing self in shower or tub, BUT requires presence of another person throughou|5
207|3 - Patient depends entirely upon another person to dress lower body.|3 - Patient depends entirely upon another person to dress lower body.|5
208|3 - Patient depends entirely upon another person to dress the upper body.|3 - Patient depends entirely upon another person to dress the upper body.|5
209|3 - Patient depends entirely upon someone else for grooming needs.|3 - Patient depends entirely upon someone else for grooming needs.|5
210|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone else to manage the equipment.|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone|5
211|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable to shift attention and recall directions more than half the time.|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable|5
212|3 - Respiratory problems (SOB, infection, obstruction)|3 - Respiratory problems (SOB, infection, obstruction)|5
213|3 - Resumption of care (after inpatient stay)|3 - Resumption of care (after inpatient stay)|5
214|3 - Several times each month|3 - Several times each month|5
215|3 - Skilled Nursing Facility|3 - Skilled Nursing Facility|5
216|3 - Stage 3|3 - Stage 3|5
217|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|5
218|3 - Three|3 - Three|5
219|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person throughout the process.|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person through|5
220|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal independently.|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal indep|5
221|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person.|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person|5
222|3 - Unknown because patient moved to a geographic location not served by this agency|3 - Unknown because patient moved to a geographic location not served by this agency|5
223|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|5
224|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|5
225|3 - With other family member|3 - With other family member|5
226|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home health services, homemaker assistance, transportation assistance, assisted living, board and care)|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home h|5
227|3-SLP/ST|3-SLP/ST|5
228|4 - At rest (during day or night)|4 - At rest (during day or night)|5
229|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|5
230|4 - Board and care or assisted living facility|4 - Board and care or assisted living facility|5
231|4 - Caregiver is completely dependent on someone else to manage all equipment.|4 - Caregiver is completely dependent on someone else to manage all equipment.|5
232|4 - Chairfast, unable to ambulate and is UNABLE to wheel self.|4 - Chairfast, unable to ambulate and is UNABLE to wheel self.|5
233|4 - Constantly|4 - Constantly|5
234|4 - Drug dependency|4 - Drug dependency|5
235|4 - Four or more|4 - Four or more|5
236|4 - Friend or neighbor or community or church member|4 - Friend or neighbor or community or church member|5
237|4 - Hispanic or Latino|4 - Hispanic or Latino|5
238|4 - Hospice|4 - Hospice|5
239|4 - Impaired decision-making|4 - Impaired decision-making|5
240|4 - Is totally dependent in toileting.|4 - Is totally dependent in toileting.|5
241|4 - Medicaid (HMO/managed care)|4 - Medicaid (HMO/managed care)|5
242|4 - None of the above|4 - None of the above|5
243|4 - Nursing home|4 - Nursing home|5
244|4 - On a daily basis|4 - On a daily basis|5
245|4 - Patient is completely dependent on someone else to manage all equipment.|4 - Patient is completely dependent on someone else to manage all equipment.|5
246|4 - Permanent placement|4 - Permanent placement|5
247|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, punches, dangerous maneuvers w/ wheelchair or other objects)|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, pu|5
248|4 - Psychosocial support (e.g., socialization, companionship, recreation)|4 - Psychosocial support (e.g., socialization, companionship, recreation)|5
249|4 - Recertification (follow-up) reassessment|4 - Recertification (follow-up) reassessment|5
250|4 - Recurrent thoughts of death|4 - Recurrent thoughts of death|5
251|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruction)|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruc|5
252|4 - Several times a week|4 - Several times a week|5
253|4 - Stage 4|4 - Stage 4|5
254|4 - Symptoms poorly controlled, history of rehospitalizations|4 - Symptoms poorly controlled, history of rehospitalizations|5
255|4 - Three or more times per week|4 - Three or more times per week|5
256|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetative state, or delirium.|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetati|5
257|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|5
258|4 - Unable to effectively participate in any housekeeping tasks.|4 - Unable to effectively participate in any housekeeping tasks.|5
259|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or unresponsive (e.g., speech is nonsensical or unintelligible).|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or u|5
260|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonresponsive.|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonr|5
261|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostomy.|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostom|5
262|4 - UNABLE to use the shower or tub and is bathed in BED OR BEDSIDE CHAIR.|4 - UNABLE to use the shower or tub and is bathed in BED OR BEDSIDE CHAIR.|5
263|4 - With a friend|4 - With a friend|5
264|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|5
265|4-OT|4-OT|5
266|5 - Advocates or facilitates patient's participation in appropriate medical care|5 - Advocates or facilitates patient's participation in appropriate medical care|5
267|5 - At least daily|5 - At least daily|5
268|5 - Bedfast, unable to ambulate or be up in a chair.|5 - Bedfast, unable to ambulate or be up in a chair.|5
269|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|5
270|5 - Disruptive or socially inappropriate behavior|5 - Disruptive or socially inappropriate behavior|5
271|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|5
272|5 - Hypo/Hyperglycemia, diabetes out of control|5 - Hypo/Hyperglycemia, diabetes out of control|5
273|5 - More often than once daily|5 - More often than once daily|5
274|5 - Native Hawaiian or Pacific Islander|5 - Native Hawaiian or Pacific Islander|5
275|5 - None of the above|5 - None of the above|5
276|5 - One to two times per week|5 - One to two times per week|5
277|5 - Other|5 - Other|5
278|5 - Other follow-up|5 - Other follow-up|5
279|5 - Paid help|5 - Paid help|5
280|5 - Patient nonresponsive or unable to speak.|5 - Patient nonresponsive or unable to speak.|5
281|5 - Thoughts of suicide|5 - Thoughts of suicide|5
282|5 - Totally unable to use the telephone.|5 - Totally unable to use the telephone.|5
283|5 - Unable to effectively participate in bathing and is totally bathed by another person.|5 - Unable to effectively participate in bathing and is totally bathed by another person.|5
284|5 - Unable to take in nutrients orally or by tube feeding.|5 - Unable to take in nutrients orally or by tube feeding.|5
285|5 - Unsafe for care at home|5 - Unsafe for care at home|5
286|5 - With paid help (other than home care agency staff)|5 - With paid help (other than home care agency staff)|5
287|5 - Workers' compensation|5 - Workers' compensation|5
288|5 - Wound infection, deteriorating wound status, new lesion/ulcer|5 - Wound infection, deteriorating wound status, new lesion/ulcer|5
289|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|5
290|6 - Delusional, hallucinatory, or paranoid behavior|6 - Delusional, hallucinatory, or paranoid behavior|5
291|6 - Financial agent, power of attorney, or conservator of finance|6 - Financial agent, power of attorney, or conservator of finance|5
292|6 - GI bleeding, obstruction|6 - GI bleeding, obstruction|5
293|6 - Less often than weekly|6 - Less often than weekly|5
294|6 - Memory loss to the extent that supervision required|6 - Memory loss to the extent that supervision required|5
295|6 - None of the above feelings observed or reported|6 - None of the above feelings observed or reported|5
296|6 - Other|6 - Other|5
297|6 - Title programs (e.g., Title III, V, or XX)|6 - Title programs (e.g., Title III, V, or XX)|5
298|6 - Transferred to an inpatient facility - patient not discharged from agency|6 - Transferred to an inpatient facility - patient not discharged from agency|5
299|6 - White|6 - White|5
300|6 - With other than above|6 - With other than above|5
301|7 - Exacerbation of CHF, fluid overload, heart failure|7 - Exacerbation of CHF, fluid overload, heart failure|5
302|7 - Health care agent, conservator of person, or medical power of attorney|7 - Health care agent, conservator of person, or medical power of attorney|5
303|7 - Hypo/Hyperglycemia, diabetes out of control|7 - Hypo/Hyperglycemia, diabetes out of control|5
304|7 - None of the above|7 - None of the above|5
305|7 - None of the above behaviors demonstrated|7 - None of the above behaviors demonstrated|5
306|7 - Other government (e.g., CHAMPUS, VA, etc.)|7 - Other government (e.g., CHAMPUS, VA, etc.)|5
307|7 - Transferred to an inpatient facility - patient discharged from agency|7 - Transferred to an inpatient facility - patient discharged from agency|5
308|8 - Death at home|8 - Death at home|5
309|8 - GI bleeding, obstruction|8 - GI bleeding, obstruction|5
310|8 - Myocardial infarction, stroke|8 - Myocardial infarction, stroke|5
311|8 - Private insurance|8 - Private insurance|5
312|9 - Chemotherapy|9 - Chemotherapy|5
313|9 - Discharge from agency|9 - Discharge from agency|5
314|9 - Other than above reasons|9 - Other than above reasons|5
315|9 - Private HMO/managed care|9 - Private HMO/managed care|5
316|NA - No caregiver|NA - No caregiver|5
317|NA - No equipment of this type used in care.|NA - No equipment of this type used in care.|5
318|NA - No inhalant/mist medications prescribed.|NA - No inhalant/mist medications prescribed.|5
319|NA - No injectable medications prescribed.|NA - No injectable medications prescribed.|5
320|NA - No inpatient facility admission|NA - No inpatient facility admission|5
321|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|5
322|NA - No Medicaid|NA - No Medicaid|5
323|NA - No Medicare|NA - No Medicare|5
324|NA - No observable pressure ulcer|NA - No observable pressure ulcer|5
325|NA - No observable stasis ulcer|NA - No observable stasis ulcer|5
326|NA - No observable surgical wound|NA - No observable surgical wound|5
327|NA - No oral medications prescribed.|NA - No oral medications prescribed.|5
328|NA - Not applicable|NA - Not applicable|5
329|NA - Patient does not have a telephone.|NA - Patient does not have a telephone.|5
330|NA - Patient has ostomy for bowel elimination|NA - Patient has ostomy for bowel elimination|5
331|NA - Patient nonresponsive|NA - Patient nonresponsive|5
332|NA - Patient on prophylactic treatment|NA - Patient on prophylactic treatment|5
333|NA - Patient was not discharged from an inpatient facility|NA - Patient was not discharged from an inpatient facility|5
334|UK - Other unknown|UK - Other unknown|5
335|UK - Reason unknown|UK - Reason unknown|5
336|UK - Unknown|UK - Unknown|5
337|UK - Unknown or Not Available|UK - Unknown or Not Available|5
341|01 - Early|01 - Early|5
342|02 - Late|02 - Late|5
343|NA - Not Applicable. No case mix group defined for this assessment.|NA - Not Applicable. No case mix group defined for this assessment.|5
344|NA - No case mix group defined by this assessment.|NA - No case mix group defined by this assessment.|5
2|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; OR (b) Is physically, cognitively, and mentally able to prepare light meals on a regular basis but has not routinely performed light meal preparation in the past (i.e., prior to this home care admission).|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; O|6
3|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and mentally able to perform all housekeeping tasks .|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and menta|6
4|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and mentally able to do laundry and access facilities.|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and menta|6
5|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying packages OR b) Physically, cognitively, and mentally able to take care of shopping, but has not done shopping in the past (i.e., prior to this home care admission).|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying|6
6|0 - Able to bathe self in SHOWER OR TUB independently.|0 - Able to bathe self in SHOWER OR TUB independently.|6
7|0 - Able to dial numbers and answer calls appropriately and as desired.|0 - Able to dial numbers and answer calls appropriately and as desired.|6
8|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body without assistance.|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body|6
9|0 - Able to get to and from the toilet independently with or without a device.|0 - Able to get to and from the toilet independently with or without a device.|6
10|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|6
11|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible public bus.|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible p|6
12|0 - Able to independently feed self.|0 - Able to independently feed self.|6
13|0 - Able to independently take the correct medication and proper dosage at the correct times.|0 - Able to independently take the correct medication and proper dosage at the correct times.|6
14|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct times.|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct ti|6
15|0 - Able to independently transfer.|0 - Able to independently transfer.|6
16|0 - Able to independently walk on even and uneven surfaces and climb stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even and uneven surfaces and climb stairs with or without railings|6
17|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings|6
18|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|6
19|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions independently.|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions indep|6
20|0 - Asymptomatic, no treatment needed at this time|0 - Asymptomatic, no treatment needed at this time|6
21|0 - Caregiver manages all tasks related to equipment completely independently.|0 - Caregiver manages all tasks related to equipment completely independently.|6
22|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations with no observable impairment.|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations w|6
23|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|6
24|0 - Life expectancy is greater than 6 months|0 - Life expectancy is greater than 6 months|6
25|0 - Never|0 - Never|6
26|0 - Never, patient is not short of breath|0 - Never, patient is not short of breath|6
27|0 - No|0 - No|6
28|0 - No emergent care services|0 - No emergent care services|6
29|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage)|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage)|6
30|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and extended or abstract conversation.|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and exte|6
31|0 - No one person|0 - No one person|6
32|0 - None of the time|0 - None of the time|6
33|0 - None, no charge for current services|0 - None, no charge for current services|6
34|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|6
35|0 - Patient does NOT have an ostomy for bowel elimination.|0 - Patient does NOT have an ostomy for bowel elimination.|6
36|0 - Patient has no pain or pain does not interfere with activity or movement|0 - Patient has no pain or pain does not interfere with activity or movement|6
37|0 - Patient manages all tasks related to equipment completely independently.|0 - Patient manages all tasks related to equipment completely independently.|6
38|0 - Poor:  little or no recovery is expected and/or further decline is imminent|0 - Poor:  little or no recovery is expected and/or further decline is imminent|6
39|0 - Timed-voiding defers incontinence|0 - Timed-voiding defers incontinence|6
40|0 - Very rarely or never has bowel incontinence|0 - Very rarely or never has bowel incontinence|6
41|0 - Zero|0 - Zero|6
42|00 - No|00 - No|6
43|01 - Yes|01 - Yes|6
44|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or mental limitations, needs assistance with heavy laundry.|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or|6
45|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the patient.|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the|6
46|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|6
47|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or supervision from another person OR c) a liquid, pureed or ground meat diet.|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or su|6
48|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|6
49|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|6
50|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independently.|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independe|6
51|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only when assisted or accompanied by another person.|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only w|6
52|1 - Able to take injectable medication at correct times if: a) individual syringes are prepared in advance by another person OR b) given daily reminders.|1 - Able to take injectable medication at correct times if: a) individual syringes are prepared in a|6
53|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance by another person OR b) given daily reminders.|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance b|6
54|1 - Able to take medication(s) at the correct times if: a) individual dosages are prepared in advance by another person , OR b) given daily reminders OR c) someone develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if: a) individual dosages are prepared in advanc|6
55|1 - Able to take medication(s) at the correct times if: a) individual dosages are prepared in advance by another person, OR b) given daily reminders OR c) someone develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if: a) individual dosages are prepared in advanc|6
56|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for the deaf) and call essential numbers.|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for t|6
57|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|6
58|1 - American Indian or Alaska Native|1 - American Indian or Alaska Native|6
59|1 - Depressed mood (e.g., feeling sad, tearful)|1 - Depressed mood (e.g., feeling sad, tearful)|6
60|1 - During the night only|1 - During the night only|6
61|1 - Fully granulating|1 - Fully granulating|6
62|1 - Good/Fair:  partial to full recovery is expected|1 - Good/Fair:  partial to full recovery is expected|6
63|1 - Good:  marked improvement in functional status is expected|1 - Good:  marked improvement in functional status is expected|6
64|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|6
65|1 - Heavy smoking|1 - Heavy smoking|6
66|1 - Hospital|1 - Hospital|6
67|1 - Hospital emergency room (includes 23-hour holding)|1 - Hospital emergency room (includes 23-hour holding)|6
68|1 - Hospitalization for EMERGENT (unscheduled) care|1 - Hospitalization for EMERGENT (unscheduled) care|6
69|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepared solutions), patient is able to manage all other aspects of equipment.|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepar|6
70|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|6
71|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|6
72|1 - In new or complex situations only|1 - In new or complex situations only|6
73|1 - Intravenous or infusion therapy (excludes TPN)|1 - Intravenous or infusion therapy (excludes TPN)|6
74|1 - Less often than daily|1 - Less often than daily|6
75|1 - Less than once a month|1 - Less than once a month|6
76|1 - Less than once weekly|1 - Less than once weekly|6
77|1 - Life expectancy is 6 months or fewer|1 - Life expectancy is 6 months or fewer|6
78|1 - Lives alone|1 - Lives alone|6
79|1 - Male|1 - Male|6
80|1 - Medicare (traditional fee-for-service)|1 - Medicare (traditional fee-for-service)|6
81|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of past 24 hours, significant memory loss so that supervision is required|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of pas|6
82|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors in word choice, grammar or speech intelligibility, needs minimal prompting or assistance).|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors i|6
83|1 - No assistance or services received|1 - No assistance or services received|6
84|1 - One|1 - One|6
85|1 - Oxygen (intermittent or continuous)|1 - Oxygen (intermittent or continuous)|6
86|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, and the surrounding layout, can count fingers at arm's length.|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, a|6
87|1 - Patient is incontinent|1 - Patient is incontinent|6
88|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|6
89|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical or treatment regimen.|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical|6
90|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient/couple/significant other)|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient|6
91|1 - Relatives, friends, or neighbors living outside the home|1 - Relatives, friends, or neighbors living outside the home|6
92|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions.|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions|6
93|1 - Requires use of a device (e.g., cane, walker) to walk alone OR requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|1 - Requires use of a device (e.g., cane, walker) to walk alone OR requires human supervision or ass|6
94|1 - Several times during day and night|1 - Several times during day and night|6
95|1 - Spouse or significant other|1 - Spouse or significant other|6
96|1 - Stage 1|1 - Stage 1|6
97|1 - Start of care - further visits planned|1 - Start of care - further visits planned|6
98|1 - Symptoms well controlled with current therapy|1 - Symptoms well controlled with current therapy|6
99|1 - Therapy services|1 - Therapy services|6
100|1 - Transfers with minimal human assistance or with use of an assistive device.|1 - Transfers with minimal human assistance or with use of an assistive device.|6
101|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitations.|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitatio|6
102|1 - Urinary incontinence|1 - Urinary incontinence|6
103|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet.|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet.|6
104|1 - When walking more than 20 feet, climbing stairs|1 - When walking more than 20 feet, climbing stairs|6
105|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary conversation. May need occasional repetition, extra time, or louder voice.|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary c|6
106|1 - With the use of devices, is able to bathe self in shower or tub independently.|1 - With the use of devices, is able to bathe self in shower or tub independently.|6
107|1 - Yes|1 - Yes|6
108|1-RN|1-RN|6
109|10 - Discharge from agency - no visits completed after start/resumption of care assessment|10 - Discharge from agency - no visits completed after start/resumption of care assessment|6
110|10 - Scheduled surgical procedure|10 - Scheduled surgical procedure|6
111|10 - Self-pay|10 - Self-pay|6
112|11 - Other|11 - Other|6
113|11 - Urinary tract infection|11 - Urinary tract infection|6
114|12 - IV catheter-related infection|12 - IV catheter-related infection|6
115|13 - Deep vein thrombosis, pulmonary embolus|13 - Deep vein thrombosis, pulmonary embolus|6
116|14 - Uncontrolled pain|14 - Uncontrolled pain|6
117|15 - Psychotic episode|15 - Psychotic episode|6
118|16 - Other than above reasons|16 - Other than above reasons|6
119|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing calls.|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing|6
120|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another person.|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another pers|6
121|2 - Able to walk only with the supervision or assistance of another person at all times.|2 - Able to walk only with the supervision or assistance of another person at all times.|6
122|2 - Aid: a) for intermittent supervision/encouragement/reminders, OR b) to get in and out of the shower/tub, OR c) for washing difficult to reach areas.|2 - Aid: a) for intermittent supervision/encouragement/reminders, OR b) to get in and out of the sho|6
123|2 - Asian|2 - Asian|6
124|2 - Caregiver requires considerable assistance from another person to manage equipment, but independently completes significant portions of task.|2 - Caregiver requires considerable assistance from another person to manage equipment, but independ|6
125|2 - Daily, but not constantly|2 - Daily, but not constantly|6
126|2 - Daughter or son|2 - Daughter or son|6
127|2 - Doctor's office emergency visit/house call|2 - Doctor's office emergency visit/house call|6
128|2 - During the day and night|2 - During the day and night|6
129|2 - Early/partial granulation|2 - Early/partial granulation|6
130|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors in word choice, organization or speech intelligibility). Speaks in phrases or short sentences.|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors|6
131|2 - Family member's residence|2 - Family member's residence|6
132|2 - Female|2 - Female|6
133|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conversation, needs frequent prompting or assistance.|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conver|6
134|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|6
135|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|6
136|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately stop activities, jeopardizes safety through actions|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately st|6
137|2 - Indwelling/suprapubic catheter|2 - Indwelling/suprapubic catheter|6
138|2 - Injury caused by fall or accident at home|2 - Injury caused by fall or accident at home|6
139|2 - Medicare (HMO/managed care)|2 - Medicare (HMO/managed care)|6
140|2 - Nausea, dehydration, malnutrition, constipation, impaction|2 - Nausea, dehydration, malnutrition, constipation, impaction|6
141|2 - Obesity|2 - Obesity|6
142|2 - On awakening or at night only|2 - On awakening or at night only|6
143|2 - Once a month|2 - Once a month|6
144|2 - One to three times weekly|2 - One to three times weekly|6
145|2 - Parenteral nutrition (TPN or lipids)|2 - Parenteral nutrition (TPN or lipids)|6
146|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic)|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic)|6
147|2 - Patient requires considerable assistance from another person to manage equipment, but independently completes portions of the task.|2 - Patient requires considerable assistance from another person to manage equipment, but independen|6
148|2 - Patient transferred to a noninstitutional hospice|2 - Patient transferred to a noninstitutional hospice|6
149|2 - Person residing in the home (EXCLUDING paid help)|2 - Person residing in the home (EXCLUDING paid help)|6
150|2 - Rehabilitation facility|2 - Rehabilitation facility|6
151|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifting of attention) or consistently requires low stimulus environment due to distractibility.|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifti|6
152|2 - Respite care|2 - Respite care|6
153|2 - Sense of failure or self reproach|2 - Sense of failure or self reproach|6
154|2 - Several times during day|2 - Several times during day|6
155|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonresponsive.|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonrespons|6
156|2 - Someone must assist the patient to groom self.|2 - Someone must assist the patient to groom self.|6
157|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|6
158|2 - Someone must help the patient put on upper body clothing.|2 - Someone must help the patient put on upper body clothing.|6
159|2 - Stage 2|2 - Stage 2|6
160|2 - Start of care - no further visits planned|2 - Start of care - no further visits planned|6
161|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitoring|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitori|6
162|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment regimen.|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment re|6
163|2 - Two|2 - Two|6
164|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistance due to cognitive or mental limitation.|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistanc|6
165|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|6
166|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assistance).|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assis|6
167|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home delivery.|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home deli|6
168|2 - Unable to prepare any light meals or reheat any delivered meals.|2 - Unable to prepare any light meals or reheat any delivered meals.|6
169|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|6
170|2 - UNABLE to take injectable medications unless administered by someone else.|2 - UNABLE to take injectable medications unless administered by someone else.|6
171|2 - UNABLE to take medication unless administered by someone else.|2 - UNABLE to take medication unless administered by someone else.|6
172|2 - UNABLE to transfer self but is able to bear weight and pivot during the transfer process.|2 - UNABLE to transfer self but is able to bear weight and pivot during the transfer process.|6
173|2 - Ventilator (continually or at night)|2 - Ventilator (continually or at night)|6
174|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less than 20 feet)|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less th|6
175|2 - With spouse or significant other|2 - With spouse or significant other|6
176|2 - Yes, assistance or services provided by family or friends|2 - Yes, assistance or services provided by family or friends|6
177|2-PT|2-PT|6
178|3 - Able to answer the telephone only some of the time or is able to carry on only a limited conversation.|3 - Able to answer the telephone only some of the time or is able to carry on only a limited convers|6
179|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube or gastrostomy.|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube|6
180|3 - Alcohol dependency|3 - Alcohol dependency|6
181|3 - All of the time|3 - All of the time|6
182|3 - Black or African-American|3 - Black or African-American|6
183|3 - Boarding home or rented room|3 - Boarding home or rented room|6
184|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment, clean/store/dispose of equipment or supplies).|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment,|6
185|3 - Chairfast, UNABLE to ambulate but is able to wheel self independently.|3 - Chairfast, UNABLE to ambulate but is able to wheel self independently.|6
186|3 - Continuous positive airway pressure|3 - Continuous positive airway pressure|6
187|3 - During the day and evening, but not constantly|3 - During the day and evening, but not constantly|6
188|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the alimentary canal)|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the|6
189|3 - Environmental support (e.g., housing, home maintenance)|3 - Environmental support (e.g., housing, home maintenance)|6
190|3 - Four to six times weekly|3 - Four to six times weekly|6
191|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessing by listener.  Speech limited to single words or short phrases.|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessin|6
192|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires multiple repetitions, restatements, demonstrations, additional time.|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires m|6
193|3 - Hopelessness|3 - Hopelessness|6
194|3 - Hospice care|3 - Hospice care|6
195|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|6
196|3 - Injury caused by fall or accident at home|3 - Injury caused by fall or accident at home|6
197|3 - Intractable pain|3 - Intractable pain|6
198|3 - Medicaid (traditional fee-for-service)|3 - Medicaid (traditional fee-for-service)|6
199|3 - Needs someone to do all shopping and errands.|3 - Needs someone to do all shopping and errands.|6
200|3 - Not healing|3 - Not healing|6
201|3 - Nursing home|3 - Nursing home|6
202|3 - Once daily|3 - Once daily|6
203|3 - Other family member|3 - Other family member|6
204|3 - Outpatient department/clinic emergency (includes urgicenter sites)|3 - Outpatient department/clinic emergency (includes urgicenter sites)|6
205|3 - Paid help|3 - Paid help|6
206|3 - Participates in bathing self in shower or tub, BUT requires presence of another person throughout the bath for assistance or supervision.|3 - Participates in bathing self in shower or tub, BUT requires presence of another person throughou|6
207|3 - Patient depends entirely upon another person to dress lower body.|3 - Patient depends entirely upon another person to dress lower body.|6
208|3 - Patient depends entirely upon another person to dress the upper body.|3 - Patient depends entirely upon another person to dress the upper body.|6
209|3 - Patient depends entirely upon someone else for grooming needs.|3 - Patient depends entirely upon someone else for grooming needs.|6
210|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone else to manage the equipment.|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone|6
211|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable to shift attention and recall directions more than half the time.|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable|6
212|3 - Respiratory problems (SOB, infection, obstruction)|3 - Respiratory problems (SOB, infection, obstruction)|6
213|3 - Resumption of care (after inpatient stay)|3 - Resumption of care (after inpatient stay)|6
214|3 - Several times each month|3 - Several times each month|6
215|3 - Skilled Nursing Facility|3 - Skilled Nursing Facility|6
216|3 - Stage 3|3 - Stage 3|6
217|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|6
218|3 - Three|3 - Three|6
219|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person throughout the process.|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person through|6
220|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal independently.|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal indep|6
221|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person.|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person|6
222|3 - Unknown because patient moved to a geographic location not served by this agency|3 - Unknown because patient moved to a geographic location not served by this agency|6
223|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|6
224|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|6
225|3 - With other family member|3 - With other family member|6
226|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home health services, homemaker assistance, transportation assistance, assisted living, board and care)|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home h|6
227|3-SLP/ST|3-SLP/ST|6
228|4 - At rest (during day or night)|4 - At rest (during day or night)|6
229|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|6
230|4 - Board and care or assisted living facility|4 - Board and care or assisted living facility|6
231|4 - Caregiver is completely dependent on someone else to manage all equipment.|4 - Caregiver is completely dependent on someone else to manage all equipment.|6
232|4 - Chairfast, unable to ambulate and is UNABLE to wheel self.|4 - Chairfast, unable to ambulate and is UNABLE to wheel self.|6
233|4 - Constantly|4 - Constantly|6
234|4 - Drug dependency|4 - Drug dependency|6
235|4 - Four or more|4 - Four or more|6
236|4 - Friend or neighbor or community or church member|4 - Friend or neighbor or community or church member|6
237|4 - Hispanic or Latino|4 - Hispanic or Latino|6
238|4 - Hospice|4 - Hospice|6
239|4 - Impaired decision-making|4 - Impaired decision-making|6
240|4 - Is totally dependent in toileting.|4 - Is totally dependent in toileting.|6
241|4 - Medicaid (HMO/managed care)|4 - Medicaid (HMO/managed care)|6
242|4 - None of the above|4 - None of the above|6
243|4 - Nursing home|4 - Nursing home|6
244|4 - On a daily basis|4 - On a daily basis|6
245|4 - Patient is completely dependent on someone else to manage all equipment.|4 - Patient is completely dependent on someone else to manage all equipment.|6
246|4 - Permanent placement|4 - Permanent placement|6
247|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, punches, dangerous maneuvers w/ wheelchair or other objects)|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, pu|6
248|4 - Psychosocial support (e.g., socialization, companionship, recreation)|4 - Psychosocial support (e.g., socialization, companionship, recreation)|6
249|4 - Recertification (follow-up) reassessment|4 - Recertification (follow-up) reassessment|6
250|4 - Recurrent thoughts of death|4 - Recurrent thoughts of death|6
251|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruction)|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruc|6
252|4 - Several times a week|4 - Several times a week|6
253|4 - Stage 4|4 - Stage 4|6
254|4 - Symptoms poorly controlled, history of rehospitalizations|4 - Symptoms poorly controlled, history of rehospitalizations|6
255|4 - Three or more times per week|4 - Three or more times per week|6
256|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetative state, or delirium.|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetati|6
257|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|6
258|4 - Unable to effectively participate in any housekeeping tasks.|4 - Unable to effectively participate in any housekeeping tasks.|6
259|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or unresponsive (e.g., speech is nonsensical or unintelligible).|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or u|6
260|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonresponsive.|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonr|6
261|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostomy.|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostom|6
262|4 - UNABLE to use the shower or tub and is bathed in BED OR BEDSIDE CHAIR.|4 - UNABLE to use the shower or tub and is bathed in BED OR BEDSIDE CHAIR.|6
263|4 - With a friend|4 - With a friend|6
264|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|6
265|4-OT|4-OT|6
266|5 - Advocates or facilitates patient's participation in appropriate medical care|5 - Advocates or facilitates patient's participation in appropriate medical care|6
267|5 - At least daily|5 - At least daily|6
268|5 - Bedfast, unable to ambulate or be up in a chair.|5 - Bedfast, unable to ambulate or be up in a chair.|6
269|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|6
270|5 - Disruptive or socially inappropriate behavior|5 - Disruptive or socially inappropriate behavior|6
271|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|6
272|5 - Hypo/Hyperglycemia, diabetes out of control|5 - Hypo/Hyperglycemia, diabetes out of control|6
273|5 - More often than once daily|5 - More often than once daily|6
274|5 - Native Hawaiian or Pacific Islander|5 - Native Hawaiian or Pacific Islander|6
275|5 - None of the above|5 - None of the above|6
276|5 - One to two times per week|5 - One to two times per week|6
277|5 - Other|5 - Other|6
278|5 - Other follow-up|5 - Other follow-up|6
279|5 - Paid help|5 - Paid help|6
280|5 - Patient nonresponsive or unable to speak.|5 - Patient nonresponsive or unable to speak.|6
281|5 - Thoughts of suicide|5 - Thoughts of suicide|6
282|5 - Totally unable to use the telephone.|5 - Totally unable to use the telephone.|6
283|5 - Unable to effectively participate in bathing and is totally bathed by another person.|5 - Unable to effectively participate in bathing and is totally bathed by another person.|6
284|5 - Unable to take in nutrients orally or by tube feeding.|5 - Unable to take in nutrients orally or by tube feeding.|6
285|5 - Unsafe for care at home|5 - Unsafe for care at home|6
286|5 - With paid help (other than home care agency staff)|5 - With paid help (other than home care agency staff)|6
287|5 - Workers' compensation|5 - Workers' compensation|6
288|5 - Wound infection, deteriorating wound status, new lesion/ulcer|5 - Wound infection, deteriorating wound status, new lesion/ulcer|6
289|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|6
290|6 - Delusional, hallucinatory, or paranoid behavior|6 - Delusional, hallucinatory, or paranoid behavior|6
291|6 - Financial agent, power of attorney, or conservator of finance|6 - Financial agent, power of attorney, or conservator of finance|6
292|6 - GI bleeding, obstruction|6 - GI bleeding, obstruction|6
293|6 - Less often than weekly|6 - Less often than weekly|6
294|6 - Memory loss to the extent that supervision required|6 - Memory loss to the extent that supervision required|6
295|6 - None of the above feelings observed or reported|6 - None of the above feelings observed or reported|6
296|6 - Other|6 - Other|6
297|6 - Title programs (e.g., Title III, V, or XX)|6 - Title programs (e.g., Title III, V, or XX)|6
298|6 - Transferred to an inpatient facility - patient not discharged from agency|6 - Transferred to an inpatient facility - patient not discharged from agency|6
299|6 - White|6 - White|6
300|6 - With other than above|6 - With other than above|6
301|7 - Exacerbation of CHF, fluid overload, heart failure|7 - Exacerbation of CHF, fluid overload, heart failure|6
302|7 - Health care agent, conservator of person, or medical power of attorney|7 - Health care agent, conservator of person, or medical power of attorney|6
303|7 - Hypo/Hyperglycemia, diabetes out of control|7 - Hypo/Hyperglycemia, diabetes out of control|6
304|7 - None of the above|7 - None of the above|6
305|7 - None of the above behaviors demonstrated|7 - None of the above behaviors demonstrated|6
306|7 - Other government (e.g., CHAMPUS, VA, etc.)|7 - Other government (e.g., CHAMPUS, VA, etc.)|6
307|7 - Transferred to an inpatient facility - patient discharged from agency|7 - Transferred to an inpatient facility - patient discharged from agency|6
308|8 - Death at home|8 - Death at home|6
309|8 - GI bleeding, obstruction|8 - GI bleeding, obstruction|6
310|8 - Myocardial infarction, stroke|8 - Myocardial infarction, stroke|6
311|8 - Private insurance|8 - Private insurance|6
312|9 - Chemotherapy|9 - Chemotherapy|6
313|9 - Discharge from agency|9 - Discharge from agency|6
314|9 - Other than above reasons|9 - Other than above reasons|6
315|9 - Private HMO/managed care|9 - Private HMO/managed care|6
316|NA - No caregiver|NA - No caregiver|6
317|NA - No equipment of this type used in care.|NA - No equipment of this type used in care.|6
318|NA - No inhalant/mist medications prescribed.|NA - No inhalant/mist medications prescribed.|6
319|NA - No injectable medications prescribed.|NA - No injectable medications prescribed.|6
320|NA - No inpatient facility admission|NA - No inpatient facility admission|6
321|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|6
322|NA - No Medicaid|NA - No Medicaid|6
323|NA - No Medicare|NA - No Medicare|6
324|NA - No observable pressure ulcer|NA - No observable pressure ulcer|6
325|NA - No observable stasis ulcer|NA - No observable stasis ulcer|6
326|NA - No observable surgical wound|NA - No observable surgical wound|6
327|NA - No oral medications prescribed.|NA - No oral medications prescribed.|6
328|NA - Not applicable|NA - Not applicable|6
329|NA - Patient does not have a telephone.|NA - Patient does not have a telephone.|6
330|NA - Patient has ostomy for bowel elimination|NA - Patient has ostomy for bowel elimination|6
331|NA - Patient nonresponsive|NA - Patient nonresponsive|6
332|NA - Patient on prophylactic treatment|NA - Patient on prophylactic treatment|6
333|NA - Patient was not discharged from an inpatient facility|NA - Patient was not discharged from an inpatient facility|6
334|UK - Other unknown|UK - Other unknown|6
335|UK - Reason unknown|UK - Reason unknown|6
336|UK - Unknown|UK - Unknown|6
337|UK - Unknown or Not Available|UK - Unknown or Not Available|6
341|01 - Early|01 - Early|6
342|02 - Late|02 - Late|6
343|NA - Not Applicable. No case mix group defined for this assessment.|NA - Not Applicable. No case mix group defined for this assessment.|6
344|NA - No case mix group defined by this assessment.|NA - No case mix group defined by this assessment.|6
2|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; OR (b) Is physically, cognitively, and mentally able to prepare light meals on a regular basis but has not routinely performed light meal preparation in the past (i.e., prior to this home care admission).|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; O|7
3|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and mentally able to perform all housekeeping tasks .|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and menta|7
4|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and mentally able to do laundry and access facilities.|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and menta|7
5|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying packages OR b) Physically, cognitively, and mentally able to take care of shopping, but has not done shopping in the past (i.e., prior to this home care admission).|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying|7
6|0 - Able to bathe self in SHOWER OR TUB independently.|0 - Able to bathe self in SHOWER OR TUB independently.|7
7|0 - Able to dial numbers and answer calls appropriately and as desired.|0 - Able to dial numbers and answer calls appropriately and as desired.|7
8|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body without assistance.|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body|7
9|0 - Able to get to and from the toilet independently with or without a device.|0 - Able to get to and from the toilet independently with or without a device.|7
10|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|7
11|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible public bus.|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible p|7
12|0 - Able to independently feed self.|0 - Able to independently feed self.|7
13|0 - Able to independently take the correct medication and proper dosage at the correct times.|0 - Able to independently take the correct medication and proper dosage at the correct times.|7
14|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct times.|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct ti|7
15|0 - Able to independently transfer.|0 - Able to independently transfer.|7
16|0 - Able to independently walk on even and uneven surfaces and climb stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even and uneven surfaces and climb stairs with or without railings|7
17|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings|7
18|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|7
19|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions independently.|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions indep|7
20|0 - Asymptomatic, no treatment needed at this time|0 - Asymptomatic, no treatment needed at this time|7
21|0 - Caregiver manages all tasks related to equipment completely independently.|0 - Caregiver manages all tasks related to equipment completely independently.|7
22|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations with no observable impairment.|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations w|7
23|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|7
24|0 - Life expectancy is greater than 6 months|0 - Life expectancy is greater than 6 months|7
25|0 - Never|0 - Never|7
26|0 - Never, patient is not short of breath|0 - Never, patient is not short of breath|7
27|0 - No|0 - No|7
28|0 - No emergent care services|0 - No emergent care services|7
29|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage)|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage)|7
30|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and extended or abstract conversation.|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and exte|7
31|0 - No one person|0 - No one person|7
32|0 - None of the time|0 - None of the time|7
33|0 - None, no charge for current services|0 - None, no charge for current services|7
34|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|7
35|0 - Patient does NOT have an ostomy for bowel elimination.|0 - Patient does NOT have an ostomy for bowel elimination.|7
36|0 - Patient has no pain or pain does not interfere with activity or movement|0 - Patient has no pain or pain does not interfere with activity or movement|7
37|0 - Patient manages all tasks related to equipment completely independently.|0 - Patient manages all tasks related to equipment completely independently.|7
38|0 - Poor:  little or no recovery is expected and/or further decline is imminent|0 - Poor:  little or no recovery is expected and/or further decline is imminent|7
39|0 - Timed-voiding defers incontinence|0 - Timed-voiding defers incontinence|7
40|0 - Very rarely or never has bowel incontinence|0 - Very rarely or never has bowel incontinence|7
41|0 - Zero|0 - Zero|7
42|00 - No|00 - No|7
43|01 - Yes|01 - Yes|7
44|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or mental limitations, needs assistance with heavy laundry.|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or|7
45|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the patient.|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the|7
46|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|7
47|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or supervision from another person OR c) a liquid, pureed or ground meat diet.|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or su|7
48|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|7
49|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|7
50|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independently.|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independe|7
51|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only when assisted or accompanied by another person.|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only w|7
52|1 - Able to take injectable medication at correct times if: a) individual syringes are prepared in advance by another person OR b) given daily reminders.|1 - Able to take injectable medication at correct times if: a) individual syringes are prepared in a|7
53|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance by another person OR b) given daily reminders.|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance b|7
54|1 - Able to take medication(s) at the correct times if: a) individual dosages are prepared in advance by another person , OR b) given daily reminders OR c) someone develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if: a) individual dosages are prepared in advanc|7
55|1 - Able to take medication(s) at the correct times if: a) individual dosages are prepared in advance by another person, OR b) given daily reminders OR c) someone develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if: a) individual dosages are prepared in advanc|7
56|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for the deaf) and call essential numbers.|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for t|7
57|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|7
58|1 - American Indian or Alaska Native|1 - American Indian or Alaska Native|7
59|1 - Depressed mood (e.g., feeling sad, tearful)|1 - Depressed mood (e.g., feeling sad, tearful)|7
60|1 - During the night only|1 - During the night only|7
61|1 - Fully granulating|1 - Fully granulating|7
62|1 - Good/Fair:  partial to full recovery is expected|1 - Good/Fair:  partial to full recovery is expected|7
63|1 - Good:  marked improvement in functional status is expected|1 - Good:  marked improvement in functional status is expected|7
64|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|7
65|1 - Heavy smoking|1 - Heavy smoking|7
66|1 - Hospital|1 - Hospital|7
67|1 - Hospital emergency room (includes 23-hour holding)|1 - Hospital emergency room (includes 23-hour holding)|7
68|1 - Hospitalization for EMERGENT (unscheduled) care|1 - Hospitalization for EMERGENT (unscheduled) care|7
69|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepared solutions), patient is able to manage all other aspects of equipment.|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepar|7
70|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|7
71|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|7
72|1 - In new or complex situations only|1 - In new or complex situations only|7
73|1 - Intravenous or infusion therapy (excludes TPN)|1 - Intravenous or infusion therapy (excludes TPN)|7
74|1 - Less often than daily|1 - Less often than daily|7
75|1 - Less than once a month|1 - Less than once a month|7
76|1 - Less than once weekly|1 - Less than once weekly|7
77|1 - Life expectancy is 6 months or fewer|1 - Life expectancy is 6 months or fewer|7
78|1 - Lives alone|1 - Lives alone|7
79|1 - Male|1 - Male|7
80|1 - Medicare (traditional fee-for-service)|1 - Medicare (traditional fee-for-service)|7
81|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of past 24 hours, significant memory loss so that supervision is required|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of pas|7
82|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors in word choice, grammar or speech intelligibility, needs minimal prompting or assistance).|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors i|7
83|1 - No assistance or services received|1 - No assistance or services received|7
84|1 - One|1 - One|7
85|1 - Oxygen (intermittent or continuous)|1 - Oxygen (intermittent or continuous)|7
86|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, and the surrounding layout, can count fingers at arm's length.|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, a|7
87|1 - Patient is incontinent|1 - Patient is incontinent|7
88|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|7
89|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical or treatment regimen.|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical|7
90|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient/couple/significant other)|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient|7
91|1 - Relatives, friends, or neighbors living outside the home|1 - Relatives, friends, or neighbors living outside the home|7
92|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions.|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions|7
93|1 - Requires use of a device (e.g., cane, walker) to walk alone OR requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|1 - Requires use of a device (e.g., cane, walker) to walk alone OR requires human supervision or ass|7
94|1 - Several times during day and night|1 - Several times during day and night|7
95|1 - Spouse or significant other|1 - Spouse or significant other|7
96|1 - Stage 1|1 - Stage 1|7
97|1 - Start of care - further visits planned|1 - Start of care - further visits planned|7
98|1 - Symptoms well controlled with current therapy|1 - Symptoms well controlled with current therapy|7
99|1 - Therapy services|1 - Therapy services|7
100|1 - Transfers with minimal human assistance or with use of an assistive device.|1 - Transfers with minimal human assistance or with use of an assistive device.|7
101|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitations.|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitatio|7
102|1 - Urinary incontinence|1 - Urinary incontinence|7
103|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet.|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet.|7
104|1 - When walking more than 20 feet, climbing stairs|1 - When walking more than 20 feet, climbing stairs|7
105|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary conversation. May need occasional repetition, extra time, or louder voice.|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary c|7
106|1 - With the use of devices, is able to bathe self in shower or tub independently.|1 - With the use of devices, is able to bathe self in shower or tub independently.|7
107|1 - Yes|1 - Yes|7
108|1-RN|1-RN|7
109|10 - Discharge from agency - no visits completed after start/resumption of care assessment|10 - Discharge from agency - no visits completed after start/resumption of care assessment|7
110|10 - Scheduled surgical procedure|10 - Scheduled surgical procedure|7
111|10 - Self-pay|10 - Self-pay|7
112|11 - Other|11 - Other|7
113|11 - Urinary tract infection|11 - Urinary tract infection|7
114|12 - IV catheter-related infection|12 - IV catheter-related infection|7
115|13 - Deep vein thrombosis, pulmonary embolus|13 - Deep vein thrombosis, pulmonary embolus|7
116|14 - Uncontrolled pain|14 - Uncontrolled pain|7
117|15 - Psychotic episode|15 - Psychotic episode|7
118|16 - Other than above reasons|16 - Other than above reasons|7
119|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing calls.|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing|7
120|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another person.|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another pers|7
121|2 - Able to walk only with the supervision or assistance of another person at all times.|2 - Able to walk only with the supervision or assistance of another person at all times.|7
122|2 - Aid: a) for intermittent supervision/encouragement/reminders, OR b) to get in and out of the shower/tub, OR c) for washing difficult to reach areas.|2 - Aid: a) for intermittent supervision/encouragement/reminders, OR b) to get in and out of the sho|7
123|2 - Asian|2 - Asian|7
124|2 - Caregiver requires considerable assistance from another person to manage equipment, but independently completes significant portions of task.|2 - Caregiver requires considerable assistance from another person to manage equipment, but independ|7
125|2 - Daily, but not constantly|2 - Daily, but not constantly|7
126|2 - Daughter or son|2 - Daughter or son|7
127|2 - Doctor's office emergency visit/house call|2 - Doctor's office emergency visit/house call|7
128|2 - During the day and night|2 - During the day and night|7
129|2 - Early/partial granulation|2 - Early/partial granulation|7
130|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors in word choice, organization or speech intelligibility). Speaks in phrases or short sentences.|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors|7
131|2 - Family member's residence|2 - Family member's residence|7
132|2 - Female|2 - Female|7
133|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conversation, needs frequent prompting or assistance.|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conver|7
134|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|7
135|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|7
136|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately stop activities, jeopardizes safety through actions|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately st|7
137|2 - Indwelling/suprapubic catheter|2 - Indwelling/suprapubic catheter|7
138|2 - Injury caused by fall or accident at home|2 - Injury caused by fall or accident at home|7
139|2 - Medicare (HMO/managed care)|2 - Medicare (HMO/managed care)|7
140|2 - Nausea, dehydration, malnutrition, constipation, impaction|2 - Nausea, dehydration, malnutrition, constipation, impaction|7
141|2 - Obesity|2 - Obesity|7
142|2 - On awakening or at night only|2 - On awakening or at night only|7
143|2 - Once a month|2 - Once a month|7
144|2 - One to three times weekly|2 - One to three times weekly|7
145|2 - Parenteral nutrition (TPN or lipids)|2 - Parenteral nutrition (TPN or lipids)|7
146|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic)|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic)|7
147|2 - Patient requires considerable assistance from another person to manage equipment, but independently completes portions of the task.|2 - Patient requires considerable assistance from another person to manage equipment, but independen|7
148|2 - Patient transferred to a noninstitutional hospice|2 - Patient transferred to a noninstitutional hospice|7
149|2 - Person residing in the home (EXCLUDING paid help)|2 - Person residing in the home (EXCLUDING paid help)|7
150|2 - Rehabilitation facility|2 - Rehabilitation facility|7
151|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifting of attention) or consistently requires low stimulus environment due to distractibility.|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifti|7
152|2 - Respite care|2 - Respite care|7
153|2 - Sense of failure or self reproach|2 - Sense of failure or self reproach|7
154|2 - Several times during day|2 - Several times during day|7
155|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonresponsive.|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonrespons|7
156|2 - Someone must assist the patient to groom self.|2 - Someone must assist the patient to groom self.|7
157|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|7
158|2 - Someone must help the patient put on upper body clothing.|2 - Someone must help the patient put on upper body clothing.|7
159|2 - Stage 2|2 - Stage 2|7
160|2 - Start of care - no further visits planned|2 - Start of care - no further visits planned|7
161|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitoring|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitori|7
162|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment regimen.|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment re|7
163|2 - Two|2 - Two|7
164|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistance due to cognitive or mental limitation.|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistanc|7
165|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|7
166|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assistance).|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assis|7
167|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home delivery.|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home deli|7
168|2 - Unable to prepare any light meals or reheat any delivered meals.|2 - Unable to prepare any light meals or reheat any delivered meals.|7
169|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|7
170|2 - UNABLE to take injectable medications unless administered by someone else.|2 - UNABLE to take injectable medications unless administered by someone else.|7
171|2 - UNABLE to take medication unless administered by someone else.|2 - UNABLE to take medication unless administered by someone else.|7
172|2 - UNABLE to transfer self but is able to bear weight and pivot during the transfer process.|2 - UNABLE to transfer self but is able to bear weight and pivot during the transfer process.|7
173|2 - Ventilator (continually or at night)|2 - Ventilator (continually or at night)|7
174|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less than 20 feet)|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less th|7
175|2 - With spouse or significant other|2 - With spouse or significant other|7
176|2 - Yes, assistance or services provided by family or friends|2 - Yes, assistance or services provided by family or friends|7
177|2-PT|2-PT|7
178|3 - Able to answer the telephone only some of the time or is able to carry on only a limited conversation.|3 - Able to answer the telephone only some of the time or is able to carry on only a limited convers|7
179|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube or gastrostomy.|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube|7
180|3 - Alcohol dependency|3 - Alcohol dependency|7
181|3 - All of the time|3 - All of the time|7
182|3 - Black or African-American|3 - Black or African-American|7
183|3 - Boarding home or rented room|3 - Boarding home or rented room|7
184|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment, clean/store/dispose of equipment or supplies).|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment,|7
185|3 - Chairfast, UNABLE to ambulate but is able to wheel self independently.|3 - Chairfast, UNABLE to ambulate but is able to wheel self independently.|7
186|3 - Continuous positive airway pressure|3 - Continuous positive airway pressure|7
187|3 - During the day and evening, but not constantly|3 - During the day and evening, but not constantly|7
188|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the alimentary canal)|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the|7
189|3 - Environmental support (e.g., housing, home maintenance)|3 - Environmental support (e.g., housing, home maintenance)|7
190|3 - Four to six times weekly|3 - Four to six times weekly|7
191|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessing by listener.  Speech limited to single words or short phrases.|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessin|7
192|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires multiple repetitions, restatements, demonstrations, additional time.|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires m|7
193|3 - Hopelessness|3 - Hopelessness|7
194|3 - Hospice care|3 - Hospice care|7
195|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|7
196|3 - Injury caused by fall or accident at home|3 - Injury caused by fall or accident at home|7
197|3 - Intractable pain|3 - Intractable pain|7
198|3 - Medicaid (traditional fee-for-service)|3 - Medicaid (traditional fee-for-service)|7
199|3 - Needs someone to do all shopping and errands.|3 - Needs someone to do all shopping and errands.|7
200|3 - Not healing|3 - Not healing|7
201|3 - Nursing home|3 - Nursing home|7
202|3 - Once daily|3 - Once daily|7
203|3 - Other family member|3 - Other family member|7
204|3 - Outpatient department/clinic emergency (includes urgicenter sites)|3 - Outpatient department/clinic emergency (includes urgicenter sites)|7
205|3 - Paid help|3 - Paid help|7
206|3 - Participates in bathing self in shower or tub, BUT requires presence of another person throughout the bath for assistance or supervision.|3 - Participates in bathing self in shower or tub, BUT requires presence of another person throughou|7
207|3 - Patient depends entirely upon another person to dress lower body.|3 - Patient depends entirely upon another person to dress lower body.|7
208|3 - Patient depends entirely upon another person to dress the upper body.|3 - Patient depends entirely upon another person to dress the upper body.|7
209|3 - Patient depends entirely upon someone else for grooming needs.|3 - Patient depends entirely upon someone else for grooming needs.|7
210|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone else to manage the equipment.|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone|7
211|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable to shift attention and recall directions more than half the time.|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable|7
212|3 - Respiratory problems (SOB, infection, obstruction)|3 - Respiratory problems (SOB, infection, obstruction)|7
213|3 - Resumption of care (after inpatient stay)|3 - Resumption of care (after inpatient stay)|7
214|3 - Several times each month|3 - Several times each month|7
215|3 - Skilled Nursing Facility|3 - Skilled Nursing Facility|7
216|3 - Stage 3|3 - Stage 3|7
217|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|7
218|3 - Three|3 - Three|7
219|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person throughout the process.|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person through|7
220|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal independently.|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal indep|7
221|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person.|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person|7
222|3 - Unknown because patient moved to a geographic location not served by this agency|3 - Unknown because patient moved to a geographic location not served by this agency|7
223|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|7
224|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|7
225|3 - With other family member|3 - With other family member|7
226|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home health services, homemaker assistance, transportation assistance, assisted living, board and care)|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home h|7
227|3-SLP/ST|3-SLP/ST|7
228|4 - At rest (during day or night)|4 - At rest (during day or night)|7
229|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|7
230|4 - Board and care or assisted living facility|4 - Board and care or assisted living facility|7
231|4 - Caregiver is completely dependent on someone else to manage all equipment.|4 - Caregiver is completely dependent on someone else to manage all equipment.|7
232|4 - Chairfast, unable to ambulate and is UNABLE to wheel self.|4 - Chairfast, unable to ambulate and is UNABLE to wheel self.|7
233|4 - Constantly|4 - Constantly|7
234|4 - Drug dependency|4 - Drug dependency|7
235|4 - Four or more|4 - Four or more|7
236|4 - Friend or neighbor or community or church member|4 - Friend or neighbor or community or church member|7
237|4 - Hispanic or Latino|4 - Hispanic or Latino|7
238|4 - Hospice|4 - Hospice|7
239|4 - Impaired decision-making|4 - Impaired decision-making|7
240|4 - Is totally dependent in toileting.|4 - Is totally dependent in toileting.|7
241|4 - Medicaid (HMO/managed care)|4 - Medicaid (HMO/managed care)|7
242|4 - None of the above|4 - None of the above|7
243|4 - Nursing home|4 - Nursing home|7
244|4 - On a daily basis|4 - On a daily basis|7
245|4 - Patient is completely dependent on someone else to manage all equipment.|4 - Patient is completely dependent on someone else to manage all equipment.|7
246|4 - Permanent placement|4 - Permanent placement|7
247|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, punches, dangerous maneuvers w/ wheelchair or other objects)|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, pu|7
248|4 - Psychosocial support (e.g., socialization, companionship, recreation)|4 - Psychosocial support (e.g., socialization, companionship, recreation)|7
249|4 - Recertification (follow-up) reassessment|4 - Recertification (follow-up) reassessment|7
250|4 - Recurrent thoughts of death|4 - Recurrent thoughts of death|7
251|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruction)|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruc|7
252|4 - Several times a week|4 - Several times a week|7
253|4 - Stage 4|4 - Stage 4|7
254|4 - Symptoms poorly controlled, history of rehospitalizations|4 - Symptoms poorly controlled, history of rehospitalizations|7
255|4 - Three or more times per week|4 - Three or more times per week|7
256|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetative state, or delirium.|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetati|7
257|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|7
258|4 - Unable to effectively participate in any housekeeping tasks.|4 - Unable to effectively participate in any housekeeping tasks.|7
259|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or unresponsive (e.g., speech is nonsensical or unintelligible).|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or u|7
260|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonresponsive.|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonr|7
261|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostomy.|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostom|7
262|4 - UNABLE to use the shower or tub and is bathed in BED OR BEDSIDE CHAIR.|4 - UNABLE to use the shower or tub and is bathed in BED OR BEDSIDE CHAIR.|7
263|4 - With a friend|4 - With a friend|7
264|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|7
265|4-OT|4-OT|7
266|5 - Advocates or facilitates patient's participation in appropriate medical care|5 - Advocates or facilitates patient's participation in appropriate medical care|7
267|5 - At least daily|5 - At least daily|7
268|5 - Bedfast, unable to ambulate or be up in a chair.|5 - Bedfast, unable to ambulate or be up in a chair.|7
269|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|7
270|5 - Disruptive or socially inappropriate behavior|5 - Disruptive or socially inappropriate behavior|7
271|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|7
272|5 - Hypo/Hyperglycemia, diabetes out of control|5 - Hypo/Hyperglycemia, diabetes out of control|7
273|5 - More often than once daily|5 - More often than once daily|7
274|5 - Native Hawaiian or Pacific Islander|5 - Native Hawaiian or Pacific Islander|7
275|5 - None of the above|5 - None of the above|7
276|5 - One to two times per week|5 - One to two times per week|7
277|5 - Other|5 - Other|7
278|5 - Other follow-up|5 - Other follow-up|7
279|5 - Paid help|5 - Paid help|7
280|5 - Patient nonresponsive or unable to speak.|5 - Patient nonresponsive or unable to speak.|7
281|5 - Thoughts of suicide|5 - Thoughts of suicide|7
282|5 - Totally unable to use the telephone.|5 - Totally unable to use the telephone.|7
283|5 - Unable to effectively participate in bathing and is totally bathed by another person.|5 - Unable to effectively participate in bathing and is totally bathed by another person.|7
284|5 - Unable to take in nutrients orally or by tube feeding.|5 - Unable to take in nutrients orally or by tube feeding.|7
285|5 - Unsafe for care at home|5 - Unsafe for care at home|7
286|5 - With paid help (other than home care agency staff)|5 - With paid help (other than home care agency staff)|7
287|5 - Workers' compensation|5 - Workers' compensation|7
288|5 - Wound infection, deteriorating wound status, new lesion/ulcer|5 - Wound infection, deteriorating wound status, new lesion/ulcer|7
289|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|7
290|6 - Delusional, hallucinatory, or paranoid behavior|6 - Delusional, hallucinatory, or paranoid behavior|7
291|6 - Financial agent, power of attorney, or conservator of finance|6 - Financial agent, power of attorney, or conservator of finance|7
292|6 - GI bleeding, obstruction|6 - GI bleeding, obstruction|7
293|6 - Less often than weekly|6 - Less often than weekly|7
294|6 - Memory loss to the extent that supervision required|6 - Memory loss to the extent that supervision required|7
295|6 - None of the above feelings observed or reported|6 - None of the above feelings observed or reported|7
296|6 - Other|6 - Other|7
297|6 - Title programs (e.g., Title III, V, or XX)|6 - Title programs (e.g., Title III, V, or XX)|7
298|6 - Transferred to an inpatient facility - patient not discharged from agency|6 - Transferred to an inpatient facility - patient not discharged from agency|7
299|6 - White|6 - White|7
300|6 - With other than above|6 - With other than above|7
301|7 - Exacerbation of CHF, fluid overload, heart failure|7 - Exacerbation of CHF, fluid overload, heart failure|7
302|7 - Health care agent, conservator of person, or medical power of attorney|7 - Health care agent, conservator of person, or medical power of attorney|7
303|7 - Hypo/Hyperglycemia, diabetes out of control|7 - Hypo/Hyperglycemia, diabetes out of control|7
304|7 - None of the above|7 - None of the above|7
305|7 - None of the above behaviors demonstrated|7 - None of the above behaviors demonstrated|7
306|7 - Other government (e.g., CHAMPUS, VA, etc.)|7 - Other government (e.g., CHAMPUS, VA, etc.)|7
307|7 - Transferred to an inpatient facility - patient discharged from agency|7 - Transferred to an inpatient facility - patient discharged from agency|7
308|8 - Death at home|8 - Death at home|7
309|8 - GI bleeding, obstruction|8 - GI bleeding, obstruction|7
310|8 - Myocardial infarction, stroke|8 - Myocardial infarction, stroke|7
311|8 - Private insurance|8 - Private insurance|7
312|9 - Chemotherapy|9 - Chemotherapy|7
313|9 - Discharge from agency|9 - Discharge from agency|7
314|9 - Other than above reasons|9 - Other than above reasons|7
315|9 - Private HMO/managed care|9 - Private HMO/managed care|7
316|NA - No caregiver|NA - No caregiver|7
317|NA - No equipment of this type used in care.|NA - No equipment of this type used in care.|7
318|NA - No inhalant/mist medications prescribed.|NA - No inhalant/mist medications prescribed.|7
319|NA - No injectable medications prescribed.|NA - No injectable medications prescribed.|7
320|NA - No inpatient facility admission|NA - No inpatient facility admission|7
321|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|7
322|NA - No Medicaid|NA - No Medicaid|7
323|NA - No Medicare|NA - No Medicare|7
324|NA - No observable pressure ulcer|NA - No observable pressure ulcer|7
325|NA - No observable stasis ulcer|NA - No observable stasis ulcer|7
326|NA - No observable surgical wound|NA - No observable surgical wound|7
327|NA - No oral medications prescribed.|NA - No oral medications prescribed.|7
328|NA - Not applicable|NA - Not applicable|7
329|NA - Patient does not have a telephone.|NA - Patient does not have a telephone.|7
330|NA - Patient has ostomy for bowel elimination|NA - Patient has ostomy for bowel elimination|7
331|NA - Patient nonresponsive|NA - Patient nonresponsive|7
332|NA - Patient on prophylactic treatment|NA - Patient on prophylactic treatment|7
333|NA - Patient was not discharged from an inpatient facility|NA - Patient was not discharged from an inpatient facility|7
334|UK - Other unknown|UK - Other unknown|7
335|UK - Reason unknown|UK - Reason unknown|7
336|UK - Unknown|UK - Unknown|7
337|UK - Unknown or Not Available|UK - Unknown or Not Available|7
341|01 - Early|01 - Early|7
342|02 - Late|02 - Late|7
343|NA - Not Applicable. No case mix group defined for this assessment.|NA - Not Applicable. No case mix group defined for this assessment.|7
344|NA - No case mix group defined by this assessment.|NA - No case mix group defined by this assessment.|7
2|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; OR (b) Is physically, cognitively, and mentally able to prepare light meals on a regular basis but has not routinely performed light meal preparation in the past (i.e., prior to this home care admission).|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; O|8
3|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and mentally able to perform all housekeeping tasks .|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and menta|8
4|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and mentally able to do laundry and access facilities.|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and menta|8
5|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying packages OR b) Physically, cognitively, and mentally able to take care of shopping, but has not done shopping in the past (i.e., prior to this home care admission).|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying|8
6|0 - Able to bathe self in SHOWER OR TUB independently.|0 - Able to bathe self in SHOWER OR TUB independently.|8
7|0 - Able to dial numbers and answer calls appropriately and as desired.|0 - Able to dial numbers and answer calls appropriately and as desired.|8
8|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body without assistance.|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body|8
9|0 - Able to get to and from the toilet independently with or without a device.|0 - Able to get to and from the toilet independently with or without a device.|8
10|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|8
11|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible public bus.|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible p|8
12|0 - Able to independently feed self.|0 - Able to independently feed self.|8
13|0 - Able to independently take the correct medication and proper dosage at the correct times.|0 - Able to independently take the correct medication and proper dosage at the correct times.|8
14|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct times.|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct ti|8
15|0 - Able to independently transfer.|0 - Able to independently transfer.|8
16|0 - Able to independently walk on even and uneven surfaces and climb stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even and uneven surfaces and climb stairs with or without railings|8
17|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings|8
18|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|8
19|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions independently.|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions indep|8
20|0 - Asymptomatic, no treatment needed at this time|0 - Asymptomatic, no treatment needed at this time|8
21|0 - Caregiver manages all tasks related to equipment completely independently.|0 - Caregiver manages all tasks related to equipment completely independently.|8
22|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations with no observable impairment.|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations w|8
23|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|8
24|0 - Life expectancy is greater than 6 months|0 - Life expectancy is greater than 6 months|8
25|0 - Never|0 - Never|8
26|0 - Never, patient is not short of breath|0 - Never, patient is not short of breath|8
27|0 - No|0 - No|8
28|0 - No emergent care services|0 - No emergent care services|8
29|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage)|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage)|8
30|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and extended or abstract conversation.|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and exte|8
31|0 - No one person|0 - No one person|8
32|0 - None of the time|0 - None of the time|8
33|0 - None, no charge for current services|0 - None, no charge for current services|8
34|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|8
35|0 - Patient does NOT have an ostomy for bowel elimination.|0 - Patient does NOT have an ostomy for bowel elimination.|8
36|0 - Patient has no pain or pain does not interfere with activity or movement|0 - Patient has no pain or pain does not interfere with activity or movement|8
37|0 - Patient manages all tasks related to equipment completely independently.|0 - Patient manages all tasks related to equipment completely independently.|8
38|0 - Poor:  little or no recovery is expected and/or further decline is imminent|0 - Poor:  little or no recovery is expected and/or further decline is imminent|8
39|0 - Timed-voiding defers incontinence|0 - Timed-voiding defers incontinence|8
40|0 - Very rarely or never has bowel incontinence|0 - Very rarely or never has bowel incontinence|8
41|0 - Zero|0 - Zero|8
42|00 - No|00 - No|8
43|01 - Yes|01 - Yes|8
44|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or mental limitations, needs assistance with heavy laundry.|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or|8
45|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the patient.|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the|8
46|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|8
47|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or supervision from another person OR c) a liquid, pureed or ground meat diet.|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or su|8
48|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|8
49|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|8
50|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independently.|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independe|8
51|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only when assisted or accompanied by another person.|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only w|8
52|1 - Able to take injectable medication at correct times if: a) individual syringes are prepared in advance by another person OR b) given daily reminders.|1 - Able to take injectable medication at correct times if: a) individual syringes are prepared in a|8
53|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance by another person OR b) given daily reminders.|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance b|8
54|1 - Able to take medication(s) at the correct times if: a) individual dosages are prepared in advance by another person , OR b) given daily reminders OR c) someone develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if: a) individual dosages are prepared in advanc|8
55|1 - Able to take medication(s) at the correct times if: a) individual dosages are prepared in advance by another person, OR b) given daily reminders OR c) someone develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if: a) individual dosages are prepared in advanc|8
56|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for the deaf) and call essential numbers.|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for t|8
57|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|8
58|1 - American Indian or Alaska Native|1 - American Indian or Alaska Native|8
59|1 - Depressed mood (e.g., feeling sad, tearful)|1 - Depressed mood (e.g., feeling sad, tearful)|8
60|1 - During the night only|1 - During the night only|8
61|1 - Fully granulating|1 - Fully granulating|8
62|1 - Good/Fair:  partial to full recovery is expected|1 - Good/Fair:  partial to full recovery is expected|8
63|1 - Good:  marked improvement in functional status is expected|1 - Good:  marked improvement in functional status is expected|8
64|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|8
65|1 - Heavy smoking|1 - Heavy smoking|8
66|1 - Hospital|1 - Hospital|8
67|1 - Hospital emergency room (includes 23-hour holding)|1 - Hospital emergency room (includes 23-hour holding)|8
68|1 - Hospitalization for EMERGENT (unscheduled) care|1 - Hospitalization for EMERGENT (unscheduled) care|8
69|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepared solutions), patient is able to manage all other aspects of equipment.|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepar|8
70|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|8
71|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|8
72|1 - In new or complex situations only|1 - In new or complex situations only|8
73|1 - Intravenous or infusion therapy (excludes TPN)|1 - Intravenous or infusion therapy (excludes TPN)|8
74|1 - Less often than daily|1 - Less often than daily|8
75|1 - Less than once a month|1 - Less than once a month|8
76|1 - Less than once weekly|1 - Less than once weekly|8
77|1 - Life expectancy is 6 months or fewer|1 - Life expectancy is 6 months or fewer|8
78|1 - Lives alone|1 - Lives alone|8
79|1 - Male|1 - Male|8
80|1 - Medicare (traditional fee-for-service)|1 - Medicare (traditional fee-for-service)|8
81|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of past 24 hours, significant memory loss so that supervision is required|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of pas|8
82|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors in word choice, grammar or speech intelligibility, needs minimal prompting or assistance).|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors i|8
83|1 - No assistance or services received|1 - No assistance or services received|8
84|1 - One|1 - One|8
85|1 - Oxygen (intermittent or continuous)|1 - Oxygen (intermittent or continuous)|8
86|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, and the surrounding layout, can count fingers at arm's length.|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, a|8
87|1 - Patient is incontinent|1 - Patient is incontinent|8
88|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|8
89|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical or treatment regimen.|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical|8
90|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient/couple/significant other)|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient|8
91|1 - Relatives, friends, or neighbors living outside the home|1 - Relatives, friends, or neighbors living outside the home|8
92|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions.|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions|8
93|1 - Requires use of a device (e.g., cane, walker) to walk alone OR requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|1 - Requires use of a device (e.g., cane, walker) to walk alone OR requires human supervision or ass|8
94|1 - Several times during day and night|1 - Several times during day and night|8
95|1 - Spouse or significant other|1 - Spouse or significant other|8
96|1 - Stage 1|1 - Stage 1|8
97|1 - Start of care - further visits planned|1 - Start of care - further visits planned|8
98|1 - Symptoms well controlled with current therapy|1 - Symptoms well controlled with current therapy|8
99|1 - Therapy services|1 - Therapy services|8
100|1 - Transfers with minimal human assistance or with use of an assistive device.|1 - Transfers with minimal human assistance or with use of an assistive device.|8
101|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitations.|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitatio|8
102|1 - Urinary incontinence|1 - Urinary incontinence|8
103|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet.|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet.|8
104|1 - When walking more than 20 feet, climbing stairs|1 - When walking more than 20 feet, climbing stairs|8
105|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary conversation. May need occasional repetition, extra time, or louder voice.|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary c|8
106|1 - With the use of devices, is able to bathe self in shower or tub independently.|1 - With the use of devices, is able to bathe self in shower or tub independently.|8
107|1 - Yes|1 - Yes|8
108|1-RN|1-RN|8
109|10 - Discharge from agency - no visits completed after start/resumption of care assessment|10 - Discharge from agency - no visits completed after start/resumption of care assessment|8
110|10 - Scheduled surgical procedure|10 - Scheduled surgical procedure|8
111|10 - Self-pay|10 - Self-pay|8
112|11 - Other|11 - Other|8
113|11 - Urinary tract infection|11 - Urinary tract infection|8
114|12 - IV catheter-related infection|12 - IV catheter-related infection|8
115|13 - Deep vein thrombosis, pulmonary embolus|13 - Deep vein thrombosis, pulmonary embolus|8
116|14 - Uncontrolled pain|14 - Uncontrolled pain|8
117|15 - Psychotic episode|15 - Psychotic episode|8
118|16 - Other than above reasons|16 - Other than above reasons|8
119|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing calls.|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing|8
120|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another person.|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another pers|8
121|2 - Able to walk only with the supervision or assistance of another person at all times.|2 - Able to walk only with the supervision or assistance of another person at all times.|8
122|2 - Aid: a) for intermittent supervision/encouragement/reminders, OR b) to get in and out of the shower/tub, OR c) for washing difficult to reach areas.|2 - Aid: a) for intermittent supervision/encouragement/reminders, OR b) to get in and out of the sho|8
123|2 - Asian|2 - Asian|8
124|2 - Caregiver requires considerable assistance from another person to manage equipment, but independently completes significant portions of task.|2 - Caregiver requires considerable assistance from another person to manage equipment, but independ|8
125|2 - Daily, but not constantly|2 - Daily, but not constantly|8
126|2 - Daughter or son|2 - Daughter or son|8
127|2 - Doctor's office emergency visit/house call|2 - Doctor's office emergency visit/house call|8
128|2 - During the day and night|2 - During the day and night|8
129|2 - Early/partial granulation|2 - Early/partial granulation|8
130|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors in word choice, organization or speech intelligibility). Speaks in phrases or short sentences.|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors|8
131|2 - Family member's residence|2 - Family member's residence|8
132|2 - Female|2 - Female|8
133|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conversation, needs frequent prompting or assistance.|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conver|8
134|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|8
135|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|8
136|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately stop activities, jeopardizes safety through actions|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately st|8
137|2 - Indwelling/suprapubic catheter|2 - Indwelling/suprapubic catheter|8
138|2 - Injury caused by fall or accident at home|2 - Injury caused by fall or accident at home|8
139|2 - Medicare (HMO/managed care)|2 - Medicare (HMO/managed care)|8
140|2 - Nausea, dehydration, malnutrition, constipation, impaction|2 - Nausea, dehydration, malnutrition, constipation, impaction|8
141|2 - Obesity|2 - Obesity|8
142|2 - On awakening or at night only|2 - On awakening or at night only|8
143|2 - Once a month|2 - Once a month|8
144|2 - One to three times weekly|2 - One to three times weekly|8
145|2 - Parenteral nutrition (TPN or lipids)|2 - Parenteral nutrition (TPN or lipids)|8
146|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic)|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic)|8
147|2 - Patient requires considerable assistance from another person to manage equipment, but independently completes portions of the task.|2 - Patient requires considerable assistance from another person to manage equipment, but independen|8
148|2 - Patient transferred to a noninstitutional hospice|2 - Patient transferred to a noninstitutional hospice|8
149|2 - Person residing in the home (EXCLUDING paid help)|2 - Person residing in the home (EXCLUDING paid help)|8
150|2 - Rehabilitation facility|2 - Rehabilitation facility|8
151|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifting of attention) or consistently requires low stimulus environment due to distractibility.|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifti|8
152|2 - Respite care|2 - Respite care|8
153|2 - Sense of failure or self reproach|2 - Sense of failure or self reproach|8
154|2 - Several times during day|2 - Several times during day|8
155|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonresponsive.|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonrespons|8
156|2 - Someone must assist the patient to groom self.|2 - Someone must assist the patient to groom self.|8
157|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|8
158|2 - Someone must help the patient put on upper body clothing.|2 - Someone must help the patient put on upper body clothing.|8
159|2 - Stage 2|2 - Stage 2|8
160|2 - Start of care - no further visits planned|2 - Start of care - no further visits planned|8
161|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitoring|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitori|8
162|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment regimen.|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment re|8
163|2 - Two|2 - Two|8
164|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistance due to cognitive or mental limitation.|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistanc|8
165|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|8
166|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assistance).|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assis|8
167|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home delivery.|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home deli|8
168|2 - Unable to prepare any light meals or reheat any delivered meals.|2 - Unable to prepare any light meals or reheat any delivered meals.|8
169|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|8
170|2 - UNABLE to take injectable medications unless administered by someone else.|2 - UNABLE to take injectable medications unless administered by someone else.|8
171|2 - UNABLE to take medication unless administered by someone else.|2 - UNABLE to take medication unless administered by someone else.|8
172|2 - UNABLE to transfer self but is able to bear weight and pivot during the transfer process.|2 - UNABLE to transfer self but is able to bear weight and pivot during the transfer process.|8
173|2 - Ventilator (continually or at night)|2 - Ventilator (continually or at night)|8
174|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less than 20 feet)|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less th|8
175|2 - With spouse or significant other|2 - With spouse or significant other|8
176|2 - Yes, assistance or services provided by family or friends|2 - Yes, assistance or services provided by family or friends|8
177|2-PT|2-PT|8
178|3 - Able to answer the telephone only some of the time or is able to carry on only a limited conversation.|3 - Able to answer the telephone only some of the time or is able to carry on only a limited convers|8
179|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube or gastrostomy.|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube|8
180|3 - Alcohol dependency|3 - Alcohol dependency|8
181|3 - All of the time|3 - All of the time|8
182|3 - Black or African-American|3 - Black or African-American|8
183|3 - Boarding home or rented room|3 - Boarding home or rented room|8
184|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment, clean/store/dispose of equipment or supplies).|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment,|8
185|3 - Chairfast, UNABLE to ambulate but is able to wheel self independently.|3 - Chairfast, UNABLE to ambulate but is able to wheel self independently.|8
186|3 - Continuous positive airway pressure|3 - Continuous positive airway pressure|8
187|3 - During the day and evening, but not constantly|3 - During the day and evening, but not constantly|8
188|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the alimentary canal)|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the|8
189|3 - Environmental support (e.g., housing, home maintenance)|3 - Environmental support (e.g., housing, home maintenance)|8
190|3 - Four to six times weekly|3 - Four to six times weekly|8
191|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessing by listener.  Speech limited to single words or short phrases.|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessin|8
192|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires multiple repetitions, restatements, demonstrations, additional time.|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires m|8
193|3 - Hopelessness|3 - Hopelessness|8
194|3 - Hospice care|3 - Hospice care|8
195|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|8
196|3 - Injury caused by fall or accident at home|3 - Injury caused by fall or accident at home|8
197|3 - Intractable pain|3 - Intractable pain|8
198|3 - Medicaid (traditional fee-for-service)|3 - Medicaid (traditional fee-for-service)|8
199|3 - Needs someone to do all shopping and errands.|3 - Needs someone to do all shopping and errands.|8
200|3 - Not healing|3 - Not healing|8
201|3 - Nursing home|3 - Nursing home|8
202|3 - Once daily|3 - Once daily|8
203|3 - Other family member|3 - Other family member|8
204|3 - Outpatient department/clinic emergency (includes urgicenter sites)|3 - Outpatient department/clinic emergency (includes urgicenter sites)|8
205|3 - Paid help|3 - Paid help|8
206|3 - Participates in bathing self in shower or tub, BUT requires presence of another person throughout the bath for assistance or supervision.|3 - Participates in bathing self in shower or tub, BUT requires presence of another person throughou|8
207|3 - Patient depends entirely upon another person to dress lower body.|3 - Patient depends entirely upon another person to dress lower body.|8
208|3 - Patient depends entirely upon another person to dress the upper body.|3 - Patient depends entirely upon another person to dress the upper body.|8
209|3 - Patient depends entirely upon someone else for grooming needs.|3 - Patient depends entirely upon someone else for grooming needs.|8
210|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone else to manage the equipment.|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone|8
211|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable to shift attention and recall directions more than half the time.|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable|8
212|3 - Respiratory problems (SOB, infection, obstruction)|3 - Respiratory problems (SOB, infection, obstruction)|8
213|3 - Resumption of care (after inpatient stay)|3 - Resumption of care (after inpatient stay)|8
214|3 - Several times each month|3 - Several times each month|8
215|3 - Skilled Nursing Facility|3 - Skilled Nursing Facility|8
216|3 - Stage 3|3 - Stage 3|8
217|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|8
218|3 - Three|3 - Three|8
219|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person throughout the process.|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person through|8
220|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal independently.|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal indep|8
221|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person.|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person|8
222|3 - Unknown because patient moved to a geographic location not served by this agency|3 - Unknown because patient moved to a geographic location not served by this agency|8
223|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|8
224|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|8
225|3 - With other family member|3 - With other family member|8
226|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home health services, homemaker assistance, transportation assistance, assisted living, board and care)|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home h|8
227|3-SLP/ST|3-SLP/ST|8
228|4 - At rest (during day or night)|4 - At rest (during day or night)|8
229|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|8
230|4 - Board and care or assisted living facility|4 - Board and care or assisted living facility|8
231|4 - Caregiver is completely dependent on someone else to manage all equipment.|4 - Caregiver is completely dependent on someone else to manage all equipment.|8
232|4 - Chairfast, unable to ambulate and is UNABLE to wheel self.|4 - Chairfast, unable to ambulate and is UNABLE to wheel self.|8
233|4 - Constantly|4 - Constantly|8
234|4 - Drug dependency|4 - Drug dependency|8
235|4 - Four or more|4 - Four or more|8
236|4 - Friend or neighbor or community or church member|4 - Friend or neighbor or community or church member|8
237|4 - Hispanic or Latino|4 - Hispanic or Latino|8
238|4 - Hospice|4 - Hospice|8
239|4 - Impaired decision-making|4 - Impaired decision-making|8
240|4 - Is totally dependent in toileting.|4 - Is totally dependent in toileting.|8
241|4 - Medicaid (HMO/managed care)|4 - Medicaid (HMO/managed care)|8
242|4 - None of the above|4 - None of the above|8
243|4 - Nursing home|4 - Nursing home|8
244|4 - On a daily basis|4 - On a daily basis|8
245|4 - Patient is completely dependent on someone else to manage all equipment.|4 - Patient is completely dependent on someone else to manage all equipment.|8
246|4 - Permanent placement|4 - Permanent placement|8
247|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, punches, dangerous maneuvers w/ wheelchair or other objects)|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, pu|8
248|4 - Psychosocial support (e.g., socialization, companionship, recreation)|4 - Psychosocial support (e.g., socialization, companionship, recreation)|8
249|4 - Recertification (follow-up) reassessment|4 - Recertification (follow-up) reassessment|8
250|4 - Recurrent thoughts of death|4 - Recurrent thoughts of death|8
251|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruction)|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruc|8
252|4 - Several times a week|4 - Several times a week|8
253|4 - Stage 4|4 - Stage 4|8
254|4 - Symptoms poorly controlled, history of rehospitalizations|4 - Symptoms poorly controlled, history of rehospitalizations|8
255|4 - Three or more times per week|4 - Three or more times per week|8
256|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetative state, or delirium.|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetati|8
257|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|8
258|4 - Unable to effectively participate in any housekeeping tasks.|4 - Unable to effectively participate in any housekeeping tasks.|8
259|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or unresponsive (e.g., speech is nonsensical or unintelligible).|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or u|8
260|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonresponsive.|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonr|8
261|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostomy.|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostom|8
262|4 - UNABLE to use the shower or tub and is bathed in BED OR BEDSIDE CHAIR.|4 - UNABLE to use the shower or tub and is bathed in BED OR BEDSIDE CHAIR.|8
263|4 - With a friend|4 - With a friend|8
264|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|8
265|4-OT|4-OT|8
266|5 - Advocates or facilitates patient's participation in appropriate medical care|5 - Advocates or facilitates patient's participation in appropriate medical care|8
267|5 - At least daily|5 - At least daily|8
268|5 - Bedfast, unable to ambulate or be up in a chair.|5 - Bedfast, unable to ambulate or be up in a chair.|8
269|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|8
270|5 - Disruptive or socially inappropriate behavior|5 - Disruptive or socially inappropriate behavior|8
271|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|8
272|5 - Hypo/Hyperglycemia, diabetes out of control|5 - Hypo/Hyperglycemia, diabetes out of control|8
273|5 - More often than once daily|5 - More often than once daily|8
274|5 - Native Hawaiian or Pacific Islander|5 - Native Hawaiian or Pacific Islander|8
275|5 - None of the above|5 - None of the above|8
276|5 - One to two times per week|5 - One to two times per week|8
277|5 - Other|5 - Other|8
278|5 - Other follow-up|5 - Other follow-up|8
279|5 - Paid help|5 - Paid help|8
280|5 - Patient nonresponsive or unable to speak.|5 - Patient nonresponsive or unable to speak.|8
281|5 - Thoughts of suicide|5 - Thoughts of suicide|8
282|5 - Totally unable to use the telephone.|5 - Totally unable to use the telephone.|8
283|5 - Unable to effectively participate in bathing and is totally bathed by another person.|5 - Unable to effectively participate in bathing and is totally bathed by another person.|8
284|5 - Unable to take in nutrients orally or by tube feeding.|5 - Unable to take in nutrients orally or by tube feeding.|8
285|5 - Unsafe for care at home|5 - Unsafe for care at home|8
286|5 - With paid help (other than home care agency staff)|5 - With paid help (other than home care agency staff)|8
287|5 - Workers' compensation|5 - Workers' compensation|8
288|5 - Wound infection, deteriorating wound status, new lesion/ulcer|5 - Wound infection, deteriorating wound status, new lesion/ulcer|8
289|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|8
290|6 - Delusional, hallucinatory, or paranoid behavior|6 - Delusional, hallucinatory, or paranoid behavior|8
291|6 - Financial agent, power of attorney, or conservator of finance|6 - Financial agent, power of attorney, or conservator of finance|8
292|6 - GI bleeding, obstruction|6 - GI bleeding, obstruction|8
293|6 - Less often than weekly|6 - Less often than weekly|8
294|6 - Memory loss to the extent that supervision required|6 - Memory loss to the extent that supervision required|8
295|6 - None of the above feelings observed or reported|6 - None of the above feelings observed or reported|8
296|6 - Other|6 - Other|8
297|6 - Title programs (e.g., Title III, V, or XX)|6 - Title programs (e.g., Title III, V, or XX)|8
298|6 - Transferred to an inpatient facility - patient not discharged from agency|6 - Transferred to an inpatient facility - patient not discharged from agency|8
299|6 - White|6 - White|8
300|6 - With other than above|6 - With other than above|8
301|7 - Exacerbation of CHF, fluid overload, heart failure|7 - Exacerbation of CHF, fluid overload, heart failure|8
302|7 - Health care agent, conservator of person, or medical power of attorney|7 - Health care agent, conservator of person, or medical power of attorney|8
303|7 - Hypo/Hyperglycemia, diabetes out of control|7 - Hypo/Hyperglycemia, diabetes out of control|8
304|7 - None of the above|7 - None of the above|8
305|7 - None of the above behaviors demonstrated|7 - None of the above behaviors demonstrated|8
306|7 - Other government (e.g., CHAMPUS, VA, etc.)|7 - Other government (e.g., CHAMPUS, VA, etc.)|8
307|7 - Transferred to an inpatient facility - patient discharged from agency|7 - Transferred to an inpatient facility - patient discharged from agency|8
308|8 - Death at home|8 - Death at home|8
309|8 - GI bleeding, obstruction|8 - GI bleeding, obstruction|8
310|8 - Myocardial infarction, stroke|8 - Myocardial infarction, stroke|8
311|8 - Private insurance|8 - Private insurance|8
312|9 - Chemotherapy|9 - Chemotherapy|8
313|9 - Discharge from agency|9 - Discharge from agency|8
314|9 - Other than above reasons|9 - Other than above reasons|8
315|9 - Private HMO/managed care|9 - Private HMO/managed care|8
316|NA - No caregiver|NA - No caregiver|8
317|NA - No equipment of this type used in care.|NA - No equipment of this type used in care.|8
318|NA - No inhalant/mist medications prescribed.|NA - No inhalant/mist medications prescribed.|8
319|NA - No injectable medications prescribed.|NA - No injectable medications prescribed.|8
320|NA - No inpatient facility admission|NA - No inpatient facility admission|8
321|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|8
322|NA - No Medicaid|NA - No Medicaid|8
323|NA - No Medicare|NA - No Medicare|8
324|NA - No observable pressure ulcer|NA - No observable pressure ulcer|8
325|NA - No observable stasis ulcer|NA - No observable stasis ulcer|8
326|NA - No observable surgical wound|NA - No observable surgical wound|8
327|NA - No oral medications prescribed.|NA - No oral medications prescribed.|8
328|NA - Not applicable|NA - Not applicable|8
329|NA - Patient does not have a telephone.|NA - Patient does not have a telephone.|8
330|NA - Patient has ostomy for bowel elimination|NA - Patient has ostomy for bowel elimination|8
331|NA - Patient nonresponsive|NA - Patient nonresponsive|8
332|NA - Patient on prophylactic treatment|NA - Patient on prophylactic treatment|8
333|NA - Patient was not discharged from an inpatient facility|NA - Patient was not discharged from an inpatient facility|8
334|UK - Other unknown|UK - Other unknown|8
335|UK - Reason unknown|UK - Reason unknown|8
336|UK - Unknown|UK - Unknown|8
337|UK - Unknown or Not Available|UK - Unknown or Not Available|8
341|01 - Early|01 - Early|8
342|02 - Late|02 - Late|8
343|NA - Not Applicable. No case mix group defined for this assessment.|NA - Not Applicable. No case mix group defined for this assessment.|8
344|NA - No case mix group defined by this assessment.|NA - No case mix group defined by this assessment.|8
2|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; OR (b) Is physically, cognitively, and mentally able to prepare light meals on a regular basis but has not routinely performed light meal preparation in the past (i.e., prior to this home care admission).|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; O|9
3|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and mentally able to perform all housekeeping tasks .|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and menta|9
4|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and mentally able to do laundry and access facilities.|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and menta|9
5|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying packages OR b) Physically, cognitively, and mentally able to take care of shopping, but has not done shopping in the past (i.e., prior to this home care admission).|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying|9
6|0 - Able to bathe self in SHOWER OR TUB independently.|0 - Able to bathe self in SHOWER OR TUB independently.|9
7|0 - Able to dial numbers and answer calls appropriately and as desired.|0 - Able to dial numbers and answer calls appropriately and as desired.|9
8|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body without assistance.|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body|9
9|0 - Able to get to and from the toilet independently with or without a device.|0 - Able to get to and from the toilet independently with or without a device.|9
10|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|9
11|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible public bus.|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible p|9
12|0 - Able to independently feed self.|0 - Able to independently feed self.|9
13|0 - Able to independently take the correct medication and proper dosage at the correct times.|0 - Able to independently take the correct medication and proper dosage at the correct times.|9
14|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct times.|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct ti|9
15|0 - Able to independently transfer.|0 - Able to independently transfer.|9
16|0 - Able to independently walk on even and uneven surfaces and climb stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even and uneven surfaces and climb stairs with or without railings|9
17|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings|9
18|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|9
19|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions independently.|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions indep|9
20|0 - Asymptomatic, no treatment needed at this time|0 - Asymptomatic, no treatment needed at this time|9
21|0 - Caregiver manages all tasks related to equipment completely independently.|0 - Caregiver manages all tasks related to equipment completely independently.|9
22|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations with no observable impairment.|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations w|9
23|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|9
24|0 - Life expectancy is greater than 6 months|0 - Life expectancy is greater than 6 months|9
25|0 - Never|0 - Never|9
26|0 - Never, patient is not short of breath|0 - Never, patient is not short of breath|9
27|0 - No|0 - No|9
28|0 - No emergent care services|0 - No emergent care services|9
29|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage)|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage)|9
30|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and extended or abstract conversation.|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and exte|9
31|0 - No one person|0 - No one person|9
32|0 - None of the time|0 - None of the time|9
33|0 - None, no charge for current services|0 - None, no charge for current services|9
34|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|9
35|0 - Patient does NOT have an ostomy for bowel elimination.|0 - Patient does NOT have an ostomy for bowel elimination.|9
36|0 - Patient has no pain or pain does not interfere with activity or movement|0 - Patient has no pain or pain does not interfere with activity or movement|9
37|0 - Patient manages all tasks related to equipment completely independently.|0 - Patient manages all tasks related to equipment completely independently.|9
38|0 - Poor:  little or no recovery is expected and/or further decline is imminent|0 - Poor:  little or no recovery is expected and/or further decline is imminent|9
39|0 - Timed-voiding defers incontinence|0 - Timed-voiding defers incontinence|9
40|0 - Very rarely or never has bowel incontinence|0 - Very rarely or never has bowel incontinence|9
41|0 - Zero|0 - Zero|9
42|00 - No|00 - No|9
43|01 - Yes|01 - Yes|9
44|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or mental limitations, needs assistance with heavy laundry.|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or|9
45|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the patient.|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the|9
46|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|9
47|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or supervision from another person OR c) a liquid, pureed or ground meat diet.|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or su|9
48|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|9
49|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|9
50|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independently.|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independe|9
51|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only when assisted or accompanied by another person.|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only w|9
52|1 - Able to take injectable medication at correct times if: a) individual syringes are prepared in advance by another person OR b) given daily reminders.|1 - Able to take injectable medication at correct times if: a) individual syringes are prepared in a|9
53|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance by another person OR b) given daily reminders.|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance b|9
54|1 - Able to take medication(s) at the correct times if: a) individual dosages are prepared in advance by another person , OR b) given daily reminders OR c) someone develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if: a) individual dosages are prepared in advanc|9
55|1 - Able to take medication(s) at the correct times if: a) individual dosages are prepared in advance by another person, OR b) given daily reminders OR c) someone develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if: a) individual dosages are prepared in advanc|9
56|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for the deaf) and call essential numbers.|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for t|9
57|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|9
58|1 - American Indian or Alaska Native|1 - American Indian or Alaska Native|9
59|1 - Depressed mood (e.g., feeling sad, tearful)|1 - Depressed mood (e.g., feeling sad, tearful)|9
60|1 - During the night only|1 - During the night only|9
61|1 - Fully granulating|1 - Fully granulating|9
62|1 - Good/Fair:  partial to full recovery is expected|1 - Good/Fair:  partial to full recovery is expected|9
63|1 - Good:  marked improvement in functional status is expected|1 - Good:  marked improvement in functional status is expected|9
64|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|9
65|1 - Heavy smoking|1 - Heavy smoking|9
66|1 - Hospital|1 - Hospital|9
67|1 - Hospital emergency room (includes 23-hour holding)|1 - Hospital emergency room (includes 23-hour holding)|9
68|1 - Hospitalization for EMERGENT (unscheduled) care|1 - Hospitalization for EMERGENT (unscheduled) care|9
69|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepared solutions), patient is able to manage all other aspects of equipment.|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepar|9
70|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|9
71|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|9
72|1 - In new or complex situations only|1 - In new or complex situations only|9
73|1 - Intravenous or infusion therapy (excludes TPN)|1 - Intravenous or infusion therapy (excludes TPN)|9
74|1 - Less often than daily|1 - Less often than daily|9
75|1 - Less than once a month|1 - Less than once a month|9
76|1 - Less than once weekly|1 - Less than once weekly|9
77|1 - Life expectancy is 6 months or fewer|1 - Life expectancy is 6 months or fewer|9
78|1 - Lives alone|1 - Lives alone|9
79|1 - Male|1 - Male|9
80|1 - Medicare (traditional fee-for-service)|1 - Medicare (traditional fee-for-service)|9
81|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of past 24 hours, significant memory loss so that supervision is required|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of pas|9
82|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors in word choice, grammar or speech intelligibility, needs minimal prompting or assistance).|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors i|9
83|1 - No assistance or services received|1 - No assistance or services received|9
84|1 - One|1 - One|9
85|1 - Oxygen (intermittent or continuous)|1 - Oxygen (intermittent or continuous)|9
86|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, and the surrounding layout, can count fingers at arm's length.|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, a|9
87|1 - Patient is incontinent|1 - Patient is incontinent|9
88|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|9
89|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical or treatment regimen.|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical|9
90|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient/couple/significant other)|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient|9
91|1 - Relatives, friends, or neighbors living outside the home|1 - Relatives, friends, or neighbors living outside the home|9
92|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions.|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions|9
93|1 - Requires use of a device (e.g., cane, walker) to walk alone OR requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|1 - Requires use of a device (e.g., cane, walker) to walk alone OR requires human supervision or ass|9
94|1 - Several times during day and night|1 - Several times during day and night|9
95|1 - Spouse or significant other|1 - Spouse or significant other|9
96|1 - Stage 1|1 - Stage 1|9
97|1 - Start of care - further visits planned|1 - Start of care - further visits planned|9
98|1 - Symptoms well controlled with current therapy|1 - Symptoms well controlled with current therapy|9
99|1 - Therapy services|1 - Therapy services|9
100|1 - Transfers with minimal human assistance or with use of an assistive device.|1 - Transfers with minimal human assistance or with use of an assistive device.|9
101|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitations.|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitatio|9
102|1 - Urinary incontinence|1 - Urinary incontinence|9
103|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet.|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet.|9
104|1 - When walking more than 20 feet, climbing stairs|1 - When walking more than 20 feet, climbing stairs|9
105|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary conversation. May need occasional repetition, extra time, or louder voice.|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary c|9
106|1 - With the use of devices, is able to bathe self in shower or tub independently.|1 - With the use of devices, is able to bathe self in shower or tub independently.|9
107|1 - Yes|1 - Yes|9
108|1-RN|1-RN|9
109|10 - Discharge from agency - no visits completed after start/resumption of care assessment|10 - Discharge from agency - no visits completed after start/resumption of care assessment|9
110|10 - Scheduled surgical procedure|10 - Scheduled surgical procedure|9
111|10 - Self-pay|10 - Self-pay|9
112|11 - Other|11 - Other|9
113|11 - Urinary tract infection|11 - Urinary tract infection|9
114|12 - IV catheter-related infection|12 - IV catheter-related infection|9
115|13 - Deep vein thrombosis, pulmonary embolus|13 - Deep vein thrombosis, pulmonary embolus|9
116|14 - Uncontrolled pain|14 - Uncontrolled pain|9
117|15 - Psychotic episode|15 - Psychotic episode|9
118|16 - Other than above reasons|16 - Other than above reasons|9
119|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing calls.|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing|9
120|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another person.|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another pers|9
121|2 - Able to walk only with the supervision or assistance of another person at all times.|2 - Able to walk only with the supervision or assistance of another person at all times.|9
122|2 - Aid: a) for intermittent supervision/encouragement/reminders, OR b) to get in and out of the shower/tub, OR c) for washing difficult to reach areas.|2 - Aid: a) for intermittent supervision/encouragement/reminders, OR b) to get in and out of the sho|9
123|2 - Asian|2 - Asian|9
124|2 - Caregiver requires considerable assistance from another person to manage equipment, but independently completes significant portions of task.|2 - Caregiver requires considerable assistance from another person to manage equipment, but independ|9
125|2 - Daily, but not constantly|2 - Daily, but not constantly|9
126|2 - Daughter or son|2 - Daughter or son|9
127|2 - Doctor's office emergency visit/house call|2 - Doctor's office emergency visit/house call|9
128|2 - During the day and night|2 - During the day and night|9
129|2 - Early/partial granulation|2 - Early/partial granulation|9
130|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors in word choice, organization or speech intelligibility). Speaks in phrases or short sentences.|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors|9
131|2 - Family member's residence|2 - Family member's residence|9
132|2 - Female|2 - Female|9
133|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conversation, needs frequent prompting or assistance.|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conver|9
134|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|9
135|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|9
136|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately stop activities, jeopardizes safety through actions|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately st|9
137|2 - Indwelling/suprapubic catheter|2 - Indwelling/suprapubic catheter|9
138|2 - Injury caused by fall or accident at home|2 - Injury caused by fall or accident at home|9
139|2 - Medicare (HMO/managed care)|2 - Medicare (HMO/managed care)|9
140|2 - Nausea, dehydration, malnutrition, constipation, impaction|2 - Nausea, dehydration, malnutrition, constipation, impaction|9
141|2 - Obesity|2 - Obesity|9
142|2 - On awakening or at night only|2 - On awakening or at night only|9
143|2 - Once a month|2 - Once a month|9
144|2 - One to three times weekly|2 - One to three times weekly|9
145|2 - Parenteral nutrition (TPN or lipids)|2 - Parenteral nutrition (TPN or lipids)|9
146|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic)|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic)|9
147|2 - Patient requires considerable assistance from another person to manage equipment, but independently completes portions of the task.|2 - Patient requires considerable assistance from another person to manage equipment, but independen|9
148|2 - Patient transferred to a noninstitutional hospice|2 - Patient transferred to a noninstitutional hospice|9
149|2 - Person residing in the home (EXCLUDING paid help)|2 - Person residing in the home (EXCLUDING paid help)|9
150|2 - Rehabilitation facility|2 - Rehabilitation facility|9
151|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifting of attention) or consistently requires low stimulus environment due to distractibility.|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifti|9
152|2 - Respite care|2 - Respite care|9
153|2 - Sense of failure or self reproach|2 - Sense of failure or self reproach|9
154|2 - Several times during day|2 - Several times during day|9
155|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonresponsive.|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonrespons|9
156|2 - Someone must assist the patient to groom self.|2 - Someone must assist the patient to groom self.|9
157|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|9
158|2 - Someone must help the patient put on upper body clothing.|2 - Someone must help the patient put on upper body clothing.|9
159|2 - Stage 2|2 - Stage 2|9
160|2 - Start of care - no further visits planned|2 - Start of care - no further visits planned|9
161|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitoring|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitori|9
162|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment regimen.|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment re|9
163|2 - Two|2 - Two|9
164|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistance due to cognitive or mental limitation.|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistanc|9
165|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|9
166|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assistance).|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assis|9
167|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home delivery.|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home deli|9
168|2 - Unable to prepare any light meals or reheat any delivered meals.|2 - Unable to prepare any light meals or reheat any delivered meals.|9
169|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|9
170|2 - UNABLE to take injectable medications unless administered by someone else.|2 - UNABLE to take injectable medications unless administered by someone else.|9
171|2 - UNABLE to take medication unless administered by someone else.|2 - UNABLE to take medication unless administered by someone else.|9
172|2 - UNABLE to transfer self but is able to bear weight and pivot during the transfer process.|2 - UNABLE to transfer self but is able to bear weight and pivot during the transfer process.|9
173|2 - Ventilator (continually or at night)|2 - Ventilator (continually or at night)|9
174|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less than 20 feet)|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less th|9
175|2 - With spouse or significant other|2 - With spouse or significant other|9
176|2 - Yes, assistance or services provided by family or friends|2 - Yes, assistance or services provided by family or friends|9
177|2-PT|2-PT|9
178|3 - Able to answer the telephone only some of the time or is able to carry on only a limited conversation.|3 - Able to answer the telephone only some of the time or is able to carry on only a limited convers|9
179|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube or gastrostomy.|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube|9
180|3 - Alcohol dependency|3 - Alcohol dependency|9
181|3 - All of the time|3 - All of the time|9
182|3 - Black or African-American|3 - Black or African-American|9
183|3 - Boarding home or rented room|3 - Boarding home or rented room|9
184|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment, clean/store/dispose of equipment or supplies).|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment,|9
185|3 - Chairfast, UNABLE to ambulate but is able to wheel self independently.|3 - Chairfast, UNABLE to ambulate but is able to wheel self independently.|9
186|3 - Continuous positive airway pressure|3 - Continuous positive airway pressure|9
187|3 - During the day and evening, but not constantly|3 - During the day and evening, but not constantly|9
188|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the alimentary canal)|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the|9
189|3 - Environmental support (e.g., housing, home maintenance)|3 - Environmental support (e.g., housing, home maintenance)|9
190|3 - Four to six times weekly|3 - Four to six times weekly|9
191|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessing by listener.  Speech limited to single words or short phrases.|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessin|9
192|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires multiple repetitions, restatements, demonstrations, additional time.|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires m|9
193|3 - Hopelessness|3 - Hopelessness|9
194|3 - Hospice care|3 - Hospice care|9
195|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|9
196|3 - Injury caused by fall or accident at home|3 - Injury caused by fall or accident at home|9
197|3 - Intractable pain|3 - Intractable pain|9
198|3 - Medicaid (traditional fee-for-service)|3 - Medicaid (traditional fee-for-service)|9
199|3 - Needs someone to do all shopping and errands.|3 - Needs someone to do all shopping and errands.|9
200|3 - Not healing|3 - Not healing|9
201|3 - Nursing home|3 - Nursing home|9
202|3 - Once daily|3 - Once daily|9
203|3 - Other family member|3 - Other family member|9
204|3 - Outpatient department/clinic emergency (includes urgicenter sites)|3 - Outpatient department/clinic emergency (includes urgicenter sites)|9
205|3 - Paid help|3 - Paid help|9
206|3 - Participates in bathing self in shower or tub, BUT requires presence of another person throughout the bath for assistance or supervision.|3 - Participates in bathing self in shower or tub, BUT requires presence of another person throughou|9
207|3 - Patient depends entirely upon another person to dress lower body.|3 - Patient depends entirely upon another person to dress lower body.|9
208|3 - Patient depends entirely upon another person to dress the upper body.|3 - Patient depends entirely upon another person to dress the upper body.|9
209|3 - Patient depends entirely upon someone else for grooming needs.|3 - Patient depends entirely upon someone else for grooming needs.|9
210|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone else to manage the equipment.|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone|9
211|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable to shift attention and recall directions more than half the time.|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable|9
212|3 - Respiratory problems (SOB, infection, obstruction)|3 - Respiratory problems (SOB, infection, obstruction)|9
213|3 - Resumption of care (after inpatient stay)|3 - Resumption of care (after inpatient stay)|9
214|3 - Several times each month|3 - Several times each month|9
215|3 - Skilled Nursing Facility|3 - Skilled Nursing Facility|9
216|3 - Stage 3|3 - Stage 3|9
217|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|9
218|3 - Three|3 - Three|9
219|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person throughout the process.|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person through|9
220|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal independently.|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal indep|9
221|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person.|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person|9
222|3 - Unknown because patient moved to a geographic location not served by this agency|3 - Unknown because patient moved to a geographic location not served by this agency|9
223|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|9
224|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|9
225|3 - With other family member|3 - With other family member|9
226|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home health services, homemaker assistance, transportation assistance, assisted living, board and care)|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home h|9
227|3-SLP/ST|3-SLP/ST|9
228|4 - At rest (during day or night)|4 - At rest (during day or night)|9
229|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|9
230|4 - Board and care or assisted living facility|4 - Board and care or assisted living facility|9
231|4 - Caregiver is completely dependent on someone else to manage all equipment.|4 - Caregiver is completely dependent on someone else to manage all equipment.|9
232|4 - Chairfast, unable to ambulate and is UNABLE to wheel self.|4 - Chairfast, unable to ambulate and is UNABLE to wheel self.|9
233|4 - Constantly|4 - Constantly|9
234|4 - Drug dependency|4 - Drug dependency|9
235|4 - Four or more|4 - Four or more|9
236|4 - Friend or neighbor or community or church member|4 - Friend or neighbor or community or church member|9
237|4 - Hispanic or Latino|4 - Hispanic or Latino|9
238|4 - Hospice|4 - Hospice|9
239|4 - Impaired decision-making|4 - Impaired decision-making|9
240|4 - Is totally dependent in toileting.|4 - Is totally dependent in toileting.|9
241|4 - Medicaid (HMO/managed care)|4 - Medicaid (HMO/managed care)|9
242|4 - None of the above|4 - None of the above|9
243|4 - Nursing home|4 - Nursing home|9
244|4 - On a daily basis|4 - On a daily basis|9
245|4 - Patient is completely dependent on someone else to manage all equipment.|4 - Patient is completely dependent on someone else to manage all equipment.|9
246|4 - Permanent placement|4 - Permanent placement|9
247|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, punches, dangerous maneuvers w/ wheelchair or other objects)|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, pu|9
248|4 - Psychosocial support (e.g., socialization, companionship, recreation)|4 - Psychosocial support (e.g., socialization, companionship, recreation)|9
249|4 - Recertification (follow-up) reassessment|4 - Recertification (follow-up) reassessment|9
250|4 - Recurrent thoughts of death|4 - Recurrent thoughts of death|9
251|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruction)|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruc|9
252|4 - Several times a week|4 - Several times a week|9
253|4 - Stage 4|4 - Stage 4|9
254|4 - Symptoms poorly controlled, history of rehospitalizations|4 - Symptoms poorly controlled, history of rehospitalizations|9
255|4 - Three or more times per week|4 - Three or more times per week|9
256|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetative state, or delirium.|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetati|9
257|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|9
258|4 - Unable to effectively participate in any housekeeping tasks.|4 - Unable to effectively participate in any housekeeping tasks.|9
259|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or unresponsive (e.g., speech is nonsensical or unintelligible).|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or u|9
260|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonresponsive.|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonr|9
261|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostomy.|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostom|9
262|4 - UNABLE to use the shower or tub and is bathed in BED OR BEDSIDE CHAIR.|4 - UNABLE to use the shower or tub and is bathed in BED OR BEDSIDE CHAIR.|9
263|4 - With a friend|4 - With a friend|9
264|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|9
265|4-OT|4-OT|9
266|5 - Advocates or facilitates patient's participation in appropriate medical care|5 - Advocates or facilitates patient's participation in appropriate medical care|9
267|5 - At least daily|5 - At least daily|9
268|5 - Bedfast, unable to ambulate or be up in a chair.|5 - Bedfast, unable to ambulate or be up in a chair.|9
269|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|9
270|5 - Disruptive or socially inappropriate behavior|5 - Disruptive or socially inappropriate behavior|9
271|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|9
272|5 - Hypo/Hyperglycemia, diabetes out of control|5 - Hypo/Hyperglycemia, diabetes out of control|9
273|5 - More often than once daily|5 - More often than once daily|9
274|5 - Native Hawaiian or Pacific Islander|5 - Native Hawaiian or Pacific Islander|9
275|5 - None of the above|5 - None of the above|9
276|5 - One to two times per week|5 - One to two times per week|9
277|5 - Other|5 - Other|9
278|5 - Other follow-up|5 - Other follow-up|9
279|5 - Paid help|5 - Paid help|9
280|5 - Patient nonresponsive or unable to speak.|5 - Patient nonresponsive or unable to speak.|9
281|5 - Thoughts of suicide|5 - Thoughts of suicide|9
282|5 - Totally unable to use the telephone.|5 - Totally unable to use the telephone.|9
283|5 - Unable to effectively participate in bathing and is totally bathed by another person.|5 - Unable to effectively participate in bathing and is totally bathed by another person.|9
284|5 - Unable to take in nutrients orally or by tube feeding.|5 - Unable to take in nutrients orally or by tube feeding.|9
285|5 - Unsafe for care at home|5 - Unsafe for care at home|9
286|5 - With paid help (other than home care agency staff)|5 - With paid help (other than home care agency staff)|9
287|5 - Workers' compensation|5 - Workers' compensation|9
288|5 - Wound infection, deteriorating wound status, new lesion/ulcer|5 - Wound infection, deteriorating wound status, new lesion/ulcer|9
289|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|9
290|6 - Delusional, hallucinatory, or paranoid behavior|6 - Delusional, hallucinatory, or paranoid behavior|9
291|6 - Financial agent, power of attorney, or conservator of finance|6 - Financial agent, power of attorney, or conservator of finance|9
292|6 - GI bleeding, obstruction|6 - GI bleeding, obstruction|9
293|6 - Less often than weekly|6 - Less often than weekly|9
294|6 - Memory loss to the extent that supervision required|6 - Memory loss to the extent that supervision required|9
295|6 - None of the above feelings observed or reported|6 - None of the above feelings observed or reported|9
296|6 - Other|6 - Other|9
297|6 - Title programs (e.g., Title III, V, or XX)|6 - Title programs (e.g., Title III, V, or XX)|9
298|6 - Transferred to an inpatient facility - patient not discharged from agency|6 - Transferred to an inpatient facility - patient not discharged from agency|9
299|6 - White|6 - White|9
300|6 - With other than above|6 - With other than above|9
301|7 - Exacerbation of CHF, fluid overload, heart failure|7 - Exacerbation of CHF, fluid overload, heart failure|9
302|7 - Health care agent, conservator of person, or medical power of attorney|7 - Health care agent, conservator of person, or medical power of attorney|9
303|7 - Hypo/Hyperglycemia, diabetes out of control|7 - Hypo/Hyperglycemia, diabetes out of control|9
304|7 - None of the above|7 - None of the above|9
305|7 - None of the above behaviors demonstrated|7 - None of the above behaviors demonstrated|9
306|7 - Other government (e.g., CHAMPUS, VA, etc.)|7 - Other government (e.g., CHAMPUS, VA, etc.)|9
307|7 - Transferred to an inpatient facility - patient discharged from agency|7 - Transferred to an inpatient facility - patient discharged from agency|9
308|8 - Death at home|8 - Death at home|9
309|8 - GI bleeding, obstruction|8 - GI bleeding, obstruction|9
310|8 - Myocardial infarction, stroke|8 - Myocardial infarction, stroke|9
311|8 - Private insurance|8 - Private insurance|9
312|9 - Chemotherapy|9 - Chemotherapy|9
313|9 - Discharge from agency|9 - Discharge from agency|9
314|9 - Other than above reasons|9 - Other than above reasons|9
315|9 - Private HMO/managed care|9 - Private HMO/managed care|9
316|NA - No caregiver|NA - No caregiver|9
317|NA - No equipment of this type used in care.|NA - No equipment of this type used in care.|9
318|NA - No inhalant/mist medications prescribed.|NA - No inhalant/mist medications prescribed.|9
319|NA - No injectable medications prescribed.|NA - No injectable medications prescribed.|9
320|NA - No inpatient facility admission|NA - No inpatient facility admission|9
321|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|9
322|NA - No Medicaid|NA - No Medicaid|9
323|NA - No Medicare|NA - No Medicare|9
324|NA - No observable pressure ulcer|NA - No observable pressure ulcer|9
325|NA - No observable stasis ulcer|NA - No observable stasis ulcer|9
326|NA - No observable surgical wound|NA - No observable surgical wound|9
327|NA - No oral medications prescribed.|NA - No oral medications prescribed.|9
328|NA - Not applicable|NA - Not applicable|9
329|NA - Patient does not have a telephone.|NA - Patient does not have a telephone.|9
330|NA - Patient has ostomy for bowel elimination|NA - Patient has ostomy for bowel elimination|9
331|NA - Patient nonresponsive|NA - Patient nonresponsive|9
332|NA - Patient on prophylactic treatment|NA - Patient on prophylactic treatment|9
333|NA - Patient was not discharged from an inpatient facility|NA - Patient was not discharged from an inpatient facility|9
334|UK - Other unknown|UK - Other unknown|9
335|UK - Reason unknown|UK - Reason unknown|9
336|UK - Unknown|UK - Unknown|9
337|UK - Unknown or Not Available|UK - Unknown or Not Available|9
341|01 - Early|01 - Early|9
342|02 - Late|02 - Late|9
343|NA - Not Applicable. No case mix group defined for this assessment.|NA - Not Applicable. No case mix group defined for this assessment.|9
344|NA - No case mix group defined by this assessment.|NA - No case mix group defined by this assessment.|9
2|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; OR (b) Is physically, cognitively, and mentally able to prepare light meals on a regular basis but has not routinely performed light meal preparation in the past (i.e., prior to this home care admission).|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; O|11
3|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and mentally able to perform all housekeeping tasks .|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and menta|11
4|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and mentally able to do laundry and access facilities.|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and menta|11
5|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying packages OR b) Physically, cognitively, and mentally able to take care of shopping, but has not done shopping in the past (i.e., prior to this home care admission).|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying|11
6|0 - Able to bathe self in SHOWER OR TUB independently.|0 - Able to bathe self in SHOWER OR TUB independently.|11
7|0 - Able to dial numbers and answer calls appropriately and as desired.|0 - Able to dial numbers and answer calls appropriately and as desired.|11
8|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body without assistance.|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body|11
9|0 - Able to get to and from the toilet independently with or without a device.|0 - Able to get to and from the toilet independently with or without a device.|11
10|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|11
11|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible public bus.|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible p|11
12|0 - Able to independently feed self.|0 - Able to independently feed self.|11
13|0 - Able to independently take the correct medication and proper dosage at the correct times.|0 - Able to independently take the correct medication and proper dosage at the correct times.|11
14|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct times.|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct ti|11
15|0 - Able to independently transfer.|0 - Able to independently transfer.|11
16|0 - Able to independently walk on even and uneven surfaces and climb stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even and uneven surfaces and climb stairs with or without railings|11
17|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings|11
18|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|11
19|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions independently.|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions indep|11
20|0 - Asymptomatic, no treatment needed at this time|0 - Asymptomatic, no treatment needed at this time|11
21|0 - Caregiver manages all tasks related to equipment completely independently.|0 - Caregiver manages all tasks related to equipment completely independently.|11
22|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations with no observable impairment.|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations w|11
23|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|11
24|0 - Life expectancy is greater than 6 months|0 - Life expectancy is greater than 6 months|11
25|0 - Never|0 - Never|11
26|0 - Never, patient is not short of breath|0 - Never, patient is not short of breath|11
27|0 - No|0 - No|11
28|0 - No emergent care services|0 - No emergent care services|11
29|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage)|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage)|11
30|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and extended or abstract conversation.|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and exte|11
31|0 - No one person|0 - No one person|11
32|0 - None of the time|0 - None of the time|11
33|0 - None, no charge for current services|0 - None, no charge for current services|11
34|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|11
35|0 - Patient does NOT have an ostomy for bowel elimination.|0 - Patient does NOT have an ostomy for bowel elimination.|11
36|0 - Patient has no pain or pain does not interfere with activity or movement|0 - Patient has no pain or pain does not interfere with activity or movement|11
37|0 - Patient manages all tasks related to equipment completely independently.|0 - Patient manages all tasks related to equipment completely independently.|11
38|0 - Poor:  little or no recovery is expected and/or further decline is imminent|0 - Poor:  little or no recovery is expected and/or further decline is imminent|11
39|0 - Timed-voiding defers incontinence|0 - Timed-voiding defers incontinence|11
40|0 - Very rarely or never has bowel incontinence|0 - Very rarely or never has bowel incontinence|11
41|0 - Zero|0 - Zero|11
42|00 - No|00 - No|11
43|01 - Yes|01 - Yes|11
44|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or mental limitations, needs assistance with heavy laundry.|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or|11
45|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the patient.|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the|11
46|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|11
47|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or supervision from another person OR c) a liquid, pureed or ground meat diet.|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or su|11
48|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|11
49|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|11
50|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independently.|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independe|11
51|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only when assisted or accompanied by another person.|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only w|11
52|1 - Able to take injectable medication at correct times if: a) individual syringes are prepared in advance by another person OR b) given daily reminders.|1 - Able to take injectable medication at correct times if: a) individual syringes are prepared in a|11
53|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance by another person OR b) given daily reminders.|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance b|11
54|1 - Able to take medication(s) at the correct times if: a) individual dosages are prepared in advance by another person , OR b) given daily reminders OR c) someone develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if: a) individual dosages are prepared in advanc|11
55|1 - Able to take medication(s) at the correct times if: a) individual dosages are prepared in advance by another person, OR b) given daily reminders OR c) someone develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if: a) individual dosages are prepared in advanc|11
56|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for the deaf) and call essential numbers.|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for t|11
57|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|11
58|1 - American Indian or Alaska Native|1 - American Indian or Alaska Native|11
59|1 - Depressed mood (e.g., feeling sad, tearful)|1 - Depressed mood (e.g., feeling sad, tearful)|11
60|1 - During the night only|1 - During the night only|11
61|1 - Fully granulating|1 - Fully granulating|11
62|1 - Good/Fair:  partial to full recovery is expected|1 - Good/Fair:  partial to full recovery is expected|11
63|1 - Good:  marked improvement in functional status is expected|1 - Good:  marked improvement in functional status is expected|11
64|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|11
65|1 - Heavy smoking|1 - Heavy smoking|11
66|1 - Hospital|1 - Hospital|11
67|1 - Hospital emergency room (includes 23-hour holding)|1 - Hospital emergency room (includes 23-hour holding)|11
68|1 - Hospitalization for EMERGENT (unscheduled) care|1 - Hospitalization for EMERGENT (unscheduled) care|11
69|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepared solutions), patient is able to manage all other aspects of equipment.|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepar|11
70|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|11
71|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|11
72|1 - In new or complex situations only|1 - In new or complex situations only|11
73|1 - Intravenous or infusion therapy (excludes TPN)|1 - Intravenous or infusion therapy (excludes TPN)|11
74|1 - Less often than daily|1 - Less often than daily|11
75|1 - Less than once a month|1 - Less than once a month|11
76|1 - Less than once weekly|1 - Less than once weekly|11
77|1 - Life expectancy is 6 months or fewer|1 - Life expectancy is 6 months or fewer|11
78|1 - Lives alone|1 - Lives alone|11
79|1 - Male|1 - Male|11
80|1 - Medicare (traditional fee-for-service)|1 - Medicare (traditional fee-for-service)|11
81|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of past 24 hours, significant memory loss so that supervision is required|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of pas|11
82|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors in word choice, grammar or speech intelligibility, needs minimal prompting or assistance).|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors i|11
83|1 - No assistance or services received|1 - No assistance or services received|11
84|1 - One|1 - One|11
85|1 - Oxygen (intermittent or continuous)|1 - Oxygen (intermittent or continuous)|11
86|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, and the surrounding layout, can count fingers at arm's length.|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, a|11
87|1 - Patient is incontinent|1 - Patient is incontinent|11
88|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|11
89|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical or treatment regimen.|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical|11
90|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient/couple/significant other)|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient|11
91|1 - Relatives, friends, or neighbors living outside the home|1 - Relatives, friends, or neighbors living outside the home|11
92|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions.|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions|11
93|1 - Requires use of a device (e.g., cane, walker) to walk alone OR requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|1 - Requires use of a device (e.g., cane, walker) to walk alone OR requires human supervision or ass|11
94|1 - Several times during day and night|1 - Several times during day and night|11
95|1 - Spouse or significant other|1 - Spouse or significant other|11
96|1 - Stage 1|1 - Stage 1|11
97|1 - Start of care - further visits planned|1 - Start of care - further visits planned|11
98|1 - Symptoms well controlled with current therapy|1 - Symptoms well controlled with current therapy|11
99|1 - Therapy services|1 - Therapy services|11
100|1 - Transfers with minimal human assistance or with use of an assistive device.|1 - Transfers with minimal human assistance or with use of an assistive device.|11
101|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitations.|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitatio|11
102|1 - Urinary incontinence|1 - Urinary incontinence|11
103|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet.|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet.|11
104|1 - When walking more than 20 feet, climbing stairs|1 - When walking more than 20 feet, climbing stairs|11
105|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary conversation. May need occasional repetition, extra time, or louder voice.|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary c|11
106|1 - With the use of devices, is able to bathe self in shower or tub independently.|1 - With the use of devices, is able to bathe self in shower or tub independently.|11
107|1 - Yes|1 - Yes|11
108|1-RN|1-RN|11
109|10 - Discharge from agency - no visits completed after start/resumption of care assessment|10 - Discharge from agency - no visits completed after start/resumption of care assessment|11
110|10 - Scheduled surgical procedure|10 - Scheduled surgical procedure|11
111|10 - Self-pay|10 - Self-pay|11
112|11 - Other|11 - Other|11
113|11 - Urinary tract infection|11 - Urinary tract infection|11
114|12 - IV catheter-related infection|12 - IV catheter-related infection|11
115|13 - Deep vein thrombosis, pulmonary embolus|13 - Deep vein thrombosis, pulmonary embolus|11
116|14 - Uncontrolled pain|14 - Uncontrolled pain|11
117|15 - Psychotic episode|15 - Psychotic episode|11
118|16 - Other than above reasons|16 - Other than above reasons|11
119|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing calls.|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing|11
120|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another person.|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another pers|11
121|2 - Able to walk only with the supervision or assistance of another person at all times.|2 - Able to walk only with the supervision or assistance of another person at all times.|11
122|2 - Aid: a) for intermittent supervision/encouragement/reminders, OR b) to get in and out of the shower/tub, OR c) for washing difficult to reach areas.|2 - Aid: a) for intermittent supervision/encouragement/reminders, OR b) to get in and out of the sho|11
123|2 - Asian|2 - Asian|11
124|2 - Caregiver requires considerable assistance from another person to manage equipment, but independently completes significant portions of task.|2 - Caregiver requires considerable assistance from another person to manage equipment, but independ|11
125|2 - Daily, but not constantly|2 - Daily, but not constantly|11
126|2 - Daughter or son|2 - Daughter or son|11
127|2 - Doctor's office emergency visit/house call|2 - Doctor's office emergency visit/house call|11
128|2 - During the day and night|2 - During the day and night|11
129|2 - Early/partial granulation|2 - Early/partial granulation|11
130|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors in word choice, organization or speech intelligibility). Speaks in phrases or short sentences.|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors|11
131|2 - Family member's residence|2 - Family member's residence|11
132|2 - Female|2 - Female|11
133|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conversation, needs frequent prompting or assistance.|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conver|11
134|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|11
135|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|11
136|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately stop activities, jeopardizes safety through actions|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately st|11
137|2 - Indwelling/suprapubic catheter|2 - Indwelling/suprapubic catheter|11
138|2 - Injury caused by fall or accident at home|2 - Injury caused by fall or accident at home|11
139|2 - Medicare (HMO/managed care)|2 - Medicare (HMO/managed care)|11
140|2 - Nausea, dehydration, malnutrition, constipation, impaction|2 - Nausea, dehydration, malnutrition, constipation, impaction|11
141|2 - Obesity|2 - Obesity|11
142|2 - On awakening or at night only|2 - On awakening or at night only|11
143|2 - Once a month|2 - Once a month|11
144|2 - One to three times weekly|2 - One to three times weekly|11
145|2 - Parenteral nutrition (TPN or lipids)|2 - Parenteral nutrition (TPN or lipids)|11
146|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic)|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic)|11
147|2 - Patient requires considerable assistance from another person to manage equipment, but independently completes portions of the task.|2 - Patient requires considerable assistance from another person to manage equipment, but independen|11
148|2 - Patient transferred to a noninstitutional hospice|2 - Patient transferred to a noninstitutional hospice|11
149|2 - Person residing in the home (EXCLUDING paid help)|2 - Person residing in the home (EXCLUDING paid help)|11
150|2 - Rehabilitation facility|2 - Rehabilitation facility|11
151|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifting of attention) or consistently requires low stimulus environment due to distractibility.|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifti|11
152|2 - Respite care|2 - Respite care|11
153|2 - Sense of failure or self reproach|2 - Sense of failure or self reproach|11
154|2 - Several times during day|2 - Several times during day|11
155|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonresponsive.|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonrespons|11
156|2 - Someone must assist the patient to groom self.|2 - Someone must assist the patient to groom self.|11
157|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|11
158|2 - Someone must help the patient put on upper body clothing.|2 - Someone must help the patient put on upper body clothing.|11
159|2 - Stage 2|2 - Stage 2|11
160|2 - Start of care - no further visits planned|2 - Start of care - no further visits planned|11
161|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitoring|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitori|11
162|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment regimen.|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment re|11
163|2 - Two|2 - Two|11
164|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistance due to cognitive or mental limitation.|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistanc|11
165|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|11
166|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assistance).|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assis|11
167|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home delivery.|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home deli|11
168|2 - Unable to prepare any light meals or reheat any delivered meals.|2 - Unable to prepare any light meals or reheat any delivered meals.|11
169|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|11
170|2 - UNABLE to take injectable medications unless administered by someone else.|2 - UNABLE to take injectable medications unless administered by someone else.|11
171|2 - UNABLE to take medication unless administered by someone else.|2 - UNABLE to take medication unless administered by someone else.|11
172|2 - UNABLE to transfer self but is able to bear weight and pivot during the transfer process.|2 - UNABLE to transfer self but is able to bear weight and pivot during the transfer process.|11
173|2 - Ventilator (continually or at night)|2 - Ventilator (continually or at night)|11
174|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less than 20 feet)|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less th|11
175|2 - With spouse or significant other|2 - With spouse or significant other|11
176|2 - Yes, assistance or services provided by family or friends|2 - Yes, assistance or services provided by family or friends|11
177|2-PT|2-PT|11
178|3 - Able to answer the telephone only some of the time or is able to carry on only a limited conversation.|3 - Able to answer the telephone only some of the time or is able to carry on only a limited convers|11
179|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube or gastrostomy.|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube|11
180|3 - Alcohol dependency|3 - Alcohol dependency|11
181|3 - All of the time|3 - All of the time|11
182|3 - Black or African-American|3 - Black or African-American|11
183|3 - Boarding home or rented room|3 - Boarding home or rented room|11
184|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment, clean/store/dispose of equipment or supplies).|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment,|11
185|3 - Chairfast, UNABLE to ambulate but is able to wheel self independently.|3 - Chairfast, UNABLE to ambulate but is able to wheel self independently.|11
186|3 - Continuous positive airway pressure|3 - Continuous positive airway pressure|11
187|3 - During the day and evening, but not constantly|3 - During the day and evening, but not constantly|11
188|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the alimentary canal)|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the|11
189|3 - Environmental support (e.g., housing, home maintenance)|3 - Environmental support (e.g., housing, home maintenance)|11
190|3 - Four to six times weekly|3 - Four to six times weekly|11
191|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessing by listener.  Speech limited to single words or short phrases.|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessin|11
192|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires multiple repetitions, restatements, demonstrations, additional time.|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires m|11
193|3 - Hopelessness|3 - Hopelessness|11
194|3 - Hospice care|3 - Hospice care|11
195|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|11
196|3 - Injury caused by fall or accident at home|3 - Injury caused by fall or accident at home|11
197|3 - Intractable pain|3 - Intractable pain|11
198|3 - Medicaid (traditional fee-for-service)|3 - Medicaid (traditional fee-for-service)|11
199|3 - Needs someone to do all shopping and errands.|3 - Needs someone to do all shopping and errands.|11
200|3 - Not healing|3 - Not healing|11
201|3 - Nursing home|3 - Nursing home|11
202|3 - Once daily|3 - Once daily|11
203|3 - Other family member|3 - Other family member|11
204|3 - Outpatient department/clinic emergency (includes urgicenter sites)|3 - Outpatient department/clinic emergency (includes urgicenter sites)|11
205|3 - Paid help|3 - Paid help|11
206|3 - Participates in bathing self in shower or tub, BUT requires presence of another person throughout the bath for assistance or supervision.|3 - Participates in bathing self in shower or tub, BUT requires presence of another person throughou|11
207|3 - Patient depends entirely upon another person to dress lower body.|3 - Patient depends entirely upon another person to dress lower body.|11
208|3 - Patient depends entirely upon another person to dress the upper body.|3 - Patient depends entirely upon another person to dress the upper body.|11
209|3 - Patient depends entirely upon someone else for grooming needs.|3 - Patient depends entirely upon someone else for grooming needs.|11
210|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone else to manage the equipment.|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone|11
211|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable to shift attention and recall directions more than half the time.|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable|11
212|3 - Respiratory problems (SOB, infection, obstruction)|3 - Respiratory problems (SOB, infection, obstruction)|11
213|3 - Resumption of care (after inpatient stay)|3 - Resumption of care (after inpatient stay)|11
214|3 - Several times each month|3 - Several times each month|11
215|3 - Skilled Nursing Facility|3 - Skilled Nursing Facility|11
216|3 - Stage 3|3 - Stage 3|11
217|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|11
218|3 - Three|3 - Three|11
219|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person throughout the process.|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person through|11
220|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal independently.|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal indep|11
221|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person.|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person|11
222|3 - Unknown because patient moved to a geographic location not served by this agency|3 - Unknown because patient moved to a geographic location not served by this agency|11
223|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|11
224|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|11
225|3 - With other family member|3 - With other family member|11
226|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home health services, homemaker assistance, transportation assistance, assisted living, board and care)|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home h|11
227|3-SLP/ST|3-SLP/ST|11
228|4 - At rest (during day or night)|4 - At rest (during day or night)|11
229|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|11
230|4 - Board and care or assisted living facility|4 - Board and care or assisted living facility|11
231|4 - Caregiver is completely dependent on someone else to manage all equipment.|4 - Caregiver is completely dependent on someone else to manage all equipment.|11
232|4 - Chairfast, unable to ambulate and is UNABLE to wheel self.|4 - Chairfast, unable to ambulate and is UNABLE to wheel self.|11
233|4 - Constantly|4 - Constantly|11
234|4 - Drug dependency|4 - Drug dependency|11
235|4 - Four or more|4 - Four or more|11
236|4 - Friend or neighbor or community or church member|4 - Friend or neighbor or community or church member|11
237|4 - Hispanic or Latino|4 - Hispanic or Latino|11
238|4 - Hospice|4 - Hospice|11
239|4 - Impaired decision-making|4 - Impaired decision-making|11
240|4 - Is totally dependent in toileting.|4 - Is totally dependent in toileting.|11
241|4 - Medicaid (HMO/managed care)|4 - Medicaid (HMO/managed care)|11
242|4 - None of the above|4 - None of the above|11
243|4 - Nursing home|4 - Nursing home|11
244|4 - On a daily basis|4 - On a daily basis|11
245|4 - Patient is completely dependent on someone else to manage all equipment.|4 - Patient is completely dependent on someone else to manage all equipment.|11
246|4 - Permanent placement|4 - Permanent placement|11
247|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, punches, dangerous maneuvers w/ wheelchair or other objects)|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, pu|11
248|4 - Psychosocial support (e.g., socialization, companionship, recreation)|4 - Psychosocial support (e.g., socialization, companionship, recreation)|11
249|4 - Recertification (follow-up) reassessment|4 - Recertification (follow-up) reassessment|11
250|4 - Recurrent thoughts of death|4 - Recurrent thoughts of death|11
251|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruction)|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruc|11
252|4 - Several times a week|4 - Several times a week|11
253|4 - Stage 4|4 - Stage 4|11
254|4 - Symptoms poorly controlled, history of rehospitalizations|4 - Symptoms poorly controlled, history of rehospitalizations|11
255|4 - Three or more times per week|4 - Three or more times per week|11
256|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetative state, or delirium.|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetati|11
257|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|11
258|4 - Unable to effectively participate in any housekeeping tasks.|4 - Unable to effectively participate in any housekeeping tasks.|11
259|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or unresponsive (e.g., speech is nonsensical or unintelligible).|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or u|11
260|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonresponsive.|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonr|11
261|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostomy.|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostom|11
262|4 - UNABLE to use the shower or tub and is bathed in BED OR BEDSIDE CHAIR.|4 - UNABLE to use the shower or tub and is bathed in BED OR BEDSIDE CHAIR.|11
263|4 - With a friend|4 - With a friend|11
264|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|11
265|4-OT|4-OT|11
266|5 - Advocates or facilitates patient's participation in appropriate medical care|5 - Advocates or facilitates patient's participation in appropriate medical care|11
267|5 - At least daily|5 - At least daily|11
268|5 - Bedfast, unable to ambulate or be up in a chair.|5 - Bedfast, unable to ambulate or be up in a chair.|11
269|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|11
270|5 - Disruptive or socially inappropriate behavior|5 - Disruptive or socially inappropriate behavior|11
271|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|11
272|5 - Hypo/Hyperglycemia, diabetes out of control|5 - Hypo/Hyperglycemia, diabetes out of control|11
273|5 - More often than once daily|5 - More often than once daily|11
274|5 - Native Hawaiian or Pacific Islander|5 - Native Hawaiian or Pacific Islander|11
275|5 - None of the above|5 - None of the above|11
276|5 - One to two times per week|5 - One to two times per week|11
277|5 - Other|5 - Other|11
278|5 - Other follow-up|5 - Other follow-up|11
279|5 - Paid help|5 - Paid help|11
280|5 - Patient nonresponsive or unable to speak.|5 - Patient nonresponsive or unable to speak.|11
281|5 - Thoughts of suicide|5 - Thoughts of suicide|11
282|5 - Totally unable to use the telephone.|5 - Totally unable to use the telephone.|11
283|5 - Unable to effectively participate in bathing and is totally bathed by another person.|5 - Unable to effectively participate in bathing and is totally bathed by another person.|11
284|5 - Unable to take in nutrients orally or by tube feeding.|5 - Unable to take in nutrients orally or by tube feeding.|11
285|5 - Unsafe for care at home|5 - Unsafe for care at home|11
286|5 - With paid help (other than home care agency staff)|5 - With paid help (other than home care agency staff)|11
287|5 - Workers' compensation|5 - Workers' compensation|11
288|5 - Wound infection, deteriorating wound status, new lesion/ulcer|5 - Wound infection, deteriorating wound status, new lesion/ulcer|11
289|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|11
290|6 - Delusional, hallucinatory, or paranoid behavior|6 - Delusional, hallucinatory, or paranoid behavior|11
291|6 - Financial agent, power of attorney, or conservator of finance|6 - Financial agent, power of attorney, or conservator of finance|11
292|6 - GI bleeding, obstruction|6 - GI bleeding, obstruction|11
293|6 - Less often than weekly|6 - Less often than weekly|11
294|6 - Memory loss to the extent that supervision required|6 - Memory loss to the extent that supervision required|11
295|6 - None of the above feelings observed or reported|6 - None of the above feelings observed or reported|11
296|6 - Other|6 - Other|11
297|6 - Title programs (e.g., Title III, V, or XX)|6 - Title programs (e.g., Title III, V, or XX)|11
298|6 - Transferred to an inpatient facility - patient not discharged from agency|6 - Transferred to an inpatient facility - patient not discharged from agency|11
299|6 - White|6 - White|11
300|6 - With other than above|6 - With other than above|11
301|7 - Exacerbation of CHF, fluid overload, heart failure|7 - Exacerbation of CHF, fluid overload, heart failure|11
302|7 - Health care agent, conservator of person, or medical power of attorney|7 - Health care agent, conservator of person, or medical power of attorney|11
303|7 - Hypo/Hyperglycemia, diabetes out of control|7 - Hypo/Hyperglycemia, diabetes out of control|11
304|7 - None of the above|7 - None of the above|11
305|7 - None of the above behaviors demonstrated|7 - None of the above behaviors demonstrated|11
306|7 - Other government (e.g., CHAMPUS, VA, etc.)|7 - Other government (e.g., CHAMPUS, VA, etc.)|11
307|7 - Transferred to an inpatient facility - patient discharged from agency|7 - Transferred to an inpatient facility - patient discharged from agency|11
308|8 - Death at home|8 - Death at home|11
309|8 - GI bleeding, obstruction|8 - GI bleeding, obstruction|11
310|8 - Myocardial infarction, stroke|8 - Myocardial infarction, stroke|11
311|8 - Private insurance|8 - Private insurance|11
312|9 - Chemotherapy|9 - Chemotherapy|11
313|9 - Discharge from agency|9 - Discharge from agency|11
314|9 - Other than above reasons|9 - Other than above reasons|11
315|9 - Private HMO/managed care|9 - Private HMO/managed care|11
316|NA - No caregiver|NA - No caregiver|11
317|NA - No equipment of this type used in care.|NA - No equipment of this type used in care.|11
318|NA - No inhalant/mist medications prescribed.|NA - No inhalant/mist medications prescribed.|11
319|NA - No injectable medications prescribed.|NA - No injectable medications prescribed.|11
320|NA - No inpatient facility admission|NA - No inpatient facility admission|11
321|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|11
322|NA - No Medicaid|NA - No Medicaid|11
323|NA - No Medicare|NA - No Medicare|11
324|NA - No observable pressure ulcer|NA - No observable pressure ulcer|11
325|NA - No observable stasis ulcer|NA - No observable stasis ulcer|11
326|NA - No observable surgical wound|NA - No observable surgical wound|11
327|NA - No oral medications prescribed.|NA - No oral medications prescribed.|11
328|NA - Not applicable|NA - Not applicable|11
329|NA - Patient does not have a telephone.|NA - Patient does not have a telephone.|11
330|NA - Patient has ostomy for bowel elimination|NA - Patient has ostomy for bowel elimination|11
331|NA - Patient nonresponsive|NA - Patient nonresponsive|11
332|NA - Patient on prophylactic treatment|NA - Patient on prophylactic treatment|11
333|NA - Patient was not discharged from an inpatient facility|NA - Patient was not discharged from an inpatient facility|11
334|UK - Other unknown|UK - Other unknown|11
335|UK - Reason unknown|UK - Reason unknown|11
336|UK - Unknown|UK - Unknown|11
337|UK - Unknown or Not Available|UK - Unknown or Not Available|11
341|01 - Early|01 - Early|11
342|02 - Late|02 - Late|11
343|NA - Not Applicable. No case mix group defined for this assessment.|NA - Not Applicable. No case mix group defined for this assessment.|11
344|NA - No case mix group defined by this assessment.|NA - No case mix group defined by this assessment.|11
2|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; OR (b) Is physically, cognitively, and mentally able to prepare light meals on a regular basis but has not routinely performed light meal preparation in the past (i.e., prior to this home care admission).|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; O|13
3|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and mentally able to perform all housekeeping tasks .|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and menta|13
4|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and mentally able to do laundry and access facilities.|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and menta|13
5|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying packages OR b) Physically, cognitively, and mentally able to take care of shopping, but has not done shopping in the past (i.e., prior to this home care admission).|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying|13
6|0 - Able to bathe self in SHOWER OR TUB independently.|0 - Able to bathe self in SHOWER OR TUB independently.|13
7|0 - Able to dial numbers and answer calls appropriately and as desired.|0 - Able to dial numbers and answer calls appropriately and as desired.|13
8|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body without assistance.|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body|13
9|0 - Able to get to and from the toilet independently with or without a device.|0 - Able to get to and from the toilet independently with or without a device.|13
10|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|13
11|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible public bus.|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible p|13
12|0 - Able to independently feed self.|0 - Able to independently feed self.|13
13|0 - Able to independently take the correct medication and proper dosage at the correct times.|0 - Able to independently take the correct medication and proper dosage at the correct times.|13
14|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct times.|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct ti|13
15|0 - Able to independently transfer.|0 - Able to independently transfer.|13
16|0 - Able to independently walk on even and uneven surfaces and climb stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even and uneven surfaces and climb stairs with or without railings|13
17|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings|13
18|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|13
19|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions independently.|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions indep|13
20|0 - Asymptomatic, no treatment needed at this time|0 - Asymptomatic, no treatment needed at this time|13
21|0 - Caregiver manages all tasks related to equipment completely independently.|0 - Caregiver manages all tasks related to equipment completely independently.|13
22|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations with no observable impairment.|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations w|13
23|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|13
24|0 - Life expectancy is greater than 6 months|0 - Life expectancy is greater than 6 months|13
25|0 - Never|0 - Never|13
26|0 - Never, patient is not short of breath|0 - Never, patient is not short of breath|13
27|0 - No|0 - No|13
28|0 - No emergent care services|0 - No emergent care services|13
29|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage)|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage)|13
30|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and extended or abstract conversation.|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and exte|13
31|0 - No one person|0 - No one person|13
32|0 - None of the time|0 - None of the time|13
33|0 - None, no charge for current services|0 - None, no charge for current services|13
34|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|13
35|0 - Patient does NOT have an ostomy for bowel elimination.|0 - Patient does NOT have an ostomy for bowel elimination.|13
36|0 - Patient has no pain or pain does not interfere with activity or movement|0 - Patient has no pain or pain does not interfere with activity or movement|13
37|0 - Patient manages all tasks related to equipment completely independently.|0 - Patient manages all tasks related to equipment completely independently.|13
38|0 - Poor:  little or no recovery is expected and/or further decline is imminent|0 - Poor:  little or no recovery is expected and/or further decline is imminent|13
39|0 - Timed-voiding defers incontinence|0 - Timed-voiding defers incontinence|13
40|0 - Very rarely or never has bowel incontinence|0 - Very rarely or never has bowel incontinence|13
41|0 - Zero|0 - Zero|13
42|00 - No|00 - No|13
43|01 - Yes|01 - Yes|13
44|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or mental limitations, needs assistance with heavy laundry.|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or|13
45|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the patient.|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the|13
46|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|13
47|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or supervision from another person OR c) a liquid, pureed or ground meat diet.|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or su|13
48|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|13
49|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|13
50|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independently.|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independe|13
51|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only when assisted or accompanied by another person.|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only w|13
52|1 - Able to take injectable medication at correct times if: a) individual syringes are prepared in advance by another person OR b) given daily reminders.|1 - Able to take injectable medication at correct times if: a) individual syringes are prepared in a|13
53|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance by another person OR b) given daily reminders.|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance b|13
54|1 - Able to take medication(s) at the correct times if: a) individual dosages are prepared in advance by another person , OR b) given daily reminders OR c) someone develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if: a) individual dosages are prepared in advanc|13
55|1 - Able to take medication(s) at the correct times if: a) individual dosages are prepared in advance by another person, OR b) given daily reminders OR c) someone develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if: a) individual dosages are prepared in advanc|13
56|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for the deaf) and call essential numbers.|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for t|13
57|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|13
58|1 - American Indian or Alaska Native|1 - American Indian or Alaska Native|13
59|1 - Depressed mood (e.g., feeling sad, tearful)|1 - Depressed mood (e.g., feeling sad, tearful)|13
60|1 - During the night only|1 - During the night only|13
61|1 - Fully granulating|1 - Fully granulating|13
62|1 - Good/Fair:  partial to full recovery is expected|1 - Good/Fair:  partial to full recovery is expected|13
63|1 - Good:  marked improvement in functional status is expected|1 - Good:  marked improvement in functional status is expected|13
64|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|13
65|1 - Heavy smoking|1 - Heavy smoking|13
66|1 - Hospital|1 - Hospital|13
67|1 - Hospital emergency room (includes 23-hour holding)|1 - Hospital emergency room (includes 23-hour holding)|13
68|1 - Hospitalization for EMERGENT (unscheduled) care|1 - Hospitalization for EMERGENT (unscheduled) care|13
69|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepared solutions), patient is able to manage all other aspects of equipment.|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepar|13
70|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|13
71|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|13
72|1 - In new or complex situations only|1 - In new or complex situations only|13
73|1 - Intravenous or infusion therapy (excludes TPN)|1 - Intravenous or infusion therapy (excludes TPN)|13
74|1 - Less often than daily|1 - Less often than daily|13
75|1 - Less than once a month|1 - Less than once a month|13
76|1 - Less than once weekly|1 - Less than once weekly|13
77|1 - Life expectancy is 6 months or fewer|1 - Life expectancy is 6 months or fewer|13
78|1 - Lives alone|1 - Lives alone|13
79|1 - Male|1 - Male|13
80|1 - Medicare (traditional fee-for-service)|1 - Medicare (traditional fee-for-service)|13
81|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of past 24 hours, significant memory loss so that supervision is required|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of pas|13
82|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors in word choice, grammar or speech intelligibility, needs minimal prompting or assistance).|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors i|13
83|1 - No assistance or services received|1 - No assistance or services received|13
84|1 - One|1 - One|13
85|1 - Oxygen (intermittent or continuous)|1 - Oxygen (intermittent or continuous)|13
86|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, and the surrounding layout, can count fingers at arm's length.|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, a|13
87|1 - Patient is incontinent|1 - Patient is incontinent|13
88|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|13
89|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical or treatment regimen.|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical|13
90|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient/couple/significant other)|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient|13
91|1 - Relatives, friends, or neighbors living outside the home|1 - Relatives, friends, or neighbors living outside the home|13
92|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions.|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions|13
93|1 - Requires use of a device (e.g., cane, walker) to walk alone OR requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|1 - Requires use of a device (e.g., cane, walker) to walk alone OR requires human supervision or ass|13
94|1 - Several times during day and night|1 - Several times during day and night|13
95|1 - Spouse or significant other|1 - Spouse or significant other|13
96|1 - Stage 1|1 - Stage 1|13
97|1 - Start of care - further visits planned|1 - Start of care - further visits planned|13
98|1 - Symptoms well controlled with current therapy|1 - Symptoms well controlled with current therapy|13
99|1 - Therapy services|1 - Therapy services|13
100|1 - Transfers with minimal human assistance or with use of an assistive device.|1 - Transfers with minimal human assistance or with use of an assistive device.|13
101|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitations.|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitatio|13
102|1 - Urinary incontinence|1 - Urinary incontinence|13
103|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet.|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet.|13
104|1 - When walking more than 20 feet, climbing stairs|1 - When walking more than 20 feet, climbing stairs|13
105|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary conversation. May need occasional repetition, extra time, or louder voice.|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary c|13
106|1 - With the use of devices, is able to bathe self in shower or tub independently.|1 - With the use of devices, is able to bathe self in shower or tub independently.|13
107|1 - Yes|1 - Yes|13
108|1-RN|1-RN|13
109|10 - Discharge from agency - no visits completed after start/resumption of care assessment|10 - Discharge from agency - no visits completed after start/resumption of care assessment|13
110|10 - Scheduled surgical procedure|10 - Scheduled surgical procedure|13
111|10 - Self-pay|10 - Self-pay|13
112|11 - Other|11 - Other|13
113|11 - Urinary tract infection|11 - Urinary tract infection|13
114|12 - IV catheter-related infection|12 - IV catheter-related infection|13
115|13 - Deep vein thrombosis, pulmonary embolus|13 - Deep vein thrombosis, pulmonary embolus|13
116|14 - Uncontrolled pain|14 - Uncontrolled pain|13
117|15 - Psychotic episode|15 - Psychotic episode|13
118|16 - Other than above reasons|16 - Other than above reasons|13
119|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing calls.|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing|13
120|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another person.|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another pers|13
121|2 - Able to walk only with the supervision or assistance of another person at all times.|2 - Able to walk only with the supervision or assistance of another person at all times.|13
122|2 - Aid: a) for intermittent supervision/encouragement/reminders, OR b) to get in and out of the shower/tub, OR c) for washing difficult to reach areas.|2 - Aid: a) for intermittent supervision/encouragement/reminders, OR b) to get in and out of the sho|13
123|2 - Asian|2 - Asian|13
124|2 - Caregiver requires considerable assistance from another person to manage equipment, but independently completes significant portions of task.|2 - Caregiver requires considerable assistance from another person to manage equipment, but independ|13
125|2 - Daily, but not constantly|2 - Daily, but not constantly|13
126|2 - Daughter or son|2 - Daughter or son|13
127|2 - Doctor's office emergency visit/house call|2 - Doctor's office emergency visit/house call|13
128|2 - During the day and night|2 - During the day and night|13
129|2 - Early/partial granulation|2 - Early/partial granulation|13
130|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors in word choice, organization or speech intelligibility). Speaks in phrases or short sentences.|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors|13
131|2 - Family member's residence|2 - Family member's residence|13
132|2 - Female|2 - Female|13
133|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conversation, needs frequent prompting or assistance.|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conver|13
134|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|13
135|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|13
136|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately stop activities, jeopardizes safety through actions|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately st|13
137|2 - Indwelling/suprapubic catheter|2 - Indwelling/suprapubic catheter|13
138|2 - Injury caused by fall or accident at home|2 - Injury caused by fall or accident at home|13
139|2 - Medicare (HMO/managed care)|2 - Medicare (HMO/managed care)|13
140|2 - Nausea, dehydration, malnutrition, constipation, impaction|2 - Nausea, dehydration, malnutrition, constipation, impaction|13
141|2 - Obesity|2 - Obesity|13
142|2 - On awakening or at night only|2 - On awakening or at night only|13
143|2 - Once a month|2 - Once a month|13
144|2 - One to three times weekly|2 - One to three times weekly|13
145|2 - Parenteral nutrition (TPN or lipids)|2 - Parenteral nutrition (TPN or lipids)|13
146|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic)|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic)|13
147|2 - Patient requires considerable assistance from another person to manage equipment, but independently completes portions of the task.|2 - Patient requires considerable assistance from another person to manage equipment, but independen|13
148|2 - Patient transferred to a noninstitutional hospice|2 - Patient transferred to a noninstitutional hospice|13
149|2 - Person residing in the home (EXCLUDING paid help)|2 - Person residing in the home (EXCLUDING paid help)|13
150|2 - Rehabilitation facility|2 - Rehabilitation facility|13
151|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifting of attention) or consistently requires low stimulus environment due to distractibility.|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifti|13
152|2 - Respite care|2 - Respite care|13
153|2 - Sense of failure or self reproach|2 - Sense of failure or self reproach|13
154|2 - Several times during day|2 - Several times during day|13
155|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonresponsive.|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonrespons|13
156|2 - Someone must assist the patient to groom self.|2 - Someone must assist the patient to groom self.|13
157|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|13
158|2 - Someone must help the patient put on upper body clothing.|2 - Someone must help the patient put on upper body clothing.|13
159|2 - Stage 2|2 - Stage 2|13
160|2 - Start of care - no further visits planned|2 - Start of care - no further visits planned|13
161|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitoring|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitori|13
162|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment regimen.|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment re|13
163|2 - Two|2 - Two|13
164|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistance due to cognitive or mental limitation.|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistanc|13
165|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|13
166|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assistance).|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assis|13
167|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home delivery.|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home deli|13
168|2 - Unable to prepare any light meals or reheat any delivered meals.|2 - Unable to prepare any light meals or reheat any delivered meals.|13
169|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|13
170|2 - UNABLE to take injectable medications unless administered by someone else.|2 - UNABLE to take injectable medications unless administered by someone else.|13
171|2 - UNABLE to take medication unless administered by someone else.|2 - UNABLE to take medication unless administered by someone else.|13
172|2 - UNABLE to transfer self but is able to bear weight and pivot during the transfer process.|2 - UNABLE to transfer self but is able to bear weight and pivot during the transfer process.|13
173|2 - Ventilator (continually or at night)|2 - Ventilator (continually or at night)|13
174|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less than 20 feet)|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less th|13
175|2 - With spouse or significant other|2 - With spouse or significant other|13
176|2 - Yes, assistance or services provided by family or friends|2 - Yes, assistance or services provided by family or friends|13
177|2-PT|2-PT|13
178|3 - Able to answer the telephone only some of the time or is able to carry on only a limited conversation.|3 - Able to answer the telephone only some of the time or is able to carry on only a limited convers|13
179|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube or gastrostomy.|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube|13
180|3 - Alcohol dependency|3 - Alcohol dependency|13
181|3 - All of the time|3 - All of the time|13
182|3 - Black or African-American|3 - Black or African-American|13
183|3 - Boarding home or rented room|3 - Boarding home or rented room|13
184|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment, clean/store/dispose of equipment or supplies).|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment,|13
185|3 - Chairfast, UNABLE to ambulate but is able to wheel self independently.|3 - Chairfast, UNABLE to ambulate but is able to wheel self independently.|13
186|3 - Continuous positive airway pressure|3 - Continuous positive airway pressure|13
187|3 - During the day and evening, but not constantly|3 - During the day and evening, but not constantly|13
188|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the alimentary canal)|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the|13
189|3 - Environmental support (e.g., housing, home maintenance)|3 - Environmental support (e.g., housing, home maintenance)|13
190|3 - Four to six times weekly|3 - Four to six times weekly|13
191|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessing by listener.  Speech limited to single words or short phrases.|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessin|13
192|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires multiple repetitions, restatements, demonstrations, additional time.|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires m|13
193|3 - Hopelessness|3 - Hopelessness|13
194|3 - Hospice care|3 - Hospice care|13
195|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|13
196|3 - Injury caused by fall or accident at home|3 - Injury caused by fall or accident at home|13
197|3 - Intractable pain|3 - Intractable pain|13
198|3 - Medicaid (traditional fee-for-service)|3 - Medicaid (traditional fee-for-service)|13
199|3 - Needs someone to do all shopping and errands.|3 - Needs someone to do all shopping and errands.|13
200|3 - Not healing|3 - Not healing|13
201|3 - Nursing home|3 - Nursing home|13
202|3 - Once daily|3 - Once daily|13
203|3 - Other family member|3 - Other family member|13
204|3 - Outpatient department/clinic emergency (includes urgicenter sites)|3 - Outpatient department/clinic emergency (includes urgicenter sites)|13
205|3 - Paid help|3 - Paid help|13
206|3 - Participates in bathing self in shower or tub, BUT requires presence of another person throughout the bath for assistance or supervision.|3 - Participates in bathing self in shower or tub, BUT requires presence of another person throughou|13
207|3 - Patient depends entirely upon another person to dress lower body.|3 - Patient depends entirely upon another person to dress lower body.|13
208|3 - Patient depends entirely upon another person to dress the upper body.|3 - Patient depends entirely upon another person to dress the upper body.|13
209|3 - Patient depends entirely upon someone else for grooming needs.|3 - Patient depends entirely upon someone else for grooming needs.|13
210|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone else to manage the equipment.|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone|13
211|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable to shift attention and recall directions more than half the time.|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable|13
212|3 - Respiratory problems (SOB, infection, obstruction)|3 - Respiratory problems (SOB, infection, obstruction)|13
213|3 - Resumption of care (after inpatient stay)|3 - Resumption of care (after inpatient stay)|13
214|3 - Several times each month|3 - Several times each month|13
215|3 - Skilled Nursing Facility|3 - Skilled Nursing Facility|13
216|3 - Stage 3|3 - Stage 3|13
217|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|13
218|3 - Three|3 - Three|13
219|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person throughout the process.|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person through|13
220|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal independently.|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal indep|13
221|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person.|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person|13
222|3 - Unknown because patient moved to a geographic location not served by this agency|3 - Unknown because patient moved to a geographic location not served by this agency|13
223|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|13
224|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|13
225|3 - With other family member|3 - With other family member|13
226|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home health services, homemaker assistance, transportation assistance, assisted living, board and care)|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home h|13
227|3-SLP/ST|3-SLP/ST|13
228|4 - At rest (during day or night)|4 - At rest (during day or night)|13
229|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|13
230|4 - Board and care or assisted living facility|4 - Board and care or assisted living facility|13
231|4 - Caregiver is completely dependent on someone else to manage all equipment.|4 - Caregiver is completely dependent on someone else to manage all equipment.|13
232|4 - Chairfast, unable to ambulate and is UNABLE to wheel self.|4 - Chairfast, unable to ambulate and is UNABLE to wheel self.|13
233|4 - Constantly|4 - Constantly|13
234|4 - Drug dependency|4 - Drug dependency|13
235|4 - Four or more|4 - Four or more|13
236|4 - Friend or neighbor or community or church member|4 - Friend or neighbor or community or church member|13
237|4 - Hispanic or Latino|4 - Hispanic or Latino|13
238|4 - Hospice|4 - Hospice|13
239|4 - Impaired decision-making|4 - Impaired decision-making|13
240|4 - Is totally dependent in toileting.|4 - Is totally dependent in toileting.|13
241|4 - Medicaid (HMO/managed care)|4 - Medicaid (HMO/managed care)|13
242|4 - None of the above|4 - None of the above|13
243|4 - Nursing home|4 - Nursing home|13
244|4 - On a daily basis|4 - On a daily basis|13
245|4 - Patient is completely dependent on someone else to manage all equipment.|4 - Patient is completely dependent on someone else to manage all equipment.|13
246|4 - Permanent placement|4 - Permanent placement|13
247|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, punches, dangerous maneuvers w/ wheelchair or other objects)|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, pu|13
248|4 - Psychosocial support (e.g., socialization, companionship, recreation)|4 - Psychosocial support (e.g., socialization, companionship, recreation)|13
249|4 - Recertification (follow-up) reassessment|4 - Recertification (follow-up) reassessment|13
250|4 - Recurrent thoughts of death|4 - Recurrent thoughts of death|13
251|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruction)|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruc|13
252|4 - Several times a week|4 - Several times a week|13
253|4 - Stage 4|4 - Stage 4|13
254|4 - Symptoms poorly controlled, history of rehospitalizations|4 - Symptoms poorly controlled, history of rehospitalizations|13
255|4 - Three or more times per week|4 - Three or more times per week|13
256|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetative state, or delirium.|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetati|13
257|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|13
258|4 - Unable to effectively participate in any housekeeping tasks.|4 - Unable to effectively participate in any housekeeping tasks.|13
259|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or unresponsive (e.g., speech is nonsensical or unintelligible).|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or u|13
260|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonresponsive.|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonr|13
261|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostomy.|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostom|13
262|4 - UNABLE to use the shower or tub and is bathed in BED OR BEDSIDE CHAIR.|4 - UNABLE to use the shower or tub and is bathed in BED OR BEDSIDE CHAIR.|13
263|4 - With a friend|4 - With a friend|13
264|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|13
265|4-OT|4-OT|13
266|5 - Advocates or facilitates patient's participation in appropriate medical care|5 - Advocates or facilitates patient's participation in appropriate medical care|13
267|5 - At least daily|5 - At least daily|13
268|5 - Bedfast, unable to ambulate or be up in a chair.|5 - Bedfast, unable to ambulate or be up in a chair.|13
269|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|13
270|5 - Disruptive or socially inappropriate behavior|5 - Disruptive or socially inappropriate behavior|13
271|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|13
272|5 - Hypo/Hyperglycemia, diabetes out of control|5 - Hypo/Hyperglycemia, diabetes out of control|13
273|5 - More often than once daily|5 - More often than once daily|13
274|5 - Native Hawaiian or Pacific Islander|5 - Native Hawaiian or Pacific Islander|13
275|5 - None of the above|5 - None of the above|13
276|5 - One to two times per week|5 - One to two times per week|13
277|5 - Other|5 - Other|13
278|5 - Other follow-up|5 - Other follow-up|13
279|5 - Paid help|5 - Paid help|13
280|5 - Patient nonresponsive or unable to speak.|5 - Patient nonresponsive or unable to speak.|13
281|5 - Thoughts of suicide|5 - Thoughts of suicide|13
282|5 - Totally unable to use the telephone.|5 - Totally unable to use the telephone.|13
283|5 - Unable to effectively participate in bathing and is totally bathed by another person.|5 - Unable to effectively participate in bathing and is totally bathed by another person.|13
284|5 - Unable to take in nutrients orally or by tube feeding.|5 - Unable to take in nutrients orally or by tube feeding.|13
285|5 - Unsafe for care at home|5 - Unsafe for care at home|13
286|5 - With paid help (other than home care agency staff)|5 - With paid help (other than home care agency staff)|13
287|5 - Workers' compensation|5 - Workers' compensation|13
288|5 - Wound infection, deteriorating wound status, new lesion/ulcer|5 - Wound infection, deteriorating wound status, new lesion/ulcer|13
289|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|13
290|6 - Delusional, hallucinatory, or paranoid behavior|6 - Delusional, hallucinatory, or paranoid behavior|13
291|6 - Financial agent, power of attorney, or conservator of finance|6 - Financial agent, power of attorney, or conservator of finance|13
292|6 - GI bleeding, obstruction|6 - GI bleeding, obstruction|13
293|6 - Less often than weekly|6 - Less often than weekly|13
294|6 - Memory loss to the extent that supervision required|6 - Memory loss to the extent that supervision required|13
295|6 - None of the above feelings observed or reported|6 - None of the above feelings observed or reported|13
296|6 - Other|6 - Other|13
297|6 - Title programs (e.g., Title III, V, or XX)|6 - Title programs (e.g., Title III, V, or XX)|13
298|6 - Transferred to an inpatient facility - patient not discharged from agency|6 - Transferred to an inpatient facility - patient not discharged from agency|13
299|6 - White|6 - White|13
300|6 - With other than above|6 - With other than above|13
301|7 - Exacerbation of CHF, fluid overload, heart failure|7 - Exacerbation of CHF, fluid overload, heart failure|13
302|7 - Health care agent, conservator of person, or medical power of attorney|7 - Health care agent, conservator of person, or medical power of attorney|13
303|7 - Hypo/Hyperglycemia, diabetes out of control|7 - Hypo/Hyperglycemia, diabetes out of control|13
304|7 - None of the above|7 - None of the above|13
305|7 - None of the above behaviors demonstrated|7 - None of the above behaviors demonstrated|13
306|7 - Other government (e.g., CHAMPUS, VA, etc.)|7 - Other government (e.g., CHAMPUS, VA, etc.)|13
307|7 - Transferred to an inpatient facility - patient discharged from agency|7 - Transferred to an inpatient facility - patient discharged from agency|13
308|8 - Death at home|8 - Death at home|13
309|8 - GI bleeding, obstruction|8 - GI bleeding, obstruction|13
310|8 - Myocardial infarction, stroke|8 - Myocardial infarction, stroke|13
311|8 - Private insurance|8 - Private insurance|13
312|9 - Chemotherapy|9 - Chemotherapy|13
313|9 - Discharge from agency|9 - Discharge from agency|13
314|9 - Other than above reasons|9 - Other than above reasons|13
315|9 - Private HMO/managed care|9 - Private HMO/managed care|13
316|NA - No caregiver|NA - No caregiver|13
317|NA - No equipment of this type used in care.|NA - No equipment of this type used in care.|13
318|NA - No inhalant/mist medications prescribed.|NA - No inhalant/mist medications prescribed.|13
319|NA - No injectable medications prescribed.|NA - No injectable medications prescribed.|13
320|NA - No inpatient facility admission|NA - No inpatient facility admission|13
321|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|13
322|NA - No Medicaid|NA - No Medicaid|13
323|NA - No Medicare|NA - No Medicare|13
324|NA - No observable pressure ulcer|NA - No observable pressure ulcer|13
325|NA - No observable stasis ulcer|NA - No observable stasis ulcer|13
326|NA - No observable surgical wound|NA - No observable surgical wound|13
327|NA - No oral medications prescribed.|NA - No oral medications prescribed.|13
328|NA - Not applicable|NA - Not applicable|13
329|NA - Patient does not have a telephone.|NA - Patient does not have a telephone.|13
330|NA - Patient has ostomy for bowel elimination|NA - Patient has ostomy for bowel elimination|13
331|NA - Patient nonresponsive|NA - Patient nonresponsive|13
332|NA - Patient on prophylactic treatment|NA - Patient on prophylactic treatment|13
333|NA - Patient was not discharged from an inpatient facility|NA - Patient was not discharged from an inpatient facility|13
334|UK - Other unknown|UK - Other unknown|13
335|UK - Reason unknown|UK - Reason unknown|13
336|UK - Unknown|UK - Unknown|13
337|UK - Unknown or Not Available|UK - Unknown or Not Available|13
341|01 - Early|01 - Early|13
342|02 - Late|02 - Late|13
343|NA - Not Applicable. No case mix group defined for this assessment.|NA - Not Applicable. No case mix group defined for this assessment.|13
344|NA - No case mix group defined by this assessment.|NA - No case mix group defined by this assessment.|13
2|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; OR (b) Is physically, cognitively, and mentally able to prepare light meals on a regular basis but has not routinely performed light meal preparation in the past (i.e., prior to this home care admission).|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; O|14
3|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and mentally able to perform all housekeeping tasks .|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and menta|14
4|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and mentally able to do laundry and access facilities.|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and menta|14
5|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying packages OR b) Physically, cognitively, and mentally able to take care of shopping, but has not done shopping in the past (i.e., prior to this home care admission).|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying|14
6|0 - Able to bathe self in SHOWER OR TUB independently.|0 - Able to bathe self in SHOWER OR TUB independently.|14
7|0 - Able to dial numbers and answer calls appropriately and as desired.|0 - Able to dial numbers and answer calls appropriately and as desired.|14
8|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body without assistance.|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body|14
9|0 - Able to get to and from the toilet independently with or without a device.|0 - Able to get to and from the toilet independently with or without a device.|14
10|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|14
11|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible public bus.|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible p|14
12|0 - Able to independently feed self.|0 - Able to independently feed self.|14
13|0 - Able to independently take the correct medication and proper dosage at the correct times.|0 - Able to independently take the correct medication and proper dosage at the correct times.|14
14|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct times.|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct ti|14
15|0 - Able to independently transfer.|0 - Able to independently transfer.|14
16|0 - Able to independently walk on even and uneven surfaces and climb stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even and uneven surfaces and climb stairs with or without railings|14
17|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings|14
18|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|14
19|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions independently.|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions indep|14
20|0 - Asymptomatic, no treatment needed at this time|0 - Asymptomatic, no treatment needed at this time|14
21|0 - Caregiver manages all tasks related to equipment completely independently.|0 - Caregiver manages all tasks related to equipment completely independently.|14
22|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations with no observable impairment.|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations w|14
23|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|14
24|0 - Life expectancy is greater than 6 months|0 - Life expectancy is greater than 6 months|14
25|0 - Never|0 - Never|14
26|0 - Never, patient is not short of breath|0 - Never, patient is not short of breath|14
27|0 - No|0 - No|14
28|0 - No emergent care services|0 - No emergent care services|14
29|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage)|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage)|14
30|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and extended or abstract conversation.|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and exte|14
31|0 - No one person|0 - No one person|14
32|0 - None of the time|0 - None of the time|14
33|0 - None, no charge for current services|0 - None, no charge for current services|14
34|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|14
35|0 - Patient does NOT have an ostomy for bowel elimination.|0 - Patient does NOT have an ostomy for bowel elimination.|14
36|0 - Patient has no pain or pain does not interfere with activity or movement|0 - Patient has no pain or pain does not interfere with activity or movement|14
37|0 - Patient manages all tasks related to equipment completely independently.|0 - Patient manages all tasks related to equipment completely independently.|14
38|0 - Poor:  little or no recovery is expected and/or further decline is imminent|0 - Poor:  little or no recovery is expected and/or further decline is imminent|14
39|0 - Timed-voiding defers incontinence|0 - Timed-voiding defers incontinence|14
40|0 - Very rarely or never has bowel incontinence|0 - Very rarely or never has bowel incontinence|14
41|0 - Zero|0 - Zero|14
42|00 - No|00 - No|14
43|01 - Yes|01 - Yes|14
44|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or mental limitations, needs assistance with heavy laundry.|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or|14
45|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the patient.|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the|14
46|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|14
47|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or supervision from another person OR c) a liquid, pureed or ground meat diet.|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or su|14
48|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|14
49|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|14
50|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independently.|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independe|14
51|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only when assisted or accompanied by another person.|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only w|14
52|1 - Able to take injectable medication at correct times if: a) individual syringes are prepared in advance by another person OR b) given daily reminders.|1 - Able to take injectable medication at correct times if: a) individual syringes are prepared in a|14
53|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance by another person OR b) given daily reminders.|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance b|14
54|1 - Able to take medication(s) at the correct times if: a) individual dosages are prepared in advance by another person , OR b) given daily reminders OR c) someone develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if: a) individual dosages are prepared in advanc|14
55|1 - Able to take medication(s) at the correct times if: a) individual dosages are prepared in advance by another person, OR b) given daily reminders OR c) someone develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if: a) individual dosages are prepared in advanc|14
56|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for the deaf) and call essential numbers.|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for t|14
57|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|14
58|1 - American Indian or Alaska Native|1 - American Indian or Alaska Native|14
59|1 - Depressed mood (e.g., feeling sad, tearful)|1 - Depressed mood (e.g., feeling sad, tearful)|14
60|1 - During the night only|1 - During the night only|14
61|1 - Fully granulating|1 - Fully granulating|14
62|1 - Good/Fair:  partial to full recovery is expected|1 - Good/Fair:  partial to full recovery is expected|14
63|1 - Good:  marked improvement in functional status is expected|1 - Good:  marked improvement in functional status is expected|14
64|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|14
65|1 - Heavy smoking|1 - Heavy smoking|14
66|1 - Hospital|1 - Hospital|14
67|1 - Hospital emergency room (includes 23-hour holding)|1 - Hospital emergency room (includes 23-hour holding)|14
68|1 - Hospitalization for EMERGENT (unscheduled) care|1 - Hospitalization for EMERGENT (unscheduled) care|14
69|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepared solutions), patient is able to manage all other aspects of equipment.|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepar|14
70|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|14
71|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|14
72|1 - In new or complex situations only|1 - In new or complex situations only|14
73|1 - Intravenous or infusion therapy (excludes TPN)|1 - Intravenous or infusion therapy (excludes TPN)|14
74|1 - Less often than daily|1 - Less often than daily|14
75|1 - Less than once a month|1 - Less than once a month|14
76|1 - Less than once weekly|1 - Less than once weekly|14
77|1 - Life expectancy is 6 months or fewer|1 - Life expectancy is 6 months or fewer|14
78|1 - Lives alone|1 - Lives alone|14
79|1 - Male|1 - Male|14
80|1 - Medicare (traditional fee-for-service)|1 - Medicare (traditional fee-for-service)|14
81|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of past 24 hours, significant memory loss so that supervision is required|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of pas|14
82|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors in word choice, grammar or speech intelligibility, needs minimal prompting or assistance).|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors i|14
83|1 - No assistance or services received|1 - No assistance or services received|14
84|1 - One|1 - One|14
85|1 - Oxygen (intermittent or continuous)|1 - Oxygen (intermittent or continuous)|14
86|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, and the surrounding layout, can count fingers at arm's length.|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, a|14
87|1 - Patient is incontinent|1 - Patient is incontinent|14
88|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|14
89|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical or treatment regimen.|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical|14
90|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient/couple/significant other)|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient|14
91|1 - Relatives, friends, or neighbors living outside the home|1 - Relatives, friends, or neighbors living outside the home|14
92|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions.|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions|14
93|1 - Requires use of a device (e.g., cane, walker) to walk alone OR requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|1 - Requires use of a device (e.g., cane, walker) to walk alone OR requires human supervision or ass|14
94|1 - Several times during day and night|1 - Several times during day and night|14
95|1 - Spouse or significant other|1 - Spouse or significant other|14
96|1 - Stage 1|1 - Stage 1|14
97|1 - Start of care - further visits planned|1 - Start of care - further visits planned|14
98|1 - Symptoms well controlled with current therapy|1 - Symptoms well controlled with current therapy|14
99|1 - Therapy services|1 - Therapy services|14
100|1 - Transfers with minimal human assistance or with use of an assistive device.|1 - Transfers with minimal human assistance or with use of an assistive device.|14
101|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitations.|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitatio|14
102|1 - Urinary incontinence|1 - Urinary incontinence|14
103|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet.|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet.|14
104|1 - When walking more than 20 feet, climbing stairs|1 - When walking more than 20 feet, climbing stairs|14
105|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary conversation. May need occasional repetition, extra time, or louder voice.|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary c|14
106|1 - With the use of devices, is able to bathe self in shower or tub independently.|1 - With the use of devices, is able to bathe self in shower or tub independently.|14
107|1 - Yes|1 - Yes|14
108|1-RN|1-RN|14
109|10 - Discharge from agency - no visits completed after start/resumption of care assessment|10 - Discharge from agency - no visits completed after start/resumption of care assessment|14
110|10 - Scheduled surgical procedure|10 - Scheduled surgical procedure|14
111|10 - Self-pay|10 - Self-pay|14
112|11 - Other|11 - Other|14
113|11 - Urinary tract infection|11 - Urinary tract infection|14
114|12 - IV catheter-related infection|12 - IV catheter-related infection|14
115|13 - Deep vein thrombosis, pulmonary embolus|13 - Deep vein thrombosis, pulmonary embolus|14
116|14 - Uncontrolled pain|14 - Uncontrolled pain|14
117|15 - Psychotic episode|15 - Psychotic episode|14
118|16 - Other than above reasons|16 - Other than above reasons|14
119|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing calls.|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing|14
120|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another person.|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another pers|14
121|2 - Able to walk only with the supervision or assistance of another person at all times.|2 - Able to walk only with the supervision or assistance of another person at all times.|14
122|2 - Aid: a) for intermittent supervision/encouragement/reminders, OR b) to get in and out of the shower/tub, OR c) for washing difficult to reach areas.|2 - Aid: a) for intermittent supervision/encouragement/reminders, OR b) to get in and out of the sho|14
123|2 - Asian|2 - Asian|14
124|2 - Caregiver requires considerable assistance from another person to manage equipment, but independently completes significant portions of task.|2 - Caregiver requires considerable assistance from another person to manage equipment, but independ|14
125|2 - Daily, but not constantly|2 - Daily, but not constantly|14
126|2 - Daughter or son|2 - Daughter or son|14
127|2 - Doctor's office emergency visit/house call|2 - Doctor's office emergency visit/house call|14
128|2 - During the day and night|2 - During the day and night|14
129|2 - Early/partial granulation|2 - Early/partial granulation|14
130|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors in word choice, organization or speech intelligibility). Speaks in phrases or short sentences.|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors|14
131|2 - Family member's residence|2 - Family member's residence|14
132|2 - Female|2 - Female|14
133|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conversation, needs frequent prompting or assistance.|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conver|14
134|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|14
135|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|14
136|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately stop activities, jeopardizes safety through actions|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately st|14
137|2 - Indwelling/suprapubic catheter|2 - Indwelling/suprapubic catheter|14
138|2 - Injury caused by fall or accident at home|2 - Injury caused by fall or accident at home|14
139|2 - Medicare (HMO/managed care)|2 - Medicare (HMO/managed care)|14
140|2 - Nausea, dehydration, malnutrition, constipation, impaction|2 - Nausea, dehydration, malnutrition, constipation, impaction|14
141|2 - Obesity|2 - Obesity|14
142|2 - On awakening or at night only|2 - On awakening or at night only|14
143|2 - Once a month|2 - Once a month|14
144|2 - One to three times weekly|2 - One to three times weekly|14
145|2 - Parenteral nutrition (TPN or lipids)|2 - Parenteral nutrition (TPN or lipids)|14
146|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic)|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic)|14
147|2 - Patient requires considerable assistance from another person to manage equipment, but independently completes portions of the task.|2 - Patient requires considerable assistance from another person to manage equipment, but independen|14
148|2 - Patient transferred to a noninstitutional hospice|2 - Patient transferred to a noninstitutional hospice|14
149|2 - Person residing in the home (EXCLUDING paid help)|2 - Person residing in the home (EXCLUDING paid help)|14
150|2 - Rehabilitation facility|2 - Rehabilitation facility|14
151|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifting of attention) or consistently requires low stimulus environment due to distractibility.|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifti|14
152|2 - Respite care|2 - Respite care|14
153|2 - Sense of failure or self reproach|2 - Sense of failure or self reproach|14
154|2 - Several times during day|2 - Several times during day|14
155|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonresponsive.|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonrespons|14
156|2 - Someone must assist the patient to groom self.|2 - Someone must assist the patient to groom self.|14
157|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|14
158|2 - Someone must help the patient put on upper body clothing.|2 - Someone must help the patient put on upper body clothing.|14
159|2 - Stage 2|2 - Stage 2|14
160|2 - Start of care - no further visits planned|2 - Start of care - no further visits planned|14
161|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitoring|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitori|14
162|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment regimen.|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment re|14
163|2 - Two|2 - Two|14
164|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistance due to cognitive or mental limitation.|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistanc|14
165|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|14
166|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assistance).|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assis|14
167|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home delivery.|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home deli|14
168|2 - Unable to prepare any light meals or reheat any delivered meals.|2 - Unable to prepare any light meals or reheat any delivered meals.|14
169|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|14
170|2 - UNABLE to take injectable medications unless administered by someone else.|2 - UNABLE to take injectable medications unless administered by someone else.|14
171|2 - UNABLE to take medication unless administered by someone else.|2 - UNABLE to take medication unless administered by someone else.|14
172|2 - UNABLE to transfer self but is able to bear weight and pivot during the transfer process.|2 - UNABLE to transfer self but is able to bear weight and pivot during the transfer process.|14
173|2 - Ventilator (continually or at night)|2 - Ventilator (continually or at night)|14
174|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less than 20 feet)|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less th|14
175|2 - With spouse or significant other|2 - With spouse or significant other|14
176|2 - Yes, assistance or services provided by family or friends|2 - Yes, assistance or services provided by family or friends|14
177|2-PT|2-PT|14
178|3 - Able to answer the telephone only some of the time or is able to carry on only a limited conversation.|3 - Able to answer the telephone only some of the time or is able to carry on only a limited convers|14
179|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube or gastrostomy.|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube|14
180|3 - Alcohol dependency|3 - Alcohol dependency|14
181|3 - All of the time|3 - All of the time|14
182|3 - Black or African-American|3 - Black or African-American|14
183|3 - Boarding home or rented room|3 - Boarding home or rented room|14
184|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment, clean/store/dispose of equipment or supplies).|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment,|14
185|3 - Chairfast, UNABLE to ambulate but is able to wheel self independently.|3 - Chairfast, UNABLE to ambulate but is able to wheel self independently.|14
186|3 - Continuous positive airway pressure|3 - Continuous positive airway pressure|14
187|3 - During the day and evening, but not constantly|3 - During the day and evening, but not constantly|14
188|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the alimentary canal)|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the|14
189|3 - Environmental support (e.g., housing, home maintenance)|3 - Environmental support (e.g., housing, home maintenance)|14
190|3 - Four to six times weekly|3 - Four to six times weekly|14
191|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessing by listener.  Speech limited to single words or short phrases.|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessin|14
192|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires multiple repetitions, restatements, demonstrations, additional time.|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires m|14
193|3 - Hopelessness|3 - Hopelessness|14
194|3 - Hospice care|3 - Hospice care|14
195|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|14
196|3 - Injury caused by fall or accident at home|3 - Injury caused by fall or accident at home|14
197|3 - Intractable pain|3 - Intractable pain|14
198|3 - Medicaid (traditional fee-for-service)|3 - Medicaid (traditional fee-for-service)|14
199|3 - Needs someone to do all shopping and errands.|3 - Needs someone to do all shopping and errands.|14
200|3 - Not healing|3 - Not healing|14
201|3 - Nursing home|3 - Nursing home|14
202|3 - Once daily|3 - Once daily|14
203|3 - Other family member|3 - Other family member|14
204|3 - Outpatient department/clinic emergency (includes urgicenter sites)|3 - Outpatient department/clinic emergency (includes urgicenter sites)|14
205|3 - Paid help|3 - Paid help|14
206|3 - Participates in bathing self in shower or tub, BUT requires presence of another person throughout the bath for assistance or supervision.|3 - Participates in bathing self in shower or tub, BUT requires presence of another person throughou|14
207|3 - Patient depends entirely upon another person to dress lower body.|3 - Patient depends entirely upon another person to dress lower body.|14
208|3 - Patient depends entirely upon another person to dress the upper body.|3 - Patient depends entirely upon another person to dress the upper body.|14
209|3 - Patient depends entirely upon someone else for grooming needs.|3 - Patient depends entirely upon someone else for grooming needs.|14
210|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone else to manage the equipment.|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone|14
211|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable to shift attention and recall directions more than half the time.|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable|14
212|3 - Respiratory problems (SOB, infection, obstruction)|3 - Respiratory problems (SOB, infection, obstruction)|14
213|3 - Resumption of care (after inpatient stay)|3 - Resumption of care (after inpatient stay)|14
214|3 - Several times each month|3 - Several times each month|14
215|3 - Skilled Nursing Facility|3 - Skilled Nursing Facility|14
216|3 - Stage 3|3 - Stage 3|14
217|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|14
218|3 - Three|3 - Three|14
219|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person throughout the process.|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person through|14
220|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal independently.|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal indep|14
221|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person.|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person|14
222|3 - Unknown because patient moved to a geographic location not served by this agency|3 - Unknown because patient moved to a geographic location not served by this agency|14
223|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|14
224|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|14
225|3 - With other family member|3 - With other family member|14
226|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home health services, homemaker assistance, transportation assistance, assisted living, board and care)|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home h|14
227|3-SLP/ST|3-SLP/ST|14
228|4 - At rest (during day or night)|4 - At rest (during day or night)|14
229|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|14
230|4 - Board and care or assisted living facility|4 - Board and care or assisted living facility|14
231|4 - Caregiver is completely dependent on someone else to manage all equipment.|4 - Caregiver is completely dependent on someone else to manage all equipment.|14
232|4 - Chairfast, unable to ambulate and is UNABLE to wheel self.|4 - Chairfast, unable to ambulate and is UNABLE to wheel self.|14
233|4 - Constantly|4 - Constantly|14
234|4 - Drug dependency|4 - Drug dependency|14
235|4 - Four or more|4 - Four or more|14
236|4 - Friend or neighbor or community or church member|4 - Friend or neighbor or community or church member|14
237|4 - Hispanic or Latino|4 - Hispanic or Latino|14
238|4 - Hospice|4 - Hospice|14
239|4 - Impaired decision-making|4 - Impaired decision-making|14
240|4 - Is totally dependent in toileting.|4 - Is totally dependent in toileting.|14
241|4 - Medicaid (HMO/managed care)|4 - Medicaid (HMO/managed care)|14
242|4 - None of the above|4 - None of the above|14
243|4 - Nursing home|4 - Nursing home|14
244|4 - On a daily basis|4 - On a daily basis|14
245|4 - Patient is completely dependent on someone else to manage all equipment.|4 - Patient is completely dependent on someone else to manage all equipment.|14
246|4 - Permanent placement|4 - Permanent placement|14
247|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, punches, dangerous maneuvers w/ wheelchair or other objects)|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, pu|14
248|4 - Psychosocial support (e.g., socialization, companionship, recreation)|4 - Psychosocial support (e.g., socialization, companionship, recreation)|14
249|4 - Recertification (follow-up) reassessment|4 - Recertification (follow-up) reassessment|14
250|4 - Recurrent thoughts of death|4 - Recurrent thoughts of death|14
251|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruction)|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruc|14
252|4 - Several times a week|4 - Several times a week|14
253|4 - Stage 4|4 - Stage 4|14
254|4 - Symptoms poorly controlled, history of rehospitalizations|4 - Symptoms poorly controlled, history of rehospitalizations|14
255|4 - Three or more times per week|4 - Three or more times per week|14
256|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetative state, or delirium.|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetati|14
257|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|14
258|4 - Unable to effectively participate in any housekeeping tasks.|4 - Unable to effectively participate in any housekeeping tasks.|14
259|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or unresponsive (e.g., speech is nonsensical or unintelligible).|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or u|14
260|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonresponsive.|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonr|14
261|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostomy.|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostom|14
262|4 - UNABLE to use the shower or tub and is bathed in BED OR BEDSIDE CHAIR.|4 - UNABLE to use the shower or tub and is bathed in BED OR BEDSIDE CHAIR.|14
263|4 - With a friend|4 - With a friend|14
264|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|14
265|4-OT|4-OT|14
266|5 - Advocates or facilitates patient's participation in appropriate medical care|5 - Advocates or facilitates patient's participation in appropriate medical care|14
267|5 - At least daily|5 - At least daily|14
268|5 - Bedfast, unable to ambulate or be up in a chair.|5 - Bedfast, unable to ambulate or be up in a chair.|14
269|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|14
270|5 - Disruptive or socially inappropriate behavior|5 - Disruptive or socially inappropriate behavior|14
271|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|14
272|5 - Hypo/Hyperglycemia, diabetes out of control|5 - Hypo/Hyperglycemia, diabetes out of control|14
273|5 - More often than once daily|5 - More often than once daily|14
274|5 - Native Hawaiian or Pacific Islander|5 - Native Hawaiian or Pacific Islander|14
275|5 - None of the above|5 - None of the above|14
276|5 - One to two times per week|5 - One to two times per week|14
277|5 - Other|5 - Other|14
278|5 - Other follow-up|5 - Other follow-up|14
279|5 - Paid help|5 - Paid help|14
280|5 - Patient nonresponsive or unable to speak.|5 - Patient nonresponsive or unable to speak.|14
281|5 - Thoughts of suicide|5 - Thoughts of suicide|14
282|5 - Totally unable to use the telephone.|5 - Totally unable to use the telephone.|14
283|5 - Unable to effectively participate in bathing and is totally bathed by another person.|5 - Unable to effectively participate in bathing and is totally bathed by another person.|14
284|5 - Unable to take in nutrients orally or by tube feeding.|5 - Unable to take in nutrients orally or by tube feeding.|14
285|5 - Unsafe for care at home|5 - Unsafe for care at home|14
286|5 - With paid help (other than home care agency staff)|5 - With paid help (other than home care agency staff)|14
287|5 - Workers' compensation|5 - Workers' compensation|14
288|5 - Wound infection, deteriorating wound status, new lesion/ulcer|5 - Wound infection, deteriorating wound status, new lesion/ulcer|14
289|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|14
290|6 - Delusional, hallucinatory, or paranoid behavior|6 - Delusional, hallucinatory, or paranoid behavior|14
291|6 - Financial agent, power of attorney, or conservator of finance|6 - Financial agent, power of attorney, or conservator of finance|14
292|6 - GI bleeding, obstruction|6 - GI bleeding, obstruction|14
293|6 - Less often than weekly|6 - Less often than weekly|14
294|6 - Memory loss to the extent that supervision required|6 - Memory loss to the extent that supervision required|14
295|6 - None of the above feelings observed or reported|6 - None of the above feelings observed or reported|14
296|6 - Other|6 - Other|14
297|6 - Title programs (e.g., Title III, V, or XX)|6 - Title programs (e.g., Title III, V, or XX)|14
298|6 - Transferred to an inpatient facility - patient not discharged from agency|6 - Transferred to an inpatient facility - patient not discharged from agency|14
299|6 - White|6 - White|14
300|6 - With other than above|6 - With other than above|14
301|7 - Exacerbation of CHF, fluid overload, heart failure|7 - Exacerbation of CHF, fluid overload, heart failure|14
302|7 - Health care agent, conservator of person, or medical power of attorney|7 - Health care agent, conservator of person, or medical power of attorney|14
303|7 - Hypo/Hyperglycemia, diabetes out of control|7 - Hypo/Hyperglycemia, diabetes out of control|14
304|7 - None of the above|7 - None of the above|14
305|7 - None of the above behaviors demonstrated|7 - None of the above behaviors demonstrated|14
306|7 - Other government (e.g., CHAMPUS, VA, etc.)|7 - Other government (e.g., CHAMPUS, VA, etc.)|14
307|7 - Transferred to an inpatient facility - patient discharged from agency|7 - Transferred to an inpatient facility - patient discharged from agency|14
308|8 - Death at home|8 - Death at home|14
309|8 - GI bleeding, obstruction|8 - GI bleeding, obstruction|14
310|8 - Myocardial infarction, stroke|8 - Myocardial infarction, stroke|14
311|8 - Private insurance|8 - Private insurance|14
312|9 - Chemotherapy|9 - Chemotherapy|14
313|9 - Discharge from agency|9 - Discharge from agency|14
314|9 - Other than above reasons|9 - Other than above reasons|14
315|9 - Private HMO/managed care|9 - Private HMO/managed care|14
316|NA - No caregiver|NA - No caregiver|14
317|NA - No equipment of this type used in care.|NA - No equipment of this type used in care.|14
318|NA - No inhalant/mist medications prescribed.|NA - No inhalant/mist medications prescribed.|14
319|NA - No injectable medications prescribed.|NA - No injectable medications prescribed.|14
320|NA - No inpatient facility admission|NA - No inpatient facility admission|14
321|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|14
322|NA - No Medicaid|NA - No Medicaid|14
323|NA - No Medicare|NA - No Medicare|14
324|NA - No observable pressure ulcer|NA - No observable pressure ulcer|14
325|NA - No observable stasis ulcer|NA - No observable stasis ulcer|14
326|NA - No observable surgical wound|NA - No observable surgical wound|14
327|NA - No oral medications prescribed.|NA - No oral medications prescribed.|14
328|NA - Not applicable|NA - Not applicable|14
329|NA - Patient does not have a telephone.|NA - Patient does not have a telephone.|14
330|NA - Patient has ostomy for bowel elimination|NA - Patient has ostomy for bowel elimination|14
331|NA - Patient nonresponsive|NA - Patient nonresponsive|14
332|NA - Patient on prophylactic treatment|NA - Patient on prophylactic treatment|14
333|NA - Patient was not discharged from an inpatient facility|NA - Patient was not discharged from an inpatient facility|14
334|UK - Other unknown|UK - Other unknown|14
335|UK - Reason unknown|UK - Reason unknown|14
336|UK - Unknown|UK - Unknown|14
337|UK - Unknown or Not Available|UK - Unknown or Not Available|14
341|01 - Early|01 - Early|14
342|02 - Late|02 - Late|14
343|NA - Not Applicable. No case mix group defined for this assessment.|NA - Not Applicable. No case mix group defined for this assessment.|14
344|NA - No case mix group defined by this assessment.|NA - No case mix group defined by this assessment.|14
2|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; OR (b) Is physically, cognitively, and mentally able to prepare light meals on a regular basis but has not routinely performed light meal preparation in the past (i.e., prior to this home care admission).|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; O|15
3|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and mentally able to perform all housekeeping tasks .|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and menta|15
4|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and mentally able to do laundry and access facilities.|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and menta|15
5|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying packages OR b) Physically, cognitively, and mentally able to take care of shopping, but has not done shopping in the past (i.e., prior to this home care admission).|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying|15
6|0 - Able to bathe self in SHOWER OR TUB independently.|0 - Able to bathe self in SHOWER OR TUB independently.|15
7|0 - Able to dial numbers and answer calls appropriately and as desired.|0 - Able to dial numbers and answer calls appropriately and as desired.|15
8|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body without assistance.|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body|15
9|0 - Able to get to and from the toilet independently with or without a device.|0 - Able to get to and from the toilet independently with or without a device.|15
10|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|15
11|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible public bus.|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible p|15
12|0 - Able to independently feed self.|0 - Able to independently feed self.|15
13|0 - Able to independently take the correct medication and proper dosage at the correct times.|0 - Able to independently take the correct medication and proper dosage at the correct times.|15
14|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct times.|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct ti|15
15|0 - Able to independently transfer.|0 - Able to independently transfer.|15
16|0 - Able to independently walk on even and uneven surfaces and climb stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even and uneven surfaces and climb stairs with or without railings|15
17|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings|15
18|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|15
19|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions independently.|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions indep|15
20|0 - Asymptomatic, no treatment needed at this time|0 - Asymptomatic, no treatment needed at this time|15
21|0 - Caregiver manages all tasks related to equipment completely independently.|0 - Caregiver manages all tasks related to equipment completely independently.|15
22|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations with no observable impairment.|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations w|15
23|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|15
24|0 - Life expectancy is greater than 6 months|0 - Life expectancy is greater than 6 months|15
25|0 - Never|0 - Never|15
26|0 - Never, patient is not short of breath|0 - Never, patient is not short of breath|15
27|0 - No|0 - No|15
28|0 - No emergent care services|0 - No emergent care services|15
29|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage)|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage)|15
30|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and extended or abstract conversation.|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and exte|15
31|0 - No one person|0 - No one person|15
32|0 - None of the time|0 - None of the time|15
33|0 - None, no charge for current services|0 - None, no charge for current services|15
34|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|15
35|0 - Patient does NOT have an ostomy for bowel elimination.|0 - Patient does NOT have an ostomy for bowel elimination.|15
36|0 - Patient has no pain or pain does not interfere with activity or movement|0 - Patient has no pain or pain does not interfere with activity or movement|15
37|0 - Patient manages all tasks related to equipment completely independently.|0 - Patient manages all tasks related to equipment completely independently.|15
38|0 - Poor:  little or no recovery is expected and/or further decline is imminent|0 - Poor:  little or no recovery is expected and/or further decline is imminent|15
39|0 - Timed-voiding defers incontinence|0 - Timed-voiding defers incontinence|15
40|0 - Very rarely or never has bowel incontinence|0 - Very rarely or never has bowel incontinence|15
41|0 - Zero|0 - Zero|15
42|00 - No|00 - No|15
43|01 - Yes|01 - Yes|15
44|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or mental limitations, needs assistance with heavy laundry.|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or|15
45|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the patient.|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the|15
46|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|15
47|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or supervision from another person OR c) a liquid, pureed or ground meat diet.|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or su|15
48|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|15
49|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|15
50|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independently.|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independe|15
51|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only when assisted or accompanied by another person.|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only w|15
52|1 - Able to take injectable medication at correct times if: a) individual syringes are prepared in advance by another person OR b) given daily reminders.|1 - Able to take injectable medication at correct times if: a) individual syringes are prepared in a|15
53|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance by another person OR b) given daily reminders.|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance b|15
54|1 - Able to take medication(s) at the correct times if: a) individual dosages are prepared in advance by another person , OR b) given daily reminders OR c) someone develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if: a) individual dosages are prepared in advanc|15
55|1 - Able to take medication(s) at the correct times if: a) individual dosages are prepared in advance by another person, OR b) given daily reminders OR c) someone develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if: a) individual dosages are prepared in advanc|15
56|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for the deaf) and call essential numbers.|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for t|15
57|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|15
58|1 - American Indian or Alaska Native|1 - American Indian or Alaska Native|15
59|1 - Depressed mood (e.g., feeling sad, tearful)|1 - Depressed mood (e.g., feeling sad, tearful)|15
60|1 - During the night only|1 - During the night only|15
61|1 - Fully granulating|1 - Fully granulating|15
62|1 - Good/Fair:  partial to full recovery is expected|1 - Good/Fair:  partial to full recovery is expected|15
63|1 - Good:  marked improvement in functional status is expected|1 - Good:  marked improvement in functional status is expected|15
64|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|15
65|1 - Heavy smoking|1 - Heavy smoking|15
66|1 - Hospital|1 - Hospital|15
67|1 - Hospital emergency room (includes 23-hour holding)|1 - Hospital emergency room (includes 23-hour holding)|15
68|1 - Hospitalization for EMERGENT (unscheduled) care|1 - Hospitalization for EMERGENT (unscheduled) care|15
69|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepared solutions), patient is able to manage all other aspects of equipment.|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepar|15
70|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|15
71|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|15
72|1 - In new or complex situations only|1 - In new or complex situations only|15
73|1 - Intravenous or infusion therapy (excludes TPN)|1 - Intravenous or infusion therapy (excludes TPN)|15
74|1 - Less often than daily|1 - Less often than daily|15
75|1 - Less than once a month|1 - Less than once a month|15
76|1 - Less than once weekly|1 - Less than once weekly|15
77|1 - Life expectancy is 6 months or fewer|1 - Life expectancy is 6 months or fewer|15
78|1 - Lives alone|1 - Lives alone|15
79|1 - Male|1 - Male|15
80|1 - Medicare (traditional fee-for-service)|1 - Medicare (traditional fee-for-service)|15
81|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of past 24 hours, significant memory loss so that supervision is required|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of pas|15
82|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors in word choice, grammar or speech intelligibility, needs minimal prompting or assistance).|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors i|15
83|1 - No assistance or services received|1 - No assistance or services received|15
84|1 - One|1 - One|15
85|1 - Oxygen (intermittent or continuous)|1 - Oxygen (intermittent or continuous)|15
86|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, and the surrounding layout, can count fingers at arm's length.|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, a|15
87|1 - Patient is incontinent|1 - Patient is incontinent|15
88|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|15
89|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical or treatment regimen.|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical|15
90|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient/couple/significant other)|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient|15
91|1 - Relatives, friends, or neighbors living outside the home|1 - Relatives, friends, or neighbors living outside the home|15
92|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions.|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions|15
93|1 - Requires use of a device (e.g., cane, walker) to walk alone OR requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|1 - Requires use of a device (e.g., cane, walker) to walk alone OR requires human supervision or ass|15
94|1 - Several times during day and night|1 - Several times during day and night|15
95|1 - Spouse or significant other|1 - Spouse or significant other|15
96|1 - Stage 1|1 - Stage 1|15
97|1 - Start of care - further visits planned|1 - Start of care - further visits planned|15
98|1 - Symptoms well controlled with current therapy|1 - Symptoms well controlled with current therapy|15
99|1 - Therapy services|1 - Therapy services|15
100|1 - Transfers with minimal human assistance or with use of an assistive device.|1 - Transfers with minimal human assistance or with use of an assistive device.|15
101|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitations.|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitatio|15
102|1 - Urinary incontinence|1 - Urinary incontinence|15
103|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet.|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet.|15
104|1 - When walking more than 20 feet, climbing stairs|1 - When walking more than 20 feet, climbing stairs|15
105|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary conversation. May need occasional repetition, extra time, or louder voice.|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary c|15
106|1 - With the use of devices, is able to bathe self in shower or tub independently.|1 - With the use of devices, is able to bathe self in shower or tub independently.|15
107|1 - Yes|1 - Yes|15
108|1-RN|1-RN|15
109|10 - Discharge from agency - no visits completed after start/resumption of care assessment|10 - Discharge from agency - no visits completed after start/resumption of care assessment|15
110|10 - Scheduled surgical procedure|10 - Scheduled surgical procedure|15
111|10 - Self-pay|10 - Self-pay|15
112|11 - Other|11 - Other|15
113|11 - Urinary tract infection|11 - Urinary tract infection|15
114|12 - IV catheter-related infection|12 - IV catheter-related infection|15
115|13 - Deep vein thrombosis, pulmonary embolus|13 - Deep vein thrombosis, pulmonary embolus|15
116|14 - Uncontrolled pain|14 - Uncontrolled pain|15
117|15 - Psychotic episode|15 - Psychotic episode|15
118|16 - Other than above reasons|16 - Other than above reasons|15
119|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing calls.|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing|15
120|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another person.|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another pers|15
121|2 - Able to walk only with the supervision or assistance of another person at all times.|2 - Able to walk only with the supervision or assistance of another person at all times.|15
122|2 - Aid: a) for intermittent supervision/encouragement/reminders, OR b) to get in and out of the shower/tub, OR c) for washing difficult to reach areas.|2 - Aid: a) for intermittent supervision/encouragement/reminders, OR b) to get in and out of the sho|15
123|2 - Asian|2 - Asian|15
124|2 - Caregiver requires considerable assistance from another person to manage equipment, but independently completes significant portions of task.|2 - Caregiver requires considerable assistance from another person to manage equipment, but independ|15
125|2 - Daily, but not constantly|2 - Daily, but not constantly|15
126|2 - Daughter or son|2 - Daughter or son|15
127|2 - Doctor's office emergency visit/house call|2 - Doctor's office emergency visit/house call|15
128|2 - During the day and night|2 - During the day and night|15
129|2 - Early/partial granulation|2 - Early/partial granulation|15
130|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors in word choice, organization or speech intelligibility). Speaks in phrases or short sentences.|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors|15
131|2 - Family member's residence|2 - Family member's residence|15
132|2 - Female|2 - Female|15
133|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conversation, needs frequent prompting or assistance.|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conver|15
134|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|15
135|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|15
136|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately stop activities, jeopardizes safety through actions|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately st|15
137|2 - Indwelling/suprapubic catheter|2 - Indwelling/suprapubic catheter|15
138|2 - Injury caused by fall or accident at home|2 - Injury caused by fall or accident at home|15
139|2 - Medicare (HMO/managed care)|2 - Medicare (HMO/managed care)|15
140|2 - Nausea, dehydration, malnutrition, constipation, impaction|2 - Nausea, dehydration, malnutrition, constipation, impaction|15
141|2 - Obesity|2 - Obesity|15
142|2 - On awakening or at night only|2 - On awakening or at night only|15
143|2 - Once a month|2 - Once a month|15
144|2 - One to three times weekly|2 - One to three times weekly|15
145|2 - Parenteral nutrition (TPN or lipids)|2 - Parenteral nutrition (TPN or lipids)|15
146|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic)|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic)|15
147|2 - Patient requires considerable assistance from another person to manage equipment, but independently completes portions of the task.|2 - Patient requires considerable assistance from another person to manage equipment, but independen|15
148|2 - Patient transferred to a noninstitutional hospice|2 - Patient transferred to a noninstitutional hospice|15
149|2 - Person residing in the home (EXCLUDING paid help)|2 - Person residing in the home (EXCLUDING paid help)|15
150|2 - Rehabilitation facility|2 - Rehabilitation facility|15
151|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifting of attention) or consistently requires low stimulus environment due to distractibility.|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifti|15
152|2 - Respite care|2 - Respite care|15
153|2 - Sense of failure or self reproach|2 - Sense of failure or self reproach|15
154|2 - Several times during day|2 - Several times during day|15
155|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonresponsive.|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonrespons|15
156|2 - Someone must assist the patient to groom self.|2 - Someone must assist the patient to groom self.|15
157|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|15
158|2 - Someone must help the patient put on upper body clothing.|2 - Someone must help the patient put on upper body clothing.|15
159|2 - Stage 2|2 - Stage 2|15
160|2 - Start of care - no further visits planned|2 - Start of care - no further visits planned|15
161|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitoring|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitori|15
162|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment regimen.|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment re|15
163|2 - Two|2 - Two|15
164|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistance due to cognitive or mental limitation.|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistanc|15
165|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|15
166|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assistance).|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assis|15
167|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home delivery.|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home deli|15
168|2 - Unable to prepare any light meals or reheat any delivered meals.|2 - Unable to prepare any light meals or reheat any delivered meals.|15
169|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|15
170|2 - UNABLE to take injectable medications unless administered by someone else.|2 - UNABLE to take injectable medications unless administered by someone else.|15
171|2 - UNABLE to take medication unless administered by someone else.|2 - UNABLE to take medication unless administered by someone else.|15
172|2 - UNABLE to transfer self but is able to bear weight and pivot during the transfer process.|2 - UNABLE to transfer self but is able to bear weight and pivot during the transfer process.|15
173|2 - Ventilator (continually or at night)|2 - Ventilator (continually or at night)|15
174|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less than 20 feet)|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less th|15
175|2 - With spouse or significant other|2 - With spouse or significant other|15
176|2 - Yes, assistance or services provided by family or friends|2 - Yes, assistance or services provided by family or friends|15
177|2-PT|2-PT|15
178|3 - Able to answer the telephone only some of the time or is able to carry on only a limited conversation.|3 - Able to answer the telephone only some of the time or is able to carry on only a limited convers|15
179|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube or gastrostomy.|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube|15
180|3 - Alcohol dependency|3 - Alcohol dependency|15
181|3 - All of the time|3 - All of the time|15
182|3 - Black or African-American|3 - Black or African-American|15
183|3 - Boarding home or rented room|3 - Boarding home or rented room|15
184|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment, clean/store/dispose of equipment or supplies).|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment,|15
185|3 - Chairfast, UNABLE to ambulate but is able to wheel self independently.|3 - Chairfast, UNABLE to ambulate but is able to wheel self independently.|15
186|3 - Continuous positive airway pressure|3 - Continuous positive airway pressure|15
187|3 - During the day and evening, but not constantly|3 - During the day and evening, but not constantly|15
188|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the alimentary canal)|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the|15
189|3 - Environmental support (e.g., housing, home maintenance)|3 - Environmental support (e.g., housing, home maintenance)|15
190|3 - Four to six times weekly|3 - Four to six times weekly|15
191|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessing by listener.  Speech limited to single words or short phrases.|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessin|15
192|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires multiple repetitions, restatements, demonstrations, additional time.|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires m|15
193|3 - Hopelessness|3 - Hopelessness|15
194|3 - Hospice care|3 - Hospice care|15
195|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|15
196|3 - Injury caused by fall or accident at home|3 - Injury caused by fall or accident at home|15
197|3 - Intractable pain|3 - Intractable pain|15
198|3 - Medicaid (traditional fee-for-service)|3 - Medicaid (traditional fee-for-service)|15
199|3 - Needs someone to do all shopping and errands.|3 - Needs someone to do all shopping and errands.|15
200|3 - Not healing|3 - Not healing|15
201|3 - Nursing home|3 - Nursing home|15
202|3 - Once daily|3 - Once daily|15
203|3 - Other family member|3 - Other family member|15
204|3 - Outpatient department/clinic emergency (includes urgicenter sites)|3 - Outpatient department/clinic emergency (includes urgicenter sites)|15
205|3 - Paid help|3 - Paid help|15
206|3 - Participates in bathing self in shower or tub, BUT requires presence of another person throughout the bath for assistance or supervision.|3 - Participates in bathing self in shower or tub, BUT requires presence of another person throughou|15
207|3 - Patient depends entirely upon another person to dress lower body.|3 - Patient depends entirely upon another person to dress lower body.|15
208|3 - Patient depends entirely upon another person to dress the upper body.|3 - Patient depends entirely upon another person to dress the upper body.|15
209|3 - Patient depends entirely upon someone else for grooming needs.|3 - Patient depends entirely upon someone else for grooming needs.|15
210|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone else to manage the equipment.|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone|15
211|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable to shift attention and recall directions more than half the time.|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable|15
212|3 - Respiratory problems (SOB, infection, obstruction)|3 - Respiratory problems (SOB, infection, obstruction)|15
213|3 - Resumption of care (after inpatient stay)|3 - Resumption of care (after inpatient stay)|15
214|3 - Several times each month|3 - Several times each month|15
215|3 - Skilled Nursing Facility|3 - Skilled Nursing Facility|15
216|3 - Stage 3|3 - Stage 3|15
217|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|15
218|3 - Three|3 - Three|15
219|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person throughout the process.|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person through|15
220|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal independently.|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal indep|15
221|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person.|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person|15
222|3 - Unknown because patient moved to a geographic location not served by this agency|3 - Unknown because patient moved to a geographic location not served by this agency|15
223|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|15
224|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|15
225|3 - With other family member|3 - With other family member|15
226|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home health services, homemaker assistance, transportation assistance, assisted living, board and care)|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home h|15
227|3-SLP/ST|3-SLP/ST|15
228|4 - At rest (during day or night)|4 - At rest (during day or night)|15
229|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|15
230|4 - Board and care or assisted living facility|4 - Board and care or assisted living facility|15
231|4 - Caregiver is completely dependent on someone else to manage all equipment.|4 - Caregiver is completely dependent on someone else to manage all equipment.|15
232|4 - Chairfast, unable to ambulate and is UNABLE to wheel self.|4 - Chairfast, unable to ambulate and is UNABLE to wheel self.|15
233|4 - Constantly|4 - Constantly|15
234|4 - Drug dependency|4 - Drug dependency|15
235|4 - Four or more|4 - Four or more|15
236|4 - Friend or neighbor or community or church member|4 - Friend or neighbor or community or church member|15
237|4 - Hispanic or Latino|4 - Hispanic or Latino|15
238|4 - Hospice|4 - Hospice|15
239|4 - Impaired decision-making|4 - Impaired decision-making|15
240|4 - Is totally dependent in toileting.|4 - Is totally dependent in toileting.|15
241|4 - Medicaid (HMO/managed care)|4 - Medicaid (HMO/managed care)|15
242|4 - None of the above|4 - None of the above|15
243|4 - Nursing home|4 - Nursing home|15
244|4 - On a daily basis|4 - On a daily basis|15
245|4 - Patient is completely dependent on someone else to manage all equipment.|4 - Patient is completely dependent on someone else to manage all equipment.|15
246|4 - Permanent placement|4 - Permanent placement|15
247|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, punches, dangerous maneuvers w/ wheelchair or other objects)|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, pu|15
248|4 - Psychosocial support (e.g., socialization, companionship, recreation)|4 - Psychosocial support (e.g., socialization, companionship, recreation)|15
249|4 - Recertification (follow-up) reassessment|4 - Recertification (follow-up) reassessment|15
250|4 - Recurrent thoughts of death|4 - Recurrent thoughts of death|15
251|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruction)|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruc|15
252|4 - Several times a week|4 - Several times a week|15
253|4 - Stage 4|4 - Stage 4|15
254|4 - Symptoms poorly controlled, history of rehospitalizations|4 - Symptoms poorly controlled, history of rehospitalizations|15
255|4 - Three or more times per week|4 - Three or more times per week|15
256|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetative state, or delirium.|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetati|15
257|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|15
258|4 - Unable to effectively participate in any housekeeping tasks.|4 - Unable to effectively participate in any housekeeping tasks.|15
259|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or unresponsive (e.g., speech is nonsensical or unintelligible).|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or u|15
260|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonresponsive.|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonr|15
261|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostomy.|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostom|15
262|4 - UNABLE to use the shower or tub and is bathed in BED OR BEDSIDE CHAIR.|4 - UNABLE to use the shower or tub and is bathed in BED OR BEDSIDE CHAIR.|15
263|4 - With a friend|4 - With a friend|15
264|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|15
265|4-OT|4-OT|15
266|5 - Advocates or facilitates patient's participation in appropriate medical care|5 - Advocates or facilitates patient's participation in appropriate medical care|15
267|5 - At least daily|5 - At least daily|15
268|5 - Bedfast, unable to ambulate or be up in a chair.|5 - Bedfast, unable to ambulate or be up in a chair.|15
269|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|15
270|5 - Disruptive or socially inappropriate behavior|5 - Disruptive or socially inappropriate behavior|15
271|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|15
272|5 - Hypo/Hyperglycemia, diabetes out of control|5 - Hypo/Hyperglycemia, diabetes out of control|15
273|5 - More often than once daily|5 - More often than once daily|15
274|5 - Native Hawaiian or Pacific Islander|5 - Native Hawaiian or Pacific Islander|15
275|5 - None of the above|5 - None of the above|15
276|5 - One to two times per week|5 - One to two times per week|15
277|5 - Other|5 - Other|15
278|5 - Other follow-up|5 - Other follow-up|15
279|5 - Paid help|5 - Paid help|15
280|5 - Patient nonresponsive or unable to speak.|5 - Patient nonresponsive or unable to speak.|15
281|5 - Thoughts of suicide|5 - Thoughts of suicide|15
282|5 - Totally unable to use the telephone.|5 - Totally unable to use the telephone.|15
283|5 - Unable to effectively participate in bathing and is totally bathed by another person.|5 - Unable to effectively participate in bathing and is totally bathed by another person.|15
284|5 - Unable to take in nutrients orally or by tube feeding.|5 - Unable to take in nutrients orally or by tube feeding.|15
285|5 - Unsafe for care at home|5 - Unsafe for care at home|15
286|5 - With paid help (other than home care agency staff)|5 - With paid help (other than home care agency staff)|15
287|5 - Workers' compensation|5 - Workers' compensation|15
288|5 - Wound infection, deteriorating wound status, new lesion/ulcer|5 - Wound infection, deteriorating wound status, new lesion/ulcer|15
289|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|15
290|6 - Delusional, hallucinatory, or paranoid behavior|6 - Delusional, hallucinatory, or paranoid behavior|15
291|6 - Financial agent, power of attorney, or conservator of finance|6 - Financial agent, power of attorney, or conservator of finance|15
292|6 - GI bleeding, obstruction|6 - GI bleeding, obstruction|15
293|6 - Less often than weekly|6 - Less often than weekly|15
294|6 - Memory loss to the extent that supervision required|6 - Memory loss to the extent that supervision required|15
295|6 - None of the above feelings observed or reported|6 - None of the above feelings observed or reported|15
296|6 - Other|6 - Other|15
297|6 - Title programs (e.g., Title III, V, or XX)|6 - Title programs (e.g., Title III, V, or XX)|15
298|6 - Transferred to an inpatient facility - patient not discharged from agency|6 - Transferred to an inpatient facility - patient not discharged from agency|15
299|6 - White|6 - White|15
300|6 - With other than above|6 - With other than above|15
301|7 - Exacerbation of CHF, fluid overload, heart failure|7 - Exacerbation of CHF, fluid overload, heart failure|15
302|7 - Health care agent, conservator of person, or medical power of attorney|7 - Health care agent, conservator of person, or medical power of attorney|15
303|7 - Hypo/Hyperglycemia, diabetes out of control|7 - Hypo/Hyperglycemia, diabetes out of control|15
304|7 - None of the above|7 - None of the above|15
305|7 - None of the above behaviors demonstrated|7 - None of the above behaviors demonstrated|15
306|7 - Other government (e.g., CHAMPUS, VA, etc.)|7 - Other government (e.g., CHAMPUS, VA, etc.)|15
307|7 - Transferred to an inpatient facility - patient discharged from agency|7 - Transferred to an inpatient facility - patient discharged from agency|15
308|8 - Death at home|8 - Death at home|15
309|8 - GI bleeding, obstruction|8 - GI bleeding, obstruction|15
310|8 - Myocardial infarction, stroke|8 - Myocardial infarction, stroke|15
311|8 - Private insurance|8 - Private insurance|15
312|9 - Chemotherapy|9 - Chemotherapy|15
313|9 - Discharge from agency|9 - Discharge from agency|15
314|9 - Other than above reasons|9 - Other than above reasons|15
315|9 - Private HMO/managed care|9 - Private HMO/managed care|15
316|NA - No caregiver|NA - No caregiver|15
317|NA - No equipment of this type used in care.|NA - No equipment of this type used in care.|15
318|NA - No inhalant/mist medications prescribed.|NA - No inhalant/mist medications prescribed.|15
319|NA - No injectable medications prescribed.|NA - No injectable medications prescribed.|15
320|NA - No inpatient facility admission|NA - No inpatient facility admission|15
321|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|15
322|NA - No Medicaid|NA - No Medicaid|15
323|NA - No Medicare|NA - No Medicare|15
324|NA - No observable pressure ulcer|NA - No observable pressure ulcer|15
325|NA - No observable stasis ulcer|NA - No observable stasis ulcer|15
326|NA - No observable surgical wound|NA - No observable surgical wound|15
327|NA - No oral medications prescribed.|NA - No oral medications prescribed.|15
328|NA - Not applicable|NA - Not applicable|15
329|NA - Patient does not have a telephone.|NA - Patient does not have a telephone.|15
330|NA - Patient has ostomy for bowel elimination|NA - Patient has ostomy for bowel elimination|15
331|NA - Patient nonresponsive|NA - Patient nonresponsive|15
332|NA - Patient on prophylactic treatment|NA - Patient on prophylactic treatment|15
333|NA - Patient was not discharged from an inpatient facility|NA - Patient was not discharged from an inpatient facility|15
334|UK - Other unknown|UK - Other unknown|15
335|UK - Reason unknown|UK - Reason unknown|15
336|UK - Unknown|UK - Unknown|15
337|UK - Unknown or Not Available|UK - Unknown or Not Available|15
341|01 - Early|01 - Early|15
342|02 - Late|02 - Late|15
343|NA - Not Applicable. No case mix group defined for this assessment.|NA - Not Applicable. No case mix group defined for this assessment.|15
344|NA - No case mix group defined by this assessment.|NA - No case mix group defined by this assessment.|15
2|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; OR (b) Is physically, cognitively, and mentally able to prepare light meals on a regular basis but has not routinely performed light meal preparation in the past (i.e., prior to this home care admission).|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; O|16
3|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and mentally able to perform all housekeeping tasks .|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and menta|16
4|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and mentally able to do laundry and access facilities.|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and menta|16
5|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying packages OR b) Physically, cognitively, and mentally able to take care of shopping, but has not done shopping in the past (i.e., prior to this home care admission).|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying|16
6|0 - Able to bathe self in SHOWER OR TUB independently.|0 - Able to bathe self in SHOWER OR TUB independently.|16
7|0 - Able to dial numbers and answer calls appropriately and as desired.|0 - Able to dial numbers and answer calls appropriately and as desired.|16
8|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body without assistance.|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body|16
9|0 - Able to get to and from the toilet independently with or without a device.|0 - Able to get to and from the toilet independently with or without a device.|16
10|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|16
11|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible public bus.|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible p|16
12|0 - Able to independently feed self.|0 - Able to independently feed self.|16
13|0 - Able to independently take the correct medication and proper dosage at the correct times.|0 - Able to independently take the correct medication and proper dosage at the correct times.|16
14|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct times.|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct ti|16
15|0 - Able to independently transfer.|0 - Able to independently transfer.|16
16|0 - Able to independently walk on even and uneven surfaces and climb stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even and uneven surfaces and climb stairs with or without railings|16
17|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings|16
18|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|16
19|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions independently.|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions indep|16
20|0 - Asymptomatic, no treatment needed at this time|0 - Asymptomatic, no treatment needed at this time|16
21|0 - Caregiver manages all tasks related to equipment completely independently.|0 - Caregiver manages all tasks related to equipment completely independently.|16
22|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations with no observable impairment.|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations w|16
23|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|16
24|0 - Life expectancy is greater than 6 months|0 - Life expectancy is greater than 6 months|16
25|0 - Never|0 - Never|16
26|0 - Never, patient is not short of breath|0 - Never, patient is not short of breath|16
27|0 - No|0 - No|16
28|0 - No emergent care services|0 - No emergent care services|16
29|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage)|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage)|16
30|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and extended or abstract conversation.|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and exte|16
31|0 - No one person|0 - No one person|16
32|0 - None of the time|0 - None of the time|16
33|0 - None, no charge for current services|0 - None, no charge for current services|16
34|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|16
35|0 - Patient does NOT have an ostomy for bowel elimination.|0 - Patient does NOT have an ostomy for bowel elimination.|16
36|0 - Patient has no pain or pain does not interfere with activity or movement|0 - Patient has no pain or pain does not interfere with activity or movement|16
37|0 - Patient manages all tasks related to equipment completely independently.|0 - Patient manages all tasks related to equipment completely independently.|16
38|0 - Poor:  little or no recovery is expected and/or further decline is imminent|0 - Poor:  little or no recovery is expected and/or further decline is imminent|16
39|0 - Timed-voiding defers incontinence|0 - Timed-voiding defers incontinence|16
40|0 - Very rarely or never has bowel incontinence|0 - Very rarely or never has bowel incontinence|16
41|0 - Zero|0 - Zero|16
42|00 - No|00 - No|16
43|01 - Yes|01 - Yes|16
44|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or mental limitations, needs assistance with heavy laundry.|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or|16
45|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the patient.|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the|16
46|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|16
47|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or supervision from another person OR c) a liquid, pureed or ground meat diet.|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or su|16
48|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|16
49|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|16
50|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independently.|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independe|16
51|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only when assisted or accompanied by another person.|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only w|16
52|1 - Able to take injectable medication at correct times if: a) individual syringes are prepared in advance by another person OR b) given daily reminders.|1 - Able to take injectable medication at correct times if: a) individual syringes are prepared in a|16
53|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance by another person OR b) given daily reminders.|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance b|16
54|1 - Able to take medication(s) at the correct times if: a) individual dosages are prepared in advance by another person , OR b) given daily reminders OR c) someone develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if: a) individual dosages are prepared in advanc|16
55|1 - Able to take medication(s) at the correct times if: a) individual dosages are prepared in advance by another person, OR b) given daily reminders OR c) someone develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if: a) individual dosages are prepared in advanc|16
56|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for the deaf) and call essential numbers.|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for t|16
57|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|16
58|1 - American Indian or Alaska Native|1 - American Indian or Alaska Native|16
59|1 - Depressed mood (e.g., feeling sad, tearful)|1 - Depressed mood (e.g., feeling sad, tearful)|16
60|1 - During the night only|1 - During the night only|16
61|1 - Fully granulating|1 - Fully granulating|16
62|1 - Good/Fair:  partial to full recovery is expected|1 - Good/Fair:  partial to full recovery is expected|16
63|1 - Good:  marked improvement in functional status is expected|1 - Good:  marked improvement in functional status is expected|16
64|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|16
65|1 - Heavy smoking|1 - Heavy smoking|16
66|1 - Hospital|1 - Hospital|16
67|1 - Hospital emergency room (includes 23-hour holding)|1 - Hospital emergency room (includes 23-hour holding)|16
68|1 - Hospitalization for EMERGENT (unscheduled) care|1 - Hospitalization for EMERGENT (unscheduled) care|16
69|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepared solutions), patient is able to manage all other aspects of equipment.|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepar|16
70|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|16
71|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|16
72|1 - In new or complex situations only|1 - In new or complex situations only|16
73|1 - Intravenous or infusion therapy (excludes TPN)|1 - Intravenous or infusion therapy (excludes TPN)|16
74|1 - Less often than daily|1 - Less often than daily|16
75|1 - Less than once a month|1 - Less than once a month|16
76|1 - Less than once weekly|1 - Less than once weekly|16
77|1 - Life expectancy is 6 months or fewer|1 - Life expectancy is 6 months or fewer|16
78|1 - Lives alone|1 - Lives alone|16
79|1 - Male|1 - Male|16
80|1 - Medicare (traditional fee-for-service)|1 - Medicare (traditional fee-for-service)|16
81|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of past 24 hours, significant memory loss so that supervision is required|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of pas|16
82|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors in word choice, grammar or speech intelligibility, needs minimal prompting or assistance).|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors i|16
83|1 - No assistance or services received|1 - No assistance or services received|16
84|1 - One|1 - One|16
85|1 - Oxygen (intermittent or continuous)|1 - Oxygen (intermittent or continuous)|16
86|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, and the surrounding layout, can count fingers at arm's length.|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, a|16
87|1 - Patient is incontinent|1 - Patient is incontinent|16
88|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|16
89|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical or treatment regimen.|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical|16
90|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient/couple/significant other)|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient|16
91|1 - Relatives, friends, or neighbors living outside the home|1 - Relatives, friends, or neighbors living outside the home|16
92|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions.|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions|16
93|1 - Requires use of a device (e.g., cane, walker) to walk alone OR requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|1 - Requires use of a device (e.g., cane, walker) to walk alone OR requires human supervision or ass|16
94|1 - Several times during day and night|1 - Several times during day and night|16
95|1 - Spouse or significant other|1 - Spouse or significant other|16
96|1 - Stage 1|1 - Stage 1|16
97|1 - Start of care - further visits planned|1 - Start of care - further visits planned|16
98|1 - Symptoms well controlled with current therapy|1 - Symptoms well controlled with current therapy|16
99|1 - Therapy services|1 - Therapy services|16
100|1 - Transfers with minimal human assistance or with use of an assistive device.|1 - Transfers with minimal human assistance or with use of an assistive device.|16
101|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitations.|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitatio|16
102|1 - Urinary incontinence|1 - Urinary incontinence|16
103|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet.|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet.|16
104|1 - When walking more than 20 feet, climbing stairs|1 - When walking more than 20 feet, climbing stairs|16
105|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary conversation. May need occasional repetition, extra time, or louder voice.|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary c|16
106|1 - With the use of devices, is able to bathe self in shower or tub independently.|1 - With the use of devices, is able to bathe self in shower or tub independently.|16
107|1 - Yes|1 - Yes|16
108|1-RN|1-RN|16
109|10 - Discharge from agency - no visits completed after start/resumption of care assessment|10 - Discharge from agency - no visits completed after start/resumption of care assessment|16
110|10 - Scheduled surgical procedure|10 - Scheduled surgical procedure|16
111|10 - Self-pay|10 - Self-pay|16
112|11 - Other|11 - Other|16
113|11 - Urinary tract infection|11 - Urinary tract infection|16
114|12 - IV catheter-related infection|12 - IV catheter-related infection|16
115|13 - Deep vein thrombosis, pulmonary embolus|13 - Deep vein thrombosis, pulmonary embolus|16
116|14 - Uncontrolled pain|14 - Uncontrolled pain|16
117|15 - Psychotic episode|15 - Psychotic episode|16
118|16 - Other than above reasons|16 - Other than above reasons|16
119|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing calls.|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing|16
120|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another person.|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another pers|16
121|2 - Able to walk only with the supervision or assistance of another person at all times.|2 - Able to walk only with the supervision or assistance of another person at all times.|16
122|2 - Aid: a) for intermittent supervision/encouragement/reminders, OR b) to get in and out of the shower/tub, OR c) for washing difficult to reach areas.|2 - Aid: a) for intermittent supervision/encouragement/reminders, OR b) to get in and out of the sho|16
123|2 - Asian|2 - Asian|16
124|2 - Caregiver requires considerable assistance from another person to manage equipment, but independently completes significant portions of task.|2 - Caregiver requires considerable assistance from another person to manage equipment, but independ|16
125|2 - Daily, but not constantly|2 - Daily, but not constantly|16
126|2 - Daughter or son|2 - Daughter or son|16
127|2 - Doctor's office emergency visit/house call|2 - Doctor's office emergency visit/house call|16
128|2 - During the day and night|2 - During the day and night|16
129|2 - Early/partial granulation|2 - Early/partial granulation|16
130|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors in word choice, organization or speech intelligibility). Speaks in phrases or short sentences.|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors|16
131|2 - Family member's residence|2 - Family member's residence|16
132|2 - Female|2 - Female|16
133|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conversation, needs frequent prompting or assistance.|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conver|16
134|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|16
135|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|16
136|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately stop activities, jeopardizes safety through actions|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately st|16
137|2 - Indwelling/suprapubic catheter|2 - Indwelling/suprapubic catheter|16
138|2 - Injury caused by fall or accident at home|2 - Injury caused by fall or accident at home|16
139|2 - Medicare (HMO/managed care)|2 - Medicare (HMO/managed care)|16
140|2 - Nausea, dehydration, malnutrition, constipation, impaction|2 - Nausea, dehydration, malnutrition, constipation, impaction|16
141|2 - Obesity|2 - Obesity|16
142|2 - On awakening or at night only|2 - On awakening or at night only|16
143|2 - Once a month|2 - Once a month|16
144|2 - One to three times weekly|2 - One to three times weekly|16
145|2 - Parenteral nutrition (TPN or lipids)|2 - Parenteral nutrition (TPN or lipids)|16
146|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic)|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic)|16
147|2 - Patient requires considerable assistance from another person to manage equipment, but independently completes portions of the task.|2 - Patient requires considerable assistance from another person to manage equipment, but independen|16
148|2 - Patient transferred to a noninstitutional hospice|2 - Patient transferred to a noninstitutional hospice|16
149|2 - Person residing in the home (EXCLUDING paid help)|2 - Person residing in the home (EXCLUDING paid help)|16
150|2 - Rehabilitation facility|2 - Rehabilitation facility|16
151|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifting of attention) or consistently requires low stimulus environment due to distractibility.|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifti|16
152|2 - Respite care|2 - Respite care|16
153|2 - Sense of failure or self reproach|2 - Sense of failure or self reproach|16
154|2 - Several times during day|2 - Several times during day|16
155|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonresponsive.|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonrespons|16
156|2 - Someone must assist the patient to groom self.|2 - Someone must assist the patient to groom self.|16
157|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|16
158|2 - Someone must help the patient put on upper body clothing.|2 - Someone must help the patient put on upper body clothing.|16
159|2 - Stage 2|2 - Stage 2|16
160|2 - Start of care - no further visits planned|2 - Start of care - no further visits planned|16
161|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitoring|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitori|16
162|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment regimen.|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment re|16
163|2 - Two|2 - Two|16
164|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistance due to cognitive or mental limitation.|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistanc|16
165|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|16
166|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assistance).|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assis|16
167|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home delivery.|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home deli|16
168|2 - Unable to prepare any light meals or reheat any delivered meals.|2 - Unable to prepare any light meals or reheat any delivered meals.|16
169|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|16
170|2 - UNABLE to take injectable medications unless administered by someone else.|2 - UNABLE to take injectable medications unless administered by someone else.|16
171|2 - UNABLE to take medication unless administered by someone else.|2 - UNABLE to take medication unless administered by someone else.|16
172|2 - UNABLE to transfer self but is able to bear weight and pivot during the transfer process.|2 - UNABLE to transfer self but is able to bear weight and pivot during the transfer process.|16
173|2 - Ventilator (continually or at night)|2 - Ventilator (continually or at night)|16
174|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less than 20 feet)|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less th|16
175|2 - With spouse or significant other|2 - With spouse or significant other|16
176|2 - Yes, assistance or services provided by family or friends|2 - Yes, assistance or services provided by family or friends|16
177|2-PT|2-PT|16
178|3 - Able to answer the telephone only some of the time or is able to carry on only a limited conversation.|3 - Able to answer the telephone only some of the time or is able to carry on only a limited convers|16
179|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube or gastrostomy.|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube|16
180|3 - Alcohol dependency|3 - Alcohol dependency|16
181|3 - All of the time|3 - All of the time|16
182|3 - Black or African-American|3 - Black or African-American|16
183|3 - Boarding home or rented room|3 - Boarding home or rented room|16
184|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment, clean/store/dispose of equipment or supplies).|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment,|16
185|3 - Chairfast, UNABLE to ambulate but is able to wheel self independently.|3 - Chairfast, UNABLE to ambulate but is able to wheel self independently.|16
186|3 - Continuous positive airway pressure|3 - Continuous positive airway pressure|16
187|3 - During the day and evening, but not constantly|3 - During the day and evening, but not constantly|16
188|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the alimentary canal)|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the|16
189|3 - Environmental support (e.g., housing, home maintenance)|3 - Environmental support (e.g., housing, home maintenance)|16
190|3 - Four to six times weekly|3 - Four to six times weekly|16
191|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessing by listener.  Speech limited to single words or short phrases.|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessin|16
192|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires multiple repetitions, restatements, demonstrations, additional time.|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires m|16
193|3 - Hopelessness|3 - Hopelessness|16
194|3 - Hospice care|3 - Hospice care|16
195|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|16
196|3 - Injury caused by fall or accident at home|3 - Injury caused by fall or accident at home|16
197|3 - Intractable pain|3 - Intractable pain|16
198|3 - Medicaid (traditional fee-for-service)|3 - Medicaid (traditional fee-for-service)|16
199|3 - Needs someone to do all shopping and errands.|3 - Needs someone to do all shopping and errands.|16
200|3 - Not healing|3 - Not healing|16
201|3 - Nursing home|3 - Nursing home|16
202|3 - Once daily|3 - Once daily|16
203|3 - Other family member|3 - Other family member|16
204|3 - Outpatient department/clinic emergency (includes urgicenter sites)|3 - Outpatient department/clinic emergency (includes urgicenter sites)|16
205|3 - Paid help|3 - Paid help|16
206|3 - Participates in bathing self in shower or tub, BUT requires presence of another person throughout the bath for assistance or supervision.|3 - Participates in bathing self in shower or tub, BUT requires presence of another person throughou|16
207|3 - Patient depends entirely upon another person to dress lower body.|3 - Patient depends entirely upon another person to dress lower body.|16
208|3 - Patient depends entirely upon another person to dress the upper body.|3 - Patient depends entirely upon another person to dress the upper body.|16
209|3 - Patient depends entirely upon someone else for grooming needs.|3 - Patient depends entirely upon someone else for grooming needs.|16
210|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone else to manage the equipment.|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone|16
211|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable to shift attention and recall directions more than half the time.|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable|16
212|3 - Respiratory problems (SOB, infection, obstruction)|3 - Respiratory problems (SOB, infection, obstruction)|16
213|3 - Resumption of care (after inpatient stay)|3 - Resumption of care (after inpatient stay)|16
214|3 - Several times each month|3 - Several times each month|16
215|3 - Skilled Nursing Facility|3 - Skilled Nursing Facility|16
216|3 - Stage 3|3 - Stage 3|16
217|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|16
218|3 - Three|3 - Three|16
219|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person throughout the process.|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person through|16
220|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal independently.|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal indep|16
221|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person.|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person|16
222|3 - Unknown because patient moved to a geographic location not served by this agency|3 - Unknown because patient moved to a geographic location not served by this agency|16
223|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|16
224|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|16
225|3 - With other family member|3 - With other family member|16
226|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home health services, homemaker assistance, transportation assistance, assisted living, board and care)|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home h|16
227|3-SLP/ST|3-SLP/ST|16
228|4 - At rest (during day or night)|4 - At rest (during day or night)|16
229|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|16
230|4 - Board and care or assisted living facility|4 - Board and care or assisted living facility|16
231|4 - Caregiver is completely dependent on someone else to manage all equipment.|4 - Caregiver is completely dependent on someone else to manage all equipment.|16
232|4 - Chairfast, unable to ambulate and is UNABLE to wheel self.|4 - Chairfast, unable to ambulate and is UNABLE to wheel self.|16
233|4 - Constantly|4 - Constantly|16
234|4 - Drug dependency|4 - Drug dependency|16
235|4 - Four or more|4 - Four or more|16
236|4 - Friend or neighbor or community or church member|4 - Friend or neighbor or community or church member|16
237|4 - Hispanic or Latino|4 - Hispanic or Latino|16
238|4 - Hospice|4 - Hospice|16
239|4 - Impaired decision-making|4 - Impaired decision-making|16
240|4 - Is totally dependent in toileting.|4 - Is totally dependent in toileting.|16
241|4 - Medicaid (HMO/managed care)|4 - Medicaid (HMO/managed care)|16
242|4 - None of the above|4 - None of the above|16
243|4 - Nursing home|4 - Nursing home|16
244|4 - On a daily basis|4 - On a daily basis|16
245|4 - Patient is completely dependent on someone else to manage all equipment.|4 - Patient is completely dependent on someone else to manage all equipment.|16
246|4 - Permanent placement|4 - Permanent placement|16
247|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, punches, dangerous maneuvers w/ wheelchair or other objects)|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, pu|16
248|4 - Psychosocial support (e.g., socialization, companionship, recreation)|4 - Psychosocial support (e.g., socialization, companionship, recreation)|16
249|4 - Recertification (follow-up) reassessment|4 - Recertification (follow-up) reassessment|16
250|4 - Recurrent thoughts of death|4 - Recurrent thoughts of death|16
251|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruction)|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruc|16
252|4 - Several times a week|4 - Several times a week|16
253|4 - Stage 4|4 - Stage 4|16
254|4 - Symptoms poorly controlled, history of rehospitalizations|4 - Symptoms poorly controlled, history of rehospitalizations|16
255|4 - Three or more times per week|4 - Three or more times per week|16
256|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetative state, or delirium.|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetati|16
257|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|16
258|4 - Unable to effectively participate in any housekeeping tasks.|4 - Unable to effectively participate in any housekeeping tasks.|16
259|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or unresponsive (e.g., speech is nonsensical or unintelligible).|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or u|16
260|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonresponsive.|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonr|16
261|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostomy.|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostom|16
262|4 - UNABLE to use the shower or tub and is bathed in BED OR BEDSIDE CHAIR.|4 - UNABLE to use the shower or tub and is bathed in BED OR BEDSIDE CHAIR.|16
263|4 - With a friend|4 - With a friend|16
264|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|16
265|4-OT|4-OT|16
266|5 - Advocates or facilitates patient's participation in appropriate medical care|5 - Advocates or facilitates patient's participation in appropriate medical care|16
267|5 - At least daily|5 - At least daily|16
268|5 - Bedfast, unable to ambulate or be up in a chair.|5 - Bedfast, unable to ambulate or be up in a chair.|16
269|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|16
270|5 - Disruptive or socially inappropriate behavior|5 - Disruptive or socially inappropriate behavior|16
271|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|16
272|5 - Hypo/Hyperglycemia, diabetes out of control|5 - Hypo/Hyperglycemia, diabetes out of control|16
273|5 - More often than once daily|5 - More often than once daily|16
274|5 - Native Hawaiian or Pacific Islander|5 - Native Hawaiian or Pacific Islander|16
275|5 - None of the above|5 - None of the above|16
276|5 - One to two times per week|5 - One to two times per week|16
277|5 - Other|5 - Other|16
278|5 - Other follow-up|5 - Other follow-up|16
279|5 - Paid help|5 - Paid help|16
280|5 - Patient nonresponsive or unable to speak.|5 - Patient nonresponsive or unable to speak.|16
281|5 - Thoughts of suicide|5 - Thoughts of suicide|16
282|5 - Totally unable to use the telephone.|5 - Totally unable to use the telephone.|16
283|5 - Unable to effectively participate in bathing and is totally bathed by another person.|5 - Unable to effectively participate in bathing and is totally bathed by another person.|16
284|5 - Unable to take in nutrients orally or by tube feeding.|5 - Unable to take in nutrients orally or by tube feeding.|16
285|5 - Unsafe for care at home|5 - Unsafe for care at home|16
286|5 - With paid help (other than home care agency staff)|5 - With paid help (other than home care agency staff)|16
287|5 - Workers' compensation|5 - Workers' compensation|16
288|5 - Wound infection, deteriorating wound status, new lesion/ulcer|5 - Wound infection, deteriorating wound status, new lesion/ulcer|16
289|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|16
290|6 - Delusional, hallucinatory, or paranoid behavior|6 - Delusional, hallucinatory, or paranoid behavior|16
291|6 - Financial agent, power of attorney, or conservator of finance|6 - Financial agent, power of attorney, or conservator of finance|16
292|6 - GI bleeding, obstruction|6 - GI bleeding, obstruction|16
293|6 - Less often than weekly|6 - Less often than weekly|16
294|6 - Memory loss to the extent that supervision required|6 - Memory loss to the extent that supervision required|16
295|6 - None of the above feelings observed or reported|6 - None of the above feelings observed or reported|16
296|6 - Other|6 - Other|16
297|6 - Title programs (e.g., Title III, V, or XX)|6 - Title programs (e.g., Title III, V, or XX)|16
298|6 - Transferred to an inpatient facility - patient not discharged from agency|6 - Transferred to an inpatient facility - patient not discharged from agency|16
299|6 - White|6 - White|16
300|6 - With other than above|6 - With other than above|16
301|7 - Exacerbation of CHF, fluid overload, heart failure|7 - Exacerbation of CHF, fluid overload, heart failure|16
302|7 - Health care agent, conservator of person, or medical power of attorney|7 - Health care agent, conservator of person, or medical power of attorney|16
303|7 - Hypo/Hyperglycemia, diabetes out of control|7 - Hypo/Hyperglycemia, diabetes out of control|16
304|7 - None of the above|7 - None of the above|16
305|7 - None of the above behaviors demonstrated|7 - None of the above behaviors demonstrated|16
306|7 - Other government (e.g., CHAMPUS, VA, etc.)|7 - Other government (e.g., CHAMPUS, VA, etc.)|16
307|7 - Transferred to an inpatient facility - patient discharged from agency|7 - Transferred to an inpatient facility - patient discharged from agency|16
308|8 - Death at home|8 - Death at home|16
309|8 - GI bleeding, obstruction|8 - GI bleeding, obstruction|16
310|8 - Myocardial infarction, stroke|8 - Myocardial infarction, stroke|16
311|8 - Private insurance|8 - Private insurance|16
312|9 - Chemotherapy|9 - Chemotherapy|16
313|9 - Discharge from agency|9 - Discharge from agency|16
314|9 - Other than above reasons|9 - Other than above reasons|16
315|9 - Private HMO/managed care|9 - Private HMO/managed care|16
316|NA - No caregiver|NA - No caregiver|16
317|NA - No equipment of this type used in care.|NA - No equipment of this type used in care.|16
318|NA - No inhalant/mist medications prescribed.|NA - No inhalant/mist medications prescribed.|16
319|NA - No injectable medications prescribed.|NA - No injectable medications prescribed.|16
320|NA - No inpatient facility admission|NA - No inpatient facility admission|16
321|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|16
322|NA - No Medicaid|NA - No Medicaid|16
323|NA - No Medicare|NA - No Medicare|16
324|NA - No observable pressure ulcer|NA - No observable pressure ulcer|16
325|NA - No observable stasis ulcer|NA - No observable stasis ulcer|16
326|NA - No observable surgical wound|NA - No observable surgical wound|16
327|NA - No oral medications prescribed.|NA - No oral medications prescribed.|16
328|NA - Not applicable|NA - Not applicable|16
329|NA - Patient does not have a telephone.|NA - Patient does not have a telephone.|16
330|NA - Patient has ostomy for bowel elimination|NA - Patient has ostomy for bowel elimination|16
331|NA - Patient nonresponsive|NA - Patient nonresponsive|16
332|NA - Patient on prophylactic treatment|NA - Patient on prophylactic treatment|16
333|NA - Patient was not discharged from an inpatient facility|NA - Patient was not discharged from an inpatient facility|16
334|UK - Other unknown|UK - Other unknown|16
335|UK - Reason unknown|UK - Reason unknown|16
336|UK - Unknown|UK - Unknown|16
337|UK - Unknown or Not Available|UK - Unknown or Not Available|16
341|01 - Early|01 - Early|16
342|02 - Late|02 - Late|16
343|NA - Not Applicable. No case mix group defined for this assessment.|NA - Not Applicable. No case mix group defined for this assessment.|16
344|NA - No case mix group defined by this assessment.|NA - No case mix group defined by this assessment.|16
2|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; OR (b) Is physically, cognitively, and mentally able to prepare light meals on a regular basis but has not routinely performed light meal preparation in the past (i.e., prior to this home care admission).|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; O|17
3|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and mentally able to perform all housekeeping tasks .|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and menta|17
4|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and mentally able to do laundry and access facilities.|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and menta|17
5|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying packages OR b) Physically, cognitively, and mentally able to take care of shopping, but has not done shopping in the past (i.e., prior to this home care admission).|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying|17
6|0 - Able to bathe self in SHOWER OR TUB independently.|0 - Able to bathe self in SHOWER OR TUB independently.|17
7|0 - Able to dial numbers and answer calls appropriately and as desired.|0 - Able to dial numbers and answer calls appropriately and as desired.|17
8|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body without assistance.|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body|17
9|0 - Able to get to and from the toilet independently with or without a device.|0 - Able to get to and from the toilet independently with or without a device.|17
10|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|17
11|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible public bus.|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible p|17
12|0 - Able to independently feed self.|0 - Able to independently feed self.|17
13|0 - Able to independently take the correct medication and proper dosage at the correct times.|0 - Able to independently take the correct medication and proper dosage at the correct times.|17
14|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct times.|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct ti|17
15|0 - Able to independently transfer.|0 - Able to independently transfer.|17
16|0 - Able to independently walk on even and uneven surfaces and climb stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even and uneven surfaces and climb stairs with or without railings|17
17|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings|17
18|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|17
19|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions independently.|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions indep|17
20|0 - Asymptomatic, no treatment needed at this time|0 - Asymptomatic, no treatment needed at this time|17
21|0 - Caregiver manages all tasks related to equipment completely independently.|0 - Caregiver manages all tasks related to equipment completely independently.|17
22|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations with no observable impairment.|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations w|17
23|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|17
24|0 - Life expectancy is greater than 6 months|0 - Life expectancy is greater than 6 months|17
25|0 - Never|0 - Never|17
26|0 - Never, patient is not short of breath|0 - Never, patient is not short of breath|17
27|0 - No|0 - No|17
28|0 - No emergent care services|0 - No emergent care services|17
29|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage)|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage)|17
30|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and extended or abstract conversation.|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and exte|17
31|0 - No one person|0 - No one person|17
32|0 - None of the time|0 - None of the time|17
33|0 - None, no charge for current services|0 - None, no charge for current services|17
34|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|17
35|0 - Patient does NOT have an ostomy for bowel elimination.|0 - Patient does NOT have an ostomy for bowel elimination.|17
36|0 - Patient has no pain or pain does not interfere with activity or movement|0 - Patient has no pain or pain does not interfere with activity or movement|17
37|0 - Patient manages all tasks related to equipment completely independently.|0 - Patient manages all tasks related to equipment completely independently.|17
38|0 - Poor:  little or no recovery is expected and/or further decline is imminent|0 - Poor:  little or no recovery is expected and/or further decline is imminent|17
39|0 - Timed-voiding defers incontinence|0 - Timed-voiding defers incontinence|17
40|0 - Very rarely or never has bowel incontinence|0 - Very rarely or never has bowel incontinence|17
41|0 - Zero|0 - Zero|17
42|00 - No|00 - No|17
43|01 - Yes|01 - Yes|17
44|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or mental limitations, needs assistance with heavy laundry.|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or|17
45|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the patient.|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the|17
46|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|17
47|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or supervision from another person OR c) a liquid, pureed or ground meat diet.|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or su|17
48|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|17
49|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|17
50|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independently.|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independe|17
51|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only when assisted or accompanied by another person.|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only w|17
52|1 - Able to take injectable medication at correct times if: a) individual syringes are prepared in advance by another person OR b) given daily reminders.|1 - Able to take injectable medication at correct times if: a) individual syringes are prepared in a|17
53|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance by another person OR b) given daily reminders.|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance b|17
54|1 - Able to take medication(s) at the correct times if: a) individual dosages are prepared in advance by another person , OR b) given daily reminders OR c) someone develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if: a) individual dosages are prepared in advanc|17
55|1 - Able to take medication(s) at the correct times if: a) individual dosages are prepared in advance by another person, OR b) given daily reminders OR c) someone develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if: a) individual dosages are prepared in advanc|17
56|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for the deaf) and call essential numbers.|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for t|17
57|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|17
58|1 - American Indian or Alaska Native|1 - American Indian or Alaska Native|17
59|1 - Depressed mood (e.g., feeling sad, tearful)|1 - Depressed mood (e.g., feeling sad, tearful)|17
60|1 - During the night only|1 - During the night only|17
61|1 - Fully granulating|1 - Fully granulating|17
62|1 - Good/Fair:  partial to full recovery is expected|1 - Good/Fair:  partial to full recovery is expected|17
63|1 - Good:  marked improvement in functional status is expected|1 - Good:  marked improvement in functional status is expected|17
64|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|17
65|1 - Heavy smoking|1 - Heavy smoking|17
66|1 - Hospital|1 - Hospital|17
67|1 - Hospital emergency room (includes 23-hour holding)|1 - Hospital emergency room (includes 23-hour holding)|17
68|1 - Hospitalization for EMERGENT (unscheduled) care|1 - Hospitalization for EMERGENT (unscheduled) care|17
69|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepared solutions), patient is able to manage all other aspects of equipment.|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepar|17
70|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|17
71|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|17
72|1 - In new or complex situations only|1 - In new or complex situations only|17
73|1 - Intravenous or infusion therapy (excludes TPN)|1 - Intravenous or infusion therapy (excludes TPN)|17
74|1 - Less often than daily|1 - Less often than daily|17
75|1 - Less than once a month|1 - Less than once a month|17
76|1 - Less than once weekly|1 - Less than once weekly|17
77|1 - Life expectancy is 6 months or fewer|1 - Life expectancy is 6 months or fewer|17
78|1 - Lives alone|1 - Lives alone|17
79|1 - Male|1 - Male|17
80|1 - Medicare (traditional fee-for-service)|1 - Medicare (traditional fee-for-service)|17
81|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of past 24 hours, significant memory loss so that supervision is required|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of pas|17
82|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors in word choice, grammar or speech intelligibility, needs minimal prompting or assistance).|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors i|17
83|1 - No assistance or services received|1 - No assistance or services received|17
84|1 - One|1 - One|17
85|1 - Oxygen (intermittent or continuous)|1 - Oxygen (intermittent or continuous)|17
86|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, and the surrounding layout, can count fingers at arm's length.|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, a|17
87|1 - Patient is incontinent|1 - Patient is incontinent|17
88|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|17
89|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical or treatment regimen.|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical|17
90|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient/couple/significant other)|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient|17
91|1 - Relatives, friends, or neighbors living outside the home|1 - Relatives, friends, or neighbors living outside the home|17
92|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions.|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions|17
93|1 - Requires use of a device (e.g., cane, walker) to walk alone OR requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|1 - Requires use of a device (e.g., cane, walker) to walk alone OR requires human supervision or ass|17
94|1 - Several times during day and night|1 - Several times during day and night|17
95|1 - Spouse or significant other|1 - Spouse or significant other|17
96|1 - Stage 1|1 - Stage 1|17
97|1 - Start of care - further visits planned|1 - Start of care - further visits planned|17
98|1 - Symptoms well controlled with current therapy|1 - Symptoms well controlled with current therapy|17
99|1 - Therapy services|1 - Therapy services|17
100|1 - Transfers with minimal human assistance or with use of an assistive device.|1 - Transfers with minimal human assistance or with use of an assistive device.|17
101|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitations.|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitatio|17
102|1 - Urinary incontinence|1 - Urinary incontinence|17
103|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet.|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet.|17
104|1 - When walking more than 20 feet, climbing stairs|1 - When walking more than 20 feet, climbing stairs|17
105|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary conversation. May need occasional repetition, extra time, or louder voice.|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary c|17
106|1 - With the use of devices, is able to bathe self in shower or tub independently.|1 - With the use of devices, is able to bathe self in shower or tub independently.|17
107|1 - Yes|1 - Yes|17
108|1-RN|1-RN|17
109|10 - Discharge from agency - no visits completed after start/resumption of care assessment|10 - Discharge from agency - no visits completed after start/resumption of care assessment|17
110|10 - Scheduled surgical procedure|10 - Scheduled surgical procedure|17
111|10 - Self-pay|10 - Self-pay|17
112|11 - Other|11 - Other|17
113|11 - Urinary tract infection|11 - Urinary tract infection|17
114|12 - IV catheter-related infection|12 - IV catheter-related infection|17
115|13 - Deep vein thrombosis, pulmonary embolus|13 - Deep vein thrombosis, pulmonary embolus|17
116|14 - Uncontrolled pain|14 - Uncontrolled pain|17
117|15 - Psychotic episode|15 - Psychotic episode|17
118|16 - Other than above reasons|16 - Other than above reasons|17
119|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing calls.|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing|17
120|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another person.|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another pers|17
121|2 - Able to walk only with the supervision or assistance of another person at all times.|2 - Able to walk only with the supervision or assistance of another person at all times.|17
122|2 - Aid: a) for intermittent supervision/encouragement/reminders, OR b) to get in and out of the shower/tub, OR c) for washing difficult to reach areas.|2 - Aid: a) for intermittent supervision/encouragement/reminders, OR b) to get in and out of the sho|17
123|2 - Asian|2 - Asian|17
124|2 - Caregiver requires considerable assistance from another person to manage equipment, but independently completes significant portions of task.|2 - Caregiver requires considerable assistance from another person to manage equipment, but independ|17
125|2 - Daily, but not constantly|2 - Daily, but not constantly|17
126|2 - Daughter or son|2 - Daughter or son|17
127|2 - Doctor's office emergency visit/house call|2 - Doctor's office emergency visit/house call|17
128|2 - During the day and night|2 - During the day and night|17
129|2 - Early/partial granulation|2 - Early/partial granulation|17
130|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors in word choice, organization or speech intelligibility). Speaks in phrases or short sentences.|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors|17
131|2 - Family member's residence|2 - Family member's residence|17
132|2 - Female|2 - Female|17
133|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conversation, needs frequent prompting or assistance.|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conver|17
134|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|17
135|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|17
136|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately stop activities, jeopardizes safety through actions|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately st|17
137|2 - Indwelling/suprapubic catheter|2 - Indwelling/suprapubic catheter|17
138|2 - Injury caused by fall or accident at home|2 - Injury caused by fall or accident at home|17
139|2 - Medicare (HMO/managed care)|2 - Medicare (HMO/managed care)|17
140|2 - Nausea, dehydration, malnutrition, constipation, impaction|2 - Nausea, dehydration, malnutrition, constipation, impaction|17
141|2 - Obesity|2 - Obesity|17
142|2 - On awakening or at night only|2 - On awakening or at night only|17
143|2 - Once a month|2 - Once a month|17
144|2 - One to three times weekly|2 - One to three times weekly|17
145|2 - Parenteral nutrition (TPN or lipids)|2 - Parenteral nutrition (TPN or lipids)|17
146|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic)|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic)|17
147|2 - Patient requires considerable assistance from another person to manage equipment, but independently completes portions of the task.|2 - Patient requires considerable assistance from another person to manage equipment, but independen|17
148|2 - Patient transferred to a noninstitutional hospice|2 - Patient transferred to a noninstitutional hospice|17
149|2 - Person residing in the home (EXCLUDING paid help)|2 - Person residing in the home (EXCLUDING paid help)|17
150|2 - Rehabilitation facility|2 - Rehabilitation facility|17
151|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifting of attention) or consistently requires low stimulus environment due to distractibility.|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifti|17
152|2 - Respite care|2 - Respite care|17
153|2 - Sense of failure or self reproach|2 - Sense of failure or self reproach|17
154|2 - Several times during day|2 - Several times during day|17
155|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonresponsive.|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonrespons|17
156|2 - Someone must assist the patient to groom self.|2 - Someone must assist the patient to groom self.|17
157|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|17
158|2 - Someone must help the patient put on upper body clothing.|2 - Someone must help the patient put on upper body clothing.|17
159|2 - Stage 2|2 - Stage 2|17
160|2 - Start of care - no further visits planned|2 - Start of care - no further visits planned|17
161|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitoring|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitori|17
162|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment regimen.|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment re|17
163|2 - Two|2 - Two|17
164|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistance due to cognitive or mental limitation.|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistanc|17
165|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|17
166|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assistance).|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assis|17
167|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home delivery.|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home deli|17
168|2 - Unable to prepare any light meals or reheat any delivered meals.|2 - Unable to prepare any light meals or reheat any delivered meals.|17
169|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|17
170|2 - UNABLE to take injectable medications unless administered by someone else.|2 - UNABLE to take injectable medications unless administered by someone else.|17
171|2 - UNABLE to take medication unless administered by someone else.|2 - UNABLE to take medication unless administered by someone else.|17
172|2 - UNABLE to transfer self but is able to bear weight and pivot during the transfer process.|2 - UNABLE to transfer self but is able to bear weight and pivot during the transfer process.|17
173|2 - Ventilator (continually or at night)|2 - Ventilator (continually or at night)|17
174|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less than 20 feet)|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less th|17
175|2 - With spouse or significant other|2 - With spouse or significant other|17
176|2 - Yes, assistance or services provided by family or friends|2 - Yes, assistance or services provided by family or friends|17
177|2-PT|2-PT|17
178|3 - Able to answer the telephone only some of the time or is able to carry on only a limited conversation.|3 - Able to answer the telephone only some of the time or is able to carry on only a limited convers|17
179|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube or gastrostomy.|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube|17
180|3 - Alcohol dependency|3 - Alcohol dependency|17
181|3 - All of the time|3 - All of the time|17
182|3 - Black or African-American|3 - Black or African-American|17
183|3 - Boarding home or rented room|3 - Boarding home or rented room|17
184|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment, clean/store/dispose of equipment or supplies).|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment,|17
185|3 - Chairfast, UNABLE to ambulate but is able to wheel self independently.|3 - Chairfast, UNABLE to ambulate but is able to wheel self independently.|17
186|3 - Continuous positive airway pressure|3 - Continuous positive airway pressure|17
187|3 - During the day and evening, but not constantly|3 - During the day and evening, but not constantly|17
188|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the alimentary canal)|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the|17
189|3 - Environmental support (e.g., housing, home maintenance)|3 - Environmental support (e.g., housing, home maintenance)|17
190|3 - Four to six times weekly|3 - Four to six times weekly|17
191|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessing by listener.  Speech limited to single words or short phrases.|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessin|17
192|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires multiple repetitions, restatements, demonstrations, additional time.|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires m|17
193|3 - Hopelessness|3 - Hopelessness|17
194|3 - Hospice care|3 - Hospice care|17
195|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|17
196|3 - Injury caused by fall or accident at home|3 - Injury caused by fall or accident at home|17
197|3 - Intractable pain|3 - Intractable pain|17
198|3 - Medicaid (traditional fee-for-service)|3 - Medicaid (traditional fee-for-service)|17
199|3 - Needs someone to do all shopping and errands.|3 - Needs someone to do all shopping and errands.|17
200|3 - Not healing|3 - Not healing|17
201|3 - Nursing home|3 - Nursing home|17
202|3 - Once daily|3 - Once daily|17
203|3 - Other family member|3 - Other family member|17
204|3 - Outpatient department/clinic emergency (includes urgicenter sites)|3 - Outpatient department/clinic emergency (includes urgicenter sites)|17
205|3 - Paid help|3 - Paid help|17
206|3 - Participates in bathing self in shower or tub, BUT requires presence of another person throughout the bath for assistance or supervision.|3 - Participates in bathing self in shower or tub, BUT requires presence of another person throughou|17
207|3 - Patient depends entirely upon another person to dress lower body.|3 - Patient depends entirely upon another person to dress lower body.|17
208|3 - Patient depends entirely upon another person to dress the upper body.|3 - Patient depends entirely upon another person to dress the upper body.|17
209|3 - Patient depends entirely upon someone else for grooming needs.|3 - Patient depends entirely upon someone else for grooming needs.|17
210|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone else to manage the equipment.|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone|17
211|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable to shift attention and recall directions more than half the time.|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable|17
212|3 - Respiratory problems (SOB, infection, obstruction)|3 - Respiratory problems (SOB, infection, obstruction)|17
213|3 - Resumption of care (after inpatient stay)|3 - Resumption of care (after inpatient stay)|17
214|3 - Several times each month|3 - Several times each month|17
215|3 - Skilled Nursing Facility|3 - Skilled Nursing Facility|17
216|3 - Stage 3|3 - Stage 3|17
217|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|17
218|3 - Three|3 - Three|17
219|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person throughout the process.|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person through|17
220|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal independently.|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal indep|17
221|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person.|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person|17
222|3 - Unknown because patient moved to a geographic location not served by this agency|3 - Unknown because patient moved to a geographic location not served by this agency|17
223|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|17
224|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|17
225|3 - With other family member|3 - With other family member|17
226|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home health services, homemaker assistance, transportation assistance, assisted living, board and care)|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home h|17
227|3-SLP/ST|3-SLP/ST|17
228|4 - At rest (during day or night)|4 - At rest (during day or night)|17
229|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|17
230|4 - Board and care or assisted living facility|4 - Board and care or assisted living facility|17
231|4 - Caregiver is completely dependent on someone else to manage all equipment.|4 - Caregiver is completely dependent on someone else to manage all equipment.|17
232|4 - Chairfast, unable to ambulate and is UNABLE to wheel self.|4 - Chairfast, unable to ambulate and is UNABLE to wheel self.|17
233|4 - Constantly|4 - Constantly|17
234|4 - Drug dependency|4 - Drug dependency|17
235|4 - Four or more|4 - Four or more|17
236|4 - Friend or neighbor or community or church member|4 - Friend or neighbor or community or church member|17
237|4 - Hispanic or Latino|4 - Hispanic or Latino|17
238|4 - Hospice|4 - Hospice|17
239|4 - Impaired decision-making|4 - Impaired decision-making|17
240|4 - Is totally dependent in toileting.|4 - Is totally dependent in toileting.|17
241|4 - Medicaid (HMO/managed care)|4 - Medicaid (HMO/managed care)|17
242|4 - None of the above|4 - None of the above|17
243|4 - Nursing home|4 - Nursing home|17
244|4 - On a daily basis|4 - On a daily basis|17
245|4 - Patient is completely dependent on someone else to manage all equipment.|4 - Patient is completely dependent on someone else to manage all equipment.|17
246|4 - Permanent placement|4 - Permanent placement|17
247|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, punches, dangerous maneuvers w/ wheelchair or other objects)|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, pu|17
248|4 - Psychosocial support (e.g., socialization, companionship, recreation)|4 - Psychosocial support (e.g., socialization, companionship, recreation)|17
249|4 - Recertification (follow-up) reassessment|4 - Recertification (follow-up) reassessment|17
250|4 - Recurrent thoughts of death|4 - Recurrent thoughts of death|17
251|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruction)|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruc|17
252|4 - Several times a week|4 - Several times a week|17
253|4 - Stage 4|4 - Stage 4|17
254|4 - Symptoms poorly controlled, history of rehospitalizations|4 - Symptoms poorly controlled, history of rehospitalizations|17
255|4 - Three or more times per week|4 - Three or more times per week|17
256|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetative state, or delirium.|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetati|17
257|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|17
258|4 - Unable to effectively participate in any housekeeping tasks.|4 - Unable to effectively participate in any housekeeping tasks.|17
259|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or unresponsive (e.g., speech is nonsensical or unintelligible).|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or u|17
260|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonresponsive.|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonr|17
261|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostomy.|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostom|17
262|4 - UNABLE to use the shower or tub and is bathed in BED OR BEDSIDE CHAIR.|4 - UNABLE to use the shower or tub and is bathed in BED OR BEDSIDE CHAIR.|17
263|4 - With a friend|4 - With a friend|17
264|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|17
265|4-OT|4-OT|17
266|5 - Advocates or facilitates patient's participation in appropriate medical care|5 - Advocates or facilitates patient's participation in appropriate medical care|17
267|5 - At least daily|5 - At least daily|17
268|5 - Bedfast, unable to ambulate or be up in a chair.|5 - Bedfast, unable to ambulate or be up in a chair.|17
269|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|17
270|5 - Disruptive or socially inappropriate behavior|5 - Disruptive or socially inappropriate behavior|17
271|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|17
272|5 - Hypo/Hyperglycemia, diabetes out of control|5 - Hypo/Hyperglycemia, diabetes out of control|17
273|5 - More often than once daily|5 - More often than once daily|17
274|5 - Native Hawaiian or Pacific Islander|5 - Native Hawaiian or Pacific Islander|17
275|5 - None of the above|5 - None of the above|17
276|5 - One to two times per week|5 - One to two times per week|17
277|5 - Other|5 - Other|17
278|5 - Other follow-up|5 - Other follow-up|17
279|5 - Paid help|5 - Paid help|17
280|5 - Patient nonresponsive or unable to speak.|5 - Patient nonresponsive or unable to speak.|17
281|5 - Thoughts of suicide|5 - Thoughts of suicide|17
282|5 - Totally unable to use the telephone.|5 - Totally unable to use the telephone.|17
283|5 - Unable to effectively participate in bathing and is totally bathed by another person.|5 - Unable to effectively participate in bathing and is totally bathed by another person.|17
284|5 - Unable to take in nutrients orally or by tube feeding.|5 - Unable to take in nutrients orally or by tube feeding.|17
285|5 - Unsafe for care at home|5 - Unsafe for care at home|17
286|5 - With paid help (other than home care agency staff)|5 - With paid help (other than home care agency staff)|17
287|5 - Workers' compensation|5 - Workers' compensation|17
288|5 - Wound infection, deteriorating wound status, new lesion/ulcer|5 - Wound infection, deteriorating wound status, new lesion/ulcer|17
289|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|17
290|6 - Delusional, hallucinatory, or paranoid behavior|6 - Delusional, hallucinatory, or paranoid behavior|17
291|6 - Financial agent, power of attorney, or conservator of finance|6 - Financial agent, power of attorney, or conservator of finance|17
292|6 - GI bleeding, obstruction|6 - GI bleeding, obstruction|17
293|6 - Less often than weekly|6 - Less often than weekly|17
294|6 - Memory loss to the extent that supervision required|6 - Memory loss to the extent that supervision required|17
295|6 - None of the above feelings observed or reported|6 - None of the above feelings observed or reported|17
296|6 - Other|6 - Other|17
297|6 - Title programs (e.g., Title III, V, or XX)|6 - Title programs (e.g., Title III, V, or XX)|17
298|6 - Transferred to an inpatient facility - patient not discharged from agency|6 - Transferred to an inpatient facility - patient not discharged from agency|17
299|6 - White|6 - White|17
300|6 - With other than above|6 - With other than above|17
301|7 - Exacerbation of CHF, fluid overload, heart failure|7 - Exacerbation of CHF, fluid overload, heart failure|17
302|7 - Health care agent, conservator of person, or medical power of attorney|7 - Health care agent, conservator of person, or medical power of attorney|17
303|7 - Hypo/Hyperglycemia, diabetes out of control|7 - Hypo/Hyperglycemia, diabetes out of control|17
304|7 - None of the above|7 - None of the above|17
305|7 - None of the above behaviors demonstrated|7 - None of the above behaviors demonstrated|17
306|7 - Other government (e.g., CHAMPUS, VA, etc.)|7 - Other government (e.g., CHAMPUS, VA, etc.)|17
307|7 - Transferred to an inpatient facility - patient discharged from agency|7 - Transferred to an inpatient facility - patient discharged from agency|17
308|8 - Death at home|8 - Death at home|17
309|8 - GI bleeding, obstruction|8 - GI bleeding, obstruction|17
310|8 - Myocardial infarction, stroke|8 - Myocardial infarction, stroke|17
311|8 - Private insurance|8 - Private insurance|17
312|9 - Chemotherapy|9 - Chemotherapy|17
313|9 - Discharge from agency|9 - Discharge from agency|17
314|9 - Other than above reasons|9 - Other than above reasons|17
315|9 - Private HMO/managed care|9 - Private HMO/managed care|17
316|NA - No caregiver|NA - No caregiver|17
317|NA - No equipment of this type used in care.|NA - No equipment of this type used in care.|17
318|NA - No inhalant/mist medications prescribed.|NA - No inhalant/mist medications prescribed.|17
319|NA - No injectable medications prescribed.|NA - No injectable medications prescribed.|17
320|NA - No inpatient facility admission|NA - No inpatient facility admission|17
321|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|17
322|NA - No Medicaid|NA - No Medicaid|17
323|NA - No Medicare|NA - No Medicare|17
324|NA - No observable pressure ulcer|NA - No observable pressure ulcer|17
325|NA - No observable stasis ulcer|NA - No observable stasis ulcer|17
326|NA - No observable surgical wound|NA - No observable surgical wound|17
327|NA - No oral medications prescribed.|NA - No oral medications prescribed.|17
328|NA - Not applicable|NA - Not applicable|17
329|NA - Patient does not have a telephone.|NA - Patient does not have a telephone.|17
330|NA - Patient has ostomy for bowel elimination|NA - Patient has ostomy for bowel elimination|17
331|NA - Patient nonresponsive|NA - Patient nonresponsive|17
332|NA - Patient on prophylactic treatment|NA - Patient on prophylactic treatment|17
333|NA - Patient was not discharged from an inpatient facility|NA - Patient was not discharged from an inpatient facility|17
334|UK - Other unknown|UK - Other unknown|17
335|UK - Reason unknown|UK - Reason unknown|17
336|UK - Unknown|UK - Unknown|17
337|UK - Unknown or Not Available|UK - Unknown or Not Available|17
341|01 - Early|01 - Early|17
342|02 - Late|02 - Late|17
343|NA - Not Applicable. No case mix group defined for this assessment.|NA - Not Applicable. No case mix group defined for this assessment.|17
344|NA - No case mix group defined by this assessment.|NA - No case mix group defined by this assessment.|17
2|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; OR (b) Is physically, cognitively, and mentally able to prepare light meals on a regular basis but has not routinely performed light meal preparation in the past (i.e., prior to this home care admission).|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; O|18
3|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and mentally able to perform all housekeeping tasks .|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and menta|18
4|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and mentally able to do laundry and access facilities.|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and menta|18
5|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying packages OR b) Physically, cognitively, and mentally able to take care of shopping, but has not done shopping in the past (i.e., prior to this home care admission).|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying|18
6|0 - Able to bathe self in SHOWER OR TUB independently.|0 - Able to bathe self in SHOWER OR TUB independently.|18
7|0 - Able to dial numbers and answer calls appropriately and as desired.|0 - Able to dial numbers and answer calls appropriately and as desired.|18
8|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body without assistance.|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body|18
9|0 - Able to get to and from the toilet independently with or without a device.|0 - Able to get to and from the toilet independently with or without a device.|18
10|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|18
11|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible public bus.|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible p|18
12|0 - Able to independently feed self.|0 - Able to independently feed self.|18
13|0 - Able to independently take the correct medication and proper dosage at the correct times.|0 - Able to independently take the correct medication and proper dosage at the correct times.|18
14|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct times.|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct ti|18
15|0 - Able to independently transfer.|0 - Able to independently transfer.|18
16|0 - Able to independently walk on even and uneven surfaces and climb stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even and uneven surfaces and climb stairs with or without railings|18
17|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings|18
18|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|18
19|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions independently.|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions indep|18
20|0 - Asymptomatic, no treatment needed at this time|0 - Asymptomatic, no treatment needed at this time|18
21|0 - Caregiver manages all tasks related to equipment completely independently.|0 - Caregiver manages all tasks related to equipment completely independently.|18
22|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations with no observable impairment.|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations w|18
23|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|18
24|0 - Life expectancy is greater than 6 months|0 - Life expectancy is greater than 6 months|18
25|0 - Never|0 - Never|18
26|0 - Never, patient is not short of breath|0 - Never, patient is not short of breath|18
27|0 - No|0 - No|18
28|0 - No emergent care services|0 - No emergent care services|18
29|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage)|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage)|18
30|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and extended or abstract conversation.|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and exte|18
31|0 - No one person|0 - No one person|18
32|0 - None of the time|0 - None of the time|18
33|0 - None, no charge for current services|0 - None, no charge for current services|18
34|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|18
35|0 - Patient does NOT have an ostomy for bowel elimination.|0 - Patient does NOT have an ostomy for bowel elimination.|18
36|0 - Patient has no pain or pain does not interfere with activity or movement|0 - Patient has no pain or pain does not interfere with activity or movement|18
37|0 - Patient manages all tasks related to equipment completely independently.|0 - Patient manages all tasks related to equipment completely independently.|18
38|0 - Poor:  little or no recovery is expected and/or further decline is imminent|0 - Poor:  little or no recovery is expected and/or further decline is imminent|18
39|0 - Timed-voiding defers incontinence|0 - Timed-voiding defers incontinence|18
40|0 - Very rarely or never has bowel incontinence|0 - Very rarely or never has bowel incontinence|18
41|0 - Zero|0 - Zero|18
42|00 - No|00 - No|18
43|01 - Yes|01 - Yes|18
44|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or mental limitations, needs assistance with heavy laundry.|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or|18
45|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the patient.|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the|18
46|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|18
47|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or supervision from another person OR c) a liquid, pureed or ground meat diet.|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or su|18
48|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|18
49|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|18
50|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independently.|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independe|18
51|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only when assisted or accompanied by another person.|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only w|18
52|1 - Able to take injectable medication at correct times if: a) individual syringes are prepared in advance by another person OR b) given daily reminders.|1 - Able to take injectable medication at correct times if: a) individual syringes are prepared in a|18
53|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance by another person OR b) given daily reminders.|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance b|18
54|1 - Able to take medication(s) at the correct times if: a) individual dosages are prepared in advance by another person , OR b) given daily reminders OR c) someone develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if: a) individual dosages are prepared in advanc|18
55|1 - Able to take medication(s) at the correct times if: a) individual dosages are prepared in advance by another person, OR b) given daily reminders OR c) someone develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if: a) individual dosages are prepared in advanc|18
56|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for the deaf) and call essential numbers.|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for t|18
57|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|18
58|1 - American Indian or Alaska Native|1 - American Indian or Alaska Native|18
59|1 - Depressed mood (e.g., feeling sad, tearful)|1 - Depressed mood (e.g., feeling sad, tearful)|18
60|1 - During the night only|1 - During the night only|18
61|1 - Fully granulating|1 - Fully granulating|18
62|1 - Good/Fair:  partial to full recovery is expected|1 - Good/Fair:  partial to full recovery is expected|18
63|1 - Good:  marked improvement in functional status is expected|1 - Good:  marked improvement in functional status is expected|18
64|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|18
65|1 - Heavy smoking|1 - Heavy smoking|18
66|1 - Hospital|1 - Hospital|18
67|1 - Hospital emergency room (includes 23-hour holding)|1 - Hospital emergency room (includes 23-hour holding)|18
68|1 - Hospitalization for EMERGENT (unscheduled) care|1 - Hospitalization for EMERGENT (unscheduled) care|18
69|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepared solutions), patient is able to manage all other aspects of equipment.|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepar|18
70|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|18
71|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|18
72|1 - In new or complex situations only|1 - In new or complex situations only|18
73|1 - Intravenous or infusion therapy (excludes TPN)|1 - Intravenous or infusion therapy (excludes TPN)|18
74|1 - Less often than daily|1 - Less often than daily|18
75|1 - Less than once a month|1 - Less than once a month|18
76|1 - Less than once weekly|1 - Less than once weekly|18
77|1 - Life expectancy is 6 months or fewer|1 - Life expectancy is 6 months or fewer|18
78|1 - Lives alone|1 - Lives alone|18
79|1 - Male|1 - Male|18
80|1 - Medicare (traditional fee-for-service)|1 - Medicare (traditional fee-for-service)|18
81|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of past 24 hours, significant memory loss so that supervision is required|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of pas|18
82|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors in word choice, grammar or speech intelligibility, needs minimal prompting or assistance).|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors i|18
83|1 - No assistance or services received|1 - No assistance or services received|18
84|1 - One|1 - One|18
85|1 - Oxygen (intermittent or continuous)|1 - Oxygen (intermittent or continuous)|18
86|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, and the surrounding layout, can count fingers at arm's length.|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, a|18
87|1 - Patient is incontinent|1 - Patient is incontinent|18
88|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|18
89|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical or treatment regimen.|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical|18
90|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient/couple/significant other)|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient|18
91|1 - Relatives, friends, or neighbors living outside the home|1 - Relatives, friends, or neighbors living outside the home|18
92|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions.|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions|18
93|1 - Requires use of a device (e.g., cane, walker) to walk alone OR requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|1 - Requires use of a device (e.g., cane, walker) to walk alone OR requires human supervision or ass|18
94|1 - Several times during day and night|1 - Several times during day and night|18
95|1 - Spouse or significant other|1 - Spouse or significant other|18
96|1 - Stage 1|1 - Stage 1|18
97|1 - Start of care - further visits planned|1 - Start of care - further visits planned|18
98|1 - Symptoms well controlled with current therapy|1 - Symptoms well controlled with current therapy|18
99|1 - Therapy services|1 - Therapy services|18
100|1 - Transfers with minimal human assistance or with use of an assistive device.|1 - Transfers with minimal human assistance or with use of an assistive device.|18
101|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitations.|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitatio|18
102|1 - Urinary incontinence|1 - Urinary incontinence|18
103|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet.|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet.|18
104|1 - When walking more than 20 feet, climbing stairs|1 - When walking more than 20 feet, climbing stairs|18
105|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary conversation. May need occasional repetition, extra time, or louder voice.|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary c|18
106|1 - With the use of devices, is able to bathe self in shower or tub independently.|1 - With the use of devices, is able to bathe self in shower or tub independently.|18
107|1 - Yes|1 - Yes|18
108|1-RN|1-RN|18
109|10 - Discharge from agency - no visits completed after start/resumption of care assessment|10 - Discharge from agency - no visits completed after start/resumption of care assessment|18
110|10 - Scheduled surgical procedure|10 - Scheduled surgical procedure|18
111|10 - Self-pay|10 - Self-pay|18
112|11 - Other|11 - Other|18
113|11 - Urinary tract infection|11 - Urinary tract infection|18
114|12 - IV catheter-related infection|12 - IV catheter-related infection|18
115|13 - Deep vein thrombosis, pulmonary embolus|13 - Deep vein thrombosis, pulmonary embolus|18
116|14 - Uncontrolled pain|14 - Uncontrolled pain|18
117|15 - Psychotic episode|15 - Psychotic episode|18
118|16 - Other than above reasons|16 - Other than above reasons|18
119|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing calls.|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing|18
120|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another person.|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another pers|18
121|2 - Able to walk only with the supervision or assistance of another person at all times.|2 - Able to walk only with the supervision or assistance of another person at all times.|18
122|2 - Aid: a) for intermittent supervision/encouragement/reminders, OR b) to get in and out of the shower/tub, OR c) for washing difficult to reach areas.|2 - Aid: a) for intermittent supervision/encouragement/reminders, OR b) to get in and out of the sho|18
123|2 - Asian|2 - Asian|18
124|2 - Caregiver requires considerable assistance from another person to manage equipment, but independently completes significant portions of task.|2 - Caregiver requires considerable assistance from another person to manage equipment, but independ|18
125|2 - Daily, but not constantly|2 - Daily, but not constantly|18
126|2 - Daughter or son|2 - Daughter or son|18
127|2 - Doctor's office emergency visit/house call|2 - Doctor's office emergency visit/house call|18
128|2 - During the day and night|2 - During the day and night|18
129|2 - Early/partial granulation|2 - Early/partial granulation|18
130|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors in word choice, organization or speech intelligibility). Speaks in phrases or short sentences.|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors|18
131|2 - Family member's residence|2 - Family member's residence|18
132|2 - Female|2 - Female|18
133|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conversation, needs frequent prompting or assistance.|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conver|18
134|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|18
135|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|18
136|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately stop activities, jeopardizes safety through actions|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately st|18
137|2 - Indwelling/suprapubic catheter|2 - Indwelling/suprapubic catheter|18
138|2 - Injury caused by fall or accident at home|2 - Injury caused by fall or accident at home|18
139|2 - Medicare (HMO/managed care)|2 - Medicare (HMO/managed care)|18
140|2 - Nausea, dehydration, malnutrition, constipation, impaction|2 - Nausea, dehydration, malnutrition, constipation, impaction|18
141|2 - Obesity|2 - Obesity|18
142|2 - On awakening or at night only|2 - On awakening or at night only|18
143|2 - Once a month|2 - Once a month|18
144|2 - One to three times weekly|2 - One to three times weekly|18
145|2 - Parenteral nutrition (TPN or lipids)|2 - Parenteral nutrition (TPN or lipids)|18
146|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic)|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic)|18
147|2 - Patient requires considerable assistance from another person to manage equipment, but independently completes portions of the task.|2 - Patient requires considerable assistance from another person to manage equipment, but independen|18
148|2 - Patient transferred to a noninstitutional hospice|2 - Patient transferred to a noninstitutional hospice|18
149|2 - Person residing in the home (EXCLUDING paid help)|2 - Person residing in the home (EXCLUDING paid help)|18
150|2 - Rehabilitation facility|2 - Rehabilitation facility|18
151|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifting of attention) or consistently requires low stimulus environment due to distractibility.|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifti|18
152|2 - Respite care|2 - Respite care|18
153|2 - Sense of failure or self reproach|2 - Sense of failure or self reproach|18
154|2 - Several times during day|2 - Several times during day|18
155|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonresponsive.|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonrespons|18
156|2 - Someone must assist the patient to groom self.|2 - Someone must assist the patient to groom self.|18
157|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|18
158|2 - Someone must help the patient put on upper body clothing.|2 - Someone must help the patient put on upper body clothing.|18
159|2 - Stage 2|2 - Stage 2|18
160|2 - Start of care - no further visits planned|2 - Start of care - no further visits planned|18
161|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitoring|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitori|18
162|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment regimen.|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment re|18
163|2 - Two|2 - Two|18
164|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistance due to cognitive or mental limitation.|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistanc|18
165|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|18
166|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assistance).|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assis|18
167|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home delivery.|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home deli|18
168|2 - Unable to prepare any light meals or reheat any delivered meals.|2 - Unable to prepare any light meals or reheat any delivered meals.|18
169|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|18
170|2 - UNABLE to take injectable medications unless administered by someone else.|2 - UNABLE to take injectable medications unless administered by someone else.|18
171|2 - UNABLE to take medication unless administered by someone else.|2 - UNABLE to take medication unless administered by someone else.|18
172|2 - UNABLE to transfer self but is able to bear weight and pivot during the transfer process.|2 - UNABLE to transfer self but is able to bear weight and pivot during the transfer process.|18
173|2 - Ventilator (continually or at night)|2 - Ventilator (continually or at night)|18
174|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less than 20 feet)|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less th|18
175|2 - With spouse or significant other|2 - With spouse or significant other|18
176|2 - Yes, assistance or services provided by family or friends|2 - Yes, assistance or services provided by family or friends|18
177|2-PT|2-PT|18
178|3 - Able to answer the telephone only some of the time or is able to carry on only a limited conversation.|3 - Able to answer the telephone only some of the time or is able to carry on only a limited convers|18
179|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube or gastrostomy.|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube|18
180|3 - Alcohol dependency|3 - Alcohol dependency|18
181|3 - All of the time|3 - All of the time|18
182|3 - Black or African-American|3 - Black or African-American|18
183|3 - Boarding home or rented room|3 - Boarding home or rented room|18
184|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment, clean/store/dispose of equipment or supplies).|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment,|18
185|3 - Chairfast, UNABLE to ambulate but is able to wheel self independently.|3 - Chairfast, UNABLE to ambulate but is able to wheel self independently.|18
186|3 - Continuous positive airway pressure|3 - Continuous positive airway pressure|18
187|3 - During the day and evening, but not constantly|3 - During the day and evening, but not constantly|18
188|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the alimentary canal)|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the|18
189|3 - Environmental support (e.g., housing, home maintenance)|3 - Environmental support (e.g., housing, home maintenance)|18
190|3 - Four to six times weekly|3 - Four to six times weekly|18
191|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessing by listener.  Speech limited to single words or short phrases.|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessin|18
192|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires multiple repetitions, restatements, demonstrations, additional time.|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires m|18
193|3 - Hopelessness|3 - Hopelessness|18
194|3 - Hospice care|3 - Hospice care|18
195|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|18
196|3 - Injury caused by fall or accident at home|3 - Injury caused by fall or accident at home|18
197|3 - Intractable pain|3 - Intractable pain|18
198|3 - Medicaid (traditional fee-for-service)|3 - Medicaid (traditional fee-for-service)|18
199|3 - Needs someone to do all shopping and errands.|3 - Needs someone to do all shopping and errands.|18
200|3 - Not healing|3 - Not healing|18
201|3 - Nursing home|3 - Nursing home|18
202|3 - Once daily|3 - Once daily|18
203|3 - Other family member|3 - Other family member|18
204|3 - Outpatient department/clinic emergency (includes urgicenter sites)|3 - Outpatient department/clinic emergency (includes urgicenter sites)|18
205|3 - Paid help|3 - Paid help|18
206|3 - Participates in bathing self in shower or tub, BUT requires presence of another person throughout the bath for assistance or supervision.|3 - Participates in bathing self in shower or tub, BUT requires presence of another person throughou|18
207|3 - Patient depends entirely upon another person to dress lower body.|3 - Patient depends entirely upon another person to dress lower body.|18
208|3 - Patient depends entirely upon another person to dress the upper body.|3 - Patient depends entirely upon another person to dress the upper body.|18
209|3 - Patient depends entirely upon someone else for grooming needs.|3 - Patient depends entirely upon someone else for grooming needs.|18
210|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone else to manage the equipment.|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone|18
211|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable to shift attention and recall directions more than half the time.|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable|18
212|3 - Respiratory problems (SOB, infection, obstruction)|3 - Respiratory problems (SOB, infection, obstruction)|18
213|3 - Resumption of care (after inpatient stay)|3 - Resumption of care (after inpatient stay)|18
214|3 - Several times each month|3 - Several times each month|18
215|3 - Skilled Nursing Facility|3 - Skilled Nursing Facility|18
216|3 - Stage 3|3 - Stage 3|18
217|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|18
218|3 - Three|3 - Three|18
219|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person throughout the process.|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person through|18
220|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal independently.|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal indep|18
221|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person.|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person|18
222|3 - Unknown because patient moved to a geographic location not served by this agency|3 - Unknown because patient moved to a geographic location not served by this agency|18
223|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|18
224|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|18
225|3 - With other family member|3 - With other family member|18
226|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home health services, homemaker assistance, transportation assistance, assisted living, board and care)|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home h|18
227|3-SLP/ST|3-SLP/ST|18
228|4 - At rest (during day or night)|4 - At rest (during day or night)|18
229|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|18
230|4 - Board and care or assisted living facility|4 - Board and care or assisted living facility|18
231|4 - Caregiver is completely dependent on someone else to manage all equipment.|4 - Caregiver is completely dependent on someone else to manage all equipment.|18
232|4 - Chairfast, unable to ambulate and is UNABLE to wheel self.|4 - Chairfast, unable to ambulate and is UNABLE to wheel self.|18
233|4 - Constantly|4 - Constantly|18
234|4 - Drug dependency|4 - Drug dependency|18
235|4 - Four or more|4 - Four or more|18
236|4 - Friend or neighbor or community or church member|4 - Friend or neighbor or community or church member|18
237|4 - Hispanic or Latino|4 - Hispanic or Latino|18
238|4 - Hospice|4 - Hospice|18
239|4 - Impaired decision-making|4 - Impaired decision-making|18
240|4 - Is totally dependent in toileting.|4 - Is totally dependent in toileting.|18
241|4 - Medicaid (HMO/managed care)|4 - Medicaid (HMO/managed care)|18
242|4 - None of the above|4 - None of the above|18
243|4 - Nursing home|4 - Nursing home|18
244|4 - On a daily basis|4 - On a daily basis|18
245|4 - Patient is completely dependent on someone else to manage all equipment.|4 - Patient is completely dependent on someone else to manage all equipment.|18
246|4 - Permanent placement|4 - Permanent placement|18
247|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, punches, dangerous maneuvers w/ wheelchair or other objects)|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, pu|18
248|4 - Psychosocial support (e.g., socialization, companionship, recreation)|4 - Psychosocial support (e.g., socialization, companionship, recreation)|18
249|4 - Recertification (follow-up) reassessment|4 - Recertification (follow-up) reassessment|18
250|4 - Recurrent thoughts of death|4 - Recurrent thoughts of death|18
251|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruction)|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruc|18
252|4 - Several times a week|4 - Several times a week|18
253|4 - Stage 4|4 - Stage 4|18
254|4 - Symptoms poorly controlled, history of rehospitalizations|4 - Symptoms poorly controlled, history of rehospitalizations|18
255|4 - Three or more times per week|4 - Three or more times per week|18
256|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetative state, or delirium.|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetati|18
257|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|18
258|4 - Unable to effectively participate in any housekeeping tasks.|4 - Unable to effectively participate in any housekeeping tasks.|18
259|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or unresponsive (e.g., speech is nonsensical or unintelligible).|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or u|18
260|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonresponsive.|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonr|18
261|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostomy.|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostom|18
262|4 - UNABLE to use the shower or tub and is bathed in BED OR BEDSIDE CHAIR.|4 - UNABLE to use the shower or tub and is bathed in BED OR BEDSIDE CHAIR.|18
263|4 - With a friend|4 - With a friend|18
264|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|18
265|4-OT|4-OT|18
266|5 - Advocates or facilitates patient's participation in appropriate medical care|5 - Advocates or facilitates patient's participation in appropriate medical care|18
267|5 - At least daily|5 - At least daily|18
268|5 - Bedfast, unable to ambulate or be up in a chair.|5 - Bedfast, unable to ambulate or be up in a chair.|18
269|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|18
270|5 - Disruptive or socially inappropriate behavior|5 - Disruptive or socially inappropriate behavior|18
271|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|18
272|5 - Hypo/Hyperglycemia, diabetes out of control|5 - Hypo/Hyperglycemia, diabetes out of control|18
273|5 - More often than once daily|5 - More often than once daily|18
274|5 - Native Hawaiian or Pacific Islander|5 - Native Hawaiian or Pacific Islander|18
275|5 - None of the above|5 - None of the above|18
276|5 - One to two times per week|5 - One to two times per week|18
277|5 - Other|5 - Other|18
278|5 - Other follow-up|5 - Other follow-up|18
279|5 - Paid help|5 - Paid help|18
280|5 - Patient nonresponsive or unable to speak.|5 - Patient nonresponsive or unable to speak.|18
281|5 - Thoughts of suicide|5 - Thoughts of suicide|18
282|5 - Totally unable to use the telephone.|5 - Totally unable to use the telephone.|18
283|5 - Unable to effectively participate in bathing and is totally bathed by another person.|5 - Unable to effectively participate in bathing and is totally bathed by another person.|18
284|5 - Unable to take in nutrients orally or by tube feeding.|5 - Unable to take in nutrients orally or by tube feeding.|18
285|5 - Unsafe for care at home|5 - Unsafe for care at home|18
286|5 - With paid help (other than home care agency staff)|5 - With paid help (other than home care agency staff)|18
287|5 - Workers' compensation|5 - Workers' compensation|18
288|5 - Wound infection, deteriorating wound status, new lesion/ulcer|5 - Wound infection, deteriorating wound status, new lesion/ulcer|18
289|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|18
290|6 - Delusional, hallucinatory, or paranoid behavior|6 - Delusional, hallucinatory, or paranoid behavior|18
291|6 - Financial agent, power of attorney, or conservator of finance|6 - Financial agent, power of attorney, or conservator of finance|18
292|6 - GI bleeding, obstruction|6 - GI bleeding, obstruction|18
293|6 - Less often than weekly|6 - Less often than weekly|18
294|6 - Memory loss to the extent that supervision required|6 - Memory loss to the extent that supervision required|18
295|6 - None of the above feelings observed or reported|6 - None of the above feelings observed or reported|18
296|6 - Other|6 - Other|18
297|6 - Title programs (e.g., Title III, V, or XX)|6 - Title programs (e.g., Title III, V, or XX)|18
298|6 - Transferred to an inpatient facility - patient not discharged from agency|6 - Transferred to an inpatient facility - patient not discharged from agency|18
299|6 - White|6 - White|18
300|6 - With other than above|6 - With other than above|18
301|7 - Exacerbation of CHF, fluid overload, heart failure|7 - Exacerbation of CHF, fluid overload, heart failure|18
302|7 - Health care agent, conservator of person, or medical power of attorney|7 - Health care agent, conservator of person, or medical power of attorney|18
303|7 - Hypo/Hyperglycemia, diabetes out of control|7 - Hypo/Hyperglycemia, diabetes out of control|18
304|7 - None of the above|7 - None of the above|18
305|7 - None of the above behaviors demonstrated|7 - None of the above behaviors demonstrated|18
306|7 - Other government (e.g., CHAMPUS, VA, etc.)|7 - Other government (e.g., CHAMPUS, VA, etc.)|18
307|7 - Transferred to an inpatient facility - patient discharged from agency|7 - Transferred to an inpatient facility - patient discharged from agency|18
308|8 - Death at home|8 - Death at home|18
309|8 - GI bleeding, obstruction|8 - GI bleeding, obstruction|18
310|8 - Myocardial infarction, stroke|8 - Myocardial infarction, stroke|18
311|8 - Private insurance|8 - Private insurance|18
312|9 - Chemotherapy|9 - Chemotherapy|18
313|9 - Discharge from agency|9 - Discharge from agency|18
314|9 - Other than above reasons|9 - Other than above reasons|18
315|9 - Private HMO/managed care|9 - Private HMO/managed care|18
316|NA - No caregiver|NA - No caregiver|18
317|NA - No equipment of this type used in care.|NA - No equipment of this type used in care.|18
318|NA - No inhalant/mist medications prescribed.|NA - No inhalant/mist medications prescribed.|18
319|NA - No injectable medications prescribed.|NA - No injectable medications prescribed.|18
320|NA - No inpatient facility admission|NA - No inpatient facility admission|18
321|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|18
322|NA - No Medicaid|NA - No Medicaid|18
323|NA - No Medicare|NA - No Medicare|18
324|NA - No observable pressure ulcer|NA - No observable pressure ulcer|18
325|NA - No observable stasis ulcer|NA - No observable stasis ulcer|18
326|NA - No observable surgical wound|NA - No observable surgical wound|18
327|NA - No oral medications prescribed.|NA - No oral medications prescribed.|18
328|NA - Not applicable|NA - Not applicable|18
329|NA - Patient does not have a telephone.|NA - Patient does not have a telephone.|18
330|NA - Patient has ostomy for bowel elimination|NA - Patient has ostomy for bowel elimination|18
331|NA - Patient nonresponsive|NA - Patient nonresponsive|18
332|NA - Patient on prophylactic treatment|NA - Patient on prophylactic treatment|18
333|NA - Patient was not discharged from an inpatient facility|NA - Patient was not discharged from an inpatient facility|18
334|UK - Other unknown|UK - Other unknown|18
335|UK - Reason unknown|UK - Reason unknown|18
336|UK - Unknown|UK - Unknown|18
337|UK - Unknown or Not Available|UK - Unknown or Not Available|18
341|01 - Early|01 - Early|18
342|02 - Late|02 - Late|18
343|NA - Not Applicable. No case mix group defined for this assessment.|NA - Not Applicable. No case mix group defined for this assessment.|18
344|NA - No case mix group defined by this assessment.|NA - No case mix group defined by this assessment.|18
2|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; OR (b) Is physically, cognitively, and mentally able to prepare light meals on a regular basis but has not routinely performed light meal preparation in the past (i.e., prior to this home care admission).|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; O|19
3|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and mentally able to perform all housekeeping tasks .|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and menta|19
4|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and mentally able to do laundry and access facilities.|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and menta|19
5|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying packages OR b) Physically, cognitively, and mentally able to take care of shopping, but has not done shopping in the past (i.e., prior to this home care admission).|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying|19
6|0 - Able to bathe self in SHOWER OR TUB independently.|0 - Able to bathe self in SHOWER OR TUB independently.|19
7|0 - Able to dial numbers and answer calls appropriately and as desired.|0 - Able to dial numbers and answer calls appropriately and as desired.|19
8|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body without assistance.|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body|19
9|0 - Able to get to and from the toilet independently with or without a device.|0 - Able to get to and from the toilet independently with or without a device.|19
10|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|19
11|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible public bus.|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible p|19
12|0 - Able to independently feed self.|0 - Able to independently feed self.|19
13|0 - Able to independently take the correct medication and proper dosage at the correct times.|0 - Able to independently take the correct medication and proper dosage at the correct times.|19
14|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct times.|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct ti|19
15|0 - Able to independently transfer.|0 - Able to independently transfer.|19
16|0 - Able to independently walk on even and uneven surfaces and climb stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even and uneven surfaces and climb stairs with or without railings|19
17|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings|19
18|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|19
19|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions independently.|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions indep|19
20|0 - Asymptomatic, no treatment needed at this time|0 - Asymptomatic, no treatment needed at this time|19
21|0 - Caregiver manages all tasks related to equipment completely independently.|0 - Caregiver manages all tasks related to equipment completely independently.|19
22|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations with no observable impairment.|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations w|19
23|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|19
24|0 - Life expectancy is greater than 6 months|0 - Life expectancy is greater than 6 months|19
25|0 - Never|0 - Never|19
26|0 - Never, patient is not short of breath|0 - Never, patient is not short of breath|19
27|0 - No|0 - No|19
28|0 - No emergent care services|0 - No emergent care services|19
29|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage)|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage)|19
30|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and extended or abstract conversation.|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and exte|19
31|0 - No one person|0 - No one person|19
32|0 - None of the time|0 - None of the time|19
33|0 - None, no charge for current services|0 - None, no charge for current services|19
34|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|19
35|0 - Patient does NOT have an ostomy for bowel elimination.|0 - Patient does NOT have an ostomy for bowel elimination.|19
36|0 - Patient has no pain or pain does not interfere with activity or movement|0 - Patient has no pain or pain does not interfere with activity or movement|19
37|0 - Patient manages all tasks related to equipment completely independently.|0 - Patient manages all tasks related to equipment completely independently.|19
38|0 - Poor:  little or no recovery is expected and/or further decline is imminent|0 - Poor:  little or no recovery is expected and/or further decline is imminent|19
39|0 - Timed-voiding defers incontinence|0 - Timed-voiding defers incontinence|19
40|0 - Very rarely or never has bowel incontinence|0 - Very rarely or never has bowel incontinence|19
41|0 - Zero|0 - Zero|19
42|00 - No|00 - No|19
43|01 - Yes|01 - Yes|19
44|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or mental limitations, needs assistance with heavy laundry.|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or|19
45|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the patient.|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the|19
46|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|19
47|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or supervision from another person OR c) a liquid, pureed or ground meat diet.|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or su|19
48|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|19
49|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|19
50|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independently.|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independe|19
51|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only when assisted or accompanied by another person.|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only w|19
52|1 - Able to take injectable medication at correct times if: a) individual syringes are prepared in advance by another person OR b) given daily reminders.|1 - Able to take injectable medication at correct times if: a) individual syringes are prepared in a|19
53|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance by another person OR b) given daily reminders.|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance b|19
54|1 - Able to take medication(s) at the correct times if: a) individual dosages are prepared in advance by another person , OR b) given daily reminders OR c) someone develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if: a) individual dosages are prepared in advanc|19
55|1 - Able to take medication(s) at the correct times if: a) individual dosages are prepared in advance by another person, OR b) given daily reminders OR c) someone develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if: a) individual dosages are prepared in advanc|19
56|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for the deaf) and call essential numbers.|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for t|19
57|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|19
58|1 - American Indian or Alaska Native|1 - American Indian or Alaska Native|19
59|1 - Depressed mood (e.g., feeling sad, tearful)|1 - Depressed mood (e.g., feeling sad, tearful)|19
60|1 - During the night only|1 - During the night only|19
61|1 - Fully granulating|1 - Fully granulating|19
62|1 - Good/Fair:  partial to full recovery is expected|1 - Good/Fair:  partial to full recovery is expected|19
63|1 - Good:  marked improvement in functional status is expected|1 - Good:  marked improvement in functional status is expected|19
64|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|19
65|1 - Heavy smoking|1 - Heavy smoking|19
66|1 - Hospital|1 - Hospital|19
67|1 - Hospital emergency room (includes 23-hour holding)|1 - Hospital emergency room (includes 23-hour holding)|19
68|1 - Hospitalization for EMERGENT (unscheduled) care|1 - Hospitalization for EMERGENT (unscheduled) care|19
69|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepared solutions), patient is able to manage all other aspects of equipment.|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepar|19
70|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|19
71|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|19
72|1 - In new or complex situations only|1 - In new or complex situations only|19
73|1 - Intravenous or infusion therapy (excludes TPN)|1 - Intravenous or infusion therapy (excludes TPN)|19
74|1 - Less often than daily|1 - Less often than daily|19
75|1 - Less than once a month|1 - Less than once a month|19
76|1 - Less than once weekly|1 - Less than once weekly|19
77|1 - Life expectancy is 6 months or fewer|1 - Life expectancy is 6 months or fewer|19
78|1 - Lives alone|1 - Lives alone|19
79|1 - Male|1 - Male|19
80|1 - Medicare (traditional fee-for-service)|1 - Medicare (traditional fee-for-service)|19
81|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of past 24 hours, significant memory loss so that supervision is required|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of pas|19
82|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors in word choice, grammar or speech intelligibility, needs minimal prompting or assistance).|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors i|19
83|1 - No assistance or services received|1 - No assistance or services received|19
84|1 - One|1 - One|19
85|1 - Oxygen (intermittent or continuous)|1 - Oxygen (intermittent or continuous)|19
86|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, and the surrounding layout, can count fingers at arm's length.|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, a|19
87|1 - Patient is incontinent|1 - Patient is incontinent|19
88|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|19
89|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical or treatment regimen.|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical|19
90|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient/couple/significant other)|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient|19
91|1 - Relatives, friends, or neighbors living outside the home|1 - Relatives, friends, or neighbors living outside the home|19
92|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions.|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions|19
93|1 - Requires use of a device (e.g., cane, walker) to walk alone OR requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|1 - Requires use of a device (e.g., cane, walker) to walk alone OR requires human supervision or ass|19
94|1 - Several times during day and night|1 - Several times during day and night|19
95|1 - Spouse or significant other|1 - Spouse or significant other|19
96|1 - Stage 1|1 - Stage 1|19
97|1 - Start of care - further visits planned|1 - Start of care - further visits planned|19
98|1 - Symptoms well controlled with current therapy|1 - Symptoms well controlled with current therapy|19
99|1 - Therapy services|1 - Therapy services|19
100|1 - Transfers with minimal human assistance or with use of an assistive device.|1 - Transfers with minimal human assistance or with use of an assistive device.|19
101|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitations.|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitatio|19
102|1 - Urinary incontinence|1 - Urinary incontinence|19
103|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet.|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet.|19
104|1 - When walking more than 20 feet, climbing stairs|1 - When walking more than 20 feet, climbing stairs|19
105|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary conversation. May need occasional repetition, extra time, or louder voice.|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary c|19
106|1 - With the use of devices, is able to bathe self in shower or tub independently.|1 - With the use of devices, is able to bathe self in shower or tub independently.|19
107|1 - Yes|1 - Yes|19
108|1-RN|1-RN|19
109|10 - Discharge from agency - no visits completed after start/resumption of care assessment|10 - Discharge from agency - no visits completed after start/resumption of care assessment|19
110|10 - Scheduled surgical procedure|10 - Scheduled surgical procedure|19
111|10 - Self-pay|10 - Self-pay|19
112|11 - Other|11 - Other|19
113|11 - Urinary tract infection|11 - Urinary tract infection|19
114|12 - IV catheter-related infection|12 - IV catheter-related infection|19
115|13 - Deep vein thrombosis, pulmonary embolus|13 - Deep vein thrombosis, pulmonary embolus|19
116|14 - Uncontrolled pain|14 - Uncontrolled pain|19
117|15 - Psychotic episode|15 - Psychotic episode|19
118|16 - Other than above reasons|16 - Other than above reasons|19
119|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing calls.|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing|19
120|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another person.|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another pers|19
121|2 - Able to walk only with the supervision or assistance of another person at all times.|2 - Able to walk only with the supervision or assistance of another person at all times.|19
122|2 - Aid: a) for intermittent supervision/encouragement/reminders, OR b) to get in and out of the shower/tub, OR c) for washing difficult to reach areas.|2 - Aid: a) for intermittent supervision/encouragement/reminders, OR b) to get in and out of the sho|19
123|2 - Asian|2 - Asian|19
124|2 - Caregiver requires considerable assistance from another person to manage equipment, but independently completes significant portions of task.|2 - Caregiver requires considerable assistance from another person to manage equipment, but independ|19
125|2 - Daily, but not constantly|2 - Daily, but not constantly|19
126|2 - Daughter or son|2 - Daughter or son|19
127|2 - Doctor's office emergency visit/house call|2 - Doctor's office emergency visit/house call|19
128|2 - During the day and night|2 - During the day and night|19
129|2 - Early/partial granulation|2 - Early/partial granulation|19
130|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors in word choice, organization or speech intelligibility). Speaks in phrases or short sentences.|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors|19
131|2 - Family member's residence|2 - Family member's residence|19
132|2 - Female|2 - Female|19
133|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conversation, needs frequent prompting or assistance.|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conver|19
134|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|19
135|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|19
136|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately stop activities, jeopardizes safety through actions|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately st|19
137|2 - Indwelling/suprapubic catheter|2 - Indwelling/suprapubic catheter|19
138|2 - Injury caused by fall or accident at home|2 - Injury caused by fall or accident at home|19
139|2 - Medicare (HMO/managed care)|2 - Medicare (HMO/managed care)|19
140|2 - Nausea, dehydration, malnutrition, constipation, impaction|2 - Nausea, dehydration, malnutrition, constipation, impaction|19
141|2 - Obesity|2 - Obesity|19
142|2 - On awakening or at night only|2 - On awakening or at night only|19
143|2 - Once a month|2 - Once a month|19
144|2 - One to three times weekly|2 - One to three times weekly|19
145|2 - Parenteral nutrition (TPN or lipids)|2 - Parenteral nutrition (TPN or lipids)|19
146|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic)|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic)|19
147|2 - Patient requires considerable assistance from another person to manage equipment, but independently completes portions of the task.|2 - Patient requires considerable assistance from another person to manage equipment, but independen|19
148|2 - Patient transferred to a noninstitutional hospice|2 - Patient transferred to a noninstitutional hospice|19
149|2 - Person residing in the home (EXCLUDING paid help)|2 - Person residing in the home (EXCLUDING paid help)|19
150|2 - Rehabilitation facility|2 - Rehabilitation facility|19
151|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifting of attention) or consistently requires low stimulus environment due to distractibility.|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifti|19
152|2 - Respite care|2 - Respite care|19
153|2 - Sense of failure or self reproach|2 - Sense of failure or self reproach|19
154|2 - Several times during day|2 - Several times during day|19
155|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonresponsive.|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonrespons|19
156|2 - Someone must assist the patient to groom self.|2 - Someone must assist the patient to groom self.|19
157|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|19
158|2 - Someone must help the patient put on upper body clothing.|2 - Someone must help the patient put on upper body clothing.|19
159|2 - Stage 2|2 - Stage 2|19
160|2 - Start of care - no further visits planned|2 - Start of care - no further visits planned|19
161|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitoring|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitori|19
162|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment regimen.|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment re|19
163|2 - Two|2 - Two|19
164|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistance due to cognitive or mental limitation.|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistanc|19
165|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|19
166|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assistance).|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assis|19
167|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home delivery.|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home deli|19
168|2 - Unable to prepare any light meals or reheat any delivered meals.|2 - Unable to prepare any light meals or reheat any delivered meals.|19
169|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|19
170|2 - UNABLE to take injectable medications unless administered by someone else.|2 - UNABLE to take injectable medications unless administered by someone else.|19
171|2 - UNABLE to take medication unless administered by someone else.|2 - UNABLE to take medication unless administered by someone else.|19
172|2 - UNABLE to transfer self but is able to bear weight and pivot during the transfer process.|2 - UNABLE to transfer self but is able to bear weight and pivot during the transfer process.|19
173|2 - Ventilator (continually or at night)|2 - Ventilator (continually or at night)|19
174|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less than 20 feet)|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less th|19
175|2 - With spouse or significant other|2 - With spouse or significant other|19
176|2 - Yes, assistance or services provided by family or friends|2 - Yes, assistance or services provided by family or friends|19
177|2-PT|2-PT|19
178|3 - Able to answer the telephone only some of the time or is able to carry on only a limited conversation.|3 - Able to answer the telephone only some of the time or is able to carry on only a limited convers|19
179|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube or gastrostomy.|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube|19
180|3 - Alcohol dependency|3 - Alcohol dependency|19
181|3 - All of the time|3 - All of the time|19
182|3 - Black or African-American|3 - Black or African-American|19
183|3 - Boarding home or rented room|3 - Boarding home or rented room|19
184|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment, clean/store/dispose of equipment or supplies).|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment,|19
185|3 - Chairfast, UNABLE to ambulate but is able to wheel self independently.|3 - Chairfast, UNABLE to ambulate but is able to wheel self independently.|19
186|3 - Continuous positive airway pressure|3 - Continuous positive airway pressure|19
187|3 - During the day and evening, but not constantly|3 - During the day and evening, but not constantly|19
188|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the alimentary canal)|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the|19
189|3 - Environmental support (e.g., housing, home maintenance)|3 - Environmental support (e.g., housing, home maintenance)|19
190|3 - Four to six times weekly|3 - Four to six times weekly|19
191|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessing by listener.  Speech limited to single words or short phrases.|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessin|19
192|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires multiple repetitions, restatements, demonstrations, additional time.|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires m|19
193|3 - Hopelessness|3 - Hopelessness|19
194|3 - Hospice care|3 - Hospice care|19
195|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|19
196|3 - Injury caused by fall or accident at home|3 - Injury caused by fall or accident at home|19
197|3 - Intractable pain|3 - Intractable pain|19
198|3 - Medicaid (traditional fee-for-service)|3 - Medicaid (traditional fee-for-service)|19
199|3 - Needs someone to do all shopping and errands.|3 - Needs someone to do all shopping and errands.|19
200|3 - Not healing|3 - Not healing|19
201|3 - Nursing home|3 - Nursing home|19
202|3 - Once daily|3 - Once daily|19
203|3 - Other family member|3 - Other family member|19
204|3 - Outpatient department/clinic emergency (includes urgicenter sites)|3 - Outpatient department/clinic emergency (includes urgicenter sites)|19
205|3 - Paid help|3 - Paid help|19
206|3 - Participates in bathing self in shower or tub, BUT requires presence of another person throughout the bath for assistance or supervision.|3 - Participates in bathing self in shower or tub, BUT requires presence of another person throughou|19
207|3 - Patient depends entirely upon another person to dress lower body.|3 - Patient depends entirely upon another person to dress lower body.|19
208|3 - Patient depends entirely upon another person to dress the upper body.|3 - Patient depends entirely upon another person to dress the upper body.|19
209|3 - Patient depends entirely upon someone else for grooming needs.|3 - Patient depends entirely upon someone else for grooming needs.|19
210|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone else to manage the equipment.|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone|19
211|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable to shift attention and recall directions more than half the time.|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable|19
212|3 - Respiratory problems (SOB, infection, obstruction)|3 - Respiratory problems (SOB, infection, obstruction)|19
213|3 - Resumption of care (after inpatient stay)|3 - Resumption of care (after inpatient stay)|19
214|3 - Several times each month|3 - Several times each month|19
215|3 - Skilled Nursing Facility|3 - Skilled Nursing Facility|19
216|3 - Stage 3|3 - Stage 3|19
217|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|19
218|3 - Three|3 - Three|19
219|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person throughout the process.|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person through|19
220|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal independently.|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal indep|19
221|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person.|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person|19
222|3 - Unknown because patient moved to a geographic location not served by this agency|3 - Unknown because patient moved to a geographic location not served by this agency|19
223|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|19
224|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|19
225|3 - With other family member|3 - With other family member|19
226|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home health services, homemaker assistance, transportation assistance, assisted living, board and care)|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home h|19
227|3-SLP/ST|3-SLP/ST|19
228|4 - At rest (during day or night)|4 - At rest (during day or night)|19
229|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|19
230|4 - Board and care or assisted living facility|4 - Board and care or assisted living facility|19
231|4 - Caregiver is completely dependent on someone else to manage all equipment.|4 - Caregiver is completely dependent on someone else to manage all equipment.|19
232|4 - Chairfast, unable to ambulate and is UNABLE to wheel self.|4 - Chairfast, unable to ambulate and is UNABLE to wheel self.|19
233|4 - Constantly|4 - Constantly|19
234|4 - Drug dependency|4 - Drug dependency|19
235|4 - Four or more|4 - Four or more|19
236|4 - Friend or neighbor or community or church member|4 - Friend or neighbor or community or church member|19
237|4 - Hispanic or Latino|4 - Hispanic or Latino|19
238|4 - Hospice|4 - Hospice|19
239|4 - Impaired decision-making|4 - Impaired decision-making|19
240|4 - Is totally dependent in toileting.|4 - Is totally dependent in toileting.|19
241|4 - Medicaid (HMO/managed care)|4 - Medicaid (HMO/managed care)|19
242|4 - None of the above|4 - None of the above|19
243|4 - Nursing home|4 - Nursing home|19
244|4 - On a daily basis|4 - On a daily basis|19
245|4 - Patient is completely dependent on someone else to manage all equipment.|4 - Patient is completely dependent on someone else to manage all equipment.|19
246|4 - Permanent placement|4 - Permanent placement|19
247|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, punches, dangerous maneuvers w/ wheelchair or other objects)|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, pu|19
248|4 - Psychosocial support (e.g., socialization, companionship, recreation)|4 - Psychosocial support (e.g., socialization, companionship, recreation)|19
249|4 - Recertification (follow-up) reassessment|4 - Recertification (follow-up) reassessment|19
250|4 - Recurrent thoughts of death|4 - Recurrent thoughts of death|19
251|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruction)|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruc|19
252|4 - Several times a week|4 - Several times a week|19
253|4 - Stage 4|4 - Stage 4|19
254|4 - Symptoms poorly controlled, history of rehospitalizations|4 - Symptoms poorly controlled, history of rehospitalizations|19
255|4 - Three or more times per week|4 - Three or more times per week|19
256|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetative state, or delirium.|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetati|19
257|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|19
258|4 - Unable to effectively participate in any housekeeping tasks.|4 - Unable to effectively participate in any housekeeping tasks.|19
259|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or unresponsive (e.g., speech is nonsensical or unintelligible).|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or u|19
260|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonresponsive.|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonr|19
261|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostomy.|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostom|19
262|4 - UNABLE to use the shower or tub and is bathed in BED OR BEDSIDE CHAIR.|4 - UNABLE to use the shower or tub and is bathed in BED OR BEDSIDE CHAIR.|19
263|4 - With a friend|4 - With a friend|19
264|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|19
265|4-OT|4-OT|19
266|5 - Advocates or facilitates patient's participation in appropriate medical care|5 - Advocates or facilitates patient's participation in appropriate medical care|19
267|5 - At least daily|5 - At least daily|19
268|5 - Bedfast, unable to ambulate or be up in a chair.|5 - Bedfast, unable to ambulate or be up in a chair.|19
269|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|19
270|5 - Disruptive or socially inappropriate behavior|5 - Disruptive or socially inappropriate behavior|19
271|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|19
272|5 - Hypo/Hyperglycemia, diabetes out of control|5 - Hypo/Hyperglycemia, diabetes out of control|19
273|5 - More often than once daily|5 - More often than once daily|19
274|5 - Native Hawaiian or Pacific Islander|5 - Native Hawaiian or Pacific Islander|19
275|5 - None of the above|5 - None of the above|19
276|5 - One to two times per week|5 - One to two times per week|19
277|5 - Other|5 - Other|19
278|5 - Other follow-up|5 - Other follow-up|19
279|5 - Paid help|5 - Paid help|19
280|5 - Patient nonresponsive or unable to speak.|5 - Patient nonresponsive or unable to speak.|19
281|5 - Thoughts of suicide|5 - Thoughts of suicide|19
282|5 - Totally unable to use the telephone.|5 - Totally unable to use the telephone.|19
283|5 - Unable to effectively participate in bathing and is totally bathed by another person.|5 - Unable to effectively participate in bathing and is totally bathed by another person.|19
284|5 - Unable to take in nutrients orally or by tube feeding.|5 - Unable to take in nutrients orally or by tube feeding.|19
285|5 - Unsafe for care at home|5 - Unsafe for care at home|19
286|5 - With paid help (other than home care agency staff)|5 - With paid help (other than home care agency staff)|19
287|5 - Workers' compensation|5 - Workers' compensation|19
288|5 - Wound infection, deteriorating wound status, new lesion/ulcer|5 - Wound infection, deteriorating wound status, new lesion/ulcer|19
289|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|19
290|6 - Delusional, hallucinatory, or paranoid behavior|6 - Delusional, hallucinatory, or paranoid behavior|19
291|6 - Financial agent, power of attorney, or conservator of finance|6 - Financial agent, power of attorney, or conservator of finance|19
292|6 - GI bleeding, obstruction|6 - GI bleeding, obstruction|19
293|6 - Less often than weekly|6 - Less often than weekly|19
294|6 - Memory loss to the extent that supervision required|6 - Memory loss to the extent that supervision required|19
295|6 - None of the above feelings observed or reported|6 - None of the above feelings observed or reported|19
296|6 - Other|6 - Other|19
297|6 - Title programs (e.g., Title III, V, or XX)|6 - Title programs (e.g., Title III, V, or XX)|19
298|6 - Transferred to an inpatient facility - patient not discharged from agency|6 - Transferred to an inpatient facility - patient not discharged from agency|19
299|6 - White|6 - White|19
300|6 - With other than above|6 - With other than above|19
301|7 - Exacerbation of CHF, fluid overload, heart failure|7 - Exacerbation of CHF, fluid overload, heart failure|19
302|7 - Health care agent, conservator of person, or medical power of attorney|7 - Health care agent, conservator of person, or medical power of attorney|19
303|7 - Hypo/Hyperglycemia, diabetes out of control|7 - Hypo/Hyperglycemia, diabetes out of control|19
304|7 - None of the above|7 - None of the above|19
305|7 - None of the above behaviors demonstrated|7 - None of the above behaviors demonstrated|19
306|7 - Other government (e.g., CHAMPUS, VA, etc.)|7 - Other government (e.g., CHAMPUS, VA, etc.)|19
307|7 - Transferred to an inpatient facility - patient discharged from agency|7 - Transferred to an inpatient facility - patient discharged from agency|19
308|8 - Death at home|8 - Death at home|19
309|8 - GI bleeding, obstruction|8 - GI bleeding, obstruction|19
310|8 - Myocardial infarction, stroke|8 - Myocardial infarction, stroke|19
311|8 - Private insurance|8 - Private insurance|19
312|9 - Chemotherapy|9 - Chemotherapy|19
313|9 - Discharge from agency|9 - Discharge from agency|19
314|9 - Other than above reasons|9 - Other than above reasons|19
315|9 - Private HMO/managed care|9 - Private HMO/managed care|19
316|NA - No caregiver|NA - No caregiver|19
317|NA - No equipment of this type used in care.|NA - No equipment of this type used in care.|19
318|NA - No inhalant/mist medications prescribed.|NA - No inhalant/mist medications prescribed.|19
319|NA - No injectable medications prescribed.|NA - No injectable medications prescribed.|19
320|NA - No inpatient facility admission|NA - No inpatient facility admission|19
321|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|19
322|NA - No Medicaid|NA - No Medicaid|19
323|NA - No Medicare|NA - No Medicare|19
324|NA - No observable pressure ulcer|NA - No observable pressure ulcer|19
325|NA - No observable stasis ulcer|NA - No observable stasis ulcer|19
326|NA - No observable surgical wound|NA - No observable surgical wound|19
327|NA - No oral medications prescribed.|NA - No oral medications prescribed.|19
328|NA - Not applicable|NA - Not applicable|19
329|NA - Patient does not have a telephone.|NA - Patient does not have a telephone.|19
330|NA - Patient has ostomy for bowel elimination|NA - Patient has ostomy for bowel elimination|19
331|NA - Patient nonresponsive|NA - Patient nonresponsive|19
332|NA - Patient on prophylactic treatment|NA - Patient on prophylactic treatment|19
333|NA - Patient was not discharged from an inpatient facility|NA - Patient was not discharged from an inpatient facility|19
334|UK - Other unknown|UK - Other unknown|19
335|UK - Reason unknown|UK - Reason unknown|19
336|UK - Unknown|UK - Unknown|19
337|UK - Unknown or Not Available|UK - Unknown or Not Available|19
341|01 - Early|01 - Early|19
342|02 - Late|02 - Late|19
343|NA - Not Applicable. No case mix group defined for this assessment.|NA - Not Applicable. No case mix group defined for this assessment.|19
344|NA - No case mix group defined by this assessment.|NA - No case mix group defined by this assessment.|19
2|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; OR (b) Is physically, cognitively, and mentally able to prepare light meals on a regular basis but has not routinely performed light meal preparation in the past (i.e., prior to this home care admission).|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; O|21
3|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and mentally able to perform all housekeeping tasks .|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and menta|21
4|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and mentally able to do laundry and access facilities.|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and menta|21
5|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying packages OR b) Physically, cognitively, and mentally able to take care of shopping, but has not done shopping in the past (i.e., prior to this home care admission).|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying|21
6|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|21
7|0 - Able to dial numbers and answer calls appropriately and as desired.|0 - Able to dial numbers and answer calls appropriately and as desired.|21
8|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body without assistance.|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body|21
9|0 - Able to get to and from the toilet and transfer independently with or without a device.|0 - Able to get to and from the toilet and transfer independently with or without a device.|21
10|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|21
11|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible public bus.|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible p|21
12|0 - Able to independently feed self.|0 - Able to independently feed self.|21
13|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|21
14|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct times.|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct ti|21
15|0 - Able to independently transfer.|0 - Able to independently transfer.|21
16|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without rail|21
17|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings|21
18|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|21
19|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions independently.|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions indep|21
20|0 - Asymptomatic, no treatment needed at this time|0 - Asymptomatic, no treatment needed at this time|21
21|0 - Caregiver manages all tasks related to equipment completely independently.|0 - Caregiver manages all tasks related to equipment completely independently.|21
22|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations with no observable impairment.|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations w|21
23|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|21
24|0 - Life expectancy is greater than 6 months|0 - Life expectancy is greater than 6 months|21
25|0 - Never|0 - Never|21
26|0 - Patient is not short of breath|0 - Patient is not short of breath|21
27|0 - No|0 - No|21
28|0 - No emergent care services|0 - No emergent care services|21
29|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [ Go to M1620 ]|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [ Go to M1620 ]|21
30|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and extended or abstract conversation.|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and exte|21
31|0 - No one person|0 - No one person|21
32|0 - None of the time|0 - None of the time|21
33|0 - None, no charge for current services|0 - None, no charge for current services|21
34|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|21
35|0 - Patient does NOT have an ostomy for bowel elimination.|0 - Patient does NOT have an ostomy for bowel elimination.|21
36|0 - Patient has no pain|0 - Patient has no pain|21
37|0 - Patient manages all tasks related to equipment completely independently.|0 - Patient manages all tasks related to equipment completely independently.|21
38|0 - Poor:  little or no recovery is expected and/or further decline is imminent|0 - Poor:  little or no recovery is expected and/or further decline is imminent|21
39|0 - Timed-voiding defers incontinence|0 - Timed-voiding defers incontinence|21
40|0 - Very rarely or never has bowel incontinence|0 - Very rarely or never has bowel incontinence|21
41|0 - Zero|0 - Zero|21
42|00 - No|00 - No|21
43|01 - Yes|01 - Yes|21
44|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or mental limitations, needs assistance with heavy laundry.|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or|21
45|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the patient.|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the|21
46|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|21
47|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or supervision from another person OR c) a liquid, pureed or ground meat diet.|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or su|21
48|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|21
49|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|21
50|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independently.|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independe|21
51|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only when assisted or accompanied by another person.|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only w|21
52|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepa|21
53|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance by another person OR b) given daily reminders.|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance b|21
54|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advan|21
55|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advan|21
56|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for the deaf) and call essential numbers.|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for t|21
57|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|21
58|1 - American Indian or Alaska Native|1 - American Indian or Alaska Native|21
59|1 - Depressed mood (e.g., feeling sad, tearful)|1 - Depressed mood (e.g., feeling sad, tearful)|21
60|1 - During the night only|1 - During the night only|21
61|1 - Fully granulating|1 - Fully granulating|21
62|1 - Good/Fair:  partial to full recovery is expected|1 - Good/Fair:  partial to full recovery is expected|21
63|1 - Good:  marked improvement in functional status is expected|1 - Good:  marked improvement in functional status is expected|21
64|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|21
65|1 - Smoking|1 - Smoking|21
66|1 - Hospital|1 - Hospital|21
67|1 - Hospital emergency room (includes 23-hour holding)|1 - Hospital emergency room (includes 23-hour holding)|21
68|1 - Hospitalization for EMERGENT (unscheduled) care|1 - Hospitalization for EMERGENT (unscheduled) care|21
69|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepared solutions), patient is able to manage all other aspects of equipment.|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepar|21
70|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|21
71|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|21
72|1 - In new or complex situations only|1 - In new or complex situations only|21
73|1 - Intravenous or infusion therapy (excludes TPN)|1 - Intravenous or infusion therapy (excludes TPN)|21
74|1 - Less often than daily|1 - Less often than daily|21
75|1 - Less than once a month|1 - Less than once a month|21
76|1 - Less than once weekly|1 - Less than once weekly|21
77|1 - Life expectancy is 6 months or fewer|1 - Life expectancy is 6 months or fewer|21
78|1 - Lives alone|1 - Lives alone|21
79|1 - Male|1 - Male|21
80|1 - Medicare (traditional fee-for-service)|1 - Medicare (traditional fee-for-service)|21
81|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of past 24 hours, significant memory loss so that supervision is required|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of pas|21
82|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors in word choice, grammar or speech intelligibility, needs minimal prompting or assistance).|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors i|21
83|1 - No assistance or services received|1 - No assistance or services received|21
84|1 - One|1 - One|21
85|1 - Oxygen (intermittent or continuous)|1 - Oxygen (intermittent or continuous)|21
86|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, and the surrounding layout, can count fingers at arm's length.|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, a|21
87|1 - Patient is incontinent|1 - Patient is incontinent|21
88|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|21
89|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical or treatment regimen.|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical|21
90|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient/couple/significant other)|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient|21
91|1 - Relatives, friends, or neighbors living outside the home|1 - Relatives, friends, or neighbors living outside the home|21
92|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions.|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions|21
93|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independentl|21
94|1 - Several times during day and night|1 - Several times during day and night|21
95|1 - Spouse or significant other|1 - Spouse or significant other|21
96|1 - Stage 1|1 - Stage 1|21
97|1 - Start of care - further visits planned|1 - Start of care - further visits planned|21
98|1 - Symptoms well controlled with current therapy|1 - Symptoms well controlled with current therapy|21
99|1 - Therapy services|1 - Therapy services|21
100|1 - Able to transfer with minimal human assistance or with use of an assistive device.|1 - Able to transfer with minimal human assistance or with use of an assistive device.|21
101|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitations.|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitatio|21
102|1 - Urinary incontinence|1 - Urinary incontinence|21
103|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and transfer.|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and|21
104|1 - When walking more than 20 feet, climbing stairs|1 - When walking more than 20 feet, climbing stairs|21
105|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary conversation. May need occasional repetition, extra time, or louder voice.|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary c|21
106|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting in and out of tub/shower|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting|21
107|1 - Yes|1 - Yes|21
108|1-RN|1-RN|21
109|10 - Discharge from agency - no visits completed after start/resumption of care assessment|10 - Discharge from agency - no visits completed after start/resumption of care assessment|21
110|10 - Scheduled surgical procedure|10 - Scheduled surgical procedure|21
111|10 - Self-pay|10 - Self-pay|21
112|11 - Other|11 - Other|21
113|11 - Urinary tract infection|11 - Urinary tract infection|21
114|12 - IV catheter-related infection|12 - IV catheter-related infection|21
115|13 - Deep vein thrombosis, pulmonary embolus|13 - Deep vein thrombosis, pulmonary embolus|21
116|14 - Uncontrolled pain|14 - Uncontrolled pain|21
117|15 - Psychotic episode|15 - Psychotic episode|21
118|16 - Other than above reasons|16 - Other than above reasons|21
119|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing calls.|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing|21
120|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another person.|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another pers|21
121|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface a|21
122|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for intermittent supervision or encouragement or reminders, OR (b) to get in and out of the shower or tub, OR (c) for washing difficult to reach areas.|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for inter|21
123|2 - Asian|2 - Asian|21
124|2 - Caregiver requires considerable assistance from another person to manage equipment, but independently completes significant portions of task.|2 - Caregiver requires considerable assistance from another person to manage equipment, but independ|21
125|2 - Daily, but not constantly|2 - Daily, but not constantly|21
126|2 - Daughter or son|2 - Daughter or son|21
127|2 - Doctor's office emergency visit/house call|2 - Doctor's office emergency visit/house call|21
128|2 - During the day and night|2 - During the day and night|21
129|2 - Early/partial granulation|2 - Early/partial granulation|21
130|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors in word choice, organization or speech intelligibility). Speaks in phrases or short sentences.|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors|21
131|2 - Family member's residence|2 - Family member's residence|21
132|2 - Female|2 - Female|21
133|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conversation, needs frequent prompting or assistance.|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conver|21
134|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|21
135|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|21
136|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately stop activities, jeopardizes safety through actions|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately st|21
137|2 - Indwelling/suprapubic catheter|2 - Indwelling/suprapubic catheter|21
138|2 - Injury caused by fall or accident at home|2 - Injury caused by fall or accident at home|21
139|2 - Medicare (HMO/managed care/Advantage plan)|2 - Medicare (HMO/managed care/Advantage plan)|21
140|2 - Nausea, dehydration, malnutrition, constipation, impaction|2 - Nausea, dehydration, malnutrition, constipation, impaction|21
141|2 - Obesity|2 - Obesity|21
142|2 - On awakening or at night only|2 - On awakening or at night only|21
143|2 - Once a month|2 - Once a month|21
144|2 - One to three times weekly|2 - One to three times weekly|21
145|2 - Parenteral nutrition (TPN or lipids)|2 - Parenteral nutrition (TPN or lipids)|21
146|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic)  [ Go to M1620 ]|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic)  [ Go|21
147|2 - Patient requires considerable assistance from another person to manage equipment, but independently completes portions of the task.|2 - Patient requires considerable assistance from another person to manage equipment, but independen|21
148|2 - Patient transferred to a noninstitutional hospice|2 - Patient transferred to a noninstitutional hospice|21
149|2 - Person residing in the home (EXCLUDING paid help)|2 - Person residing in the home (EXCLUDING paid help)|21
150|2 - Rehabilitation facility|2 - Rehabilitation facility|21
151|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifting of attention) or consistently requires low stimulus environment due to distractibility.|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifti|21
152|2 - Respite care|2 - Respite care|21
153|2 - Sense of failure or self reproach|2 - Sense of failure or self reproach|21
154|2 - Several times during day|2 - Several times during day|21
155|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonresponsive.|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonrespons|21
156|2 - Someone must assist the patient to groom self.|2 - Someone must assist the patient to groom self.|21
157|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|21
158|2 - Someone must help the patient put on upper body clothing.|2 - Someone must help the patient put on upper body clothing.|21
159|2 - Stage 2|2 - Stage 2|21
160|2 - Start of care - no further visits planned|2 - Start of care - no further visits planned|21
161|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitoring|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitori|21
162|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment regimen.|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment re|21
163|2 - Two|2 - Two|21
164|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistance due to cognitive or mental limitation.|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistanc|21
165|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|21
166|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assistance).|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assis|21
167|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home delivery.|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home deli|21
168|2 - Unable to prepare any light meals or reheat any delivered meals.|2 - Unable to prepare any light meals or reheat any delivered meals.|21
169|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|21
170|2 - UNABLE to take injectable medications unless administered by someone else.|2 - UNABLE to take injectable medications unless administered by someone else.|21
171|2 - UNABLE to take medication unless administered by someone else.|2 - UNABLE to take medication unless administered by someone else.|21
172|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|21
173|2 - Ventilator (continually or at night)|2 - Ventilator (continually or at night)|21
174|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less than 20 feet)|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less th|21
175|2 - With spouse or significant other|2 - With spouse or significant other|21
176|2 - Yes, assistance or services provided by family or friends|2 - Yes, assistance or services provided by family or friends|21
177|2-PT|2-PT|21
178|3 - Able to answer the telephone only some of the time or is able to carry on only a limited conversation.|3 - Able to answer the telephone only some of the time or is able to carry on only a limited convers|21
179|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube or gastrostomy.|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube|21
180|3 - Alcohol dependency|3 - Alcohol dependency|21
181|3 - All of the time|3 - All of the time|21
182|3 - Black or African-American|3 - Black or African-American|21
183|3 - Boarding home or rented room|3 - Boarding home or rented room|21
184|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment, clean/store/dispose of equipment or supplies).|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment,|21
185|3 -Able to walk only with the supervision or assistance of another person at all times.|3 -Able to walk only with the supervision or assistance of another person at all times.|21
186|3 - Continuous / Bi-level positive airway pressure|3 - Continuous / Bi-level positive airway pressure|21
187|3 - During the day and evening, but not constantly|3 - During the day and evening, but not constantly|21
188|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the alimentary canal)|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the|21
189|3 - Environmental support (e.g., housing, home maintenance)|3 - Environmental support (e.g., housing, home maintenance)|21
190|3 - Four to six times weekly|3 - Four to six times weekly|21
191|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessing by listener.  Speech limited to single words or short phrases.|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessin|21
192|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires multiple repetitions, restatements, demonstrations, additional time.|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires m|21
193|3 - Hopelessness|3 - Hopelessness|21
194|3 - Hospice care|3 - Hospice care|21
195|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|21
196|3 - Injury caused by fall or accident at home|3 - Injury caused by fall or accident at home|21
197|3 - Intractable pain|3 - Intractable pain|21
198|3 - Medicaid (traditional fee-for-service)|3 - Medicaid (traditional fee-for-service)|21
199|3 - Needs someone to do all shopping and errands.|3 - Needs someone to do all shopping and errands.|21
200|3 - Not healing|3 - Not healing|21
201|3 - Nursing home|3 - Nursing home|21
202|3 - Once daily|3 - Once daily|21
203|3 - Other family member|3 - Other family member|21
204|3 - Outpatient department/clinic emergency (includes urgicenter sites)|3 - Outpatient department/clinic emergency (includes urgicenter sites)|21
205|3 - Paid help|3 - Paid help|21
206|3 - Able to participate in bathing self in shower or tub, but requires presence of another person throughout the bath for assistance or supervision.|3 - Able to participate in bathing self in shower or tub, but requires presence of another person th|21
207|3 - Patient depends entirely upon another person to dress lower body.|3 - Patient depends entirely upon another person to dress lower body.|21
208|3 - Patient depends entirely upon another person to dress the upper body.|3 - Patient depends entirely upon another person to dress the upper body.|21
209|3 - Patient depends entirely upon someone else for grooming needs.|3 - Patient depends entirely upon someone else for grooming needs.|21
210|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone else to manage the equipment.|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone|21
211|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable to shift attention and recall directions more than half the time.|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable|21
212|3 - Respiratory problems (SOB, infection, obstruction)|3 - Respiratory problems (SOB, infection, obstruction)|21
213|3 - Resumption of care (after inpatient stay)|3 - Resumption of care (after inpatient stay)|21
214|3 - Several times each month|3 - Several times each month|21
215|3 - Skilled Nursing Facility|3 - Skilled Nursing Facility|21
216|3 - Stage 3|3 - Stage 3|21
217|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|21
218|3 - Three|3 - Three|21
219|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person throughout the process.|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person through|21
220|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal independently.|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal indep|21
221|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person.|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person|21
222|3 - Unknown because patient moved to a geographic location not served by this agency|3 - Unknown because patient moved to a geographic location not served by this agency|21
223|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|21
224|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|21
225|3 - With other family member|3 - With other family member|21
226|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home health services, homemaker assistance, transportation assistance, assisted living, board and care)|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home h|21
227|3-SLP/ST|3-SLP/ST|21
228|4 - At rest (during day or night)|4 - At rest (during day or night)|21
229|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|21
230|4 - Board and care or assisted living facility|4 - Board and care or assisted living facility|21
231|4 - Caregiver is completely dependent on someone else to manage all equipment.|4 - Caregiver is completely dependent on someone else to manage all equipment.|21
232|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|21
233|4 - Constantly|4 - Constantly|21
234|4 - Drug dependency|4 - Drug dependency|21
235|4 - Four or more|4 - Four or more|21
236|4 - Friend or neighbor or community or church member|4 - Friend or neighbor or community or church member|21
237|4 - Hispanic or Latino|4 - Hispanic or Latino|21
238|4 - Hospice|4 - Hospice|21
239|4 - Impaired decision-making|4 - Impaired decision-making|21
240|4 - Is totally dependent in toileting.|4 - Is totally dependent in toileting.|21
241|4 - Medicaid (HMO/managed care)|4 - Medicaid (HMO/managed care)|21
242|4 - None of the above|4 - None of the above|21
243|4 - Nursing home|4 - Nursing home|21
244|4 - On a daily basis|4 - On a daily basis|21
245|4 - Patient is completely dependent on someone else to manage all equipment.|4 - Patient is completely dependent on someone else to manage all equipment.|21
246|4 - Permanent placement|4 - Permanent placement|21
247|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, punches, dangerous maneuvers w/ wheelchair or other objects)|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, pu|21
248|4 - Psychosocial support (e.g., socialization, companionship, recreation)|4 - Psychosocial support (e.g., socialization, companionship, recreation)|21
249|4 - Recertification (follow-up) reassessment|4 - Recertification (follow-up) reassessment|21
250|4 - Recurrent thoughts of death|4 - Recurrent thoughts of death|21
251|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruction)|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruc|21
252|4 - Several times a week|4 - Several times a week|21
253|4 - Stage 4|4 - Stage 4|21
254|4 - Symptoms poorly controlled, history of re-hospitalizations|4 - Symptoms poorly controlled, history of re-hospitalizations|21
255|4 - Three or more times per week|4 - Three or more times per week|21
256|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetative state, or delirium.|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetati|21
257|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|21
258|4 - Unable to effectively participate in any housekeeping tasks.|4 - Unable to effectively participate in any housekeeping tasks.|21
259|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or unresponsive (e.g., speech is nonsensical or unintelligible).|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or u|21
260|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonresponsive.|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonr|21
261|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostomy.|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostom|21
262|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of devices at the sink, in chair, or on commode|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of|21
263|4 - With a friend|4 - With a friend|21
264|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|21
265|4-OT|4-OT|21
266|5 - Advocates or facilitates patient's participation in appropriate medical care|5 - Advocates or facilitates patient's participation in appropriate medical care|21
267|5 - At least daily|5 - At least daily|21
268|6 - Bedfast, unable to ambulate or be up in a chair.|6 - Bedfast, unable to ambulate or be up in a chair.|21
269|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|21
270|5 - Disruptive or socially inappropriate behavior|5 - Disruptive or socially inappropriate behavior|21
271|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|21
272|5 - Hypo/Hyperglycemia, diabetes out of control|5 - Hypo/Hyperglycemia, diabetes out of control|21
273|5 - More often than once daily|5 - More often than once daily|21
274|5 - Native Hawaiian or Pacific Islander|5 - Native Hawaiian or Pacific Islander|21
275|5 - None of the above|5 - None of the above|21
276|5 - One to two times per week|5 - One to two times per week|21
277|5 - Other|5 - Other|21
278|5 - Other follow-up|5 - Other follow-up|21
279|5 - Paid help|5 - Paid help|21
280|5 - Patient nonresponsive or unable to speak.|5 - Patient nonresponsive or unable to speak.|21
281|5 - Thoughts of suicide|5 - Thoughts of suicide|21
282|5 - Totally unable to use the telephone.|5 - Totally unable to use the telephone.|21
283|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|21
284|5 - Unable to take in nutrients orally or by tube feeding.|5 - Unable to take in nutrients orally or by tube feeding.|21
285|5 - Unsafe for care at home|5 - Unsafe for care at home|21
286|5 - With paid help (other than home care agency staff)|5 - With paid help (other than home care agency staff)|21
287|5 - Workers' compensation|5 - Workers' compensation|21
288|5 - Wound infection, deteriorating wound status, new lesion/ulcer|5 - Wound infection, deteriorating wound status, new lesion/ulcer|21
289|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|21
290|6 - Delusional, hallucinatory, or paranoid behavior|6 - Delusional, hallucinatory, or paranoid behavior|21
291|6 - Financial agent, power of attorney, or conservator of finance|6 - Financial agent, power of attorney, or conservator of finance|21
292|6 - GI bleeding, obstruction|6 - GI bleeding, obstruction|21
293|6 - Less often than weekly|6 - Less often than weekly|21
294|6 - Memory loss to the extent that supervision required|6 - Memory loss to the extent that supervision required|21
295|6 - None of the above feelings observed or reported|6 - None of the above feelings observed or reported|21
296|6 - Other|6 - Other|21
297|6 - Title programs (e.g., Title III, V, or XX)|6 - Title programs (e.g., Title III, V, or XX)|21
298|6 - Transferred to an inpatient facility - patient not discharged from agency|6 - Transferred to an inpatient facility - patient not discharged from agency|21
299|6 - White|6 - White|21
300|6 - With other than above|6 - With other than above|21
301|7 - Exacerbation of CHF, fluid overload, heart failure|7 - Exacerbation of CHF, fluid overload, heart failure|21
302|7 - Health care agent, conservator of person, or medical power of attorney|7 - Health care agent, conservator of person, or medical power of attorney|21
303|7 - Hypo/Hyperglycemia, diabetes out of control|7 - Hypo/Hyperglycemia, diabetes out of control|21
304|7 - None of the above|7 - None of the above|21
305|7 - None of the above behaviors demonstrated|7 - None of the above behaviors demonstrated|21
306|7 - Other government (e.g., TriCare, VA, etc.)|7 - Other government (e.g., TriCare, VA, etc.)|21
307|7 - Transferred to an inpatient facility - patient discharged from agency|7 - Transferred to an inpatient facility - patient discharged from agency|21
308|8 - Death at home|8 - Death at home|21
309|8 - GI bleeding, obstruction|8 - GI bleeding, obstruction|21
310|8 - Myocardial infarction, stroke|8 - Myocardial infarction, stroke|21
311|8 - Private insurance|8 - Private insurance|21
312|9 - Chemotherapy|9 - Chemotherapy|21
313|9 - Discharge from agency|9 - Discharge from agency|21
314|9 - Other than above reasons|9 - Other than above reasons|21
315|9 - Private HMO/managed care|9 - Private HMO/managed care|21
316|NA - No caregiver|NA - No caregiver|21
317|NA - No equipment of this type used in care.|NA - No equipment of this type used in care.|21
318|NA - No inhalant/mist medications prescribed.|NA - No inhalant/mist medications prescribed.|21
319|NA - No injectable medications prescribed.|NA - No injectable medications prescribed.|21
320|NA - No inpatient facility admission|NA - No inpatient facility admission|21
321|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|21
322|NA - No Medicaid|NA - No Medicaid|21
323|NA - No Medicare|NA - No Medicare|21
324|NA - No observable pressure ulcer|NA - No observable pressure ulcer|21
325|NA - No observable stasis ulcer|NA - No observable stasis ulcer|21
326|NA - No observable surgical wound|NA - No observable surgical wound|21
327|NA - No oral medications prescribed.|NA - No oral medications prescribed.|21
328|NA - Not applicable|NA - Not applicable|21
329|NA - Patient does not have a telephone.|NA - Patient does not have a telephone.|21
330|NA - Patient has ostomy for bowel elimination|NA - Patient has ostomy for bowel elimination|21
331|NA - Patient nonresponsive|NA - Patient nonresponsive|21
332|NA - Patient on prophylactic treatment|NA - Patient on prophylactic treatment|21
333|NA - Patient was not discharged from an inpatient facility [Go to M1016 ]|NA - Patient was not discharged from an inpatient facility [Go to M1016 ]|21
334|UK - Other unknown|UK - Other unknown|21
335|UK - Reason unknown|UK - Reason unknown|21
336|UK - Unknown|UK - Unknown|21
337|UK - Unknown or Not Available|UK - Unknown or Not Available|21
341|01 - Early|01 - Early|21
342|02 - Late|02 - Late|21
343|NA - Not Applicable. No case mix group defined for this assessment.|NA - Not Applicable. No case mix group defined for this assessment.|21
344|NA - No case mix group defined by this assessment.|NA - No case mix group defined by this assessment.|21
345|1 - Recent decline in mental, emotional, or behavioral status|1 - Recent decline in mental, emotional, or behavioral status|21
346|2 - Multiple hospitalizations (2 or more) in the past 12 months|2 - Multiple hospitalizations (2 or more) in the past 12 months|21
347|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|21
348|4 - Taking five or more medications|4 - Taking five or more medications|21
349|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|21
350|6 - Other|6 - Other|21
351|7 - None of the above|7 - None of the above|21
352|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond tho|21
353|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable without heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable wi|21
354|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious complications and death.|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious compl|21
355|3 - The patient has serious progressive conditions that could lead to death within a year.|3 - The patient has serious progressive conditions that could lead to death within a year.|21
356|UK - The patient+s situation is unknown or unclear.|UK - The patient+s situation is unknown or unclear.|21
357|1 - Yes [ Go to M1050 ]|1 - Yes [ Go to M1050 ]|21
358|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this influenza season. [ Go to M1050 ]|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this i|21
359|1 - Received from another health care provider (e.g., physician)|1 - Received from another health care provider (e.g., physician)|21
360|2 - Received from your agency previously during this year+s flu season|2 - Received from your agency previously during this year+s flu season|21
361|3 - Offered and declined|3 - Offered and declined|21
362|4 - Assessed and determined to have medical contraindication(s)|4 - Assessed and determined to have medical contraindication(s)|21
363|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|21
364|6 - Inability to obtain vaccine due to declared shortage|6 - Inability to obtain vaccine due to declared shortage|21
365|1 - Yes [ Go to M1500 at TRN; Go to M1230 at DC ]|1 - Yes [ Go to M1500 at TRN; Go to M1230 at DC ]|21
366|1 - Patient has received PPV in the past|1 - Patient has received PPV in the past|21
367|2 - Offered and declined|2 - Offered and declined|21
368|3 - Assessed and determined to have medical contraindication(s)|3 - Assessed and determined to have medical contraindication(s)|21
369|4 - Not indicated; patient does not meet age/condition guidelines for PPV|4 - Not indicated; patient does not meet age/condition guidelines for PPV|21
370|5 - None of the above|5 - None of the above|21
371|0 - Adequate: hears normal conversation without difficulty.|0 - Adequate: hears normal conversation without difficulty.|21
372|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to increase volume or speak distinctly.|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to in|21
373|2 - Severely Impaired: absence of useful hearing.|2 - Severely Impaired: absence of useful hearing.|21
374|UK - Unable to assess hearing.|UK - Unable to assess hearing.|21
375|0 - Understands: clear comprehension without cues or repetitions.|0 - Understands: clear comprehension without cues or repetitions.|21
376|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Requires cues at times to understand.|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Req|21
377|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequently requires cues to understand.|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequentl|21
378|3 - Rarely/Never Understands|3 - Rarely/Never Understands|21
379|UK - Unable to assess understanding.|UK - Unable to assess understanding.|21
380|0 - No standardized assessment conducted|0 - No standardized assessment conducted|21
381|1 - Yes, and it does not indicate severe pain|1 - Yes, and it does not indicate severe pain|21
382|2 - Yes, and it indicates severe pain|2 - Yes, and it indicates severe pain|21
383|0 - Patient has no pain|0 - Patient has no pain|21
384|1 - Patient has pain that does not interfere with activity or movement|1 - Patient has pain that does not interfere with activity or movement|21
385|2 - Less often than daily|2 - Less often than daily|21
386|3 - Daily, but not constantly|3 - Daily, but not constantly|21
387|4 - All of the time|4 - All of the time|21
388|0 - No assessment conducted [ Go to M1306 ]|0 - No assessment conducted [ Go to M1306 ]|21
389|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc., without use of standardized tool|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc.,|21
390|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|21
391|0 - No [ Go to M1322]|0 - No [ Go to M1322]|21
392|0 v Newly epithelialized|0 v Newly epithelialized|21
393|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|21
394|2 - Yes, patient has observable stasis ulcers ONLY|2 - Yes, patient has observable stasis ulcers ONLY|21
395|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable dressing) [Go to M1340]|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable|21
396|0 - No [ Go to M1350 ]|0 - No [ Go to M1350 ]|21
397|1 - Yes, patient has at least one (observable) surgical wound|1 - Yes, patient has at least one (observable) surgical wound|21
398|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1350 ]|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1350 ]|21
399|0 - Patient is not short of breath|0 - Patient is not short of breath|21
400|3 - Continuous Bi-level positive airway pressure|3 - Continuous Bi-level positive airway pressure|21
401|0 - No [ Go to M1732 at TRN; Go to M1600 at DC ]|0 - No [ Go to M1732 at TRN; Go to M1600 at DC ]|21
402|2 - Not assessed [Go to M1732 at TRN; Go to M1600 at DC ]|2 - Not assessed [Go to M1732 at TRN; Go to M1600 at DC ]|21
403|NA - Patient does not have diagnosis of heart failure [Go to M2004 at TRN; Go to M1600 at DC]|NA - Patient does not have diagnosis of heart failure [Go to M2004 at TRN; Go to M1600 at DC]|21
404|0 - No action taken|0 - No action taken|21
405|1 - Patient+s physician (or other primary care practitioner) contacted the same day|1 - Patient+s physician (or other primary care practitioner) contacted the same day|21
406|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|21
407|3 - Implement physician-ordered patient-specific established parameters for treatment|3 - Implement physician-ordered patient-specific established parameters for treatment|21
408|4 - Patient education or other clinical interventions|4 - Patient education or other clinical interventions|21
409|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequency, telehealth, etc.)|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequ|21
410|1 - Occasional stress incontinence|1 - Occasional stress incontinence|21
411|2 - During the night only|2 - During the night only|21
412|3 - During the day only|3 - During the day only|21
413|4 - During the day and night|4 - During the day and night|21
414|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|21
415|0 - Able to manage toileting hygiene and clothing management without assistance.|0 - Able to manage toileting hygiene and clothing management without assistance.|21
416|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implements are laid out for the patient.|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implemen|21
417|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|21
418|3 - Patient depends entirely upon another person to maintain toileting hygiene.|3 - Patient depends entirely upon another person to maintain toileting hygiene.|21
419|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independent|21
420|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface|21
421|0 - No multi-factor falls risk assessment conducted.|0 - No multi-factor falls risk assessment conducted.|21
422|1 - Yes, and it does not indicate a risk for falls.|1 - Yes, and it does not indicate a risk for falls.|21
423|2 - Yes, and it indicates a risk for falls.|2 - Yes, and it indicates a risk for falls.|21
424|0 - Not assessed/reviewed [ Go to M2010 ]|0 - Not assessed/reviewed [ Go to M2010 ]|21
425|1 - No problems found during review [ Go to M2010 ]|1 - No problems found during review [ Go to M2010 ]|21
426|2 - Problems found during review|2 - Problems found during review|21
427|NA - Patient is not taking any medications [ Go to M2040 ]|NA - Patient is not taking any medications [ Go to M2040 ]|21
428|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special precautions associated with all high-risk medications|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special p|21
429|NA - Patient not taking any drugs|NA - Patient not taking any drugs|21
430|2 - Able to take medication(s) at the correct times if given reminders by another person at the appropriate times|2 - Able to take medication(s) at the correct times if given reminders by another person at the appr|21
431|3 - Unable to take medication unless administered by another person.|3 - Unable to take medication unless administered by another person.|21
432|1 - At least daily|1 - At least daily|21
433|2 - Three or more times per week|2 - Three or more times per week|21
434|3 - One to two times per week|3 - One to two times per week|21
435|4 - Received, but less often than weekly|4 - Received, but less often than weekly|21
436|5 - No assistance received|5 - No assistance received|21
437|0 - No [Go to M2400]|0 - No [Go to M2400]|21
438|1 - Yes, used hospital emergency department WITHOUT hospital admission|1 - Yes, used hospital emergency department WITHOUT hospital admission|21
439|2 - Yes, used hospital emergency department WITH hospital admission|2 - Yes, used hospital emergency department WITH hospital admission|21
440|UK - Unknown [Go to M2400]|UK - Unknown [Go to M2400]|21
441|2 - Injury caused by fall|2 - Injury caused by fall|21
442|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|21
443|4 - Other respiratory problem|4 - Other respiratory problem|21
444|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|21
445|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|21
446|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|21
447|8 - Other heart disease|8 - Other heart disease|21
448|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|21
449|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|21
450|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|21
451|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|21
452|13 - Urinary tract infection|13 - Urinary tract infection|21
453|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|21
454|15 - Wound infection or deterioration|15 - Wound infection or deterioration|21
455|16 - Uncontrolled pain|16 - Uncontrolled pain|21
456|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|21
457|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|21
458|19 - Other than above reasons|19 - Other than above reasons|21
459|2 - Patient remained in the community (with formal assistive services)|2 - Patient remained in the community (with formal assistive services)|21
460|3 - Patient transferred to a noninstitutional hospice|3 - Patient transferred to a noninstitutional hospice|21
461|4 - Unknown because patient moved to a geographic location not served by this agency|4 - Unknown because patient moved to a geographic location not served by this agency|21
462|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|21
463|4 - Other respiratory problem|4 - Other respiratory problem|21
464|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|21
465|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|21
466|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|21
467|8 - Other heart disease|8 - Other heart disease|21
468|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|21
469|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|21
470|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|21
471|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|21
472|13 - Urinary tract infection|13 - Urinary tract infection|21
473|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|21
474|15 - Wound infection or deterioration|15 - Wound infection or deterioration|21
475|16 - Uncontrolled pain|16 - Uncontrolled pain|21
476|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|21
477|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|21
478|19 - Scheduled treatment or procedure|19 - Scheduled treatment or procedure|21
479|20 - Other than above reasons|20 - Other than above reasons|21
480|UK - Reason unknown [Go to M0903]|UK - Reason unknown [Go to M0903]|21
482|01 - Patient lives alone around the clock|01 - Patient lives alone around the clock|21
483|02 - Patient lives alone regular daytime|02 - Patient lives alone regular daytime|21
484|03 - Patient lives alone regular nighttime|03 - Patient lives alone regular nighttime|21
485|04 - Patient lives alone occassional/short term assistance|04 - Patient lives alone occassional/short term assistance|21
486|05 - Patient lives alone no assisstance available|05 - Patient lives alone no assisstance available|21
487|06 - Patient lives with other person(s) in the home around the clock|06 - Patient lives with other person(s) in the home around the clock|21
488|07 - Patient lives with other person(s) in the home regular daytime|07 - Patient lives with other person(s) in the home regular daytime|21
489|08 - Patient lives with other person(s) in the home regular nighttime|08 - Patient lives with other person(s) in the home regular nighttime|21
490|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|21
491|10 - Patient lives with other person(s) in the home no assistance available|10 - Patient lives with other person(s) in the home no assistance available|21
492|1 - Was present at the most recent SOC/ROC assessment|1 - Was present at the most recent SOC/ROC assessment|21
493|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|21
494|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|21
495|0 - Newly epithelialized|0 - Newly epithelialized|21
496|0 - No [ Go to M1340 ]|0 - No [ Go to M1340 ]|21
498|0 - Independent|0 - Independent|21
499|1 - Needed Some Help|1 - Needed Some Help|21
500|2 - Dependent|2 - Dependent|21
502|0 - No assistance needed in this area|0 - No assistance needed in this area|21
503|1 - Caregiver(s) currently provide assistance|1 - Caregiver(s) currently provide assistance|21
504|2 - Caregiver(s) need training/ supportive services to provide assistance|2 - Caregiver(s) need training/ supportive services to provide assistance|21
505|3 - Caregiver(s) not likely to provide assistance|3 - Caregiver(s) not likely to provide assistance|21
506|4 - Unclear if Caregiver(s) will provide assistance|4 - Unclear if Caregiver(s) will provide assistance|21
507|5 - Assistance needed, but no Caregiver(s) available|5 - Assistance needed, but no Caregiver(s) available|21
508|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will use standardized clinical guidelines accessible for all care providers to reference|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will|21
509|NA - Patient is not diabetic or is bilateral amputee|NA - Patient is not diabetic or is bilateral amputee|21
510|NA - Patient is not assessed to be at risk for falls|NA - Patient is not assessed to be at risk for falls|21
511|NA - Patient has no diagnosis or symptoms of depression|NA - Patient has no diagnosis or symptoms of depression|21
512|NA - No pain identified|NA - No pain identified|21
513|NA - Patient is not assessed to be at risk for pressure ulcers|NA - Patient is not assessed to be at risk for pressure ulcers|21
514|NA - Patient has no pressure ulcers with need for moist wound healing|NA - Patient has no pressure ulcers with need for moist wound healing|21
515|1 - Long-term nursing facility (NF)|1 - Long-term nursing facility (NF)|21
516|2 - Skilled nursing facility (SNF / TCU)|2 - Skilled nursing facility (SNF / TCU)|21
517|3 - Short stay acute hospital (IPP S)|3 - Short stay acute hospital (IPP S)|21
518|4 - Long-term care hospital (LTCH)|4 - Long-term care hospital (LTCH)|21
519|5 - Inpatient rehabilitation hospital or unit (IRF)|5 - Inpatient rehabilitation hospital or unit (IRF)|21
520|6 - Psychiatric hospital or unit|6 - Psychiatric hospital or unit|21
521|7 - Other|7 - Other|21
522|NA - Patient was not discharged from an inpatient facility [Go to M1016]|NA - Patient was not discharged from an inpatient facility [Go to M1016]|21
523|6 - Unable to participate effectively in bathing and is bathed totally by another person|6 - Unable to participate effectively in bathing and is bathed totally by another person|21
524|4 - Chairfast, unable to ambulate but is able to wheel self independently.|4 - Chairfast, unable to ambulate but is able to wheel self independently.|21
525|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask patient: "Over the last two weeks, how often have you been bothered by any of the following problems")  *Copyright+ Pfizer Inc. All rights reserved. Reproduced with permission.|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask|21
526|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluation for depression.|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluat|21
527|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet criteria for further evaluation for depression.|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet|21
528|0 - Not at all  0 - 1 day|0 - Not at all  0 - 1 day|21
529|1 - Several days  2 - 6 days|1 - Several days  2 - 6 days|21
530|2 - More than half of the days  7 - 11 days|2 - More than half of the days  7 - 11 days|21
531|3 - Nearly every day  12 - 14 days|3 - Nearly every day  12 - 14 days|21
532|NA - N/A  Unable to respond|NA - N/A  Unable to respond|21
533|2 - Able to take medication(s) at the correct times if given reminders by another person based on the frequency of the injection|2 - Able to take medication(s) at the correct times if given reminders by another person based on th|21
534|3 - Unable to take injectable medication unless administered by another person.|3 - Unable to take injectable medication unless administered by another person.|21
535|11 - Patient lives in congregate situation (e.g., assisted living) around the clock|11 - Patient lives in congregate situation (e.g., assisted living) around the clock|21
536|12 - Patient lives in congregate situation (e.g., assisted living) regular daytime|12 - Patient lives in congregate situation (e.g., assisted living) regular daytime|21
537|13 - Patient lives in congregate situation (e.g., assisted living) regular nighttime|13 - Patient lives in congregate situation (e.g., assisted living) regular nighttime|21
538|14 - Patient lives in congregate situation (e.g., assisted living) occasional / short-term assistance|14 - Patient lives in congregate situation (e.g., assisted living) occasional / short-term assistanc|21
539|15 - Patient lives in congregate situation (e.g., assisted living) no assistance available|15 - Patient lives in congregate situation (e.g., assisted living) no assistance available|21
545|NA - No observable pressure ulcer or unhealed pressure ulcer|NA - No observable pressure ulcer or unhealed pressure ulcer|21
582|NA - No specific SOC date ordered by physician|NA - No specific SOC date ordered by physician|21
585|UK - Inpatient Discharge Date Unknown|UK - Inpatient Discharge Date Unknown|21
2|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; OR (b) Is physically, cognitively, and mentally able to prepare light meals on a regular basis but has not routinely performed light meal preparation in the past (i.e., prior to this home care admission).|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; O|23
3|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and mentally able to perform all housekeeping tasks .|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and menta|23
4|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and mentally able to do laundry and access facilities.|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and menta|23
5|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying packages OR b) Physically, cognitively, and mentally able to take care of shopping, but has not done shopping in the past (i.e., prior to this home care admission).|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying|23
6|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|23
7|0 - Able to dial numbers and answer calls appropriately and as desired.|0 - Able to dial numbers and answer calls appropriately and as desired.|23
8|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body without assistance.|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body|23
9|0 - Able to get to and from the toilet and transfer independently with or without a device.|0 - Able to get to and from the toilet and transfer independently with or without a device.|23
10|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|23
11|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible public bus.|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible p|23
12|0 - Able to independently feed self.|0 - Able to independently feed self.|23
13|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|23
14|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct times.|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct ti|23
15|0 - Able to independently transfer.|0 - Able to independently transfer.|23
16|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without rail|23
17|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings|23
18|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|23
19|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions independently.|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions indep|23
20|0 - Asymptomatic, no treatment needed at this time|0 - Asymptomatic, no treatment needed at this time|23
21|0 - Caregiver manages all tasks related to equipment completely independently.|0 - Caregiver manages all tasks related to equipment completely independently.|23
22|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations with no observable impairment.|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations w|23
23|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|23
24|0 - Life expectancy is greater than 6 months|0 - Life expectancy is greater than 6 months|23
25|0 - Never|0 - Never|23
26|0 - Patient is not short of breath|0 - Patient is not short of breath|23
27|0 - No|0 - No|23
28|0 - No emergent care services|0 - No emergent care services|23
29|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [ Go to M1620 ]|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [ Go to M1620 ]|23
30|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and extended or abstract conversation.|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and exte|23
31|0 - No one person|0 - No one person|23
32|0 - None of the time|0 - None of the time|23
33|0 - None, no charge for current services|0 - None, no charge for current services|23
34|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|23
35|0 - Patient does NOT have an ostomy for bowel elimination.|0 - Patient does NOT have an ostomy for bowel elimination.|23
36|0 - Patient has no pain|0 - Patient has no pain|23
37|0 - Patient manages all tasks related to equipment completely independently.|0 - Patient manages all tasks related to equipment completely independently.|23
38|0 - Poor:  little or no recovery is expected and/or further decline is imminent|0 - Poor:  little or no recovery is expected and/or further decline is imminent|23
39|0 - Timed-voiding defers incontinence|0 - Timed-voiding defers incontinence|23
40|0 - Very rarely or never has bowel incontinence|0 - Very rarely or never has bowel incontinence|23
41|0 - Zero|0 - Zero|23
42|00 - No|00 - No|23
43|01 - Yes|01 - Yes|23
44|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or mental limitations, needs assistance with heavy laundry.|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or|23
45|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the patient.|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the|23
46|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|23
47|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or supervision from another person OR c) a liquid, pureed or ground meat diet.|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or su|23
48|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|23
49|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|23
50|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independently.|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independe|23
51|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only when assisted or accompanied by another person.|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only w|23
52|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepa|23
53|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance by another person OR b) given daily reminders.|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance b|23
54|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advan|23
55|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advan|23
56|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for the deaf) and call essential numbers.|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for t|23
57|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|23
58|1 - American Indian or Alaska Native|1 - American Indian or Alaska Native|23
59|1 - Depressed mood (e.g., feeling sad, tearful)|1 - Depressed mood (e.g., feeling sad, tearful)|23
60|1 - During the night only|1 - During the night only|23
61|1 - Fully granulating|1 - Fully granulating|23
62|1 - Good/Fair:  partial to full recovery is expected|1 - Good/Fair:  partial to full recovery is expected|23
63|1 - Good:  marked improvement in functional status is expected|1 - Good:  marked improvement in functional status is expected|23
64|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|23
65|1 - Smoking|1 - Smoking|23
66|1 - Hospital|1 - Hospital|23
67|1 - Hospital emergency room (includes 23-hour holding)|1 - Hospital emergency room (includes 23-hour holding)|23
68|1 - Hospitalization for EMERGENT (unscheduled) care|1 - Hospitalization for EMERGENT (unscheduled) care|23
69|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepared solutions), patient is able to manage all other aspects of equipment.|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepar|23
70|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|23
71|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|23
72|1 - In new or complex situations only|1 - In new or complex situations only|23
73|1 - Intravenous or infusion therapy (excludes TPN)|1 - Intravenous or infusion therapy (excludes TPN)|23
74|1 - Less often than daily|1 - Less often than daily|23
75|1 - Less than once a month|1 - Less than once a month|23
76|1 - Less than once weekly|1 - Less than once weekly|23
77|1 - Life expectancy is 6 months or fewer|1 - Life expectancy is 6 months or fewer|23
78|1 - Lives alone|1 - Lives alone|23
79|1 - Male|1 - Male|23
80|1 - Medicare (traditional fee-for-service)|1 - Medicare (traditional fee-for-service)|23
81|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of past 24 hours, significant memory loss so that supervision is required|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of pas|23
82|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors in word choice, grammar or speech intelligibility, needs minimal prompting or assistance).|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors i|23
83|1 - No assistance or services received|1 - No assistance or services received|23
84|1 - One|1 - One|23
85|1 - Oxygen (intermittent or continuous)|1 - Oxygen (intermittent or continuous)|23
86|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, and the surrounding layout, can count fingers at arm's length.|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, a|23
87|1 - Patient is incontinent|1 - Patient is incontinent|23
88|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|23
89|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical or treatment regimen.|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical|23
90|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient/couple/significant other)|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient|23
91|1 - Relatives, friends, or neighbors living outside the home|1 - Relatives, friends, or neighbors living outside the home|23
92|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions.|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions|23
93|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independentl|23
94|1 - Several times during day and night|1 - Several times during day and night|23
95|1 - Spouse or significant other|1 - Spouse or significant other|23
96|1 - Stage 1|1 - Stage 1|23
97|1 - Start of care - further visits planned|1 - Start of care - further visits planned|23
98|1 - Symptoms well controlled with current therapy|1 - Symptoms well controlled with current therapy|23
99|1 - Therapy services|1 - Therapy services|23
100|1 - Able to transfer with minimal human assistance or with use of an assistive device.|1 - Able to transfer with minimal human assistance or with use of an assistive device.|23
101|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitations.|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitatio|23
102|1 - Urinary incontinence|1 - Urinary incontinence|23
103|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and transfer.|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and|23
104|1 - When walking more than 20 feet, climbing stairs|1 - When walking more than 20 feet, climbing stairs|23
105|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary conversation. May need occasional repetition, extra time, or louder voice.|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary c|23
106|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting in and out of tub/shower|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting|23
107|1 - Yes|1 - Yes|23
108|1-RN|1-RN|23
109|10 - Discharge from agency - no visits completed after start/resumption of care assessment|10 - Discharge from agency - no visits completed after start/resumption of care assessment|23
110|10 - Scheduled surgical procedure|10 - Scheduled surgical procedure|23
111|10 - Self-pay|10 - Self-pay|23
112|11 - Other|11 - Other|23
113|11 - Urinary tract infection|11 - Urinary tract infection|23
114|12 - IV catheter-related infection|12 - IV catheter-related infection|23
115|13 - Deep vein thrombosis, pulmonary embolus|13 - Deep vein thrombosis, pulmonary embolus|23
116|14 - Uncontrolled pain|14 - Uncontrolled pain|23
117|15 - Psychotic episode|15 - Psychotic episode|23
118|16 - Other than above reasons|16 - Other than above reasons|23
119|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing calls.|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing|23
120|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another person.|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another pers|23
121|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface a|23
122|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for intermittent supervision or encouragement or reminders, OR (b) to get in and out of the shower or tub, OR (c) for washing difficult to reach areas.|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for inter|23
123|2 - Asian|2 - Asian|23
124|2 - Caregiver requires considerable assistance from another person to manage equipment, but independently completes significant portions of task.|2 - Caregiver requires considerable assistance from another person to manage equipment, but independ|23
125|2 - Daily, but not constantly|2 - Daily, but not constantly|23
126|2 - Daughter or son|2 - Daughter or son|23
127|2 - Doctor's office emergency visit/house call|2 - Doctor's office emergency visit/house call|23
128|2 - During the day and night|2 - During the day and night|23
129|2 - Early/partial granulation|2 - Early/partial granulation|23
130|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors in word choice, organization or speech intelligibility). Speaks in phrases or short sentences.|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors|23
131|2 - Family member's residence|2 - Family member's residence|23
132|2 - Female|2 - Female|23
133|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conversation, needs frequent prompting or assistance.|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conver|23
134|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|23
135|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|23
136|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately stop activities, jeopardizes safety through actions|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately st|23
137|2 - Indwelling/suprapubic catheter|2 - Indwelling/suprapubic catheter|23
138|2 - Injury caused by fall or accident at home|2 - Injury caused by fall or accident at home|23
139|2 - Medicare (HMO/managed care/Advantage plan)|2 - Medicare (HMO/managed care/Advantage plan)|23
140|2 - Nausea, dehydration, malnutrition, constipation, impaction|2 - Nausea, dehydration, malnutrition, constipation, impaction|23
141|2 - Obesity|2 - Obesity|23
142|2 - On awakening or at night only|2 - On awakening or at night only|23
143|2 - Once a month|2 - Once a month|23
144|2 - One to three times weekly|2 - One to three times weekly|23
145|2 - Parenteral nutrition (TPN or lipids)|2 - Parenteral nutrition (TPN or lipids)|23
146|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic)  [ Go to M1620 ]|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic)  [ Go|23
147|2 - Patient requires considerable assistance from another person to manage equipment, but independently completes portions of the task.|2 - Patient requires considerable assistance from another person to manage equipment, but independen|23
148|2 - Patient transferred to a noninstitutional hospice|2 - Patient transferred to a noninstitutional hospice|23
149|2 - Person residing in the home (EXCLUDING paid help)|2 - Person residing in the home (EXCLUDING paid help)|23
150|2 - Rehabilitation facility|2 - Rehabilitation facility|23
151|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifting of attention) or consistently requires low stimulus environment due to distractibility.|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifti|23
152|2 - Respite care|2 - Respite care|23
153|2 - Sense of failure or self reproach|2 - Sense of failure or self reproach|23
154|2 - Several times during day|2 - Several times during day|23
155|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonresponsive.|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonrespons|23
156|2 - Someone must assist the patient to groom self.|2 - Someone must assist the patient to groom self.|23
157|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|23
158|2 - Someone must help the patient put on upper body clothing.|2 - Someone must help the patient put on upper body clothing.|23
159|2 - Stage 2|2 - Stage 2|23
160|2 - Start of care - no further visits planned|2 - Start of care - no further visits planned|23
161|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitoring|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitori|23
162|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment regimen.|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment re|23
163|2 - Two|2 - Two|23
164|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistance due to cognitive or mental limitation.|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistanc|23
165|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|23
166|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assistance).|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assis|23
167|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home delivery.|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home deli|23
168|2 - Unable to prepare any light meals or reheat any delivered meals.|2 - Unable to prepare any light meals or reheat any delivered meals.|23
169|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|23
170|2 - UNABLE to take injectable medications unless administered by someone else.|2 - UNABLE to take injectable medications unless administered by someone else.|23
171|2 - UNABLE to take medication unless administered by someone else.|2 - UNABLE to take medication unless administered by someone else.|23
172|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|23
173|2 - Ventilator (continually or at night)|2 - Ventilator (continually or at night)|23
174|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less than 20 feet)|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less th|23
175|2 - With spouse or significant other|2 - With spouse or significant other|23
176|2 - Yes, assistance or services provided by family or friends|2 - Yes, assistance or services provided by family or friends|23
177|2-PT|2-PT|23
178|3 - Able to answer the telephone only some of the time or is able to carry on only a limited conversation.|3 - Able to answer the telephone only some of the time or is able to carry on only a limited convers|23
179|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube or gastrostomy.|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube|23
180|3 - Alcohol dependency|3 - Alcohol dependency|23
181|3 - All of the time|3 - All of the time|23
182|3 - Black or African-American|3 - Black or African-American|23
183|3 - Boarding home or rented room|3 - Boarding home or rented room|23
184|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment, clean/store/dispose of equipment or supplies).|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment,|23
185|3 -Able to walk only with the supervision or assistance of another person at all times.|3 -Able to walk only with the supervision or assistance of another person at all times.|23
186|3 - Continuous / Bi-level positive airway pressure|3 - Continuous / Bi-level positive airway pressure|23
187|3 - During the day and evening, but not constantly|3 - During the day and evening, but not constantly|23
188|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the alimentary canal)|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the|23
189|3 - Environmental support (e.g., housing, home maintenance)|3 - Environmental support (e.g., housing, home maintenance)|23
190|3 - Four to six times weekly|3 - Four to six times weekly|23
191|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessing by listener.  Speech limited to single words or short phrases.|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessin|23
192|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires multiple repetitions, restatements, demonstrations, additional time.|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires m|23
193|3 - Hopelessness|3 - Hopelessness|23
194|3 - Hospice care|3 - Hospice care|23
195|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|23
196|3 - Injury caused by fall or accident at home|3 - Injury caused by fall or accident at home|23
197|3 - Intractable pain|3 - Intractable pain|23
198|3 - Medicaid (traditional fee-for-service)|3 - Medicaid (traditional fee-for-service)|23
199|3 - Needs someone to do all shopping and errands.|3 - Needs someone to do all shopping and errands.|23
200|3 - Not healing|3 - Not healing|23
201|3 - Nursing home|3 - Nursing home|23
202|3 - Once daily|3 - Once daily|23
203|3 - Other family member|3 - Other family member|23
204|3 - Outpatient department/clinic emergency (includes urgicenter sites)|3 - Outpatient department/clinic emergency (includes urgicenter sites)|23
205|3 - Paid help|3 - Paid help|23
206|3 - Able to participate in bathing self in shower or tub, but requires presence of another person throughout the bath for assistance or supervision.|3 - Able to participate in bathing self in shower or tub, but requires presence of another person th|23
207|3 - Patient depends entirely upon another person to dress lower body.|3 - Patient depends entirely upon another person to dress lower body.|23
208|3 - Patient depends entirely upon another person to dress the upper body.|3 - Patient depends entirely upon another person to dress the upper body.|23
209|3 - Patient depends entirely upon someone else for grooming needs.|3 - Patient depends entirely upon someone else for grooming needs.|23
210|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone else to manage the equipment.|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone|23
211|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable to shift attention and recall directions more than half the time.|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable|23
212|3 - Respiratory problems (SOB, infection, obstruction)|3 - Respiratory problems (SOB, infection, obstruction)|23
213|3 - Resumption of care (after inpatient stay)|3 - Resumption of care (after inpatient stay)|23
214|3 - Several times each month|3 - Several times each month|23
215|3 - Skilled Nursing Facility|3 - Skilled Nursing Facility|23
216|3 - Stage 3|3 - Stage 3|23
217|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|23
218|3 - Three|3 - Three|23
219|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person throughout the process.|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person through|23
220|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal independently.|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal indep|23
221|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person.|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person|23
222|3 - Unknown because patient moved to a geographic location not served by this agency|3 - Unknown because patient moved to a geographic location not served by this agency|23
223|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|23
224|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|23
225|3 - With other family member|3 - With other family member|23
226|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home health services, homemaker assistance, transportation assistance, assisted living, board and care)|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home h|23
227|3-SLP/ST|3-SLP/ST|23
228|4 - At rest (during day or night)|4 - At rest (during day or night)|23
229|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|23
230|4 - Board and care or assisted living facility|4 - Board and care or assisted living facility|23
231|4 - Caregiver is completely dependent on someone else to manage all equipment.|4 - Caregiver is completely dependent on someone else to manage all equipment.|23
232|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|23
233|4 - Constantly|4 - Constantly|23
234|4 - Drug dependency|4 - Drug dependency|23
235|4 - Four or more|4 - Four or more|23
236|4 - Friend or neighbor or community or church member|4 - Friend or neighbor or community or church member|23
237|4 - Hispanic or Latino|4 - Hispanic or Latino|23
238|4 - Hospice|4 - Hospice|23
239|4 - Impaired decision-making|4 - Impaired decision-making|23
240|4 - Is totally dependent in toileting.|4 - Is totally dependent in toileting.|23
241|4 - Medicaid (HMO/managed care)|4 - Medicaid (HMO/managed care)|23
242|4 - None of the above|4 - None of the above|23
243|4 - Nursing home|4 - Nursing home|23
244|4 - On a daily basis|4 - On a daily basis|23
245|4 - Patient is completely dependent on someone else to manage all equipment.|4 - Patient is completely dependent on someone else to manage all equipment.|23
246|4 - Permanent placement|4 - Permanent placement|23
247|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, punches, dangerous maneuvers w/ wheelchair or other objects)|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, pu|23
248|4 - Psychosocial support (e.g., socialization, companionship, recreation)|4 - Psychosocial support (e.g., socialization, companionship, recreation)|23
249|4 - Recertification (follow-up) reassessment|4 - Recertification (follow-up) reassessment|23
250|4 - Recurrent thoughts of death|4 - Recurrent thoughts of death|23
251|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruction)|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruc|23
252|4 - Several times a week|4 - Several times a week|23
253|4 - Stage 4|4 - Stage 4|23
254|4 - Symptoms poorly controlled, history of re-hospitalizations|4 - Symptoms poorly controlled, history of re-hospitalizations|23
255|4 - Three or more times per week|4 - Three or more times per week|23
256|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetative state, or delirium.|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetati|23
257|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|23
258|4 - Unable to effectively participate in any housekeeping tasks.|4 - Unable to effectively participate in any housekeeping tasks.|23
259|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or unresponsive (e.g., speech is nonsensical or unintelligible).|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or u|23
260|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonresponsive.|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonr|23
261|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostomy.|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostom|23
262|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of devices at the sink, in chair, or on commode|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of|23
263|4 - With a friend|4 - With a friend|23
264|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|23
265|4-OT|4-OT|23
266|5 - Advocates or facilitates patient's participation in appropriate medical care|5 - Advocates or facilitates patient's participation in appropriate medical care|23
267|5 - At least daily|5 - At least daily|23
268|6 - Bedfast, unable to ambulate or be up in a chair.|6 - Bedfast, unable to ambulate or be up in a chair.|23
269|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|23
270|5 - Disruptive or socially inappropriate behavior|5 - Disruptive or socially inappropriate behavior|23
271|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|23
272|5 - Hypo/Hyperglycemia, diabetes out of control|5 - Hypo/Hyperglycemia, diabetes out of control|23
273|5 - More often than once daily|5 - More often than once daily|23
274|5 - Native Hawaiian or Pacific Islander|5 - Native Hawaiian or Pacific Islander|23
275|5 - None of the above|5 - None of the above|23
276|5 - One to two times per week|5 - One to two times per week|23
277|5 - Other|5 - Other|23
278|5 - Other follow-up|5 - Other follow-up|23
279|5 - Paid help|5 - Paid help|23
280|5 - Patient nonresponsive or unable to speak.|5 - Patient nonresponsive or unable to speak.|23
281|5 - Thoughts of suicide|5 - Thoughts of suicide|23
282|5 - Totally unable to use the telephone.|5 - Totally unable to use the telephone.|23
283|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|23
284|5 - Unable to take in nutrients orally or by tube feeding.|5 - Unable to take in nutrients orally or by tube feeding.|23
285|5 - Unsafe for care at home|5 - Unsafe for care at home|23
286|5 - With paid help (other than home care agency staff)|5 - With paid help (other than home care agency staff)|23
287|5 - Workers' compensation|5 - Workers' compensation|23
288|5 - Wound infection, deteriorating wound status, new lesion/ulcer|5 - Wound infection, deteriorating wound status, new lesion/ulcer|23
289|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|23
290|6 - Delusional, hallucinatory, or paranoid behavior|6 - Delusional, hallucinatory, or paranoid behavior|23
291|6 - Financial agent, power of attorney, or conservator of finance|6 - Financial agent, power of attorney, or conservator of finance|23
292|6 - GI bleeding, obstruction|6 - GI bleeding, obstruction|23
293|6 - Less often than weekly|6 - Less often than weekly|23
294|6 - Memory loss to the extent that supervision required|6 - Memory loss to the extent that supervision required|23
295|6 - None of the above feelings observed or reported|6 - None of the above feelings observed or reported|23
296|6 - Other|6 - Other|23
297|6 - Title programs (e.g., Title III, V, or XX)|6 - Title programs (e.g., Title III, V, or XX)|23
298|6 - Transferred to an inpatient facility - patient not discharged from agency|6 - Transferred to an inpatient facility - patient not discharged from agency|23
299|6 - White|6 - White|23
300|6 - With other than above|6 - With other than above|23
301|7 - Exacerbation of CHF, fluid overload, heart failure|7 - Exacerbation of CHF, fluid overload, heart failure|23
302|7 - Health care agent, conservator of person, or medical power of attorney|7 - Health care agent, conservator of person, or medical power of attorney|23
303|7 - Hypo/Hyperglycemia, diabetes out of control|7 - Hypo/Hyperglycemia, diabetes out of control|23
304|7 - None of the above|7 - None of the above|23
305|7 - None of the above behaviors demonstrated|7 - None of the above behaviors demonstrated|23
306|7 - Other government (e.g., TriCare, VA, etc.)|7 - Other government (e.g., TriCare, VA, etc.)|23
307|7 - Transferred to an inpatient facility - patient discharged from agency|7 - Transferred to an inpatient facility - patient discharged from agency|23
308|8 - Death at home|8 - Death at home|23
309|8 - GI bleeding, obstruction|8 - GI bleeding, obstruction|23
310|8 - Myocardial infarction, stroke|8 - Myocardial infarction, stroke|23
311|8 - Private insurance|8 - Private insurance|23
312|9 - Chemotherapy|9 - Chemotherapy|23
313|9 - Discharge from agency|9 - Discharge from agency|23
314|9 - Other than above reasons|9 - Other than above reasons|23
315|9 - Private HMO/managed care|9 - Private HMO/managed care|23
316|NA - No caregiver|NA - No caregiver|23
317|NA - No equipment of this type used in care.|NA - No equipment of this type used in care.|23
318|NA - No inhalant/mist medications prescribed.|NA - No inhalant/mist medications prescribed.|23
319|NA - No injectable medications prescribed.|NA - No injectable medications prescribed.|23
320|NA - No inpatient facility admission|NA - No inpatient facility admission|23
321|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|23
322|NA - No Medicaid|NA - No Medicaid|23
323|NA - No Medicare|NA - No Medicare|23
324|NA - No observable pressure ulcer or unhealed pressure ulcer|NA - No observable pressure ulcer or unhealed pressure ulcer|23
325|NA - No observable stasis ulcer|NA - No observable stasis ulcer|23
326|NA - No observable surgical wound|NA - No observable surgical wound|23
327|NA - No oral medications prescribed.|NA - No oral medications prescribed.|23
328|NA - Not applicable|NA - Not applicable|23
329|NA - Patient does not have a telephone.|NA - Patient does not have a telephone.|23
330|NA - Patient has ostomy for bowel elimination|NA - Patient has ostomy for bowel elimination|23
331|NA - Patient nonresponsive|NA - Patient nonresponsive|23
332|NA - Patient on prophylactic treatment|NA - Patient on prophylactic treatment|23
333|NA - Patient was not discharged from an inpatient facility [Go to M1016 ]|NA - Patient was not discharged from an inpatient facility [Go to M1016 ]|23
334|UK - Other unknown|UK - Other unknown|23
335|UK - Reason unknown|UK - Reason unknown|23
336|UK - Unknown|UK - Unknown|23
337|UK - Unknown or Not Available|UK - Unknown or Not Available|23
341|01 - Early|01 - Early|23
342|02 - Late|02 - Late|23
343|NA - Not Applicable. No case mix group defined for this assessment.|NA - Not Applicable. No case mix group defined for this assessment.|23
344|NA - No case mix group defined by this assessment.|NA - No case mix group defined by this assessment.|23
345|1 - Recent decline in mental, emotional, or behavioral status|1 - Recent decline in mental, emotional, or behavioral status|23
346|2 - Multiple hospitalizations (2 or more) in the past 12 months|2 - Multiple hospitalizations (2 or more) in the past 12 months|23
347|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|23
348|4 - Taking five or more medications|4 - Taking five or more medications|23
349|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|23
350|6 - Other|6 - Other|23
351|7 - None of the above|7 - None of the above|23
352|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond tho|23
353|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable without heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable wi|23
354|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious complications and death.|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious compl|23
355|3 - The patient has serious progressive conditions that could lead to death within a year.|3 - The patient has serious progressive conditions that could lead to death within a year.|23
356|UK - The patient+s situation is unknown or unclear.|UK - The patient+s situation is unknown or unclear.|23
357|1 - Yes [ Go to M1050 ]|1 - Yes [ Go to M1050 ]|23
358|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this influenza season. [ Go to M1050 ]|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this i|23
359|1 - Received from another health care provider (e.g., physician)|1 - Received from another health care provider (e.g., physician)|23
360|2 - Received from your agency previously during this year+s flu season|2 - Received from your agency previously during this year+s flu season|23
361|3 - Offered and declined|3 - Offered and declined|23
362|4 - Assessed and determined to have medical contraindication(s)|4 - Assessed and determined to have medical contraindication(s)|23
363|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|23
364|6 - Inability to obtain vaccine due to declared shortage|6 - Inability to obtain vaccine due to declared shortage|23
365|1 - Yes [ Go to M1500 at TRN; Go to M1230 at DC ]|1 - Yes [ Go to M1500 at TRN; Go to M1230 at DC ]|23
366|1 - Patient has received PPV in the past|1 - Patient has received PPV in the past|23
367|2 - Offered and declined|2 - Offered and declined|23
368|3 - Assessed and determined to have medical contraindication(s)|3 - Assessed and determined to have medical contraindication(s)|23
369|4 - Not indicated; patient does not meet age/condition guidelines for PPV|4 - Not indicated; patient does not meet age/condition guidelines for PPV|23
370|5 - None of the above|5 - None of the above|23
371|0 - Adequate: hears normal conversation without difficulty.|0 - Adequate: hears normal conversation without difficulty.|23
372|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to increase volume or speak distinctly.|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to in|23
373|2 - Severely Impaired: absence of useful hearing.|2 - Severely Impaired: absence of useful hearing.|23
374|UK - Unable to assess hearing.|UK - Unable to assess hearing.|23
375|0 - Understands: clear comprehension without cues or repetitions.|0 - Understands: clear comprehension without cues or repetitions.|23
376|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Requires cues at times to understand.|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Req|23
377|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequently requires cues to understand.|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequentl|23
378|3 - Rarely/Never Understands|3 - Rarely/Never Understands|23
379|UK - Unable to assess understanding.|UK - Unable to assess understanding.|23
380|0 - No standardized assessment conducted|0 - No standardized assessment conducted|23
381|1 - Yes, and it does not indicate severe pain|1 - Yes, and it does not indicate severe pain|23
382|2 - Yes, and it indicates severe pain|2 - Yes, and it indicates severe pain|23
383|0 - Patient has no pain|0 - Patient has no pain|23
384|1 - Patient has pain that does not interfere with activity or movement|1 - Patient has pain that does not interfere with activity or movement|23
385|2 - Less often than daily|2 - Less often than daily|23
386|3 - Daily, but not constantly|3 - Daily, but not constantly|23
387|4 - All of the time|4 - All of the time|23
388|0 - No assessment conducted [ Go to M1306 ]|0 - No assessment conducted [ Go to M1306 ]|23
389|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc., without use of standardized tool|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc.,|23
390|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|23
391|0 - No [ Go to M1322]|0 - No [ Go to M1322]|23
392|0 v Newly epithelialized|0 v Newly epithelialized|23
393|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|23
394|2 - Yes, patient has observable stasis ulcers ONLY|2 - Yes, patient has observable stasis ulcers ONLY|23
395|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable dressing) [Go to M1340]|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable|23
396|0 - No [ Go to M1350 ]|0 - No [ Go to M1350 ]|23
397|1 - Yes, patient has at least one (observable) surgical wound|1 - Yes, patient has at least one (observable) surgical wound|23
398|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1350 ]|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1350 ]|23
399|0 - Patient is not short of breath|0 - Patient is not short of breath|23
400|3 - Continuous Bi-level positive airway pressure|3 - Continuous Bi-level positive airway pressure|23
401|0 - No [ Go to M1732 at TRN; Go to M1600 at DC ]|0 - No [ Go to M1732 at TRN; Go to M1600 at DC ]|23
402|2 - Not assessed [Go to M1732 at TRN; Go to M1600 at DC ]|2 - Not assessed [Go to M1732 at TRN; Go to M1600 at DC ]|23
403|NA - Patient does not have diagnosis of heart failure [Go to M2004 at TRN; Go to M1600 at DC]|NA - Patient does not have diagnosis of heart failure [Go to M2004 at TRN; Go to M1600 at DC]|23
404|0 - No action taken|0 - No action taken|23
405|1 - Patient+s physician (or other primary care practitioner) contacted the same day|1 - Patient+s physician (or other primary care practitioner) contacted the same day|23
406|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|23
407|3 - Implement physician-ordered patient-specific established parameters for treatment|3 - Implement physician-ordered patient-specific established parameters for treatment|23
408|4 - Patient education or other clinical interventions|4 - Patient education or other clinical interventions|23
409|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequency, telehealth, etc.)|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequ|23
410|1 - Occasional stress incontinence|1 - Occasional stress incontinence|23
411|2 - During the night only|2 - During the night only|23
412|3 - During the day only|3 - During the day only|23
413|4 - During the day and night|4 - During the day and night|23
414|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|23
415|0 - Able to manage toileting hygiene and clothing management without assistance.|0 - Able to manage toileting hygiene and clothing management without assistance.|23
416|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implements are laid out for the patient.|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implemen|23
417|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|23
418|3 - Patient depends entirely upon another person to maintain toileting hygiene.|3 - Patient depends entirely upon another person to maintain toileting hygiene.|23
419|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independent|23
420|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface|23
421|0 - No multi-factor falls risk assessment conducted.|0 - No multi-factor falls risk assessment conducted.|23
422|1 - Yes, and it does not indicate a risk for falls.|1 - Yes, and it does not indicate a risk for falls.|23
423|2 - Yes, and it indicates a risk for falls.|2 - Yes, and it indicates a risk for falls.|23
424|0 - Not assessed/reviewed [ Go to M2010 ]|0 - Not assessed/reviewed [ Go to M2010 ]|23
425|1 - No problems found during review [ Go to M2010 ]|1 - No problems found during review [ Go to M2010 ]|23
426|2 - Problems found during review|2 - Problems found during review|23
427|NA - Patient is not taking any medications [ Go to M2040 ]|NA - Patient is not taking any medications [ Go to M2040 ]|23
428|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special precautions associated with all high-risk medications|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special p|23
429|NA - Patient not taking any drugs|NA - Patient not taking any drugs|23
430|2 - Able to take medication(s) at the correct times if given reminders by another person at the appropriate times|2 - Able to take medication(s) at the correct times if given reminders by another person at the appr|23
431|3 - Unable to take medication unless administered by another person.|3 - Unable to take medication unless administered by another person.|23
432|1 - At least daily|1 - At least daily|23
433|2 - Three or more times per week|2 - Three or more times per week|23
434|3 - One to two times per week|3 - One to two times per week|23
435|4 - Received, but less often than weekly|4 - Received, but less often than weekly|23
436|5 - No assistance received|5 - No assistance received|23
437|0 - No [Go to M2400]|0 - No [Go to M2400]|23
438|1 - Yes, used hospital emergency department WITHOUT hospital admission|1 - Yes, used hospital emergency department WITHOUT hospital admission|23
439|2 - Yes, used hospital emergency department WITH hospital admission|2 - Yes, used hospital emergency department WITH hospital admission|23
440|UK - Unknown [Go to M2400]|UK - Unknown [Go to M2400]|23
441|2 - Injury caused by fall|2 - Injury caused by fall|23
442|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|23
443|4 - Other respiratory problem|4 - Other respiratory problem|23
444|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|23
445|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|23
446|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|23
447|8 - Other heart disease|8 - Other heart disease|23
448|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|23
449|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|23
450|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|23
451|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|23
452|13 - Urinary tract infection|13 - Urinary tract infection|23
453|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|23
454|15 - Wound infection or deterioration|15 - Wound infection or deterioration|23
455|16 - Uncontrolled pain|16 - Uncontrolled pain|23
456|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|23
457|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|23
458|19 - Other than above reasons|19 - Other than above reasons|23
459|2 - Patient remained in the community (with formal assistive services)|2 - Patient remained in the community (with formal assistive services)|23
460|3 - Patient transferred to a noninstitutional hospice|3 - Patient transferred to a noninstitutional hospice|23
461|4 - Unknown because patient moved to a geographic location not served by this agency|4 - Unknown because patient moved to a geographic location not served by this agency|23
462|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|23
463|4 - Other respiratory problem|4 - Other respiratory problem|23
464|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|23
465|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|23
466|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|23
467|8 - Other heart disease|8 - Other heart disease|23
468|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|23
469|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|23
470|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|23
471|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|23
472|13 - Urinary tract infection|13 - Urinary tract infection|23
473|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|23
474|15 - Wound infection or deterioration|15 - Wound infection or deterioration|23
475|16 - Uncontrolled pain|16 - Uncontrolled pain|23
476|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|23
477|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|23
478|19 - Scheduled treatment or procedure|19 - Scheduled treatment or procedure|23
479|20 - Other than above reasons|20 - Other than above reasons|23
480|UK - Reason unknown [Go to M0903]|UK - Reason unknown [Go to M0903]|23
482|01 - Patient lives alone around the clock|01 - Patient lives alone around the clock|23
483|02 - Patient lives alone regular daytime|02 - Patient lives alone regular daytime|23
484|03 - Patient lives alone regular nighttime|03 - Patient lives alone regular nighttime|23
485|04 - Patient lives alone occassional/short term assistance|04 - Patient lives alone occassional/short term assistance|23
486|05 - Patient lives alone no assisstance available|05 - Patient lives alone no assisstance available|23
487|06 - Patient lives with other person(s) in the home around the clock|06 - Patient lives with other person(s) in the home around the clock|23
488|07 - Patient lives with other person(s) in the home regular daytime|07 - Patient lives with other person(s) in the home regular daytime|23
489|08 - Patient lives with other person(s) in the home regular nighttime|08 - Patient lives with other person(s) in the home regular nighttime|23
490|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|23
491|10 - Patient lives with other person(s) in the home no assistance available|10 - Patient lives with other person(s) in the home no assistance available|23
492|1 - Was present at the most recent SOC/ROC assessment|1 - Was present at the most recent SOC/ROC assessment|23
493|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|23
494|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|23
495|0 - Newly epithelialized|0 - Newly epithelialized|23
496|0 - No [ Go to M1340 ]|0 - No [ Go to M1340 ]|23
498|0 - Independent|0 - Independent|23
499|1 - Needed Some Help|1 - Needed Some Help|23
500|2 - Dependent|2 - Dependent|23
502|0 - No assistance needed in this area|0 - No assistance needed in this area|23
503|1 - Caregiver(s) currently provide assistance|1 - Caregiver(s) currently provide assistance|23
504|2 - Caregiver(s) need training/ supportive services to provide assistance|2 - Caregiver(s) need training/ supportive services to provide assistance|23
505|3 - Caregiver(s) not likely to provide assistance|3 - Caregiver(s) not likely to provide assistance|23
506|4 - Unclear if Caregiver(s) will provide assistance|4 - Unclear if Caregiver(s) will provide assistance|23
507|5 - Assistance needed, but no Caregiver(s) available|5 - Assistance needed, but no Caregiver(s) available|23
508|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will use standardized clinical guidelines accessible for all care providers to reference|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will|23
509|NA - Patient is not diabetic or is bilateral amputee|NA - Patient is not diabetic or is bilateral amputee|23
510|NA - Patient is not assessed to be at risk for falls|NA - Patient is not assessed to be at risk for falls|23
511|NA - Patient has no diagnosis or symptoms of depression|NA - Patient has no diagnosis or symptoms of depression|23
512|NA - No pain identified|NA - No pain identified|23
513|NA - Patient is not assessed to be at risk for pressure ulcers|NA - Patient is not assessed to be at risk for pressure ulcers|23
514|NA - Patient has no pressure ulcers with need for moist wound healing|NA - Patient has no pressure ulcers with need for moist wound healing|23
515|1 - Long-term nursing facility (NF)|1 - Long-term nursing facility (NF)|23
516|2 - Skilled nursing facility (SNF / TCU)|2 - Skilled nursing facility (SNF / TCU)|23
517|3 - Short stay acute hospital (IPP S)|3 - Short stay acute hospital (IPP S)|23
518|4 - Long-term care hospital (LTCH)|4 - Long-term care hospital (LTCH)|23
519|5 - Inpatient rehabilitation hospital or unit (IRF)|5 - Inpatient rehabilitation hospital or unit (IRF)|23
520|6 - Psychiatric hospital or unit|6 - Psychiatric hospital or unit|23
521|7 - Other|7 - Other|23
522|NA - Patient was not discharged from an inpatient facility [Go to M1016]|NA - Patient was not discharged from an inpatient facility [Go to M1016]|23
523|6 - Unable to participate effectively in bathing and is bathed totally by another person|6 - Unable to participate effectively in bathing and is bathed totally by another person|23
524|4 - Chairfast, unable to ambulate but is able to wheel self independently.|4 - Chairfast, unable to ambulate but is able to wheel self independently.|23
525|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask patient: "Over the last two weeks, how often have you been bothered by any of the following problems")  *Copyright+ Pfizer Inc. All rights reserved. Reproduced with permission.|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask|23
526|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluation for depression.|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluat|23
527|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet criteria for further evaluation for depression.|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet|23
528|0 - Not at all  0 - 1 day|0 - Not at all  0 - 1 day|23
529|1 - Several days  2 - 6 days|1 - Several days  2 - 6 days|23
530|2 - More than half of the days  7 - 11 days|2 - More than half of the days  7 - 11 days|23
531|3 - Nearly every day  12 - 14 days|3 - Nearly every day  12 - 14 days|23
532|NA - N/A  Unable to respond|NA - N/A  Unable to respond|23
533|2 - Able to take medication(s) at the correct times if given reminders by another person based on the frequency of the injection|2 - Able to take medication(s) at the correct times if given reminders by another person based on th|23
534|3 - Unable to take injectable medication unless administered by another person.|3 - Unable to take injectable medication unless administered by another person.|23
540|11 - Patient lives in congregate situation (e.g., assisted living) around the clock|11 - Patient lives in congregate situation (e.g., assisted living) around the clock|23
541|12 - Patient lives in congregate situation (e.g., assisted living) regular daytime|12 - Patient lives in congregate situation (e.g., assisted living) regular daytime|23
542|13 - Patient lives in congregate situation (e.g., assisted living) regular nighttime|13 - Patient lives in congregate situation (e.g., assisted living) regular nighttime|23
543|14 - Patient lives in congregate situation (e.g., assisted living) occasional / short-term assistance|14 - Patient lives in congregate situation (e.g., assisted living) occasional / short-term assistanc|23
544|15 - Patient lives in congregate situation (e.g., assisted living) no available assistance|15 - Patient lives in congregate situation (e.g., assisted living) no available assistance|23
546|NA - No observable pressure ulcer|NA - No observable pressure ulcer|23
583|NA - No specific SOC date ordered by physician|NA - No specific SOC date ordered by physician|23
586|UK - Inpatient Discharge Date Unknown|UK - Inpatient Discharge Date Unknown|23
2|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; OR (b) Is physically, cognitively, and mentally able to prepare light meals on a regular basis but has not routinely performed light meal preparation in the past (i.e., prior to this home care admission).|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; O|24
3|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and mentally able to perform all housekeeping tasks .|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and menta|24
4|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and mentally able to do laundry and access facilities.|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and menta|24
5|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying packages OR b) Physically, cognitively, and mentally able to take care of shopping, but has not done shopping in the past (i.e., prior to this home care admission).|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying|24
6|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|24
7|0 - Able to dial numbers and answer calls appropriately and as desired.|0 - Able to dial numbers and answer calls appropriately and as desired.|24
8|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body without assistance.|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body|24
9|0 - Able to get to and from the toilet and transfer independently with or without a device.|0 - Able to get to and from the toilet and transfer independently with or without a device.|24
10|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|24
11|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible public bus.|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible p|24
12|0 - Able to independently feed self.|0 - Able to independently feed self.|24
13|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|24
14|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct times.|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct ti|24
15|0 - Able to independently transfer.|0 - Able to independently transfer.|24
16|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without rail|24
17|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings|24
18|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|24
19|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions independently.|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions indep|24
20|0 - Asymptomatic, no treatment needed at this time|0 - Asymptomatic, no treatment needed at this time|24
21|0 - Caregiver manages all tasks related to equipment completely independently.|0 - Caregiver manages all tasks related to equipment completely independently.|24
22|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations with no observable impairment.|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations w|24
23|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|24
24|0 - Life expectancy is greater than 6 months|0 - Life expectancy is greater than 6 months|24
25|0 - Never|0 - Never|24
26|0 - Patient is not short of breath|0 - Patient is not short of breath|24
27|0 - No|0 - No|24
28|0 - No emergent care services|0 - No emergent care services|24
29|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [Goto M1620]|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [Goto M1620]|24
30|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and extended or abstract conversation.|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and exte|24
31|0 - No one person|0 - No one person|24
32|0 - None of the time|0 - None of the time|24
33|0 - None, no charge for current services|0 - None, no charge for current services|24
34|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|24
35|0 - Patient does NOT have an ostomy for bowel elimination.|0 - Patient does NOT have an ostomy for bowel elimination.|24
36|0 - Patient has no pain|0 - Patient has no pain|24
37|0 - Patient manages all tasks related to equipment completely independently.|0 - Patient manages all tasks related to equipment completely independently.|24
38|0 - Poor:  little or no recovery is expected and/or further decline is imminent|0 - Poor:  little or no recovery is expected and/or further decline is imminent|24
39|0 - Timed-voiding defers incontinence|0 - Timed-voiding defers incontinence|24
40|0 - Very rarely or never has bowel incontinence|0 - Very rarely or never has bowel incontinence|24
41|0 - Zero|0 - Zero|24
42|00 - No|00 - No|24
43|01 - Yes|01 - Yes|24
44|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or mental limitations, needs assistance with heavy laundry.|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or|24
45|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the patient.|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the|24
46|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|24
47|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or supervision from another person OR c) a liquid, pureed or ground meat diet.|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or su|24
48|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|24
49|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|24
50|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independently.|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independe|24
51|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only when assisted or accompanied by another person.|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only w|24
52|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepa|24
53|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance by another person OR b) given daily reminders.|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance b|24
54|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advan|24
55|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advan|24
56|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for the deaf) and call essential numbers.|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for t|24
57|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|24
58|1 - American Indian or Alaska Native|1 - American Indian or Alaska Native|24
59|1 - Depressed mood (e.g., feeling sad, tearful)|1 - Depressed mood (e.g., feeling sad, tearful)|24
60|1 - During the night only|1 - During the night only|24
61|1 - Fully granulating|1 - Fully granulating|24
62|1 - Good/Fair:  partial to full recovery is expected|1 - Good/Fair:  partial to full recovery is expected|24
63|1 - Good:  marked improvement in functional status is expected|1 - Good:  marked improvement in functional status is expected|24
64|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|24
65|1 - Smoking|1 - Smoking|24
66|1 - Hospital|1 - Hospital|24
67|1 - Hospital emergency room (includes 23-hour holding)|1 - Hospital emergency room (includes 23-hour holding)|24
68|1 - Hospitalization for EMERGENT (unscheduled) care|1 - Hospitalization for EMERGENT (unscheduled) care|24
69|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepared solutions), patient is able to manage all other aspects of equipment.|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepar|24
70|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|24
71|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|24
72|1 - In new or complex situations only|1 - In new or complex situations only|24
73|1 - Intravenous or infusion therapy (excludes TPN)|1 - Intravenous or infusion therapy (excludes TPN)|24
74|1 - Less often than daily|1 - Less often than daily|24
75|1 - Less than once a month|1 - Less than once a month|24
76|1 - Less than once weekly|1 - Less than once weekly|24
77|1 - Life expectancy is 6 months or fewer|1 - Life expectancy is 6 months or fewer|24
78|1 - Lives alone|1 - Lives alone|24
79|1 - Male|1 - Male|24
80|1 - Medicare (traditional fee-for-service)|1 - Medicare (traditional fee-for-service)|24
81|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of past 24 hours, significant memory loss so that supervision is required|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of pas|24
82|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors in word choice, grammar or speech intelligibility, needs minimal prompting or assistance).|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors i|24
83|1 - No assistance or services received|1 - No assistance or services received|24
84|1 - One|1 - One|24
85|1 - Oxygen (intermittent or continuous)|1 - Oxygen (intermittent or continuous)|24
86|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, and the surrounding layout, can count fingers at arm's length.|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, a|24
87|1 - Patient is incontinent|1 - Patient is incontinent|24
88|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|24
89|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical or treatment regimen.|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical|24
90|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient/couple/significant other)|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient|24
91|1 - Relatives, friends, or neighbors living outside the home|1 - Relatives, friends, or neighbors living outside the home|24
92|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions.|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions|24
93|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independentl|24
94|1 - Several times during day and night|1 - Several times during day and night|24
95|1 - Spouse or significant other|1 - Spouse or significant other|24
96|1 - Stage 1|1 - Stage 1|24
97|1 - Start of care - further visits planned|1 - Start of care - further visits planned|24
98|1 - Symptoms well controlled with current therapy|1 - Symptoms well controlled with current therapy|24
99|1 - Therapy services|1 - Therapy services|24
100|1 - Able to transfer with minimal human assistance or with use of an assistive device.|1 - Able to transfer with minimal human assistance or with use of an assistive device.|24
101|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitations.|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitatio|24
102|1 - Urinary incontinence|1 - Urinary incontinence|24
103|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and transfer.|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and|24
104|1 - When walking more than 20 feet, climbing stairs|1 - When walking more than 20 feet, climbing stairs|24
105|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary conversation. May need occasional repetition, extra time, or louder voice.|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary c|24
106|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting in and out of tub/shower|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting|24
107|1 - Yes|1 - Yes|24
108|1-RN|1-RN|24
109|10 - Discharge from agency - no visits completed after start/resumption of care assessment|10 - Discharge from agency - no visits completed after start/resumption of care assessment|24
110|10 - Scheduled surgical procedure|10 - Scheduled surgical procedure|24
111|10 - Self-pay|10 - Self-pay|24
112|11 - Other|11 - Other|24
113|11 - Urinary tract infection|11 - Urinary tract infection|24
114|12 - IV catheter-related infection|12 - IV catheter-related infection|24
115|13 - Deep vein thrombosis, pulmonary embolus|13 - Deep vein thrombosis, pulmonary embolus|24
116|14 - Uncontrolled pain|14 - Uncontrolled pain|24
117|15 - Psychotic episode|15 - Psychotic episode|24
118|16 - Other than above reasons|16 - Other than above reasons|24
119|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing calls.|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing|24
120|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another person.|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another pers|24
121|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface a|24
122|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for intermittent supervision or encouragement or reminders, OR (b) to get in and out of the shower or tub, OR (c) for washing difficult to reach areas.|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for inter|24
123|2 - Asian|2 - Asian|24
124|2 - Caregiver requires considerable assistance from another person to manage equipment, but independently completes significant portions of task.|2 - Caregiver requires considerable assistance from another person to manage equipment, but independ|24
125|2 - Daily, but not constantly|2 - Daily, but not constantly|24
126|2 - Daughter or son|2 - Daughter or son|24
127|2 - Doctor's office emergency visit/house call|2 - Doctor's office emergency visit/house call|24
128|2 - During the day and night|2 - During the day and night|24
129|2 - Early/partial granulation|2 - Early/partial granulation|24
130|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors in word choice, organization or speech intelligibility). Speaks in phrases or short sentences.|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors|24
131|2 - Family member's residence|2 - Family member's residence|24
132|2 - Female|2 - Female|24
133|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conversation, needs frequent prompting or assistance.|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conver|24
134|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|24
135|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|24
136|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately stop activities, jeopardizes safety through actions|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately st|24
137|2 - Indwelling/suprapubic catheter|2 - Indwelling/suprapubic catheter|24
138|2 - Injury caused by fall or accident at home|2 - Injury caused by fall or accident at home|24
139|2 - Medicare (HMO/managed care/Advantage plan)|2 - Medicare (HMO/managed care/Advantage plan)|24
140|2 - Nausea, dehydration, malnutrition, constipation, impaction|2 - Nausea, dehydration, malnutrition, constipation, impaction|24
141|2 - Obesity|2 - Obesity|24
142|2 - On awakening or at night only|2 - On awakening or at night only|24
143|2 - Once a month|2 - Once a month|24
144|2 - One to three times weekly|2 - One to three times weekly|24
145|2 - Parenteral nutrition (TPN or lipids)|2 - Parenteral nutrition (TPN or lipids)|24
146|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic) [ Go to M1620 ]|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic) [ Go|24
147|2 - Patient requires considerable assistance from another person to manage equipment, but independently completes portions of the task.|2 - Patient requires considerable assistance from another person to manage equipment, but independen|24
148|2 - Patient transferred to a noninstitutional hospice|2 - Patient transferred to a noninstitutional hospice|24
149|2 - Person residing in the home (EXCLUDING paid help)|2 - Person residing in the home (EXCLUDING paid help)|24
150|2 - Rehabilitation facility|2 - Rehabilitation facility|24
151|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifting of attention) or consistently requires low stimulus environment due to distractibility.|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifti|24
152|2 - Respite care|2 - Respite care|24
153|2 - Sense of failure or self reproach|2 - Sense of failure or self reproach|24
154|2 - Several times during day|2 - Several times during day|24
155|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonresponsive.|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonrespons|24
156|2 - Someone must assist the patient to groom self.|2 - Someone must assist the patient to groom self.|24
157|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|24
158|2 - Someone must help the patient put on upper body clothing.|2 - Someone must help the patient put on upper body clothing.|24
159|2 - Stage 2|2 - Stage 2|24
160|2 - Start of care - no further visits planned|2 - Start of care - no further visits planned|24
161|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitoring|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitori|24
162|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment regimen.|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment re|24
163|2 - Two|2 - Two|24
164|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistance due to cognitive or mental limitation.|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistanc|24
165|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|24
166|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assistance).|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assis|24
167|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home delivery.|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home deli|24
168|2 - Unable to prepare any light meals or reheat any delivered meals.|2 - Unable to prepare any light meals or reheat any delivered meals.|24
169|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|24
170|2 - UNABLE to take injectable medications unless administered by someone else.|2 - UNABLE to take injectable medications unless administered by someone else.|24
171|2 - UNABLE to take medication unless administered by someone else.|2 - UNABLE to take medication unless administered by someone else.|24
172|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|24
173|2 - Ventilator (continually or at night)|2 - Ventilator (continually or at night)|24
174|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less than 20 feet)|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less th|24
175|2 - With spouse or significant other|2 - With spouse or significant other|24
176|2 - Yes, assistance or services provided by family or friends|2 - Yes, assistance or services provided by family or friends|24
177|2-PT|2-PT|24
178|3 - Able to answer the telephone only some of the time or is able to carry on only a limited conversation.|3 - Able to answer the telephone only some of the time or is able to carry on only a limited convers|24
179|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube or gastrostomy.|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube|24
180|3 - Alcohol dependency|3 - Alcohol dependency|24
181|3 - All of the time|3 - All of the time|24
182|3 - Black or African-American|3 - Black or African-American|24
183|3 - Boarding home or rented room|3 - Boarding home or rented room|24
184|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment, clean/store/dispose of equipment or supplies).|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment,|24
185|3 -Able to walk only with the supervision or assistance of another person at all times.|3 -Able to walk only with the supervision or assistance of another person at all times.|24
186|3 - Continuous / Bi-level positive airway pressure|3 - Continuous / Bi-level positive airway pressure|24
187|3 - During the day and evening, but not constantly|3 - During the day and evening, but not constantly|24
188|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the alimentary canal)|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the|24
189|3 - Environmental support (e.g., housing, home maintenance)|3 - Environmental support (e.g., housing, home maintenance)|24
190|3 - Four to six times weekly|3 - Four to six times weekly|24
191|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessing by listener.  Speech limited to single words or short phrases.|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessin|24
192|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires multiple repetitions, restatements, demonstrations, additional time.|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires m|24
193|3 - Hopelessness|3 - Hopelessness|24
194|3 - Hospice care|3 - Hospice care|24
195|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|24
196|3 - Injury caused by fall or accident at home|3 - Injury caused by fall or accident at home|24
197|3 - Intractable pain|3 - Intractable pain|24
198|3 - Medicaid (traditional fee-for-service)|3 - Medicaid (traditional fee-for-service)|24
199|3 - Needs someone to do all shopping and errands.|3 - Needs someone to do all shopping and errands.|24
200|3 - Not healing|3 - Not healing|24
201|3 - Nursing home|3 - Nursing home|24
202|3 - Once daily|3 - Once daily|24
203|3 - Other family member|3 - Other family member|24
204|3 - Outpatient department/clinic emergency (includes urgicenter sites)|3 - Outpatient department/clinic emergency (includes urgicenter sites)|24
205|3 - Paid help|3 - Paid help|24
206|3 - Able to participate in bathing self in shower or tub, but requires presence of another person throughout the bath for assistance or supervision.|3 - Able to participate in bathing self in shower or tub, but requires presence of another person th|24
207|3 - Patient depends entirely upon another person to dress lower body.|3 - Patient depends entirely upon another person to dress lower body.|24
208|3 - Patient depends entirely upon another person to dress the upper body.|3 - Patient depends entirely upon another person to dress the upper body.|24
209|3 - Patient depends entirely upon someone else for grooming needs.|3 - Patient depends entirely upon someone else for grooming needs.|24
210|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone else to manage the equipment.|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone|24
211|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable to shift attention and recall directions more than half the time.|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable|24
212|3 - Respiratory problems (SOB, infection, obstruction)|3 - Respiratory problems (SOB, infection, obstruction)|24
213|3 - Resumption of care (after inpatient stay)|3 - Resumption of care (after inpatient stay)|24
214|3 - Several times each month|3 - Several times each month|24
215|3 - Skilled Nursing Facility|3 - Skilled Nursing Facility|24
216|3 - Stage 3|3 - Stage 3|24
217|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|24
218|3 - Three|3 - Three|24
219|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person throughout the process.|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person through|24
220|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal independently.|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal indep|24
221|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person.|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person|24
222|3 - Unknown because patient moved to a geographic location not served by this agency|3 - Unknown because patient moved to a geographic location not served by this agency|24
223|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|24
224|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|24
225|3 - With other family member|3 - With other family member|24
226|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home health services, homemaker assistance, transportation assistance, assisted living, board and care)|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home h|24
227|3-SLP/ST|3-SLP/ST|24
228|4 - At rest (during day or night)|4 - At rest (during day or night)|24
229|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|24
230|4 - Board and care or assisted living facility|4 - Board and care or assisted living facility|24
231|4 - Caregiver is completely dependent on someone else to manage all equipment.|4 - Caregiver is completely dependent on someone else to manage all equipment.|24
232|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|24
233|4 - Constantly|4 - Constantly|24
234|4 - Drug dependency|4 - Drug dependency|24
235|4 - Four or more|4 - Four or more|24
236|4 - Friend or neighbor or community or church member|4 - Friend or neighbor or community or church member|24
237|4 - Hispanic or Latino|4 - Hispanic or Latino|24
238|4 - Hospice|4 - Hospice|24
239|4 - Impaired decision-making|4 - Impaired decision-making|24
240|4 - Is totally dependent in toileting.|4 - Is totally dependent in toileting.|24
241|4 - Medicaid (HMO/managed care)|4 - Medicaid (HMO/managed care)|24
242|4 - None of the above|4 - None of the above|24
243|4 - Nursing home|4 - Nursing home|24
244|4 - On a daily basis|4 - On a daily basis|24
245|4 - Patient is completely dependent on someone else to manage all equipment.|4 - Patient is completely dependent on someone else to manage all equipment.|24
246|4 - Permanent placement|4 - Permanent placement|24
247|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, punches, dangerous maneuvers w/ wheelchair or other objects)|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, pu|24
248|4 - Psychosocial support (e.g., socialization, companionship, recreation)|4 - Psychosocial support (e.g., socialization, companionship, recreation)|24
249|4 - Recertification (follow-up) reassessment|4 - Recertification (follow-up) reassessment|24
250|4 - Recurrent thoughts of death|4 - Recurrent thoughts of death|24
251|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruction)|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruc|24
252|4 - Several times a week|4 - Several times a week|24
253|4 - Stage 4|4 - Stage 4|24
254|4 - Symptoms poorly controlled, history of re-hospitalizations|4 - Symptoms poorly controlled, history of re-hospitalizations|24
255|4 - Three or more times per week|4 - Three or more times per week|24
256|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetative state, or delirium.|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetati|24
257|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|24
258|4 - Unable to effectively participate in any housekeeping tasks.|4 - Unable to effectively participate in any housekeeping tasks.|24
259|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or unresponsive (e.g., speech is nonsensical or unintelligible).|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or u|24
260|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonresponsive.|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonr|24
261|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostomy.|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostom|24
262|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of devices at the sink, in chair, or on commode|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of|24
263|4 - With a friend|4 - With a friend|24
264|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|24
265|4-OT|4-OT|24
266|5 - Advocates or facilitates patient's participation in appropriate medical care|5 - Advocates or facilitates patient's participation in appropriate medical care|24
267|5 - At least daily|5 - At least daily|24
268|6 - Bedfast, unable to ambulate or be up in a chair.|6 - Bedfast, unable to ambulate or be up in a chair.|24
269|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|24
270|5 - Disruptive or socially inappropriate behavior|5 - Disruptive or socially inappropriate behavior|24
271|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|24
272|5 - Hypo/Hyperglycemia, diabetes out of control|5 - Hypo/Hyperglycemia, diabetes out of control|24
273|5 - More often than once daily|5 - More often than once daily|24
274|5 - Native Hawaiian or Pacific Islander|5 - Native Hawaiian or Pacific Islander|24
275|5 - None of the above|5 - None of the above|24
276|5 - One to two times per week|5 - One to two times per week|24
277|5 - Other|5 - Other|24
278|5 - Other follow-up|5 - Other follow-up|24
279|5 - Paid help|5 - Paid help|24
280|5 - Patient nonresponsive or unable to speak.|5 - Patient nonresponsive or unable to speak.|24
281|5 - Thoughts of suicide|5 - Thoughts of suicide|24
282|5 - Totally unable to use the telephone.|5 - Totally unable to use the telephone.|24
283|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|24
284|5 - Unable to take in nutrients orally or by tube feeding.|5 - Unable to take in nutrients orally or by tube feeding.|24
285|5 - Unsafe for care at home|5 - Unsafe for care at home|24
286|5 - With paid help (other than home care agency staff)|5 - With paid help (other than home care agency staff)|24
287|5 - Workers' compensation|5 - Workers' compensation|24
288|5 - Wound infection, deteriorating wound status, new lesion/ulcer|5 - Wound infection, deteriorating wound status, new lesion/ulcer|24
289|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|24
290|6 - Delusional, hallucinatory, or paranoid behavior|6 - Delusional, hallucinatory, or paranoid behavior|24
291|6 - Financial agent, power of attorney, or conservator of finance|6 - Financial agent, power of attorney, or conservator of finance|24
292|6 - GI bleeding, obstruction|6 - GI bleeding, obstruction|24
293|6 - Less often than weekly|6 - Less often than weekly|24
294|6 - Memory loss to the extent that supervision required|6 - Memory loss to the extent that supervision required|24
295|6 - None of the above feelings observed or reported|6 - None of the above feelings observed or reported|24
296|6 - Other|6 - Other|24
297|6 - Title programs (e.g., Title III, V, or XX)|6 - Title programs (e.g., Title III, V, or XX)|24
298|6 - Transferred to an inpatient facility - patient not discharged from agency|6 - Transferred to an inpatient facility - patient not discharged from agency|24
299|6 - White|6 - White|24
300|6 - With other than above|6 - With other than above|24
301|7 - Exacerbation of CHF, fluid overload, heart failure|7 - Exacerbation of CHF, fluid overload, heart failure|24
302|7 - Health care agent, conservator of person, or medical power of attorney|7 - Health care agent, conservator of person, or medical power of attorney|24
303|7 - Hypo/Hyperglycemia, diabetes out of control|7 - Hypo/Hyperglycemia, diabetes out of control|24
304|7 - None of the above|7 - None of the above|24
305|7 - None of the above behaviors demonstrated|7 - None of the above behaviors demonstrated|24
306|7 - Other government (e.g., TriCare, VA, etc.)|7 - Other government (e.g., TriCare, VA, etc.)|24
307|7 - Transferred to an inpatient facility - patient discharged from agency|7 - Transferred to an inpatient facility - patient discharged from agency|24
308|8 - Death at home|8 - Death at home|24
309|8 - GI bleeding, obstruction|8 - GI bleeding, obstruction|24
310|8 - Myocardial infarction, stroke|8 - Myocardial infarction, stroke|24
311|8 - Private insurance|8 - Private insurance|24
312|9 - Chemotherapy|9 - Chemotherapy|24
313|9 - Discharge from agency|9 - Discharge from agency|24
314|9 - Other than above reasons|9 - Other than above reasons|24
315|9 - Private HMO/managed care|9 - Private HMO/managed care|24
316|NA - No caregiver|NA - No caregiver|24
317|NA - No equipment of this type used in care.|NA - No equipment of this type used in care.|24
318|NA - No inhalant/mist medications prescribed.|NA - No inhalant/mist medications prescribed.|24
319|NA - No injectable medications prescribed.|NA - No injectable medications prescribed.|24
320|NA - No inpatient facility admission|NA - No inpatient facility admission|24
321|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|24
322|NA - No Medicaid|NA - No Medicaid|24
323|NA - No Medicare|NA - No Medicare|24
324|NA - No observable pressure ulcer or unhealed pressure ulcer|NA - No observable pressure ulcer or unhealed pressure ulcer|24
325|NA - No observable stasis ulcer|NA - No observable stasis ulcer|24
326|NA - No observable surgical wound|NA - No observable surgical wound|24
327|NA - No oral medications prescribed.|NA - No oral medications prescribed.|24
328|NA - Not applicable|NA - Not applicable|24
329|NA - Patient does not have a telephone.|NA - Patient does not have a telephone.|24
330|NA - Patient has ostomy for bowel elimination|NA - Patient has ostomy for bowel elimination|24
331|NA - Patient nonresponsive|NA - Patient nonresponsive|24
332|NA - Patient on prophylactic treatment|NA - Patient on prophylactic treatment|24
333|NA - Patient was not discharged from an inpatient facility [Go to M1016 ]|NA - Patient was not discharged from an inpatient facility [Go to M1016 ]|24
334|UK - Other unknown|UK - Other unknown|24
335|UK - Reason unknown|UK - Reason unknown|24
336|UK - Unknown|UK - Unknown|24
337|UK - Unknown or Not Available|UK - Unknown or Not Available|24
341|01 - Early|01 - Early|24
342|02 - Late|02 - Late|24
343|NA - Not Applicable. No case mix group defined for this assessment.|NA - Not Applicable. No case mix group defined for this assessment.|24
344|NA - No case mix group defined by this assessment.|NA - No case mix group defined by this assessment.|24
345|1 - Recent decline in mental, emotional, or behavioral status|1 - Recent decline in mental, emotional, or behavioral status|24
346|2 - Multiple hospitalizations (2 or more) in the past 12 months|2 - Multiple hospitalizations (2 or more) in the past 12 months|24
347|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|24
348|4 - Taking five or more medications|4 - Taking five or more medications|24
349|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|24
350|6 - Other|6 - Other|24
351|7 - None of the above|7 - None of the above|24
352|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond tho|24
353|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable without heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable wi|24
354|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious complications and death.|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious compl|24
355|3 - The patient has serious progressive conditions that could lead to death within a year.|3 - The patient has serious progressive conditions that could lead to death within a year.|24
356|UK - The patient+s situation is unknown or unclear.|UK - The patient+s situation is unknown or unclear.|24
357|1 - Yes [ Go to M1050 ]|1 - Yes [ Go to M1050 ]|24
358|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this influenza season. [ Go to M1050 ]|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this i|24
359|1 - Received from another health care provider (e.g., physician)|1 - Received from another health care provider (e.g., physician)|24
360|2 - Received from your agency previously during this year+s flu season|2 - Received from your agency previously during this year+s flu season|24
361|3 - Offered and declined|3 - Offered and declined|24
362|4 - Assessed and determined to have medical contraindication(s)|4 - Assessed and determined to have medical contraindication(s)|24
363|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|24
364|6 - Inability to obtain vaccine due to declared shortage|6 - Inability to obtain vaccine due to declared shortage|24
365|1 - Yes [ Go to M1500 at TRN; Go to M1230 at DC ]|1 - Yes [ Go to M1500 at TRN; Go to M1230 at DC ]|24
366|1 - Patient has received PPV in the past|1 - Patient has received PPV in the past|24
367|2 - Offered and declined|2 - Offered and declined|24
368|3 - Assessed and determined to have medical contraindication(s)|3 - Assessed and determined to have medical contraindication(s)|24
369|4 - Not indicated; patient does not meet age/condition guidelines for PPV|4 - Not indicated; patient does not meet age/condition guidelines for PPV|24
370|5 - None of the above|5 - None of the above|24
371|0 - Adequate: hears normal conversation without difficulty.|0 - Adequate: hears normal conversation without difficulty.|24
372|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to increase volume or speak distinctly.|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to in|24
373|2 - Severely Impaired: absence of useful hearing.|2 - Severely Impaired: absence of useful hearing.|24
374|UK - Unable to assess hearing.|UK - Unable to assess hearing.|24
375|0 - Understands: clear comprehension without cues or repetitions.|0 - Understands: clear comprehension without cues or repetitions.|24
376|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Requires cues at times to understand.|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Req|24
377|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequently requires cues to understand.|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequentl|24
378|3 - Rarely/Never Understands|3 - Rarely/Never Understands|24
379|UK - Unable to assess understanding.|UK - Unable to assess understanding.|24
380|0 - No standardized assessment conducted|0 - No standardized assessment conducted|24
381|1 - Yes, and it does not indicate severe pain|1 - Yes, and it does not indicate severe pain|24
382|2 - Yes, and it indicates severe pain|2 - Yes, and it indicates severe pain|24
383|0 - Patient has no pain|0 - Patient has no pain|24
384|1 - Patient has pain that does not interfere with activity or movement|1 - Patient has pain that does not interfere with activity or movement|24
385|2 - Less often than daily|2 - Less often than daily|24
386|3 - Daily, but not constantly|3 - Daily, but not constantly|24
387|4 - All of the time|4 - All of the time|24
388|0 - No assessment conducted [ Go to M1306 ]|0 - No assessment conducted [ Go to M1306 ]|24
389|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc., without use of standardized tool|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc.,|24
390|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|24
391|0 - No [ Go to M1322]|0 - No [ Go to M1322]|24
392|0 v Newly epithelialized|0 v Newly epithelialized|24
393|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|24
394|2 - Yes, patient has observable stasis ulcers ONLY|2 - Yes, patient has observable stasis ulcers ONLY|24
395|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable dressing) [Go to M1340]|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable|24
396|0 - No [ Go to M1350 ]|0 - No [ Go to M1350 ]|24
397|1 - Yes, patient has at least one (observable) surgical wound|1 - Yes, patient has at least one (observable) surgical wound|24
398|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1350 ]|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1350 ]|24
399|0 - Patient is not short of breath|0 - Patient is not short of breath|24
400|3 - Continuous Bi-level positive airway pressure|3 - Continuous Bi-level positive airway pressure|24
401|0 - No [ Go to M1732 at TRN; Go to M1600 at DC ]|0 - No [ Go to M1732 at TRN; Go to M1600 at DC ]|24
402|2 - Not assessed [Go to M1732 at TRN; Go to M1600 at DC ]|2 - Not assessed [Go to M1732 at TRN; Go to M1600 at DC ]|24
403|NA - Patient does not have diagnosis of heart failure [Go to M2004 at TRN; Go to M1600 at DC]|NA - Patient does not have diagnosis of heart failure [Go to M2004 at TRN; Go to M1600 at DC]|24
404|0 - No action taken|0 - No action taken|24
405|1 - Patient+s physician (or other primary care practitioner) contacted the same day|1 - Patient+s physician (or other primary care practitioner) contacted the same day|24
406|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|24
407|3 - Implement physician-ordered patient-specific established parameters for treatment|3 - Implement physician-ordered patient-specific established parameters for treatment|24
408|4 - Patient education or other clinical interventions|4 - Patient education or other clinical interventions|24
409|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequency, telehealth, etc.)|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequ|24
410|1 - Occasional stress incontinence|1 - Occasional stress incontinence|24
411|2 - During the night only|2 - During the night only|24
412|3 - During the day only|3 - During the day only|24
413|4 - During the day and night|4 - During the day and night|24
414|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|24
415|0 - Able to manage toileting hygiene and clothing management without assistance.|0 - Able to manage toileting hygiene and clothing management without assistance.|24
416|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implements are laid out for the patient.|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implemen|24
417|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|24
418|3 - Patient depends entirely upon another person to maintain toileting hygiene.|3 - Patient depends entirely upon another person to maintain toileting hygiene.|24
419|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independent|24
420|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface|24
421|0 - No multi-factor falls risk assessment conducted.|0 - No multi-factor falls risk assessment conducted.|24
422|1 - Yes, and it does not indicate a risk for falls.|1 - Yes, and it does not indicate a risk for falls.|24
423|2 - Yes, and it indicates a risk for falls.|2 - Yes, and it indicates a risk for falls.|24
424|0 - Not assessed/reviewed [ Go to M2010 ]|0 - Not assessed/reviewed [ Go to M2010 ]|24
425|1 - No problems found during review [ Go to M2010 ]|1 - No problems found during review [ Go to M2010 ]|24
426|2 - Problems found during review|2 - Problems found during review|24
427|NA - Patient is not taking any medications [ Go to M2040 ]|NA - Patient is not taking any medications [ Go to M2040 ]|24
428|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special precautions associated with all high-risk medications|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special p|24
429|NA - Patient not taking any drugs|NA - Patient not taking any drugs|24
430|2 - Able to take medication(s) at the correct times if given reminders by another person at the appropriate times|2 - Able to take medication(s) at the correct times if given reminders by another person at the appr|24
431|3 - Unable to take medication unless administered by another person.|3 - Unable to take medication unless administered by another person.|24
432|1 - At least daily|1 - At least daily|24
433|2 - Three or more times per week|2 - Three or more times per week|24
434|3 - One to two times per week|3 - One to two times per week|24
435|4 - Received, but less often than weekly|4 - Received, but less often than weekly|24
436|5 - No assistance received|5 - No assistance received|24
437|0 - No [Go to M2400]|0 - No [Go to M2400]|24
438|1 - Yes, used hospital emergency department WITHOUT hospital admission|1 - Yes, used hospital emergency department WITHOUT hospital admission|24
439|2 - Yes, used hospital emergency department WITH hospital admission|2 - Yes, used hospital emergency department WITH hospital admission|24
440|UK - Unknown [Go to M2400]|UK - Unknown [Go to M2400]|24
441|2 - Injury caused by fall|2 - Injury caused by fall|24
442|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|24
443|4 - Other respiratory problem|4 - Other respiratory problem|24
444|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|24
445|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|24
446|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|24
447|8 - Other heart disease|8 - Other heart disease|24
448|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|24
449|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|24
450|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|24
451|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|24
452|13 - Urinary tract infection|13 - Urinary tract infection|24
453|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|24
454|15 - Wound infection or deterioration|15 - Wound infection or deterioration|24
455|16 - Uncontrolled pain|16 - Uncontrolled pain|24
456|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|24
457|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|24
458|19 - Other than above reasons|19 - Other than above reasons|24
459|2 - Patient remained in the community (with formal assistive services)|2 - Patient remained in the community (with formal assistive services)|24
460|3 - Patient transferred to a noninstitutional hospice|3 - Patient transferred to a noninstitutional hospice|24
461|4 - Unknown because patient moved to a geographic location not served by this agency|4 - Unknown because patient moved to a geographic location not served by this agency|24
462|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|24
463|4 - Other respiratory problem|4 - Other respiratory problem|24
464|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|24
465|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|24
466|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|24
467|8 - Other heart disease|8 - Other heart disease|24
468|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|24
469|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|24
470|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|24
471|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|24
472|13 - Urinary tract infection|13 - Urinary tract infection|24
473|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|24
474|15 - Wound infection or deterioration|15 - Wound infection or deterioration|24
475|16 - Uncontrolled pain|16 - Uncontrolled pain|24
476|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|24
477|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|24
478|19 - Scheduled treatment or procedure|19 - Scheduled treatment or procedure|24
479|20 - Other than above reasons|20 - Other than above reasons|24
480|UK - Reason unknown [Go to M0903]|UK - Reason unknown [Go to M0903]|24
482|01 - Patient lives alone around the clock|01 - Patient lives alone around the clock|24
483|02 - Patient lives alone regular daytime|02 - Patient lives alone regular daytime|24
484|03 - Patient lives alone regular nighttime|03 - Patient lives alone regular nighttime|24
485|04 - Patient lives alone occassional/short term assistance|04 - Patient lives alone occassional/short term assistance|24
486|05 - Patient lives alone no assisstance available|05 - Patient lives alone no assisstance available|24
487|06 - Patient lives with other person(s) in the home around the clock|06 - Patient lives with other person(s) in the home around the clock|24
488|07 - Patient lives with other person(s) in the home regular daytime|07 - Patient lives with other person(s) in the home regular daytime|24
489|08 - Patient lives with other person(s) in the home regular nighttime|08 - Patient lives with other person(s) in the home regular nighttime|24
490|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|24
491|10 - Patient lives with other person(s) in the home no assistance available|10 - Patient lives with other person(s) in the home no assistance available|24
492|1 - Was present at the most recent SOC/ROC assessment|1 - Was present at the most recent SOC/ROC assessment|24
493|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|24
494|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|24
495|0 - Newly epithelialized|0 - Newly epithelialized|24
496|0 - No [ Go to M1340 ]|0 - No [ Go to M1340 ]|24
498|0 - Independent|0 - Independent|24
499|1 - Needed Some Help|1 - Needed Some Help|24
500|2 - Dependent|2 - Dependent|24
502|0 - No assistance needed in this area|0 - No assistance needed in this area|24
503|1 - Caregiver(s) currently provide assistance|1 - Caregiver(s) currently provide assistance|24
504|2 - Caregiver(s) need training/ supportive services to provide assistance|2 - Caregiver(s) need training/ supportive services to provide assistance|24
505|3 - Caregiver(s) not likely to provide assistance|3 - Caregiver(s) not likely to provide assistance|24
506|4 - Unclear if Caregiver(s) will provide assistance|4 - Unclear if Caregiver(s) will provide assistance|24
507|5 - Assistance needed, but no Caregiver(s) available|5 - Assistance needed, but no Caregiver(s) available|24
508|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will use standardized clinical guidelines accessible for all care providers to reference|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will|24
510|NA - Patient is not assessed to be at risk for falls|NA - Patient is not assessed to be at risk for falls|24
511|NA - Patient has no diagnosis or symptoms of depression|NA - Patient has no diagnosis or symptoms of depression|24
512|NA - No pain identified|NA - No pain identified|24
513|NA - Patient is not assessed to be at risk for pressure ulcers|NA - Patient is not assessed to be at risk for pressure ulcers|24
514|NA - Patient has no pressure ulcers with need for moist wound healing|NA - Patient has no pressure ulcers with need for moist wound healing|24
515|1 - Long-term nursing facility (NF)|1 - Long-term nursing facility (NF)|24
516|2 - Skilled nursing facility (SNF / TCU)|2 - Skilled nursing facility (SNF / TCU)|24
517|3 - Short stay acute hospital (IPP S)|3 - Short stay acute hospital (IPP S)|24
518|4 - Long-term care hospital (LTCH)|4 - Long-term care hospital (LTCH)|24
519|5 - Inpatient rehabilitation hospital or unit (IRF)|5 - Inpatient rehabilitation hospital or unit (IRF)|24
520|6 - Psychiatric hospital or unit|6 - Psychiatric hospital or unit|24
521|7 - Other|7 - Other|24
522|NA - Patient was not discharged from an inpatient facility [Goto M1016]|NA - Patient was not discharged from an inpatient facility [Goto M1016]|24
523|6 - Unable to participate effectively in bathing and is bathed totally by another person|6 - Unable to participate effectively in bathing and is bathed totally by another person|24
524|4 - Chairfast, unable to ambulate but is able to wheel self independently.|4 - Chairfast, unable to ambulate but is able to wheel self independently.|24
525|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask patient: "Over the last two weeks, how often have you been bothered by any of the following problems")  *Copyright+ Pfizer Inc. All rights reserved. Reproduced with permission.|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask|24
526|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluation for depression.|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluat|24
527|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet criteria for further evaluation for depression.|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet|24
528|0 - Not at all  0 - 1 day|0 - Not at all  0 - 1 day|24
529|1 - Several days  2 - 6 days|1 - Several days  2 - 6 days|24
530|2 - More than half of the days  7 - 11 days|2 - More than half of the days  7 - 11 days|24
531|3 - Nearly every day  12 - 14 days|3 - Nearly every day  12 - 14 days|24
532|NA - N/A  Unable to respond|NA - N/A  Unable to respond|24
533|2 - Able to take medication(s) at the correct times if given reminders by another person based on the frequency of the injection|2 - Able to take medication(s) at the correct times if given reminders by another person based on th|24
534|3 - Unable to take injectable medication unless administered by another person.|3 - Unable to take injectable medication unless administered by another person.|24
2|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; OR (b) Is physically, cognitively, and mentally able to prepare light meals on a regular basis but has not routinely performed light meal preparation in the past (i.e., prior to this home care admission).|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; O|25
3|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and mentally able to perform all housekeeping tasks .|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and menta|25
4|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and mentally able to do laundry and access facilities.|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and menta|25
5|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying packages OR b) Physically, cognitively, and mentally able to take care of shopping, but has not done shopping in the past (i.e., prior to this home care admission).|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying|25
6|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|25
7|0 - Able to dial numbers and answer calls appropriately and as desired.|0 - Able to dial numbers and answer calls appropriately and as desired.|25
8|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body without assistance.|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body|25
9|0 - Able to get to and from the toilet and transfer independently with or without a device.|0 - Able to get to and from the toilet and transfer independently with or without a device.|25
10|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|25
11|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible public bus.|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible p|25
12|0 - Able to independently feed self.|0 - Able to independently feed self.|25
13|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|25
14|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct times.|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct ti|25
15|0 - Able to independently transfer.|0 - Able to independently transfer.|25
16|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without rail|25
17|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings|25
18|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|25
19|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions independently.|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions indep|25
20|0 - Asymptomatic, no treatment needed at this time|0 - Asymptomatic, no treatment needed at this time|25
21|0 - Caregiver manages all tasks related to equipment completely independently.|0 - Caregiver manages all tasks related to equipment completely independently.|25
22|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations with no observable impairment.|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations w|25
23|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|25
24|0 - Life expectancy is greater than 6 months|0 - Life expectancy is greater than 6 months|25
25|0 - Never|0 - Never|25
26|0 - Patient is not short of breath|0 - Patient is not short of breath|25
27|0 - No|0 - No|25
28|0 - No emergent care services|0 - No emergent care services|25
29|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [Goto M1620]|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [Goto M1620]|25
30|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and extended or abstract conversation.|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and exte|25
31|0 - No one person|0 - No one person|25
32|0 - None of the time|0 - None of the time|25
33|0 - None, no charge for current services|0 - None, no charge for current services|25
34|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|25
35|0 - Patient does NOT have an ostomy for bowel elimination.|0 - Patient does NOT have an ostomy for bowel elimination.|25
36|0 - Patient has no pain|0 - Patient has no pain|25
37|0 - Patient manages all tasks related to equipment completely independently.|0 - Patient manages all tasks related to equipment completely independently.|25
38|0 - Poor:  little or no recovery is expected and/or further decline is imminent|0 - Poor:  little or no recovery is expected and/or further decline is imminent|25
39|0 - Timed-voiding defers incontinence|0 - Timed-voiding defers incontinence|25
40|0 - Very rarely or never has bowel incontinence|0 - Very rarely or never has bowel incontinence|25
41|0 - Zero|0 - Zero|25
42|00 - No|00 - No|25
43|01 - Yes|01 - Yes|25
44|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or mental limitations, needs assistance with heavy laundry.|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or|25
45|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the patient.|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the|25
46|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|25
47|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or supervision from another person OR c) a liquid, pureed or ground meat diet.|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or su|25
48|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|25
49|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|25
50|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independently.|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independe|25
51|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only when assisted or accompanied by another person.|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only w|25
52|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepa|25
53|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance by another person OR b) given daily reminders.|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance b|25
54|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advan|25
55|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advan|25
56|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for the deaf) and call essential numbers.|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for t|25
57|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|25
58|1 - American Indian or Alaska Native|1 - American Indian or Alaska Native|25
59|1 - Depressed mood (e.g., feeling sad, tearful)|1 - Depressed mood (e.g., feeling sad, tearful)|25
60|1 - During the night only|1 - During the night only|25
61|1 - Fully granulating|1 - Fully granulating|25
62|1 - Good/Fair:  partial to full recovery is expected|1 - Good/Fair:  partial to full recovery is expected|25
63|1 - Good:  marked improvement in functional status is expected|1 - Good:  marked improvement in functional status is expected|25
64|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|25
65|1 - Smoking|1 - Smoking|25
66|1 - Hospital|1 - Hospital|25
67|1 - Hospital emergency room (includes 23-hour holding)|1 - Hospital emergency room (includes 23-hour holding)|25
68|1 - Hospitalization for EMERGENT (unscheduled) care|1 - Hospitalization for EMERGENT (unscheduled) care|25
69|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepared solutions), patient is able to manage all other aspects of equipment.|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepar|25
70|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|25
71|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|25
72|1 - In new or complex situations only|1 - In new or complex situations only|25
73|1 - Intravenous or infusion therapy (excludes TPN)|1 - Intravenous or infusion therapy (excludes TPN)|25
74|1 - Less often than daily|1 - Less often than daily|25
75|1 - Less than once a month|1 - Less than once a month|25
76|1 - Less than once weekly|1 - Less than once weekly|25
77|1 - Life expectancy is 6 months or fewer|1 - Life expectancy is 6 months or fewer|25
78|1 - Lives alone|1 - Lives alone|25
79|1 - Male|1 - Male|25
80|1 - Medicare (traditional fee-for-service)|1 - Medicare (traditional fee-for-service)|25
81|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of past 24 hours, significant memory loss so that supervision is required|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of pas|25
82|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors in word choice, grammar or speech intelligibility, needs minimal prompting or assistance).|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors i|25
83|1 - No assistance or services received|1 - No assistance or services received|25
84|1 - One|1 - One|25
85|1 - Oxygen (intermittent or continuous)|1 - Oxygen (intermittent or continuous)|25
86|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, and the surrounding layout, can count fingers at arm's length.|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, a|25
87|1 - Patient is incontinent|1 - Patient is incontinent|25
88|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|25
89|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical or treatment regimen.|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical|25
90|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient/couple/significant other)|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient|25
91|1 - Relatives, friends, or neighbors living outside the home|1 - Relatives, friends, or neighbors living outside the home|25
92|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions.|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions|25
93|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independentl|25
94|1 - Several times during day and night|1 - Several times during day and night|25
95|1 - Spouse or significant other|1 - Spouse or significant other|25
96|1 - Stage 1|1 - Stage 1|25
97|1 - Start of care - further visits planned|1 - Start of care - further visits planned|25
98|1 - Symptoms well controlled with current therapy|1 - Symptoms well controlled with current therapy|25
99|1 - Therapy services|1 - Therapy services|25
100|1 - Able to transfer with minimal human assistance or with use of an assistive device.|1 - Able to transfer with minimal human assistance or with use of an assistive device.|25
101|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitations.|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitatio|25
102|1 - Urinary incontinence|1 - Urinary incontinence|25
103|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and transfer.|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and|25
104|1 - When walking more than 20 feet, climbing stairs|1 - When walking more than 20 feet, climbing stairs|25
105|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary conversation. May need occasional repetition, extra time, or louder voice.|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary c|25
106|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting in and out of tub/shower|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting|25
107|1 - Yes|1 - Yes|25
108|1-RN|1-RN|25
109|10 - Discharge from agency - no visits completed after start/resumption of care assessment|10 - Discharge from agency - no visits completed after start/resumption of care assessment|25
110|10 - Scheduled surgical procedure|10 - Scheduled surgical procedure|25
111|10 - Self-pay|10 - Self-pay|25
112|11 - Other|11 - Other|25
113|11 - Urinary tract infection|11 - Urinary tract infection|25
114|12 - IV catheter-related infection|12 - IV catheter-related infection|25
115|13 - Deep vein thrombosis, pulmonary embolus|13 - Deep vein thrombosis, pulmonary embolus|25
116|14 - Uncontrolled pain|14 - Uncontrolled pain|25
117|15 - Psychotic episode|15 - Psychotic episode|25
118|16 - Other than above reasons|16 - Other than above reasons|25
119|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing calls.|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing|25
120|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another person.|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another pers|25
121|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface a|25
122|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for intermittent supervision or encouragement or reminders, OR (b) to get in and out of the shower or tub, OR (c) for washing difficult to reach areas.|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for inter|25
123|2 - Asian|2 - Asian|25
124|2 - Caregiver requires considerable assistance from another person to manage equipment, but independently completes significant portions of task.|2 - Caregiver requires considerable assistance from another person to manage equipment, but independ|25
125|2 - Daily, but not constantly|2 - Daily, but not constantly|25
126|2 - Daughter or son|2 - Daughter or son|25
127|2 - Doctor's office emergency visit/house call|2 - Doctor's office emergency visit/house call|25
128|2 - During the day and night|2 - During the day and night|25
129|2 - Early/partial granulation|2 - Early/partial granulation|25
130|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors in word choice, organization or speech intelligibility). Speaks in phrases or short sentences.|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors|25
131|2 - Family member's residence|2 - Family member's residence|25
132|2 - Female|2 - Female|25
133|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conversation, needs frequent prompting or assistance.|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conver|25
134|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|25
135|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|25
136|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately stop activities, jeopardizes safety through actions|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately st|25
137|2 - Indwelling/suprapubic catheter|2 - Indwelling/suprapubic catheter|25
138|2 - Injury caused by fall or accident at home|2 - Injury caused by fall or accident at home|25
139|2 - Medicare (HMO/managed care/Advantage plan)|2 - Medicare (HMO/managed care/Advantage plan)|25
140|2 - Nausea, dehydration, malnutrition, constipation, impaction|2 - Nausea, dehydration, malnutrition, constipation, impaction|25
141|2 - Obesity|2 - Obesity|25
142|2 - On awakening or at night only|2 - On awakening or at night only|25
143|2 - Once a month|2 - Once a month|25
144|2 - One to three times weekly|2 - One to three times weekly|25
145|2 - Parenteral nutrition (TPN or lipids)|2 - Parenteral nutrition (TPN or lipids)|25
146|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic) [ Go to M1620 ]|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic) [ Go|25
147|2 - Patient requires considerable assistance from another person to manage equipment, but independently completes portions of the task.|2 - Patient requires considerable assistance from another person to manage equipment, but independen|25
148|2 - Patient transferred to a noninstitutional hospice|2 - Patient transferred to a noninstitutional hospice|25
149|2 - Person residing in the home (EXCLUDING paid help)|2 - Person residing in the home (EXCLUDING paid help)|25
150|2 - Rehabilitation facility|2 - Rehabilitation facility|25
151|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifting of attention) or consistently requires low stimulus environment due to distractibility.|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifti|25
152|2 - Respite care|2 - Respite care|25
153|2 - Sense of failure or self reproach|2 - Sense of failure or self reproach|25
154|2 - Several times during day|2 - Several times during day|25
155|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonresponsive.|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonrespons|25
156|2 - Someone must assist the patient to groom self.|2 - Someone must assist the patient to groom self.|25
157|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|25
158|2 - Someone must help the patient put on upper body clothing.|2 - Someone must help the patient put on upper body clothing.|25
159|2 - Stage 2|2 - Stage 2|25
160|2 - Start of care - no further visits planned|2 - Start of care - no further visits planned|25
161|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitoring|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitori|25
162|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment regimen.|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment re|25
163|2 - Two|2 - Two|25
164|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistance due to cognitive or mental limitation.|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistanc|25
165|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|25
166|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assistance).|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assis|25
167|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home delivery.|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home deli|25
168|2 - Unable to prepare any light meals or reheat any delivered meals.|2 - Unable to prepare any light meals or reheat any delivered meals.|25
169|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|25
170|2 - UNABLE to take injectable medications unless administered by someone else.|2 - UNABLE to take injectable medications unless administered by someone else.|25
171|2 - UNABLE to take medication unless administered by someone else.|2 - UNABLE to take medication unless administered by someone else.|25
172|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|25
173|2 - Ventilator (continually or at night)|2 - Ventilator (continually or at night)|25
174|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less than 20 feet)|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less th|25
175|2 - With spouse or significant other|2 - With spouse or significant other|25
176|2 - Yes, assistance or services provided by family or friends|2 - Yes, assistance or services provided by family or friends|25
177|2-PT|2-PT|25
178|3 - Able to answer the telephone only some of the time or is able to carry on only a limited conversation.|3 - Able to answer the telephone only some of the time or is able to carry on only a limited convers|25
179|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube or gastrostomy.|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube|25
180|3 - Alcohol dependency|3 - Alcohol dependency|25
181|3 - All of the time|3 - All of the time|25
182|3 - Black or African-American|3 - Black or African-American|25
183|3 - Boarding home or rented room|3 - Boarding home or rented room|25
184|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment, clean/store/dispose of equipment or supplies).|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment,|25
185|3 -Able to walk only with the supervision or assistance of another person at all times.|3 -Able to walk only with the supervision or assistance of another person at all times.|25
186|3 - Continuous / Bi-level positive airway pressure|3 - Continuous / Bi-level positive airway pressure|25
187|3 - During the day and evening, but not constantly|3 - During the day and evening, but not constantly|25
188|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the alimentary canal)|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the|25
189|3 - Environmental support (e.g., housing, home maintenance)|3 - Environmental support (e.g., housing, home maintenance)|25
190|3 - Four to six times weekly|3 - Four to six times weekly|25
191|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessing by listener.  Speech limited to single words or short phrases.|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessin|25
192|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires multiple repetitions, restatements, demonstrations, additional time.|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires m|25
193|3 - Hopelessness|3 - Hopelessness|25
194|3 - Hospice care|3 - Hospice care|25
195|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|25
196|3 - Injury caused by fall or accident at home|3 - Injury caused by fall or accident at home|25
197|3 - Intractable pain|3 - Intractable pain|25
198|3 - Medicaid (traditional fee-for-service)|3 - Medicaid (traditional fee-for-service)|25
199|3 - Needs someone to do all shopping and errands.|3 - Needs someone to do all shopping and errands.|25
200|3 - Not healing|3 - Not healing|25
201|3 - Nursing home|3 - Nursing home|25
202|3 - Once daily|3 - Once daily|25
203|3 - Other family member|3 - Other family member|25
204|3 - Outpatient department/clinic emergency (includes urgicenter sites)|3 - Outpatient department/clinic emergency (includes urgicenter sites)|25
205|3 - Paid help|3 - Paid help|25
206|3 - Able to participate in bathing self in shower or tub, but requires presence of another person throughout the bath for assistance or supervision.|3 - Able to participate in bathing self in shower or tub, but requires presence of another person th|25
207|3 - Patient depends entirely upon another person to dress lower body.|3 - Patient depends entirely upon another person to dress lower body.|25
208|3 - Patient depends entirely upon another person to dress the upper body.|3 - Patient depends entirely upon another person to dress the upper body.|25
209|3 - Patient depends entirely upon someone else for grooming needs.|3 - Patient depends entirely upon someone else for grooming needs.|25
210|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone else to manage the equipment.|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone|25
211|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable to shift attention and recall directions more than half the time.|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable|25
212|3 - Respiratory problems (SOB, infection, obstruction)|3 - Respiratory problems (SOB, infection, obstruction)|25
213|3 - Resumption of care (after inpatient stay)|3 - Resumption of care (after inpatient stay)|25
214|3 - Several times each month|3 - Several times each month|25
215|3 - Skilled Nursing Facility|3 - Skilled Nursing Facility|25
216|3 - Stage 3|3 - Stage 3|25
217|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|25
218|3 - Three|3 - Three|25
219|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person throughout the process.|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person through|25
220|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal independently.|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal indep|25
221|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person.|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person|25
222|3 - Unknown because patient moved to a geographic location not served by this agency|3 - Unknown because patient moved to a geographic location not served by this agency|25
223|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|25
224|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|25
225|3 - With other family member|3 - With other family member|25
226|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home health services, homemaker assistance, transportation assistance, assisted living, board and care)|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home h|25
227|3-SLP/ST|3-SLP/ST|25
228|4 - At rest (during day or night)|4 - At rest (during day or night)|25
229|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|25
230|4 - Board and care or assisted living facility|4 - Board and care or assisted living facility|25
231|4 - Caregiver is completely dependent on someone else to manage all equipment.|4 - Caregiver is completely dependent on someone else to manage all equipment.|25
232|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|25
233|4 - Constantly|4 - Constantly|25
234|4 - Drug dependency|4 - Drug dependency|25
235|4 - Four or more|4 - Four or more|25
236|4 - Friend or neighbor or community or church member|4 - Friend or neighbor or community or church member|25
237|4 - Hispanic or Latino|4 - Hispanic or Latino|25
238|4 - Hospice|4 - Hospice|25
239|4 - Impaired decision-making|4 - Impaired decision-making|25
240|4 - Is totally dependent in toileting.|4 - Is totally dependent in toileting.|25
241|4 - Medicaid (HMO/managed care)|4 - Medicaid (HMO/managed care)|25
242|4 - None of the above|4 - None of the above|25
243|4 - Nursing home|4 - Nursing home|25
244|4 - On a daily basis|4 - On a daily basis|25
245|4 - Patient is completely dependent on someone else to manage all equipment.|4 - Patient is completely dependent on someone else to manage all equipment.|25
246|4 - Permanent placement|4 - Permanent placement|25
247|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, punches, dangerous maneuvers w/ wheelchair or other objects)|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, pu|25
248|4 - Psychosocial support (e.g., socialization, companionship, recreation)|4 - Psychosocial support (e.g., socialization, companionship, recreation)|25
249|4 - Recertification (follow-up) reassessment|4 - Recertification (follow-up) reassessment|25
250|4 - Recurrent thoughts of death|4 - Recurrent thoughts of death|25
251|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruction)|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruc|25
252|4 - Several times a week|4 - Several times a week|25
253|4 - Stage 4|4 - Stage 4|25
254|4 - Symptoms poorly controlled, history of re-hospitalizations|4 - Symptoms poorly controlled, history of re-hospitalizations|25
255|4 - Three or more times per week|4 - Three or more times per week|25
256|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetative state, or delirium.|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetati|25
257|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|25
258|4 - Unable to effectively participate in any housekeeping tasks.|4 - Unable to effectively participate in any housekeeping tasks.|25
259|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or unresponsive (e.g., speech is nonsensical or unintelligible).|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or u|25
260|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonresponsive.|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonr|25
261|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostomy.|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostom|25
262|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of devices at the sink, in chair, or on commode|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of|25
263|4 - With a friend|4 - With a friend|25
264|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|25
265|4-OT|4-OT|25
266|5 - Advocates or facilitates patient's participation in appropriate medical care|5 - Advocates or facilitates patient's participation in appropriate medical care|25
267|5 - At least daily|5 - At least daily|25
268|6 - Bedfast, unable to ambulate or be up in a chair.|6 - Bedfast, unable to ambulate or be up in a chair.|25
269|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|25
270|5 - Disruptive or socially inappropriate behavior|5 - Disruptive or socially inappropriate behavior|25
271|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|25
272|5 - Hypo/Hyperglycemia, diabetes out of control|5 - Hypo/Hyperglycemia, diabetes out of control|25
273|5 - More often than once daily|5 - More often than once daily|25
274|5 - Native Hawaiian or Pacific Islander|5 - Native Hawaiian or Pacific Islander|25
275|5 - None of the above|5 - None of the above|25
276|5 - One to two times per week|5 - One to two times per week|25
277|5 - Other|5 - Other|25
278|5 - Other follow-up|5 - Other follow-up|25
279|5 - Paid help|5 - Paid help|25
280|5 - Patient nonresponsive or unable to speak.|5 - Patient nonresponsive or unable to speak.|25
281|5 - Thoughts of suicide|5 - Thoughts of suicide|25
282|5 - Totally unable to use the telephone.|5 - Totally unable to use the telephone.|25
283|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|25
284|5 - Unable to take in nutrients orally or by tube feeding.|5 - Unable to take in nutrients orally or by tube feeding.|25
285|5 - Unsafe for care at home|5 - Unsafe for care at home|25
286|5 - With paid help (other than home care agency staff)|5 - With paid help (other than home care agency staff)|25
287|5 - Workers' compensation|5 - Workers' compensation|25
288|5 - Wound infection, deteriorating wound status, new lesion/ulcer|5 - Wound infection, deteriorating wound status, new lesion/ulcer|25
289|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|25
290|6 - Delusional, hallucinatory, or paranoid behavior|6 - Delusional, hallucinatory, or paranoid behavior|25
291|6 - Financial agent, power of attorney, or conservator of finance|6 - Financial agent, power of attorney, or conservator of finance|25
292|6 - GI bleeding, obstruction|6 - GI bleeding, obstruction|25
293|6 - Less often than weekly|6 - Less often than weekly|25
294|6 - Memory loss to the extent that supervision required|6 - Memory loss to the extent that supervision required|25
295|6 - None of the above feelings observed or reported|6 - None of the above feelings observed or reported|25
296|6 - Other|6 - Other|25
297|6 - Title programs (e.g., Title III, V, or XX)|6 - Title programs (e.g., Title III, V, or XX)|25
298|6 - Transferred to an inpatient facility - patient not discharged from agency|6 - Transferred to an inpatient facility - patient not discharged from agency|25
299|6 - White|6 - White|25
300|6 - With other than above|6 - With other than above|25
301|7 - Exacerbation of CHF, fluid overload, heart failure|7 - Exacerbation of CHF, fluid overload, heart failure|25
302|7 - Health care agent, conservator of person, or medical power of attorney|7 - Health care agent, conservator of person, or medical power of attorney|25
303|7 - Hypo/Hyperglycemia, diabetes out of control|7 - Hypo/Hyperglycemia, diabetes out of control|25
304|7 - None of the above|7 - None of the above|25
305|7 - None of the above behaviors demonstrated|7 - None of the above behaviors demonstrated|25
306|7 - Other government (e.g., TriCare, VA, etc.)|7 - Other government (e.g., TriCare, VA, etc.)|25
307|7 - Transferred to an inpatient facility - patient discharged from agency|7 - Transferred to an inpatient facility - patient discharged from agency|25
308|8 - Death at home|8 - Death at home|25
309|8 - GI bleeding, obstruction|8 - GI bleeding, obstruction|25
310|8 - Myocardial infarction, stroke|8 - Myocardial infarction, stroke|25
311|8 - Private insurance|8 - Private insurance|25
312|9 - Chemotherapy|9 - Chemotherapy|25
313|9 - Discharge from agency|9 - Discharge from agency|25
314|9 - Other than above reasons|9 - Other than above reasons|25
315|9 - Private HMO/managed care|9 - Private HMO/managed care|25
316|NA - No caregiver|NA - No caregiver|25
317|NA - No equipment of this type used in care.|NA - No equipment of this type used in care.|25
318|NA - No inhalant/mist medications prescribed.|NA - No inhalant/mist medications prescribed.|25
319|NA - No injectable medications prescribed.|NA - No injectable medications prescribed.|25
320|NA - No inpatient facility admission|NA - No inpatient facility admission|25
321|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|25
322|NA - No Medicaid|NA - No Medicaid|25
323|NA - No Medicare|NA - No Medicare|25
324|NA - No observable pressure ulcer or unhealed pressure ulcer|NA - No observable pressure ulcer or unhealed pressure ulcer|25
325|NA - No observable stasis ulcer|NA - No observable stasis ulcer|25
326|NA - No observable surgical wound|NA - No observable surgical wound|25
327|NA - No oral medications prescribed.|NA - No oral medications prescribed.|25
328|NA - Not applicable|NA - Not applicable|25
329|NA - Patient does not have a telephone.|NA - Patient does not have a telephone.|25
330|NA - Patient has ostomy for bowel elimination|NA - Patient has ostomy for bowel elimination|25
331|NA - Patient nonresponsive|NA - Patient nonresponsive|25
332|NA - Patient on prophylactic treatment|NA - Patient on prophylactic treatment|25
333|NA - Patient was not discharged from an inpatient facility [Go to M1016 ]|NA - Patient was not discharged from an inpatient facility [Go to M1016 ]|25
334|UK - Other unknown|UK - Other unknown|25
335|UK - Reason unknown|UK - Reason unknown|25
336|UK - Unknown|UK - Unknown|25
337|UK - Unknown or Not Available|UK - Unknown or Not Available|25
341|01 - Early|01 - Early|25
342|02 - Late|02 - Late|25
343|NA - Not Applicable. No case mix group defined for this assessment.|NA - Not Applicable. No case mix group defined for this assessment.|25
344|NA - No case mix group defined by this assessment.|NA - No case mix group defined by this assessment.|25
345|1 - Recent decline in mental, emotional, or behavioral status|1 - Recent decline in mental, emotional, or behavioral status|25
346|2 - Multiple hospitalizations (2 or more) in the past 12 months|2 - Multiple hospitalizations (2 or more) in the past 12 months|25
347|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|25
348|4 - Taking five or more medications|4 - Taking five or more medications|25
349|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|25
350|6 - Other|6 - Other|25
351|7 - None of the above|7 - None of the above|25
352|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond tho|25
353|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable without heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable wi|25
354|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious complications and death.|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious compl|25
355|3 - The patient has serious progressive conditions that could lead to death within a year.|3 - The patient has serious progressive conditions that could lead to death within a year.|25
356|UK - The patient+s situation is unknown or unclear.|UK - The patient+s situation is unknown or unclear.|25
357|1 - Yes [ Go to M1050 ]|1 - Yes [ Go to M1050 ]|25
358|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this influenza season. [ Go to M1050 ]|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this i|25
359|1 - Received from another health care provider (e.g., physician)|1 - Received from another health care provider (e.g., physician)|25
360|2 - Received from your agency previously during this year+s flu season|2 - Received from your agency previously during this year+s flu season|25
361|3 - Offered and declined|3 - Offered and declined|25
362|4 - Assessed and determined to have medical contraindication(s)|4 - Assessed and determined to have medical contraindication(s)|25
363|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|25
364|6 - Inability to obtain vaccine due to declared shortage|6 - Inability to obtain vaccine due to declared shortage|25
365|1 - Yes [ Go to M1500 at TRN; Go to M1230 at DC ]|1 - Yes [ Go to M1500 at TRN; Go to M1230 at DC ]|25
366|1 - Patient has received PPV in the past|1 - Patient has received PPV in the past|25
367|2 - Offered and declined|2 - Offered and declined|25
368|3 - Assessed and determined to have medical contraindication(s)|3 - Assessed and determined to have medical contraindication(s)|25
369|4 - Not indicated; patient does not meet age/condition guidelines for PPV|4 - Not indicated; patient does not meet age/condition guidelines for PPV|25
370|5 - None of the above|5 - None of the above|25
371|0 - Adequate: hears normal conversation without difficulty.|0 - Adequate: hears normal conversation without difficulty.|25
372|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to increase volume or speak distinctly.|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to in|25
373|2 - Severely Impaired: absence of useful hearing.|2 - Severely Impaired: absence of useful hearing.|25
374|UK - Unable to assess hearing.|UK - Unable to assess hearing.|25
375|0 - Understands: clear comprehension without cues or repetitions.|0 - Understands: clear comprehension without cues or repetitions.|25
376|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Requires cues at times to understand.|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Req|25
377|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequently requires cues to understand.|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequentl|25
378|3 - Rarely/Never Understands|3 - Rarely/Never Understands|25
379|UK - Unable to assess understanding.|UK - Unable to assess understanding.|25
380|0 - No standardized assessment conducted|0 - No standardized assessment conducted|25
381|1 - Yes, and it does not indicate severe pain|1 - Yes, and it does not indicate severe pain|25
382|2 - Yes, and it indicates severe pain|2 - Yes, and it indicates severe pain|25
383|0 - Patient has no pain|0 - Patient has no pain|25
384|1 - Patient has pain that does not interfere with activity or movement|1 - Patient has pain that does not interfere with activity or movement|25
385|2 - Less often than daily|2 - Less often than daily|25
386|3 - Daily, but not constantly|3 - Daily, but not constantly|25
387|4 - All of the time|4 - All of the time|25
388|0 - No assessment conducted [ Go to M1306 ]|0 - No assessment conducted [ Go to M1306 ]|25
389|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc., without use of standardized tool|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc.,|25
390|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|25
391|0 - No [ Go to M1322]|0 - No [ Go to M1322]|25
392|0 v Newly epithelialized|0 v Newly epithelialized|25
393|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|25
394|2 - Yes, patient has observable stasis ulcers ONLY|2 - Yes, patient has observable stasis ulcers ONLY|25
395|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable dressing) [Go to M1340]|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable|25
396|0 - No [ Go to M1350 ]|0 - No [ Go to M1350 ]|25
397|1 - Yes, patient has at least one (observable) surgical wound|1 - Yes, patient has at least one (observable) surgical wound|25
398|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1350 ]|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1350 ]|25
399|0 - Patient is not short of breath|0 - Patient is not short of breath|25
400|3 - Continuous Bi-level positive airway pressure|3 - Continuous Bi-level positive airway pressure|25
401|0 - No [ Go to M1732 at TRN; Go to M1600 at DC ]|0 - No [ Go to M1732 at TRN; Go to M1600 at DC ]|25
402|2 - Not assessed [Go to M1732 at TRN; Go to M1600 at DC ]|2 - Not assessed [Go to M1732 at TRN; Go to M1600 at DC ]|25
403|NA - Patient does not have diagnosis of heart failure [Go to M2004 at TRN; Go to M1600 at DC]|NA - Patient does not have diagnosis of heart failure [Go to M2004 at TRN; Go to M1600 at DC]|25
404|0 - No action taken|0 - No action taken|25
405|1 - Patient+s physician (or other primary care practitioner) contacted the same day|1 - Patient+s physician (or other primary care practitioner) contacted the same day|25
406|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|25
407|3 - Implement physician-ordered patient-specific established parameters for treatment|3 - Implement physician-ordered patient-specific established parameters for treatment|25
408|4 - Patient education or other clinical interventions|4 - Patient education or other clinical interventions|25
409|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequency, telehealth, etc.)|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequ|25
410|1 - Occasional stress incontinence|1 - Occasional stress incontinence|25
411|2 - During the night only|2 - During the night only|25
412|3 - During the day only|3 - During the day only|25
413|4 - During the day and night|4 - During the day and night|25
414|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|25
415|0 - Able to manage toileting hygiene and clothing management without assistance.|0 - Able to manage toileting hygiene and clothing management without assistance.|25
416|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implements are laid out for the patient.|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implemen|25
417|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|25
418|3 - Patient depends entirely upon another person to maintain toileting hygiene.|3 - Patient depends entirely upon another person to maintain toileting hygiene.|25
419|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independent|25
420|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface|25
421|0 - No multi-factor falls risk assessment conducted.|0 - No multi-factor falls risk assessment conducted.|25
422|1 - Yes, and it does not indicate a risk for falls.|1 - Yes, and it does not indicate a risk for falls.|25
423|2 - Yes, and it indicates a risk for falls.|2 - Yes, and it indicates a risk for falls.|25
424|0 - Not assessed/reviewed [ Go to M2010 ]|0 - Not assessed/reviewed [ Go to M2010 ]|25
425|1 - No problems found during review [ Go to M2010 ]|1 - No problems found during review [ Go to M2010 ]|25
426|2 - Problems found during review|2 - Problems found during review|25
427|NA - Patient is not taking any medications [ Go to M2040 ]|NA - Patient is not taking any medications [ Go to M2040 ]|25
428|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special precautions associated with all high-risk medications|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special p|25
429|NA - Patient not taking any drugs|NA - Patient not taking any drugs|25
430|2 - Able to take medication(s) at the correct times if given reminders by another person at the appropriate times|2 - Able to take medication(s) at the correct times if given reminders by another person at the appr|25
431|3 - Unable to take medication unless administered by another person.|3 - Unable to take medication unless administered by another person.|25
432|1 - At least daily|1 - At least daily|25
433|2 - Three or more times per week|2 - Three or more times per week|25
434|3 - One to two times per week|3 - One to two times per week|25
435|4 - Received, but less often than weekly|4 - Received, but less often than weekly|25
436|5 - No assistance received|5 - No assistance received|25
437|0 - No [Go to M2400]|0 - No [Go to M2400]|25
438|1 - Yes, used hospital emergency department WITHOUT hospital admission|1 - Yes, used hospital emergency department WITHOUT hospital admission|25
439|2 - Yes, used hospital emergency department WITH hospital admission|2 - Yes, used hospital emergency department WITH hospital admission|25
440|UK - Unknown [Go to M2400]|UK - Unknown [Go to M2400]|25
441|2 - Injury caused by fall|2 - Injury caused by fall|25
442|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|25
443|4 - Other respiratory problem|4 - Other respiratory problem|25
444|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|25
445|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|25
446|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|25
447|8 - Other heart disease|8 - Other heart disease|25
448|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|25
449|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|25
450|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|25
451|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|25
452|13 - Urinary tract infection|13 - Urinary tract infection|25
453|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|25
454|15 - Wound infection or deterioration|15 - Wound infection or deterioration|25
455|16 - Uncontrolled pain|16 - Uncontrolled pain|25
456|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|25
457|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|25
458|19 - Other than above reasons|19 - Other than above reasons|25
459|2 - Patient remained in the community (with formal assistive services)|2 - Patient remained in the community (with formal assistive services)|25
460|3 - Patient transferred to a noninstitutional hospice|3 - Patient transferred to a noninstitutional hospice|25
461|4 - Unknown because patient moved to a geographic location not served by this agency|4 - Unknown because patient moved to a geographic location not served by this agency|25
462|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|25
463|4 - Other respiratory problem|4 - Other respiratory problem|25
464|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|25
465|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|25
466|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|25
467|8 - Other heart disease|8 - Other heart disease|25
468|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|25
469|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|25
470|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|25
471|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|25
472|13 - Urinary tract infection|13 - Urinary tract infection|25
473|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|25
474|15 - Wound infection or deterioration|15 - Wound infection or deterioration|25
475|16 - Uncontrolled pain|16 - Uncontrolled pain|25
476|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|25
477|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|25
478|19 - Scheduled treatment or procedure|19 - Scheduled treatment or procedure|25
479|20 - Other than above reasons|20 - Other than above reasons|25
480|UK - Reason unknown [Go to M0903]|UK - Reason unknown [Go to M0903]|25
482|01 - Patient lives alone around the clock|01 - Patient lives alone around the clock|25
483|02 - Patient lives alone regular daytime|02 - Patient lives alone regular daytime|25
484|03 - Patient lives alone regular nighttime|03 - Patient lives alone regular nighttime|25
485|04 - Patient lives alone occassional/short term assistance|04 - Patient lives alone occassional/short term assistance|25
486|05 - Patient lives alone no assisstance available|05 - Patient lives alone no assisstance available|25
487|06 - Patient lives with other person(s) in the home around the clock|06 - Patient lives with other person(s) in the home around the clock|25
488|07 - Patient lives with other person(s) in the home regular daytime|07 - Patient lives with other person(s) in the home regular daytime|25
489|08 - Patient lives with other person(s) in the home regular nighttime|08 - Patient lives with other person(s) in the home regular nighttime|25
490|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|25
491|10 - Patient lives with other person(s) in the home no assistance available|10 - Patient lives with other person(s) in the home no assistance available|25
492|1 - Was present at the most recent SOC/ROC assessment|1 - Was present at the most recent SOC/ROC assessment|25
493|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|25
494|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|25
495|0 - Newly epithelialized|0 - Newly epithelialized|25
496|0 - No [ Go to M1340 ]|0 - No [ Go to M1340 ]|25
498|0 - Independent|0 - Independent|25
499|1 - Needed Some Help|1 - Needed Some Help|25
500|2 - Dependent|2 - Dependent|25
502|0 - No assistance needed in this area|0 - No assistance needed in this area|25
503|1 - Caregiver(s) currently provide assistance|1 - Caregiver(s) currently provide assistance|25
504|2 - Caregiver(s) need training/ supportive services to provide assistance|2 - Caregiver(s) need training/ supportive services to provide assistance|25
505|3 - Caregiver(s) not likely to provide assistance|3 - Caregiver(s) not likely to provide assistance|25
506|4 - Unclear if Caregiver(s) will provide assistance|4 - Unclear if Caregiver(s) will provide assistance|25
507|5 - Assistance needed, but no Caregiver(s) available|5 - Assistance needed, but no Caregiver(s) available|25
508|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will use standardized clinical guidelines accessible for all care providers to reference|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will|25
510|NA - Patient is not assessed to be at risk for falls|NA - Patient is not assessed to be at risk for falls|25
511|NA - Patient has no diagnosis or symptoms of depression|NA - Patient has no diagnosis or symptoms of depression|25
512|NA - No pain identified|NA - No pain identified|25
513|NA - Patient is not assessed to be at risk for pressure ulcers|NA - Patient is not assessed to be at risk for pressure ulcers|25
514|NA - Patient has no pressure ulcers with need for moist wound healing|NA - Patient has no pressure ulcers with need for moist wound healing|25
515|1 - Long-term nursing facility (NF)|1 - Long-term nursing facility (NF)|25
516|2 - Skilled nursing facility (SNF / TCU)|2 - Skilled nursing facility (SNF / TCU)|25
517|3 - Short stay acute hospital (IPP S)|3 - Short stay acute hospital (IPP S)|25
518|4 - Long-term care hospital (LTCH)|4 - Long-term care hospital (LTCH)|25
519|5 - Inpatient rehabilitation hospital or unit (IRF)|5 - Inpatient rehabilitation hospital or unit (IRF)|25
520|6 - Psychiatric hospital or unit|6 - Psychiatric hospital or unit|25
521|7 - Other|7 - Other|25
522|NA - Patient was not discharged from an inpatient facility [Goto M1016]|NA - Patient was not discharged from an inpatient facility [Goto M1016]|25
523|6 - Unable to participate effectively in bathing and is bathed totally by another person|6 - Unable to participate effectively in bathing and is bathed totally by another person|25
524|4 - Chairfast, unable to ambulate but is able to wheel self independently.|4 - Chairfast, unable to ambulate but is able to wheel self independently.|25
525|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask patient: "Over the last two weeks, how often have you been bothered by any of the following problems")   *Copyright+ Pfizer Inc. All rights reserved. Reproduced with permission.|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask|25
526|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluation for depression.|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluat|25
527|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet criteria for further evaluation for depression.|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet|25
528|0 - Not at all  0 - 1 day|0 - Not at all  0 - 1 day|25
529|1 - Several days  2 - 6 days|1 - Several days  2 - 6 days|25
530|2 - More than half of the days  7 - 11 days|2 - More than half of the days  7 - 11 days|25
531|3 - Nearly every day  12 - 14 days|3 - Nearly every day  12 - 14 days|25
532|NA - N/A  Unable to respond|NA - N/A  Unable to respond|25
533|2 - Able to take medication(s) at the correct times if given reminders by another person based on the frequency of the injection|2 - Able to take medication(s) at the correct times if given reminders by another person based on th|25
534|3 - Unable to take injectable medication unless administered by another person.|3 - Unable to take injectable medication unless administered by another person.|25
2|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; OR (b) Is physically, cognitively, and mentally able to prepare light meals on a regular basis but has not routinely performed light meal preparation in the past (i.e., prior to this home care admission).|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; O|26
3|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and mentally able to perform all housekeeping tasks .|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and menta|26
4|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and mentally able to do laundry and access facilities.|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and menta|26
5|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying packages OR b) Physically, cognitively, and mentally able to take care of shopping, but has not done shopping in the past (i.e., prior to this home care admission).|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying|26
6|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|26
7|0 - Able to dial numbers and answer calls appropriately and as desired.|0 - Able to dial numbers and answer calls appropriately and as desired.|26
8|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body without assistance.|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body|26
9|0 - Able to get to and from the toilet and transfer independently with or without a device.|0 - Able to get to and from the toilet and transfer independently with or without a device.|26
10|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|26
11|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible public bus.|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible p|26
12|0 - Able to independently feed self.|0 - Able to independently feed self.|26
13|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|26
14|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct times.|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct ti|26
15|0 - Able to independently transfer.|0 - Able to independently transfer.|26
16|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without rail|26
17|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings|26
18|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|26
19|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions independently.|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions indep|26
20|0 - Asymptomatic, no treatment needed at this time|0 - Asymptomatic, no treatment needed at this time|26
21|0 - Caregiver manages all tasks related to equipment completely independently.|0 - Caregiver manages all tasks related to equipment completely independently.|26
22|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations with no observable impairment.|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations w|26
23|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|26
24|0 - Life expectancy is greater than 6 months|0 - Life expectancy is greater than 6 months|26
25|0 - Never|0 - Never|26
26|0 - Patient is not short of breath|0 - Patient is not short of breath|26
27|0 - No|0 - No|26
28|0 - No emergent care services|0 - No emergent care services|26
29|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [Goto 1620]|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [Goto 1620]|26
30|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and extended or abstract conversation.|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and exte|26
31|0 - No one person|0 - No one person|26
32|0 - None of the time|0 - None of the time|26
33|0 - None, no charge for current services|0 - None, no charge for current services|26
34|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|26
35|0 - Patient does NOT have an ostomy for bowel elimination.|0 - Patient does NOT have an ostomy for bowel elimination.|26
36|0 - Patient has no pain|0 - Patient has no pain|26
37|0 - Patient manages all tasks related to equipment completely independently.|0 - Patient manages all tasks related to equipment completely independently.|26
38|0 - Poor:  little or no recovery is expected and/or further decline is imminent|0 - Poor:  little or no recovery is expected and/or further decline is imminent|26
39|0 - Timed-voiding defers incontinence|0 - Timed-voiding defers incontinence|26
40|0 - Very rarely or never has bowel incontinence|0 - Very rarely or never has bowel incontinence|26
41|0 - Zero|0 - Zero|26
42|00 - No|00 - No|26
43|01 - Yes|01 - Yes|26
44|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or mental limitations, needs assistance with heavy laundry.|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or|26
45|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the patient.|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the|26
46|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|26
47|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or supervision from another person OR c) a liquid, pureed or ground meat diet.|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or su|26
48|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|26
49|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|26
50|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independently.|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independe|26
51|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only when assisted or accompanied by another person.|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only w|26
52|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepa|26
53|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance by another person OR b) given daily reminders.|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance b|26
54|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advan|26
55|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advan|26
56|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for the deaf) and call essential numbers.|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for t|26
57|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|26
58|1 - American Indian or Alaska Native|1 - American Indian or Alaska Native|26
59|1 - Depressed mood (e.g., feeling sad, tearful)|1 - Depressed mood (e.g., feeling sad, tearful)|26
60|1 - During the night only|1 - During the night only|26
61|1 - Fully granulating|1 - Fully granulating|26
62|1 - Good/Fair:  partial to full recovery is expected|1 - Good/Fair:  partial to full recovery is expected|26
63|1 - Good:  marked improvement in functional status is expected|1 - Good:  marked improvement in functional status is expected|26
64|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|26
65|1 - Smoking|1 - Smoking|26
66|1 - Hospital|1 - Hospital|26
67|1 - Hospital emergency room (includes 23-hour holding)|1 - Hospital emergency room (includes 23-hour holding)|26
68|1 - Hospitalization for EMERGENT (unscheduled) care|1 - Hospitalization for EMERGENT (unscheduled) care|26
69|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepared solutions), patient is able to manage all other aspects of equipment.|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepar|26
70|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|26
71|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|26
72|1 - In new or complex situations only|1 - In new or complex situations only|26
73|1 - Intravenous or infusion therapy (excludes TPN)|1 - Intravenous or infusion therapy (excludes TPN)|26
74|1 - Less often than daily|1 - Less often than daily|26
75|1 - Less than once a month|1 - Less than once a month|26
76|1 - Less than once weekly|1 - Less than once weekly|26
77|1 - Life expectancy is 6 months or fewer|1 - Life expectancy is 6 months or fewer|26
78|1 - Lives alone|1 - Lives alone|26
79|1 - Male|1 - Male|26
80|1 - Medicare (traditional fee-for-service)|1 - Medicare (traditional fee-for-service)|26
81|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of past 24 hours, significant memory loss so that supervision is required|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of pas|26
82|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors in word choice, grammar or speech intelligibility, needs minimal prompting or assistance).|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors i|26
83|1 - No assistance or services received|1 - No assistance or services received|26
84|1 - One|1 - One|26
85|1 - Oxygen (intermittent or continuous)|1 - Oxygen (intermittent or continuous)|26
86|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, and the surrounding layout, can count fingers at arm's length.|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, a|26
87|1 - Patient is incontinent|1 - Patient is incontinent|26
88|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|26
89|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical or treatment regimen.|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical|26
90|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient/couple/significant other)|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient|26
91|1 - Relatives, friends, or neighbors living outside the home|1 - Relatives, friends, or neighbors living outside the home|26
92|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions.|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions|26
93|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independentl|26
94|1 - Several times during day and night|1 - Several times during day and night|26
95|1 - Spouse or significant other|1 - Spouse or significant other|26
96|1 - Stage 1|1 - Stage 1|26
97|1 - Start of care - further visits planned|1 - Start of care - further visits planned|26
98|1 - Symptoms well controlled with current therapy|1 - Symptoms well controlled with current therapy|26
99|1 - Therapy services|1 - Therapy services|26
100|1 - Able to transfer with minimal human assistance or with use of an assistive device.|1 - Able to transfer with minimal human assistance or with use of an assistive device.|26
101|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitations.|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitatio|26
102|1 - Urinary incontinence|1 - Urinary incontinence|26
103|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and transfer.|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and|26
104|1 - When walking more than 20 feet, climbing stairs|1 - When walking more than 20 feet, climbing stairs|26
105|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary conversation. May need occasional repetition, extra time, or louder voice.|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary c|26
106|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting in and out of tub/shower|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting|26
107|1 - Yes|1 - Yes|26
108|1-RN|1-RN|26
109|10 - Discharge from agency - no visits completed after start/resumption of care assessment|10 - Discharge from agency - no visits completed after start/resumption of care assessment|26
110|10 - Scheduled surgical procedure|10 - Scheduled surgical procedure|26
111|10 - Self-pay|10 - Self-pay|26
112|11 - Other|11 - Other|26
113|11 - Urinary tract infection|11 - Urinary tract infection|26
114|12 - IV catheter-related infection|12 - IV catheter-related infection|26
115|13 - Deep vein thrombosis, pulmonary embolus|13 - Deep vein thrombosis, pulmonary embolus|26
116|14 - Uncontrolled pain|14 - Uncontrolled pain|26
117|15 - Psychotic episode|15 - Psychotic episode|26
118|16 - Other than above reasons|16 - Other than above reasons|26
119|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing calls.|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing|26
120|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another person.|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another pers|26
121|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface a|26
122|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for intermittent supervision or encouragement or reminders, OR (b) to get in and out of the shower or tub, OR (c) for washing difficult to reach areas.|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for inter|26
123|2 - Asian|2 - Asian|26
124|2 - Caregiver requires considerable assistance from another person to manage equipment, but independently completes significant portions of task.|2 - Caregiver requires considerable assistance from another person to manage equipment, but independ|26
125|2 - Daily, but not constantly|2 - Daily, but not constantly|26
126|2 - Daughter or son|2 - Daughter or son|26
127|2 - Doctor's office emergency visit/house call|2 - Doctor's office emergency visit/house call|26
128|2 - During the day and night|2 - During the day and night|26
129|2 - Early/partial granulation|2 - Early/partial granulation|26
130|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors in word choice, organization or speech intelligibility). Speaks in phrases or short sentences.|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors|26
131|2 - Family member's residence|2 - Family member's residence|26
132|2 - Female|2 - Female|26
133|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conversation, needs frequent prompting or assistance.|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conver|26
134|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|26
135|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|26
136|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately stop activities, jeopardizes safety through actions|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately st|26
137|2 - Indwelling/suprapubic catheter|2 - Indwelling/suprapubic catheter|26
138|2 - Injury caused by fall|2 - Injury caused by fall|26
139|2 - Medicare (HMO/managed care/Advantage plan)|2 - Medicare (HMO/managed care/Advantage plan)|26
140|2 - Nausea, dehydration, malnutrition, constipation, impaction|2 - Nausea, dehydration, malnutrition, constipation, impaction|26
141|2 - Obesity|2 - Obesity|26
142|2 - On awakening or at night only|2 - On awakening or at night only|26
143|2 - Once a month|2 - Once a month|26
144|2 - One to three times weekly|2 - One to three times weekly|26
145|2 - Parenteral nutrition (TPN or lipids)|2 - Parenteral nutrition (TPN or lipids)|26
146|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic) [ Go to M1620]|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic) [ Go|26
147|2 - Patient requires considerable assistance from another person to manage equipment, but independently completes portions of the task.|2 - Patient requires considerable assistance from another person to manage equipment, but independen|26
148|2 - Patient transferred to a noninstitutional hospice|2 - Patient transferred to a noninstitutional hospice|26
149|2 - Person residing in the home (EXCLUDING paid help)|2 - Person residing in the home (EXCLUDING paid help)|26
150|2 - Rehabilitation facility|2 - Rehabilitation facility|26
151|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifting of attention) or consistently requires low stimulus environment due to distractibility.|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifti|26
152|2 - Respite care|2 - Respite care|26
153|2 - Sense of failure or self reproach|2 - Sense of failure or self reproach|26
154|2 - Several times during day|2 - Several times during day|26
155|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonresponsive.|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonrespons|26
156|2 - Someone must assist the patient to groom self.|2 - Someone must assist the patient to groom self.|26
157|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|26
158|2 - Someone must help the patient put on upper body clothing.|2 - Someone must help the patient put on upper body clothing.|26
159|2 - Stage 2|2 - Stage 2|26
160|2 - Start of care - no further visits planned|2 - Start of care - no further visits planned|26
161|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitoring|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitori|26
162|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment regimen.|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment re|26
163|2 - Two|2 - Two|26
164|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistance due to cognitive or mental limitation.|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistanc|26
165|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|26
166|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assistance).|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assis|26
167|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home delivery.|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home deli|26
168|2 - Unable to prepare any light meals or reheat any delivered meals.|2 - Unable to prepare any light meals or reheat any delivered meals.|26
169|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|26
170|2 - UNABLE to take injectable medications unless administered by someone else.|2 - UNABLE to take injectable medications unless administered by someone else.|26
171|2 - UNABLE to take medication unless administered by someone else.|2 - UNABLE to take medication unless administered by someone else.|26
172|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|26
173|2 - Ventilator (continually or at night)|2 - Ventilator (continually or at night)|26
174|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less than 20 feet)|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less th|26
175|2 - With spouse or significant other|2 - With spouse or significant other|26
176|2 - Yes, assistance or services provided by family or friends|2 - Yes, assistance or services provided by family or friends|26
177|2-PT|2-PT|26
178|3 - Able to answer the telephone only some of the time or is able to carry on only a limited conversation.|3 - Able to answer the telephone only some of the time or is able to carry on only a limited convers|26
179|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube or gastrostomy.|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube|26
180|3 - Alcohol dependency|3 - Alcohol dependency|26
181|3 - All of the time|3 - All of the time|26
182|3 - Black or African-American|3 - Black or African-American|26
183|3 - Boarding home or rented room|3 - Boarding home or rented room|26
184|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment, clean/store/dispose of equipment or supplies).|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment,|26
185|3 -Able to walk only with the supervision or assistance of another person at all times.|3 -Able to walk only with the supervision or assistance of another person at all times.|26
186|3 - Continuous / Bi-level positive airway pressure|3 - Continuous / Bi-level positive airway pressure|26
187|3 - During the day and evening, but not constantly|3 - During the day and evening, but not constantly|26
188|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the alimentary canal)|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the|26
189|3 - Environmental support (e.g., housing, home maintenance)|3 - Environmental support (e.g., housing, home maintenance)|26
190|3 - Four to six times weekly|3 - Four to six times weekly|26
191|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessing by listener.  Speech limited to single words or short phrases.|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessin|26
192|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires multiple repetitions, restatements, demonstrations, additional time.|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires m|26
193|3 - Hopelessness|3 - Hopelessness|26
194|3 - Hospice care|3 - Hospice care|26
195|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|26
196|3 - Injury caused by fall or accident at home|3 - Injury caused by fall or accident at home|26
197|3 - Intractable pain|3 - Intractable pain|26
198|3 - Medicaid (traditional fee-for-service)|3 - Medicaid (traditional fee-for-service)|26
199|3 - Needs someone to do all shopping and errands.|3 - Needs someone to do all shopping and errands.|26
200|3 - Not healing|3 - Not healing|26
201|3 - Nursing home|3 - Nursing home|26
202|3 - Once daily|3 - Once daily|26
203|3 - Other family member|3 - Other family member|26
204|3 - Outpatient department/clinic emergency (includes urgicenter sites)|3 - Outpatient department/clinic emergency (includes urgicenter sites)|26
205|3 - Paid help|3 - Paid help|26
206|3 - Able to participate in bathing self in shower or tub, but requires presence of another person throughout the bath for assistance or supervision.|3 - Able to participate in bathing self in shower or tub, but requires presence of another person th|26
207|3 - Patient depends entirely upon another person to dress lower body.|3 - Patient depends entirely upon another person to dress lower body.|26
208|3 - Patient depends entirely upon another person to dress the upper body.|3 - Patient depends entirely upon another person to dress the upper body.|26
209|3 - Patient depends entirely upon someone else for grooming needs.|3 - Patient depends entirely upon someone else for grooming needs.|26
210|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone else to manage the equipment.|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone|26
211|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable to shift attention and recall directions more than half the time.|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable|26
212|3 - Respiratory problems (SOB, infection, obstruction)|3 - Respiratory problems (SOB, infection, obstruction)|26
213|3 - Resumption of care (after inpatient stay)|3 - Resumption of care (after inpatient stay)|26
214|3 - Several times each month|3 - Several times each month|26
215|3 - Skilled Nursing Facility|3 - Skilled Nursing Facility|26
216|3 - Stage 3|3 - Stage 3|26
217|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|26
218|3 - Three|3 - Three|26
219|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person throughout the process.|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person through|26
220|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal independently.|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal indep|26
221|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person.|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person|26
222|3 - Unknown because patient moved to a geographic location not served by this agency|3 - Unknown because patient moved to a geographic location not served by this agency|26
223|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|26
224|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|26
225|3 - With other family member|3 - With other family member|26
226|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home health services, homemaker assistance, transportation assistance, assisted living, board and care)|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home h|26
227|3-SLP/ST|3-SLP/ST|26
228|4 - At rest (during day or night)|4 - At rest (during day or night)|26
229|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|26
230|4 - Board and care or assisted living facility|4 - Board and care or assisted living facility|26
231|4 - Caregiver is completely dependent on someone else to manage all equipment.|4 - Caregiver is completely dependent on someone else to manage all equipment.|26
232|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|26
233|4 - Constantly|4 - Constantly|26
234|4 - Drug dependency|4 - Drug dependency|26
235|4 - Four or more|4 - Four or more|26
236|4 - Friend or neighbor or community or church member|4 - Friend or neighbor or community or church member|26
237|4 - Hispanic or Latino|4 - Hispanic or Latino|26
238|4 - Hospice|4 - Hospice|26
239|4 - Impaired decision-making|4 - Impaired decision-making|26
240|4 - Is totally dependent in toileting.|4 - Is totally dependent in toileting.|26
241|4 - Medicaid (HMO/managed care)|4 - Medicaid (HMO/managed care)|26
242|4 - None of the above|4 - None of the above|26
243|4 - Nursing home|4 - Nursing home|26
244|4 - On a daily basis|4 - On a daily basis|26
245|4 - Patient is completely dependent on someone else to manage all equipment.|4 - Patient is completely dependent on someone else to manage all equipment.|26
246|4 - Permanent placement|4 - Permanent placement|26
247|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, punches, dangerous maneuvers w/ wheelchair or other objects)|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, pu|26
248|4 - Psychosocial support (e.g., socialization, companionship, recreation)|4 - Psychosocial support (e.g., socialization, companionship, recreation)|26
249|4 - Recertification (follow-up) reassessment|4 - Recertification (follow-up) reassessment|26
250|4 - Recurrent thoughts of death|4 - Recurrent thoughts of death|26
251|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruction)|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruc|26
252|4 - Several times a week|4 - Several times a week|26
253|4 - Stage 4|4 - Stage 4|26
254|4 - Symptoms poorly controlled, history of rehospitalizations|4 - Symptoms poorly controlled, history of rehospitalizations|26
255|4 - Three or more times per week|4 - Three or more times per week|26
256|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetative state, or delirium.|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetati|26
257|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|26
258|4 - Unable to effectively participate in any housekeeping tasks.|4 - Unable to effectively participate in any housekeeping tasks.|26
259|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or unresponsive (e.g., speech is nonsensical or unintelligible).|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or u|26
260|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonresponsive.|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonr|26
261|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostomy.|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostom|26
262|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of devices at the sink, in chair, or on commode|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of|26
263|4 - With a friend|4 - With a friend|26
264|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|26
265|4-OT|4-OT|26
266|5 - Advocates or facilitates patient's participation in appropriate medical care|5 - Advocates or facilitates patient's participation in appropriate medical care|26
267|5 - At least daily|5 - At least daily|26
268|6 - Bedfast, unable to ambulate or be up in a chair.|6 - Bedfast, unable to ambulate or be up in a chair.|26
269|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|26
270|5 - Disruptive or socially inappropriate behavior|5 - Disruptive or socially inappropriate behavior|26
271|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|26
272|5 - Hypo/Hyperglycemia, diabetes out of control|5 - Hypo/Hyperglycemia, diabetes out of control|26
273|5 - More often than once daily|5 - More often than once daily|26
274|5 - Native Hawaiian or Pacific Islander|5 - Native Hawaiian or Pacific Islander|26
275|5 - None of the above|5 - None of the above|26
276|5 - One to two times per week|5 - One to two times per week|26
277|5 - Other|5 - Other|26
278|5 - Other follow-up|5 - Other follow-up|26
279|5 - Paid help|5 - Paid help|26
280|5 - Patient nonresponsive or unable to speak.|5 - Patient nonresponsive or unable to speak.|26
281|5 - Thoughts of suicide|5 - Thoughts of suicide|26
282|5 - Totally unable to use the telephone.|5 - Totally unable to use the telephone.|26
283|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|26
284|5 - Unable to take in nutrients orally or by tube feeding.|5 - Unable to take in nutrients orally or by tube feeding.|26
285|5 - Unsafe for care at home|5 - Unsafe for care at home|26
286|5 - With paid help (other than home care agency staff)|5 - With paid help (other than home care agency staff)|26
287|5 - Workers' compensation|5 - Workers' compensation|26
288|5 - Wound infection, deteriorating wound status, new lesion/ulcer|5 - Wound infection, deteriorating wound status, new lesion/ulcer|26
289|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|26
290|6 - Delusional, hallucinatory, or paranoid behavior|6 - Delusional, hallucinatory, or paranoid behavior|26
291|6 - Financial agent, power of attorney, or conservator of finance|6 - Financial agent, power of attorney, or conservator of finance|26
292|6 - GI bleeding, obstruction|6 - GI bleeding, obstruction|26
293|6 - Less often than weekly|6 - Less often than weekly|26
294|6 - Memory loss to the extent that supervision required|6 - Memory loss to the extent that supervision required|26
295|6 - None of the above feelings observed or reported|6 - None of the above feelings observed or reported|26
296|6 - Other|6 - Other|26
297|6 - Title programs (e.g., Title III, V, or XX)|6 - Title programs (e.g., Title III, V, or XX)|26
298|6 - Transferred to an inpatient facility - patient not discharged from agency|6 - Transferred to an inpatient facility - patient not discharged from agency|26
299|6 - White|6 - White|26
300|6 - With other than above|6 - With other than above|26
301|7 - Exacerbation of CHF, fluid overload, heart failure|7 - Exacerbation of CHF, fluid overload, heart failure|26
302|7 - Health care agent, conservator of person, or medical power of attorney|7 - Health care agent, conservator of person, or medical power of attorney|26
303|7 - Hypo/Hyperglycemia, diabetes out of control|7 - Hypo/Hyperglycemia, diabetes out of control|26
304|7 - None of the above|7 - None of the above|26
305|7 - None of the above behaviors demonstrated|7 - None of the above behaviors demonstrated|26
306|7 - Other government (e.g., TriCare, VA, etc.)|7 - Other government (e.g., TriCare, VA, etc.)|26
307|7 - Transferred to an inpatient facility - patient discharged from agency|7 - Transferred to an inpatient facility - patient discharged from agency|26
308|8 - Death at home|8 - Death at home|26
309|8 - GI bleeding, obstruction|8 - GI bleeding, obstruction|26
310|8 - Myocardial infarction, stroke|8 - Myocardial infarction, stroke|26
311|8 - Private insurance|8 - Private insurance|26
312|9 - Chemotherapy|9 - Chemotherapy|26
313|9 - Discharge from agency|9 - Discharge from agency|26
314|9 - Other than above reasons|9 - Other than above reasons|26
315|9 - Private HMO/managed care|9 - Private HMO/managed care|26
316|NA - No caregiver|NA - No caregiver|26
317|NA - No equipment of this type used in care.|NA - No equipment of this type used in care.|26
318|NA - No inhalant/mist medications prescribed.|NA - No inhalant/mist medications prescribed.|26
319|NA - No injectable medications prescribed.|NA - No injectable medications prescribed.|26
320|NA - No inpatient facility admission|NA - No inpatient facility admission|26
321|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|26
322|NA - No Medicaid|NA - No Medicaid|26
323|NA - No Medicare|NA - No Medicare|26
324|NA - No observable pressure ulcer or unhealed pressure ulcer|NA - No observable pressure ulcer or unhealed pressure ulcer|26
325|NA - No observable stasis ulcer|NA - No observable stasis ulcer|26
326|NA - No observable surgical wound|NA - No observable surgical wound|26
327|NA - No oral medications prescribed.|NA - No oral medications prescribed.|26
328|NA - Not applicable|NA - Not applicable|26
329|NA - Patient does not have a telephone.|NA - Patient does not have a telephone.|26
330|NA - Patient has ostomy for bowel elimination|NA - Patient has ostomy for bowel elimination|26
331|NA - Patient nonresponsive|NA - Patient nonresponsive|26
332|NA - Patient on prophylactic treatment|NA - Patient on prophylactic treatment|26
333|NA - Patient was not discharged from an inpatient facility [Go to M1016 ]|NA - Patient was not discharged from an inpatient facility [Go to M1016 ]|26
334|UK - Other unknown|UK - Other unknown|26
335|UK - Reason unknown|UK - Reason unknown|26
336|UK - Unknown|UK - Unknown|26
337|UK - Unknown or Not Available|UK - Unknown or Not Available|26
341|01 - Early|01 - Early|26
342|02 - Late|02 - Late|26
343|NA - Not Applicable. No case mix group defined for this assessment.|NA - Not Applicable. No case mix group defined for this assessment.|26
344|NA - No case mix group defined by this assessment.|NA - No case mix group defined by this assessment.|26
345|1 - Recent decline in mental, emotional, or behavioral status|1 - Recent decline in mental, emotional, or behavioral status|26
346|2 - Multiple hospitalizations (2 or more) in the past 12 months|2 - Multiple hospitalizations (2 or more) in the past 12 months|26
347|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|26
348|4 - Taking five or more medications|4 - Taking five or more medications|26
349|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|26
350|6 - Other|6 - Other|26
351|7 - None of the above|7 - None of the above|26
352|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond tho|26
353|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable without heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable wi|26
354|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious complications and death.|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious compl|26
355|3 - The patient has serious progressive conditions that could lead to death within a year.|3 - The patient has serious progressive conditions that could lead to death within a year.|26
356|UK - The patient+s situation is unknown or unclear.|UK - The patient+s situation is unknown or unclear.|26
357|1 - Yes [ Go to M1050 ]|1 - Yes [ Go to M1050 ]|26
358|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this influenza season. [ Go to M1050 ]|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this i|26
359|1 - Received from another health care provider (e.g., physician)|1 - Received from another health care provider (e.g., physician)|26
360|2 - Received from your agency previously during this year+s flu season|2 - Received from your agency previously during this year+s flu season|26
361|3 - Offered and declined|3 - Offered and declined|26
362|4 - Assessed and determined to have medical contraindication(s)|4 - Assessed and determined to have medical contraindication(s)|26
363|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|26
364|6 - Inability to obtain vaccine due to declared shortage|6 - Inability to obtain vaccine due to declared shortage|26
365|1 - Yes [ Go to M1500 at TRN; Go to M1230 at DC ]|1 - Yes [ Go to M1500 at TRN; Go to M1230 at DC ]|26
366|1 - Patient has received PPV in the past|1 - Patient has received PPV in the past|26
367|2 - Offered and declined|2 - Offered and declined|26
368|3 - Assessed and determined to have medical contraindication(s)|3 - Assessed and determined to have medical contraindication(s)|26
369|4 - Not indicated; patient does not meet age/condition guidelines for PPV|4 - Not indicated; patient does not meet age/condition guidelines for PPV|26
370|5 - None of the above|5 - None of the above|26
371|0 - Adequate: hears normal conversation without difficulty.|0 - Adequate: hears normal conversation without difficulty.|26
372|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to increase volume or speak distinctly.|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to in|26
373|2 - Severely Impaired: absence of useful hearing.|2 - Severely Impaired: absence of useful hearing.|26
374|UK - Unable to assess hearing.|UK - Unable to assess hearing.|26
375|0 - Understands: clear comprehension without cues or repetitions.|0 - Understands: clear comprehension without cues or repetitions.|26
376|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Requires cues at times to understand.|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Req|26
377|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequently requires cues to understand.|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequentl|26
378|3 - Rarely/Never Understands|3 - Rarely/Never Understands|26
379|UK - Unable to assess understanding.|UK - Unable to assess understanding.|26
380|0 - No standardized assessment conducted|0 - No standardized assessment conducted|26
381|1 - Yes, and it does not indicate severe pain|1 - Yes, and it does not indicate severe pain|26
382|2 - Yes, and it indicates severe pain|2 - Yes, and it indicates severe pain|26
383|0 - Patient has no pain|0 - Patient has no pain|26
384|1 - Patient has pain that does not interfere with activity or movement|1 - Patient has pain that does not interfere with activity or movement|26
385|2 - Less often than daily|2 - Less often than daily|26
386|3 - Daily, but not constantly|3 - Daily, but not constantly|26
387|4 - All of the time|4 - All of the time|26
388|0 - No assessment conducted [ Go to M1306 ]|0 - No assessment conducted [ Go to M1306 ]|26
389|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc., without use of standardized tool|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc.,|26
390|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|26
391|0 - No [ Go to M1322]|0 - No [ Go to M1322]|26
392|0 v Newly epithelialized|0 v Newly epithelialized|26
393|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|26
394|2 - Yes, patient has observable stasis ulcers ONLY|2 - Yes, patient has observable stasis ulcers ONLY|26
395|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable dressing) [Go to M1340]|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable|26
396|0 - No [ Go to M1350 ]|0 - No [ Go to M1350 ]|26
397|1 - Yes, patient has at least one (observable) surgical wound|1 - Yes, patient has at least one (observable) surgical wound|26
398|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1350 ]|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1350 ]|26
399|0 - Patient is not short of breath|0 - Patient is not short of breath|26
400|3 - Continuous Bi-level positive airway pressure|3 - Continuous Bi-level positive airway pressure|26
401|0 - No [ Go to M2004 at TRN; Go to M1600 at DC ]|0 - No [ Go to M2004 at TRN; Go to M1600 at DC ]|26
402|2 - Not assessed [Go to M2004 at TRN; Go to M1600 at DC ]|2 - Not assessed [Go to M2004 at TRN; Go to M1600 at DC ]|26
403|NA - Patient does not have diagnosis of heart failure [Go to M2004 at TRN; Go to M1600 at DC]|NA - Patient does not have diagnosis of heart failure [Go to M2004 at TRN; Go to M1600 at DC]|26
404|0 - No action taken|0 - No action taken|26
405|1 - Patient+s physician (or other primary care practitioner) contacted the same day|1 - Patient+s physician (or other primary care practitioner) contacted the same day|26
406|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|26
407|3 - Implement physician-ordered patient-specific established parameters for treatment|3 - Implement physician-ordered patient-specific established parameters for treatment|26
408|4 - Patient education or other clinical interventions|4 - Patient education or other clinical interventions|26
409|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequency, telehealth, etc.)|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequ|26
410|1 - Occasional stress incontinence|1 - Occasional stress incontinence|26
411|2 - During the night only|2 - During the night only|26
412|3 - During the day only|3 - During the day only|26
413|4 - During the day and night|4 - During the day and night|26
414|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|26
415|0 - Able to manage toileting hygiene and clothing management without assistance.|0 - Able to manage toileting hygiene and clothing management without assistance.|26
416|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implements are laid out for the patient.|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implemen|26
417|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|26
418|3 - Patient depends entirely upon another person to maintain toileting hygiene.|3 - Patient depends entirely upon another person to maintain toileting hygiene.|26
419|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independent|26
420|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface|26
421|0 - No multi-factor falls risk assessment conducted.|0 - No multi-factor falls risk assessment conducted.|26
422|1 - Yes, and it does not indicate a risk for falls.|1 - Yes, and it does not indicate a risk for falls.|26
423|2 - Yes, and it indicates a risk for falls.|2 - Yes, and it indicates a risk for falls.|26
424|0 - Not assessed/reviewed [ Go to M2010 ]|0 - Not assessed/reviewed [ Go to M2010 ]|26
425|1 - No problems found during review [ Go to M2010 ]|1 - No problems found during review [ Go to M2010 ]|26
426|2 - Problems found during review|2 - Problems found during review|26
427|NA - Patient is not taking any medications [ Go to M2040 ]|NA - Patient is not taking any medications [ Go to M2040 ]|26
428|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special precautions associated with all high-risk medications|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special p|26
429|NA - Patient not taking any drugs|NA - Patient not taking any drugs|26
430|2 - Able to take medication(s) at the correct times if given reminders by another person at the appropriate times|2 - Able to take medication(s) at the correct times if given reminders by another person at the appr|26
431|3 - Unable to take medication unless administered by another person.|3 - Unable to take medication unless administered by another person.|26
432|1 - At least daily|1 - At least daily|26
433|2 - Three or more times per week|2 - Three or more times per week|26
434|3 - One to two times per week|3 - One to two times per week|26
435|4 - Received, but less often than weekly|4 - Received, but less often than weekly|26
436|5 - No assistance received|5 - No assistance received|26
437|0 - No [Go to M2400]|0 - No [Go to M2400]|26
438|1 - Yes, used hospital emergency department WITHOUT hospital admission|1 - Yes, used hospital emergency department WITHOUT hospital admission|26
439|2 - Yes, used hospital emergency department WITH hospital admission|2 - Yes, used hospital emergency department WITH hospital admission|26
440|UK - Unknown [Go to M2400]|UK - Unknown [Go to M2400]|26
441|2 - Injury caused by fall|2 - Injury caused by fall|26
442|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|26
443|4 - Other respiratory problem|4 - Other respiratory problem|26
444|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|26
445|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|26
446|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|26
447|8 - Other heart disease|8 - Other heart disease|26
448|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|26
449|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|26
450|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|26
451|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|26
452|13 - Urinary tract infection|13 - Urinary tract infection|26
453|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|26
454|15 - Wound infection or deterioration|15 - Wound infection or deterioration|26
455|16 - Uncontrolled pain|16 - Uncontrolled pain|26
456|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|26
457|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|26
458|19 - Other than above reasons|19 - Other than above reasons|26
459|2 - Patient remained in the community (with formal assistive services)|2 - Patient remained in the community (with formal assistive services)|26
460|3 - Patient transferred to a noninstitutional hospice|3 - Patient transferred to a noninstitutional hospice|26
461|4 - Unknown because patient moved to a geographic location not served by this agency|4 - Unknown because patient moved to a geographic location not served by this agency|26
462|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|26
463|4 - Other respiratory problem|4 - Other respiratory problem|26
464|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|26
465|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|26
466|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|26
467|8 - Other heart disease|8 - Other heart disease|26
468|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|26
469|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|26
470|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|26
471|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|26
472|13 - Urinary tract infection|13 - Urinary tract infection|26
473|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|26
474|15 - Wound infection or deterioration|15 - Wound infection or deterioration|26
475|16 - Uncontrolled pain|16 - Uncontrolled pain|26
476|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|26
477|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|26
478|19 - Scheduled treatment or procedure|19 - Scheduled treatment or procedure|26
479|20 - Other than above reasons|20 - Other than above reasons|26
480|UK - Reason unknown [Go to M0903]|UK - Reason unknown [Go to M0903]|26
482|01 - Patient lives alone around the clock|01 - Patient lives alone around the clock|26
483|02 - Patient lives alone regular daytime|02 - Patient lives alone regular daytime|26
484|03 - Patient lives alone regular nighttime|03 - Patient lives alone regular nighttime|26
485|04 - Patient lives alone occassional/short term assistance|04 - Patient lives alone occassional/short term assistance|26
486|05 - Patient lives alone no assisstance available|05 - Patient lives alone no assisstance available|26
487|06 - Patient lives with other person(s) in the home around the clock|06 - Patient lives with other person(s) in the home around the clock|26
488|07 - Patient lives with other person(s) in the home regular daytime|07 - Patient lives with other person(s) in the home regular daytime|26
489|08 - Patient lives with other person(s) in the home regular nighttime|08 - Patient lives with other person(s) in the home regular nighttime|26
490|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|26
491|10 - Patient lives with other person(s) in the home no assistance available|10 - Patient lives with other person(s) in the home no assistance available|26
492|1 - Was present at the most recent SOC/ROC assessment|1 - Was present at the most recent SOC/ROC assessment|26
493|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|26
494|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|26
495|0 - Newly epithelialized|0 - Newly epithelialized|26
496|0 - No [ Go to M1340 ]|0 - No [ Go to M1340 ]|26
498|0 - Independent|0 - Independent|26
499|1 - Needed Some Help|1 - Needed Some Help|26
500|2 - Dependent|2 - Dependent|26
502|0 - No assistance needed in this area|0 - No assistance needed in this area|26
503|1 - Caregiver(s) currently provide assistance|1 - Caregiver(s) currently provide assistance|26
504|2 - Caregiver(s) need training/ supportive services to provide assistance|2 - Caregiver(s) need training/ supportive services to provide assistance|26
505|3 - Caregiver(s) not likely to provide assistance|3 - Caregiver(s) not likely to provide assistance|26
506|4 - Unclear if Caregiver(s) will provide assistance|4 - Unclear if Caregiver(s) will provide assistance|26
507|5 - Assistance needed, but no Caregiver(s) available|5 - Assistance needed, but no Caregiver(s) available|26
508|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will use standardized clinical guidelines accessible for all care providers to reference|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will|26
510|NA - Patient is not assessed to be at risk for falls|NA - Patient is not assessed to be at risk for falls|26
511|NA - Patient has no diagnosis or symptoms of depression|NA - Patient has no diagnosis or symptoms of depression|26
512|NA - No pain identified|NA - No pain identified|26
513|NA - Patient is not assessed to be at risk for pressure ulcers|NA - Patient is not assessed to be at risk for pressure ulcers|26
514|NA - Patient has no pressure ulcers with need for moist wound healing|NA - Patient has no pressure ulcers with need for moist wound healing|26
515|1 - Long-term nursing facility (NF)|1 - Long-term nursing facility (NF)|26
516|2 - Skilled nursing facility (SNF / TCU)|2 - Skilled nursing facility (SNF / TCU)|26
517|3 - Short stay acute hospital (IPP S)|3 - Short stay acute hospital (IPP S)|26
518|4 - Long-term care hospital (LTCH)|4 - Long-term care hospital (LTCH)|26
519|5 - Inpatient rehabilitation hospital or unit (IRF)|5 - Inpatient rehabilitation hospital or unit (IRF)|26
520|6 - Psychiatric hospital or unit|6 - Psychiatric hospital or unit|26
521|7 - Other|7 - Other|26
522|NA - Patient was not discharged from an inpatient facility [Goto M1016]|NA - Patient was not discharged from an inpatient facility [Goto M1016]|26
523|6 - Unable to participate effectively in bathing and is bathed totally by another person|6 - Unable to participate effectively in bathing and is bathed totally by another person|26
524|4 - Chairfast, unable to ambulate but is able to wheel self independently.|4 - Chairfast, unable to ambulate but is able to wheel self independently.|26
525|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask patient: "Over the last two weeks, how often have you been bothered by any of the following problems")|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask|26
526|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluation for depression.|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluat|26
527|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet criteria for further evaluation for depression.|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet|26
528|0 - Not at all  0 - 1 day|0 - Not at all  0 - 1 day|26
529|1 - Several days  2 - 6 days|1 - Several days  2 - 6 days|26
530|2 - More than half of the days  7 - 11 days|2 - More than half of the days  7 - 11 days|26
531|3 - Nearly every day  12 - 14 days|3 - Nearly every day  12 - 14 days|26
532|NA - N/A  Unable to respond|NA - N/A  Unable to respond|26
533|2 - Able to take medication(s) at the correct times if given reminders by another person based on the frequency of the injection|2 - Able to take medication(s) at the correct times if given reminders by another person based on th|26
534|3 - Unable to take injectable medication unless administered by another person.|3 - Unable to take injectable medication unless administered by another person.|26
547|NA - No clinically significant medication issues identified since the previous OASIS assessment|NA - No clinically significant medication issues identified since the previous OASIS assessment|26
552|1 - Hospital [ Go to M2430 ]|1 - Hospital [ Go to M2430 ]|26
553|2 - Rehabilitation facility [ Go to M0903 ]|2 - Rehabilitation facility [ Go to M0903 ]|26
554|3 - Nursing home [ Go to M2440 ]|3 - Nursing home [ Go to M2440 ]|26
555|4 - Hospice [ Go to M0903 ]|4 - Hospice [ Go to M0903 ]|26
557|NA - Patient is not diabetic or is bilateral amputee|NA - Patient is not diabetic or is bilateral amputee|26
558|NA - Formal multi-factor Fall Risk Assessment indicates the patient was not at risk for falls since the last OASIS assessment|NA - Formal multi-factor Fall Risk Assessment indicates the patient was not at risk for falls since|26
559|NA - Formal assessment indicates patient did not meet criteria for depression AND patient did not have diagnosis of depression since the last OASIS assessment|NA - Formal assessment indicates patient did not meet criteria for depression AND patient did not ha|26
560|NA - Formal assessment did not indicate pain since the last OASIS assessment|NA - Formal assessment did not indicate pain since the last OASIS assessment|26
561|NA - Formal assessment indicates the patient was not at risk of pressure ulcers since the last OASIS assessment|NA - Formal assessment indicates the patient was not at risk of pressure ulcers since the last OASIS|26
562|NA - Dressings that support the principles of moist wound healing not indicated for this patient's pressure ulcers OR patient has no pressure ulcers with need for moist wound healing|NA - Dressings that support the principles of moist wound healing not indicated for this patient's p|26
2|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; OR (b) Is physically, cognitively, and mentally able to prepare light meals on a regular basis but has not routinely performed light meal preparation in the past (i.e., prior to this home care admission).|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; O|27
3|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and mentally able to perform all housekeeping tasks .|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and menta|27
4|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and mentally able to do laundry and access facilities.|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and menta|27
5|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying packages OR b) Physically, cognitively, and mentally able to take care of shopping, but has not done shopping in the past (i.e., prior to this home care admission).|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying|27
6|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|27
7|0 - Able to dial numbers and answer calls appropriately and as desired.|0 - Able to dial numbers and answer calls appropriately and as desired.|27
8|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body without assistance.|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body|27
9|0 - Able to get to and from the toilet and transfer independently with or without a device.|0 - Able to get to and from the toilet and transfer independently with or without a device.|27
10|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|27
11|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible public bus.|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible p|27
12|0 - Able to independently feed self.|0 - Able to independently feed self.|27
13|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|27
14|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct times.|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct ti|27
15|0 - Able to independently transfer.|0 - Able to independently transfer.|27
16|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without rail|27
17|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings|27
18|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|27
19|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions independently.|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions indep|27
20|0 - Asymptomatic, no treatment needed at this time|0 - Asymptomatic, no treatment needed at this time|27
21|0 - Caregiver manages all tasks related to equipment completely independently.|0 - Caregiver manages all tasks related to equipment completely independently.|27
22|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations with no observable impairment.|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations w|27
23|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|27
24|0 - Life expectancy is greater than 6 months|0 - Life expectancy is greater than 6 months|27
25|0 - Never|0 - Never|27
26|0 - Patient is not short of breath|0 - Patient is not short of breath|27
27|0 - No|0 - No|27
28|0 - No emergent care services|0 - No emergent care services|27
29|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [Goto 1620]|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [Goto 1620]|27
30|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and extended or abstract conversation.|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and exte|27
31|0 - No one person|0 - No one person|27
32|0 - None of the time|0 - None of the time|27
33|0 - None, no charge for current services|0 - None, no charge for current services|27
34|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|27
35|0 - Patient does NOT have an ostomy for bowel elimination.|0 - Patient does NOT have an ostomy for bowel elimination.|27
36|0 - Patient has no pain|0 - Patient has no pain|27
37|0 - Patient manages all tasks related to equipment completely independently.|0 - Patient manages all tasks related to equipment completely independently.|27
38|0 - Poor:  little or no recovery is expected and/or further decline is imminent|0 - Poor:  little or no recovery is expected and/or further decline is imminent|27
39|0 - Timed-voiding defers incontinence|0 - Timed-voiding defers incontinence|27
40|0 - Very rarely or never has bowel incontinence|0 - Very rarely or never has bowel incontinence|27
41|0 - Zero|0 - Zero|27
42|00 - No|00 - No|27
43|01 - Yes|01 - Yes|27
44|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or mental limitations, needs assistance with heavy laundry.|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or|27
45|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the patient.|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the|27
46|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|27
47|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or supervision from another person OR c) a liquid, pureed or ground meat diet.|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or su|27
48|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|27
49|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|27
50|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independently.|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independe|27
51|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only when assisted or accompanied by another person.|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only w|27
52|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepa|27
53|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance by another person OR b) given daily reminders.|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance b|27
54|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advan|27
55|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advan|27
56|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for the deaf) and call essential numbers.|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for t|27
57|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|27
58|1 - American Indian or Alaska Native|1 - American Indian or Alaska Native|27
59|1 - Depressed mood (e.g., feeling sad, tearful)|1 - Depressed mood (e.g., feeling sad, tearful)|27
60|1 - During the night only|1 - During the night only|27
61|1 - Fully granulating|1 - Fully granulating|27
62|1 - Good/Fair:  partial to full recovery is expected|1 - Good/Fair:  partial to full recovery is expected|27
63|1 - Good:  marked improvement in functional status is expected|1 - Good:  marked improvement in functional status is expected|27
64|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|27
65|1 - Smoking|1 - Smoking|27
66|1 - Hospital|1 - Hospital|27
67|1 - Hospital emergency room (includes 23-hour holding)|1 - Hospital emergency room (includes 23-hour holding)|27
68|1 - Hospitalization for EMERGENT (unscheduled) care|1 - Hospitalization for EMERGENT (unscheduled) care|27
69|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepared solutions), patient is able to manage all other aspects of equipment.|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepar|27
70|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|27
71|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|27
72|1 - In new or complex situations only|1 - In new or complex situations only|27
73|1 - Intravenous or infusion therapy (excludes TPN)|1 - Intravenous or infusion therapy (excludes TPN)|27
74|1 - Less often than daily|1 - Less often than daily|27
75|1 - Less than once a month|1 - Less than once a month|27
76|1 - Less than once weekly|1 - Less than once weekly|27
77|1 - Life expectancy is 6 months or fewer|1 - Life expectancy is 6 months or fewer|27
78|1 - Lives alone|1 - Lives alone|27
79|1 - Male|1 - Male|27
80|1 - Medicare (traditional fee-for-service)|1 - Medicare (traditional fee-for-service)|27
81|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of past 24 hours, significant memory loss so that supervision is required|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of pas|27
82|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors in word choice, grammar or speech intelligibility, needs minimal prompting or assistance).|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors i|27
83|1 - No assistance or services received|1 - No assistance or services received|27
84|1 - One|1 - One|27
85|1 - Oxygen (intermittent or continuous)|1 - Oxygen (intermittent or continuous)|27
86|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, and the surrounding layout, can count fingers at arm's length.|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, a|27
87|1 - Patient is incontinent|1 - Patient is incontinent|27
88|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|27
89|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical or treatment regimen.|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical|27
90|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient/couple/significant other)|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient|27
91|1 - Relatives, friends, or neighbors living outside the home|1 - Relatives, friends, or neighbors living outside the home|27
92|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions.|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions|27
93|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independentl|27
94|1 - Several times during day and night|1 - Several times during day and night|27
95|1 - Spouse or significant other|1 - Spouse or significant other|27
96|1 - Stage 1|1 - Stage 1|27
97|1 - Start of care - further visits planned|1 - Start of care - further visits planned|27
98|1 - Symptoms well controlled with current therapy|1 - Symptoms well controlled with current therapy|27
99|1 - Therapy services|1 - Therapy services|27
100|1 - Able to transfer with minimal human assistance or with use of an assistive device.|1 - Able to transfer with minimal human assistance or with use of an assistive device.|27
101|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitations.|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitatio|27
102|1 - Urinary incontinence|1 - Urinary incontinence|27
103|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and transfer.|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and|27
104|1 - When walking more than 20 feet, climbing stairs|1 - When walking more than 20 feet, climbing stairs|27
105|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary conversation. May need occasional repetition, extra time, or louder voice.|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary c|27
106|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting in and out of tub/shower|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting|27
107|1 - Yes|1 - Yes|27
108|1-RN|1-RN|27
109|10 - Discharge from agency - no visits completed after start/resumption of care assessment|10 - Discharge from agency - no visits completed after start/resumption of care assessment|27
110|10 - Scheduled surgical procedure|10 - Scheduled surgical procedure|27
111|10 - Self-pay|10 - Self-pay|27
112|11 - Other|11 - Other|27
113|11 - Urinary tract infection|11 - Urinary tract infection|27
114|12 - IV catheter-related infection|12 - IV catheter-related infection|27
115|13 - Deep vein thrombosis, pulmonary embolus|13 - Deep vein thrombosis, pulmonary embolus|27
116|14 - Uncontrolled pain|14 - Uncontrolled pain|27
117|15 - Psychotic episode|15 - Psychotic episode|27
118|16 - Other than above reasons|16 - Other than above reasons|27
119|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing calls.|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing|27
120|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another person.|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another pers|27
121|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface a|27
122|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for intermittent supervision or encouragement or reminders, OR (b) to get in and out of the shower or tub, OR (c) for washing difficult to reach areas.|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for inter|27
123|2 - Asian|2 - Asian|27
124|2 - Caregiver requires considerable assistance from another person to manage equipment, but independently completes significant portions of task.|2 - Caregiver requires considerable assistance from another person to manage equipment, but independ|27
125|2 - Daily, but not constantly|2 - Daily, but not constantly|27
126|2 - Daughter or son|2 - Daughter or son|27
127|2 - Doctor's office emergency visit/house call|2 - Doctor's office emergency visit/house call|27
128|2 - During the day and night|2 - During the day and night|27
129|2 - Early/partial granulation|2 - Early/partial granulation|27
130|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors in word choice, organization or speech intelligibility). Speaks in phrases or short sentences.|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors|27
131|2 - Family member's residence|2 - Family member's residence|27
132|2 - Female|2 - Female|27
133|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conversation, needs frequent prompting or assistance.|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conver|27
134|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|27
135|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|27
136|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately stop activities, jeopardizes safety through actions|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately st|27
137|2 - Indwelling/suprapubic catheter|2 - Indwelling/suprapubic catheter|27
138|2 - Injury caused by fall|2 - Injury caused by fall|27
139|2 - Medicare (HMO/managed care/Advantage plan)|2 - Medicare (HMO/managed care/Advantage plan)|27
140|2 - Nausea, dehydration, malnutrition, constipation, impaction|2 - Nausea, dehydration, malnutrition, constipation, impaction|27
141|2 - Obesity|2 - Obesity|27
142|2 - On awakening or at night only|2 - On awakening or at night only|27
143|2 - Once a month|2 - Once a month|27
144|2 - One to three times weekly|2 - One to three times weekly|27
145|2 - Parenteral nutrition (TPN or lipids)|2 - Parenteral nutrition (TPN or lipids)|27
146|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic) [ Go to M1620]|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic) [ Go|27
147|2 - Patient requires considerable assistance from another person to manage equipment, but independently completes portions of the task.|2 - Patient requires considerable assistance from another person to manage equipment, but independen|27
148|2 - Patient transferred to a noninstitutional hospice|2 - Patient transferred to a noninstitutional hospice|27
149|2 - Person residing in the home (EXCLUDING paid help)|2 - Person residing in the home (EXCLUDING paid help)|27
150|2 - Rehabilitation facility|2 - Rehabilitation facility|27
151|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifting of attention) or consistently requires low stimulus environment due to distractibility.|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifti|27
152|2 - Respite care|2 - Respite care|27
153|2 - Sense of failure or self reproach|2 - Sense of failure or self reproach|27
154|2 - Several times during day|2 - Several times during day|27
155|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonresponsive.|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonrespons|27
156|2 - Someone must assist the patient to groom self.|2 - Someone must assist the patient to groom self.|27
157|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|27
158|2 - Someone must help the patient put on upper body clothing.|2 - Someone must help the patient put on upper body clothing.|27
159|2 - Stage 2|2 - Stage 2|27
160|2 - Start of care - no further visits planned|2 - Start of care - no further visits planned|27
161|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitoring|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitori|27
162|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment regimen.|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment re|27
163|2 - Two|2 - Two|27
164|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistance due to cognitive or mental limitation.|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistanc|27
165|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|27
166|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assistance).|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assis|27
167|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home delivery.|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home deli|27
168|2 - Unable to prepare any light meals or reheat any delivered meals.|2 - Unable to prepare any light meals or reheat any delivered meals.|27
169|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|27
170|2 - UNABLE to take injectable medications unless administered by someone else.|2 - UNABLE to take injectable medications unless administered by someone else.|27
171|2 - UNABLE to take medication unless administered by someone else.|2 - UNABLE to take medication unless administered by someone else.|27
172|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|27
173|2 - Ventilator (continually or at night)|2 - Ventilator (continually or at night)|27
174|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less than 20 feet)|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less th|27
175|2 - With spouse or significant other|2 - With spouse or significant other|27
176|2 - Yes, assistance or services provided by family or friends|2 - Yes, assistance or services provided by family or friends|27
177|2-PT|2-PT|27
178|3 - Able to answer the telephone only some of the time or is able to carry on only a limited conversation.|3 - Able to answer the telephone only some of the time or is able to carry on only a limited convers|27
179|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube or gastrostomy.|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube|27
180|3 - Alcohol dependency|3 - Alcohol dependency|27
181|3 - All of the time|3 - All of the time|27
182|3 - Black or African-American|3 - Black or African-American|27
183|3 - Boarding home or rented room|3 - Boarding home or rented room|27
184|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment, clean/store/dispose of equipment or supplies).|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment,|27
185|3 -Able to walk only with the supervision or assistance of another person at all times.|3 -Able to walk only with the supervision or assistance of another person at all times.|27
186|3 - Continuous / Bi-level positive airway pressure|3 - Continuous / Bi-level positive airway pressure|27
187|3 - During the day and evening, but not constantly|3 - During the day and evening, but not constantly|27
188|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the alimentary canal)|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the|27
189|3 - Environmental support (e.g., housing, home maintenance)|3 - Environmental support (e.g., housing, home maintenance)|27
190|3 - Four to six times weekly|3 - Four to six times weekly|27
191|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessing by listener.  Speech limited to single words or short phrases.|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessin|27
192|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires multiple repetitions, restatements, demonstrations, additional time.|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires m|27
193|3 - Hopelessness|3 - Hopelessness|27
194|3 - Hospice care|3 - Hospice care|27
195|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|27
196|3 - Injury caused by fall or accident at home|3 - Injury caused by fall or accident at home|27
197|3 - Intractable pain|3 - Intractable pain|27
198|3 - Medicaid (traditional fee-for-service)|3 - Medicaid (traditional fee-for-service)|27
199|3 - Needs someone to do all shopping and errands.|3 - Needs someone to do all shopping and errands.|27
200|3 - Not healing|3 - Not healing|27
201|3 - Nursing home|3 - Nursing home|27
202|3 - Once daily|3 - Once daily|27
203|3 - Other family member|3 - Other family member|27
204|3 - Outpatient department/clinic emergency (includes urgicenter sites)|3 - Outpatient department/clinic emergency (includes urgicenter sites)|27
205|3 - Paid help|3 - Paid help|27
206|3 - Able to participate in bathing self in shower or tub, but requires presence of another person throughout the bath for assistance or supervision.|3 - Able to participate in bathing self in shower or tub, but requires presence of another person th|27
207|3 - Patient depends entirely upon another person to dress lower body.|3 - Patient depends entirely upon another person to dress lower body.|27
208|3 - Patient depends entirely upon another person to dress the upper body.|3 - Patient depends entirely upon another person to dress the upper body.|27
209|3 - Patient depends entirely upon someone else for grooming needs.|3 - Patient depends entirely upon someone else for grooming needs.|27
210|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone else to manage the equipment.|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone|27
211|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable to shift attention and recall directions more than half the time.|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable|27
212|3 - Respiratory problems (SOB, infection, obstruction)|3 - Respiratory problems (SOB, infection, obstruction)|27
213|3 - Resumption of care (after inpatient stay)|3 - Resumption of care (after inpatient stay)|27
214|3 - Several times each month|3 - Several times each month|27
215|3 - Skilled Nursing Facility|3 - Skilled Nursing Facility|27
216|3 - Stage 3|3 - Stage 3|27
217|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|27
218|3 - Three|3 - Three|27
219|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person throughout the process.|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person through|27
220|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal independently.|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal indep|27
221|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person.|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person|27
222|3 - Unknown because patient moved to a geographic location not served by this agency|3 - Unknown because patient moved to a geographic location not served by this agency|27
223|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|27
224|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|27
225|3 - With other family member|3 - With other family member|27
226|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home health services, homemaker assistance, transportation assistance, assisted living, board and care)|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home h|27
227|3-SLP/ST|3-SLP/ST|27
228|4 - At rest (during day or night)|4 - At rest (during day or night)|27
229|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|27
230|4 - Board and care or assisted living facility|4 - Board and care or assisted living facility|27
231|4 - Caregiver is completely dependent on someone else to manage all equipment.|4 - Caregiver is completely dependent on someone else to manage all equipment.|27
232|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|27
233|4 - Constantly|4 - Constantly|27
234|4 - Drug dependency|4 - Drug dependency|27
235|4 - Four or more|4 - Four or more|27
236|4 - Friend or neighbor or community or church member|4 - Friend or neighbor or community or church member|27
237|4 - Hispanic or Latino|4 - Hispanic or Latino|27
238|4 - Hospice|4 - Hospice|27
239|4 - Impaired decision-making|4 - Impaired decision-making|27
240|4 - Is totally dependent in toileting.|4 - Is totally dependent in toileting.|27
241|4 - Medicaid (HMO/managed care)|4 - Medicaid (HMO/managed care)|27
242|4 - None of the above|4 - None of the above|27
243|4 - Nursing home|4 - Nursing home|27
244|4 - On a daily basis|4 - On a daily basis|27
245|4 - Patient is completely dependent on someone else to manage all equipment.|4 - Patient is completely dependent on someone else to manage all equipment.|27
246|4 - Permanent placement|4 - Permanent placement|27
247|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, punches, dangerous maneuvers w/ wheelchair or other objects)|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, pu|27
248|4 - Psychosocial support (e.g., socialization, companionship, recreation)|4 - Psychosocial support (e.g., socialization, companionship, recreation)|27
249|4 - Recertification (follow-up) reassessment|4 - Recertification (follow-up) reassessment|27
250|4 - Recurrent thoughts of death|4 - Recurrent thoughts of death|27
251|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruction)|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruc|27
252|4 - Several times a week|4 - Several times a week|27
253|4 - Stage 4|4 - Stage 4|27
254|4 - Symptoms poorly controlled, history of rehospitalizations|4 - Symptoms poorly controlled, history of rehospitalizations|27
255|4 - Three or more times per week|4 - Three or more times per week|27
256|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetative state, or delirium.|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetati|27
257|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|27
258|4 - Unable to effectively participate in any housekeeping tasks.|4 - Unable to effectively participate in any housekeeping tasks.|27
259|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or unresponsive (e.g., speech is nonsensical or unintelligible).|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or u|27
260|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonresponsive.|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonr|27
261|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostomy.|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostom|27
262|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of devices at the sink, in chair, or on commode|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of|27
263|4 - With a friend|4 - With a friend|27
264|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|27
265|4-OT|4-OT|27
266|5 - Advocates or facilitates patient's participation in appropriate medical care|5 - Advocates or facilitates patient's participation in appropriate medical care|27
267|5 - At least daily|5 - At least daily|27
268|6 - Bedfast, unable to ambulate or be up in a chair.|6 - Bedfast, unable to ambulate or be up in a chair.|27
269|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|27
270|5 - Disruptive or socially inappropriate behavior|5 - Disruptive or socially inappropriate behavior|27
271|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|27
272|5 - Hypo/Hyperglycemia, diabetes out of control|5 - Hypo/Hyperglycemia, diabetes out of control|27
273|5 - More often than once daily|5 - More often than once daily|27
274|5 - Native Hawaiian or Pacific Islander|5 - Native Hawaiian or Pacific Islander|27
275|5 - None of the above|5 - None of the above|27
276|5 - One to two times per week|5 - One to two times per week|27
277|5 - Other|5 - Other|27
278|5 - Other follow-up|5 - Other follow-up|27
279|5 - Paid help|5 - Paid help|27
280|5 - Patient nonresponsive or unable to speak.|5 - Patient nonresponsive or unable to speak.|27
281|5 - Thoughts of suicide|5 - Thoughts of suicide|27
282|5 - Totally unable to use the telephone.|5 - Totally unable to use the telephone.|27
283|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|27
284|5 - Unable to take in nutrients orally or by tube feeding.|5 - Unable to take in nutrients orally or by tube feeding.|27
285|5 - Unsafe for care at home|5 - Unsafe for care at home|27
286|5 - With paid help (other than home care agency staff)|5 - With paid help (other than home care agency staff)|27
287|5 - Workers' compensation|5 - Workers' compensation|27
288|5 - Wound infection, deteriorating wound status, new lesion/ulcer|5 - Wound infection, deteriorating wound status, new lesion/ulcer|27
289|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|27
290|6 - Delusional, hallucinatory, or paranoid behavior|6 - Delusional, hallucinatory, or paranoid behavior|27
291|6 - Financial agent, power of attorney, or conservator of finance|6 - Financial agent, power of attorney, or conservator of finance|27
292|6 - GI bleeding, obstruction|6 - GI bleeding, obstruction|27
293|6 - Less often than weekly|6 - Less often than weekly|27
294|6 - Memory loss to the extent that supervision required|6 - Memory loss to the extent that supervision required|27
295|6 - None of the above feelings observed or reported|6 - None of the above feelings observed or reported|27
296|6 - Other|6 - Other|27
297|6 - Title programs (e.g., Title III, V, or XX)|6 - Title programs (e.g., Title III, V, or XX)|27
298|6 - Transferred to an inpatient facility - patient not discharged from agency|6 - Transferred to an inpatient facility - patient not discharged from agency|27
299|6 - White|6 - White|27
300|6 - With other than above|6 - With other than above|27
301|7 - Exacerbation of CHF, fluid overload, heart failure|7 - Exacerbation of CHF, fluid overload, heart failure|27
302|7 - Health care agent, conservator of person, or medical power of attorney|7 - Health care agent, conservator of person, or medical power of attorney|27
303|7 - Hypo/Hyperglycemia, diabetes out of control|7 - Hypo/Hyperglycemia, diabetes out of control|27
304|7 - None of the above|7 - None of the above|27
305|7 - None of the above behaviors demonstrated|7 - None of the above behaviors demonstrated|27
306|7 - Other government (e.g., TriCare, VA, etc.)|7 - Other government (e.g., TriCare, VA, etc.)|27
307|7 - Transferred to an inpatient facility - patient discharged from agency|7 - Transferred to an inpatient facility - patient discharged from agency|27
308|8 - Death at home|8 - Death at home|27
309|8 - GI bleeding, obstruction|8 - GI bleeding, obstruction|27
310|8 - Myocardial infarction, stroke|8 - Myocardial infarction, stroke|27
311|8 - Private insurance|8 - Private insurance|27
312|9 - Chemotherapy|9 - Chemotherapy|27
313|9 - Discharge from agency|9 - Discharge from agency|27
314|9 - Other than above reasons|9 - Other than above reasons|27
315|9 - Private HMO/managed care|9 - Private HMO/managed care|27
316|NA - No caregiver|NA - No caregiver|27
317|NA - No equipment of this type used in care.|NA - No equipment of this type used in care.|27
318|NA - No inhalant/mist medications prescribed.|NA - No inhalant/mist medications prescribed.|27
319|NA - No injectable medications prescribed.|NA - No injectable medications prescribed.|27
320|NA - No inpatient facility admission|NA - No inpatient facility admission|27
321|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|27
322|NA - No Medicaid|NA - No Medicaid|27
323|NA - No Medicare|NA - No Medicare|27
324|NA - No observable pressure ulcer or unhealed pressure ulcer|NA - No observable pressure ulcer or unhealed pressure ulcer|27
325|NA - No observable stasis ulcer|NA - No observable stasis ulcer|27
326|NA - No observable surgical wound|NA - No observable surgical wound|27
327|NA - No oral medications prescribed.|NA - No oral medications prescribed.|27
328|NA - Not applicable|NA - Not applicable|27
329|NA - Patient does not have a telephone.|NA - Patient does not have a telephone.|27
330|NA - Patient has ostomy for bowel elimination|NA - Patient has ostomy for bowel elimination|27
331|NA - Patient nonresponsive|NA - Patient nonresponsive|27
332|NA - Patient on prophylactic treatment|NA - Patient on prophylactic treatment|27
333|NA - Patient was not discharged from an inpatient facility [Go to M1016 ]|NA - Patient was not discharged from an inpatient facility [Go to M1016 ]|27
334|UK - Other unknown|UK - Other unknown|27
335|UK - Reason unknown|UK - Reason unknown|27
336|UK - Unknown|UK - Unknown|27
337|UK - Unknown or Not Available|UK - Unknown or Not Available|27
341|01 - Early|01 - Early|27
342|02 - Late|02 - Late|27
343|NA - Not Applicable. No case mix group defined for this assessment.|NA - Not Applicable. No case mix group defined for this assessment.|27
344|NA - No case mix group defined by this assessment.|NA - No case mix group defined by this assessment.|27
345|1 - Recent decline in mental, emotional, or behavioral status|1 - Recent decline in mental, emotional, or behavioral status|27
346|2 - Multiple hospitalizations (2 or more) in the past 12 months|2 - Multiple hospitalizations (2 or more) in the past 12 months|27
347|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|27
348|4 - Taking five or more medications|4 - Taking five or more medications|27
349|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|27
350|6 - Other|6 - Other|27
351|7 - None of the above|7 - None of the above|27
352|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond tho|27
353|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable without heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable wi|27
354|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious complications and death.|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious compl|27
355|3 - The patient has serious progressive conditions that could lead to death within a year.|3 - The patient has serious progressive conditions that could lead to death within a year.|27
356|UK - The patient+s situation is unknown or unclear.|UK - The patient+s situation is unknown or unclear.|27
357|1 - Yes [ Go to M1050 ]|1 - Yes [ Go to M1050 ]|27
358|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this influenza season. [ Go to M1050 ]|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this i|27
359|1 - Received from another health care provider (e.g., physician)|1 - Received from another health care provider (e.g., physician)|27
360|2 - Received from your agency previously during this year+s flu season|2 - Received from your agency previously during this year+s flu season|27
361|3 - Offered and declined|3 - Offered and declined|27
362|4 - Assessed and determined to have medical contraindication(s)|4 - Assessed and determined to have medical contraindication(s)|27
363|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|27
364|6 - Inability to obtain vaccine due to declared shortage|6 - Inability to obtain vaccine due to declared shortage|27
365|1 - Yes [ Go to M1500 at TRN; Go to M1230 at DC ]|1 - Yes [ Go to M1500 at TRN; Go to M1230 at DC ]|27
366|1 - Patient has received PPV in the past|1 - Patient has received PPV in the past|27
367|2 - Offered and declined|2 - Offered and declined|27
368|3 - Assessed and determined to have medical contraindication(s)|3 - Assessed and determined to have medical contraindication(s)|27
369|4 - Not indicated; patient does not meet age/condition guidelines for PPV|4 - Not indicated; patient does not meet age/condition guidelines for PPV|27
370|5 - None of the above|5 - None of the above|27
371|0 - Adequate: hears normal conversation without difficulty.|0 - Adequate: hears normal conversation without difficulty.|27
372|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to increase volume or speak distinctly.|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to in|27
373|2 - Severely Impaired: absence of useful hearing.|2 - Severely Impaired: absence of useful hearing.|27
374|UK - Unable to assess hearing.|UK - Unable to assess hearing.|27
375|0 - Understands: clear comprehension without cues or repetitions.|0 - Understands: clear comprehension without cues or repetitions.|27
376|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Requires cues at times to understand.|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Req|27
377|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequently requires cues to understand.|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequentl|27
378|3 - Rarely/Never Understands|3 - Rarely/Never Understands|27
379|UK - Unable to assess understanding.|UK - Unable to assess understanding.|27
380|0 - No standardized assessment conducted|0 - No standardized assessment conducted|27
381|1 - Yes, and it does not indicate severe pain|1 - Yes, and it does not indicate severe pain|27
382|2 - Yes, and it indicates severe pain|2 - Yes, and it indicates severe pain|27
383|0 - Patient has no pain|0 - Patient has no pain|27
384|1 - Patient has pain that does not interfere with activity or movement|1 - Patient has pain that does not interfere with activity or movement|27
385|2 - Less often than daily|2 - Less often than daily|27
386|3 - Daily, but not constantly|3 - Daily, but not constantly|27
387|4 - All of the time|4 - All of the time|27
388|0 - No assessment conducted [ Go to M1306 ]|0 - No assessment conducted [ Go to M1306 ]|27
389|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc., without use of standardized tool|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc.,|27
390|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|27
391|0 - No [ Go to M1322]|0 - No [ Go to M1322]|27
392|0 v Newly epithelialized|0 v Newly epithelialized|27
393|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|27
394|2 - Yes, patient has observable stasis ulcers ONLY|2 - Yes, patient has observable stasis ulcers ONLY|27
395|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable dressing) [Go to M1340]|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable|27
396|0 - No [ Go to M1350 ]|0 - No [ Go to M1350 ]|27
397|1 - Yes, patient has at least one (observable) surgical wound|1 - Yes, patient has at least one (observable) surgical wound|27
398|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1350 ]|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1350 ]|27
399|0 - Patient is not short of breath|0 - Patient is not short of breath|27
400|3 - Continuous Bi-level positive airway pressure|3 - Continuous Bi-level positive airway pressure|27
401|0 - No [ Go to M2004 at TRN; Go to M1600 at DC ]|0 - No [ Go to M2004 at TRN; Go to M1600 at DC ]|27
402|2 - Not assessed [Go to M2004 at TRN; Go to M1600 at DC ]|2 - Not assessed [Go to M2004 at TRN; Go to M1600 at DC ]|27
403|NA - Patient does not have diagnosis of heart failure [Go to M2004 at TRN; Go to M1600 at DC]|NA - Patient does not have diagnosis of heart failure [Go to M2004 at TRN; Go to M1600 at DC]|27
404|0 - No action taken|0 - No action taken|27
405|1 - Patient+s physician (or other primary care practitioner) contacted the same day|1 - Patient+s physician (or other primary care practitioner) contacted the same day|27
406|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|27
407|3 - Implement physician-ordered patient-specific established parameters for treatment|3 - Implement physician-ordered patient-specific established parameters for treatment|27
408|4 - Patient education or other clinical interventions|4 - Patient education or other clinical interventions|27
409|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequency, telehealth, etc.)|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequ|27
410|1 - Occasional stress incontinence|1 - Occasional stress incontinence|27
411|2 - During the night only|2 - During the night only|27
412|3 - During the day only|3 - During the day only|27
413|4 - During the day and night|4 - During the day and night|27
414|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|27
415|0 - Able to manage toileting hygiene and clothing management without assistance.|0 - Able to manage toileting hygiene and clothing management without assistance.|27
416|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implements are laid out for the patient.|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implemen|27
417|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|27
418|3 - Patient depends entirely upon another person to maintain toileting hygiene.|3 - Patient depends entirely upon another person to maintain toileting hygiene.|27
419|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independent|27
420|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface|27
421|0 - No multi-factor falls risk assessment conducted.|0 - No multi-factor falls risk assessment conducted.|27
422|1 - Yes, and it does not indicate a risk for falls.|1 - Yes, and it does not indicate a risk for falls.|27
423|2 - Yes, and it indicates a risk for falls.|2 - Yes, and it indicates a risk for falls.|27
424|0 - Not assessed/reviewed [ Go to M2010 ]|0 - Not assessed/reviewed [ Go to M2010 ]|27
425|1 - No problems found during review [ Go to M2010 ]|1 - No problems found during review [ Go to M2010 ]|27
426|2 - Problems found during review|2 - Problems found during review|27
427|NA - Patient is not taking any medications [ Go to M2040 ]|NA - Patient is not taking any medications [ Go to M2040 ]|27
428|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special precautions associated with all high-risk medications|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special p|27
429|NA - Patient not taking any drugs|NA - Patient not taking any drugs|27
430|2 - Able to take medication(s) at the correct times if given reminders by another person at the appropriate times|2 - Able to take medication(s) at the correct times if given reminders by another person at the appr|27
431|3 - Unable to take medication unless administered by another person.|3 - Unable to take medication unless administered by another person.|27
432|1 - At least daily|1 - At least daily|27
433|2 - Three or more times per week|2 - Three or more times per week|27
434|3 - One to two times per week|3 - One to two times per week|27
435|4 - Received, but less often than weekly|4 - Received, but less often than weekly|27
436|5 - No assistance received|5 - No assistance received|27
437|0 - No [Go to M2400]|0 - No [Go to M2400]|27
438|1 - Yes, used hospital emergency department WITHOUT hospital admission|1 - Yes, used hospital emergency department WITHOUT hospital admission|27
439|2 - Yes, used hospital emergency department WITH hospital admission|2 - Yes, used hospital emergency department WITH hospital admission|27
440|UK - Unknown [Go to M2400]|UK - Unknown [Go to M2400]|27
441|2 - Injury caused by fall|2 - Injury caused by fall|27
442|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|27
443|4 - Other respiratory problem|4 - Other respiratory problem|27
444|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|27
445|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|27
446|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|27
447|8 - Other heart disease|8 - Other heart disease|27
448|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|27
449|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|27
450|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|27
451|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|27
452|13 - Urinary tract infection|13 - Urinary tract infection|27
453|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|27
454|15 - Wound infection or deterioration|15 - Wound infection or deterioration|27
455|16 - Uncontrolled pain|16 - Uncontrolled pain|27
456|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|27
457|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|27
458|19 - Other than above reasons|19 - Other than above reasons|27
459|2 - Patient remained in the community (with formal assistive services)|2 - Patient remained in the community (with formal assistive services)|27
460|3 - Patient transferred to a noninstitutional hospice|3 - Patient transferred to a noninstitutional hospice|27
461|4 - Unknown because patient moved to a geographic location not served by this agency|4 - Unknown because patient moved to a geographic location not served by this agency|27
462|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|27
463|4 - Other respiratory problem|4 - Other respiratory problem|27
464|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|27
465|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|27
466|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|27
467|8 - Other heart disease|8 - Other heart disease|27
468|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|27
469|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|27
470|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|27
471|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|27
472|13 - Urinary tract infection|13 - Urinary tract infection|27
473|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|27
474|15 - Wound infection or deterioration|15 - Wound infection or deterioration|27
475|16 - Uncontrolled pain|16 - Uncontrolled pain|27
476|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|27
477|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|27
478|19 - Scheduled treatment or procedure|19 - Scheduled treatment or procedure|27
479|20 - Other than above reasons|20 - Other than above reasons|27
480|UK - Reason unknown [Go to M0903]|UK - Reason unknown [Go to M0903]|27
482|01 - Patient lives alone around the clock|01 - Patient lives alone around the clock|27
483|02 - Patient lives alone regular daytime|02 - Patient lives alone regular daytime|27
484|03 - Patient lives alone regular nighttime|03 - Patient lives alone regular nighttime|27
485|04 - Patient lives alone occassional/short term assistance|04 - Patient lives alone occassional/short term assistance|27
486|05 - Patient lives alone no assisstance available|05 - Patient lives alone no assisstance available|27
487|06 - Patient lives with other person(s) in the home around the clock|06 - Patient lives with other person(s) in the home around the clock|27
488|07 - Patient lives with other person(s) in the home regular daytime|07 - Patient lives with other person(s) in the home regular daytime|27
489|08 - Patient lives with other person(s) in the home regular nighttime|08 - Patient lives with other person(s) in the home regular nighttime|27
490|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|27
491|10 - Patient lives with other person(s) in the home no assistance available|10 - Patient lives with other person(s) in the home no assistance available|27
492|1 - Was present at the most recent SOC/ROC assessment|1 - Was present at the most recent SOC/ROC assessment|27
493|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|27
494|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|27
495|0 - Newly epithelialized|0 - Newly epithelialized|27
496|0 - No [ Go to M1340 ]|0 - No [ Go to M1340 ]|27
498|0 - Independent|0 - Independent|27
499|1 - Needed Some Help|1 - Needed Some Help|27
500|2 - Dependent|2 - Dependent|27
502|0 - No assistance needed in this area|0 - No assistance needed in this area|27
503|1 - Caregiver(s) currently provide assistance|1 - Caregiver(s) currently provide assistance|27
504|2 - Caregiver(s) need training/ supportive services to provide assistance|2 - Caregiver(s) need training/ supportive services to provide assistance|27
505|3 - Caregiver(s) not likely to provide assistance|3 - Caregiver(s) not likely to provide assistance|27
506|4 - Unclear if Caregiver(s) will provide assistance|4 - Unclear if Caregiver(s) will provide assistance|27
507|5 - Assistance needed, but no Caregiver(s) available|5 - Assistance needed, but no Caregiver(s) available|27
508|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will use standardized clinical guidelines accessible for all care providers to reference|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will|27
510|NA - Patient is not assessed to be at risk for falls|NA - Patient is not assessed to be at risk for falls|27
511|NA - Patient has no diagnosis or symptoms of depression|NA - Patient has no diagnosis or symptoms of depression|27
512|NA - No pain identified|NA - No pain identified|27
513|NA - Patient is not assessed to be at risk for pressure ulcers|NA - Patient is not assessed to be at risk for pressure ulcers|27
514|NA - Patient has no pressure ulcers with need for moist wound healing|NA - Patient has no pressure ulcers with need for moist wound healing|27
515|1 - Long-term nursing facility (NF)|1 - Long-term nursing facility (NF)|27
516|2 - Skilled nursing facility (SNF / TCU)|2 - Skilled nursing facility (SNF / TCU)|27
517|3 - Short stay acute hospital (IPP S)|3 - Short stay acute hospital (IPP S)|27
518|4 - Long-term care hospital (LTCH)|4 - Long-term care hospital (LTCH)|27
519|5 - Inpatient rehabilitation hospital or unit (IRF)|5 - Inpatient rehabilitation hospital or unit (IRF)|27
520|6 - Psychiatric hospital or unit|6 - Psychiatric hospital or unit|27
521|7 - Other|7 - Other|27
522|NA - Patient was not discharged from an inpatient facility [Goto M1016]|NA - Patient was not discharged from an inpatient facility [Goto M1016]|27
523|6 - Unable to participate effectively in bathing and is bathed totally by another person|6 - Unable to participate effectively in bathing and is bathed totally by another person|27
524|4 - Chairfast, unable to ambulate but is able to wheel self independently.|4 - Chairfast, unable to ambulate but is able to wheel self independently.|27
525|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask patient: "Over the last two weeks, how often have you been bothered by any of the following problems")|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask|27
526|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluation for depression.|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluat|27
527|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet criteria for further evaluation for depression.|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet|27
528|0 - Not at all  0 - 1 day|0 - Not at all  0 - 1 day|27
529|1 - Several days  2 - 6 days|1 - Several days  2 - 6 days|27
530|2 - More than half of the days  7 - 11 days|2 - More than half of the days  7 - 11 days|27
531|3 - Nearly every day  12 - 14 days|3 - Nearly every day  12 - 14 days|27
532|NA - N/A  Unable to respond|NA - N/A  Unable to respond|27
533|2 - Able to take medication(s) at the correct times if given reminders by another person based on the frequency of the injection|2 - Able to take medication(s) at the correct times if given reminders by another person based on th|27
534|3 - Unable to take injectable medication unless administered by another person.|3 - Unable to take injectable medication unless administered by another person.|27
547|NA - No clinically significant medication issues identified since the previous OASIS assessment|NA - No clinically significant medication issues identified since the previous OASIS assessment|27
552|1 - Hospital [ Go to M2430 ]|1 - Hospital [ Go to M2430 ]|27
553|2 - Rehabilitation facility [ Go to M0903 ]|2 - Rehabilitation facility [ Go to M0903 ]|27
554|3 - Nursing home [ Go to M2440 ]|3 - Nursing home [ Go to M2440 ]|27
555|4 - Hospice [ Go to M0903 ]|4 - Hospice [ Go to M0903 ]|27
564|NA - Patient is not diabetic or is bilateral amputee|NA - Patient is not diabetic or is bilateral amputee|27
565|NA - Formal multi-factor Fall Risk Assessment indicates the patient was not at risk for falls since the last OASIS assessment|NA - Formal multi-factor Fall Risk Assessment indicates the patient was not at risk for falls since|27
566|NA - Formal assessment indicates patient did not meet criteria for depression AND patient did not have diagnosis of depression since the last OASIS assessment|NA - Formal assessment indicates patient did not meet criteria for depression AND patient did not ha|27
567|NA - Formal assessment did not indicate pain since the last OASIS assessment|NA - Formal assessment did not indicate pain since the last OASIS assessment|27
568|NA - Formal assessment indicates the patient was not at risk of pressure ulcers since the last OASIS assessment|NA - Formal assessment indicates the patient was not at risk of pressure ulcers since the last OASIS|27
569|NA - Dressings that support the principles of moist wound healing not indicated for this patient's pressure ulcers OR patient has no pressure ulcers with need for moist wound healing|NA - Dressings that support the principles of moist wound healing not indicated for this patient's p|27
2|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; OR (b) Is physically, cognitively, and mentally able to prepare light meals on a regular basis but has not routinely performed light meal preparation in the past (i.e., prior to this home care admission).|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; O|28
3|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and mentally able to perform all housekeeping tasks .|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and menta|28
4|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and mentally able to do laundry and access facilities.|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and menta|28
5|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying packages OR b) Physically, cognitively, and mentally able to take care of shopping, but has not done shopping in the past (i.e., prior to this home care admission).|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying|28
6|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|28
7|0 - Able to dial numbers and answer calls appropriately and as desired.|0 - Able to dial numbers and answer calls appropriately and as desired.|28
8|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body without assistance.|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body|28
9|0 - Able to get to and from the toilet and transfer independently with or without a device.|0 - Able to get to and from the toilet and transfer independently with or without a device.|28
10|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|28
11|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible public bus.|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible p|28
12|0 - Able to independently feed self.|0 - Able to independently feed self.|28
13|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|28
14|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct times.|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct ti|28
15|0 - Able to independently transfer.|0 - Able to independently transfer.|28
16|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without rail|28
17|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings|28
18|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|28
19|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions independently.|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions indep|28
20|0 - Asymptomatic, no treatment needed at this time|0 - Asymptomatic, no treatment needed at this time|28
21|0 - Caregiver manages all tasks related to equipment completely independently.|0 - Caregiver manages all tasks related to equipment completely independently.|28
22|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations with no observable impairment.|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations w|28
23|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|28
24|0 - Life expectancy is greater than 6 months|0 - Life expectancy is greater than 6 months|28
25|0 - Never|0 - Never|28
26|0 - Patient is not short of breath|0 - Patient is not short of breath|28
27|0 - No|0 - No|28
28|0 - No emergent care services|0 - No emergent care services|28
29|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [Goto 1620]|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [Goto 1620]|28
30|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and extended or abstract conversation.|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and exte|28
31|0 - No one person|0 - No one person|28
32|0 - None of the time|0 - None of the time|28
33|0 - None, no charge for current services|0 - None, no charge for current services|28
34|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|28
35|0 - Patient does NOT have an ostomy for bowel elimination.|0 - Patient does NOT have an ostomy for bowel elimination.|28
36|0 - Patient has no pain|0 - Patient has no pain|28
37|0 - Patient manages all tasks related to equipment completely independently.|0 - Patient manages all tasks related to equipment completely independently.|28
38|0 - Poor:  little or no recovery is expected and/or further decline is imminent|0 - Poor:  little or no recovery is expected and/or further decline is imminent|28
39|0 - Timed-voiding defers incontinence|0 - Timed-voiding defers incontinence|28
40|0 - Very rarely or never has bowel incontinence|0 - Very rarely or never has bowel incontinence|28
41|0 - Zero|0 - Zero|28
42|00 - No|00 - No|28
43|01 - Yes|01 - Yes|28
44|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or mental limitations, needs assistance with heavy laundry.|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or|28
45|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the patient.|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the|28
46|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|28
47|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or supervision from another person OR c) a liquid, pureed or ground meat diet.|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or su|28
48|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|28
49|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|28
50|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independently.|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independe|28
51|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only when assisted or accompanied by another person.|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only w|28
52|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepa|28
53|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance by another person OR b) given daily reminders.|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance b|28
54|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advan|28
55|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advan|28
56|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for the deaf) and call essential numbers.|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for t|28
57|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|28
58|1 - American Indian or Alaska Native|1 - American Indian or Alaska Native|28
59|1 - Depressed mood (e.g., feeling sad, tearful)|1 - Depressed mood (e.g., feeling sad, tearful)|28
60|1 - During the night only|1 - During the night only|28
61|1 - Fully granulating|1 - Fully granulating|28
62|1 - Good/Fair:  partial to full recovery is expected|1 - Good/Fair:  partial to full recovery is expected|28
63|1 - Good:  marked improvement in functional status is expected|1 - Good:  marked improvement in functional status is expected|28
64|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|28
65|1 - Smoking|1 - Smoking|28
66|1 - Hospital|1 - Hospital|28
67|1 - Hospital emergency room (includes 23-hour holding)|1 - Hospital emergency room (includes 23-hour holding)|28
68|1 - Hospitalization for EMERGENT (unscheduled) care|1 - Hospitalization for EMERGENT (unscheduled) care|28
69|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepared solutions), patient is able to manage all other aspects of equipment.|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepar|28
70|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|28
71|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|28
72|1 - In new or complex situations only|1 - In new or complex situations only|28
73|1 - Intravenous or infusion therapy (excludes TPN)|1 - Intravenous or infusion therapy (excludes TPN)|28
74|1 - Less often than daily|1 - Less often than daily|28
75|1 - Less than once a month|1 - Less than once a month|28
76|1 - Less than once weekly|1 - Less than once weekly|28
77|1 - Life expectancy is 6 months or fewer|1 - Life expectancy is 6 months or fewer|28
78|1 - Lives alone|1 - Lives alone|28
79|1 - Male|1 - Male|28
80|1 - Medicare (traditional fee-for-service)|1 - Medicare (traditional fee-for-service)|28
81|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of past 24 hours, significant memory loss so that supervision is required|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of pas|28
82|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors in word choice, grammar or speech intelligibility, needs minimal prompting or assistance).|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors i|28
83|1 - No assistance or services received|1 - No assistance or services received|28
84|1 - One|1 - One|28
85|1 - Oxygen (intermittent or continuous)|1 - Oxygen (intermittent or continuous)|28
86|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, and the surrounding layout, can count fingers at arm's length.|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, a|28
87|1 - Patient is incontinent|1 - Patient is incontinent|28
88|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|28
89|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical or treatment regimen.|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical|28
90|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient/couple/significant other)|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient|28
91|1 - Relatives, friends, or neighbors living outside the home|1 - Relatives, friends, or neighbors living outside the home|28
92|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions.|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions|28
93|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independentl|28
94|1 - Several times during day and night|1 - Several times during day and night|28
95|1 - Spouse or significant other|1 - Spouse or significant other|28
96|1 - Stage 1|1 - Stage 1|28
97|1 - Start of care - further visits planned|1 - Start of care - further visits planned|28
98|1 - Symptoms well controlled with current therapy|1 - Symptoms well controlled with current therapy|28
99|1 - Therapy services|1 - Therapy services|28
100|1 - Able to transfer with minimal human assistance or with use of an assistive device.|1 - Able to transfer with minimal human assistance or with use of an assistive device.|28
101|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitations.|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitatio|28
102|1 - Urinary incontinence|1 - Urinary incontinence|28
103|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and transfer.|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and|28
104|1 - When walking more than 20 feet, climbing stairs|1 - When walking more than 20 feet, climbing stairs|28
105|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary conversation. May need occasional repetition, extra time, or louder voice.|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary c|28
106|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting in and out of tub/shower|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting|28
107|1 - Yes|1 - Yes|28
108|1-RN|1-RN|28
109|10 - Discharge from agency - no visits completed after start/resumption of care assessment|10 - Discharge from agency - no visits completed after start/resumption of care assessment|28
110|10 - Scheduled surgical procedure|10 - Scheduled surgical procedure|28
111|10 - Self-pay|10 - Self-pay|28
112|11 - Other|11 - Other|28
113|11 - Urinary tract infection|11 - Urinary tract infection|28
114|12 - IV catheter-related infection|12 - IV catheter-related infection|28
115|13 - Deep vein thrombosis, pulmonary embolus|13 - Deep vein thrombosis, pulmonary embolus|28
116|14 - Uncontrolled pain|14 - Uncontrolled pain|28
117|15 - Psychotic episode|15 - Psychotic episode|28
118|16 - Other than above reasons|16 - Other than above reasons|28
119|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing calls.|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing|28
120|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another person.|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another pers|28
121|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface a|28
122|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for intermittent supervision or encouragement or reminders, OR (b) to get in and out of the shower or tub, OR (c) for washing difficult to reach areas.|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for inter|28
123|2 - Asian|2 - Asian|28
124|2 - Caregiver requires considerable assistance from another person to manage equipment, but independently completes significant portions of task.|2 - Caregiver requires considerable assistance from another person to manage equipment, but independ|28
125|2 - Daily, but not constantly|2 - Daily, but not constantly|28
126|2 - Daughter or son|2 - Daughter or son|28
127|2 - Doctor's office emergency visit/house call|2 - Doctor's office emergency visit/house call|28
128|2 - During the day and night|2 - During the day and night|28
129|2 - Early/partial granulation|2 - Early/partial granulation|28
130|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors in word choice, organization or speech intelligibility). Speaks in phrases or short sentences.|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors|28
131|2 - Family member's residence|2 - Family member's residence|28
132|2 - Female|2 - Female|28
133|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conversation, needs frequent prompting or assistance.|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conver|28
134|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|28
135|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|28
136|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately stop activities, jeopardizes safety through actions|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately st|28
137|2 - Indwelling/suprapubic catheter|2 - Indwelling/suprapubic catheter|28
138|2 - Injury caused by fall or accident at home|2 - Injury caused by fall or accident at home|28
139|2 - Medicare (HMO/managed care/Advantage plan)|2 - Medicare (HMO/managed care/Advantage plan)|28
140|2 - Nausea, dehydration, malnutrition, constipation, impaction|2 - Nausea, dehydration, malnutrition, constipation, impaction|28
141|2 - Obesity|2 - Obesity|28
142|2 - On awakening or at night only|2 - On awakening or at night only|28
143|2 - Once a month|2 - Once a month|28
144|2 - One to three times weekly|2 - One to three times weekly|28
145|2 - Parenteral nutrition (TPN or lipids)|2 - Parenteral nutrition (TPN or lipids)|28
146|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic) [ Go to M1620]|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic) [ Go|28
147|2 - Patient requires considerable assistance from another person to manage equipment, but independently completes portions of the task.|2 - Patient requires considerable assistance from another person to manage equipment, but independen|28
148|2 - Patient transferred to a noninstitutional hospice|2 - Patient transferred to a noninstitutional hospice|28
149|2 - Person residing in the home (EXCLUDING paid help)|2 - Person residing in the home (EXCLUDING paid help)|28
150|2 - Rehabilitation facility|2 - Rehabilitation facility|28
151|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifting of attention) or consistently requires low stimulus environment due to distractibility.|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifti|28
152|2 - Respite care|2 - Respite care|28
153|2 - Sense of failure or self reproach|2 - Sense of failure or self reproach|28
154|2 - Several times during day|2 - Several times during day|28
155|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonresponsive.|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonrespons|28
156|2 - Someone must assist the patient to groom self.|2 - Someone must assist the patient to groom self.|28
157|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|28
158|2 - Someone must help the patient put on upper body clothing.|2 - Someone must help the patient put on upper body clothing.|28
159|2 - Stage 2|2 - Stage 2|28
160|2 - Start of care - no further visits planned|2 - Start of care - no further visits planned|28
161|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitoring|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitori|28
162|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment regimen.|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment re|28
163|2 - Two|2 - Two|28
164|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistance due to cognitive or mental limitation.|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistanc|28
165|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|28
166|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assistance).|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assis|28
167|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home delivery.|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home deli|28
168|2 - Unable to prepare any light meals or reheat any delivered meals.|2 - Unable to prepare any light meals or reheat any delivered meals.|28
169|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|28
170|2 - UNABLE to take injectable medications unless administered by someone else.|2 - UNABLE to take injectable medications unless administered by someone else.|28
171|2 - UNABLE to take medication unless administered by someone else.|2 - UNABLE to take medication unless administered by someone else.|28
172|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|28
173|2 - Ventilator (continually or at night)|2 - Ventilator (continually or at night)|28
174|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less than 20 feet)|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less th|28
175|2 - With spouse or significant other|2 - With spouse or significant other|28
176|2 - Yes, assistance or services provided by family or friends|2 - Yes, assistance or services provided by family or friends|28
177|2-PT|2-PT|28
178|3 - Able to answer the telephone only some of the time or is able to carry on only a limited conversation.|3 - Able to answer the telephone only some of the time or is able to carry on only a limited convers|28
179|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube or gastrostomy.|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube|28
180|3 - Alcohol dependency|3 - Alcohol dependency|28
181|3 - All of the time|3 - All of the time|28
182|3 - Black or African-American|3 - Black or African-American|28
183|3 - Boarding home or rented room|3 - Boarding home or rented room|28
184|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment, clean/store/dispose of equipment or supplies).|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment,|28
185|3 -Able to walk only with the supervision or assistance of another person at all times.|3 -Able to walk only with the supervision or assistance of another person at all times.|28
186|3 - Continuous / Bi-level positive airway pressure|3 - Continuous / Bi-level positive airway pressure|28
187|3 - During the day and evening, but not constantly|3 - During the day and evening, but not constantly|28
188|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the alimentary canal)|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the|28
189|3 - Environmental support (e.g., housing, home maintenance)|3 - Environmental support (e.g., housing, home maintenance)|28
190|3 - Four to six times weekly|3 - Four to six times weekly|28
191|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessing by listener.  Speech limited to single words or short phrases.|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessin|28
192|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires multiple repetitions, restatements, demonstrations, additional time.|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires m|28
193|3 - Hopelessness|3 - Hopelessness|28
194|3 - Hospice care|3 - Hospice care|28
195|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|28
196|3 - Injury caused by fall or accident at home|3 - Injury caused by fall or accident at home|28
197|3 - Intractable pain|3 - Intractable pain|28
198|3 - Medicaid (traditional fee-for-service)|3 - Medicaid (traditional fee-for-service)|28
199|3 - Needs someone to do all shopping and errands.|3 - Needs someone to do all shopping and errands.|28
200|3 - Not healing|3 - Not healing|28
201|3 - Nursing home|3 - Nursing home|28
202|3 - Once daily|3 - Once daily|28
203|3 - Other family member|3 - Other family member|28
204|3 - Outpatient department/clinic emergency (includes urgicenter sites)|3 - Outpatient department/clinic emergency (includes urgicenter sites)|28
205|3 - Paid help|3 - Paid help|28
206|3 - Able to participate in bathing self in shower or tub, but requires presence of another person throughout the bath for assistance or supervision.|3 - Able to participate in bathing self in shower or tub, but requires presence of another person th|28
207|3 - Patient depends entirely upon another person to dress lower body.|3 - Patient depends entirely upon another person to dress lower body.|28
208|3 - Patient depends entirely upon another person to dress the upper body.|3 - Patient depends entirely upon another person to dress the upper body.|28
209|3 - Patient depends entirely upon someone else for grooming needs.|3 - Patient depends entirely upon someone else for grooming needs.|28
210|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone else to manage the equipment.|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone|28
211|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable to shift attention and recall directions more than half the time.|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable|28
212|3 - Respiratory problems (SOB, infection, obstruction)|3 - Respiratory problems (SOB, infection, obstruction)|28
213|3 - Resumption of care (after inpatient stay)|3 - Resumption of care (after inpatient stay)|28
214|3 - Several times each month|3 - Several times each month|28
215|3 - Skilled Nursing Facility|3 - Skilled Nursing Facility|28
216|3 - Stage 3|3 - Stage 3|28
217|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|28
218|3 - Three|3 - Three|28
219|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person throughout the process.|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person through|28
220|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal independently.|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal indep|28
221|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person.|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person|28
222|3 - Unknown because patient moved to a geographic location not served by this agency|3 - Unknown because patient moved to a geographic location not served by this agency|28
223|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|28
224|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|28
225|3 - With other family member|3 - With other family member|28
226|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home health services, homemaker assistance, transportation assistance, assisted living, board and care)|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home h|28
227|3-SLP/ST|3-SLP/ST|28
228|4 - At rest (during day or night)|4 - At rest (during day or night)|28
229|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|28
230|4 - Board and care or assisted living facility|4 - Board and care or assisted living facility|28
231|4 - Caregiver is completely dependent on someone else to manage all equipment.|4 - Caregiver is completely dependent on someone else to manage all equipment.|28
232|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|28
233|4 - Constantly|4 - Constantly|28
234|4 - Drug dependency|4 - Drug dependency|28
235|4 - Four or more|4 - Four or more|28
236|4 - Friend or neighbor or community or church member|4 - Friend or neighbor or community or church member|28
237|4 - Hispanic or Latino|4 - Hispanic or Latino|28
238|4 - Hospice|4 - Hospice|28
239|4 - Impaired decision-making|4 - Impaired decision-making|28
240|4 - Is totally dependent in toileting.|4 - Is totally dependent in toileting.|28
241|4 - Medicaid (HMO/managed care)|4 - Medicaid (HMO/managed care)|28
242|4 - None of the above|4 - None of the above|28
243|4 - Nursing home|4 - Nursing home|28
244|4 - On a daily basis|4 - On a daily basis|28
245|4 - Patient is completely dependent on someone else to manage all equipment.|4 - Patient is completely dependent on someone else to manage all equipment.|28
246|4 - Permanent placement|4 - Permanent placement|28
247|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, punches, dangerous maneuvers w/ wheelchair or other objects)|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, pu|28
248|4 - Psychosocial support (e.g., socialization, companionship, recreation)|4 - Psychosocial support (e.g., socialization, companionship, recreation)|28
249|4 - Recertification (follow-up) reassessment|4 - Recertification (follow-up) reassessment|28
250|4 - Recurrent thoughts of death|4 - Recurrent thoughts of death|28
251|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruction)|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruc|28
252|4 - Several times a week|4 - Several times a week|28
253|4 - Stage 4|4 - Stage 4|28
254|4 - Symptoms poorly controlled, history of rehospitalizations|4 - Symptoms poorly controlled, history of rehospitalizations|28
255|4 - Three or more times per week|4 - Three or more times per week|28
256|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetative state, or delirium.|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetati|28
257|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|28
258|4 - Unable to effectively participate in any housekeeping tasks.|4 - Unable to effectively participate in any housekeeping tasks.|28
259|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or unresponsive (e.g., speech is nonsensical or unintelligible).|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or u|28
260|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonresponsive.|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonr|28
261|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostomy.|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostom|28
262|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of devices at the sink, in chair, or on commode|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of|28
263|4 - With a friend|4 - With a friend|28
264|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|28
265|4-OT|4-OT|28
266|5 - Advocates or facilitates patient's participation in appropriate medical care|5 - Advocates or facilitates patient's participation in appropriate medical care|28
267|5 - At least daily|5 - At least daily|28
268|6 - Bedfast, unable to ambulate or be up in a chair.|6 - Bedfast, unable to ambulate or be up in a chair.|28
269|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|28
270|5 - Disruptive or socially inappropriate behavior|5 - Disruptive or socially inappropriate behavior|28
271|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|28
272|5 - Hypo/Hyperglycemia, diabetes out of control|5 - Hypo/Hyperglycemia, diabetes out of control|28
273|5 - More often than once daily|5 - More often than once daily|28
274|5 - Native Hawaiian or Pacific Islander|5 - Native Hawaiian or Pacific Islander|28
275|5 - None of the above|5 - None of the above|28
276|5 - One to two times per week|5 - One to two times per week|28
277|5 - Other|5 - Other|28
278|5 - Other follow-up|5 - Other follow-up|28
279|5 - Paid help|5 - Paid help|28
280|5 - Patient nonresponsive or unable to speak.|5 - Patient nonresponsive or unable to speak.|28
281|5 - Thoughts of suicide|5 - Thoughts of suicide|28
282|5 - Totally unable to use the telephone.|5 - Totally unable to use the telephone.|28
283|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|28
284|5 - Unable to take in nutrients orally or by tube feeding.|5 - Unable to take in nutrients orally or by tube feeding.|28
285|5 - Unsafe for care at home|5 - Unsafe for care at home|28
286|5 - With paid help (other than home care agency staff)|5 - With paid help (other than home care agency staff)|28
287|5 - Workers' compensation|5 - Workers' compensation|28
288|5 - Wound infection, deteriorating wound status, new lesion/ulcer|5 - Wound infection, deteriorating wound status, new lesion/ulcer|28
289|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|28
290|6 - Delusional, hallucinatory, or paranoid behavior|6 - Delusional, hallucinatory, or paranoid behavior|28
291|6 - Financial agent, power of attorney, or conservator of finance|6 - Financial agent, power of attorney, or conservator of finance|28
292|6 - GI bleeding, obstruction|6 - GI bleeding, obstruction|28
293|6 - Less often than weekly|6 - Less often than weekly|28
294|6 - Memory loss to the extent that supervision required|6 - Memory loss to the extent that supervision required|28
295|6 - None of the above feelings observed or reported|6 - None of the above feelings observed or reported|28
296|6 - Other|6 - Other|28
297|6 - Title programs (e.g., Title III, V, or XX)|6 - Title programs (e.g., Title III, V, or XX)|28
298|6 - Transferred to an inpatient facility - patient not discharged from agency|6 - Transferred to an inpatient facility - patient not discharged from agency|28
299|6 - White|6 - White|28
300|6 - With other than above|6 - With other than above|28
301|7 - Exacerbation of CHF, fluid overload, heart failure|7 - Exacerbation of CHF, fluid overload, heart failure|28
302|7 - Health care agent, conservator of person, or medical power of attorney|7 - Health care agent, conservator of person, or medical power of attorney|28
303|7 - Hypo/Hyperglycemia, diabetes out of control|7 - Hypo/Hyperglycemia, diabetes out of control|28
304|7 - None of the above|7 - None of the above|28
305|7 - None of the above behaviors demonstrated|7 - None of the above behaviors demonstrated|28
306|7 - Other government (e.g., TriCare, VA, etc.)|7 - Other government (e.g., TriCare, VA, etc.)|28
307|7 - Transferred to an inpatient facility - patient discharged from agency|7 - Transferred to an inpatient facility - patient discharged from agency|28
308|8 - Death at home|8 - Death at home|28
309|8 - GI bleeding, obstruction|8 - GI bleeding, obstruction|28
310|8 - Myocardial infarction, stroke|8 - Myocardial infarction, stroke|28
311|8 - Private insurance|8 - Private insurance|28
312|9 - Chemotherapy|9 - Chemotherapy|28
313|9 - Discharge from agency|9 - Discharge from agency|28
314|9 - Other than above reasons|9 - Other than above reasons|28
315|9 - Private HMO/managed care|9 - Private HMO/managed care|28
316|NA - No caregiver|NA - No caregiver|28
317|NA - No equipment of this type used in care.|NA - No equipment of this type used in care.|28
318|NA - No inhalant/mist medications prescribed.|NA - No inhalant/mist medications prescribed.|28
319|NA - No injectable medications prescribed.|NA - No injectable medications prescribed.|28
320|NA - No inpatient facility admission|NA - No inpatient facility admission|28
321|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|28
322|NA - No Medicaid|NA - No Medicaid|28
323|NA - No Medicare|NA - No Medicare|28
324|NA - No observable pressure ulcer or unhealed pressure ulcer|NA - No observable pressure ulcer or unhealed pressure ulcer|28
325|NA - No observable stasis ulcer|NA - No observable stasis ulcer|28
326|NA - No observable surgical wound|NA - No observable surgical wound|28
327|NA - No oral medications prescribed.|NA - No oral medications prescribed.|28
328|NA - Not applicable|NA - Not applicable|28
329|NA - Patient does not have a telephone.|NA - Patient does not have a telephone.|28
330|NA - Patient has ostomy for bowel elimination|NA - Patient has ostomy for bowel elimination|28
331|NA - Patient nonresponsive|NA - Patient nonresponsive|28
332|NA - Patient on prophylactic treatment|NA - Patient on prophylactic treatment|28
333|NA - Patient was not discharged from an inpatient facility [Go to M1016 ]|NA - Patient was not discharged from an inpatient facility [Go to M1016 ]|28
334|UK - Other unknown|UK - Other unknown|28
335|UK - Reason unknown|UK - Reason unknown|28
336|UK - Unknown|UK - Unknown|28
337|UK - Unknown or Not Available|UK - Unknown or Not Available|28
341|01 - Early|01 - Early|28
342|02 - Late|02 - Late|28
343|NA - Not Applicable. No case mix group defined for this assessment.|NA - Not Applicable. No case mix group defined for this assessment.|28
344|NA - No case mix group defined by this assessment.|NA - No case mix group defined by this assessment.|28
345|1 - Recent decline in mental, emotional, or behavioral status|1 - Recent decline in mental, emotional, or behavioral status|28
346|2 - Multiple hospitalizations (2 or more) in the past 12 months|2 - Multiple hospitalizations (2 or more) in the past 12 months|28
347|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|28
348|4 - Taking five or more medications|4 - Taking five or more medications|28
349|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|28
350|6 - Other|6 - Other|28
351|7 - None of the above|7 - None of the above|28
352|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond tho|28
353|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable without heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable wi|28
354|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious complications and death.|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious compl|28
355|3 - The patient has serious progressive conditions that could lead to death within a year.|3 - The patient has serious progressive conditions that could lead to death within a year.|28
356|UK - The patient+s situation is unknown or unclear.|UK - The patient+s situation is unknown or unclear.|28
357|1 - Yes [ Go to M1050 ]|1 - Yes [ Go to M1050 ]|28
358|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this influenza season. [ Go to M1050 ]|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this i|28
359|1 - Received from another health care provider (e.g., physician)|1 - Received from another health care provider (e.g., physician)|28
360|2 - Received from your agency previously during this year+s flu season|2 - Received from your agency previously during this year+s flu season|28
361|3 - Offered and declined|3 - Offered and declined|28
362|4 - Assessed and determined to have medical contraindication(s)|4 - Assessed and determined to have medical contraindication(s)|28
363|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|28
364|6 - Inability to obtain vaccine due to declared shortage|6 - Inability to obtain vaccine due to declared shortage|28
365|1 - Yes [ Go to M1500 at TRN; Go to M1230 at DC ]|1 - Yes [ Go to M1500 at TRN; Go to M1230 at DC ]|28
366|1 - Patient has received PPV in the past|1 - Patient has received PPV in the past|28
367|2 - Offered and declined|2 - Offered and declined|28
368|3 - Assessed and determined to have medical contraindication(s)|3 - Assessed and determined to have medical contraindication(s)|28
369|4 - Not indicated; patient does not meet age/condition guidelines for PPV|4 - Not indicated; patient does not meet age/condition guidelines for PPV|28
370|5 - None of the above|5 - None of the above|28
371|0 - Adequate: hears normal conversation without difficulty.|0 - Adequate: hears normal conversation without difficulty.|28
372|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to increase volume or speak distinctly.|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to in|28
373|2 - Severely Impaired: absence of useful hearing.|2 - Severely Impaired: absence of useful hearing.|28
374|UK - Unable to assess hearing.|UK - Unable to assess hearing.|28
375|0 - Understands: clear comprehension without cues or repetitions.|0 - Understands: clear comprehension without cues or repetitions.|28
376|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Requires cues at times to understand.|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Req|28
377|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequently requires cues to understand.|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequentl|28
378|3 - Rarely/Never Understands|3 - Rarely/Never Understands|28
379|UK - Unable to assess understanding.|UK - Unable to assess understanding.|28
380|0 - No standardized assessment conducted|0 - No standardized assessment conducted|28
381|1 - Yes, and it does not indicate severe pain|1 - Yes, and it does not indicate severe pain|28
382|2 - Yes, and it indicates severe pain|2 - Yes, and it indicates severe pain|28
383|0 - Patient has no pain|0 - Patient has no pain|28
384|1 - Patient has pain that does not interfere with activity or movement|1 - Patient has pain that does not interfere with activity or movement|28
385|2 - Less often than daily|2 - Less often than daily|28
386|3 - Daily, but not constantly|3 - Daily, but not constantly|28
387|4 - All of the time|4 - All of the time|28
388|0 - No assessment conducted [ Go to M1306 ]|0 - No assessment conducted [ Go to M1306 ]|28
389|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc., without use of standardized tool|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc.,|28
390|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|28
391|0 - No [ Go to M1322]|0 - No [ Go to M1322]|28
392|0 v Newly epithelialized|0 v Newly epithelialized|28
393|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|28
394|2 - Yes, patient has observable stasis ulcers ONLY|2 - Yes, patient has observable stasis ulcers ONLY|28
395|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable dressing) [Go to M1340]|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable|28
396|0 - No [ Go to M1350 ]|0 - No [ Go to M1350 ]|28
397|1 - Yes, patient has at least one (observable) surgical wound|1 - Yes, patient has at least one (observable) surgical wound|28
398|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1350 ]|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1350 ]|28
399|0 - Patient is not short of breath|0 - Patient is not short of breath|28
400|3 - Continuous Bi-level positive airway pressure|3 - Continuous Bi-level positive airway pressure|28
401|0 - No [ Go to M2004 at TRN; Go to M1600 at DC ]|0 - No [ Go to M2004 at TRN; Go to M1600 at DC ]|28
402|2 - Not assessed [Go to M2004 at TRN; Go to M1600 at DC ]|2 - Not assessed [Go to M2004 at TRN; Go to M1600 at DC ]|28
403|NA - Patient does not have diagnosis of heart failure [Go to M2004 at TRN; Go to M1600 at DC]|NA - Patient does not have diagnosis of heart failure [Go to M2004 at TRN; Go to M1600 at DC]|28
404|0 - No action taken|0 - No action taken|28
405|1 - Patient+s physician (or other primary care practitioner) contacted the same day|1 - Patient+s physician (or other primary care practitioner) contacted the same day|28
406|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|28
407|3 - Implement physician-ordered patient-specific established parameters for treatment|3 - Implement physician-ordered patient-specific established parameters for treatment|28
408|4 - Patient education or other clinical interventions|4 - Patient education or other clinical interventions|28
409|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequency, telehealth, etc.)|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequ|28
410|1 - Occasional stress incontinence|1 - Occasional stress incontinence|28
411|2 - During the night only|2 - During the night only|28
412|3 - During the day only|3 - During the day only|28
413|4 - During the day and night|4 - During the day and night|28
414|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|28
415|0 - Able to manage toileting hygiene and clothing management without assistance.|0 - Able to manage toileting hygiene and clothing management without assistance.|28
416|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implements are laid out for the patient.|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implemen|28
417|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|28
418|3 - Patient depends entirely upon another person to maintain toileting hygiene.|3 - Patient depends entirely upon another person to maintain toileting hygiene.|28
419|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independent|28
420|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface|28
421|0 - No multi-factor falls risk assessment conducted.|0 - No multi-factor falls risk assessment conducted.|28
422|1 - Yes, and it does not indicate a risk for falls.|1 - Yes, and it does not indicate a risk for falls.|28
423|2 - Yes, and it indicates a risk for falls.|2 - Yes, and it indicates a risk for falls.|28
424|0 - Not assessed/reviewed [ Go to M2010 ]|0 - Not assessed/reviewed [ Go to M2010 ]|28
425|1 - No problems found during review [ Go to M2010 ]|1 - No problems found during review [ Go to M2010 ]|28
426|2 - Problems found during review|2 - Problems found during review|28
427|NA - Patient is not taking any medications [ Go to M2040 ]|NA - Patient is not taking any medications [ Go to M2040 ]|28
428|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special precautions associated with all high-risk medications|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special p|28
429|NA - Patient not taking any drugs|NA - Patient not taking any drugs|28
430|2 - Able to take medication(s) at the correct times if given reminders by another person at the appropriate times|2 - Able to take medication(s) at the correct times if given reminders by another person at the appr|28
431|3 - Unable to take medication unless administered by another person.|3 - Unable to take medication unless administered by another person.|28
432|1 - At least daily|1 - At least daily|28
433|2 - Three or more times per week|2 - Three or more times per week|28
434|3 - One to two times per week|3 - One to two times per week|28
435|4 - Received, but less often than weekly|4 - Received, but less often than weekly|28
436|5 - No assistance received|5 - No assistance received|28
437|0 - No [Go to M2400]|0 - No [Go to M2400]|28
438|1 - Yes, used hospital emergency department WITHOUT hospital admission|1 - Yes, used hospital emergency department WITHOUT hospital admission|28
439|2 - Yes, used hospital emergency department WITH hospital admission|2 - Yes, used hospital emergency department WITH hospital admission|28
440|UK - Unknown [Go to M2400]|UK - Unknown [Go to M2400]|28
441|2 - Injury caused by fall|2 - Injury caused by fall|28
442|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|28
443|4 - Other respiratory problem|4 - Other respiratory problem|28
444|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|28
445|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|28
446|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|28
447|8 - Other heart disease|8 - Other heart disease|28
448|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|28
449|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|28
450|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|28
451|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|28
452|13 - Urinary tract infection|13 - Urinary tract infection|28
453|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|28
454|15 - Wound infection or deterioration|15 - Wound infection or deterioration|28
455|16 - Uncontrolled pain|16 - Uncontrolled pain|28
456|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|28
457|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|28
458|19 - Other than above reasons|19 - Other than above reasons|28
459|2 - Patient remained in the community (with formal assistive services)|2 - Patient remained in the community (with formal assistive services)|28
460|3 - Patient transferred to a noninstitutional hospice|3 - Patient transferred to a noninstitutional hospice|28
461|4 - Unknown because patient moved to a geographic location not served by this agency|4 - Unknown because patient moved to a geographic location not served by this agency|28
462|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|28
463|4 - Other respiratory problem|4 - Other respiratory problem|28
464|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|28
465|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|28
466|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|28
467|8 - Other heart disease|8 - Other heart disease|28
468|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|28
469|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|28
470|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|28
471|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|28
472|13 - Urinary tract infection|13 - Urinary tract infection|28
473|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|28
474|15 - Wound infection or deterioration|15 - Wound infection or deterioration|28
475|16 - Uncontrolled pain|16 - Uncontrolled pain|28
476|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|28
477|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|28
478|19 - Scheduled treatment or procedure|19 - Scheduled treatment or procedure|28
479|20 - Other than above reasons|20 - Other than above reasons|28
480|UK - Reason unknown [Go to M0903]|UK - Reason unknown [Go to M0903]|28
482|01 - Patient lives alone around the clock|01 - Patient lives alone around the clock|28
483|02 - Patient lives alone regular daytime|02 - Patient lives alone regular daytime|28
484|03 - Patient lives alone regular nighttime|03 - Patient lives alone regular nighttime|28
485|04 - Patient lives alone occassional/short term assistance|04 - Patient lives alone occassional/short term assistance|28
486|05 - Patient lives alone no assisstance available|05 - Patient lives alone no assisstance available|28
487|06 - Patient lives with other person(s) in the home around the clock|06 - Patient lives with other person(s) in the home around the clock|28
488|07 - Patient lives with other person(s) in the home regular daytime|07 - Patient lives with other person(s) in the home regular daytime|28
489|08 - Patient lives with other person(s) in the home regular nighttime|08 - Patient lives with other person(s) in the home regular nighttime|28
490|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|28
491|10 - Patient lives with other person(s) in the home no assistance available|10 - Patient lives with other person(s) in the home no assistance available|28
492|1 - Was present at the most recent SOC/ROC assessment|1 - Was present at the most recent SOC/ROC assessment|28
493|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|28
494|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|28
495|0 - Newly epithelialized|0 - Newly epithelialized|28
496|0 - No [ Go to M1340 ]|0 - No [ Go to M1340 ]|28
498|0 - Independent|0 - Independent|28
499|1 - Needed Some Help|1 - Needed Some Help|28
500|2 - Dependent|2 - Dependent|28
502|0 - No assistance needed in this area|0 - No assistance needed in this area|28
503|1 - Caregiver(s) currently provide assistance|1 - Caregiver(s) currently provide assistance|28
504|2 - Caregiver(s) need training/ supportive services to provide assistance|2 - Caregiver(s) need training/ supportive services to provide assistance|28
505|3 - Caregiver(s) not likely to provide assistance|3 - Caregiver(s) not likely to provide assistance|28
506|4 - Unclear if Caregiver(s) will provide assistance|4 - Unclear if Caregiver(s) will provide assistance|28
507|5 - Assistance needed, but no Caregiver(s) available|5 - Assistance needed, but no Caregiver(s) available|28
508|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will use standardized clinical guidelines accessible for all care providers to reference|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will|28
510|NA - Patient is not assessed to be at risk for falls|NA - Patient is not assessed to be at risk for falls|28
511|NA - Patient has no diagnosis or symptoms of depression|NA - Patient has no diagnosis or symptoms of depression|28
512|NA - No pain identified|NA - No pain identified|28
513|NA - Patient is not assessed to be at risk for pressure ulcers|NA - Patient is not assessed to be at risk for pressure ulcers|28
514|NA - Patient has no pressure ulcers with need for moist wound healing|NA - Patient has no pressure ulcers with need for moist wound healing|28
515|1 - Long-term nursing facility (NF)|1 - Long-term nursing facility (NF)|28
516|2 - Skilled nursing facility (SNF / TCU)|2 - Skilled nursing facility (SNF / TCU)|28
517|3 - Short stay acute hospital (IPP S)|3 - Short stay acute hospital (IPP S)|28
518|4 - Long-term care hospital (LTCH)|4 - Long-term care hospital (LTCH)|28
519|5 - Inpatient rehabilitation hospital or unit (IRF)|5 - Inpatient rehabilitation hospital or unit (IRF)|28
520|6 - Psychiatric hospital or unit|6 - Psychiatric hospital or unit|28
521|7 - Other|7 - Other|28
522|NA - Patient was not discharged from an inpatient facility [Goto M1016]|NA - Patient was not discharged from an inpatient facility [Goto M1016]|28
523|6 - Unable to participate effectively in bathing and is bathed totally by another person|6 - Unable to participate effectively in bathing and is bathed totally by another person|28
524|4 - Chairfast, unable to ambulate but is able to wheel self independently.|4 - Chairfast, unable to ambulate but is able to wheel self independently.|28
525|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask patient: "Over the last two weeks, how often have you been bothered by any of the following problems")|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask|28
526|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluation for depression.|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluat|28
527|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet criteria for further evaluation for depression.|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet|28
528|0 - Not at all  0 - 1 day|0 - Not at all  0 - 1 day|28
529|1 - Several days  2 - 6 days|1 - Several days  2 - 6 days|28
530|2 - More than half of the days  7 - 11 days|2 - More than half of the days  7 - 11 days|28
531|3 - Nearly every day  12 - 14 days|3 - Nearly every day  12 - 14 days|28
532|NA - N/A  Unable to respond|NA - N/A  Unable to respond|28
533|2 - Able to take medication(s) at the correct times if given reminders by another person based on the frequency of the injection|2 - Able to take medication(s) at the correct times if given reminders by another person based on th|28
534|3 - Unable to take injectable medication unless administered by another person.|3 - Unable to take injectable medication unless administered by another person.|28
547|NA - No clinically significant medication issues identified since the previous OASIS assessment|NA - No clinically significant medication issues identified since the previous OASIS assessment|28
552|1 - Hospital [ Go to M2430 ]|1 - Hospital [ Go to M2430 ]|28
553|2 - Rehabilitation facility [ Go to M0903 ]|2 - Rehabilitation facility [ Go to M0903 ]|28
554|3 - Nursing home [ Go to M2440 ]|3 - Nursing home [ Go to M2440 ]|28
555|4 - Hospice [ Go to M0903 ]|4 - Hospice [ Go to M0903 ]|28
2|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; OR (b) Is physically, cognitively, and mentally able to prepare light meals on a regular basis but has not routinely performed light meal preparation in the past (i.e., prior to this home care admission).|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; O|29
3|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and mentally able to perform all housekeeping tasks .|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and menta|29
4|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and mentally able to do laundry and access facilities.|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and menta|29
5|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying packages OR b) Physically, cognitively, and mentally able to take care of shopping, but has not done shopping in the past (i.e., prior to this home care admission).|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying|29
6|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|29
7|0 - Able to dial numbers and answer calls appropriately and as desired.|0 - Able to dial numbers and answer calls appropriately and as desired.|29
8|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body without assistance.|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body|29
9|0 - Able to get to and from the toilet and transfer independently with or without a device.|0 - Able to get to and from the toilet and transfer independently with or without a device.|29
10|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|29
11|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible public bus.|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible p|29
12|0 - Able to independently feed self.|0 - Able to independently feed self.|29
13|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|29
14|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct times.|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct ti|29
15|0 - Able to independently transfer.|0 - Able to independently transfer.|29
16|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without rail|29
17|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings|29
18|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|29
19|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions independently.|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions indep|29
20|0 - Asymptomatic, no treatment needed at this time|0 - Asymptomatic, no treatment needed at this time|29
21|0 - Caregiver manages all tasks related to equipment completely independently.|0 - Caregiver manages all tasks related to equipment completely independently.|29
22|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations with no observable impairment.|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations w|29
23|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|29
24|0 - Life expectancy is greater than 6 months|0 - Life expectancy is greater than 6 months|29
25|0 - Never|0 - Never|29
26|0 - Patient is not short of breath|0 - Patient is not short of breath|29
27|0 - No|0 - No|29
28|0 - No emergent care services|0 - No emergent care services|29
29|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [Goto M1620]|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [Goto M1620]|29
30|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and extended or abstract conversation.|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and exte|29
31|0 - No one person|0 - No one person|29
32|0 - None of the time|0 - None of the time|29
33|0 - None, no charge for current services|0 - None, no charge for current services|29
34|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|29
35|0 - Patient does NOT have an ostomy for bowel elimination.|0 - Patient does NOT have an ostomy for bowel elimination.|29
36|0 - Patient has no pain|0 - Patient has no pain|29
37|0 - Patient manages all tasks related to equipment completely independently.|0 - Patient manages all tasks related to equipment completely independently.|29
38|0 - Poor:  little or no recovery is expected and/or further decline is imminent|0 - Poor:  little or no recovery is expected and/or further decline is imminent|29
39|0 - Timed-voiding defers incontinence|0 - Timed-voiding defers incontinence|29
40|0 - Very rarely or never has bowel incontinence|0 - Very rarely or never has bowel incontinence|29
41|0 - Zero|0 - Zero|29
42|00 - No|00 - No|29
43|01 - Yes|01 - Yes|29
44|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or mental limitations, needs assistance with heavy laundry.|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or|29
45|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the patient.|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the|29
46|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|29
47|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or supervision from another person OR c) a liquid, pureed or ground meat diet.|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or su|29
48|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|29
49|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|29
50|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independently.|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independe|29
51|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only when assisted or accompanied by another person.|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only w|29
52|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepa|29
53|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance by another person OR b) given daily reminders.|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance b|29
54|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advan|29
55|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advan|29
56|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for the deaf) and call essential numbers.|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for t|29
57|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|29
58|1 - American Indian or Alaska Native|1 - American Indian or Alaska Native|29
59|1 - Depressed mood (e.g., feeling sad, tearful)|1 - Depressed mood (e.g., feeling sad, tearful)|29
60|1 - During the night only|1 - During the night only|29
61|1 - Fully granulating|1 - Fully granulating|29
62|1 - Good/Fair:  partial to full recovery is expected|1 - Good/Fair:  partial to full recovery is expected|29
63|1 - Good:  marked improvement in functional status is expected|1 - Good:  marked improvement in functional status is expected|29
64|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|29
65|1 - Smoking|1 - Smoking|29
66|1 - Hospital [ Go to M2430 ]|1 - Hospital [ Go to M2430 ]|29
67|1 - Hospital emergency room (includes 23-hour holding)|1 - Hospital emergency room (includes 23-hour holding)|29
68|1 - Hospitalization for EMERGENT (unscheduled) care|1 - Hospitalization for EMERGENT (unscheduled) care|29
69|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepared solutions), patient is able to manage all other aspects of equipment.|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepar|29
70|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|29
71|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|29
72|1 - In new or complex situations only|1 - In new or complex situations only|29
73|1 - Intravenous or infusion therapy (excludes TPN)|1 - Intravenous or infusion therapy (excludes TPN)|29
74|1 - Less often than daily|1 - Less often than daily|29
75|1 - Less than once a month|1 - Less than once a month|29
76|1 - Less than once weekly|1 - Less than once weekly|29
77|1 - Life expectancy is 6 months or fewer|1 - Life expectancy is 6 months or fewer|29
78|1 - Lives alone|1 - Lives alone|29
79|1 - Male|1 - Male|29
80|1 - Medicare (traditional fee-for-service)|1 - Medicare (traditional fee-for-service)|29
81|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of past 24 hours, significant memory loss so that supervision is required|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of pas|29
82|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors in word choice, grammar or speech intelligibility, needs minimal prompting or assistance).|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors i|29
83|1 - No assistance or services received|1 - No assistance or services received|29
84|1 - One|1 - One|29
85|1 - Oxygen (intermittent or continuous)|1 - Oxygen (intermittent or continuous)|29
86|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, and the surrounding layout, can count fingers at arm's length.|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, a|29
87|1 - Patient is incontinent|1 - Patient is incontinent|29
88|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|29
89|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical or treatment regimen.|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical|29
90|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient/couple/significant other)|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient|29
91|1 - Relatives, friends, or neighbors living outside the home|1 - Relatives, friends, or neighbors living outside the home|29
92|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions.|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions|29
93|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independentl|29
94|1 - Several times during day and night|1 - Several times during day and night|29
95|1 - Spouse or significant other|1 - Spouse or significant other|29
96|1 - Stage 1|1 - Stage 1|29
97|1 - Start of care - further visits planned|1 - Start of care - further visits planned|29
98|1 - Symptoms well controlled with current therapy|1 - Symptoms well controlled with current therapy|29
99|1 - Therapy services|1 - Therapy services|29
100|1 - Able to transfer with minimal human assistance or with use of an assistive device.|1 - Able to transfer with minimal human assistance or with use of an assistive device.|29
101|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitations.|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitatio|29
102|1 - Urinary incontinence|1 - Urinary incontinence|29
103|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and transfer.|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and|29
104|1 - When walking more than 20 feet, climbing stairs|1 - When walking more than 20 feet, climbing stairs|29
105|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary conversation. May need occasional repetition, extra time, or louder voice.|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary c|29
106|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting in and out of tub/shower|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting|29
107|1 - Yes|1 - Yes|29
108|1-RN|1-RN|29
109|10 - Discharge from agency - no visits completed after start/resumption of care assessment|10 - Discharge from agency - no visits completed after start/resumption of care assessment|29
110|10 - Scheduled surgical procedure|10 - Scheduled surgical procedure|29
111|10 - Self-pay|10 - Self-pay|29
112|11 - Other|11 - Other|29
113|11 - Urinary tract infection|11 - Urinary tract infection|29
114|12 - IV catheter-related infection|12 - IV catheter-related infection|29
115|13 - Deep vein thrombosis, pulmonary embolus|13 - Deep vein thrombosis, pulmonary embolus|29
116|14 - Uncontrolled pain|14 - Uncontrolled pain|29
117|15 - Psychotic episode|15 - Psychotic episode|29
118|16 - Other than above reasons|16 - Other than above reasons|29
119|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing calls.|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing|29
120|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another person.|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another pers|29
121|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface a|29
122|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for intermittent supervision or encouragement or reminders, OR (b) to get in and out of the shower or tub, OR (c) for washing difficult to reach areas.|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for inter|29
123|2 - Asian|2 - Asian|29
124|2 - Caregiver requires considerable assistance from another person to manage equipment, but independently completes significant portions of task.|2 - Caregiver requires considerable assistance from another person to manage equipment, but independ|29
125|2 - Daily, but not constantly|2 - Daily, but not constantly|29
126|2 - Daughter or son|2 - Daughter or son|29
127|2 - Doctor's office emergency visit/house call|2 - Doctor's office emergency visit/house call|29
128|2 - During the day and night|2 - During the day and night|29
129|2 - Early/partial granulation|2 - Early/partial granulation|29
130|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors in word choice, organization or speech intelligibility). Speaks in phrases or short sentences.|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors|29
131|2 - Family member's residence|2 - Family member's residence|29
132|2 - Female|2 - Female|29
133|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conversation, needs frequent prompting or assistance.|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conver|29
134|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|29
135|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|29
136|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately stop activities, jeopardizes safety through actions|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately st|29
137|2 - Indwelling/suprapubic catheter|2 - Indwelling/suprapubic catheter|29
138|2 - Injury caused by fall or accident at home|2 - Injury caused by fall or accident at home|29
139|2 - Medicare (HMO/managed care/Advantage plan)|2 - Medicare (HMO/managed care/Advantage plan)|29
140|2 - Nausea, dehydration, malnutrition, constipation, impaction|2 - Nausea, dehydration, malnutrition, constipation, impaction|29
141|2 - Obesity|2 - Obesity|29
142|2 - On awakening or at night only|2 - On awakening or at night only|29
143|2 - Once a month|2 - Once a month|29
144|2 - One to three times weekly|2 - One to three times weekly|29
145|2 - Parenteral nutrition (TPN or lipids)|2 - Parenteral nutrition (TPN or lipids)|29
146|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic) [ Go to M1620 ]|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic) [ Go|29
147|2 - Patient requires considerable assistance from another person to manage equipment, but independently completes portions of the task.|2 - Patient requires considerable assistance from another person to manage equipment, but independen|29
148|2 - Patient transferred to a noninstitutional hospice|2 - Patient transferred to a noninstitutional hospice|29
149|2 - Person residing in the home (EXCLUDING paid help)|2 - Person residing in the home (EXCLUDING paid help)|29
150|2 - Rehabilitation facility [ Go to M0903 ]|2 - Rehabilitation facility [ Go to M0903 ]|29
151|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifting of attention) or consistently requires low stimulus environment due to distractibility.|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifti|29
152|2 - Respite care|2 - Respite care|29
153|2 - Sense of failure or self reproach|2 - Sense of failure or self reproach|29
154|2 - Several times during day|2 - Several times during day|29
155|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonresponsive.|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonrespons|29
156|2 - Someone must assist the patient to groom self.|2 - Someone must assist the patient to groom self.|29
157|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|29
158|2 - Someone must help the patient put on upper body clothing.|2 - Someone must help the patient put on upper body clothing.|29
159|2 - Stage 2|2 - Stage 2|29
160|2 - Start of care - no further visits planned|2 - Start of care - no further visits planned|29
161|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitoring|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitori|29
162|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment regimen.|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment re|29
163|2 - Two|2 - Two|29
164|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistance due to cognitive or mental limitation.|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistanc|29
165|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|29
166|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assistance).|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assis|29
167|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home delivery.|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home deli|29
168|2 - Unable to prepare any light meals or reheat any delivered meals.|2 - Unable to prepare any light meals or reheat any delivered meals.|29
169|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|29
170|2 - UNABLE to take injectable medications unless administered by someone else.|2 - UNABLE to take injectable medications unless administered by someone else.|29
171|2 - UNABLE to take medication unless administered by someone else.|2 - UNABLE to take medication unless administered by someone else.|29
172|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|29
173|2 - Ventilator (continually or at night)|2 - Ventilator (continually or at night)|29
174|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less than 20 feet)|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less th|29
175|2 - With spouse or significant other|2 - With spouse or significant other|29
176|2 - Yes, assistance or services provided by family or friends|2 - Yes, assistance or services provided by family or friends|29
177|2-PT|2-PT|29
178|3 - Able to answer the telephone only some of the time or is able to carry on only a limited conversation.|3 - Able to answer the telephone only some of the time or is able to carry on only a limited convers|29
179|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube or gastrostomy.|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube|29
180|3 - Alcohol dependency|3 - Alcohol dependency|29
181|3 - All of the time|3 - All of the time|29
182|3 - Black or African-American|3 - Black or African-American|29
183|3 - Boarding home or rented room|3 - Boarding home or rented room|29
184|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment, clean/store/dispose of equipment or supplies).|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment,|29
185|3 -Able to walk only with the supervision or assistance of another person at all times.|3 -Able to walk only with the supervision or assistance of another person at all times.|29
186|3 - Continuous / Bi-level positive airway pressure|3 - Continuous / Bi-level positive airway pressure|29
187|3 - During the day and evening, but not constantly|3 - During the day and evening, but not constantly|29
188|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the alimentary canal)|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the|29
189|3 - Environmental support (e.g., housing, home maintenance)|3 - Environmental support (e.g., housing, home maintenance)|29
190|3 - Four to six times weekly|3 - Four to six times weekly|29
191|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessing by listener.  Speech limited to single words or short phrases.|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessin|29
192|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires multiple repetitions, restatements, demonstrations, additional time.|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires m|29
193|3 - Hopelessness|3 - Hopelessness|29
194|3 - Hospice care|3 - Hospice care|29
195|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|29
196|3 - Injury caused by fall or accident at home|3 - Injury caused by fall or accident at home|29
197|3 - Intractable pain|3 - Intractable pain|29
198|3 - Medicaid (traditional fee-for-service)|3 - Medicaid (traditional fee-for-service)|29
199|3 - Needs someone to do all shopping and errands.|3 - Needs someone to do all shopping and errands.|29
200|3 - Not healing|3 - Not healing|29
201|3 - Nursing home [ Go to M2440 ]|3 - Nursing home [ Go to M2440 ]|29
202|3 - Once daily|3 - Once daily|29
203|3 - Other family member|3 - Other family member|29
204|3 - Outpatient department/clinic emergency (includes urgicenter sites)|3 - Outpatient department/clinic emergency (includes urgicenter sites)|29
205|3 - Paid help|3 - Paid help|29
206|3 - Able to participate in bathing self in shower or tub, but requires presence of another person throughout the bath for assistance or supervision.|3 - Able to participate in bathing self in shower or tub, but requires presence of another person th|29
207|3 - Patient depends entirely upon another person to dress lower body.|3 - Patient depends entirely upon another person to dress lower body.|29
208|3 - Patient depends entirely upon another person to dress the upper body.|3 - Patient depends entirely upon another person to dress the upper body.|29
209|3 - Patient depends entirely upon someone else for grooming needs.|3 - Patient depends entirely upon someone else for grooming needs.|29
210|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone else to manage the equipment.|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone|29
211|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable to shift attention and recall directions more than half the time.|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable|29
212|3 - Respiratory problems (SOB, infection, obstruction)|3 - Respiratory problems (SOB, infection, obstruction)|29
213|3 - Resumption of care (after inpatient stay)|3 - Resumption of care (after inpatient stay)|29
214|3 - Several times each month|3 - Several times each month|29
215|3 - Skilled Nursing Facility|3 - Skilled Nursing Facility|29
216|3 - Stage 3|3 - Stage 3|29
217|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|29
218|3 - Three|3 - Three|29
219|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person throughout the process.|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person through|29
220|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal independently.|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal indep|29
221|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person.|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person|29
222|3 - Unknown because patient moved to a geographic location not served by this agency|3 - Unknown because patient moved to a geographic location not served by this agency|29
223|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|29
224|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|29
225|3 - With other family member|3 - With other family member|29
226|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home health services, homemaker assistance, transportation assistance, assisted living, board and care)|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home h|29
227|3-SLP/ST|3-SLP/ST|29
228|4 - At rest (during day or night)|4 - At rest (during day or night)|29
229|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|29
230|4 - Board and care or assisted living facility|4 - Board and care or assisted living facility|29
231|4 - Caregiver is completely dependent on someone else to manage all equipment.|4 - Caregiver is completely dependent on someone else to manage all equipment.|29
232|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|29
233|4 - Constantly|4 - Constantly|29
234|4 - Drug dependency|4 - Drug dependency|29
235|4 - Four or more|4 - Four or more|29
236|4 - Friend or neighbor or community or church member|4 - Friend or neighbor or community or church member|29
237|4 - Hispanic or Latino|4 - Hispanic or Latino|29
238|4 - Hospice [ Go to M0903 ]|4 - Hospice [ Go to M0903 ]|29
239|4 - Impaired decision-making|4 - Impaired decision-making|29
240|4 - Is totally dependent in toileting.|4 - Is totally dependent in toileting.|29
241|4 - Medicaid (HMO/managed care)|4 - Medicaid (HMO/managed care)|29
242|4 - None of the above|4 - None of the above|29
243|4 - Nursing home|4 - Nursing home|29
244|4 - On a daily basis|4 - On a daily basis|29
245|4 - Patient is completely dependent on someone else to manage all equipment.|4 - Patient is completely dependent on someone else to manage all equipment.|29
246|4 - Permanent placement|4 - Permanent placement|29
247|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, punches, dangerous maneuvers w/ wheelchair or other objects)|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, pu|29
248|4 - Psychosocial support (e.g., socialization, companionship, recreation)|4 - Psychosocial support (e.g., socialization, companionship, recreation)|29
249|4 - Recertification (follow-up) reassessment|4 - Recertification (follow-up) reassessment|29
250|4 - Recurrent thoughts of death|4 - Recurrent thoughts of death|29
251|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruction)|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruc|29
252|4 - Several times a week|4 - Several times a week|29
253|4 - Stage 4|4 - Stage 4|29
254|4 - Symptoms poorly controlled, history of re-hospitalizations|4 - Symptoms poorly controlled, history of re-hospitalizations|29
255|4 - Three or more times per week|4 - Three or more times per week|29
256|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetative state, or delirium.|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetati|29
257|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|29
258|4 - Unable to effectively participate in any housekeeping tasks.|4 - Unable to effectively participate in any housekeeping tasks.|29
259|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or unresponsive (e.g., speech is nonsensical or unintelligible).|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or u|29
260|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonresponsive.|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonr|29
261|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostomy.|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostom|29
262|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of devices at the sink, in chair, or on commode|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of|29
263|4 - With a friend|4 - With a friend|29
264|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|29
265|4-OT|4-OT|29
266|5 - Advocates or facilitates patient's participation in appropriate medical care|5 - Advocates or facilitates patient's participation in appropriate medical care|29
267|5 - At least daily|5 - At least daily|29
268|6 - Bedfast, unable to ambulate or be up in a chair.|6 - Bedfast, unable to ambulate or be up in a chair.|29
269|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|29
270|5 - Disruptive or socially inappropriate behavior|5 - Disruptive or socially inappropriate behavior|29
271|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|29
272|5 - Hypo/Hyperglycemia, diabetes out of control|5 - Hypo/Hyperglycemia, diabetes out of control|29
273|5 - More often than once daily|5 - More often than once daily|29
274|5 - Native Hawaiian or Pacific Islander|5 - Native Hawaiian or Pacific Islander|29
275|5 - None of the above|5 - None of the above|29
276|5 - One to two times per week|5 - One to two times per week|29
277|5 - Other|5 - Other|29
278|5 - Other follow-up|5 - Other follow-up|29
279|5 - Paid help|5 - Paid help|29
280|5 - Patient nonresponsive or unable to speak.|5 - Patient nonresponsive or unable to speak.|29
281|5 - Thoughts of suicide|5 - Thoughts of suicide|29
282|5 - Totally unable to use the telephone.|5 - Totally unable to use the telephone.|29
283|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|29
284|5 - Unable to take in nutrients orally or by tube feeding.|5 - Unable to take in nutrients orally or by tube feeding.|29
285|5 - Unsafe for care at home|5 - Unsafe for care at home|29
286|5 - With paid help (other than home care agency staff)|5 - With paid help (other than home care agency staff)|29
287|5 - Workers' compensation|5 - Workers' compensation|29
288|5 - Wound infection, deteriorating wound status, new lesion/ulcer|5 - Wound infection, deteriorating wound status, new lesion/ulcer|29
289|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|29
290|6 - Delusional, hallucinatory, or paranoid behavior|6 - Delusional, hallucinatory, or paranoid behavior|29
291|6 - Financial agent, power of attorney, or conservator of finance|6 - Financial agent, power of attorney, or conservator of finance|29
292|6 - GI bleeding, obstruction|6 - GI bleeding, obstruction|29
293|6 - Less often than weekly|6 - Less often than weekly|29
294|6 - Memory loss to the extent that supervision required|6 - Memory loss to the extent that supervision required|29
295|6 - None of the above feelings observed or reported|6 - None of the above feelings observed or reported|29
296|6 - Other|6 - Other|29
297|6 - Title programs (e.g., Title III, V, or XX)|6 - Title programs (e.g., Title III, V, or XX)|29
298|6 - Transferred to an inpatient facility - patient not discharged from agency|6 - Transferred to an inpatient facility - patient not discharged from agency|29
299|6 - White|6 - White|29
300|6 - With other than above|6 - With other than above|29
301|7 - Exacerbation of CHF, fluid overload, heart failure|7 - Exacerbation of CHF, fluid overload, heart failure|29
302|7 - Health care agent, conservator of person, or medical power of attorney|7 - Health care agent, conservator of person, or medical power of attorney|29
303|7 - Hypo/Hyperglycemia, diabetes out of control|7 - Hypo/Hyperglycemia, diabetes out of control|29
304|7 - None of the above|7 - None of the above|29
305|7 - None of the above behaviors demonstrated|7 - None of the above behaviors demonstrated|29
306|7 - Other government (e.g., TriCare, VA, etc.)|7 - Other government (e.g., TriCare, VA, etc.)|29
307|7 - Transferred to an inpatient facility - patient discharged from agency|7 - Transferred to an inpatient facility - patient discharged from agency|29
308|8 - Death at home|8 - Death at home|29
309|8 - GI bleeding, obstruction|8 - GI bleeding, obstruction|29
310|8 - Myocardial infarction, stroke|8 - Myocardial infarction, stroke|29
311|8 - Private insurance|8 - Private insurance|29
312|9 - Chemotherapy|9 - Chemotherapy|29
313|9 - Discharge from agency|9 - Discharge from agency|29
314|9 - Other than above reasons|9 - Other than above reasons|29
315|9 - Private HMO/managed care|9 - Private HMO/managed care|29
316|NA - No caregiver|NA - No caregiver|29
317|NA - No equipment of this type used in care.|NA - No equipment of this type used in care.|29
318|NA - No inhalant/mist medications prescribed.|NA - No inhalant/mist medications prescribed.|29
319|NA - No injectable medications prescribed.|NA - No injectable medications prescribed.|29
320|NA - No inpatient facility admission|NA - No inpatient facility admission|29
321|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|29
322|NA - No Medicaid|NA - No Medicaid|29
323|NA - No Medicare|NA - No Medicare|29
324|NA - No observable pressure ulcer|NA - No observable pressure ulcer|29
325|NA - No observable stasis ulcer|NA - No observable stasis ulcer|29
326|NA - No observable surgical wound|NA - No observable surgical wound|29
327|NA - No oral medications prescribed.|NA - No oral medications prescribed.|29
328|NA - Not applicable|NA - Not applicable|29
329|NA - Patient does not have a telephone.|NA - Patient does not have a telephone.|29
330|NA - Patient has ostomy for bowel elimination|NA - Patient has ostomy for bowel elimination|29
331|NA - Patient nonresponsive|NA - Patient nonresponsive|29
332|NA - Patient on prophylactic treatment|NA - Patient on prophylactic treatment|29
333|NA - Patient was not discharged from an inpatient facility [Go to M1016 ]|NA - Patient was not discharged from an inpatient facility [Go to M1016 ]|29
334|UK - Other unknown|UK - Other unknown|29
335|UK - Reason unknown|UK - Reason unknown|29
336|UK - Unknown|UK - Unknown|29
337|UK - Unknown or Not Available|UK - Unknown or Not Available|29
341|01 - Early|01 - Early|29
342|02 - Late|02 - Late|29
343|NA - Not Applicable. No case mix group defined for this assessment.|NA - Not Applicable. No case mix group defined for this assessment.|29
344|NA - No case mix group defined by this assessment.|NA - No case mix group defined by this assessment.|29
345|1 - Recent decline in mental, emotional, or behavioral status|1 - Recent decline in mental, emotional, or behavioral status|29
346|2 - Multiple hospitalizations (2 or more) in the past 12 months|2 - Multiple hospitalizations (2 or more) in the past 12 months|29
347|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|29
348|4 - Taking five or more medications|4 - Taking five or more medications|29
349|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|29
350|6 - Other|6 - Other|29
351|7 - None of the above|7 - None of the above|29
352|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond tho|29
353|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable without heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable wi|29
354|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious complications and death.|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious compl|29
355|3 - The patient has serious progressive conditions that could lead to death within a year.|3 - The patient has serious progressive conditions that could lead to death within a year.|29
356|UK - The patient+s situation is unknown or unclear.|UK - The patient+s situation is unknown or unclear.|29
357|1 - Yes [ Go to M1050 ]|1 - Yes [ Go to M1050 ]|29
358|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this influenza season. [ Go to M1050 ]|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this i|29
359|1 - Received from another health care provider (e.g., physician)|1 - Received from another health care provider (e.g., physician)|29
360|2 - Received from your agency previously during this year+s flu season|2 - Received from your agency previously during this year+s flu season|29
361|3 - Offered and declined|3 - Offered and declined|29
362|4 - Assessed and determined to have medical contraindication(s)|4 - Assessed and determined to have medical contraindication(s)|29
363|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|29
364|6 - Inability to obtain vaccine due to declared shortage|6 - Inability to obtain vaccine due to declared shortage|29
365|1 - Yes [ Go to M1500 at TRN; Go to M1230 at DC ]|1 - Yes [ Go to M1500 at TRN; Go to M1230 at DC ]|29
366|1 - Patient has received PPV in the past|1 - Patient has received PPV in the past|29
367|2 - Offered and declined|2 - Offered and declined|29
368|3 - Assessed and determined to have medical contraindication(s)|3 - Assessed and determined to have medical contraindication(s)|29
369|4 - Not indicated; patient does not meet age/condition guidelines for PPV|4 - Not indicated; patient does not meet age/condition guidelines for PPV|29
370|5 - None of the above|5 - None of the above|29
371|0 - Adequate: hears normal conversation without difficulty.|0 - Adequate: hears normal conversation without difficulty.|29
372|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to increase volume or speak distinctly.|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to in|29
373|2 - Severely Impaired: absence of useful hearing.|2 - Severely Impaired: absence of useful hearing.|29
374|UK - Unable to assess hearing.|UK - Unable to assess hearing.|29
375|0 - Understands: clear comprehension without cues or repetitions.|0 - Understands: clear comprehension without cues or repetitions.|29
376|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Requires cues at times to understand.|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Req|29
377|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequently requires cues to understand.|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequentl|29
378|3 - Rarely/Never Understands|3 - Rarely/Never Understands|29
379|UK - Unable to assess understanding.|UK - Unable to assess understanding.|29
380|0 - No standardized assessment conducted|0 - No standardized assessment conducted|29
381|1 - Yes, and it does not indicate severe pain|1 - Yes, and it does not indicate severe pain|29
382|2 - Yes, and it indicates severe pain|2 - Yes, and it indicates severe pain|29
383|0 - Patient has no pain|0 - Patient has no pain|29
384|1 - Patient has pain that does not interfere with activity or movement|1 - Patient has pain that does not interfere with activity or movement|29
385|2 - Less often than daily|2 - Less often than daily|29
386|3 - Daily, but not constantly|3 - Daily, but not constantly|29
387|4 - All of the time|4 - All of the time|29
388|0 - No assessment conducted [ Go to M1306 ]|0 - No assessment conducted [ Go to M1306 ]|29
389|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc., without use of standardized tool|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc.,|29
390|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|29
391|0 - No [ Go to M1322]|0 - No [ Go to M1322]|29
392|0 v Newly epithelialized|0 v Newly epithelialized|29
393|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|29
394|2 - Yes, patient has observable stasis ulcers ONLY|2 - Yes, patient has observable stasis ulcers ONLY|29
395|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable dressing) [Go to M1340]|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable|29
396|0 - No [ Go to M1350 ]|0 - No [ Go to M1350 ]|29
397|1 - Yes, patient has at least one (observable) surgical wound|1 - Yes, patient has at least one (observable) surgical wound|29
398|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1350 ]|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1350 ]|29
399|0 - Patient is not short of breath|0 - Patient is not short of breath|29
400|3 - Continuous Bi-level positive airway pressure|3 - Continuous Bi-level positive airway pressure|29
401|0 - No [ Go to M1732 at TRN; Go to M1600 at DC ]|0 - No [ Go to M1732 at TRN; Go to M1600 at DC ]|29
402|2 - Not assessed [Go to M1732 at TRN; Go to M1600 at DC ]|2 - Not assessed [Go to M1732 at TRN; Go to M1600 at DC ]|29
403|NA - Patient does not have diagnosis of heart failure [Go to M2004 at TRN; Go to M1600 at DC]|NA - Patient does not have diagnosis of heart failure [Go to M2004 at TRN; Go to M1600 at DC]|29
404|0 - No action taken|0 - No action taken|29
405|1 - Patient+s physician (or other primary care practitioner) contacted the same day|1 - Patient+s physician (or other primary care practitioner) contacted the same day|29
406|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|29
407|3 - Implement physician-ordered patient-specific established parameters for treatment|3 - Implement physician-ordered patient-specific established parameters for treatment|29
408|4 - Patient education or other clinical interventions|4 - Patient education or other clinical interventions|29
409|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequency, telehealth, etc.)|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequ|29
410|1 - Occasional stress incontinence|1 - Occasional stress incontinence|29
411|2 - During the night only|2 - During the night only|29
412|3 - During the day only|3 - During the day only|29
413|4 - During the day and night|4 - During the day and night|29
414|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|29
415|0 - Able to manage toileting hygiene and clothing management without assistance.|0 - Able to manage toileting hygiene and clothing management without assistance.|29
416|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implements are laid out for the patient.|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implemen|29
417|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|29
418|3 - Patient depends entirely upon another person to maintain toileting hygiene.|3 - Patient depends entirely upon another person to maintain toileting hygiene.|29
419|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independent|29
420|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface|29
421|0 - No multi-factor falls risk assessment conducted.|0 - No multi-factor falls risk assessment conducted.|29
422|1 - Yes, and it does not indicate a risk for falls.|1 - Yes, and it does not indicate a risk for falls.|29
423|2 - Yes, and it indicates a risk for falls.|2 - Yes, and it indicates a risk for falls.|29
424|0 - Not assessed/reviewed [ Go to M2010 ]|0 - Not assessed/reviewed [ Go to M2010 ]|29
425|1 - No problems found during review [ Go to M2010 ]|1 - No problems found during review [ Go to M2010 ]|29
426|2 - Problems found during review|2 - Problems found during review|29
427|NA - Patient is not taking any medications [ Go to M2040 ]|NA - Patient is not taking any medications [ Go to M2040 ]|29
428|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special precautions associated with all high-risk medications|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special p|29
429|NA - Patient not taking any drugs|NA - Patient not taking any drugs|29
430|2 - Able to take medication(s) at the correct times if given reminders by another person at the appropriate times|2 - Able to take medication(s) at the correct times if given reminders by another person at the appr|29
431|3 - Unable to take medication unless administered by another person.|3 - Unable to take medication unless administered by another person.|29
432|1 - At least daily|1 - At least daily|29
433|2 - Three or more times per week|2 - Three or more times per week|29
434|3 - One to two times per week|3 - One to two times per week|29
435|4 - Received, but less often than weekly|4 - Received, but less often than weekly|29
436|5 - No assistance received|5 - No assistance received|29
437|0 - No [Go to M2400]|0 - No [Go to M2400]|29
438|1 - Yes, used hospital emergency department WITHOUT hospital admission|1 - Yes, used hospital emergency department WITHOUT hospital admission|29
439|2 - Yes, used hospital emergency department WITH hospital admission|2 - Yes, used hospital emergency department WITH hospital admission|29
440|UK - Unknown [Go to M2400]|UK - Unknown [Go to M2400]|29
441|2 - Injury caused by fall|2 - Injury caused by fall|29
442|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|29
443|4 - Other respiratory problem|4 - Other respiratory problem|29
444|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|29
445|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|29
446|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|29
447|8 - Other heart disease|8 - Other heart disease|29
448|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|29
449|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|29
450|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|29
451|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|29
452|13 - Urinary tract infection|13 - Urinary tract infection|29
453|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|29
454|15 - Wound infection or deterioration|15 - Wound infection or deterioration|29
455|16 - Uncontrolled pain|16 - Uncontrolled pain|29
456|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|29
457|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|29
458|19 - Other than above reasons|19 - Other than above reasons|29
459|2 - Patient remained in the community (with formal assistive services)|2 - Patient remained in the community (with formal assistive services)|29
460|3 - Patient transferred to a noninstitutional hospice|3 - Patient transferred to a noninstitutional hospice|29
461|4 - Unknown because patient moved to a geographic location not served by this agency|4 - Unknown because patient moved to a geographic location not served by this agency|29
462|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|29
463|4 - Other respiratory problem|4 - Other respiratory problem|29
464|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|29
465|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|29
466|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|29
467|8 - Other heart disease|8 - Other heart disease|29
468|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|29
469|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|29
470|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|29
471|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|29
472|13 - Urinary tract infection|13 - Urinary tract infection|29
473|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|29
474|15 - Wound infection or deterioration|15 - Wound infection or deterioration|29
475|16 - Uncontrolled pain|16 - Uncontrolled pain|29
476|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|29
477|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|29
478|19 - Scheduled treatment or procedure|19 - Scheduled treatment or procedure|29
479|20 - Other than above reasons|20 - Other than above reasons|29
480|UK - Reason unknown [Go to M0903]|UK - Reason unknown [Go to M0903]|29
482|01 - Patient lives alone around the clock|01 - Patient lives alone around the clock|29
483|02 - Patient lives alone regular daytime|02 - Patient lives alone regular daytime|29
484|03 - Patient lives alone regular nighttime|03 - Patient lives alone regular nighttime|29
485|04 - Patient lives alone occassional/short term assistance|04 - Patient lives alone occassional/short term assistance|29
486|05 - Patient lives alone no assisstance available|05 - Patient lives alone no assisstance available|29
487|06 - Patient lives with other person(s) in the home around the clock|06 - Patient lives with other person(s) in the home around the clock|29
488|07 - Patient lives with other person(s) in the home regular daytime|07 - Patient lives with other person(s) in the home regular daytime|29
489|08 - Patient lives with other person(s) in the home regular nighttime|08 - Patient lives with other person(s) in the home regular nighttime|29
490|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|29
491|10 - Patient lives with other person(s) in the home no assistance available|10 - Patient lives with other person(s) in the home no assistance available|29
492|1 - Was present at the most recent SOC/ROC assessment [Goto M1308A1]|1 - Was present at the most recent SOC/ROC assessment [Goto M1308A1]|29
493|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|29
494|NA - No non-epithelialized Stage II pressure ulcers are present at discharge [Goto M1308A1]|NA - No non-epithelialized Stage II pressure ulcers are present at discharge [Goto M1308A1]|29
495|0 - Newly epithelialized|0 - Newly epithelialized|29
496|0 - No [ Go to M1340 ]|0 - No [ Go to M1340 ]|29
498|0 - Independent|0 - Independent|29
499|1 - Needed Some Help|1 - Needed Some Help|29
500|2 - Dependent|2 - Dependent|29
502|0 - No assistance needed in this area|0 - No assistance needed in this area|29
503|1 - Caregiver(s) currently provide assistance|1 - Caregiver(s) currently provide assistance|29
504|2 - Caregiver(s) need training/ supportive services to provide assistance|2 - Caregiver(s) need training/ supportive services to provide assistance|29
505|3 - Caregiver(s) not likely to provide assistance|3 - Caregiver(s) not likely to provide assistance|29
506|4 - Unclear if Caregiver(s) will provide assistance|4 - Unclear if Caregiver(s) will provide assistance|29
507|5 - Assistance needed, but no Caregiver(s) available|5 - Assistance needed, but no Caregiver(s) available|29
508|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will use standardized clinical guidelines accessible for all care providers to reference|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will|29
510|NA - Patient is not assessed to be at risk for falls|NA - Patient is not assessed to be at risk for falls|29
511|NA - Patient has no diagnosis or symptoms of depression|NA - Patient has no diagnosis or symptoms of depression|29
512|NA - No pain identified|NA - No pain identified|29
513|NA - Patient is not assessed to be at risk for pressure ulcers|NA - Patient is not assessed to be at risk for pressure ulcers|29
514|NA - Patient has no pressure ulcers with need for moist wound healing|NA - Patient has no pressure ulcers with need for moist wound healing|29
515|1 - Long-term nursing facility (NF)|1 - Long-term nursing facility (NF)|29
516|2 - Skilled nursing facility (SNF / TCU)|2 - Skilled nursing facility (SNF / TCU)|29
517|3 - Short stay acute hospital (IPP S)|3 - Short stay acute hospital (IPP S)|29
518|4 - Long-term care hospital (LTCH)|4 - Long-term care hospital (LTCH)|29
519|5 - Inpatient rehabilitation hospital or unit (IRF)|5 - Inpatient rehabilitation hospital or unit (IRF)|29
520|6 - Psychiatric hospital or unit|6 - Psychiatric hospital or unit|29
521|7 - Other|7 - Other|29
522|NA - Patient was not discharged from an inpatient facility [Goto M1016]|NA - Patient was not discharged from an inpatient facility [Goto M1016]|29
523|6 - Unable to participate effectively in bathing and is bathed totally by another person|6 - Unable to participate effectively in bathing and is bathed totally by another person|29
524|4 - Chairfast, unable to ambulate but is able to wheel self independently.|4 - Chairfast, unable to ambulate but is able to wheel self independently.|29
525|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask patient: "Over the last two weeks, how often have you been bothered by any of the following problems")  *Copyright+ Pfizer Inc. All rights reserved. Reproduced with permission.|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask|29
526|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluation for depression.|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluat|29
527|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet criteria for further evaluation for depression.|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet|29
528|0 - Not at all  0 - 1 day|0 - Not at all  0 - 1 day|29
529|1 - Several days  2 - 6 days|1 - Several days  2 - 6 days|29
530|2 - More than half of the days  7 - 11 days|2 - More than half of the days  7 - 11 days|29
531|3 - Nearly every day  12 - 14 days|3 - Nearly every day  12 - 14 days|29
532|NA - N/A  Unable to respond|NA - N/A  Unable to respond|29
533|2 - Able to take medication(s) at the correct times if given reminders by another person based on the frequency of the injection|2 - Able to take medication(s) at the correct times if given reminders by another person based on th|29
534|3 - Unable to take injectable medication unless administered by another person.|3 - Unable to take injectable medication unless administered by another person.|29
570|NA - No observable pressure ulcer or unhealed pressure ulcer|NA - No observable pressure ulcer or unhealed pressure ulcer|29
571|NA - No clinically significant medication issues identified since the previous OASIS assessment|NA - No clinically significant medication issues identified since the previous OASIS assessment|29
572|NA - Patient is not diabetic or is bilateral amputee|NA - Patient is not diabetic or is bilateral amputee|29
573|NA - Formal multi-factor Fall Risk Assessment indicates the patient was not at risk for falls since the last OASIS assessment|NA - Formal multi-factor Fall Risk Assessment indicates the patient was not at risk for falls since|29
574|NA - Formal assessment indicates patient did not meet criteria for depression AND patient did not have diagnosis of depression since the last OASIS assessment|NA - Formal assessment indicates patient did not meet criteria for depression AND patient did not ha|29
575|NA - Formal assessment did not indicate pain since the last OASIS assessment|NA - Formal assessment did not indicate pain since the last OASIS assessment|29
576|NA - Formal assessment indicates the patient was not at risk of pressure ulcers since the last OASIS assessment|NA - Formal assessment indicates the patient was not at risk of pressure ulcers since the last OASIS|29
577|NA - Dressings that support the principles of moist wound healing not indicated for this patient's pressure ulcers OR patient has no pressure ulcers with need for moist wound healing|NA - Dressings that support the principles of moist wound healing not indicated for this patient's p|29
578|1 - Patient remained in the community (without formal assistive services)|1 - Patient remained in the community (without formal assistive services)|29
579|2 - Patient remained in the community (with formal assistive services)|2 - Patient remained in the community (with formal assistive services)|29
580|3 - Patient transferred to a non-institutional hospice|3 - Patient transferred to a non-institutional hospice|29
581|4 - Unknown because patient moved to a geographic location not served by this agency|4 - Unknown because patient moved to a geographic location not served by this agency|29
2|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; OR (b) Is physically, cognitively, and mentally able to prepare light meals on a regular basis but has not routinely performed light meal preparation in the past (i.e., prior to this home care admission).|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; O|31
3|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and mentally able to perform all housekeeping tasks .|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and menta|31
4|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and mentally able to do laundry and access facilities.|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and menta|31
5|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying packages OR b) Physically, cognitively, and mentally able to take care of shopping, but has not done shopping in the past (i.e., prior to this home care admission).|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying|31
6|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|31
7|0 - Able to dial numbers and answer calls appropriately and as desired.|0 - Able to dial numbers and answer calls appropriately and as desired.|31
8|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body without assistance.|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body|31
9|0 - Able to get to and from the toilet and transfer independently with or without a device.|0 - Able to get to and from the toilet and transfer independently with or without a device.|31
10|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|31
11|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible public bus.|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible p|31
12|0 - Able to independently feed self.|0 - Able to independently feed self.|31
13|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|31
14|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct times.|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct ti|31
15|0 - Able to independently transfer.|0 - Able to independently transfer.|31
16|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without rail|31
17|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings|31
18|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|31
19|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions independently.|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions indep|31
20|0 - Asymptomatic, no treatment needed at this time|0 - Asymptomatic, no treatment needed at this time|31
21|0 - Caregiver manages all tasks related to equipment completely independently.|0 - Caregiver manages all tasks related to equipment completely independently.|31
22|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations with no observable impairment.|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations w|31
23|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|31
24|0 - Life expectancy is greater than 6 months|0 - Life expectancy is greater than 6 months|31
25|0 - Never|0 - Never|31
26|0 - Patient is not short of breath|0 - Patient is not short of breath|31
27|0 - No|0 - No|31
28|0 - No emergent care services|0 - No emergent care services|31
29|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [ Go to M1620 ]|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [ Go to M1620 ]|31
30|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and extended or abstract conversation.|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and exte|31
31|0 - No one person|0 - No one person|31
32|0 - None of the time|0 - None of the time|31
33|0 - None, no charge for current services|0 - None, no charge for current services|31
34|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|31
35|0 - Patient does NOT have an ostomy for bowel elimination.|0 - Patient does NOT have an ostomy for bowel elimination.|31
36|0 - Patient has no pain|0 - Patient has no pain|31
37|0 - Patient manages all tasks related to equipment completely independently.|0 - Patient manages all tasks related to equipment completely independently.|31
38|0 - Poor:  little or no recovery is expected and/or further decline is imminent|0 - Poor:  little or no recovery is expected and/or further decline is imminent|31
39|0 - Timed-voiding defers incontinence|0 - Timed-voiding defers incontinence|31
40|0 - Very rarely or never has bowel incontinence|0 - Very rarely or never has bowel incontinence|31
41|0 - Zero|0 - Zero|31
42|00 - No|00 - No|31
43|01 - Yes|01 - Yes|31
44|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or mental limitations, needs assistance with heavy laundry.|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or|31
45|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the patient.|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the|31
46|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|31
47|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or supervision from another person OR c) a liquid, pureed or ground meat diet.|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or su|31
48|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|31
49|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|31
50|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independently.|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independe|31
51|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only when assisted or accompanied by another person.|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only w|31
52|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepa|31
53|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance by another person OR b) given daily reminders.|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance b|31
54|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advan|31
55|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advan|31
56|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for the deaf) and call essential numbers.|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for t|31
57|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|31
58|1 - American Indian or Alaska Native|1 - American Indian or Alaska Native|31
59|1 - Depressed mood (e.g., feeling sad, tearful)|1 - Depressed mood (e.g., feeling sad, tearful)|31
60|1 - During the night only|1 - During the night only|31
61|1 - Fully granulating|1 - Fully granulating|31
62|1 - Good/Fair:  partial to full recovery is expected|1 - Good/Fair:  partial to full recovery is expected|31
63|1 - Good:  marked improvement in functional status is expected|1 - Good:  marked improvement in functional status is expected|31
64|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|31
65|1 - Smoking|1 - Smoking|31
66|1 - Hospital|1 - Hospital|31
67|1 - Hospital emergency room (includes 23-hour holding)|1 - Hospital emergency room (includes 23-hour holding)|31
68|1 - Hospitalization for EMERGENT (unscheduled) care|1 - Hospitalization for EMERGENT (unscheduled) care|31
69|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepared solutions), patient is able to manage all other aspects of equipment.|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepar|31
70|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|31
71|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|31
72|1 - In new or complex situations only|1 - In new or complex situations only|31
73|1 - Intravenous or infusion therapy (excludes TPN)|1 - Intravenous or infusion therapy (excludes TPN)|31
74|1 - Less often than daily|1 - Less often than daily|31
75|1 - Less than once a month|1 - Less than once a month|31
76|1 - Less than once weekly|1 - Less than once weekly|31
77|1 - Life expectancy is 6 months or fewer|1 - Life expectancy is 6 months or fewer|31
78|1 - Lives alone|1 - Lives alone|31
79|1 - Male|1 - Male|31
80|1 - Medicare (traditional fee-for-service)|1 - Medicare (traditional fee-for-service)|31
81|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of past 24 hours, significant memory loss so that supervision is required|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of pas|31
82|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors in word choice, grammar or speech intelligibility, needs minimal prompting or assistance).|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors i|31
83|1 - No assistance or services received|1 - No assistance or services received|31
84|1 - One|1 - One|31
85|1 - Oxygen (intermittent or continuous)|1 - Oxygen (intermittent or continuous)|31
86|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, and the surrounding layout, can count fingers at arm's length.|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, a|31
87|1 - Patient is incontinent|1 - Patient is incontinent|31
88|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|31
89|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical or treatment regimen.|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical|31
90|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient/couple/significant other)|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient|31
91|1 - Relatives, friends, or neighbors living outside the home|1 - Relatives, friends, or neighbors living outside the home|31
92|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions.|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions|31
93|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independentl|31
94|1 - Several times during day and night|1 - Several times during day and night|31
95|1 - Spouse or significant other|1 - Spouse or significant other|31
96|1 - Stage 1|1 - Stage 1|31
97|1 - Start of care - further visits planned|1 - Start of care - further visits planned|31
98|1 - Symptoms well controlled with current therapy|1 - Symptoms well controlled with current therapy|31
99|1 - Therapy services|1 - Therapy services|31
100|1 - Able to transfer with minimal human assistance or with use of an assistive device.|1 - Able to transfer with minimal human assistance or with use of an assistive device.|31
101|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitations.|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitatio|31
102|1 - Urinary incontinence|1 - Urinary incontinence|31
103|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and transfer.|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and|31
104|1 - When walking more than 20 feet, climbing stairs|1 - When walking more than 20 feet, climbing stairs|31
105|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary conversation. May need occasional repetition, extra time, or louder voice.|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary c|31
106|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting in and out of tub/shower|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting|31
107|1 - Yes|1 - Yes|31
108|1-RN|1-RN|31
109|10 - Discharge from agency - no visits completed after start/resumption of care assessment|10 - Discharge from agency - no visits completed after start/resumption of care assessment|31
110|10 - Scheduled surgical procedure|10 - Scheduled surgical procedure|31
111|10 - Self-pay|10 - Self-pay|31
112|11 - Other|11 - Other|31
113|11 - Urinary tract infection|11 - Urinary tract infection|31
114|12 - IV catheter-related infection|12 - IV catheter-related infection|31
115|13 - Deep vein thrombosis, pulmonary embolus|13 - Deep vein thrombosis, pulmonary embolus|31
116|14 - Uncontrolled pain|14 - Uncontrolled pain|31
117|15 - Psychotic episode|15 - Psychotic episode|31
118|16 - Other than above reasons|16 - Other than above reasons|31
119|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing calls.|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing|31
120|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another person.|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another pers|31
121|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface a|31
122|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for intermittent supervision or encouragement or reminders, OR (b) to get in and out of the shower or tub, OR (c) for washing difficult to reach areas.|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for inter|31
123|2 - Asian|2 - Asian|31
124|2 - Caregiver requires considerable assistance from another person to manage equipment, but independently completes significant portions of task.|2 - Caregiver requires considerable assistance from another person to manage equipment, but independ|31
125|2 - Daily, but not constantly|2 - Daily, but not constantly|31
126|2 - Daughter or son|2 - Daughter or son|31
127|2 - Doctor's office emergency visit/house call|2 - Doctor's office emergency visit/house call|31
128|2 - During the day and night|2 - During the day and night|31
129|2 - Early/partial granulation|2 - Early/partial granulation|31
130|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors in word choice, organization or speech intelligibility). Speaks in phrases or short sentences.|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors|31
131|2 - Family member's residence|2 - Family member's residence|31
132|2 - Female|2 - Female|31
133|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conversation, needs frequent prompting or assistance.|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conver|31
134|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|31
135|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|31
136|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately stop activities, jeopardizes safety through actions|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately st|31
137|2 - Indwelling/suprapubic catheter|2 - Indwelling/suprapubic catheter|31
138|2 - Injury caused by fall or accident at home|2 - Injury caused by fall or accident at home|31
139|2 - Medicare (HMO/managed care/Advantage plan)|2 - Medicare (HMO/managed care/Advantage plan)|31
140|2 - Nausea, dehydration, malnutrition, constipation, impaction|2 - Nausea, dehydration, malnutrition, constipation, impaction|31
141|2 - Obesity|2 - Obesity|31
142|2 - On awakening or at night only|2 - On awakening or at night only|31
143|2 - Once a month|2 - Once a month|31
144|2 - One to three times weekly|2 - One to three times weekly|31
145|2 - Parenteral nutrition (TPN or lipids)|2 - Parenteral nutrition (TPN or lipids)|31
146|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic)  [ Go to M1620 ]|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic)  [ Go|31
147|2 - Patient requires considerable assistance from another person to manage equipment, but independently completes portions of the task.|2 - Patient requires considerable assistance from another person to manage equipment, but independen|31
148|2 - Patient transferred to a noninstitutional hospice|2 - Patient transferred to a noninstitutional hospice|31
149|2 - Person residing in the home (EXCLUDING paid help)|2 - Person residing in the home (EXCLUDING paid help)|31
150|2 - Rehabilitation facility|2 - Rehabilitation facility|31
151|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifting of attention) or consistently requires low stimulus environment due to distractibility.|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifti|31
152|2 - Respite care|2 - Respite care|31
153|2 - Sense of failure or self reproach|2 - Sense of failure or self reproach|31
154|2 - Several times during day|2 - Several times during day|31
155|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonresponsive.|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonrespons|31
156|2 - Someone must assist the patient to groom self.|2 - Someone must assist the patient to groom self.|31
157|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|31
158|2 - Someone must help the patient put on upper body clothing.|2 - Someone must help the patient put on upper body clothing.|31
159|2 - Stage 2|2 - Stage 2|31
160|2 - Start of care - no further visits planned|2 - Start of care - no further visits planned|31
161|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitoring|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitori|31
162|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment regimen.|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment re|31
163|2 - Two|2 - Two|31
164|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistance due to cognitive or mental limitation.|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistanc|31
165|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|31
166|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assistance).|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assis|31
167|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home delivery.|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home deli|31
168|2 - Unable to prepare any light meals or reheat any delivered meals.|2 - Unable to prepare any light meals or reheat any delivered meals.|31
169|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|31
170|2 - UNABLE to take injectable medications unless administered by someone else.|2 - UNABLE to take injectable medications unless administered by someone else.|31
171|2 - UNABLE to take medication unless administered by someone else.|2 - UNABLE to take medication unless administered by someone else.|31
172|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|31
173|2 - Ventilator (continually or at night)|2 - Ventilator (continually or at night)|31
174|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less than 20 feet)|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less th|31
175|2 - With spouse or significant other|2 - With spouse or significant other|31
176|2 - Yes, assistance or services provided by family or friends|2 - Yes, assistance or services provided by family or friends|31
177|2-PT|2-PT|31
178|3 - Able to answer the telephone only some of the time or is able to carry on only a limited conversation.|3 - Able to answer the telephone only some of the time or is able to carry on only a limited convers|31
179|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube or gastrostomy.|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube|31
180|3 - Alcohol dependency|3 - Alcohol dependency|31
181|3 - All of the time|3 - All of the time|31
182|3 - Black or African-American|3 - Black or African-American|31
183|3 - Boarding home or rented room|3 - Boarding home or rented room|31
184|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment, clean/store/dispose of equipment or supplies).|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment,|31
185|3 -Able to walk only with the supervision or assistance of another person at all times.|3 -Able to walk only with the supervision or assistance of another person at all times.|31
186|3 - Continuous / Bi-level positive airway pressure|3 - Continuous / Bi-level positive airway pressure|31
187|3 - During the day and evening, but not constantly|3 - During the day and evening, but not constantly|31
188|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the alimentary canal)|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the|31
189|3 - Environmental support (e.g., housing, home maintenance)|3 - Environmental support (e.g., housing, home maintenance)|31
190|3 - Four to six times weekly|3 - Four to six times weekly|31
191|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessing by listener.  Speech limited to single words or short phrases.|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessin|31
192|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires multiple repetitions, restatements, demonstrations, additional time.|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires m|31
193|3 - Hopelessness|3 - Hopelessness|31
194|3 - Hospice care|3 - Hospice care|31
195|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|31
196|3 - Injury caused by fall or accident at home|3 - Injury caused by fall or accident at home|31
197|3 - Intractable pain|3 - Intractable pain|31
198|3 - Medicaid (traditional fee-for-service)|3 - Medicaid (traditional fee-for-service)|31
199|3 - Needs someone to do all shopping and errands.|3 - Needs someone to do all shopping and errands.|31
200|3 - Not healing|3 - Not healing|31
201|3 - Nursing home|3 - Nursing home|31
202|3 - Once daily|3 - Once daily|31
203|3 - Other family member|3 - Other family member|31
204|3 - Outpatient department/clinic emergency (includes urgicenter sites)|3 - Outpatient department/clinic emergency (includes urgicenter sites)|31
205|3 - Paid help|3 - Paid help|31
206|3 - Able to participate in bathing self in shower or tub, but requires presence of another person throughout the bath for assistance or supervision.|3 - Able to participate in bathing self in shower or tub, but requires presence of another person th|31
207|3 - Patient depends entirely upon another person to dress lower body.|3 - Patient depends entirely upon another person to dress lower body.|31
208|3 - Patient depends entirely upon another person to dress the upper body.|3 - Patient depends entirely upon another person to dress the upper body.|31
209|3 - Patient depends entirely upon someone else for grooming needs.|3 - Patient depends entirely upon someone else for grooming needs.|31
210|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone else to manage the equipment.|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone|31
211|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable to shift attention and recall directions more than half the time.|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable|31
212|3 - Respiratory problems (SOB, infection, obstruction)|3 - Respiratory problems (SOB, infection, obstruction)|31
213|3 - Resumption of care (after inpatient stay)|3 - Resumption of care (after inpatient stay)|31
214|3 - Several times each month|3 - Several times each month|31
215|3 - Skilled Nursing Facility|3 - Skilled Nursing Facility|31
216|3 - Stage 3|3 - Stage 3|31
217|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|31
218|3 - Three|3 - Three|31
219|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person throughout the process.|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person through|31
220|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal independently.|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal indep|31
221|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person.|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person|31
222|3 - Unknown because patient moved to a geographic location not served by this agency|3 - Unknown because patient moved to a geographic location not served by this agency|31
223|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|31
224|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|31
225|3 - With other family member|3 - With other family member|31
226|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home health services, homemaker assistance, transportation assistance, assisted living, board and care)|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home h|31
227|3-SLP/ST|3-SLP/ST|31
228|4 - At rest (during day or night)|4 - At rest (during day or night)|31
229|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|31
230|4 - Board and care or assisted living facility|4 - Board and care or assisted living facility|31
231|4 - Caregiver is completely dependent on someone else to manage all equipment.|4 - Caregiver is completely dependent on someone else to manage all equipment.|31
232|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|31
233|4 - Constantly|4 - Constantly|31
234|4 - Drug dependency|4 - Drug dependency|31
235|4 - Four or more|4 - Four or more|31
236|4 - Friend or neighbor or community or church member|4 - Friend or neighbor or community or church member|31
237|4 - Hispanic or Latino|4 - Hispanic or Latino|31
238|4 - Hospice|4 - Hospice|31
239|4 - Impaired decision-making|4 - Impaired decision-making|31
240|4 - Is totally dependent in toileting.|4 - Is totally dependent in toileting.|31
241|4 - Medicaid (HMO/managed care)|4 - Medicaid (HMO/managed care)|31
242|4 - None of the above|4 - None of the above|31
243|4 - Nursing home|4 - Nursing home|31
244|4 - On a daily basis|4 - On a daily basis|31
245|4 - Patient is completely dependent on someone else to manage all equipment.|4 - Patient is completely dependent on someone else to manage all equipment.|31
246|4 - Permanent placement|4 - Permanent placement|31
247|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, punches, dangerous maneuvers w/ wheelchair or other objects)|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, pu|31
248|4 - Psychosocial support (e.g., socialization, companionship, recreation)|4 - Psychosocial support (e.g., socialization, companionship, recreation)|31
249|4 - Recertification (follow-up) reassessment|4 - Recertification (follow-up) reassessment|31
250|4 - Recurrent thoughts of death|4 - Recurrent thoughts of death|31
251|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruction)|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruc|31
252|4 - Several times a week|4 - Several times a week|31
253|4 - Stage 4|4 - Stage 4|31
254|4 - Symptoms poorly controlled, history of re-hospitalizations|4 - Symptoms poorly controlled, history of re-hospitalizations|31
255|4 - Three or more times per week|4 - Three or more times per week|31
256|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetative state, or delirium.|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetati|31
257|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|31
258|4 - Unable to effectively participate in any housekeeping tasks.|4 - Unable to effectively participate in any housekeeping tasks.|31
259|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or unresponsive (e.g., speech is nonsensical or unintelligible).|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or u|31
260|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonresponsive.|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonr|31
261|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostomy.|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostom|31
262|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of devices at the sink, in chair, or on commode|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of|31
263|4 - With a friend|4 - With a friend|31
264|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|31
265|4-OT|4-OT|31
266|5 - Advocates or facilitates patient's participation in appropriate medical care|5 - Advocates or facilitates patient's participation in appropriate medical care|31
267|5 - At least daily|5 - At least daily|31
268|6 - Bedfast, unable to ambulate or be up in a chair.|6 - Bedfast, unable to ambulate or be up in a chair.|31
269|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|31
270|5 - Disruptive or socially inappropriate behavior|5 - Disruptive or socially inappropriate behavior|31
271|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|31
272|5 - Hypo/Hyperglycemia, diabetes out of control|5 - Hypo/Hyperglycemia, diabetes out of control|31
273|5 - More often than once daily|5 - More often than once daily|31
274|5 - Native Hawaiian or Pacific Islander|5 - Native Hawaiian or Pacific Islander|31
275|5 - None of the above|5 - None of the above|31
276|5 - One to two times per week|5 - One to two times per week|31
277|5 - Other|5 - Other|31
278|5 - Other follow-up|5 - Other follow-up|31
279|5 - Paid help|5 - Paid help|31
280|5 - Patient nonresponsive or unable to speak.|5 - Patient nonresponsive or unable to speak.|31
281|5 - Thoughts of suicide|5 - Thoughts of suicide|31
282|5 - Totally unable to use the telephone.|5 - Totally unable to use the telephone.|31
283|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|31
284|5 - Unable to take in nutrients orally or by tube feeding.|5 - Unable to take in nutrients orally or by tube feeding.|31
285|5 - Unsafe for care at home|5 - Unsafe for care at home|31
286|5 - With paid help (other than home care agency staff)|5 - With paid help (other than home care agency staff)|31
287|5 - Workers' compensation|5 - Workers' compensation|31
288|5 - Wound infection, deteriorating wound status, new lesion/ulcer|5 - Wound infection, deteriorating wound status, new lesion/ulcer|31
289|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|31
290|6 - Delusional, hallucinatory, or paranoid behavior|6 - Delusional, hallucinatory, or paranoid behavior|31
291|6 - Financial agent, power of attorney, or conservator of finance|6 - Financial agent, power of attorney, or conservator of finance|31
292|6 - GI bleeding, obstruction|6 - GI bleeding, obstruction|31
293|6 - Less often than weekly|6 - Less often than weekly|31
294|6 - Memory loss to the extent that supervision required|6 - Memory loss to the extent that supervision required|31
295|6 - None of the above feelings observed or reported|6 - None of the above feelings observed or reported|31
296|6 - Other|6 - Other|31
297|6 - Title programs (e.g., Title III, V, or XX)|6 - Title programs (e.g., Title III, V, or XX)|31
298|6 - Transferred to an inpatient facility - patient not discharged from agency|6 - Transferred to an inpatient facility - patient not discharged from agency|31
299|6 - White|6 - White|31
300|6 - With other than above|6 - With other than above|31
301|7 - Exacerbation of CHF, fluid overload, heart failure|7 - Exacerbation of CHF, fluid overload, heart failure|31
302|7 - Health care agent, conservator of person, or medical power of attorney|7 - Health care agent, conservator of person, or medical power of attorney|31
303|7 - Hypo/Hyperglycemia, diabetes out of control|7 - Hypo/Hyperglycemia, diabetes out of control|31
304|7 - None of the above|7 - None of the above|31
305|7 - None of the above behaviors demonstrated|7 - None of the above behaviors demonstrated|31
306|7 - Other government (e.g., TriCare, VA, etc.)|7 - Other government (e.g., TriCare, VA, etc.)|31
307|7 - Transferred to an inpatient facility - patient discharged from agency|7 - Transferred to an inpatient facility - patient discharged from agency|31
308|8 - Death at home|8 - Death at home|31
309|8 - GI bleeding, obstruction|8 - GI bleeding, obstruction|31
310|8 - Myocardial infarction, stroke|8 - Myocardial infarction, stroke|31
311|8 - Private insurance|8 - Private insurance|31
312|9 - Chemotherapy|9 - Chemotherapy|31
313|9 - Discharge from agency|9 - Discharge from agency|31
314|9 - Other than above reasons|9 - Other than above reasons|31
315|9 - Private HMO/managed care|9 - Private HMO/managed care|31
316|NA - No caregiver|NA - No caregiver|31
317|NA - No equipment of this type used in care.|NA - No equipment of this type used in care.|31
318|NA - No inhalant/mist medications prescribed.|NA - No inhalant/mist medications prescribed.|31
319|NA - No injectable medications prescribed.|NA - No injectable medications prescribed.|31
320|NA - No inpatient facility admission|NA - No inpatient facility admission|31
321|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|31
322|NA - No Medicaid|NA - No Medicaid|31
323|NA - No Medicare|NA - No Medicare|31
324|NA - No observable pressure ulcer|NA - No observable pressure ulcer|31
325|NA - No observable stasis ulcer|NA - No observable stasis ulcer|31
326|NA - No observable surgical wound|NA - No observable surgical wound|31
327|NA - No oral medications prescribed.|NA - No oral medications prescribed.|31
328|NA - Not applicable|NA - Not applicable|31
329|NA - Patient does not have a telephone.|NA - Patient does not have a telephone.|31
330|NA - Patient has ostomy for bowel elimination|NA - Patient has ostomy for bowel elimination|31
331|NA - Patient nonresponsive|NA - Patient nonresponsive|31
332|NA - Patient on prophylactic treatment|NA - Patient on prophylactic treatment|31
333|NA - Patient was not discharged from an inpatient facility [Go to M1016 ]|NA - Patient was not discharged from an inpatient facility [Go to M1016 ]|31
334|UK - Other unknown|UK - Other unknown|31
335|UK - Reason unknown|UK - Reason unknown|31
336|UK - Unknown|UK - Unknown|31
337|UK - Unknown or Not Available|UK - Unknown or Not Available|31
341|01 - Early|01 - Early|31
342|02 - Late|02 - Late|31
343|NA - Not Applicable. No case mix group defined for this assessment.|NA - Not Applicable. No case mix group defined for this assessment.|31
344|NA - No case mix group defined by this assessment.|NA - No case mix group defined by this assessment.|31
345|1 - Recent decline in mental, emotional, or behavioral status|1 - Recent decline in mental, emotional, or behavioral status|31
346|2 - Multiple hospitalizations (2 or more) in the past 12 months|2 - Multiple hospitalizations (2 or more) in the past 12 months|31
347|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|31
348|4 - Taking five or more medications|4 - Taking five or more medications|31
349|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|31
350|6 - Other|6 - Other|31
351|7 - None of the above|7 - None of the above|31
352|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond tho|31
353|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable without heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable wi|31
354|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious complications and death.|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious compl|31
355|3 - The patient has serious progressive conditions that could lead to death within a year.|3 - The patient has serious progressive conditions that could lead to death within a year.|31
356|UK - The patient+s situation is unknown or unclear.|UK - The patient+s situation is unknown or unclear.|31
357|1 - Yes [ Go to M1050 ]|1 - Yes [ Go to M1050 ]|31
358|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this influenza season. [ Go to M1050 ]|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this i|31
359|1 - Received from another health care provider (e.g., physician)|1 - Received from another health care provider (e.g., physician)|31
360|2 - Received from your agency previously during this year+s flu season|2 - Received from your agency previously during this year+s flu season|31
361|3 - Offered and declined|3 - Offered and declined|31
362|4 - Assessed and determined to have medical contraindication(s)|4 - Assessed and determined to have medical contraindication(s)|31
363|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|31
364|6 - Inability to obtain vaccine due to declared shortage|6 - Inability to obtain vaccine due to declared shortage|31
365|1 - Yes [ Go to M1500 at TRN; Go to M1230 at DC ]|1 - Yes [ Go to M1500 at TRN; Go to M1230 at DC ]|31
366|1 - Patient has received PPV in the past|1 - Patient has received PPV in the past|31
367|2 - Offered and declined|2 - Offered and declined|31
368|3 - Assessed and determined to have medical contraindication(s)|3 - Assessed and determined to have medical contraindication(s)|31
369|4 - Not indicated; patient does not meet age/condition guidelines for PPV|4 - Not indicated; patient does not meet age/condition guidelines for PPV|31
370|5 - None of the above|5 - None of the above|31
371|0 - Adequate: hears normal conversation without difficulty.|0 - Adequate: hears normal conversation without difficulty.|31
372|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to increase volume or speak distinctly.|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to in|31
373|2 - Severely Impaired: absence of useful hearing.|2 - Severely Impaired: absence of useful hearing.|31
374|UK - Unable to assess hearing.|UK - Unable to assess hearing.|31
375|0 - Understands: clear comprehension without cues or repetitions.|0 - Understands: clear comprehension without cues or repetitions.|31
376|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Requires cues at times to understand.|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Req|31
377|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequently requires cues to understand.|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequentl|31
378|3 - Rarely/Never Understands|3 - Rarely/Never Understands|31
379|UK - Unable to assess understanding.|UK - Unable to assess understanding.|31
380|0 - No standardized assessment conducted|0 - No standardized assessment conducted|31
381|1 - Yes, and it does not indicate severe pain|1 - Yes, and it does not indicate severe pain|31
382|2 - Yes, and it indicates severe pain|2 - Yes, and it indicates severe pain|31
383|0 - Patient has no pain|0 - Patient has no pain|31
384|1 - Patient has pain that does not interfere with activity or movement|1 - Patient has pain that does not interfere with activity or movement|31
385|2 - Less often than daily|2 - Less often than daily|31
386|3 - Daily, but not constantly|3 - Daily, but not constantly|31
387|4 - All of the time|4 - All of the time|31
388|0 - No assessment conducted [ Go to M1306 ]|0 - No assessment conducted [ Go to M1306 ]|31
389|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc., without use of standardized tool|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc.,|31
390|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|31
391|0 - No [ Go to M1322]|0 - No [ Go to M1322]|31
392|0 v Newly epithelialized|0 v Newly epithelialized|31
393|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|31
394|2 - Yes, patient has observable stasis ulcers ONLY|2 - Yes, patient has observable stasis ulcers ONLY|31
395|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable dressing) [Go to M1340]|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable|31
396|0 - No [ Go to M1350 ]|0 - No [ Go to M1350 ]|31
397|1 - Yes, patient has at least one (observable) surgical wound|1 - Yes, patient has at least one (observable) surgical wound|31
398|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1350 ]|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1350 ]|31
399|0 - Patient is not short of breath|0 - Patient is not short of breath|31
400|3 - Continuous Bi-level positive airway pressure|3 - Continuous Bi-level positive airway pressure|31
401|0 - No [ Go to M1732 at TRN; Go to M1600 at DC ]|0 - No [ Go to M1732 at TRN; Go to M1600 at DC ]|31
402|2 - Not assessed [Go to M1732 at TRN; Go to M1600 at DC ]|2 - Not assessed [Go to M1732 at TRN; Go to M1600 at DC ]|31
403|NA - Patient does not have diagnosis of heart failure [Go to M2004 at TRN; Go to M1600 at DC]|NA - Patient does not have diagnosis of heart failure [Go to M2004 at TRN; Go to M1600 at DC]|31
404|0 - No action taken|0 - No action taken|31
405|1 - Patient+s physician (or other primary care practitioner) contacted the same day|1 - Patient+s physician (or other primary care practitioner) contacted the same day|31
406|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|31
407|3 - Implement physician-ordered patient-specific established parameters for treatment|3 - Implement physician-ordered patient-specific established parameters for treatment|31
408|4 - Patient education or other clinical interventions|4 - Patient education or other clinical interventions|31
409|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequency, telehealth, etc.)|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequ|31
410|1 - Occasional stress incontinence|1 - Occasional stress incontinence|31
411|2 - During the night only|2 - During the night only|31
412|3 - During the day only|3 - During the day only|31
413|4 - During the day and night|4 - During the day and night|31
414|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|31
415|0 - Able to manage toileting hygiene and clothing management without assistance.|0 - Able to manage toileting hygiene and clothing management without assistance.|31
416|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implements are laid out for the patient.|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implemen|31
417|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|31
418|3 - Patient depends entirely upon another person to maintain toileting hygiene.|3 - Patient depends entirely upon another person to maintain toileting hygiene.|31
419|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independent|31
420|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface|31
421|0 - No multi-factor falls risk assessment conducted.|0 - No multi-factor falls risk assessment conducted.|31
422|1 - Yes, and it does not indicate a risk for falls.|1 - Yes, and it does not indicate a risk for falls.|31
423|2 - Yes, and it indicates a risk for falls.|2 - Yes, and it indicates a risk for falls.|31
424|0 - Not assessed/reviewed [ Go to M2010 ]|0 - Not assessed/reviewed [ Go to M2010 ]|31
425|1 - No problems found during review [ Go to M2010 ]|1 - No problems found during review [ Go to M2010 ]|31
426|2 - Problems found during review|2 - Problems found during review|31
427|NA - Patient is not taking any medications [ Go to M2040 ]|NA - Patient is not taking any medications [ Go to M2040 ]|31
428|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special precautions associated with all high-risk medications|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special p|31
429|NA - Patient not taking any drugs|NA - Patient not taking any drugs|31
430|2 - Able to take medication(s) at the correct times if given reminders by another person at the appropriate times|2 - Able to take medication(s) at the correct times if given reminders by another person at the appr|31
431|3 - Unable to take medication unless administered by another person.|3 - Unable to take medication unless administered by another person.|31
432|1 - At least daily|1 - At least daily|31
433|2 - Three or more times per week|2 - Three or more times per week|31
434|3 - One to two times per week|3 - One to two times per week|31
435|4 - Received, but less often than weekly|4 - Received, but less often than weekly|31
436|5 - No assistance received|5 - No assistance received|31
437|0 - No [Go to M2400]|0 - No [Go to M2400]|31
438|1 - Yes, used hospital emergency department WITHOUT hospital admission|1 - Yes, used hospital emergency department WITHOUT hospital admission|31
439|2 - Yes, used hospital emergency department WITH hospital admission|2 - Yes, used hospital emergency department WITH hospital admission|31
440|UK - Unknown [Go to M2400]|UK - Unknown [Go to M2400]|31
441|2 - Injury caused by fall|2 - Injury caused by fall|31
442|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|31
443|4 - Other respiratory problem|4 - Other respiratory problem|31
444|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|31
445|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|31
446|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|31
447|8 - Other heart disease|8 - Other heart disease|31
448|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|31
449|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|31
450|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|31
451|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|31
452|13 - Urinary tract infection|13 - Urinary tract infection|31
453|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|31
454|15 - Wound infection or deterioration|15 - Wound infection or deterioration|31
455|16 - Uncontrolled pain|16 - Uncontrolled pain|31
456|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|31
457|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|31
458|19 - Other than above reasons|19 - Other than above reasons|31
459|2 - Patient remained in the community (with formal assistive services)|2 - Patient remained in the community (with formal assistive services)|31
460|3 - Patient transferred to a noninstitutional hospice|3 - Patient transferred to a noninstitutional hospice|31
461|4 - Unknown because patient moved to a geographic location not served by this agency|4 - Unknown because patient moved to a geographic location not served by this agency|31
462|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|31
463|4 - Other respiratory problem|4 - Other respiratory problem|31
464|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|31
465|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|31
466|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|31
467|8 - Other heart disease|8 - Other heart disease|31
468|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|31
469|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|31
470|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|31
471|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|31
472|13 - Urinary tract infection|13 - Urinary tract infection|31
473|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|31
474|15 - Wound infection or deterioration|15 - Wound infection or deterioration|31
475|16 - Uncontrolled pain|16 - Uncontrolled pain|31
476|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|31
477|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|31
478|19 - Scheduled treatment or procedure|19 - Scheduled treatment or procedure|31
479|20 - Other than above reasons|20 - Other than above reasons|31
480|UK - Reason unknown [Go to M0903]|UK - Reason unknown [Go to M0903]|31
482|01 - Patient lives alone around the clock|01 - Patient lives alone around the clock|31
483|02 - Patient lives alone regular daytime|02 - Patient lives alone regular daytime|31
484|03 - Patient lives alone regular nighttime|03 - Patient lives alone regular nighttime|31
485|04 - Patient lives alone occassional/short term assistance|04 - Patient lives alone occassional/short term assistance|31
486|05 - Patient lives alone no assisstance available|05 - Patient lives alone no assisstance available|31
487|06 - Patient lives with other person(s) in the home around the clock|06 - Patient lives with other person(s) in the home around the clock|31
488|07 - Patient lives with other person(s) in the home regular daytime|07 - Patient lives with other person(s) in the home regular daytime|31
489|08 - Patient lives with other person(s) in the home regular nighttime|08 - Patient lives with other person(s) in the home regular nighttime|31
490|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|31
491|10 - Patient lives with other person(s) in the home no assistance available|10 - Patient lives with other person(s) in the home no assistance available|31
492|1 - Was present at the most recent SOC/ROC assessment|1 - Was present at the most recent SOC/ROC assessment|31
493|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|31
494|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|31
495|0 - Newly epithelialized|0 - Newly epithelialized|31
496|0 - No [ Go to M1340 ]|0 - No [ Go to M1340 ]|31
498|0 - Independent|0 - Independent|31
499|1 - Needed Some Help|1 - Needed Some Help|31
500|2 - Dependent|2 - Dependent|31
502|0 - No assistance needed in this area|0 - No assistance needed in this area|31
503|1 - Caregiver(s) currently provide assistance|1 - Caregiver(s) currently provide assistance|31
504|2 - Caregiver(s) need training/ supportive services to provide assistance|2 - Caregiver(s) need training/ supportive services to provide assistance|31
505|3 - Caregiver(s) not likely to provide assistance|3 - Caregiver(s) not likely to provide assistance|31
506|4 - Unclear if Caregiver(s) will provide assistance|4 - Unclear if Caregiver(s) will provide assistance|31
507|5 - Assistance needed, but no Caregiver(s) available|5 - Assistance needed, but no Caregiver(s) available|31
508|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will use standardized clinical guidelines accessible for all care providers to reference|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will|31
509|NA - Patient is not diabetic or is bilateral amputee|NA - Patient is not diabetic or is bilateral amputee|31
510|NA - Patient is not assessed to be at risk for falls|NA - Patient is not assessed to be at risk for falls|31
511|NA - Patient has no diagnosis or symptoms of depression|NA - Patient has no diagnosis or symptoms of depression|31
512|NA - No pain identified|NA - No pain identified|31
513|NA - Patient is not assessed to be at risk for pressure ulcers|NA - Patient is not assessed to be at risk for pressure ulcers|31
514|NA - Patient has no pressure ulcers with need for moist wound healing|NA - Patient has no pressure ulcers with need for moist wound healing|31
515|1 - Long-term nursing facility (NF)|1 - Long-term nursing facility (NF)|31
516|2 - Skilled nursing facility (SNF / TCU)|2 - Skilled nursing facility (SNF / TCU)|31
517|3 - Short stay acute hospital (IPP S)|3 - Short stay acute hospital (IPP S)|31
518|4 - Long-term care hospital (LTCH)|4 - Long-term care hospital (LTCH)|31
519|5 - Inpatient rehabilitation hospital or unit (IRF)|5 - Inpatient rehabilitation hospital or unit (IRF)|31
520|6 - Psychiatric hospital or unit|6 - Psychiatric hospital or unit|31
521|7 - Other|7 - Other|31
522|NA - Patient was not discharged from an inpatient facility [Go to M1016]|NA - Patient was not discharged from an inpatient facility [Go to M1016]|31
523|6 - Unable to participate effectively in bathing and is bathed totally by another person|6 - Unable to participate effectively in bathing and is bathed totally by another person|31
524|4 - Chairfast, unable to ambulate but is able to wheel self independently.|4 - Chairfast, unable to ambulate but is able to wheel self independently.|31
525|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask patient: "Over the last two weeks, how often have you been bothered by any of the following problems")  *Copyright+ Pfizer Inc. All rights reserved. Reproduced with permission.|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask|31
526|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluation for depression.|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluat|31
527|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet criteria for further evaluation for depression.|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet|31
528|0 - Not at all  0 - 1 day|0 - Not at all  0 - 1 day|31
529|1 - Several days  2 - 6 days|1 - Several days  2 - 6 days|31
530|2 - More than half of the days  7 - 11 days|2 - More than half of the days  7 - 11 days|31
531|3 - Nearly every day  12 - 14 days|3 - Nearly every day  12 - 14 days|31
532|NA - N/A  Unable to respond|NA - N/A  Unable to respond|31
533|2 - Able to take medication(s) at the correct times if given reminders by another person based on the frequency of the injection|2 - Able to take medication(s) at the correct times if given reminders by another person based on th|31
534|3 - Unable to take injectable medication unless administered by another person.|3 - Unable to take injectable medication unless administered by another person.|31
535|11 - Patient lives in congregate situation (e.g., assisted living) around the clock|11 - Patient lives in congregate situation (e.g., assisted living) around the clock|31
536|12 - Patient lives in congregate situation (e.g., assisted living) regular daytime|12 - Patient lives in congregate situation (e.g., assisted living) regular daytime|31
537|13 - Patient lives in congregate situation (e.g., assisted living) regular nighttime|13 - Patient lives in congregate situation (e.g., assisted living) regular nighttime|31
538|14 - Patient lives in congregate situation (e.g., assisted living) occasional / short-term assistance|14 - Patient lives in congregate situation (e.g., assisted living) occasional / short-term assistanc|31
539|15 - Patient lives in congregate situation (e.g., assisted living) no assistance available|15 - Patient lives in congregate situation (e.g., assisted living) no assistance available|31
545|NA - No observable pressure ulcer or unhealed pressure ulcer|NA - No observable pressure ulcer or unhealed pressure ulcer|31
582|NA - No specific SOC date ordered by physician|NA - No specific SOC date ordered by physician|31
585|UK - Inpatient Discharge Date Unknown|UK - Inpatient Discharge Date Unknown|31
2|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; OR (b) Is physically, cognitively, and mentally able to prepare light meals on a regular basis but has not routinely performed light meal preparation in the past (i.e., prior to this home care admission).|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; O|33
3|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and mentally able to perform all housekeeping tasks .|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and menta|33
4|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and mentally able to do laundry and access facilities.|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and menta|33
5|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying packages OR b) Physically, cognitively, and mentally able to take care of shopping, but has not done shopping in the past (i.e., prior to this home care admission).|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying|33
6|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|33
7|0 - Able to dial numbers and answer calls appropriately and as desired.|0 - Able to dial numbers and answer calls appropriately and as desired.|33
8|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body without assistance.|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body|33
9|0 - Able to get to and from the toilet and transfer independently with or without a device.|0 - Able to get to and from the toilet and transfer independently with or without a device.|33
10|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|33
11|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible public bus.|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible p|33
12|0 - Able to independently feed self.|0 - Able to independently feed self.|33
13|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|33
14|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct times.|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct ti|33
15|0 - Able to independently transfer.|0 - Able to independently transfer.|33
16|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without rail|33
17|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings|33
18|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|33
19|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions independently.|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions indep|33
20|0 - Asymptomatic, no treatment needed at this time|0 - Asymptomatic, no treatment needed at this time|33
21|0 - Caregiver manages all tasks related to equipment completely independently.|0 - Caregiver manages all tasks related to equipment completely independently.|33
22|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations with no observable impairment.|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations w|33
23|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|33
24|0 - Life expectancy is greater than 6 months|0 - Life expectancy is greater than 6 months|33
25|0 - Never|0 - Never|33
26|0 - Patient is not short of breath|0 - Patient is not short of breath|33
27|0 - No|0 - No|33
28|0 - No emergent care services|0 - No emergent care services|33
29|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [ Go to M1620 ]|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [ Go to M1620 ]|33
30|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and extended or abstract conversation.|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and exte|33
31|0 - No one person|0 - No one person|33
32|0 - None of the time|0 - None of the time|33
33|0 - None, no charge for current services|0 - None, no charge for current services|33
34|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|33
35|0 - Patient does NOT have an ostomy for bowel elimination.|0 - Patient does NOT have an ostomy for bowel elimination.|33
36|0 - Patient has no pain|0 - Patient has no pain|33
37|0 - Patient manages all tasks related to equipment completely independently.|0 - Patient manages all tasks related to equipment completely independently.|33
38|0 - Poor:  little or no recovery is expected and/or further decline is imminent|0 - Poor:  little or no recovery is expected and/or further decline is imminent|33
39|0 - Timed-voiding defers incontinence|0 - Timed-voiding defers incontinence|33
40|0 - Very rarely or never has bowel incontinence|0 - Very rarely or never has bowel incontinence|33
41|0 - Zero|0 - Zero|33
42|00 - No|00 - No|33
43|01 - Yes|01 - Yes|33
44|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or mental limitations, needs assistance with heavy laundry.|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or|33
45|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the patient.|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the|33
46|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|33
47|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or supervision from another person OR c) a liquid, pureed or ground meat diet.|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or su|33
48|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|33
49|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|33
50|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independently.|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independe|33
51|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only when assisted or accompanied by another person.|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only w|33
52|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepa|33
53|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance by another person OR b) given daily reminders.|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance b|33
54|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advan|33
55|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advan|33
56|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for the deaf) and call essential numbers.|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for t|33
57|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|33
58|1 - American Indian or Alaska Native|1 - American Indian or Alaska Native|33
59|1 - Depressed mood (e.g., feeling sad, tearful)|1 - Depressed mood (e.g., feeling sad, tearful)|33
60|1 - During the night only|1 - During the night only|33
61|1 - Fully granulating|1 - Fully granulating|33
62|1 - Good/Fair:  partial to full recovery is expected|1 - Good/Fair:  partial to full recovery is expected|33
63|1 - Good:  marked improvement in functional status is expected|1 - Good:  marked improvement in functional status is expected|33
64|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|33
65|1 - Smoking|1 - Smoking|33
66|1 - Hospital|1 - Hospital|33
67|1 - Hospital emergency room (includes 23-hour holding)|1 - Hospital emergency room (includes 23-hour holding)|33
68|1 - Hospitalization for EMERGENT (unscheduled) care|1 - Hospitalization for EMERGENT (unscheduled) care|33
69|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepared solutions), patient is able to manage all other aspects of equipment.|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepar|33
70|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|33
71|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|33
72|1 - In new or complex situations only|1 - In new or complex situations only|33
73|1 - Intravenous or infusion therapy (excludes TPN)|1 - Intravenous or infusion therapy (excludes TPN)|33
74|1 - Less often than daily|1 - Less often than daily|33
75|1 - Less than once a month|1 - Less than once a month|33
76|1 - Less than once weekly|1 - Less than once weekly|33
77|1 - Life expectancy is 6 months or fewer|1 - Life expectancy is 6 months or fewer|33
78|1 - Lives alone|1 - Lives alone|33
79|1 - Male|1 - Male|33
80|1 - Medicare (traditional fee-for-service)|1 - Medicare (traditional fee-for-service)|33
81|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of past 24 hours, significant memory loss so that supervision is required|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of pas|33
82|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors in word choice, grammar or speech intelligibility, needs minimal prompting or assistance).|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors i|33
83|1 - No assistance or services received|1 - No assistance or services received|33
84|1 - One|1 - One|33
85|1 - Oxygen (intermittent or continuous)|1 - Oxygen (intermittent or continuous)|33
86|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, and the surrounding layout, can count fingers at arm's length.|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, a|33
87|1 - Patient is incontinent|1 - Patient is incontinent|33
88|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|33
89|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical or treatment regimen.|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical|33
90|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient/couple/significant other)|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient|33
91|1 - Relatives, friends, or neighbors living outside the home|1 - Relatives, friends, or neighbors living outside the home|33
92|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions.|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions|33
93|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independentl|33
94|1 - Several times during day and night|1 - Several times during day and night|33
95|1 - Spouse or significant other|1 - Spouse or significant other|33
96|1 - Stage 1|1 - Stage 1|33
97|1 - Start of care - further visits planned|1 - Start of care - further visits planned|33
98|1 - Symptoms well controlled with current therapy|1 - Symptoms well controlled with current therapy|33
99|1 - Therapy services|1 - Therapy services|33
100|1 - Able to transfer with minimal human assistance or with use of an assistive device.|1 - Able to transfer with minimal human assistance or with use of an assistive device.|33
101|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitations.|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitatio|33
102|1 - Urinary incontinence|1 - Urinary incontinence|33
103|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and transfer.|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and|33
104|1 - When walking more than 20 feet, climbing stairs|1 - When walking more than 20 feet, climbing stairs|33
105|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary conversation. May need occasional repetition, extra time, or louder voice.|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary c|33
106|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting in and out of tub/shower|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting|33
107|1 - Yes|1 - Yes|33
108|1-RN|1-RN|33
109|10 - Discharge from agency - no visits completed after start/resumption of care assessment|10 - Discharge from agency - no visits completed after start/resumption of care assessment|33
110|10 - Scheduled surgical procedure|10 - Scheduled surgical procedure|33
111|10 - Self-pay|10 - Self-pay|33
112|11 - Other|11 - Other|33
113|11 - Urinary tract infection|11 - Urinary tract infection|33
114|12 - IV catheter-related infection|12 - IV catheter-related infection|33
115|13 - Deep vein thrombosis, pulmonary embolus|13 - Deep vein thrombosis, pulmonary embolus|33
116|14 - Uncontrolled pain|14 - Uncontrolled pain|33
117|15 - Psychotic episode|15 - Psychotic episode|33
118|16 - Other than above reasons|16 - Other than above reasons|33
119|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing calls.|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing|33
120|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another person.|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another pers|33
121|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface a|33
122|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for intermittent supervision or encouragement or reminders, OR (b) to get in and out of the shower or tub, OR (c) for washing difficult to reach areas.|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for inter|33
123|2 - Asian|2 - Asian|33
124|2 - Caregiver requires considerable assistance from another person to manage equipment, but independently completes significant portions of task.|2 - Caregiver requires considerable assistance from another person to manage equipment, but independ|33
125|2 - Daily, but not constantly|2 - Daily, but not constantly|33
126|2 - Daughter or son|2 - Daughter or son|33
127|2 - Doctor's office emergency visit/house call|2 - Doctor's office emergency visit/house call|33
128|2 - During the day and night|2 - During the day and night|33
129|2 - Early/partial granulation|2 - Early/partial granulation|33
130|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors in word choice, organization or speech intelligibility). Speaks in phrases or short sentences.|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors|33
131|2 - Family member's residence|2 - Family member's residence|33
132|2 - Female|2 - Female|33
133|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conversation, needs frequent prompting or assistance.|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conver|33
134|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|33
135|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|33
136|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately stop activities, jeopardizes safety through actions|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately st|33
137|2 - Indwelling/suprapubic catheter|2 - Indwelling/suprapubic catheter|33
138|2 - Injury caused by fall or accident at home|2 - Injury caused by fall or accident at home|33
139|2 - Medicare (HMO/managed care/Advantage plan)|2 - Medicare (HMO/managed care/Advantage plan)|33
140|2 - Nausea, dehydration, malnutrition, constipation, impaction|2 - Nausea, dehydration, malnutrition, constipation, impaction|33
141|2 - Obesity|2 - Obesity|33
142|2 - On awakening or at night only|2 - On awakening or at night only|33
143|2 - Once a month|2 - Once a month|33
144|2 - One to three times weekly|2 - One to three times weekly|33
145|2 - Parenteral nutrition (TPN or lipids)|2 - Parenteral nutrition (TPN or lipids)|33
146|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic)  [ Go to M1620 ]|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic)  [ Go|33
147|2 - Patient requires considerable assistance from another person to manage equipment, but independently completes portions of the task.|2 - Patient requires considerable assistance from another person to manage equipment, but independen|33
148|2 - Patient transferred to a noninstitutional hospice|2 - Patient transferred to a noninstitutional hospice|33
149|2 - Person residing in the home (EXCLUDING paid help)|2 - Person residing in the home (EXCLUDING paid help)|33
150|2 - Rehabilitation facility|2 - Rehabilitation facility|33
151|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifting of attention) or consistently requires low stimulus environment due to distractibility.|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifti|33
152|2 - Respite care|2 - Respite care|33
153|2 - Sense of failure or self reproach|2 - Sense of failure or self reproach|33
154|2 - Several times during day|2 - Several times during day|33
155|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonresponsive.|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonrespons|33
156|2 - Someone must assist the patient to groom self.|2 - Someone must assist the patient to groom self.|33
157|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|33
158|2 - Someone must help the patient put on upper body clothing.|2 - Someone must help the patient put on upper body clothing.|33
159|2 - Stage 2|2 - Stage 2|33
160|2 - Start of care - no further visits planned|2 - Start of care - no further visits planned|33
161|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitoring|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitori|33
162|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment regimen.|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment re|33
163|2 - Two|2 - Two|33
164|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistance due to cognitive or mental limitation.|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistanc|33
165|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|33
166|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assistance).|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assis|33
167|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home delivery.|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home deli|33
168|2 - Unable to prepare any light meals or reheat any delivered meals.|2 - Unable to prepare any light meals or reheat any delivered meals.|33
169|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|33
170|2 - UNABLE to take injectable medications unless administered by someone else.|2 - UNABLE to take injectable medications unless administered by someone else.|33
171|2 - UNABLE to take medication unless administered by someone else.|2 - UNABLE to take medication unless administered by someone else.|33
172|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|33
173|2 - Ventilator (continually or at night)|2 - Ventilator (continually or at night)|33
174|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less than 20 feet)|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less th|33
175|2 - With spouse or significant other|2 - With spouse or significant other|33
176|2 - Yes, assistance or services provided by family or friends|2 - Yes, assistance or services provided by family or friends|33
177|2-PT|2-PT|33
178|3 - Able to answer the telephone only some of the time or is able to carry on only a limited conversation.|3 - Able to answer the telephone only some of the time or is able to carry on only a limited convers|33
179|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube or gastrostomy.|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube|33
180|3 - Alcohol dependency|3 - Alcohol dependency|33
181|3 - All of the time|3 - All of the time|33
182|3 - Black or African-American|3 - Black or African-American|33
183|3 - Boarding home or rented room|3 - Boarding home or rented room|33
184|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment, clean/store/dispose of equipment or supplies).|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment,|33
185|3 -Able to walk only with the supervision or assistance of another person at all times.|3 -Able to walk only with the supervision or assistance of another person at all times.|33
186|3 - Continuous / Bi-level positive airway pressure|3 - Continuous / Bi-level positive airway pressure|33
187|3 - During the day and evening, but not constantly|3 - During the day and evening, but not constantly|33
188|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the alimentary canal)|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the|33
189|3 - Environmental support (e.g., housing, home maintenance)|3 - Environmental support (e.g., housing, home maintenance)|33
190|3 - Four to six times weekly|3 - Four to six times weekly|33
191|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessing by listener.  Speech limited to single words or short phrases.|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessin|33
192|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires multiple repetitions, restatements, demonstrations, additional time.|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires m|33
193|3 - Hopelessness|3 - Hopelessness|33
194|3 - Hospice care|3 - Hospice care|33
195|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|33
196|3 - Injury caused by fall or accident at home|3 - Injury caused by fall or accident at home|33
197|3 - Intractable pain|3 - Intractable pain|33
198|3 - Medicaid (traditional fee-for-service)|3 - Medicaid (traditional fee-for-service)|33
199|3 - Needs someone to do all shopping and errands.|3 - Needs someone to do all shopping and errands.|33
200|3 - Not healing|3 - Not healing|33
201|3 - Nursing home|3 - Nursing home|33
202|3 - Once daily|3 - Once daily|33
203|3 - Other family member|3 - Other family member|33
204|3 - Outpatient department/clinic emergency (includes urgicenter sites)|3 - Outpatient department/clinic emergency (includes urgicenter sites)|33
205|3 - Paid help|3 - Paid help|33
206|3 - Able to participate in bathing self in shower or tub, but requires presence of another person throughout the bath for assistance or supervision.|3 - Able to participate in bathing self in shower or tub, but requires presence of another person th|33
207|3 - Patient depends entirely upon another person to dress lower body.|3 - Patient depends entirely upon another person to dress lower body.|33
208|3 - Patient depends entirely upon another person to dress the upper body.|3 - Patient depends entirely upon another person to dress the upper body.|33
209|3 - Patient depends entirely upon someone else for grooming needs.|3 - Patient depends entirely upon someone else for grooming needs.|33
210|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone else to manage the equipment.|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone|33
211|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable to shift attention and recall directions more than half the time.|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable|33
212|3 - Respiratory problems (SOB, infection, obstruction)|3 - Respiratory problems (SOB, infection, obstruction)|33
213|3 - Resumption of care (after inpatient stay)|3 - Resumption of care (after inpatient stay)|33
214|3 - Several times each month|3 - Several times each month|33
215|3 - Skilled Nursing Facility|3 - Skilled Nursing Facility|33
216|3 - Stage 3|3 - Stage 3|33
217|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|33
218|3 - Three|3 - Three|33
219|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person throughout the process.|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person through|33
220|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal independently.|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal indep|33
221|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person.|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person|33
222|3 - Unknown because patient moved to a geographic location not served by this agency|3 - Unknown because patient moved to a geographic location not served by this agency|33
223|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|33
224|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|33
225|3 - With other family member|3 - With other family member|33
226|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home health services, homemaker assistance, transportation assistance, assisted living, board and care)|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home h|33
227|3-SLP/ST|3-SLP/ST|33
228|4 - At rest (during day or night)|4 - At rest (during day or night)|33
229|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|33
230|4 - Board and care or assisted living facility|4 - Board and care or assisted living facility|33
231|4 - Caregiver is completely dependent on someone else to manage all equipment.|4 - Caregiver is completely dependent on someone else to manage all equipment.|33
232|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|33
233|4 - Constantly|4 - Constantly|33
234|4 - Drug dependency|4 - Drug dependency|33
235|4 - Four or more|4 - Four or more|33
236|4 - Friend or neighbor or community or church member|4 - Friend or neighbor or community or church member|33
237|4 - Hispanic or Latino|4 - Hispanic or Latino|33
238|4 - Hospice|4 - Hospice|33
239|4 - Impaired decision-making|4 - Impaired decision-making|33
240|4 - Is totally dependent in toileting.|4 - Is totally dependent in toileting.|33
241|4 - Medicaid (HMO/managed care)|4 - Medicaid (HMO/managed care)|33
242|4 - None of the above|4 - None of the above|33
243|4 - Nursing home|4 - Nursing home|33
244|4 - On a daily basis|4 - On a daily basis|33
245|4 - Patient is completely dependent on someone else to manage all equipment.|4 - Patient is completely dependent on someone else to manage all equipment.|33
246|4 - Permanent placement|4 - Permanent placement|33
247|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, punches, dangerous maneuvers w/ wheelchair or other objects)|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, pu|33
248|4 - Psychosocial support (e.g., socialization, companionship, recreation)|4 - Psychosocial support (e.g., socialization, companionship, recreation)|33
249|4 - Recertification (follow-up) reassessment|4 - Recertification (follow-up) reassessment|33
250|4 - Recurrent thoughts of death|4 - Recurrent thoughts of death|33
251|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruction)|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruc|33
252|4 - Several times a week|4 - Several times a week|33
253|4 - Stage 4|4 - Stage 4|33
254|4 - Symptoms poorly controlled, history of re-hospitalizations|4 - Symptoms poorly controlled, history of re-hospitalizations|33
255|4 - Three or more times per week|4 - Three or more times per week|33
256|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetative state, or delirium.|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetati|33
257|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|33
258|4 - Unable to effectively participate in any housekeeping tasks.|4 - Unable to effectively participate in any housekeeping tasks.|33
259|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or unresponsive (e.g., speech is nonsensical or unintelligible).|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or u|33
260|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonresponsive.|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonr|33
261|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostomy.|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostom|33
262|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of devices at the sink, in chair, or on commode|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of|33
263|4 - With a friend|4 - With a friend|33
264|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|33
265|4-OT|4-OT|33
266|5 - Advocates or facilitates patient's participation in appropriate medical care|5 - Advocates or facilitates patient's participation in appropriate medical care|33
267|5 - At least daily|5 - At least daily|33
268|6 - Bedfast, unable to ambulate or be up in a chair.|6 - Bedfast, unable to ambulate or be up in a chair.|33
269|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|33
270|5 - Disruptive or socially inappropriate behavior|5 - Disruptive or socially inappropriate behavior|33
271|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|33
272|5 - Hypo/Hyperglycemia, diabetes out of control|5 - Hypo/Hyperglycemia, diabetes out of control|33
273|5 - More often than once daily|5 - More often than once daily|33
274|5 - Native Hawaiian or Pacific Islander|5 - Native Hawaiian or Pacific Islander|33
275|5 - None of the above|5 - None of the above|33
276|5 - One to two times per week|5 - One to two times per week|33
277|5 - Other|5 - Other|33
278|5 - Other follow-up|5 - Other follow-up|33
279|5 - Paid help|5 - Paid help|33
280|5 - Patient nonresponsive or unable to speak.|5 - Patient nonresponsive or unable to speak.|33
281|5 - Thoughts of suicide|5 - Thoughts of suicide|33
282|5 - Totally unable to use the telephone.|5 - Totally unable to use the telephone.|33
283|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|33
284|5 - Unable to take in nutrients orally or by tube feeding.|5 - Unable to take in nutrients orally or by tube feeding.|33
285|5 - Unsafe for care at home|5 - Unsafe for care at home|33
286|5 - With paid help (other than home care agency staff)|5 - With paid help (other than home care agency staff)|33
287|5 - Workers' compensation|5 - Workers' compensation|33
288|5 - Wound infection, deteriorating wound status, new lesion/ulcer|5 - Wound infection, deteriorating wound status, new lesion/ulcer|33
289|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|33
290|6 - Delusional, hallucinatory, or paranoid behavior|6 - Delusional, hallucinatory, or paranoid behavior|33
291|6 - Financial agent, power of attorney, or conservator of finance|6 - Financial agent, power of attorney, or conservator of finance|33
292|6 - GI bleeding, obstruction|6 - GI bleeding, obstruction|33
293|6 - Less often than weekly|6 - Less often than weekly|33
294|6 - Memory loss to the extent that supervision required|6 - Memory loss to the extent that supervision required|33
295|6 - None of the above feelings observed or reported|6 - None of the above feelings observed or reported|33
296|6 - Other|6 - Other|33
297|6 - Title programs (e.g., Title III, V, or XX)|6 - Title programs (e.g., Title III, V, or XX)|33
298|6 - Transferred to an inpatient facility - patient not discharged from agency|6 - Transferred to an inpatient facility - patient not discharged from agency|33
299|6 - White|6 - White|33
300|6 - With other than above|6 - With other than above|33
301|7 - Exacerbation of CHF, fluid overload, heart failure|7 - Exacerbation of CHF, fluid overload, heart failure|33
302|7 - Health care agent, conservator of person, or medical power of attorney|7 - Health care agent, conservator of person, or medical power of attorney|33
303|7 - Hypo/Hyperglycemia, diabetes out of control|7 - Hypo/Hyperglycemia, diabetes out of control|33
304|7 - None of the above|7 - None of the above|33
305|7 - None of the above behaviors demonstrated|7 - None of the above behaviors demonstrated|33
306|7 - Other government (e.g., TriCare, VA, etc.)|7 - Other government (e.g., TriCare, VA, etc.)|33
307|7 - Transferred to an inpatient facility - patient discharged from agency|7 - Transferred to an inpatient facility - patient discharged from agency|33
308|8 - Death at home|8 - Death at home|33
309|8 - GI bleeding, obstruction|8 - GI bleeding, obstruction|33
310|8 - Myocardial infarction, stroke|8 - Myocardial infarction, stroke|33
311|8 - Private insurance|8 - Private insurance|33
312|9 - Chemotherapy|9 - Chemotherapy|33
313|9 - Discharge from agency|9 - Discharge from agency|33
314|9 - Other than above reasons|9 - Other than above reasons|33
315|9 - Private HMO/managed care|9 - Private HMO/managed care|33
316|NA - No caregiver|NA - No caregiver|33
317|NA - No equipment of this type used in care.|NA - No equipment of this type used in care.|33
318|NA - No inhalant/mist medications prescribed.|NA - No inhalant/mist medications prescribed.|33
319|NA - No injectable medications prescribed.|NA - No injectable medications prescribed.|33
320|NA - No inpatient facility admission|NA - No inpatient facility admission|33
321|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|33
322|NA - No Medicaid|NA - No Medicaid|33
323|NA - No Medicare|NA - No Medicare|33
324|NA - No observable pressure ulcer or unhealed pressure ulcer|NA - No observable pressure ulcer or unhealed pressure ulcer|33
325|NA - No observable stasis ulcer|NA - No observable stasis ulcer|33
326|NA - No observable surgical wound|NA - No observable surgical wound|33
327|NA - No oral medications prescribed.|NA - No oral medications prescribed.|33
328|NA - Not applicable|NA - Not applicable|33
329|NA - Patient does not have a telephone.|NA - Patient does not have a telephone.|33
330|NA - Patient has ostomy for bowel elimination|NA - Patient has ostomy for bowel elimination|33
331|NA - Patient nonresponsive|NA - Patient nonresponsive|33
332|NA - Patient on prophylactic treatment|NA - Patient on prophylactic treatment|33
333|NA - Patient was not discharged from an inpatient facility [Go to M1016 ]|NA - Patient was not discharged from an inpatient facility [Go to M1016 ]|33
334|UK - Other unknown|UK - Other unknown|33
335|UK - Reason unknown|UK - Reason unknown|33
336|UK - Unknown|UK - Unknown|33
337|UK - Unknown or Not Available|UK - Unknown or Not Available|33
341|01 - Early|01 - Early|33
342|02 - Late|02 - Late|33
343|NA - Not Applicable. No case mix group defined for this assessment.|NA - Not Applicable. No case mix group defined for this assessment.|33
344|NA - No case mix group defined by this assessment.|NA - No case mix group defined by this assessment.|33
345|1 - Recent decline in mental, emotional, or behavioral status|1 - Recent decline in mental, emotional, or behavioral status|33
346|2 - Multiple hospitalizations (2 or more) in the past 12 months|2 - Multiple hospitalizations (2 or more) in the past 12 months|33
347|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|33
348|4 - Taking five or more medications|4 - Taking five or more medications|33
349|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|33
350|6 - Other|6 - Other|33
351|7 - None of the above|7 - None of the above|33
352|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond tho|33
353|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable without heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable wi|33
354|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious complications and death.|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious compl|33
355|3 - The patient has serious progressive conditions that could lead to death within a year.|3 - The patient has serious progressive conditions that could lead to death within a year.|33
356|UK - The patient+s situation is unknown or unclear.|UK - The patient+s situation is unknown or unclear.|33
357|1 - Yes [ Go to M1050 ]|1 - Yes [ Go to M1050 ]|33
358|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this influenza season. [ Go to M1050 ]|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this i|33
359|1 - Received from another health care provider (e.g., physician)|1 - Received from another health care provider (e.g., physician)|33
360|2 - Received from your agency previously during this year+s flu season|2 - Received from your agency previously during this year+s flu season|33
361|3 - Offered and declined|3 - Offered and declined|33
362|4 - Assessed and determined to have medical contraindication(s)|4 - Assessed and determined to have medical contraindication(s)|33
363|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|33
364|6 - Inability to obtain vaccine due to declared shortage|6 - Inability to obtain vaccine due to declared shortage|33
365|1 - Yes [ Go to M1500 at TRN; Go to M1230 at DC ]|1 - Yes [ Go to M1500 at TRN; Go to M1230 at DC ]|33
366|1 - Patient has received PPV in the past|1 - Patient has received PPV in the past|33
367|2 - Offered and declined|2 - Offered and declined|33
368|3 - Assessed and determined to have medical contraindication(s)|3 - Assessed and determined to have medical contraindication(s)|33
369|4 - Not indicated; patient does not meet age/condition guidelines for PPV|4 - Not indicated; patient does not meet age/condition guidelines for PPV|33
370|5 - None of the above|5 - None of the above|33
371|0 - Adequate: hears normal conversation without difficulty.|0 - Adequate: hears normal conversation without difficulty.|33
372|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to increase volume or speak distinctly.|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to in|33
373|2 - Severely Impaired: absence of useful hearing.|2 - Severely Impaired: absence of useful hearing.|33
374|UK - Unable to assess hearing.|UK - Unable to assess hearing.|33
375|0 - Understands: clear comprehension without cues or repetitions.|0 - Understands: clear comprehension without cues or repetitions.|33
376|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Requires cues at times to understand.|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Req|33
377|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequently requires cues to understand.|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequentl|33
378|3 - Rarely/Never Understands|3 - Rarely/Never Understands|33
379|UK - Unable to assess understanding.|UK - Unable to assess understanding.|33
380|0 - No standardized assessment conducted|0 - No standardized assessment conducted|33
381|1 - Yes, and it does not indicate severe pain|1 - Yes, and it does not indicate severe pain|33
382|2 - Yes, and it indicates severe pain|2 - Yes, and it indicates severe pain|33
383|0 - Patient has no pain|0 - Patient has no pain|33
384|1 - Patient has pain that does not interfere with activity or movement|1 - Patient has pain that does not interfere with activity or movement|33
385|2 - Less often than daily|2 - Less often than daily|33
386|3 - Daily, but not constantly|3 - Daily, but not constantly|33
387|4 - All of the time|4 - All of the time|33
388|0 - No assessment conducted [ Go to M1306 ]|0 - No assessment conducted [ Go to M1306 ]|33
389|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc., without use of standardized tool|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc.,|33
390|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|33
391|0 - No [ Go to M1322]|0 - No [ Go to M1322]|33
392|0 v Newly epithelialized|0 v Newly epithelialized|33
393|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|33
394|2 - Yes, patient has observable stasis ulcers ONLY|2 - Yes, patient has observable stasis ulcers ONLY|33
395|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable dressing) [Go to M1340]|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable|33
396|0 - No [ Go to M1350 ]|0 - No [ Go to M1350 ]|33
397|1 - Yes, patient has at least one (observable) surgical wound|1 - Yes, patient has at least one (observable) surgical wound|33
398|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1350 ]|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1350 ]|33
399|0 - Patient is not short of breath|0 - Patient is not short of breath|33
400|3 - Continuous Bi-level positive airway pressure|3 - Continuous Bi-level positive airway pressure|33
401|0 - No [ Go to M1732 at TRN; Go to M1600 at DC ]|0 - No [ Go to M1732 at TRN; Go to M1600 at DC ]|33
402|2 - Not assessed [Go to M1732 at TRN; Go to M1600 at DC ]|2 - Not assessed [Go to M1732 at TRN; Go to M1600 at DC ]|33
403|NA - Patient does not have diagnosis of heart failure [Go to M2004 at TRN; Go to M1600 at DC]|NA - Patient does not have diagnosis of heart failure [Go to M2004 at TRN; Go to M1600 at DC]|33
404|0 - No action taken|0 - No action taken|33
405|1 - Patient+s physician (or other primary care practitioner) contacted the same day|1 - Patient+s physician (or other primary care practitioner) contacted the same day|33
406|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|33
407|3 - Implement physician-ordered patient-specific established parameters for treatment|3 - Implement physician-ordered patient-specific established parameters for treatment|33
408|4 - Patient education or other clinical interventions|4 - Patient education or other clinical interventions|33
409|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequency, telehealth, etc.)|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequ|33
410|1 - Occasional stress incontinence|1 - Occasional stress incontinence|33
411|2 - During the night only|2 - During the night only|33
412|3 - During the day only|3 - During the day only|33
413|4 - During the day and night|4 - During the day and night|33
414|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|33
415|0 - Able to manage toileting hygiene and clothing management without assistance.|0 - Able to manage toileting hygiene and clothing management without assistance.|33
416|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implements are laid out for the patient.|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implemen|33
417|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|33
418|3 - Patient depends entirely upon another person to maintain toileting hygiene.|3 - Patient depends entirely upon another person to maintain toileting hygiene.|33
419|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independent|33
420|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface|33
421|0 - No multi-factor falls risk assessment conducted.|0 - No multi-factor falls risk assessment conducted.|33
422|1 - Yes, and it does not indicate a risk for falls.|1 - Yes, and it does not indicate a risk for falls.|33
423|2 - Yes, and it indicates a risk for falls.|2 - Yes, and it indicates a risk for falls.|33
424|0 - Not assessed/reviewed [ Go to M2010 ]|0 - Not assessed/reviewed [ Go to M2010 ]|33
425|1 - No problems found during review [ Go to M2010 ]|1 - No problems found during review [ Go to M2010 ]|33
426|2 - Problems found during review|2 - Problems found during review|33
427|NA - Patient is not taking any medications [ Go to M2040 ]|NA - Patient is not taking any medications [ Go to M2040 ]|33
428|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special precautions associated with all high-risk medications|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special p|33
429|NA - Patient not taking any drugs|NA - Patient not taking any drugs|33
430|2 - Able to take medication(s) at the correct times if given reminders by another person at the appropriate times|2 - Able to take medication(s) at the correct times if given reminders by another person at the appr|33
431|3 - Unable to take medication unless administered by another person.|3 - Unable to take medication unless administered by another person.|33
432|1 - At least daily|1 - At least daily|33
433|2 - Three or more times per week|2 - Three or more times per week|33
434|3 - One to two times per week|3 - One to two times per week|33
435|4 - Received, but less often than weekly|4 - Received, but less often than weekly|33
436|5 - No assistance received|5 - No assistance received|33
437|0 - No [Go to M2400]|0 - No [Go to M2400]|33
438|1 - Yes, used hospital emergency department WITHOUT hospital admission|1 - Yes, used hospital emergency department WITHOUT hospital admission|33
439|2 - Yes, used hospital emergency department WITH hospital admission|2 - Yes, used hospital emergency department WITH hospital admission|33
440|UK - Unknown [Go to M2400]|UK - Unknown [Go to M2400]|33
441|2 - Injury caused by fall|2 - Injury caused by fall|33
442|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|33
443|4 - Other respiratory problem|4 - Other respiratory problem|33
444|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|33
445|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|33
446|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|33
447|8 - Other heart disease|8 - Other heart disease|33
448|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|33
449|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|33
450|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|33
451|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|33
452|13 - Urinary tract infection|13 - Urinary tract infection|33
453|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|33
454|15 - Wound infection or deterioration|15 - Wound infection or deterioration|33
455|16 - Uncontrolled pain|16 - Uncontrolled pain|33
456|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|33
457|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|33
458|19 - Other than above reasons|19 - Other than above reasons|33
459|2 - Patient remained in the community (with formal assistive services)|2 - Patient remained in the community (with formal assistive services)|33
460|3 - Patient transferred to a noninstitutional hospice|3 - Patient transferred to a noninstitutional hospice|33
461|4 - Unknown because patient moved to a geographic location not served by this agency|4 - Unknown because patient moved to a geographic location not served by this agency|33
462|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|33
463|4 - Other respiratory problem|4 - Other respiratory problem|33
464|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|33
465|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|33
466|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|33
467|8 - Other heart disease|8 - Other heart disease|33
468|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|33
469|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|33
470|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|33
471|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|33
472|13 - Urinary tract infection|13 - Urinary tract infection|33
473|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|33
474|15 - Wound infection or deterioration|15 - Wound infection or deterioration|33
475|16 - Uncontrolled pain|16 - Uncontrolled pain|33
476|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|33
477|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|33
478|19 - Scheduled treatment or procedure|19 - Scheduled treatment or procedure|33
479|20 - Other than above reasons|20 - Other than above reasons|33
480|UK - Reason unknown [Go to M0903]|UK - Reason unknown [Go to M0903]|33
482|01 - Patient lives alone around the clock|01 - Patient lives alone around the clock|33
483|02 - Patient lives alone regular daytime|02 - Patient lives alone regular daytime|33
484|03 - Patient lives alone regular nighttime|03 - Patient lives alone regular nighttime|33
485|04 - Patient lives alone occassional/short term assistance|04 - Patient lives alone occassional/short term assistance|33
486|05 - Patient lives alone no assisstance available|05 - Patient lives alone no assisstance available|33
487|06 - Patient lives with other person(s) in the home around the clock|06 - Patient lives with other person(s) in the home around the clock|33
488|07 - Patient lives with other person(s) in the home regular daytime|07 - Patient lives with other person(s) in the home regular daytime|33
489|08 - Patient lives with other person(s) in the home regular nighttime|08 - Patient lives with other person(s) in the home regular nighttime|33
490|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|33
491|10 - Patient lives with other person(s) in the home no assistance available|10 - Patient lives with other person(s) in the home no assistance available|33
492|1 - Was present at the most recent SOC/ROC assessment|1 - Was present at the most recent SOC/ROC assessment|33
493|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|33
494|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|33
495|0 - Newly epithelialized|0 - Newly epithelialized|33
496|0 - No [ Go to M1340 ]|0 - No [ Go to M1340 ]|33
498|0 - Independent|0 - Independent|33
499|1 - Needed Some Help|1 - Needed Some Help|33
500|2 - Dependent|2 - Dependent|33
502|0 - No assistance needed in this area|0 - No assistance needed in this area|33
503|1 - Caregiver(s) currently provide assistance|1 - Caregiver(s) currently provide assistance|33
504|2 - Caregiver(s) need training/ supportive services to provide assistance|2 - Caregiver(s) need training/ supportive services to provide assistance|33
505|3 - Caregiver(s) not likely to provide assistance|3 - Caregiver(s) not likely to provide assistance|33
506|4 - Unclear if Caregiver(s) will provide assistance|4 - Unclear if Caregiver(s) will provide assistance|33
507|5 - Assistance needed, but no Caregiver(s) available|5 - Assistance needed, but no Caregiver(s) available|33
508|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will use standardized clinical guidelines accessible for all care providers to reference|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will|33
509|NA - Patient is not diabetic or is bilateral amputee|NA - Patient is not diabetic or is bilateral amputee|33
510|NA - Patient is not assessed to be at risk for falls|NA - Patient is not assessed to be at risk for falls|33
511|NA - Patient has no diagnosis or symptoms of depression|NA - Patient has no diagnosis or symptoms of depression|33
512|NA - No pain identified|NA - No pain identified|33
513|NA - Patient is not assessed to be at risk for pressure ulcers|NA - Patient is not assessed to be at risk for pressure ulcers|33
514|NA - Patient has no pressure ulcers with need for moist wound healing|NA - Patient has no pressure ulcers with need for moist wound healing|33
515|1 - Long-term nursing facility (NF)|1 - Long-term nursing facility (NF)|33
516|2 - Skilled nursing facility (SNF / TCU)|2 - Skilled nursing facility (SNF / TCU)|33
517|3 - Short stay acute hospital (IPP S)|3 - Short stay acute hospital (IPP S)|33
518|4 - Long-term care hospital (LTCH)|4 - Long-term care hospital (LTCH)|33
519|5 - Inpatient rehabilitation hospital or unit (IRF)|5 - Inpatient rehabilitation hospital or unit (IRF)|33
520|6 - Psychiatric hospital or unit|6 - Psychiatric hospital or unit|33
521|7 - Other|7 - Other|33
522|NA - Patient was not discharged from an inpatient facility [Go to M1016]|NA - Patient was not discharged from an inpatient facility [Go to M1016]|33
523|6 - Unable to participate effectively in bathing and is bathed totally by another person|6 - Unable to participate effectively in bathing and is bathed totally by another person|33
524|4 - Chairfast, unable to ambulate but is able to wheel self independently.|4 - Chairfast, unable to ambulate but is able to wheel self independently.|33
525|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask patient: "Over the last two weeks, how often have you been bothered by any of the following problems")  *Copyright+ Pfizer Inc. All rights reserved. Reproduced with permission.|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask|33
526|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluation for depression.|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluat|33
527|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet criteria for further evaluation for depression.|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet|33
528|0 - Not at all  0 - 1 day|0 - Not at all  0 - 1 day|33
529|1 - Several days  2 - 6 days|1 - Several days  2 - 6 days|33
530|2 - More than half of the days  7 - 11 days|2 - More than half of the days  7 - 11 days|33
531|3 - Nearly every day  12 - 14 days|3 - Nearly every day  12 - 14 days|33
532|NA - N/A  Unable to respond|NA - N/A  Unable to respond|33
533|2 - Able to take medication(s) at the correct times if given reminders by another person based on the frequency of the injection|2 - Able to take medication(s) at the correct times if given reminders by another person based on th|33
534|3 - Unable to take injectable medication unless administered by another person.|3 - Unable to take injectable medication unless administered by another person.|33
540|11 - Patient lives in congregate situation (e.g., assisted living) around the clock|11 - Patient lives in congregate situation (e.g., assisted living) around the clock|33
541|12 - Patient lives in congregate situation (e.g., assisted living) regular daytime|12 - Patient lives in congregate situation (e.g., assisted living) regular daytime|33
542|13 - Patient lives in congregate situation (e.g., assisted living) regular nighttime|13 - Patient lives in congregate situation (e.g., assisted living) regular nighttime|33
543|14 - Patient lives in congregate situation (e.g., assisted living) occasional / short-term assistance|14 - Patient lives in congregate situation (e.g., assisted living) occasional / short-term assistanc|33
544|15 - Patient lives in congregate situation (e.g., assisted living) no available assistance|15 - Patient lives in congregate situation (e.g., assisted living) no available assistance|33
546|NA - No observable pressure ulcer|NA - No observable pressure ulcer|33
583|NA - No specific SOC date ordered by physician|NA - No specific SOC date ordered by physician|33
586|UK - Inpatient Discharge Date Unknown|UK - Inpatient Discharge Date Unknown|33
2|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; OR (b) Is physically, cognitively, and mentally able to prepare light meals on a regular basis but has not routinely performed light meal preparation in the past (i.e., prior to this home care admission).|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; O|34
3|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and mentally able to perform all housekeeping tasks .|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and menta|34
4|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and mentally able to do laundry and access facilities.|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and menta|34
5|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying packages OR b) Physically, cognitively, and mentally able to take care of shopping, but has not done shopping in the past (i.e., prior to this home care admission).|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying|34
6|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|34
7|0 - Able to dial numbers and answer calls appropriately and as desired.|0 - Able to dial numbers and answer calls appropriately and as desired.|34
8|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body without assistance.|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body|34
9|0 - Able to get to and from the toilet and transfer independently with or without a device.|0 - Able to get to and from the toilet and transfer independently with or without a device.|34
10|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|34
11|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible public bus.|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible p|34
12|0 - Able to independently feed self.|0 - Able to independently feed self.|34
13|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|34
14|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct times.|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct ti|34
15|0 - Able to independently transfer.|0 - Able to independently transfer.|34
16|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without rail|34
17|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings|34
18|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|34
19|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions independently.|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions indep|34
20|0 - Asymptomatic, no treatment needed at this time|0 - Asymptomatic, no treatment needed at this time|34
21|0 - Caregiver manages all tasks related to equipment completely independently.|0 - Caregiver manages all tasks related to equipment completely independently.|34
22|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations with no observable impairment.|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations w|34
23|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|34
24|0 - Life expectancy is greater than 6 months|0 - Life expectancy is greater than 6 months|34
25|0 - Never|0 - Never|34
26|0 - Patient is not short of breath|0 - Patient is not short of breath|34
27|0 - No|0 - No|34
28|0 - No emergent care services|0 - No emergent care services|34
29|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [Goto M1620]|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [Goto M1620]|34
30|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and extended or abstract conversation.|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and exte|34
31|0 - No one person|0 - No one person|34
32|0 - None of the time|0 - None of the time|34
33|0 - None, no charge for current services|0 - None, no charge for current services|34
34|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|34
35|0 - Patient does NOT have an ostomy for bowel elimination.|0 - Patient does NOT have an ostomy for bowel elimination.|34
36|0 - Patient has no pain|0 - Patient has no pain|34
37|0 - Patient manages all tasks related to equipment completely independently.|0 - Patient manages all tasks related to equipment completely independently.|34
38|0 - Poor:  little or no recovery is expected and/or further decline is imminent|0 - Poor:  little or no recovery is expected and/or further decline is imminent|34
39|0 - Timed-voiding defers incontinence|0 - Timed-voiding defers incontinence|34
40|0 - Very rarely or never has bowel incontinence|0 - Very rarely or never has bowel incontinence|34
41|0 - Zero|0 - Zero|34
42|00 - No|00 - No|34
43|01 - Yes|01 - Yes|34
44|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or mental limitations, needs assistance with heavy laundry.|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or|34
45|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the patient.|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the|34
46|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|34
47|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or supervision from another person OR c) a liquid, pureed or ground meat diet.|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or su|34
48|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|34
49|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|34
50|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independently.|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independe|34
51|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only when assisted or accompanied by another person.|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only w|34
52|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepa|34
53|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance by another person OR b) given daily reminders.|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance b|34
54|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advan|34
55|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advan|34
56|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for the deaf) and call essential numbers.|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for t|34
57|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|34
58|1 - American Indian or Alaska Native|1 - American Indian or Alaska Native|34
59|1 - Depressed mood (e.g., feeling sad, tearful)|1 - Depressed mood (e.g., feeling sad, tearful)|34
60|1 - During the night only|1 - During the night only|34
61|1 - Fully granulating|1 - Fully granulating|34
62|1 - Good/Fair:  partial to full recovery is expected|1 - Good/Fair:  partial to full recovery is expected|34
63|1 - Good:  marked improvement in functional status is expected|1 - Good:  marked improvement in functional status is expected|34
64|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|34
65|1 - Smoking|1 - Smoking|34
66|1 - Hospital|1 - Hospital|34
67|1 - Hospital emergency room (includes 23-hour holding)|1 - Hospital emergency room (includes 23-hour holding)|34
68|1 - Hospitalization for EMERGENT (unscheduled) care|1 - Hospitalization for EMERGENT (unscheduled) care|34
69|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepared solutions), patient is able to manage all other aspects of equipment.|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepar|34
70|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|34
71|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|34
72|1 - In new or complex situations only|1 - In new or complex situations only|34
73|1 - Intravenous or infusion therapy (excludes TPN)|1 - Intravenous or infusion therapy (excludes TPN)|34
74|1 - Less often than daily|1 - Less often than daily|34
75|1 - Less than once a month|1 - Less than once a month|34
76|1 - Less than once weekly|1 - Less than once weekly|34
77|1 - Life expectancy is 6 months or fewer|1 - Life expectancy is 6 months or fewer|34
78|1 - Lives alone|1 - Lives alone|34
79|1 - Male|1 - Male|34
80|1 - Medicare (traditional fee-for-service)|1 - Medicare (traditional fee-for-service)|34
81|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of past 24 hours, significant memory loss so that supervision is required|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of pas|34
82|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors in word choice, grammar or speech intelligibility, needs minimal prompting or assistance).|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors i|34
83|1 - No assistance or services received|1 - No assistance or services received|34
84|1 - One|1 - One|34
85|1 - Oxygen (intermittent or continuous)|1 - Oxygen (intermittent or continuous)|34
86|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, and the surrounding layout, can count fingers at arm's length.|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, a|34
87|1 - Patient is incontinent|1 - Patient is incontinent|34
88|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|34
89|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical or treatment regimen.|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical|34
90|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient/couple/significant other)|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient|34
91|1 - Relatives, friends, or neighbors living outside the home|1 - Relatives, friends, or neighbors living outside the home|34
92|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions.|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions|34
93|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independentl|34
94|1 - Several times during day and night|1 - Several times during day and night|34
95|1 - Spouse or significant other|1 - Spouse or significant other|34
96|1 - Stage 1|1 - Stage 1|34
97|1 - Start of care - further visits planned|1 - Start of care - further visits planned|34
98|1 - Symptoms well controlled with current therapy|1 - Symptoms well controlled with current therapy|34
99|1 - Therapy services|1 - Therapy services|34
100|1 - Able to transfer with minimal human assistance or with use of an assistive device.|1 - Able to transfer with minimal human assistance or with use of an assistive device.|34
101|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitations.|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitatio|34
102|1 - Urinary incontinence|1 - Urinary incontinence|34
103|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and transfer.|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and|34
104|1 - When walking more than 20 feet, climbing stairs|1 - When walking more than 20 feet, climbing stairs|34
105|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary conversation. May need occasional repetition, extra time, or louder voice.|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary c|34
106|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting in and out of tub/shower|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting|34
107|1 - Yes|1 - Yes|34
108|1-RN|1-RN|34
109|10 - Discharge from agency - no visits completed after start/resumption of care assessment|10 - Discharge from agency - no visits completed after start/resumption of care assessment|34
110|10 - Scheduled surgical procedure|10 - Scheduled surgical procedure|34
111|10 - Self-pay|10 - Self-pay|34
112|11 - Other|11 - Other|34
113|11 - Urinary tract infection|11 - Urinary tract infection|34
114|12 - IV catheter-related infection|12 - IV catheter-related infection|34
115|13 - Deep vein thrombosis, pulmonary embolus|13 - Deep vein thrombosis, pulmonary embolus|34
116|14 - Uncontrolled pain|14 - Uncontrolled pain|34
117|15 - Psychotic episode|15 - Psychotic episode|34
118|16 - Other than above reasons|16 - Other than above reasons|34
119|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing calls.|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing|34
120|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another person.|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another pers|34
121|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface a|34
122|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for intermittent supervision or encouragement or reminders, OR (b) to get in and out of the shower or tub, OR (c) for washing difficult to reach areas.|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for inter|34
123|2 - Asian|2 - Asian|34
124|2 - Caregiver requires considerable assistance from another person to manage equipment, but independently completes significant portions of task.|2 - Caregiver requires considerable assistance from another person to manage equipment, but independ|34
125|2 - Daily, but not constantly|2 - Daily, but not constantly|34
126|2 - Daughter or son|2 - Daughter or son|34
127|2 - Doctor's office emergency visit/house call|2 - Doctor's office emergency visit/house call|34
128|2 - During the day and night|2 - During the day and night|34
129|2 - Early/partial granulation|2 - Early/partial granulation|34
130|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors in word choice, organization or speech intelligibility). Speaks in phrases or short sentences.|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors|34
131|2 - Family member's residence|2 - Family member's residence|34
132|2 - Female|2 - Female|34
133|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conversation, needs frequent prompting or assistance.|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conver|34
134|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|34
135|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|34
136|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately stop activities, jeopardizes safety through actions|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately st|34
137|2 - Indwelling/suprapubic catheter|2 - Indwelling/suprapubic catheter|34
138|2 - Injury caused by fall or accident at home|2 - Injury caused by fall or accident at home|34
139|2 - Medicare (HMO/managed care/Advantage plan)|2 - Medicare (HMO/managed care/Advantage plan)|34
140|2 - Nausea, dehydration, malnutrition, constipation, impaction|2 - Nausea, dehydration, malnutrition, constipation, impaction|34
141|2 - Obesity|2 - Obesity|34
142|2 - On awakening or at night only|2 - On awakening or at night only|34
143|2 - Once a month|2 - Once a month|34
144|2 - One to three times weekly|2 - One to three times weekly|34
145|2 - Parenteral nutrition (TPN or lipids)|2 - Parenteral nutrition (TPN or lipids)|34
146|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic) [ Go to M1620 ]|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic) [ Go|34
147|2 - Patient requires considerable assistance from another person to manage equipment, but independently completes portions of the task.|2 - Patient requires considerable assistance from another person to manage equipment, but independen|34
148|2 - Patient transferred to a noninstitutional hospice|2 - Patient transferred to a noninstitutional hospice|34
149|2 - Person residing in the home (EXCLUDING paid help)|2 - Person residing in the home (EXCLUDING paid help)|34
150|2 - Rehabilitation facility|2 - Rehabilitation facility|34
151|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifting of attention) or consistently requires low stimulus environment due to distractibility.|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifti|34
152|2 - Respite care|2 - Respite care|34
153|2 - Sense of failure or self reproach|2 - Sense of failure or self reproach|34
154|2 - Several times during day|2 - Several times during day|34
155|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonresponsive.|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonrespons|34
156|2 - Someone must assist the patient to groom self.|2 - Someone must assist the patient to groom self.|34
157|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|34
158|2 - Someone must help the patient put on upper body clothing.|2 - Someone must help the patient put on upper body clothing.|34
159|2 - Stage 2|2 - Stage 2|34
160|2 - Start of care - no further visits planned|2 - Start of care - no further visits planned|34
161|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitoring|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitori|34
162|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment regimen.|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment re|34
163|2 - Two|2 - Two|34
164|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistance due to cognitive or mental limitation.|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistanc|34
165|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|34
166|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assistance).|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assis|34
167|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home delivery.|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home deli|34
168|2 - Unable to prepare any light meals or reheat any delivered meals.|2 - Unable to prepare any light meals or reheat any delivered meals.|34
169|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|34
170|2 - UNABLE to take injectable medications unless administered by someone else.|2 - UNABLE to take injectable medications unless administered by someone else.|34
171|2 - UNABLE to take medication unless administered by someone else.|2 - UNABLE to take medication unless administered by someone else.|34
172|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|34
173|2 - Ventilator (continually or at night)|2 - Ventilator (continually or at night)|34
174|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less than 20 feet)|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less th|34
175|2 - With spouse or significant other|2 - With spouse or significant other|34
176|2 - Yes, assistance or services provided by family or friends|2 - Yes, assistance or services provided by family or friends|34
177|2-PT|2-PT|34
178|3 - Able to answer the telephone only some of the time or is able to carry on only a limited conversation.|3 - Able to answer the telephone only some of the time or is able to carry on only a limited convers|34
179|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube or gastrostomy.|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube|34
180|3 - Alcohol dependency|3 - Alcohol dependency|34
181|3 - All of the time|3 - All of the time|34
182|3 - Black or African-American|3 - Black or African-American|34
183|3 - Boarding home or rented room|3 - Boarding home or rented room|34
184|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment, clean/store/dispose of equipment or supplies).|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment,|34
185|3 -Able to walk only with the supervision or assistance of another person at all times.|3 -Able to walk only with the supervision or assistance of another person at all times.|34
186|3 - Continuous / Bi-level positive airway pressure|3 - Continuous / Bi-level positive airway pressure|34
187|3 - During the day and evening, but not constantly|3 - During the day and evening, but not constantly|34
188|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the alimentary canal)|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the|34
189|3 - Environmental support (e.g., housing, home maintenance)|3 - Environmental support (e.g., housing, home maintenance)|34
190|3 - Four to six times weekly|3 - Four to six times weekly|34
191|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessing by listener.  Speech limited to single words or short phrases.|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessin|34
192|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires multiple repetitions, restatements, demonstrations, additional time.|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires m|34
193|3 - Hopelessness|3 - Hopelessness|34
194|3 - Hospice care|3 - Hospice care|34
195|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|34
196|3 - Injury caused by fall or accident at home|3 - Injury caused by fall or accident at home|34
197|3 - Intractable pain|3 - Intractable pain|34
198|3 - Medicaid (traditional fee-for-service)|3 - Medicaid (traditional fee-for-service)|34
199|3 - Needs someone to do all shopping and errands.|3 - Needs someone to do all shopping and errands.|34
200|3 - Not healing|3 - Not healing|34
201|3 - Nursing home|3 - Nursing home|34
202|3 - Once daily|3 - Once daily|34
203|3 - Other family member|3 - Other family member|34
204|3 - Outpatient department/clinic emergency (includes urgicenter sites)|3 - Outpatient department/clinic emergency (includes urgicenter sites)|34
205|3 - Paid help|3 - Paid help|34
206|3 - Able to participate in bathing self in shower or tub, but requires presence of another person throughout the bath for assistance or supervision.|3 - Able to participate in bathing self in shower or tub, but requires presence of another person th|34
207|3 - Patient depends entirely upon another person to dress lower body.|3 - Patient depends entirely upon another person to dress lower body.|34
208|3 - Patient depends entirely upon another person to dress the upper body.|3 - Patient depends entirely upon another person to dress the upper body.|34
209|3 - Patient depends entirely upon someone else for grooming needs.|3 - Patient depends entirely upon someone else for grooming needs.|34
210|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone else to manage the equipment.|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone|34
211|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable to shift attention and recall directions more than half the time.|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable|34
212|3 - Respiratory problems (SOB, infection, obstruction)|3 - Respiratory problems (SOB, infection, obstruction)|34
213|3 - Resumption of care (after inpatient stay)|3 - Resumption of care (after inpatient stay)|34
214|3 - Several times each month|3 - Several times each month|34
215|3 - Skilled Nursing Facility|3 - Skilled Nursing Facility|34
216|3 - Stage 3|3 - Stage 3|34
217|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|34
218|3 - Three|3 - Three|34
219|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person throughout the process.|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person through|34
220|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal independently.|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal indep|34
221|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person.|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person|34
222|3 - Unknown because patient moved to a geographic location not served by this agency|3 - Unknown because patient moved to a geographic location not served by this agency|34
223|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|34
224|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|34
225|3 - With other family member|3 - With other family member|34
226|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home health services, homemaker assistance, transportation assistance, assisted living, board and care)|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home h|34
227|3-SLP/ST|3-SLP/ST|34
228|4 - At rest (during day or night)|4 - At rest (during day or night)|34
229|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|34
230|4 - Board and care or assisted living facility|4 - Board and care or assisted living facility|34
231|4 - Caregiver is completely dependent on someone else to manage all equipment.|4 - Caregiver is completely dependent on someone else to manage all equipment.|34
232|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|34
233|4 - Constantly|4 - Constantly|34
234|4 - Drug dependency|4 - Drug dependency|34
235|4 - Four or more|4 - Four or more|34
236|4 - Friend or neighbor or community or church member|4 - Friend or neighbor or community or church member|34
237|4 - Hispanic or Latino|4 - Hispanic or Latino|34
238|4 - Hospice|4 - Hospice|34
239|4 - Impaired decision-making|4 - Impaired decision-making|34
240|4 - Is totally dependent in toileting.|4 - Is totally dependent in toileting.|34
241|4 - Medicaid (HMO/managed care)|4 - Medicaid (HMO/managed care)|34
242|4 - None of the above|4 - None of the above|34
243|4 - Nursing home|4 - Nursing home|34
244|4 - On a daily basis|4 - On a daily basis|34
245|4 - Patient is completely dependent on someone else to manage all equipment.|4 - Patient is completely dependent on someone else to manage all equipment.|34
246|4 - Permanent placement|4 - Permanent placement|34
247|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, punches, dangerous maneuvers w/ wheelchair or other objects)|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, pu|34
248|4 - Psychosocial support (e.g., socialization, companionship, recreation)|4 - Psychosocial support (e.g., socialization, companionship, recreation)|34
249|4 - Recertification (follow-up) reassessment|4 - Recertification (follow-up) reassessment|34
250|4 - Recurrent thoughts of death|4 - Recurrent thoughts of death|34
251|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruction)|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruc|34
252|4 - Several times a week|4 - Several times a week|34
253|4 - Stage 4|4 - Stage 4|34
254|4 - Symptoms poorly controlled, history of re-hospitalizations|4 - Symptoms poorly controlled, history of re-hospitalizations|34
255|4 - Three or more times per week|4 - Three or more times per week|34
256|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetative state, or delirium.|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetati|34
257|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|34
258|4 - Unable to effectively participate in any housekeeping tasks.|4 - Unable to effectively participate in any housekeeping tasks.|34
259|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or unresponsive (e.g., speech is nonsensical or unintelligible).|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or u|34
260|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonresponsive.|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonr|34
261|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostomy.|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostom|34
262|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of devices at the sink, in chair, or on commode|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of|34
263|4 - With a friend|4 - With a friend|34
264|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|34
265|4-OT|4-OT|34
266|5 - Advocates or facilitates patient's participation in appropriate medical care|5 - Advocates or facilitates patient's participation in appropriate medical care|34
267|5 - At least daily|5 - At least daily|34
268|6 - Bedfast, unable to ambulate or be up in a chair.|6 - Bedfast, unable to ambulate or be up in a chair.|34
269|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|34
270|5 - Disruptive or socially inappropriate behavior|5 - Disruptive or socially inappropriate behavior|34
271|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|34
272|5 - Hypo/Hyperglycemia, diabetes out of control|5 - Hypo/Hyperglycemia, diabetes out of control|34
273|5 - More often than once daily|5 - More often than once daily|34
274|5 - Native Hawaiian or Pacific Islander|5 - Native Hawaiian or Pacific Islander|34
275|5 - None of the above|5 - None of the above|34
276|5 - One to two times per week|5 - One to two times per week|34
277|5 - Other|5 - Other|34
278|5 - Other follow-up|5 - Other follow-up|34
279|5 - Paid help|5 - Paid help|34
280|5 - Patient nonresponsive or unable to speak.|5 - Patient nonresponsive or unable to speak.|34
281|5 - Thoughts of suicide|5 - Thoughts of suicide|34
282|5 - Totally unable to use the telephone.|5 - Totally unable to use the telephone.|34
283|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|34
284|5 - Unable to take in nutrients orally or by tube feeding.|5 - Unable to take in nutrients orally or by tube feeding.|34
285|5 - Unsafe for care at home|5 - Unsafe for care at home|34
286|5 - With paid help (other than home care agency staff)|5 - With paid help (other than home care agency staff)|34
287|5 - Workers' compensation|5 - Workers' compensation|34
288|5 - Wound infection, deteriorating wound status, new lesion/ulcer|5 - Wound infection, deteriorating wound status, new lesion/ulcer|34
289|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|34
290|6 - Delusional, hallucinatory, or paranoid behavior|6 - Delusional, hallucinatory, or paranoid behavior|34
291|6 - Financial agent, power of attorney, or conservator of finance|6 - Financial agent, power of attorney, or conservator of finance|34
292|6 - GI bleeding, obstruction|6 - GI bleeding, obstruction|34
293|6 - Less often than weekly|6 - Less often than weekly|34
294|6 - Memory loss to the extent that supervision required|6 - Memory loss to the extent that supervision required|34
295|6 - None of the above feelings observed or reported|6 - None of the above feelings observed or reported|34
296|6 - Other|6 - Other|34
297|6 - Title programs (e.g., Title III, V, or XX)|6 - Title programs (e.g., Title III, V, or XX)|34
298|6 - Transferred to an inpatient facility - patient not discharged from agency|6 - Transferred to an inpatient facility - patient not discharged from agency|34
299|6 - White|6 - White|34
300|6 - With other than above|6 - With other than above|34
301|7 - Exacerbation of CHF, fluid overload, heart failure|7 - Exacerbation of CHF, fluid overload, heart failure|34
302|7 - Health care agent, conservator of person, or medical power of attorney|7 - Health care agent, conservator of person, or medical power of attorney|34
303|7 - Hypo/Hyperglycemia, diabetes out of control|7 - Hypo/Hyperglycemia, diabetes out of control|34
304|7 - None of the above|7 - None of the above|34
305|7 - None of the above behaviors demonstrated|7 - None of the above behaviors demonstrated|34
306|7 - Other government (e.g., TriCare, VA, etc.)|7 - Other government (e.g., TriCare, VA, etc.)|34
307|7 - Transferred to an inpatient facility - patient discharged from agency|7 - Transferred to an inpatient facility - patient discharged from agency|34
308|8 - Death at home|8 - Death at home|34
309|8 - GI bleeding, obstruction|8 - GI bleeding, obstruction|34
310|8 - Myocardial infarction, stroke|8 - Myocardial infarction, stroke|34
311|8 - Private insurance|8 - Private insurance|34
312|9 - Chemotherapy|9 - Chemotherapy|34
313|9 - Discharge from agency|9 - Discharge from agency|34
314|9 - Other than above reasons|9 - Other than above reasons|34
315|9 - Private HMO/managed care|9 - Private HMO/managed care|34
316|NA - No caregiver|NA - No caregiver|34
317|NA - No equipment of this type used in care.|NA - No equipment of this type used in care.|34
318|NA - No inhalant/mist medications prescribed.|NA - No inhalant/mist medications prescribed.|34
319|NA - No injectable medications prescribed.|NA - No injectable medications prescribed.|34
320|NA - No inpatient facility admission|NA - No inpatient facility admission|34
321|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|34
322|NA - No Medicaid|NA - No Medicaid|34
323|NA - No Medicare|NA - No Medicare|34
324|NA - No observable pressure ulcer or unhealed pressure ulcer|NA - No observable pressure ulcer or unhealed pressure ulcer|34
325|NA - No observable stasis ulcer|NA - No observable stasis ulcer|34
326|NA - No observable surgical wound|NA - No observable surgical wound|34
327|NA - No oral medications prescribed.|NA - No oral medications prescribed.|34
328|NA - Not applicable|NA - Not applicable|34
329|NA - Patient does not have a telephone.|NA - Patient does not have a telephone.|34
330|NA - Patient has ostomy for bowel elimination|NA - Patient has ostomy for bowel elimination|34
331|NA - Patient nonresponsive|NA - Patient nonresponsive|34
332|NA - Patient on prophylactic treatment|NA - Patient on prophylactic treatment|34
333|NA - Patient was not discharged from an inpatient facility [Go to M1016 ]|NA - Patient was not discharged from an inpatient facility [Go to M1016 ]|34
334|UK - Other unknown|UK - Other unknown|34
335|UK - Reason unknown|UK - Reason unknown|34
336|UK - Unknown|UK - Unknown|34
337|UK - Unknown or Not Available|UK - Unknown or Not Available|34
341|01 - Early|01 - Early|34
342|02 - Late|02 - Late|34
343|NA - Not Applicable. No case mix group defined for this assessment.|NA - Not Applicable. No case mix group defined for this assessment.|34
344|NA - No case mix group defined by this assessment.|NA - No case mix group defined by this assessment.|34
345|1 - Recent decline in mental, emotional, or behavioral status|1 - Recent decline in mental, emotional, or behavioral status|34
346|2 - Multiple hospitalizations (2 or more) in the past 12 months|2 - Multiple hospitalizations (2 or more) in the past 12 months|34
347|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|34
348|4 - Taking five or more medications|4 - Taking five or more medications|34
349|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|34
350|6 - Other|6 - Other|34
351|7 - None of the above|7 - None of the above|34
352|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond tho|34
353|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable without heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable wi|34
354|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious complications and death.|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious compl|34
355|3 - The patient has serious progressive conditions that could lead to death within a year.|3 - The patient has serious progressive conditions that could lead to death within a year.|34
356|UK - The patient+s situation is unknown or unclear.|UK - The patient+s situation is unknown or unclear.|34
357|1 - Yes [ Go to M1050 ]|1 - Yes [ Go to M1050 ]|34
358|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this influenza season. [ Go to M1050 ]|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this i|34
359|1 - Received from another health care provider (e.g., physician)|1 - Received from another health care provider (e.g., physician)|34
360|2 - Received from your agency previously during this year+s flu season|2 - Received from your agency previously during this year+s flu season|34
361|3 - Offered and declined|3 - Offered and declined|34
362|4 - Assessed and determined to have medical contraindication(s)|4 - Assessed and determined to have medical contraindication(s)|34
363|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|34
364|6 - Inability to obtain vaccine due to declared shortage|6 - Inability to obtain vaccine due to declared shortage|34
365|1 - Yes [ Go to M1500 at TRN; Go to M1230 at DC ]|1 - Yes [ Go to M1500 at TRN; Go to M1230 at DC ]|34
366|1 - Patient has received PPV in the past|1 - Patient has received PPV in the past|34
367|2 - Offered and declined|2 - Offered and declined|34
368|3 - Assessed and determined to have medical contraindication(s)|3 - Assessed and determined to have medical contraindication(s)|34
369|4 - Not indicated; patient does not meet age/condition guidelines for PPV|4 - Not indicated; patient does not meet age/condition guidelines for PPV|34
370|5 - None of the above|5 - None of the above|34
371|0 - Adequate: hears normal conversation without difficulty.|0 - Adequate: hears normal conversation without difficulty.|34
372|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to increase volume or speak distinctly.|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to in|34
373|2 - Severely Impaired: absence of useful hearing.|2 - Severely Impaired: absence of useful hearing.|34
374|UK - Unable to assess hearing.|UK - Unable to assess hearing.|34
375|0 - Understands: clear comprehension without cues or repetitions.|0 - Understands: clear comprehension without cues or repetitions.|34
376|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Requires cues at times to understand.|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Req|34
377|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequently requires cues to understand.|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequentl|34
378|3 - Rarely/Never Understands|3 - Rarely/Never Understands|34
379|UK - Unable to assess understanding.|UK - Unable to assess understanding.|34
380|0 - No standardized assessment conducted|0 - No standardized assessment conducted|34
381|1 - Yes, and it does not indicate severe pain|1 - Yes, and it does not indicate severe pain|34
382|2 - Yes, and it indicates severe pain|2 - Yes, and it indicates severe pain|34
383|0 - Patient has no pain|0 - Patient has no pain|34
384|1 - Patient has pain that does not interfere with activity or movement|1 - Patient has pain that does not interfere with activity or movement|34
385|2 - Less often than daily|2 - Less often than daily|34
386|3 - Daily, but not constantly|3 - Daily, but not constantly|34
387|4 - All of the time|4 - All of the time|34
388|0 - No assessment conducted [ Go to M1306 ]|0 - No assessment conducted [ Go to M1306 ]|34
389|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc., without use of standardized tool|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc.,|34
390|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|34
391|0 - No [ Go to M1322]|0 - No [ Go to M1322]|34
392|0 v Newly epithelialized|0 v Newly epithelialized|34
393|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|34
394|2 - Yes, patient has observable stasis ulcers ONLY|2 - Yes, patient has observable stasis ulcers ONLY|34
395|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable dressing) [Go to M1340]|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable|34
396|0 - No [ Go to M1350 ]|0 - No [ Go to M1350 ]|34
397|1 - Yes, patient has at least one (observable) surgical wound|1 - Yes, patient has at least one (observable) surgical wound|34
398|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1350 ]|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1350 ]|34
399|0 - Patient is not short of breath|0 - Patient is not short of breath|34
400|3 - Continuous Bi-level positive airway pressure|3 - Continuous Bi-level positive airway pressure|34
401|0 - No [ Go to M1732 at TRN; Go to M1600 at DC ]|0 - No [ Go to M1732 at TRN; Go to M1600 at DC ]|34
402|2 - Not assessed [Go to M1732 at TRN; Go to M1600 at DC ]|2 - Not assessed [Go to M1732 at TRN; Go to M1600 at DC ]|34
403|NA - Patient does not have diagnosis of heart failure [Go to M2004 at TRN; Go to M1600 at DC]|NA - Patient does not have diagnosis of heart failure [Go to M2004 at TRN; Go to M1600 at DC]|34
404|0 - No action taken|0 - No action taken|34
405|1 - Patient+s physician (or other primary care practitioner) contacted the same day|1 - Patient+s physician (or other primary care practitioner) contacted the same day|34
406|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|34
407|3 - Implement physician-ordered patient-specific established parameters for treatment|3 - Implement physician-ordered patient-specific established parameters for treatment|34
408|4 - Patient education or other clinical interventions|4 - Patient education or other clinical interventions|34
409|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequency, telehealth, etc.)|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequ|34
410|1 - Occasional stress incontinence|1 - Occasional stress incontinence|34
411|2 - During the night only|2 - During the night only|34
412|3 - During the day only|3 - During the day only|34
413|4 - During the day and night|4 - During the day and night|34
414|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|34
415|0 - Able to manage toileting hygiene and clothing management without assistance.|0 - Able to manage toileting hygiene and clothing management without assistance.|34
416|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implements are laid out for the patient.|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implemen|34
417|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|34
418|3 - Patient depends entirely upon another person to maintain toileting hygiene.|3 - Patient depends entirely upon another person to maintain toileting hygiene.|34
419|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independent|34
420|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface|34
421|0 - No multi-factor falls risk assessment conducted.|0 - No multi-factor falls risk assessment conducted.|34
422|1 - Yes, and it does not indicate a risk for falls.|1 - Yes, and it does not indicate a risk for falls.|34
423|2 - Yes, and it indicates a risk for falls.|2 - Yes, and it indicates a risk for falls.|34
424|0 - Not assessed/reviewed [ Go to M2010 ]|0 - Not assessed/reviewed [ Go to M2010 ]|34
425|1 - No problems found during review [ Go to M2010 ]|1 - No problems found during review [ Go to M2010 ]|34
426|2 - Problems found during review|2 - Problems found during review|34
427|NA - Patient is not taking any medications [ Go to M2040 ]|NA - Patient is not taking any medications [ Go to M2040 ]|34
428|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special precautions associated with all high-risk medications|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special p|34
429|NA - Patient not taking any drugs|NA - Patient not taking any drugs|34
430|2 - Able to take medication(s) at the correct times if given reminders by another person at the appropriate times|2 - Able to take medication(s) at the correct times if given reminders by another person at the appr|34
431|3 - Unable to take medication unless administered by another person.|3 - Unable to take medication unless administered by another person.|34
432|1 - At least daily|1 - At least daily|34
433|2 - Three or more times per week|2 - Three or more times per week|34
434|3 - One to two times per week|3 - One to two times per week|34
435|4 - Received, but less often than weekly|4 - Received, but less often than weekly|34
436|5 - No assistance received|5 - No assistance received|34
437|0 - No [Go to M2400]|0 - No [Go to M2400]|34
438|1 - Yes, used hospital emergency department WITHOUT hospital admission|1 - Yes, used hospital emergency department WITHOUT hospital admission|34
439|2 - Yes, used hospital emergency department WITH hospital admission|2 - Yes, used hospital emergency department WITH hospital admission|34
440|UK - Unknown [Go to M2400]|UK - Unknown [Go to M2400]|34
441|2 - Injury caused by fall|2 - Injury caused by fall|34
442|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|34
443|4 - Other respiratory problem|4 - Other respiratory problem|34
444|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|34
445|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|34
446|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|34
447|8 - Other heart disease|8 - Other heart disease|34
448|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|34
449|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|34
450|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|34
451|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|34
452|13 - Urinary tract infection|13 - Urinary tract infection|34
453|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|34
454|15 - Wound infection or deterioration|15 - Wound infection or deterioration|34
455|16 - Uncontrolled pain|16 - Uncontrolled pain|34
456|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|34
457|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|34
458|19 - Other than above reasons|19 - Other than above reasons|34
459|2 - Patient remained in the community (with formal assistive services)|2 - Patient remained in the community (with formal assistive services)|34
460|3 - Patient transferred to a noninstitutional hospice|3 - Patient transferred to a noninstitutional hospice|34
461|4 - Unknown because patient moved to a geographic location not served by this agency|4 - Unknown because patient moved to a geographic location not served by this agency|34
462|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|34
463|4 - Other respiratory problem|4 - Other respiratory problem|34
464|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|34
465|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|34
466|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|34
467|8 - Other heart disease|8 - Other heart disease|34
468|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|34
469|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|34
470|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|34
471|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|34
472|13 - Urinary tract infection|13 - Urinary tract infection|34
473|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|34
474|15 - Wound infection or deterioration|15 - Wound infection or deterioration|34
475|16 - Uncontrolled pain|16 - Uncontrolled pain|34
476|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|34
477|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|34
478|19 - Scheduled treatment or procedure|19 - Scheduled treatment or procedure|34
479|20 - Other than above reasons|20 - Other than above reasons|34
480|UK - Reason unknown [Go to M0903]|UK - Reason unknown [Go to M0903]|34
482|01 - Patient lives alone around the clock|01 - Patient lives alone around the clock|34
483|02 - Patient lives alone regular daytime|02 - Patient lives alone regular daytime|34
484|03 - Patient lives alone regular nighttime|03 - Patient lives alone regular nighttime|34
485|04 - Patient lives alone occassional/short term assistance|04 - Patient lives alone occassional/short term assistance|34
486|05 - Patient lives alone no assisstance available|05 - Patient lives alone no assisstance available|34
487|06 - Patient lives with other person(s) in the home around the clock|06 - Patient lives with other person(s) in the home around the clock|34
488|07 - Patient lives with other person(s) in the home regular daytime|07 - Patient lives with other person(s) in the home regular daytime|34
489|08 - Patient lives with other person(s) in the home regular nighttime|08 - Patient lives with other person(s) in the home regular nighttime|34
490|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|34
491|10 - Patient lives with other person(s) in the home no assistance available|10 - Patient lives with other person(s) in the home no assistance available|34
492|1 - Was present at the most recent SOC/ROC assessment|1 - Was present at the most recent SOC/ROC assessment|34
493|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|34
494|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|34
495|0 - Newly epithelialized|0 - Newly epithelialized|34
496|0 - No [ Go to M1340 ]|0 - No [ Go to M1340 ]|34
498|0 - Independent|0 - Independent|34
499|1 - Needed Some Help|1 - Needed Some Help|34
500|2 - Dependent|2 - Dependent|34
502|0 - No assistance needed in this area|0 - No assistance needed in this area|34
503|1 - Caregiver(s) currently provide assistance|1 - Caregiver(s) currently provide assistance|34
504|2 - Caregiver(s) need training/ supportive services to provide assistance|2 - Caregiver(s) need training/ supportive services to provide assistance|34
505|3 - Caregiver(s) not likely to provide assistance|3 - Caregiver(s) not likely to provide assistance|34
506|4 - Unclear if Caregiver(s) will provide assistance|4 - Unclear if Caregiver(s) will provide assistance|34
507|5 - Assistance needed, but no Caregiver(s) available|5 - Assistance needed, but no Caregiver(s) available|34
508|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will use standardized clinical guidelines accessible for all care providers to reference|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will|34
510|NA - Patient is not assessed to be at risk for falls|NA - Patient is not assessed to be at risk for falls|34
511|NA - Patient has no diagnosis or symptoms of depression|NA - Patient has no diagnosis or symptoms of depression|34
512|NA - No pain identified|NA - No pain identified|34
513|NA - Patient is not assessed to be at risk for pressure ulcers|NA - Patient is not assessed to be at risk for pressure ulcers|34
514|NA - Patient has no pressure ulcers with need for moist wound healing|NA - Patient has no pressure ulcers with need for moist wound healing|34
515|1 - Long-term nursing facility (NF)|1 - Long-term nursing facility (NF)|34
516|2 - Skilled nursing facility (SNF / TCU)|2 - Skilled nursing facility (SNF / TCU)|34
517|3 - Short stay acute hospital (IPP S)|3 - Short stay acute hospital (IPP S)|34
518|4 - Long-term care hospital (LTCH)|4 - Long-term care hospital (LTCH)|34
519|5 - Inpatient rehabilitation hospital or unit (IRF)|5 - Inpatient rehabilitation hospital or unit (IRF)|34
520|6 - Psychiatric hospital or unit|6 - Psychiatric hospital or unit|34
521|7 - Other|7 - Other|34
522|NA - Patient was not discharged from an inpatient facility [Goto M1016]|NA - Patient was not discharged from an inpatient facility [Goto M1016]|34
523|6 - Unable to participate effectively in bathing and is bathed totally by another person|6 - Unable to participate effectively in bathing and is bathed totally by another person|34
524|4 - Chairfast, unable to ambulate but is able to wheel self independently.|4 - Chairfast, unable to ambulate but is able to wheel self independently.|34
525|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask patient: "Over the last two weeks, how often have you been bothered by any of the following problems")  *Copyright+ Pfizer Inc. All rights reserved. Reproduced with permission.|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask|34
526|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluation for depression.|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluat|34
527|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet criteria for further evaluation for depression.|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet|34
528|0 - Not at all  0 - 1 day|0 - Not at all  0 - 1 day|34
529|1 - Several days  2 - 6 days|1 - Several days  2 - 6 days|34
530|2 - More than half of the days  7 - 11 days|2 - More than half of the days  7 - 11 days|34
531|3 - Nearly every day  12 - 14 days|3 - Nearly every day  12 - 14 days|34
532|NA - N/A  Unable to respond|NA - N/A  Unable to respond|34
533|2 - Able to take medication(s) at the correct times if given reminders by another person based on the frequency of the injection|2 - Able to take medication(s) at the correct times if given reminders by another person based on th|34
534|3 - Unable to take injectable medication unless administered by another person.|3 - Unable to take injectable medication unless administered by another person.|34
2|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; OR (b) Is physically, cognitively, and mentally able to prepare light meals on a regular basis but has not routinely performed light meal preparation in the past (i.e., prior to this home care admission).|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; O|35
3|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and mentally able to perform all housekeeping tasks .|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and menta|35
4|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and mentally able to do laundry and access facilities.|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and menta|35
5|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying packages OR b) Physically, cognitively, and mentally able to take care of shopping, but has not done shopping in the past (i.e., prior to this home care admission).|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying|35
6|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|35
7|0 - Able to dial numbers and answer calls appropriately and as desired.|0 - Able to dial numbers and answer calls appropriately and as desired.|35
8|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body without assistance.|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body|35
9|0 - Able to get to and from the toilet and transfer independently with or without a device.|0 - Able to get to and from the toilet and transfer independently with or without a device.|35
10|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|35
11|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible public bus.|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible p|35
12|0 - Able to independently feed self.|0 - Able to independently feed self.|35
13|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|35
14|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct times.|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct ti|35
15|0 - Able to independently transfer.|0 - Able to independently transfer.|35
16|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without rail|35
17|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings|35
18|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|35
19|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions independently.|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions indep|35
20|0 - Asymptomatic, no treatment needed at this time|0 - Asymptomatic, no treatment needed at this time|35
21|0 - Caregiver manages all tasks related to equipment completely independently.|0 - Caregiver manages all tasks related to equipment completely independently.|35
22|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations with no observable impairment.|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations w|35
23|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|35
24|0 - Life expectancy is greater than 6 months|0 - Life expectancy is greater than 6 months|35
25|0 - Never|0 - Never|35
26|0 - Patient is not short of breath|0 - Patient is not short of breath|35
27|0 - No|0 - No|35
28|0 - No emergent care services|0 - No emergent care services|35
29|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [Goto M1620]|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [Goto M1620]|35
30|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and extended or abstract conversation.|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and exte|35
31|0 - No one person|0 - No one person|35
32|0 - None of the time|0 - None of the time|35
33|0 - None, no charge for current services|0 - None, no charge for current services|35
34|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|35
35|0 - Patient does NOT have an ostomy for bowel elimination.|0 - Patient does NOT have an ostomy for bowel elimination.|35
36|0 - Patient has no pain|0 - Patient has no pain|35
37|0 - Patient manages all tasks related to equipment completely independently.|0 - Patient manages all tasks related to equipment completely independently.|35
38|0 - Poor:  little or no recovery is expected and/or further decline is imminent|0 - Poor:  little or no recovery is expected and/or further decline is imminent|35
39|0 - Timed-voiding defers incontinence|0 - Timed-voiding defers incontinence|35
40|0 - Very rarely or never has bowel incontinence|0 - Very rarely or never has bowel incontinence|35
41|0 - Zero|0 - Zero|35
42|00 - No|00 - No|35
43|01 - Yes|01 - Yes|35
44|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or mental limitations, needs assistance with heavy laundry.|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or|35
45|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the patient.|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the|35
46|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|35
47|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or supervision from another person OR c) a liquid, pureed or ground meat diet.|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or su|35
48|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|35
49|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|35
50|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independently.|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independe|35
51|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only when assisted or accompanied by another person.|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only w|35
52|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepa|35
53|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance by another person OR b) given daily reminders.|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance b|35
54|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advan|35
55|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advan|35
56|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for the deaf) and call essential numbers.|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for t|35
57|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|35
58|1 - American Indian or Alaska Native|1 - American Indian or Alaska Native|35
59|1 - Depressed mood (e.g., feeling sad, tearful)|1 - Depressed mood (e.g., feeling sad, tearful)|35
60|1 - During the night only|1 - During the night only|35
61|1 - Fully granulating|1 - Fully granulating|35
62|1 - Good/Fair:  partial to full recovery is expected|1 - Good/Fair:  partial to full recovery is expected|35
63|1 - Good:  marked improvement in functional status is expected|1 - Good:  marked improvement in functional status is expected|35
64|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|35
65|1 - Smoking|1 - Smoking|35
66|1 - Hospital|1 - Hospital|35
67|1 - Hospital emergency room (includes 23-hour holding)|1 - Hospital emergency room (includes 23-hour holding)|35
68|1 - Hospitalization for EMERGENT (unscheduled) care|1 - Hospitalization for EMERGENT (unscheduled) care|35
69|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepared solutions), patient is able to manage all other aspects of equipment.|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepar|35
70|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|35
71|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|35
72|1 - In new or complex situations only|1 - In new or complex situations only|35
73|1 - Intravenous or infusion therapy (excludes TPN)|1 - Intravenous or infusion therapy (excludes TPN)|35
74|1 - Less often than daily|1 - Less often than daily|35
75|1 - Less than once a month|1 - Less than once a month|35
76|1 - Less than once weekly|1 - Less than once weekly|35
77|1 - Life expectancy is 6 months or fewer|1 - Life expectancy is 6 months or fewer|35
78|1 - Lives alone|1 - Lives alone|35
79|1 - Male|1 - Male|35
80|1 - Medicare (traditional fee-for-service)|1 - Medicare (traditional fee-for-service)|35
81|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of past 24 hours, significant memory loss so that supervision is required|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of pas|35
82|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors in word choice, grammar or speech intelligibility, needs minimal prompting or assistance).|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors i|35
83|1 - No assistance or services received|1 - No assistance or services received|35
84|1 - One|1 - One|35
85|1 - Oxygen (intermittent or continuous)|1 - Oxygen (intermittent or continuous)|35
86|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, and the surrounding layout, can count fingers at arm's length.|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, a|35
87|1 - Patient is incontinent|1 - Patient is incontinent|35
88|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|35
89|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical or treatment regimen.|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical|35
90|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient/couple/significant other)|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient|35
91|1 - Relatives, friends, or neighbors living outside the home|1 - Relatives, friends, or neighbors living outside the home|35
92|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions.|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions|35
93|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independentl|35
94|1 - Several times during day and night|1 - Several times during day and night|35
95|1 - Spouse or significant other|1 - Spouse or significant other|35
96|1 - Stage 1|1 - Stage 1|35
97|1 - Start of care - further visits planned|1 - Start of care - further visits planned|35
98|1 - Symptoms well controlled with current therapy|1 - Symptoms well controlled with current therapy|35
99|1 - Therapy services|1 - Therapy services|35
100|1 - Able to transfer with minimal human assistance or with use of an assistive device.|1 - Able to transfer with minimal human assistance or with use of an assistive device.|35
101|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitations.|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitatio|35
102|1 - Urinary incontinence|1 - Urinary incontinence|35
103|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and transfer.|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and|35
104|1 - When walking more than 20 feet, climbing stairs|1 - When walking more than 20 feet, climbing stairs|35
105|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary conversation. May need occasional repetition, extra time, or louder voice.|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary c|35
106|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting in and out of tub/shower|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting|35
107|1 - Yes|1 - Yes|35
108|1-RN|1-RN|35
109|10 - Discharge from agency - no visits completed after start/resumption of care assessment|10 - Discharge from agency - no visits completed after start/resumption of care assessment|35
110|10 - Scheduled surgical procedure|10 - Scheduled surgical procedure|35
111|10 - Self-pay|10 - Self-pay|35
112|11 - Other|11 - Other|35
113|11 - Urinary tract infection|11 - Urinary tract infection|35
114|12 - IV catheter-related infection|12 - IV catheter-related infection|35
115|13 - Deep vein thrombosis, pulmonary embolus|13 - Deep vein thrombosis, pulmonary embolus|35
116|14 - Uncontrolled pain|14 - Uncontrolled pain|35
117|15 - Psychotic episode|15 - Psychotic episode|35
118|16 - Other than above reasons|16 - Other than above reasons|35
119|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing calls.|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing|35
120|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another person.|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another pers|35
121|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface a|35
122|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for intermittent supervision or encouragement or reminders, OR (b) to get in and out of the shower or tub, OR (c) for washing difficult to reach areas.|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for inter|35
123|2 - Asian|2 - Asian|35
124|2 - Caregiver requires considerable assistance from another person to manage equipment, but independently completes significant portions of task.|2 - Caregiver requires considerable assistance from another person to manage equipment, but independ|35
125|2 - Daily, but not constantly|2 - Daily, but not constantly|35
126|2 - Daughter or son|2 - Daughter or son|35
127|2 - Doctor's office emergency visit/house call|2 - Doctor's office emergency visit/house call|35
128|2 - During the day and night|2 - During the day and night|35
129|2 - Early/partial granulation|2 - Early/partial granulation|35
130|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors in word choice, organization or speech intelligibility). Speaks in phrases or short sentences.|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors|35
131|2 - Family member's residence|2 - Family member's residence|35
132|2 - Female|2 - Female|35
133|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conversation, needs frequent prompting or assistance.|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conver|35
134|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|35
135|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|35
136|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately stop activities, jeopardizes safety through actions|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately st|35
137|2 - Indwelling/suprapubic catheter|2 - Indwelling/suprapubic catheter|35
138|2 - Injury caused by fall or accident at home|2 - Injury caused by fall or accident at home|35
139|2 - Medicare (HMO/managed care/Advantage plan)|2 - Medicare (HMO/managed care/Advantage plan)|35
140|2 - Nausea, dehydration, malnutrition, constipation, impaction|2 - Nausea, dehydration, malnutrition, constipation, impaction|35
141|2 - Obesity|2 - Obesity|35
142|2 - On awakening or at night only|2 - On awakening or at night only|35
143|2 - Once a month|2 - Once a month|35
144|2 - One to three times weekly|2 - One to three times weekly|35
145|2 - Parenteral nutrition (TPN or lipids)|2 - Parenteral nutrition (TPN or lipids)|35
146|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic) [ Go to M1620 ]|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic) [ Go|35
147|2 - Patient requires considerable assistance from another person to manage equipment, but independently completes portions of the task.|2 - Patient requires considerable assistance from another person to manage equipment, but independen|35
148|2 - Patient transferred to a noninstitutional hospice|2 - Patient transferred to a noninstitutional hospice|35
149|2 - Person residing in the home (EXCLUDING paid help)|2 - Person residing in the home (EXCLUDING paid help)|35
150|2 - Rehabilitation facility|2 - Rehabilitation facility|35
151|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifting of attention) or consistently requires low stimulus environment due to distractibility.|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifti|35
152|2 - Respite care|2 - Respite care|35
153|2 - Sense of failure or self reproach|2 - Sense of failure or self reproach|35
154|2 - Several times during day|2 - Several times during day|35
155|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonresponsive.|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonrespons|35
156|2 - Someone must assist the patient to groom self.|2 - Someone must assist the patient to groom self.|35
157|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|35
158|2 - Someone must help the patient put on upper body clothing.|2 - Someone must help the patient put on upper body clothing.|35
159|2 - Stage 2|2 - Stage 2|35
160|2 - Start of care - no further visits planned|2 - Start of care - no further visits planned|35
161|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitoring|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitori|35
162|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment regimen.|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment re|35
163|2 - Two|2 - Two|35
164|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistance due to cognitive or mental limitation.|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistanc|35
165|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|35
166|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assistance).|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assis|35
167|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home delivery.|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home deli|35
168|2 - Unable to prepare any light meals or reheat any delivered meals.|2 - Unable to prepare any light meals or reheat any delivered meals.|35
169|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|35
170|2 - UNABLE to take injectable medications unless administered by someone else.|2 - UNABLE to take injectable medications unless administered by someone else.|35
171|2 - UNABLE to take medication unless administered by someone else.|2 - UNABLE to take medication unless administered by someone else.|35
172|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|35
173|2 - Ventilator (continually or at night)|2 - Ventilator (continually or at night)|35
174|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less than 20 feet)|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less th|35
175|2 - With spouse or significant other|2 - With spouse or significant other|35
176|2 - Yes, assistance or services provided by family or friends|2 - Yes, assistance or services provided by family or friends|35
177|2-PT|2-PT|35
178|3 - Able to answer the telephone only some of the time or is able to carry on only a limited conversation.|3 - Able to answer the telephone only some of the time or is able to carry on only a limited convers|35
179|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube or gastrostomy.|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube|35
180|3 - Alcohol dependency|3 - Alcohol dependency|35
181|3 - All of the time|3 - All of the time|35
182|3 - Black or African-American|3 - Black or African-American|35
183|3 - Boarding home or rented room|3 - Boarding home or rented room|35
184|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment, clean/store/dispose of equipment or supplies).|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment,|35
185|3 -Able to walk only with the supervision or assistance of another person at all times.|3 -Able to walk only with the supervision or assistance of another person at all times.|35
186|3 - Continuous / Bi-level positive airway pressure|3 - Continuous / Bi-level positive airway pressure|35
187|3 - During the day and evening, but not constantly|3 - During the day and evening, but not constantly|35
188|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the alimentary canal)|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the|35
189|3 - Environmental support (e.g., housing, home maintenance)|3 - Environmental support (e.g., housing, home maintenance)|35
190|3 - Four to six times weekly|3 - Four to six times weekly|35
191|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessing by listener.  Speech limited to single words or short phrases.|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessin|35
192|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires multiple repetitions, restatements, demonstrations, additional time.|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires m|35
193|3 - Hopelessness|3 - Hopelessness|35
194|3 - Hospice care|3 - Hospice care|35
195|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|35
196|3 - Injury caused by fall or accident at home|3 - Injury caused by fall or accident at home|35
197|3 - Intractable pain|3 - Intractable pain|35
198|3 - Medicaid (traditional fee-for-service)|3 - Medicaid (traditional fee-for-service)|35
199|3 - Needs someone to do all shopping and errands.|3 - Needs someone to do all shopping and errands.|35
200|3 - Not healing|3 - Not healing|35
201|3 - Nursing home|3 - Nursing home|35
202|3 - Once daily|3 - Once daily|35
203|3 - Other family member|3 - Other family member|35
204|3 - Outpatient department/clinic emergency (includes urgicenter sites)|3 - Outpatient department/clinic emergency (includes urgicenter sites)|35
205|3 - Paid help|3 - Paid help|35
206|3 - Able to participate in bathing self in shower or tub, but requires presence of another person throughout the bath for assistance or supervision.|3 - Able to participate in bathing self in shower or tub, but requires presence of another person th|35
207|3 - Patient depends entirely upon another person to dress lower body.|3 - Patient depends entirely upon another person to dress lower body.|35
208|3 - Patient depends entirely upon another person to dress the upper body.|3 - Patient depends entirely upon another person to dress the upper body.|35
209|3 - Patient depends entirely upon someone else for grooming needs.|3 - Patient depends entirely upon someone else for grooming needs.|35
210|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone else to manage the equipment.|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone|35
211|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable to shift attention and recall directions more than half the time.|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable|35
212|3 - Respiratory problems (SOB, infection, obstruction)|3 - Respiratory problems (SOB, infection, obstruction)|35
213|3 - Resumption of care (after inpatient stay)|3 - Resumption of care (after inpatient stay)|35
214|3 - Several times each month|3 - Several times each month|35
215|3 - Skilled Nursing Facility|3 - Skilled Nursing Facility|35
216|3 - Stage 3|3 - Stage 3|35
217|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|35
218|3 - Three|3 - Three|35
219|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person throughout the process.|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person through|35
220|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal independently.|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal indep|35
221|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person.|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person|35
222|3 - Unknown because patient moved to a geographic location not served by this agency|3 - Unknown because patient moved to a geographic location not served by this agency|35
223|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|35
224|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|35
225|3 - With other family member|3 - With other family member|35
226|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home health services, homemaker assistance, transportation assistance, assisted living, board and care)|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home h|35
227|3-SLP/ST|3-SLP/ST|35
228|4 - At rest (during day or night)|4 - At rest (during day or night)|35
229|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|35
230|4 - Board and care or assisted living facility|4 - Board and care or assisted living facility|35
231|4 - Caregiver is completely dependent on someone else to manage all equipment.|4 - Caregiver is completely dependent on someone else to manage all equipment.|35
232|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|35
233|4 - Constantly|4 - Constantly|35
234|4 - Drug dependency|4 - Drug dependency|35
235|4 - Four or more|4 - Four or more|35
236|4 - Friend or neighbor or community or church member|4 - Friend or neighbor or community or church member|35
237|4 - Hispanic or Latino|4 - Hispanic or Latino|35
238|4 - Hospice|4 - Hospice|35
239|4 - Impaired decision-making|4 - Impaired decision-making|35
240|4 - Is totally dependent in toileting.|4 - Is totally dependent in toileting.|35
241|4 - Medicaid (HMO/managed care)|4 - Medicaid (HMO/managed care)|35
242|4 - None of the above|4 - None of the above|35
243|4 - Nursing home|4 - Nursing home|35
244|4 - On a daily basis|4 - On a daily basis|35
245|4 - Patient is completely dependent on someone else to manage all equipment.|4 - Patient is completely dependent on someone else to manage all equipment.|35
246|4 - Permanent placement|4 - Permanent placement|35
247|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, punches, dangerous maneuvers w/ wheelchair or other objects)|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, pu|35
248|4 - Psychosocial support (e.g., socialization, companionship, recreation)|4 - Psychosocial support (e.g., socialization, companionship, recreation)|35
249|4 - Recertification (follow-up) reassessment|4 - Recertification (follow-up) reassessment|35
250|4 - Recurrent thoughts of death|4 - Recurrent thoughts of death|35
251|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruction)|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruc|35
252|4 - Several times a week|4 - Several times a week|35
253|4 - Stage 4|4 - Stage 4|35
254|4 - Symptoms poorly controlled, history of re-hospitalizations|4 - Symptoms poorly controlled, history of re-hospitalizations|35
255|4 - Three or more times per week|4 - Three or more times per week|35
256|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetative state, or delirium.|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetati|35
257|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|35
258|4 - Unable to effectively participate in any housekeeping tasks.|4 - Unable to effectively participate in any housekeeping tasks.|35
259|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or unresponsive (e.g., speech is nonsensical or unintelligible).|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or u|35
260|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonresponsive.|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonr|35
261|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostomy.|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostom|35
262|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of devices at the sink, in chair, or on commode|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of|35
263|4 - With a friend|4 - With a friend|35
264|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|35
265|4-OT|4-OT|35
266|5 - Advocates or facilitates patient's participation in appropriate medical care|5 - Advocates or facilitates patient's participation in appropriate medical care|35
267|5 - At least daily|5 - At least daily|35
268|6 - Bedfast, unable to ambulate or be up in a chair.|6 - Bedfast, unable to ambulate or be up in a chair.|35
269|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|35
270|5 - Disruptive or socially inappropriate behavior|5 - Disruptive or socially inappropriate behavior|35
271|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|35
272|5 - Hypo/Hyperglycemia, diabetes out of control|5 - Hypo/Hyperglycemia, diabetes out of control|35
273|5 - More often than once daily|5 - More often than once daily|35
274|5 - Native Hawaiian or Pacific Islander|5 - Native Hawaiian or Pacific Islander|35
275|5 - None of the above|5 - None of the above|35
276|5 - One to two times per week|5 - One to two times per week|35
277|5 - Other|5 - Other|35
278|5 - Other follow-up|5 - Other follow-up|35
279|5 - Paid help|5 - Paid help|35
280|5 - Patient nonresponsive or unable to speak.|5 - Patient nonresponsive or unable to speak.|35
281|5 - Thoughts of suicide|5 - Thoughts of suicide|35
282|5 - Totally unable to use the telephone.|5 - Totally unable to use the telephone.|35
283|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|35
284|5 - Unable to take in nutrients orally or by tube feeding.|5 - Unable to take in nutrients orally or by tube feeding.|35
285|5 - Unsafe for care at home|5 - Unsafe for care at home|35
286|5 - With paid help (other than home care agency staff)|5 - With paid help (other than home care agency staff)|35
287|5 - Workers' compensation|5 - Workers' compensation|35
288|5 - Wound infection, deteriorating wound status, new lesion/ulcer|5 - Wound infection, deteriorating wound status, new lesion/ulcer|35
289|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|35
290|6 - Delusional, hallucinatory, or paranoid behavior|6 - Delusional, hallucinatory, or paranoid behavior|35
291|6 - Financial agent, power of attorney, or conservator of finance|6 - Financial agent, power of attorney, or conservator of finance|35
292|6 - GI bleeding, obstruction|6 - GI bleeding, obstruction|35
293|6 - Less often than weekly|6 - Less often than weekly|35
294|6 - Memory loss to the extent that supervision required|6 - Memory loss to the extent that supervision required|35
295|6 - None of the above feelings observed or reported|6 - None of the above feelings observed or reported|35
296|6 - Other|6 - Other|35
297|6 - Title programs (e.g., Title III, V, or XX)|6 - Title programs (e.g., Title III, V, or XX)|35
298|6 - Transferred to an inpatient facility - patient not discharged from agency|6 - Transferred to an inpatient facility - patient not discharged from agency|35
299|6 - White|6 - White|35
300|6 - With other than above|6 - With other than above|35
301|7 - Exacerbation of CHF, fluid overload, heart failure|7 - Exacerbation of CHF, fluid overload, heart failure|35
302|7 - Health care agent, conservator of person, or medical power of attorney|7 - Health care agent, conservator of person, or medical power of attorney|35
303|7 - Hypo/Hyperglycemia, diabetes out of control|7 - Hypo/Hyperglycemia, diabetes out of control|35
304|7 - None of the above|7 - None of the above|35
305|7 - None of the above behaviors demonstrated|7 - None of the above behaviors demonstrated|35
306|7 - Other government (e.g., TriCare, VA, etc.)|7 - Other government (e.g., TriCare, VA, etc.)|35
307|7 - Transferred to an inpatient facility - patient discharged from agency|7 - Transferred to an inpatient facility - patient discharged from agency|35
308|8 - Death at home|8 - Death at home|35
309|8 - GI bleeding, obstruction|8 - GI bleeding, obstruction|35
310|8 - Myocardial infarction, stroke|8 - Myocardial infarction, stroke|35
311|8 - Private insurance|8 - Private insurance|35
312|9 - Chemotherapy|9 - Chemotherapy|35
313|9 - Discharge from agency|9 - Discharge from agency|35
314|9 - Other than above reasons|9 - Other than above reasons|35
315|9 - Private HMO/managed care|9 - Private HMO/managed care|35
316|NA - No caregiver|NA - No caregiver|35
317|NA - No equipment of this type used in care.|NA - No equipment of this type used in care.|35
318|NA - No inhalant/mist medications prescribed.|NA - No inhalant/mist medications prescribed.|35
319|NA - No injectable medications prescribed.|NA - No injectable medications prescribed.|35
320|NA - No inpatient facility admission|NA - No inpatient facility admission|35
321|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|35
322|NA - No Medicaid|NA - No Medicaid|35
323|NA - No Medicare|NA - No Medicare|35
324|NA - No observable pressure ulcer or unhealed pressure ulcer|NA - No observable pressure ulcer or unhealed pressure ulcer|35
325|NA - No observable stasis ulcer|NA - No observable stasis ulcer|35
326|NA - No observable surgical wound|NA - No observable surgical wound|35
327|NA - No oral medications prescribed.|NA - No oral medications prescribed.|35
328|NA - Not applicable|NA - Not applicable|35
329|NA - Patient does not have a telephone.|NA - Patient does not have a telephone.|35
330|NA - Patient has ostomy for bowel elimination|NA - Patient has ostomy for bowel elimination|35
331|NA - Patient nonresponsive|NA - Patient nonresponsive|35
332|NA - Patient on prophylactic treatment|NA - Patient on prophylactic treatment|35
333|NA - Patient was not discharged from an inpatient facility [Go to M1016 ]|NA - Patient was not discharged from an inpatient facility [Go to M1016 ]|35
334|UK - Other unknown|UK - Other unknown|35
335|UK - Reason unknown|UK - Reason unknown|35
336|UK - Unknown|UK - Unknown|35
337|UK - Unknown or Not Available|UK - Unknown or Not Available|35
341|01 - Early|01 - Early|35
342|02 - Late|02 - Late|35
343|NA - Not Applicable. No case mix group defined for this assessment.|NA - Not Applicable. No case mix group defined for this assessment.|35
344|NA - No case mix group defined by this assessment.|NA - No case mix group defined by this assessment.|35
345|1 - Recent decline in mental, emotional, or behavioral status|1 - Recent decline in mental, emotional, or behavioral status|35
346|2 - Multiple hospitalizations (2 or more) in the past 12 months|2 - Multiple hospitalizations (2 or more) in the past 12 months|35
347|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|35
348|4 - Taking five or more medications|4 - Taking five or more medications|35
349|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|35
350|6 - Other|6 - Other|35
351|7 - None of the above|7 - None of the above|35
352|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond tho|35
353|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable without heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable wi|35
354|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious complications and death.|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious compl|35
355|3 - The patient has serious progressive conditions that could lead to death within a year.|3 - The patient has serious progressive conditions that could lead to death within a year.|35
356|UK - The patient+s situation is unknown or unclear.|UK - The patient+s situation is unknown or unclear.|35
357|1 - Yes [ Go to M1050 ]|1 - Yes [ Go to M1050 ]|35
358|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this influenza season. [ Go to M1050 ]|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this i|35
359|1 - Received from another health care provider (e.g., physician)|1 - Received from another health care provider (e.g., physician)|35
360|2 - Received from your agency previously during this year+s flu season|2 - Received from your agency previously during this year+s flu season|35
361|3 - Offered and declined|3 - Offered and declined|35
362|4 - Assessed and determined to have medical contraindication(s)|4 - Assessed and determined to have medical contraindication(s)|35
363|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|35
364|6 - Inability to obtain vaccine due to declared shortage|6 - Inability to obtain vaccine due to declared shortage|35
365|1 - Yes [ Go to M1500 at TRN; Go to M1230 at DC ]|1 - Yes [ Go to M1500 at TRN; Go to M1230 at DC ]|35
366|1 - Patient has received PPV in the past|1 - Patient has received PPV in the past|35
367|2 - Offered and declined|2 - Offered and declined|35
368|3 - Assessed and determined to have medical contraindication(s)|3 - Assessed and determined to have medical contraindication(s)|35
369|4 - Not indicated; patient does not meet age/condition guidelines for PPV|4 - Not indicated; patient does not meet age/condition guidelines for PPV|35
370|5 - None of the above|5 - None of the above|35
371|0 - Adequate: hears normal conversation without difficulty.|0 - Adequate: hears normal conversation without difficulty.|35
372|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to increase volume or speak distinctly.|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to in|35
373|2 - Severely Impaired: absence of useful hearing.|2 - Severely Impaired: absence of useful hearing.|35
374|UK - Unable to assess hearing.|UK - Unable to assess hearing.|35
375|0 - Understands: clear comprehension without cues or repetitions.|0 - Understands: clear comprehension without cues or repetitions.|35
376|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Requires cues at times to understand.|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Req|35
377|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequently requires cues to understand.|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequentl|35
378|3 - Rarely/Never Understands|3 - Rarely/Never Understands|35
379|UK - Unable to assess understanding.|UK - Unable to assess understanding.|35
380|0 - No standardized assessment conducted|0 - No standardized assessment conducted|35
381|1 - Yes, and it does not indicate severe pain|1 - Yes, and it does not indicate severe pain|35
382|2 - Yes, and it indicates severe pain|2 - Yes, and it indicates severe pain|35
383|0 - Patient has no pain|0 - Patient has no pain|35
384|1 - Patient has pain that does not interfere with activity or movement|1 - Patient has pain that does not interfere with activity or movement|35
385|2 - Less often than daily|2 - Less often than daily|35
386|3 - Daily, but not constantly|3 - Daily, but not constantly|35
387|4 - All of the time|4 - All of the time|35
388|0 - No assessment conducted [ Go to M1306 ]|0 - No assessment conducted [ Go to M1306 ]|35
389|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc., without use of standardized tool|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc.,|35
390|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|35
391|0 - No [ Go to M1322]|0 - No [ Go to M1322]|35
392|0 v Newly epithelialized|0 v Newly epithelialized|35
393|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|35
394|2 - Yes, patient has observable stasis ulcers ONLY|2 - Yes, patient has observable stasis ulcers ONLY|35
395|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable dressing) [Go to M1340]|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable|35
396|0 - No [ Go to M1350 ]|0 - No [ Go to M1350 ]|35
397|1 - Yes, patient has at least one (observable) surgical wound|1 - Yes, patient has at least one (observable) surgical wound|35
398|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1350 ]|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1350 ]|35
399|0 - Patient is not short of breath|0 - Patient is not short of breath|35
400|3 - Continuous Bi-level positive airway pressure|3 - Continuous Bi-level positive airway pressure|35
401|0 - No [ Go to M1732 at TRN; Go to M1600 at DC ]|0 - No [ Go to M1732 at TRN; Go to M1600 at DC ]|35
402|2 - Not assessed [Go to M1732 at TRN; Go to M1600 at DC ]|2 - Not assessed [Go to M1732 at TRN; Go to M1600 at DC ]|35
403|NA - Patient does not have diagnosis of heart failure [Go to M2004 at TRN; Go to M1600 at DC]|NA - Patient does not have diagnosis of heart failure [Go to M2004 at TRN; Go to M1600 at DC]|35
404|0 - No action taken|0 - No action taken|35
405|1 - Patient+s physician (or other primary care practitioner) contacted the same day|1 - Patient+s physician (or other primary care practitioner) contacted the same day|35
406|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|35
407|3 - Implement physician-ordered patient-specific established parameters for treatment|3 - Implement physician-ordered patient-specific established parameters for treatment|35
408|4 - Patient education or other clinical interventions|4 - Patient education or other clinical interventions|35
409|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequency, telehealth, etc.)|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequ|35
410|1 - Occasional stress incontinence|1 - Occasional stress incontinence|35
411|2 - During the night only|2 - During the night only|35
412|3 - During the day only|3 - During the day only|35
413|4 - During the day and night|4 - During the day and night|35
414|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|35
415|0 - Able to manage toileting hygiene and clothing management without assistance.|0 - Able to manage toileting hygiene and clothing management without assistance.|35
416|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implements are laid out for the patient.|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implemen|35
417|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|35
418|3 - Patient depends entirely upon another person to maintain toileting hygiene.|3 - Patient depends entirely upon another person to maintain toileting hygiene.|35
419|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independent|35
420|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface|35
421|0 - No multi-factor falls risk assessment conducted.|0 - No multi-factor falls risk assessment conducted.|35
422|1 - Yes, and it does not indicate a risk for falls.|1 - Yes, and it does not indicate a risk for falls.|35
423|2 - Yes, and it indicates a risk for falls.|2 - Yes, and it indicates a risk for falls.|35
424|0 - Not assessed/reviewed [ Go to M2010 ]|0 - Not assessed/reviewed [ Go to M2010 ]|35
425|1 - No problems found during review [ Go to M2010 ]|1 - No problems found during review [ Go to M2010 ]|35
426|2 - Problems found during review|2 - Problems found during review|35
427|NA - Patient is not taking any medications [ Go to M2040 ]|NA - Patient is not taking any medications [ Go to M2040 ]|35
428|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special precautions associated with all high-risk medications|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special p|35
429|NA - Patient not taking any drugs|NA - Patient not taking any drugs|35
430|2 - Able to take medication(s) at the correct times if given reminders by another person at the appropriate times|2 - Able to take medication(s) at the correct times if given reminders by another person at the appr|35
431|3 - Unable to take medication unless administered by another person.|3 - Unable to take medication unless administered by another person.|35
432|1 - At least daily|1 - At least daily|35
433|2 - Three or more times per week|2 - Three or more times per week|35
434|3 - One to two times per week|3 - One to two times per week|35
435|4 - Received, but less often than weekly|4 - Received, but less often than weekly|35
436|5 - No assistance received|5 - No assistance received|35
437|0 - No [Go to M2400]|0 - No [Go to M2400]|35
438|1 - Yes, used hospital emergency department WITHOUT hospital admission|1 - Yes, used hospital emergency department WITHOUT hospital admission|35
439|2 - Yes, used hospital emergency department WITH hospital admission|2 - Yes, used hospital emergency department WITH hospital admission|35
440|UK - Unknown [Go to M2400]|UK - Unknown [Go to M2400]|35
441|2 - Injury caused by fall|2 - Injury caused by fall|35
442|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|35
443|4 - Other respiratory problem|4 - Other respiratory problem|35
444|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|35
445|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|35
446|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|35
447|8 - Other heart disease|8 - Other heart disease|35
448|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|35
449|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|35
450|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|35
451|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|35
452|13 - Urinary tract infection|13 - Urinary tract infection|35
453|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|35
454|15 - Wound infection or deterioration|15 - Wound infection or deterioration|35
455|16 - Uncontrolled pain|16 - Uncontrolled pain|35
456|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|35
457|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|35
458|19 - Other than above reasons|19 - Other than above reasons|35
459|2 - Patient remained in the community (with formal assistive services)|2 - Patient remained in the community (with formal assistive services)|35
460|3 - Patient transferred to a noninstitutional hospice|3 - Patient transferred to a noninstitutional hospice|35
461|4 - Unknown because patient moved to a geographic location not served by this agency|4 - Unknown because patient moved to a geographic location not served by this agency|35
462|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|35
463|4 - Other respiratory problem|4 - Other respiratory problem|35
464|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|35
465|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|35
466|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|35
467|8 - Other heart disease|8 - Other heart disease|35
468|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|35
469|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|35
470|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|35
471|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|35
472|13 - Urinary tract infection|13 - Urinary tract infection|35
473|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|35
474|15 - Wound infection or deterioration|15 - Wound infection or deterioration|35
475|16 - Uncontrolled pain|16 - Uncontrolled pain|35
476|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|35
477|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|35
478|19 - Scheduled treatment or procedure|19 - Scheduled treatment or procedure|35
479|20 - Other than above reasons|20 - Other than above reasons|35
480|UK - Reason unknown [Go to M0903]|UK - Reason unknown [Go to M0903]|35
482|01 - Patient lives alone around the clock|01 - Patient lives alone around the clock|35
483|02 - Patient lives alone regular daytime|02 - Patient lives alone regular daytime|35
484|03 - Patient lives alone regular nighttime|03 - Patient lives alone regular nighttime|35
485|04 - Patient lives alone occassional/short term assistance|04 - Patient lives alone occassional/short term assistance|35
486|05 - Patient lives alone no assisstance available|05 - Patient lives alone no assisstance available|35
487|06 - Patient lives with other person(s) in the home around the clock|06 - Patient lives with other person(s) in the home around the clock|35
488|07 - Patient lives with other person(s) in the home regular daytime|07 - Patient lives with other person(s) in the home regular daytime|35
489|08 - Patient lives with other person(s) in the home regular nighttime|08 - Patient lives with other person(s) in the home regular nighttime|35
490|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|35
491|10 - Patient lives with other person(s) in the home no assistance available|10 - Patient lives with other person(s) in the home no assistance available|35
492|1 - Was present at the most recent SOC/ROC assessment|1 - Was present at the most recent SOC/ROC assessment|35
493|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|35
494|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|35
495|0 - Newly epithelialized|0 - Newly epithelialized|35
496|0 - No [ Go to M1340 ]|0 - No [ Go to M1340 ]|35
498|0 - Independent|0 - Independent|35
499|1 - Needed Some Help|1 - Needed Some Help|35
500|2 - Dependent|2 - Dependent|35
502|0 - No assistance needed in this area|0 - No assistance needed in this area|35
503|1 - Caregiver(s) currently provide assistance|1 - Caregiver(s) currently provide assistance|35
504|2 - Caregiver(s) need training/ supportive services to provide assistance|2 - Caregiver(s) need training/ supportive services to provide assistance|35
505|3 - Caregiver(s) not likely to provide assistance|3 - Caregiver(s) not likely to provide assistance|35
506|4 - Unclear if Caregiver(s) will provide assistance|4 - Unclear if Caregiver(s) will provide assistance|35
507|5 - Assistance needed, but no Caregiver(s) available|5 - Assistance needed, but no Caregiver(s) available|35
508|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will use standardized clinical guidelines accessible for all care providers to reference|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will|35
510|NA - Patient is not assessed to be at risk for falls|NA - Patient is not assessed to be at risk for falls|35
511|NA - Patient has no diagnosis or symptoms of depression|NA - Patient has no diagnosis or symptoms of depression|35
512|NA - No pain identified|NA - No pain identified|35
513|NA - Patient is not assessed to be at risk for pressure ulcers|NA - Patient is not assessed to be at risk for pressure ulcers|35
514|NA - Patient has no pressure ulcers with need for moist wound healing|NA - Patient has no pressure ulcers with need for moist wound healing|35
515|1 - Long-term nursing facility (NF)|1 - Long-term nursing facility (NF)|35
516|2 - Skilled nursing facility (SNF / TCU)|2 - Skilled nursing facility (SNF / TCU)|35
517|3 - Short stay acute hospital (IPP S)|3 - Short stay acute hospital (IPP S)|35
518|4 - Long-term care hospital (LTCH)|4 - Long-term care hospital (LTCH)|35
519|5 - Inpatient rehabilitation hospital or unit (IRF)|5 - Inpatient rehabilitation hospital or unit (IRF)|35
520|6 - Psychiatric hospital or unit|6 - Psychiatric hospital or unit|35
521|7 - Other|7 - Other|35
522|NA - Patient was not discharged from an inpatient facility [Goto M1016]|NA - Patient was not discharged from an inpatient facility [Goto M1016]|35
523|6 - Unable to participate effectively in bathing and is bathed totally by another person|6 - Unable to participate effectively in bathing and is bathed totally by another person|35
524|4 - Chairfast, unable to ambulate but is able to wheel self independently.|4 - Chairfast, unable to ambulate but is able to wheel self independently.|35
525|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask patient: "Over the last two weeks, how often have you been bothered by any of the following problems")   *Copyright+ Pfizer Inc. All rights reserved. Reproduced with permission.|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask|35
526|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluation for depression.|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluat|35
527|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet criteria for further evaluation for depression.|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet|35
528|0 - Not at all  0 - 1 day|0 - Not at all  0 - 1 day|35
529|1 - Several days  2 - 6 days|1 - Several days  2 - 6 days|35
530|2 - More than half of the days  7 - 11 days|2 - More than half of the days  7 - 11 days|35
531|3 - Nearly every day  12 - 14 days|3 - Nearly every day  12 - 14 days|35
532|NA - N/A  Unable to respond|NA - N/A  Unable to respond|35
533|2 - Able to take medication(s) at the correct times if given reminders by another person based on the frequency of the injection|2 - Able to take medication(s) at the correct times if given reminders by another person based on th|35
534|3 - Unable to take injectable medication unless administered by another person.|3 - Unable to take injectable medication unless administered by another person.|35
2|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; OR (b) Is physically, cognitively, and mentally able to prepare light meals on a regular basis but has not routinely performed light meal preparation in the past (i.e., prior to this home care admission).|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; O|36
3|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and mentally able to perform all housekeeping tasks .|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and menta|36
4|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and mentally able to do laundry and access facilities.|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and menta|36
5|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying packages OR b) Physically, cognitively, and mentally able to take care of shopping, but has not done shopping in the past (i.e., prior to this home care admission).|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying|36
6|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|36
7|0 - Able to dial numbers and answer calls appropriately and as desired.|0 - Able to dial numbers and answer calls appropriately and as desired.|36
8|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body without assistance.|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body|36
9|0 - Able to get to and from the toilet and transfer independently with or without a device.|0 - Able to get to and from the toilet and transfer independently with or without a device.|36
10|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|36
11|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible public bus.|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible p|36
12|0 - Able to independently feed self.|0 - Able to independently feed self.|36
13|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|36
14|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct times.|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct ti|36
15|0 - Able to independently transfer.|0 - Able to independently transfer.|36
16|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without rail|36
17|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings|36
18|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|36
19|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions independently.|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions indep|36
20|0 - Asymptomatic, no treatment needed at this time|0 - Asymptomatic, no treatment needed at this time|36
21|0 - Caregiver manages all tasks related to equipment completely independently.|0 - Caregiver manages all tasks related to equipment completely independently.|36
22|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations with no observable impairment.|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations w|36
23|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|36
24|0 - Life expectancy is greater than 6 months|0 - Life expectancy is greater than 6 months|36
25|0 - Never|0 - Never|36
26|0 - Patient is not short of breath|0 - Patient is not short of breath|36
27|0 - No|0 - No|36
28|0 - No emergent care services|0 - No emergent care services|36
29|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [Goto 1620]|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [Goto 1620]|36
30|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and extended or abstract conversation.|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and exte|36
31|0 - No one person|0 - No one person|36
32|0 - None of the time|0 - None of the time|36
33|0 - None, no charge for current services|0 - None, no charge for current services|36
34|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|36
35|0 - Patient does NOT have an ostomy for bowel elimination.|0 - Patient does NOT have an ostomy for bowel elimination.|36
36|0 - Patient has no pain|0 - Patient has no pain|36
37|0 - Patient manages all tasks related to equipment completely independently.|0 - Patient manages all tasks related to equipment completely independently.|36
38|0 - Poor:  little or no recovery is expected and/or further decline is imminent|0 - Poor:  little or no recovery is expected and/or further decline is imminent|36
39|0 - Timed-voiding defers incontinence|0 - Timed-voiding defers incontinence|36
40|0 - Very rarely or never has bowel incontinence|0 - Very rarely or never has bowel incontinence|36
41|0 - Zero|0 - Zero|36
42|00 - No|00 - No|36
43|01 - Yes|01 - Yes|36
44|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or mental limitations, needs assistance with heavy laundry.|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or|36
45|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the patient.|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the|36
46|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|36
47|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or supervision from another person OR c) a liquid, pureed or ground meat diet.|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or su|36
48|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|36
49|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|36
50|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independently.|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independe|36
51|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only when assisted or accompanied by another person.|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only w|36
52|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepa|36
53|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance by another person OR b) given daily reminders.|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance b|36
54|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advan|36
55|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advan|36
56|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for the deaf) and call essential numbers.|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for t|36
57|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|36
58|1 - American Indian or Alaska Native|1 - American Indian or Alaska Native|36
59|1 - Depressed mood (e.g., feeling sad, tearful)|1 - Depressed mood (e.g., feeling sad, tearful)|36
60|1 - During the night only|1 - During the night only|36
61|1 - Fully granulating|1 - Fully granulating|36
62|1 - Good/Fair:  partial to full recovery is expected|1 - Good/Fair:  partial to full recovery is expected|36
63|1 - Good:  marked improvement in functional status is expected|1 - Good:  marked improvement in functional status is expected|36
64|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|36
65|1 - Smoking|1 - Smoking|36
66|1 - Hospital|1 - Hospital|36
67|1 - Hospital emergency room (includes 23-hour holding)|1 - Hospital emergency room (includes 23-hour holding)|36
68|1 - Hospitalization for EMERGENT (unscheduled) care|1 - Hospitalization for EMERGENT (unscheduled) care|36
69|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepared solutions), patient is able to manage all other aspects of equipment.|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepar|36
70|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|36
71|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|36
72|1 - In new or complex situations only|1 - In new or complex situations only|36
73|1 - Intravenous or infusion therapy (excludes TPN)|1 - Intravenous or infusion therapy (excludes TPN)|36
74|1 - Less often than daily|1 - Less often than daily|36
75|1 - Less than once a month|1 - Less than once a month|36
76|1 - Less than once weekly|1 - Less than once weekly|36
77|1 - Life expectancy is 6 months or fewer|1 - Life expectancy is 6 months or fewer|36
78|1 - Lives alone|1 - Lives alone|36
79|1 - Male|1 - Male|36
80|1 - Medicare (traditional fee-for-service)|1 - Medicare (traditional fee-for-service)|36
81|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of past 24 hours, significant memory loss so that supervision is required|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of pas|36
82|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors in word choice, grammar or speech intelligibility, needs minimal prompting or assistance).|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors i|36
83|1 - No assistance or services received|1 - No assistance or services received|36
84|1 - One|1 - One|36
85|1 - Oxygen (intermittent or continuous)|1 - Oxygen (intermittent or continuous)|36
86|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, and the surrounding layout, can count fingers at arm's length.|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, a|36
87|1 - Patient is incontinent|1 - Patient is incontinent|36
88|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|36
89|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical or treatment regimen.|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical|36
90|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient/couple/significant other)|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient|36
91|1 - Relatives, friends, or neighbors living outside the home|1 - Relatives, friends, or neighbors living outside the home|36
92|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions.|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions|36
93|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independentl|36
94|1 - Several times during day and night|1 - Several times during day and night|36
95|1 - Spouse or significant other|1 - Spouse or significant other|36
96|1 - Stage 1|1 - Stage 1|36
97|1 - Start of care - further visits planned|1 - Start of care - further visits planned|36
98|1 - Symptoms well controlled with current therapy|1 - Symptoms well controlled with current therapy|36
99|1 - Therapy services|1 - Therapy services|36
100|1 - Able to transfer with minimal human assistance or with use of an assistive device.|1 - Able to transfer with minimal human assistance or with use of an assistive device.|36
101|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitations.|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitatio|36
102|1 - Urinary incontinence|1 - Urinary incontinence|36
103|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and transfer.|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and|36
104|1 - When walking more than 20 feet, climbing stairs|1 - When walking more than 20 feet, climbing stairs|36
105|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary conversation. May need occasional repetition, extra time, or louder voice.|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary c|36
106|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting in and out of tub/shower|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting|36
107|1 - Yes|1 - Yes|36
108|1-RN|1-RN|36
109|10 - Discharge from agency - no visits completed after start/resumption of care assessment|10 - Discharge from agency - no visits completed after start/resumption of care assessment|36
110|10 - Scheduled surgical procedure|10 - Scheduled surgical procedure|36
111|10 - Self-pay|10 - Self-pay|36
112|11 - Other|11 - Other|36
113|11 - Urinary tract infection|11 - Urinary tract infection|36
114|12 - IV catheter-related infection|12 - IV catheter-related infection|36
115|13 - Deep vein thrombosis, pulmonary embolus|13 - Deep vein thrombosis, pulmonary embolus|36
116|14 - Uncontrolled pain|14 - Uncontrolled pain|36
117|15 - Psychotic episode|15 - Psychotic episode|36
118|16 - Other than above reasons|16 - Other than above reasons|36
119|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing calls.|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing|36
120|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another person.|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another pers|36
121|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface a|36
122|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for intermittent supervision or encouragement or reminders, OR (b) to get in and out of the shower or tub, OR (c) for washing difficult to reach areas.|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for inter|36
123|2 - Asian|2 - Asian|36
124|2 - Caregiver requires considerable assistance from another person to manage equipment, but independently completes significant portions of task.|2 - Caregiver requires considerable assistance from another person to manage equipment, but independ|36
125|2 - Daily, but not constantly|2 - Daily, but not constantly|36
126|2 - Daughter or son|2 - Daughter or son|36
127|2 - Doctor's office emergency visit/house call|2 - Doctor's office emergency visit/house call|36
128|2 - During the day and night|2 - During the day and night|36
129|2 - Early/partial granulation|2 - Early/partial granulation|36
130|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors in word choice, organization or speech intelligibility). Speaks in phrases or short sentences.|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors|36
131|2 - Family member's residence|2 - Family member's residence|36
132|2 - Female|2 - Female|36
133|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conversation, needs frequent prompting or assistance.|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conver|36
134|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|36
135|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|36
136|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately stop activities, jeopardizes safety through actions|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately st|36
137|2 - Indwelling/suprapubic catheter|2 - Indwelling/suprapubic catheter|36
138|2 - Injury caused by fall|2 - Injury caused by fall|36
139|2 - Medicare (HMO/managed care/Advantage plan)|2 - Medicare (HMO/managed care/Advantage plan)|36
140|2 - Nausea, dehydration, malnutrition, constipation, impaction|2 - Nausea, dehydration, malnutrition, constipation, impaction|36
141|2 - Obesity|2 - Obesity|36
142|2 - On awakening or at night only|2 - On awakening or at night only|36
143|2 - Once a month|2 - Once a month|36
144|2 - One to three times weekly|2 - One to three times weekly|36
145|2 - Parenteral nutrition (TPN or lipids)|2 - Parenteral nutrition (TPN or lipids)|36
146|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic) [ Go to M1620]|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic) [ Go|36
147|2 - Patient requires considerable assistance from another person to manage equipment, but independently completes portions of the task.|2 - Patient requires considerable assistance from another person to manage equipment, but independen|36
148|2 - Patient transferred to a noninstitutional hospice|2 - Patient transferred to a noninstitutional hospice|36
149|2 - Person residing in the home (EXCLUDING paid help)|2 - Person residing in the home (EXCLUDING paid help)|36
150|2 - Rehabilitation facility|2 - Rehabilitation facility|36
151|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifting of attention) or consistently requires low stimulus environment due to distractibility.|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifti|36
152|2 - Respite care|2 - Respite care|36
153|2 - Sense of failure or self reproach|2 - Sense of failure or self reproach|36
154|2 - Several times during day|2 - Several times during day|36
155|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonresponsive.|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonrespons|36
156|2 - Someone must assist the patient to groom self.|2 - Someone must assist the patient to groom self.|36
157|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|36
158|2 - Someone must help the patient put on upper body clothing.|2 - Someone must help the patient put on upper body clothing.|36
159|2 - Stage 2|2 - Stage 2|36
160|2 - Start of care - no further visits planned|2 - Start of care - no further visits planned|36
161|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitoring|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitori|36
162|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment regimen.|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment re|36
163|2 - Two|2 - Two|36
164|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistance due to cognitive or mental limitation.|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistanc|36
165|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|36
166|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assistance).|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assis|36
167|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home delivery.|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home deli|36
168|2 - Unable to prepare any light meals or reheat any delivered meals.|2 - Unable to prepare any light meals or reheat any delivered meals.|36
169|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|36
170|2 - UNABLE to take injectable medications unless administered by someone else.|2 - UNABLE to take injectable medications unless administered by someone else.|36
171|2 - UNABLE to take medication unless administered by someone else.|2 - UNABLE to take medication unless administered by someone else.|36
172|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|36
173|2 - Ventilator (continually or at night)|2 - Ventilator (continually or at night)|36
174|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less than 20 feet)|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less th|36
175|2 - With spouse or significant other|2 - With spouse or significant other|36
176|2 - Yes, assistance or services provided by family or friends|2 - Yes, assistance or services provided by family or friends|36
177|2-PT|2-PT|36
178|3 - Able to answer the telephone only some of the time or is able to carry on only a limited conversation.|3 - Able to answer the telephone only some of the time or is able to carry on only a limited convers|36
179|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube or gastrostomy.|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube|36
180|3 - Alcohol dependency|3 - Alcohol dependency|36
181|3 - All of the time|3 - All of the time|36
182|3 - Black or African-American|3 - Black or African-American|36
183|3 - Boarding home or rented room|3 - Boarding home or rented room|36
184|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment, clean/store/dispose of equipment or supplies).|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment,|36
185|3 -Able to walk only with the supervision or assistance of another person at all times.|3 -Able to walk only with the supervision or assistance of another person at all times.|36
186|3 - Continuous / Bi-level positive airway pressure|3 - Continuous / Bi-level positive airway pressure|36
187|3 - During the day and evening, but not constantly|3 - During the day and evening, but not constantly|36
188|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the alimentary canal)|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the|36
189|3 - Environmental support (e.g., housing, home maintenance)|3 - Environmental support (e.g., housing, home maintenance)|36
190|3 - Four to six times weekly|3 - Four to six times weekly|36
191|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessing by listener.  Speech limited to single words or short phrases.|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessin|36
192|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires multiple repetitions, restatements, demonstrations, additional time.|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires m|36
193|3 - Hopelessness|3 - Hopelessness|36
194|3 - Hospice care|3 - Hospice care|36
195|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|36
196|3 - Injury caused by fall or accident at home|3 - Injury caused by fall or accident at home|36
197|3 - Intractable pain|3 - Intractable pain|36
198|3 - Medicaid (traditional fee-for-service)|3 - Medicaid (traditional fee-for-service)|36
199|3 - Needs someone to do all shopping and errands.|3 - Needs someone to do all shopping and errands.|36
200|3 - Not healing|3 - Not healing|36
201|3 - Nursing home|3 - Nursing home|36
202|3 - Once daily|3 - Once daily|36
203|3 - Other family member|3 - Other family member|36
204|3 - Outpatient department/clinic emergency (includes urgicenter sites)|3 - Outpatient department/clinic emergency (includes urgicenter sites)|36
205|3 - Paid help|3 - Paid help|36
206|3 - Able to participate in bathing self in shower or tub, but requires presence of another person throughout the bath for assistance or supervision.|3 - Able to participate in bathing self in shower or tub, but requires presence of another person th|36
207|3 - Patient depends entirely upon another person to dress lower body.|3 - Patient depends entirely upon another person to dress lower body.|36
208|3 - Patient depends entirely upon another person to dress the upper body.|3 - Patient depends entirely upon another person to dress the upper body.|36
209|3 - Patient depends entirely upon someone else for grooming needs.|3 - Patient depends entirely upon someone else for grooming needs.|36
210|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone else to manage the equipment.|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone|36
211|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable to shift attention and recall directions more than half the time.|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable|36
212|3 - Respiratory problems (SOB, infection, obstruction)|3 - Respiratory problems (SOB, infection, obstruction)|36
213|3 - Resumption of care (after inpatient stay)|3 - Resumption of care (after inpatient stay)|36
214|3 - Several times each month|3 - Several times each month|36
215|3 - Skilled Nursing Facility|3 - Skilled Nursing Facility|36
216|3 - Stage 3|3 - Stage 3|36
217|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|36
218|3 - Three|3 - Three|36
219|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person throughout the process.|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person through|36
220|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal independently.|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal indep|36
221|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person.|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person|36
222|3 - Unknown because patient moved to a geographic location not served by this agency|3 - Unknown because patient moved to a geographic location not served by this agency|36
223|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|36
224|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|36
225|3 - With other family member|3 - With other family member|36
226|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home health services, homemaker assistance, transportation assistance, assisted living, board and care)|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home h|36
227|3-SLP/ST|3-SLP/ST|36
228|4 - At rest (during day or night)|4 - At rest (during day or night)|36
229|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|36
230|4 - Board and care or assisted living facility|4 - Board and care or assisted living facility|36
231|4 - Caregiver is completely dependent on someone else to manage all equipment.|4 - Caregiver is completely dependent on someone else to manage all equipment.|36
232|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|36
233|4 - Constantly|4 - Constantly|36
234|4 - Drug dependency|4 - Drug dependency|36
235|4 - Four or more|4 - Four or more|36
236|4 - Friend or neighbor or community or church member|4 - Friend or neighbor or community or church member|36
237|4 - Hispanic or Latino|4 - Hispanic or Latino|36
238|4 - Hospice|4 - Hospice|36
239|4 - Impaired decision-making|4 - Impaired decision-making|36
240|4 - Is totally dependent in toileting.|4 - Is totally dependent in toileting.|36
241|4 - Medicaid (HMO/managed care)|4 - Medicaid (HMO/managed care)|36
242|4 - None of the above|4 - None of the above|36
243|4 - Nursing home|4 - Nursing home|36
244|4 - On a daily basis|4 - On a daily basis|36
245|4 - Patient is completely dependent on someone else to manage all equipment.|4 - Patient is completely dependent on someone else to manage all equipment.|36
246|4 - Permanent placement|4 - Permanent placement|36
247|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, punches, dangerous maneuvers w/ wheelchair or other objects)|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, pu|36
248|4 - Psychosocial support (e.g., socialization, companionship, recreation)|4 - Psychosocial support (e.g., socialization, companionship, recreation)|36
249|4 - Recertification (follow-up) reassessment|4 - Recertification (follow-up) reassessment|36
250|4 - Recurrent thoughts of death|4 - Recurrent thoughts of death|36
251|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruction)|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruc|36
252|4 - Several times a week|4 - Several times a week|36
253|4 - Stage 4|4 - Stage 4|36
254|4 - Symptoms poorly controlled, history of rehospitalizations|4 - Symptoms poorly controlled, history of rehospitalizations|36
255|4 - Three or more times per week|4 - Three or more times per week|36
256|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetative state, or delirium.|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetati|36
257|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|36
258|4 - Unable to effectively participate in any housekeeping tasks.|4 - Unable to effectively participate in any housekeeping tasks.|36
259|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or unresponsive (e.g., speech is nonsensical or unintelligible).|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or u|36
260|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonresponsive.|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonr|36
261|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostomy.|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostom|36
262|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of devices at the sink, in chair, or on commode|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of|36
263|4 - With a friend|4 - With a friend|36
264|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|36
265|4-OT|4-OT|36
266|5 - Advocates or facilitates patient's participation in appropriate medical care|5 - Advocates or facilitates patient's participation in appropriate medical care|36
267|5 - At least daily|5 - At least daily|36
268|6 - Bedfast, unable to ambulate or be up in a chair.|6 - Bedfast, unable to ambulate or be up in a chair.|36
269|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|36
270|5 - Disruptive or socially inappropriate behavior|5 - Disruptive or socially inappropriate behavior|36
271|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|36
272|5 - Hypo/Hyperglycemia, diabetes out of control|5 - Hypo/Hyperglycemia, diabetes out of control|36
273|5 - More often than once daily|5 - More often than once daily|36
274|5 - Native Hawaiian or Pacific Islander|5 - Native Hawaiian or Pacific Islander|36
275|5 - None of the above|5 - None of the above|36
276|5 - One to two times per week|5 - One to two times per week|36
277|5 - Other|5 - Other|36
278|5 - Other follow-up|5 - Other follow-up|36
279|5 - Paid help|5 - Paid help|36
280|5 - Patient nonresponsive or unable to speak.|5 - Patient nonresponsive or unable to speak.|36
281|5 - Thoughts of suicide|5 - Thoughts of suicide|36
282|5 - Totally unable to use the telephone.|5 - Totally unable to use the telephone.|36
283|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|36
284|5 - Unable to take in nutrients orally or by tube feeding.|5 - Unable to take in nutrients orally or by tube feeding.|36
285|5 - Unsafe for care at home|5 - Unsafe for care at home|36
286|5 - With paid help (other than home care agency staff)|5 - With paid help (other than home care agency staff)|36
287|5 - Workers' compensation|5 - Workers' compensation|36
288|5 - Wound infection, deteriorating wound status, new lesion/ulcer|5 - Wound infection, deteriorating wound status, new lesion/ulcer|36
289|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|36
290|6 - Delusional, hallucinatory, or paranoid behavior|6 - Delusional, hallucinatory, or paranoid behavior|36
291|6 - Financial agent, power of attorney, or conservator of finance|6 - Financial agent, power of attorney, or conservator of finance|36
292|6 - GI bleeding, obstruction|6 - GI bleeding, obstruction|36
293|6 - Less often than weekly|6 - Less often than weekly|36
294|6 - Memory loss to the extent that supervision required|6 - Memory loss to the extent that supervision required|36
295|6 - None of the above feelings observed or reported|6 - None of the above feelings observed or reported|36
296|6 - Other|6 - Other|36
297|6 - Title programs (e.g., Title III, V, or XX)|6 - Title programs (e.g., Title III, V, or XX)|36
298|6 - Transferred to an inpatient facility - patient not discharged from agency|6 - Transferred to an inpatient facility - patient not discharged from agency|36
299|6 - White|6 - White|36
300|6 - With other than above|6 - With other than above|36
301|7 - Exacerbation of CHF, fluid overload, heart failure|7 - Exacerbation of CHF, fluid overload, heart failure|36
302|7 - Health care agent, conservator of person, or medical power of attorney|7 - Health care agent, conservator of person, or medical power of attorney|36
303|7 - Hypo/Hyperglycemia, diabetes out of control|7 - Hypo/Hyperglycemia, diabetes out of control|36
304|7 - None of the above|7 - None of the above|36
305|7 - None of the above behaviors demonstrated|7 - None of the above behaviors demonstrated|36
306|7 - Other government (e.g., TriCare, VA, etc.)|7 - Other government (e.g., TriCare, VA, etc.)|36
307|7 - Transferred to an inpatient facility - patient discharged from agency|7 - Transferred to an inpatient facility - patient discharged from agency|36
308|8 - Death at home|8 - Death at home|36
309|8 - GI bleeding, obstruction|8 - GI bleeding, obstruction|36
310|8 - Myocardial infarction, stroke|8 - Myocardial infarction, stroke|36
311|8 - Private insurance|8 - Private insurance|36
312|9 - Chemotherapy|9 - Chemotherapy|36
313|9 - Discharge from agency|9 - Discharge from agency|36
314|9 - Other than above reasons|9 - Other than above reasons|36
315|9 - Private HMO/managed care|9 - Private HMO/managed care|36
316|NA - No caregiver|NA - No caregiver|36
317|NA - No equipment of this type used in care.|NA - No equipment of this type used in care.|36
318|NA - No inhalant/mist medications prescribed.|NA - No inhalant/mist medications prescribed.|36
319|NA - No injectable medications prescribed.|NA - No injectable medications prescribed.|36
320|NA - No inpatient facility admission|NA - No inpatient facility admission|36
321|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|36
322|NA - No Medicaid|NA - No Medicaid|36
323|NA - No Medicare|NA - No Medicare|36
324|NA - No observable pressure ulcer or unhealed pressure ulcer|NA - No observable pressure ulcer or unhealed pressure ulcer|36
325|NA - No observable stasis ulcer|NA - No observable stasis ulcer|36
326|NA - No observable surgical wound|NA - No observable surgical wound|36
327|NA - No oral medications prescribed.|NA - No oral medications prescribed.|36
328|NA - Not applicable|NA - Not applicable|36
329|NA - Patient does not have a telephone.|NA - Patient does not have a telephone.|36
330|NA - Patient has ostomy for bowel elimination|NA - Patient has ostomy for bowel elimination|36
331|NA - Patient nonresponsive|NA - Patient nonresponsive|36
332|NA - Patient on prophylactic treatment|NA - Patient on prophylactic treatment|36
333|NA - Patient was not discharged from an inpatient facility [Go to M1016 ]|NA - Patient was not discharged from an inpatient facility [Go to M1016 ]|36
334|UK - Other unknown|UK - Other unknown|36
335|UK - Reason unknown|UK - Reason unknown|36
336|UK - Unknown|UK - Unknown|36
337|UK - Unknown or Not Available|UK - Unknown or Not Available|36
341|01 - Early|01 - Early|36
342|02 - Late|02 - Late|36
343|NA - Not Applicable. No case mix group defined for this assessment.|NA - Not Applicable. No case mix group defined for this assessment.|36
344|NA - No case mix group defined by this assessment.|NA - No case mix group defined by this assessment.|36
345|1 - Recent decline in mental, emotional, or behavioral status|1 - Recent decline in mental, emotional, or behavioral status|36
346|2 - Multiple hospitalizations (2 or more) in the past 12 months|2 - Multiple hospitalizations (2 or more) in the past 12 months|36
347|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|36
348|4 - Taking five or more medications|4 - Taking five or more medications|36
349|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|36
350|6 - Other|6 - Other|36
351|7 - None of the above|7 - None of the above|36
352|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond tho|36
353|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable without heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable wi|36
354|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious complications and death.|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious compl|36
355|3 - The patient has serious progressive conditions that could lead to death within a year.|3 - The patient has serious progressive conditions that could lead to death within a year.|36
356|UK - The patient+s situation is unknown or unclear.|UK - The patient+s situation is unknown or unclear.|36
357|1 - Yes [ Go to M1050 ]|1 - Yes [ Go to M1050 ]|36
358|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this influenza season. [ Go to M1050 ]|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this i|36
359|1 - Received from another health care provider (e.g., physician)|1 - Received from another health care provider (e.g., physician)|36
360|2 - Received from your agency previously during this year+s flu season|2 - Received from your agency previously during this year+s flu season|36
361|3 - Offered and declined|3 - Offered and declined|36
362|4 - Assessed and determined to have medical contraindication(s)|4 - Assessed and determined to have medical contraindication(s)|36
363|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|36
364|6 - Inability to obtain vaccine due to declared shortage|6 - Inability to obtain vaccine due to declared shortage|36
365|1 - Yes [ Go to M1500 at TRN; Go to M1230 at DC ]|1 - Yes [ Go to M1500 at TRN; Go to M1230 at DC ]|36
366|1 - Patient has received PPV in the past|1 - Patient has received PPV in the past|36
367|2 - Offered and declined|2 - Offered and declined|36
368|3 - Assessed and determined to have medical contraindication(s)|3 - Assessed and determined to have medical contraindication(s)|36
369|4 - Not indicated; patient does not meet age/condition guidelines for PPV|4 - Not indicated; patient does not meet age/condition guidelines for PPV|36
370|5 - None of the above|5 - None of the above|36
371|0 - Adequate: hears normal conversation without difficulty.|0 - Adequate: hears normal conversation without difficulty.|36
372|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to increase volume or speak distinctly.|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to in|36
373|2 - Severely Impaired: absence of useful hearing.|2 - Severely Impaired: absence of useful hearing.|36
374|UK - Unable to assess hearing.|UK - Unable to assess hearing.|36
375|0 - Understands: clear comprehension without cues or repetitions.|0 - Understands: clear comprehension without cues or repetitions.|36
376|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Requires cues at times to understand.|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Req|36
377|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequently requires cues to understand.|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequentl|36
378|3 - Rarely/Never Understands|3 - Rarely/Never Understands|36
379|UK - Unable to assess understanding.|UK - Unable to assess understanding.|36
380|0 - No standardized assessment conducted|0 - No standardized assessment conducted|36
381|1 - Yes, and it does not indicate severe pain|1 - Yes, and it does not indicate severe pain|36
382|2 - Yes, and it indicates severe pain|2 - Yes, and it indicates severe pain|36
383|0 - Patient has no pain|0 - Patient has no pain|36
384|1 - Patient has pain that does not interfere with activity or movement|1 - Patient has pain that does not interfere with activity or movement|36
385|2 - Less often than daily|2 - Less often than daily|36
386|3 - Daily, but not constantly|3 - Daily, but not constantly|36
387|4 - All of the time|4 - All of the time|36
388|0 - No assessment conducted [ Go to M1306 ]|0 - No assessment conducted [ Go to M1306 ]|36
389|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc., without use of standardized tool|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc.,|36
390|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|36
391|0 - No [ Go to M1322]|0 - No [ Go to M1322]|36
392|0 v Newly epithelialized|0 v Newly epithelialized|36
393|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|36
394|2 - Yes, patient has observable stasis ulcers ONLY|2 - Yes, patient has observable stasis ulcers ONLY|36
395|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable dressing) [Go to M1340]|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable|36
396|0 - No [ Go to M1350 ]|0 - No [ Go to M1350 ]|36
397|1 - Yes, patient has at least one (observable) surgical wound|1 - Yes, patient has at least one (observable) surgical wound|36
398|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1350 ]|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1350 ]|36
399|0 - Patient is not short of breath|0 - Patient is not short of breath|36
400|3 - Continuous Bi-level positive airway pressure|3 - Continuous Bi-level positive airway pressure|36
401|0 - No [ Go to M2004 at TRN; Go to M1600 at DC ]|0 - No [ Go to M2004 at TRN; Go to M1600 at DC ]|36
402|2 - Not assessed [Go to M2004 at TRN; Go to M1600 at DC ]|2 - Not assessed [Go to M2004 at TRN; Go to M1600 at DC ]|36
403|NA - Patient does not have diagnosis of heart failure [Go to M2004 at TRN; Go to M1600 at DC]|NA - Patient does not have diagnosis of heart failure [Go to M2004 at TRN; Go to M1600 at DC]|36
404|0 - No action taken|0 - No action taken|36
405|1 - Patient+s physician (or other primary care practitioner) contacted the same day|1 - Patient+s physician (or other primary care practitioner) contacted the same day|36
406|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|36
407|3 - Implement physician-ordered patient-specific established parameters for treatment|3 - Implement physician-ordered patient-specific established parameters for treatment|36
408|4 - Patient education or other clinical interventions|4 - Patient education or other clinical interventions|36
409|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequency, telehealth, etc.)|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequ|36
410|1 - Occasional stress incontinence|1 - Occasional stress incontinence|36
411|2 - During the night only|2 - During the night only|36
412|3 - During the day only|3 - During the day only|36
413|4 - During the day and night|4 - During the day and night|36
414|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|36
415|0 - Able to manage toileting hygiene and clothing management without assistance.|0 - Able to manage toileting hygiene and clothing management without assistance.|36
416|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implements are laid out for the patient.|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implemen|36
417|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|36
418|3 - Patient depends entirely upon another person to maintain toileting hygiene.|3 - Patient depends entirely upon another person to maintain toileting hygiene.|36
419|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independent|36
420|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface|36
421|0 - No multi-factor falls risk assessment conducted.|0 - No multi-factor falls risk assessment conducted.|36
422|1 - Yes, and it does not indicate a risk for falls.|1 - Yes, and it does not indicate a risk for falls.|36
423|2 - Yes, and it indicates a risk for falls.|2 - Yes, and it indicates a risk for falls.|36
424|0 - Not assessed/reviewed [ Go to M2010 ]|0 - Not assessed/reviewed [ Go to M2010 ]|36
425|1 - No problems found during review [ Go to M2010 ]|1 - No problems found during review [ Go to M2010 ]|36
426|2 - Problems found during review|2 - Problems found during review|36
427|NA - Patient is not taking any medications [ Go to M2040 ]|NA - Patient is not taking any medications [ Go to M2040 ]|36
428|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special precautions associated with all high-risk medications|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special p|36
429|NA - Patient not taking any drugs|NA - Patient not taking any drugs|36
430|2 - Able to take medication(s) at the correct times if given reminders by another person at the appropriate times|2 - Able to take medication(s) at the correct times if given reminders by another person at the appr|36
431|3 - Unable to take medication unless administered by another person.|3 - Unable to take medication unless administered by another person.|36
432|1 - At least daily|1 - At least daily|36
433|2 - Three or more times per week|2 - Three or more times per week|36
434|3 - One to two times per week|3 - One to two times per week|36
435|4 - Received, but less often than weekly|4 - Received, but less often than weekly|36
436|5 - No assistance received|5 - No assistance received|36
437|0 - No [Go to M2400]|0 - No [Go to M2400]|36
438|1 - Yes, used hospital emergency department WITHOUT hospital admission|1 - Yes, used hospital emergency department WITHOUT hospital admission|36
439|2 - Yes, used hospital emergency department WITH hospital admission|2 - Yes, used hospital emergency department WITH hospital admission|36
440|UK - Unknown [Go to M2400]|UK - Unknown [Go to M2400]|36
441|2 - Injury caused by fall|2 - Injury caused by fall|36
442|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|36
443|4 - Other respiratory problem|4 - Other respiratory problem|36
444|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|36
445|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|36
446|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|36
447|8 - Other heart disease|8 - Other heart disease|36
448|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|36
449|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|36
450|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|36
451|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|36
452|13 - Urinary tract infection|13 - Urinary tract infection|36
453|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|36
454|15 - Wound infection or deterioration|15 - Wound infection or deterioration|36
455|16 - Uncontrolled pain|16 - Uncontrolled pain|36
456|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|36
457|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|36
458|19 - Other than above reasons|19 - Other than above reasons|36
459|2 - Patient remained in the community (with formal assistive services)|2 - Patient remained in the community (with formal assistive services)|36
460|3 - Patient transferred to a noninstitutional hospice|3 - Patient transferred to a noninstitutional hospice|36
461|4 - Unknown because patient moved to a geographic location not served by this agency|4 - Unknown because patient moved to a geographic location not served by this agency|36
462|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|36
463|4 - Other respiratory problem|4 - Other respiratory problem|36
464|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|36
465|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|36
466|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|36
467|8 - Other heart disease|8 - Other heart disease|36
468|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|36
469|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|36
470|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|36
471|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|36
472|13 - Urinary tract infection|13 - Urinary tract infection|36
473|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|36
474|15 - Wound infection or deterioration|15 - Wound infection or deterioration|36
475|16 - Uncontrolled pain|16 - Uncontrolled pain|36
476|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|36
477|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|36
478|19 - Scheduled treatment or procedure|19 - Scheduled treatment or procedure|36
479|20 - Other than above reasons|20 - Other than above reasons|36
480|UK - Reason unknown [Go to M0903]|UK - Reason unknown [Go to M0903]|36
482|01 - Patient lives alone around the clock|01 - Patient lives alone around the clock|36
483|02 - Patient lives alone regular daytime|02 - Patient lives alone regular daytime|36
484|03 - Patient lives alone regular nighttime|03 - Patient lives alone regular nighttime|36
485|04 - Patient lives alone occassional/short term assistance|04 - Patient lives alone occassional/short term assistance|36
486|05 - Patient lives alone no assisstance available|05 - Patient lives alone no assisstance available|36
487|06 - Patient lives with other person(s) in the home around the clock|06 - Patient lives with other person(s) in the home around the clock|36
488|07 - Patient lives with other person(s) in the home regular daytime|07 - Patient lives with other person(s) in the home regular daytime|36
489|08 - Patient lives with other person(s) in the home regular nighttime|08 - Patient lives with other person(s) in the home regular nighttime|36
490|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|36
491|10 - Patient lives with other person(s) in the home no assistance available|10 - Patient lives with other person(s) in the home no assistance available|36
492|1 - Was present at the most recent SOC/ROC assessment|1 - Was present at the most recent SOC/ROC assessment|36
493|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|36
494|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|36
495|0 - Newly epithelialized|0 - Newly epithelialized|36
496|0 - No [ Go to M1340 ]|0 - No [ Go to M1340 ]|36
498|0 - Independent|0 - Independent|36
499|1 - Needed Some Help|1 - Needed Some Help|36
500|2 - Dependent|2 - Dependent|36
502|0 - No assistance needed in this area|0 - No assistance needed in this area|36
503|1 - Caregiver(s) currently provide assistance|1 - Caregiver(s) currently provide assistance|36
504|2 - Caregiver(s) need training/ supportive services to provide assistance|2 - Caregiver(s) need training/ supportive services to provide assistance|36
505|3 - Caregiver(s) not likely to provide assistance|3 - Caregiver(s) not likely to provide assistance|36
506|4 - Unclear if Caregiver(s) will provide assistance|4 - Unclear if Caregiver(s) will provide assistance|36
507|5 - Assistance needed, but no Caregiver(s) available|5 - Assistance needed, but no Caregiver(s) available|36
508|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will use standardized clinical guidelines accessible for all care providers to reference|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will|36
510|NA - Patient is not assessed to be at risk for falls|NA - Patient is not assessed to be at risk for falls|36
511|NA - Patient has no diagnosis or symptoms of depression|NA - Patient has no diagnosis or symptoms of depression|36
512|NA - No pain identified|NA - No pain identified|36
513|NA - Patient is not assessed to be at risk for pressure ulcers|NA - Patient is not assessed to be at risk for pressure ulcers|36
514|NA - Patient has no pressure ulcers with need for moist wound healing|NA - Patient has no pressure ulcers with need for moist wound healing|36
515|1 - Long-term nursing facility (NF)|1 - Long-term nursing facility (NF)|36
516|2 - Skilled nursing facility (SNF / TCU)|2 - Skilled nursing facility (SNF / TCU)|36
517|3 - Short stay acute hospital (IPP S)|3 - Short stay acute hospital (IPP S)|36
518|4 - Long-term care hospital (LTCH)|4 - Long-term care hospital (LTCH)|36
519|5 - Inpatient rehabilitation hospital or unit (IRF)|5 - Inpatient rehabilitation hospital or unit (IRF)|36
520|6 - Psychiatric hospital or unit|6 - Psychiatric hospital or unit|36
521|7 - Other|7 - Other|36
522|NA - Patient was not discharged from an inpatient facility [Goto M1016]|NA - Patient was not discharged from an inpatient facility [Goto M1016]|36
523|6 - Unable to participate effectively in bathing and is bathed totally by another person|6 - Unable to participate effectively in bathing and is bathed totally by another person|36
524|4 - Chairfast, unable to ambulate but is able to wheel self independently.|4 - Chairfast, unable to ambulate but is able to wheel self independently.|36
525|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask patient: "Over the last two weeks, how often have you been bothered by any of the following problems")|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask|36
526|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluation for depression.|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluat|36
527|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet criteria for further evaluation for depression.|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet|36
528|0 - Not at all  0 - 1 day|0 - Not at all  0 - 1 day|36
529|1 - Several days  2 - 6 days|1 - Several days  2 - 6 days|36
530|2 - More than half of the days  7 - 11 days|2 - More than half of the days  7 - 11 days|36
531|3 - Nearly every day  12 - 14 days|3 - Nearly every day  12 - 14 days|36
532|NA - N/A  Unable to respond|NA - N/A  Unable to respond|36
533|2 - Able to take medication(s) at the correct times if given reminders by another person based on the frequency of the injection|2 - Able to take medication(s) at the correct times if given reminders by another person based on th|36
534|3 - Unable to take injectable medication unless administered by another person.|3 - Unable to take injectable medication unless administered by another person.|36
547|NA - No clinically significant medication issues identified since the previous OASIS assessment|NA - No clinically significant medication issues identified since the previous OASIS assessment|36
552|1 - Hospital [ Go to M2430 ]|1 - Hospital [ Go to M2430 ]|36
553|2 - Rehabilitation facility [ Go to M0903 ]|2 - Rehabilitation facility [ Go to M0903 ]|36
554|3 - Nursing home [ Go to M2440 ]|3 - Nursing home [ Go to M2440 ]|36
555|4 - Hospice [ Go to M0903 ]|4 - Hospice [ Go to M0903 ]|36
557|NA - Patient is not diabetic or is bilateral amputee|NA - Patient is not diabetic or is bilateral amputee|36
558|NA - Formal multi-factor Fall Risk Assessment indicates the patient was not at risk for falls since the last OASIS assessment|NA - Formal multi-factor Fall Risk Assessment indicates the patient was not at risk for falls since|36
559|NA - Formal assessment indicates patient did not meet criteria for depression AND patient did not have diagnosis of depression since the last OASIS assessment|NA - Formal assessment indicates patient did not meet criteria for depression AND patient did not ha|36
560|NA - Formal assessment did not indicate pain since the last OASIS assessment|NA - Formal assessment did not indicate pain since the last OASIS assessment|36
561|NA - Formal assessment indicates the patient was not at risk of pressure ulcers since the last OASIS assessment|NA - Formal assessment indicates the patient was not at risk of pressure ulcers since the last OASIS|36
562|NA - Dressings that support the principles of moist wound healing not indicated for this patient's pressure ulcers OR patient has no pressure ulcers with need for moist wound healing|NA - Dressings that support the principles of moist wound healing not indicated for this patient's p|36
2|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; OR (b) Is physically, cognitively, and mentally able to prepare light meals on a regular basis but has not routinely performed light meal preparation in the past (i.e., prior to this home care admission).|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; O|37
3|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and mentally able to perform all housekeeping tasks .|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and menta|37
4|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and mentally able to do laundry and access facilities.|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and menta|37
5|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying packages OR b) Physically, cognitively, and mentally able to take care of shopping, but has not done shopping in the past (i.e., prior to this home care admission).|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying|37
6|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|37
7|0 - Able to dial numbers and answer calls appropriately and as desired.|0 - Able to dial numbers and answer calls appropriately and as desired.|37
8|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body without assistance.|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body|37
9|0 - Able to get to and from the toilet and transfer independently with or without a device.|0 - Able to get to and from the toilet and transfer independently with or without a device.|37
10|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|37
11|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible public bus.|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible p|37
12|0 - Able to independently feed self.|0 - Able to independently feed self.|37
13|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|37
14|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct times.|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct ti|37
15|0 - Able to independently transfer.|0 - Able to independently transfer.|37
16|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without rail|37
17|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings|37
18|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|37
19|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions independently.|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions indep|37
20|0 - Asymptomatic, no treatment needed at this time|0 - Asymptomatic, no treatment needed at this time|37
21|0 - Caregiver manages all tasks related to equipment completely independently.|0 - Caregiver manages all tasks related to equipment completely independently.|37
22|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations with no observable impairment.|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations w|37
23|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|37
24|0 - Life expectancy is greater than 6 months|0 - Life expectancy is greater than 6 months|37
25|0 - Never|0 - Never|37
26|0 - Patient is not short of breath|0 - Patient is not short of breath|37
27|0 - No|0 - No|37
28|0 - No emergent care services|0 - No emergent care services|37
29|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [Goto 1620]|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [Goto 1620]|37
30|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and extended or abstract conversation.|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and exte|37
31|0 - No one person|0 - No one person|37
32|0 - None of the time|0 - None of the time|37
33|0 - None, no charge for current services|0 - None, no charge for current services|37
34|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|37
35|0 - Patient does NOT have an ostomy for bowel elimination.|0 - Patient does NOT have an ostomy for bowel elimination.|37
36|0 - Patient has no pain|0 - Patient has no pain|37
37|0 - Patient manages all tasks related to equipment completely independently.|0 - Patient manages all tasks related to equipment completely independently.|37
38|0 - Poor:  little or no recovery is expected and/or further decline is imminent|0 - Poor:  little or no recovery is expected and/or further decline is imminent|37
39|0 - Timed-voiding defers incontinence|0 - Timed-voiding defers incontinence|37
40|0 - Very rarely or never has bowel incontinence|0 - Very rarely or never has bowel incontinence|37
41|0 - Zero|0 - Zero|37
42|00 - No|00 - No|37
43|01 - Yes|01 - Yes|37
44|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or mental limitations, needs assistance with heavy laundry.|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or|37
45|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the patient.|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the|37
46|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|37
47|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or supervision from another person OR c) a liquid, pureed or ground meat diet.|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or su|37
48|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|37
49|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|37
50|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independently.|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independe|37
51|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only when assisted or accompanied by another person.|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only w|37
52|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepa|37
53|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance by another person OR b) given daily reminders.|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance b|37
54|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advan|37
55|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advan|37
56|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for the deaf) and call essential numbers.|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for t|37
57|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|37
58|1 - American Indian or Alaska Native|1 - American Indian or Alaska Native|37
59|1 - Depressed mood (e.g., feeling sad, tearful)|1 - Depressed mood (e.g., feeling sad, tearful)|37
60|1 - During the night only|1 - During the night only|37
61|1 - Fully granulating|1 - Fully granulating|37
62|1 - Good/Fair:  partial to full recovery is expected|1 - Good/Fair:  partial to full recovery is expected|37
63|1 - Good:  marked improvement in functional status is expected|1 - Good:  marked improvement in functional status is expected|37
64|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|37
65|1 - Smoking|1 - Smoking|37
66|1 - Hospital|1 - Hospital|37
67|1 - Hospital emergency room (includes 23-hour holding)|1 - Hospital emergency room (includes 23-hour holding)|37
68|1 - Hospitalization for EMERGENT (unscheduled) care|1 - Hospitalization for EMERGENT (unscheduled) care|37
69|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepared solutions), patient is able to manage all other aspects of equipment.|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepar|37
70|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|37
71|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|37
72|1 - In new or complex situations only|1 - In new or complex situations only|37
73|1 - Intravenous or infusion therapy (excludes TPN)|1 - Intravenous or infusion therapy (excludes TPN)|37
74|1 - Less often than daily|1 - Less often than daily|37
75|1 - Less than once a month|1 - Less than once a month|37
76|1 - Less than once weekly|1 - Less than once weekly|37
77|1 - Life expectancy is 6 months or fewer|1 - Life expectancy is 6 months or fewer|37
78|1 - Lives alone|1 - Lives alone|37
79|1 - Male|1 - Male|37
80|1 - Medicare (traditional fee-for-service)|1 - Medicare (traditional fee-for-service)|37
81|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of past 24 hours, significant memory loss so that supervision is required|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of pas|37
82|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors in word choice, grammar or speech intelligibility, needs minimal prompting or assistance).|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors i|37
83|1 - No assistance or services received|1 - No assistance or services received|37
84|1 - One|1 - One|37
85|1 - Oxygen (intermittent or continuous)|1 - Oxygen (intermittent or continuous)|37
86|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, and the surrounding layout, can count fingers at arm's length.|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, a|37
87|1 - Patient is incontinent|1 - Patient is incontinent|37
88|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|37
89|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical or treatment regimen.|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical|37
90|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient/couple/significant other)|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient|37
91|1 - Relatives, friends, or neighbors living outside the home|1 - Relatives, friends, or neighbors living outside the home|37
92|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions.|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions|37
93|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independentl|37
94|1 - Several times during day and night|1 - Several times during day and night|37
95|1 - Spouse or significant other|1 - Spouse or significant other|37
96|1 - Stage 1|1 - Stage 1|37
97|1 - Start of care - further visits planned|1 - Start of care - further visits planned|37
98|1 - Symptoms well controlled with current therapy|1 - Symptoms well controlled with current therapy|37
99|1 - Therapy services|1 - Therapy services|37
100|1 - Able to transfer with minimal human assistance or with use of an assistive device.|1 - Able to transfer with minimal human assistance or with use of an assistive device.|37
101|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitations.|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitatio|37
102|1 - Urinary incontinence|1 - Urinary incontinence|37
103|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and transfer.|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and|37
104|1 - When walking more than 20 feet, climbing stairs|1 - When walking more than 20 feet, climbing stairs|37
105|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary conversation. May need occasional repetition, extra time, or louder voice.|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary c|37
106|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting in and out of tub/shower|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting|37
107|1 - Yes|1 - Yes|37
108|1-RN|1-RN|37
109|10 - Discharge from agency - no visits completed after start/resumption of care assessment|10 - Discharge from agency - no visits completed after start/resumption of care assessment|37
110|10 - Scheduled surgical procedure|10 - Scheduled surgical procedure|37
111|10 - Self-pay|10 - Self-pay|37
112|11 - Other|11 - Other|37
113|11 - Urinary tract infection|11 - Urinary tract infection|37
114|12 - IV catheter-related infection|12 - IV catheter-related infection|37
115|13 - Deep vein thrombosis, pulmonary embolus|13 - Deep vein thrombosis, pulmonary embolus|37
116|14 - Uncontrolled pain|14 - Uncontrolled pain|37
117|15 - Psychotic episode|15 - Psychotic episode|37
118|16 - Other than above reasons|16 - Other than above reasons|37
119|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing calls.|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing|37
120|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another person.|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another pers|37
121|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface a|37
122|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for intermittent supervision or encouragement or reminders, OR (b) to get in and out of the shower or tub, OR (c) for washing difficult to reach areas.|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for inter|37
123|2 - Asian|2 - Asian|37
124|2 - Caregiver requires considerable assistance from another person to manage equipment, but independently completes significant portions of task.|2 - Caregiver requires considerable assistance from another person to manage equipment, but independ|37
125|2 - Daily, but not constantly|2 - Daily, but not constantly|37
126|2 - Daughter or son|2 - Daughter or son|37
127|2 - Doctor's office emergency visit/house call|2 - Doctor's office emergency visit/house call|37
128|2 - During the day and night|2 - During the day and night|37
129|2 - Early/partial granulation|2 - Early/partial granulation|37
130|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors in word choice, organization or speech intelligibility). Speaks in phrases or short sentences.|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors|37
131|2 - Family member's residence|2 - Family member's residence|37
132|2 - Female|2 - Female|37
133|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conversation, needs frequent prompting or assistance.|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conver|37
134|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|37
135|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|37
136|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately stop activities, jeopardizes safety through actions|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately st|37
137|2 - Indwelling/suprapubic catheter|2 - Indwelling/suprapubic catheter|37
138|2 - Injury caused by fall|2 - Injury caused by fall|37
139|2 - Medicare (HMO/managed care/Advantage plan)|2 - Medicare (HMO/managed care/Advantage plan)|37
140|2 - Nausea, dehydration, malnutrition, constipation, impaction|2 - Nausea, dehydration, malnutrition, constipation, impaction|37
141|2 - Obesity|2 - Obesity|37
142|2 - On awakening or at night only|2 - On awakening or at night only|37
143|2 - Once a month|2 - Once a month|37
144|2 - One to three times weekly|2 - One to three times weekly|37
145|2 - Parenteral nutrition (TPN or lipids)|2 - Parenteral nutrition (TPN or lipids)|37
146|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic) [ Go to M1620]|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic) [ Go|37
147|2 - Patient requires considerable assistance from another person to manage equipment, but independently completes portions of the task.|2 - Patient requires considerable assistance from another person to manage equipment, but independen|37
148|2 - Patient transferred to a noninstitutional hospice|2 - Patient transferred to a noninstitutional hospice|37
149|2 - Person residing in the home (EXCLUDING paid help)|2 - Person residing in the home (EXCLUDING paid help)|37
150|2 - Rehabilitation facility|2 - Rehabilitation facility|37
151|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifting of attention) or consistently requires low stimulus environment due to distractibility.|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifti|37
152|2 - Respite care|2 - Respite care|37
153|2 - Sense of failure or self reproach|2 - Sense of failure or self reproach|37
154|2 - Several times during day|2 - Several times during day|37
155|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonresponsive.|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonrespons|37
156|2 - Someone must assist the patient to groom self.|2 - Someone must assist the patient to groom self.|37
157|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|37
158|2 - Someone must help the patient put on upper body clothing.|2 - Someone must help the patient put on upper body clothing.|37
159|2 - Stage 2|2 - Stage 2|37
160|2 - Start of care - no further visits planned|2 - Start of care - no further visits planned|37
161|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitoring|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitori|37
162|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment regimen.|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment re|37
163|2 - Two|2 - Two|37
164|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistance due to cognitive or mental limitation.|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistanc|37
165|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|37
166|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assistance).|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assis|37
167|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home delivery.|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home deli|37
168|2 - Unable to prepare any light meals or reheat any delivered meals.|2 - Unable to prepare any light meals or reheat any delivered meals.|37
169|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|37
170|2 - UNABLE to take injectable medications unless administered by someone else.|2 - UNABLE to take injectable medications unless administered by someone else.|37
171|2 - UNABLE to take medication unless administered by someone else.|2 - UNABLE to take medication unless administered by someone else.|37
172|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|37
173|2 - Ventilator (continually or at night)|2 - Ventilator (continually or at night)|37
174|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less than 20 feet)|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less th|37
175|2 - With spouse or significant other|2 - With spouse or significant other|37
176|2 - Yes, assistance or services provided by family or friends|2 - Yes, assistance or services provided by family or friends|37
177|2-PT|2-PT|37
178|3 - Able to answer the telephone only some of the time or is able to carry on only a limited conversation.|3 - Able to answer the telephone only some of the time or is able to carry on only a limited convers|37
179|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube or gastrostomy.|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube|37
180|3 - Alcohol dependency|3 - Alcohol dependency|37
181|3 - All of the time|3 - All of the time|37
182|3 - Black or African-American|3 - Black or African-American|37
183|3 - Boarding home or rented room|3 - Boarding home or rented room|37
184|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment, clean/store/dispose of equipment or supplies).|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment,|37
185|3 -Able to walk only with the supervision or assistance of another person at all times.|3 -Able to walk only with the supervision or assistance of another person at all times.|37
186|3 - Continuous / Bi-level positive airway pressure|3 - Continuous / Bi-level positive airway pressure|37
187|3 - During the day and evening, but not constantly|3 - During the day and evening, but not constantly|37
188|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the alimentary canal)|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the|37
189|3 - Environmental support (e.g., housing, home maintenance)|3 - Environmental support (e.g., housing, home maintenance)|37
190|3 - Four to six times weekly|3 - Four to six times weekly|37
191|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessing by listener.  Speech limited to single words or short phrases.|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessin|37
192|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires multiple repetitions, restatements, demonstrations, additional time.|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires m|37
193|3 - Hopelessness|3 - Hopelessness|37
194|3 - Hospice care|3 - Hospice care|37
195|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|37
196|3 - Injury caused by fall or accident at home|3 - Injury caused by fall or accident at home|37
197|3 - Intractable pain|3 - Intractable pain|37
198|3 - Medicaid (traditional fee-for-service)|3 - Medicaid (traditional fee-for-service)|37
199|3 - Needs someone to do all shopping and errands.|3 - Needs someone to do all shopping and errands.|37
200|3 - Not healing|3 - Not healing|37
201|3 - Nursing home|3 - Nursing home|37
202|3 - Once daily|3 - Once daily|37
203|3 - Other family member|3 - Other family member|37
204|3 - Outpatient department/clinic emergency (includes urgicenter sites)|3 - Outpatient department/clinic emergency (includes urgicenter sites)|37
205|3 - Paid help|3 - Paid help|37
206|3 - Able to participate in bathing self in shower or tub, but requires presence of another person throughout the bath for assistance or supervision.|3 - Able to participate in bathing self in shower or tub, but requires presence of another person th|37
207|3 - Patient depends entirely upon another person to dress lower body.|3 - Patient depends entirely upon another person to dress lower body.|37
208|3 - Patient depends entirely upon another person to dress the upper body.|3 - Patient depends entirely upon another person to dress the upper body.|37
209|3 - Patient depends entirely upon someone else for grooming needs.|3 - Patient depends entirely upon someone else for grooming needs.|37
210|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone else to manage the equipment.|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone|37
211|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable to shift attention and recall directions more than half the time.|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable|37
212|3 - Respiratory problems (SOB, infection, obstruction)|3 - Respiratory problems (SOB, infection, obstruction)|37
213|3 - Resumption of care (after inpatient stay)|3 - Resumption of care (after inpatient stay)|37
214|3 - Several times each month|3 - Several times each month|37
215|3 - Skilled Nursing Facility|3 - Skilled Nursing Facility|37
216|3 - Stage 3|3 - Stage 3|37
217|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|37
218|3 - Three|3 - Three|37
219|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person throughout the process.|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person through|37
220|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal independently.|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal indep|37
221|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person.|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person|37
222|3 - Unknown because patient moved to a geographic location not served by this agency|3 - Unknown because patient moved to a geographic location not served by this agency|37
223|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|37
224|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|37
225|3 - With other family member|3 - With other family member|37
226|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home health services, homemaker assistance, transportation assistance, assisted living, board and care)|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home h|37
227|3-SLP/ST|3-SLP/ST|37
228|4 - At rest (during day or night)|4 - At rest (during day or night)|37
229|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|37
230|4 - Board and care or assisted living facility|4 - Board and care or assisted living facility|37
231|4 - Caregiver is completely dependent on someone else to manage all equipment.|4 - Caregiver is completely dependent on someone else to manage all equipment.|37
232|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|37
233|4 - Constantly|4 - Constantly|37
234|4 - Drug dependency|4 - Drug dependency|37
235|4 - Four or more|4 - Four or more|37
236|4 - Friend or neighbor or community or church member|4 - Friend or neighbor or community or church member|37
237|4 - Hispanic or Latino|4 - Hispanic or Latino|37
238|4 - Hospice|4 - Hospice|37
239|4 - Impaired decision-making|4 - Impaired decision-making|37
240|4 - Is totally dependent in toileting.|4 - Is totally dependent in toileting.|37
241|4 - Medicaid (HMO/managed care)|4 - Medicaid (HMO/managed care)|37
242|4 - None of the above|4 - None of the above|37
243|4 - Nursing home|4 - Nursing home|37
244|4 - On a daily basis|4 - On a daily basis|37
245|4 - Patient is completely dependent on someone else to manage all equipment.|4 - Patient is completely dependent on someone else to manage all equipment.|37
246|4 - Permanent placement|4 - Permanent placement|37
247|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, punches, dangerous maneuvers w/ wheelchair or other objects)|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, pu|37
248|4 - Psychosocial support (e.g., socialization, companionship, recreation)|4 - Psychosocial support (e.g., socialization, companionship, recreation)|37
249|4 - Recertification (follow-up) reassessment|4 - Recertification (follow-up) reassessment|37
250|4 - Recurrent thoughts of death|4 - Recurrent thoughts of death|37
251|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruction)|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruc|37
252|4 - Several times a week|4 - Several times a week|37
253|4 - Stage 4|4 - Stage 4|37
254|4 - Symptoms poorly controlled, history of rehospitalizations|4 - Symptoms poorly controlled, history of rehospitalizations|37
255|4 - Three or more times per week|4 - Three or more times per week|37
256|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetative state, or delirium.|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetati|37
257|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|37
258|4 - Unable to effectively participate in any housekeeping tasks.|4 - Unable to effectively participate in any housekeeping tasks.|37
259|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or unresponsive (e.g., speech is nonsensical or unintelligible).|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or u|37
260|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonresponsive.|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonr|37
261|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostomy.|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostom|37
262|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of devices at the sink, in chair, or on commode|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of|37
263|4 - With a friend|4 - With a friend|37
264|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|37
265|4-OT|4-OT|37
266|5 - Advocates or facilitates patient's participation in appropriate medical care|5 - Advocates or facilitates patient's participation in appropriate medical care|37
267|5 - At least daily|5 - At least daily|37
268|6 - Bedfast, unable to ambulate or be up in a chair.|6 - Bedfast, unable to ambulate or be up in a chair.|37
269|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|37
270|5 - Disruptive or socially inappropriate behavior|5 - Disruptive or socially inappropriate behavior|37
271|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|37
272|5 - Hypo/Hyperglycemia, diabetes out of control|5 - Hypo/Hyperglycemia, diabetes out of control|37
273|5 - More often than once daily|5 - More often than once daily|37
274|5 - Native Hawaiian or Pacific Islander|5 - Native Hawaiian or Pacific Islander|37
275|5 - None of the above|5 - None of the above|37
276|5 - One to two times per week|5 - One to two times per week|37
277|5 - Other|5 - Other|37
278|5 - Other follow-up|5 - Other follow-up|37
279|5 - Paid help|5 - Paid help|37
280|5 - Patient nonresponsive or unable to speak.|5 - Patient nonresponsive or unable to speak.|37
281|5 - Thoughts of suicide|5 - Thoughts of suicide|37
282|5 - Totally unable to use the telephone.|5 - Totally unable to use the telephone.|37
283|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|37
284|5 - Unable to take in nutrients orally or by tube feeding.|5 - Unable to take in nutrients orally or by tube feeding.|37
285|5 - Unsafe for care at home|5 - Unsafe for care at home|37
286|5 - With paid help (other than home care agency staff)|5 - With paid help (other than home care agency staff)|37
287|5 - Workers' compensation|5 - Workers' compensation|37
288|5 - Wound infection, deteriorating wound status, new lesion/ulcer|5 - Wound infection, deteriorating wound status, new lesion/ulcer|37
289|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|37
290|6 - Delusional, hallucinatory, or paranoid behavior|6 - Delusional, hallucinatory, or paranoid behavior|37
291|6 - Financial agent, power of attorney, or conservator of finance|6 - Financial agent, power of attorney, or conservator of finance|37
292|6 - GI bleeding, obstruction|6 - GI bleeding, obstruction|37
293|6 - Less often than weekly|6 - Less often than weekly|37
294|6 - Memory loss to the extent that supervision required|6 - Memory loss to the extent that supervision required|37
295|6 - None of the above feelings observed or reported|6 - None of the above feelings observed or reported|37
296|6 - Other|6 - Other|37
297|6 - Title programs (e.g., Title III, V, or XX)|6 - Title programs (e.g., Title III, V, or XX)|37
298|6 - Transferred to an inpatient facility - patient not discharged from agency|6 - Transferred to an inpatient facility - patient not discharged from agency|37
299|6 - White|6 - White|37
300|6 - With other than above|6 - With other than above|37
301|7 - Exacerbation of CHF, fluid overload, heart failure|7 - Exacerbation of CHF, fluid overload, heart failure|37
302|7 - Health care agent, conservator of person, or medical power of attorney|7 - Health care agent, conservator of person, or medical power of attorney|37
303|7 - Hypo/Hyperglycemia, diabetes out of control|7 - Hypo/Hyperglycemia, diabetes out of control|37
304|7 - None of the above|7 - None of the above|37
305|7 - None of the above behaviors demonstrated|7 - None of the above behaviors demonstrated|37
306|7 - Other government (e.g., TriCare, VA, etc.)|7 - Other government (e.g., TriCare, VA, etc.)|37
307|7 - Transferred to an inpatient facility - patient discharged from agency|7 - Transferred to an inpatient facility - patient discharged from agency|37
308|8 - Death at home|8 - Death at home|37
309|8 - GI bleeding, obstruction|8 - GI bleeding, obstruction|37
310|8 - Myocardial infarction, stroke|8 - Myocardial infarction, stroke|37
311|8 - Private insurance|8 - Private insurance|37
312|9 - Chemotherapy|9 - Chemotherapy|37
313|9 - Discharge from agency|9 - Discharge from agency|37
314|9 - Other than above reasons|9 - Other than above reasons|37
315|9 - Private HMO/managed care|9 - Private HMO/managed care|37
316|NA - No caregiver|NA - No caregiver|37
317|NA - No equipment of this type used in care.|NA - No equipment of this type used in care.|37
318|NA - No inhalant/mist medications prescribed.|NA - No inhalant/mist medications prescribed.|37
319|NA - No injectable medications prescribed.|NA - No injectable medications prescribed.|37
320|NA - No inpatient facility admission|NA - No inpatient facility admission|37
321|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|37
322|NA - No Medicaid|NA - No Medicaid|37
323|NA - No Medicare|NA - No Medicare|37
324|NA - No observable pressure ulcer or unhealed pressure ulcer|NA - No observable pressure ulcer or unhealed pressure ulcer|37
325|NA - No observable stasis ulcer|NA - No observable stasis ulcer|37
326|NA - No observable surgical wound|NA - No observable surgical wound|37
327|NA - No oral medications prescribed.|NA - No oral medications prescribed.|37
328|NA - Not applicable|NA - Not applicable|37
329|NA - Patient does not have a telephone.|NA - Patient does not have a telephone.|37
330|NA - Patient has ostomy for bowel elimination|NA - Patient has ostomy for bowel elimination|37
331|NA - Patient nonresponsive|NA - Patient nonresponsive|37
332|NA - Patient on prophylactic treatment|NA - Patient on prophylactic treatment|37
333|NA - Patient was not discharged from an inpatient facility [Go to M1016 ]|NA - Patient was not discharged from an inpatient facility [Go to M1016 ]|37
334|UK - Other unknown|UK - Other unknown|37
335|UK - Reason unknown|UK - Reason unknown|37
336|UK - Unknown|UK - Unknown|37
337|UK - Unknown or Not Available|UK - Unknown or Not Available|37
341|01 - Early|01 - Early|37
342|02 - Late|02 - Late|37
343|NA - Not Applicable. No case mix group defined for this assessment.|NA - Not Applicable. No case mix group defined for this assessment.|37
344|NA - No case mix group defined by this assessment.|NA - No case mix group defined by this assessment.|37
345|1 - Recent decline in mental, emotional, or behavioral status|1 - Recent decline in mental, emotional, or behavioral status|37
346|2 - Multiple hospitalizations (2 or more) in the past 12 months|2 - Multiple hospitalizations (2 or more) in the past 12 months|37
347|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|37
348|4 - Taking five or more medications|4 - Taking five or more medications|37
349|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|37
350|6 - Other|6 - Other|37
351|7 - None of the above|7 - None of the above|37
352|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond tho|37
353|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable without heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable wi|37
354|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious complications and death.|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious compl|37
355|3 - The patient has serious progressive conditions that could lead to death within a year.|3 - The patient has serious progressive conditions that could lead to death within a year.|37
356|UK - The patient+s situation is unknown or unclear.|UK - The patient+s situation is unknown or unclear.|37
357|1 - Yes [ Go to M1050 ]|1 - Yes [ Go to M1050 ]|37
358|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this influenza season. [ Go to M1050 ]|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this i|37
359|1 - Received from another health care provider (e.g., physician)|1 - Received from another health care provider (e.g., physician)|37
360|2 - Received from your agency previously during this year+s flu season|2 - Received from your agency previously during this year+s flu season|37
361|3 - Offered and declined|3 - Offered and declined|37
362|4 - Assessed and determined to have medical contraindication(s)|4 - Assessed and determined to have medical contraindication(s)|37
363|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|37
364|6 - Inability to obtain vaccine due to declared shortage|6 - Inability to obtain vaccine due to declared shortage|37
365|1 - Yes [ Go to M1500 at TRN; Go to M1230 at DC ]|1 - Yes [ Go to M1500 at TRN; Go to M1230 at DC ]|37
366|1 - Patient has received PPV in the past|1 - Patient has received PPV in the past|37
367|2 - Offered and declined|2 - Offered and declined|37
368|3 - Assessed and determined to have medical contraindication(s)|3 - Assessed and determined to have medical contraindication(s)|37
369|4 - Not indicated; patient does not meet age/condition guidelines for PPV|4 - Not indicated; patient does not meet age/condition guidelines for PPV|37
370|5 - None of the above|5 - None of the above|37
371|0 - Adequate: hears normal conversation without difficulty.|0 - Adequate: hears normal conversation without difficulty.|37
372|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to increase volume or speak distinctly.|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to in|37
373|2 - Severely Impaired: absence of useful hearing.|2 - Severely Impaired: absence of useful hearing.|37
374|UK - Unable to assess hearing.|UK - Unable to assess hearing.|37
375|0 - Understands: clear comprehension without cues or repetitions.|0 - Understands: clear comprehension without cues or repetitions.|37
376|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Requires cues at times to understand.|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Req|37
377|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequently requires cues to understand.|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequentl|37
378|3 - Rarely/Never Understands|3 - Rarely/Never Understands|37
379|UK - Unable to assess understanding.|UK - Unable to assess understanding.|37
380|0 - No standardized assessment conducted|0 - No standardized assessment conducted|37
381|1 - Yes, and it does not indicate severe pain|1 - Yes, and it does not indicate severe pain|37
382|2 - Yes, and it indicates severe pain|2 - Yes, and it indicates severe pain|37
383|0 - Patient has no pain|0 - Patient has no pain|37
384|1 - Patient has pain that does not interfere with activity or movement|1 - Patient has pain that does not interfere with activity or movement|37
385|2 - Less often than daily|2 - Less often than daily|37
386|3 - Daily, but not constantly|3 - Daily, but not constantly|37
387|4 - All of the time|4 - All of the time|37
388|0 - No assessment conducted [ Go to M1306 ]|0 - No assessment conducted [ Go to M1306 ]|37
389|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc., without use of standardized tool|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc.,|37
390|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|37
391|0 - No [ Go to M1322]|0 - No [ Go to M1322]|37
392|0 v Newly epithelialized|0 v Newly epithelialized|37
393|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|37
394|2 - Yes, patient has observable stasis ulcers ONLY|2 - Yes, patient has observable stasis ulcers ONLY|37
395|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable dressing) [Go to M1340]|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable|37
396|0 - No [ Go to M1350 ]|0 - No [ Go to M1350 ]|37
397|1 - Yes, patient has at least one (observable) surgical wound|1 - Yes, patient has at least one (observable) surgical wound|37
398|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1350 ]|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1350 ]|37
399|0 - Patient is not short of breath|0 - Patient is not short of breath|37
400|3 - Continuous Bi-level positive airway pressure|3 - Continuous Bi-level positive airway pressure|37
401|0 - No [ Go to M2004 at TRN; Go to M1600 at DC ]|0 - No [ Go to M2004 at TRN; Go to M1600 at DC ]|37
402|2 - Not assessed [Go to M2004 at TRN; Go to M1600 at DC ]|2 - Not assessed [Go to M2004 at TRN; Go to M1600 at DC ]|37
403|NA - Patient does not have diagnosis of heart failure [Go to M2004 at TRN; Go to M1600 at DC]|NA - Patient does not have diagnosis of heart failure [Go to M2004 at TRN; Go to M1600 at DC]|37
404|0 - No action taken|0 - No action taken|37
405|1 - Patient+s physician (or other primary care practitioner) contacted the same day|1 - Patient+s physician (or other primary care practitioner) contacted the same day|37
406|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|37
407|3 - Implement physician-ordered patient-specific established parameters for treatment|3 - Implement physician-ordered patient-specific established parameters for treatment|37
408|4 - Patient education or other clinical interventions|4 - Patient education or other clinical interventions|37
409|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequency, telehealth, etc.)|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequ|37
410|1 - Occasional stress incontinence|1 - Occasional stress incontinence|37
411|2 - During the night only|2 - During the night only|37
412|3 - During the day only|3 - During the day only|37
413|4 - During the day and night|4 - During the day and night|37
414|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|37
415|0 - Able to manage toileting hygiene and clothing management without assistance.|0 - Able to manage toileting hygiene and clothing management without assistance.|37
416|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implements are laid out for the patient.|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implemen|37
417|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|37
418|3 - Patient depends entirely upon another person to maintain toileting hygiene.|3 - Patient depends entirely upon another person to maintain toileting hygiene.|37
419|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independent|37
420|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface|37
421|0 - No multi-factor falls risk assessment conducted.|0 - No multi-factor falls risk assessment conducted.|37
422|1 - Yes, and it does not indicate a risk for falls.|1 - Yes, and it does not indicate a risk for falls.|37
423|2 - Yes, and it indicates a risk for falls.|2 - Yes, and it indicates a risk for falls.|37
424|0 - Not assessed/reviewed [ Go to M2010 ]|0 - Not assessed/reviewed [ Go to M2010 ]|37
425|1 - No problems found during review [ Go to M2010 ]|1 - No problems found during review [ Go to M2010 ]|37
426|2 - Problems found during review|2 - Problems found during review|37
427|NA - Patient is not taking any medications [ Go to M2040 ]|NA - Patient is not taking any medications [ Go to M2040 ]|37
428|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special precautions associated with all high-risk medications|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special p|37
429|NA - Patient not taking any drugs|NA - Patient not taking any drugs|37
430|2 - Able to take medication(s) at the correct times if given reminders by another person at the appropriate times|2 - Able to take medication(s) at the correct times if given reminders by another person at the appr|37
431|3 - Unable to take medication unless administered by another person.|3 - Unable to take medication unless administered by another person.|37
432|1 - At least daily|1 - At least daily|37
433|2 - Three or more times per week|2 - Three or more times per week|37
434|3 - One to two times per week|3 - One to two times per week|37
435|4 - Received, but less often than weekly|4 - Received, but less often than weekly|37
436|5 - No assistance received|5 - No assistance received|37
437|0 - No [Go to M2400]|0 - No [Go to M2400]|37
438|1 - Yes, used hospital emergency department WITHOUT hospital admission|1 - Yes, used hospital emergency department WITHOUT hospital admission|37
439|2 - Yes, used hospital emergency department WITH hospital admission|2 - Yes, used hospital emergency department WITH hospital admission|37
440|UK - Unknown [Go to M2400]|UK - Unknown [Go to M2400]|37
441|2 - Injury caused by fall|2 - Injury caused by fall|37
442|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|37
443|4 - Other respiratory problem|4 - Other respiratory problem|37
444|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|37
445|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|37
446|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|37
447|8 - Other heart disease|8 - Other heart disease|37
448|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|37
449|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|37
450|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|37
451|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|37
452|13 - Urinary tract infection|13 - Urinary tract infection|37
453|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|37
454|15 - Wound infection or deterioration|15 - Wound infection or deterioration|37
455|16 - Uncontrolled pain|16 - Uncontrolled pain|37
456|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|37
457|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|37
458|19 - Other than above reasons|19 - Other than above reasons|37
459|2 - Patient remained in the community (with formal assistive services)|2 - Patient remained in the community (with formal assistive services)|37
460|3 - Patient transferred to a noninstitutional hospice|3 - Patient transferred to a noninstitutional hospice|37
461|4 - Unknown because patient moved to a geographic location not served by this agency|4 - Unknown because patient moved to a geographic location not served by this agency|37
462|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|37
463|4 - Other respiratory problem|4 - Other respiratory problem|37
464|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|37
465|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|37
466|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|37
467|8 - Other heart disease|8 - Other heart disease|37
468|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|37
469|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|37
470|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|37
471|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|37
472|13 - Urinary tract infection|13 - Urinary tract infection|37
473|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|37
474|15 - Wound infection or deterioration|15 - Wound infection or deterioration|37
475|16 - Uncontrolled pain|16 - Uncontrolled pain|37
476|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|37
477|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|37
478|19 - Scheduled treatment or procedure|19 - Scheduled treatment or procedure|37
479|20 - Other than above reasons|20 - Other than above reasons|37
480|UK - Reason unknown [Go to M0903]|UK - Reason unknown [Go to M0903]|37
482|01 - Patient lives alone around the clock|01 - Patient lives alone around the clock|37
483|02 - Patient lives alone regular daytime|02 - Patient lives alone regular daytime|37
484|03 - Patient lives alone regular nighttime|03 - Patient lives alone regular nighttime|37
485|04 - Patient lives alone occassional/short term assistance|04 - Patient lives alone occassional/short term assistance|37
486|05 - Patient lives alone no assisstance available|05 - Patient lives alone no assisstance available|37
487|06 - Patient lives with other person(s) in the home around the clock|06 - Patient lives with other person(s) in the home around the clock|37
488|07 - Patient lives with other person(s) in the home regular daytime|07 - Patient lives with other person(s) in the home regular daytime|37
489|08 - Patient lives with other person(s) in the home regular nighttime|08 - Patient lives with other person(s) in the home regular nighttime|37
490|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|37
491|10 - Patient lives with other person(s) in the home no assistance available|10 - Patient lives with other person(s) in the home no assistance available|37
492|1 - Was present at the most recent SOC/ROC assessment|1 - Was present at the most recent SOC/ROC assessment|37
493|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|37
494|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|37
495|0 - Newly epithelialized|0 - Newly epithelialized|37
496|0 - No [ Go to M1340 ]|0 - No [ Go to M1340 ]|37
498|0 - Independent|0 - Independent|37
499|1 - Needed Some Help|1 - Needed Some Help|37
500|2 - Dependent|2 - Dependent|37
502|0 - No assistance needed in this area|0 - No assistance needed in this area|37
503|1 - Caregiver(s) currently provide assistance|1 - Caregiver(s) currently provide assistance|37
504|2 - Caregiver(s) need training/ supportive services to provide assistance|2 - Caregiver(s) need training/ supportive services to provide assistance|37
505|3 - Caregiver(s) not likely to provide assistance|3 - Caregiver(s) not likely to provide assistance|37
506|4 - Unclear if Caregiver(s) will provide assistance|4 - Unclear if Caregiver(s) will provide assistance|37
507|5 - Assistance needed, but no Caregiver(s) available|5 - Assistance needed, but no Caregiver(s) available|37
508|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will use standardized clinical guidelines accessible for all care providers to reference|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will|37
510|NA - Patient is not assessed to be at risk for falls|NA - Patient is not assessed to be at risk for falls|37
511|NA - Patient has no diagnosis or symptoms of depression|NA - Patient has no diagnosis or symptoms of depression|37
512|NA - No pain identified|NA - No pain identified|37
513|NA - Patient is not assessed to be at risk for pressure ulcers|NA - Patient is not assessed to be at risk for pressure ulcers|37
514|NA - Patient has no pressure ulcers with need for moist wound healing|NA - Patient has no pressure ulcers with need for moist wound healing|37
515|1 - Long-term nursing facility (NF)|1 - Long-term nursing facility (NF)|37
516|2 - Skilled nursing facility (SNF / TCU)|2 - Skilled nursing facility (SNF / TCU)|37
517|3 - Short stay acute hospital (IPP S)|3 - Short stay acute hospital (IPP S)|37
518|4 - Long-term care hospital (LTCH)|4 - Long-term care hospital (LTCH)|37
519|5 - Inpatient rehabilitation hospital or unit (IRF)|5 - Inpatient rehabilitation hospital or unit (IRF)|37
520|6 - Psychiatric hospital or unit|6 - Psychiatric hospital or unit|37
521|7 - Other|7 - Other|37
522|NA - Patient was not discharged from an inpatient facility [Goto M1016]|NA - Patient was not discharged from an inpatient facility [Goto M1016]|37
523|6 - Unable to participate effectively in bathing and is bathed totally by another person|6 - Unable to participate effectively in bathing and is bathed totally by another person|37
524|4 - Chairfast, unable to ambulate but is able to wheel self independently.|4 - Chairfast, unable to ambulate but is able to wheel self independently.|37
525|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask patient: "Over the last two weeks, how often have you been bothered by any of the following problems")|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask|37
526|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluation for depression.|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluat|37
527|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet criteria for further evaluation for depression.|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet|37
528|0 - Not at all  0 - 1 day|0 - Not at all  0 - 1 day|37
529|1 - Several days  2 - 6 days|1 - Several days  2 - 6 days|37
530|2 - More than half of the days  7 - 11 days|2 - More than half of the days  7 - 11 days|37
531|3 - Nearly every day  12 - 14 days|3 - Nearly every day  12 - 14 days|37
532|NA - N/A  Unable to respond|NA - N/A  Unable to respond|37
533|2 - Able to take medication(s) at the correct times if given reminders by another person based on the frequency of the injection|2 - Able to take medication(s) at the correct times if given reminders by another person based on th|37
534|3 - Unable to take injectable medication unless administered by another person.|3 - Unable to take injectable medication unless administered by another person.|37
547|NA - No clinically significant medication issues identified since the previous OASIS assessment|NA - No clinically significant medication issues identified since the previous OASIS assessment|37
552|1 - Hospital [ Go to M2430 ]|1 - Hospital [ Go to M2430 ]|37
553|2 - Rehabilitation facility [ Go to M0903 ]|2 - Rehabilitation facility [ Go to M0903 ]|37
554|3 - Nursing home [ Go to M2440 ]|3 - Nursing home [ Go to M2440 ]|37
555|4 - Hospice [ Go to M0903 ]|4 - Hospice [ Go to M0903 ]|37
564|NA - Patient is not diabetic or is bilateral amputee|NA - Patient is not diabetic or is bilateral amputee|37
565|NA - Formal multi-factor Fall Risk Assessment indicates the patient was not at risk for falls since the last OASIS assessment|NA - Formal multi-factor Fall Risk Assessment indicates the patient was not at risk for falls since|37
566|NA - Formal assessment indicates patient did not meet criteria for depression AND patient did not have diagnosis of depression since the last OASIS assessment|NA - Formal assessment indicates patient did not meet criteria for depression AND patient did not ha|37
567|NA - Formal assessment did not indicate pain since the last OASIS assessment|NA - Formal assessment did not indicate pain since the last OASIS assessment|37
568|NA - Formal assessment indicates the patient was not at risk of pressure ulcers since the last OASIS assessment|NA - Formal assessment indicates the patient was not at risk of pressure ulcers since the last OASIS|37
569|NA - Dressings that support the principles of moist wound healing not indicated for this patient's pressure ulcers OR patient has no pressure ulcers with need for moist wound healing|NA - Dressings that support the principles of moist wound healing not indicated for this patient's p|37
2|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; OR (b) Is physically, cognitively, and mentally able to prepare light meals on a regular basis but has not routinely performed light meal preparation in the past (i.e., prior to this home care admission).|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; O|38
3|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and mentally able to perform all housekeeping tasks .|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and menta|38
4|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and mentally able to do laundry and access facilities.|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and menta|38
5|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying packages OR b) Physically, cognitively, and mentally able to take care of shopping, but has not done shopping in the past (i.e., prior to this home care admission).|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying|38
6|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|38
7|0 - Able to dial numbers and answer calls appropriately and as desired.|0 - Able to dial numbers and answer calls appropriately and as desired.|38
8|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body without assistance.|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body|38
9|0 - Able to get to and from the toilet and transfer independently with or without a device.|0 - Able to get to and from the toilet and transfer independently with or without a device.|38
10|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|38
11|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible public bus.|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible p|38
12|0 - Able to independently feed self.|0 - Able to independently feed self.|38
13|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|38
14|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct times.|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct ti|38
15|0 - Able to independently transfer.|0 - Able to independently transfer.|38
16|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without rail|38
17|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings|38
18|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|38
19|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions independently.|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions indep|38
20|0 - Asymptomatic, no treatment needed at this time|0 - Asymptomatic, no treatment needed at this time|38
21|0 - Caregiver manages all tasks related to equipment completely independently.|0 - Caregiver manages all tasks related to equipment completely independently.|38
22|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations with no observable impairment.|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations w|38
23|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|38
24|0 - Life expectancy is greater than 6 months|0 - Life expectancy is greater than 6 months|38
25|0 - Never|0 - Never|38
26|0 - Patient is not short of breath|0 - Patient is not short of breath|38
27|0 - No|0 - No|38
28|0 - No emergent care services|0 - No emergent care services|38
29|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [Goto 1620]|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [Goto 1620]|38
30|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and extended or abstract conversation.|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and exte|38
31|0 - No one person|0 - No one person|38
32|0 - None of the time|0 - None of the time|38
33|0 - None, no charge for current services|0 - None, no charge for current services|38
34|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|38
35|0 - Patient does NOT have an ostomy for bowel elimination.|0 - Patient does NOT have an ostomy for bowel elimination.|38
36|0 - Patient has no pain|0 - Patient has no pain|38
37|0 - Patient manages all tasks related to equipment completely independently.|0 - Patient manages all tasks related to equipment completely independently.|38
38|0 - Poor:  little or no recovery is expected and/or further decline is imminent|0 - Poor:  little or no recovery is expected and/or further decline is imminent|38
39|0 - Timed-voiding defers incontinence|0 - Timed-voiding defers incontinence|38
40|0 - Very rarely or never has bowel incontinence|0 - Very rarely or never has bowel incontinence|38
41|0 - Zero|0 - Zero|38
42|00 - No|00 - No|38
43|01 - Yes|01 - Yes|38
44|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or mental limitations, needs assistance with heavy laundry.|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or|38
45|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the patient.|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the|38
46|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|38
47|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or supervision from another person OR c) a liquid, pureed or ground meat diet.|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or su|38
48|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|38
49|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|38
50|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independently.|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independe|38
51|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only when assisted or accompanied by another person.|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only w|38
52|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepa|38
53|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance by another person OR b) given daily reminders.|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance b|38
54|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advan|38
55|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advan|38
56|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for the deaf) and call essential numbers.|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for t|38
57|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|38
58|1 - American Indian or Alaska Native|1 - American Indian or Alaska Native|38
59|1 - Depressed mood (e.g., feeling sad, tearful)|1 - Depressed mood (e.g., feeling sad, tearful)|38
60|1 - During the night only|1 - During the night only|38
61|1 - Fully granulating|1 - Fully granulating|38
62|1 - Good/Fair:  partial to full recovery is expected|1 - Good/Fair:  partial to full recovery is expected|38
63|1 - Good:  marked improvement in functional status is expected|1 - Good:  marked improvement in functional status is expected|38
64|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|38
65|1 - Smoking|1 - Smoking|38
66|1 - Hospital|1 - Hospital|38
67|1 - Hospital emergency room (includes 23-hour holding)|1 - Hospital emergency room (includes 23-hour holding)|38
68|1 - Hospitalization for EMERGENT (unscheduled) care|1 - Hospitalization for EMERGENT (unscheduled) care|38
69|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepared solutions), patient is able to manage all other aspects of equipment.|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepar|38
70|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|38
71|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|38
72|1 - In new or complex situations only|1 - In new or complex situations only|38
73|1 - Intravenous or infusion therapy (excludes TPN)|1 - Intravenous or infusion therapy (excludes TPN)|38
74|1 - Less often than daily|1 - Less often than daily|38
75|1 - Less than once a month|1 - Less than once a month|38
76|1 - Less than once weekly|1 - Less than once weekly|38
77|1 - Life expectancy is 6 months or fewer|1 - Life expectancy is 6 months or fewer|38
78|1 - Lives alone|1 - Lives alone|38
79|1 - Male|1 - Male|38
80|1 - Medicare (traditional fee-for-service)|1 - Medicare (traditional fee-for-service)|38
81|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of past 24 hours, significant memory loss so that supervision is required|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of pas|38
82|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors in word choice, grammar or speech intelligibility, needs minimal prompting or assistance).|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors i|38
83|1 - No assistance or services received|1 - No assistance or services received|38
84|1 - One|1 - One|38
85|1 - Oxygen (intermittent or continuous)|1 - Oxygen (intermittent or continuous)|38
86|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, and the surrounding layout, can count fingers at arm's length.|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, a|38
87|1 - Patient is incontinent|1 - Patient is incontinent|38
88|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|38
89|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical or treatment regimen.|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical|38
90|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient/couple/significant other)|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient|38
91|1 - Relatives, friends, or neighbors living outside the home|1 - Relatives, friends, or neighbors living outside the home|38
92|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions.|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions|38
93|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independentl|38
94|1 - Several times during day and night|1 - Several times during day and night|38
95|1 - Spouse or significant other|1 - Spouse or significant other|38
96|1 - Stage 1|1 - Stage 1|38
97|1 - Start of care - further visits planned|1 - Start of care - further visits planned|38
98|1 - Symptoms well controlled with current therapy|1 - Symptoms well controlled with current therapy|38
99|1 - Therapy services|1 - Therapy services|38
100|1 - Able to transfer with minimal human assistance or with use of an assistive device.|1 - Able to transfer with minimal human assistance or with use of an assistive device.|38
101|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitations.|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitatio|38
102|1 - Urinary incontinence|1 - Urinary incontinence|38
103|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and transfer.|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and|38
104|1 - When walking more than 20 feet, climbing stairs|1 - When walking more than 20 feet, climbing stairs|38
105|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary conversation. May need occasional repetition, extra time, or louder voice.|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary c|38
106|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting in and out of tub/shower|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting|38
107|1 - Yes|1 - Yes|38
108|1-RN|1-RN|38
109|10 - Discharge from agency - no visits completed after start/resumption of care assessment|10 - Discharge from agency - no visits completed after start/resumption of care assessment|38
110|10 - Scheduled surgical procedure|10 - Scheduled surgical procedure|38
111|10 - Self-pay|10 - Self-pay|38
112|11 - Other|11 - Other|38
113|11 - Urinary tract infection|11 - Urinary tract infection|38
114|12 - IV catheter-related infection|12 - IV catheter-related infection|38
115|13 - Deep vein thrombosis, pulmonary embolus|13 - Deep vein thrombosis, pulmonary embolus|38
116|14 - Uncontrolled pain|14 - Uncontrolled pain|38
117|15 - Psychotic episode|15 - Psychotic episode|38
118|16 - Other than above reasons|16 - Other than above reasons|38
119|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing calls.|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing|38
120|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another person.|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another pers|38
121|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface a|38
122|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for intermittent supervision or encouragement or reminders, OR (b) to get in and out of the shower or tub, OR (c) for washing difficult to reach areas.|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for inter|38
123|2 - Asian|2 - Asian|38
124|2 - Caregiver requires considerable assistance from another person to manage equipment, but independently completes significant portions of task.|2 - Caregiver requires considerable assistance from another person to manage equipment, but independ|38
125|2 - Daily, but not constantly|2 - Daily, but not constantly|38
126|2 - Daughter or son|2 - Daughter or son|38
127|2 - Doctor's office emergency visit/house call|2 - Doctor's office emergency visit/house call|38
128|2 - During the day and night|2 - During the day and night|38
129|2 - Early/partial granulation|2 - Early/partial granulation|38
130|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors in word choice, organization or speech intelligibility). Speaks in phrases or short sentences.|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors|38
131|2 - Family member's residence|2 - Family member's residence|38
132|2 - Female|2 - Female|38
133|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conversation, needs frequent prompting or assistance.|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conver|38
134|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|38
135|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|38
136|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately stop activities, jeopardizes safety through actions|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately st|38
137|2 - Indwelling/suprapubic catheter|2 - Indwelling/suprapubic catheter|38
138|2 - Injury caused by fall or accident at home|2 - Injury caused by fall or accident at home|38
139|2 - Medicare (HMO/managed care/Advantage plan)|2 - Medicare (HMO/managed care/Advantage plan)|38
140|2 - Nausea, dehydration, malnutrition, constipation, impaction|2 - Nausea, dehydration, malnutrition, constipation, impaction|38
141|2 - Obesity|2 - Obesity|38
142|2 - On awakening or at night only|2 - On awakening or at night only|38
143|2 - Once a month|2 - Once a month|38
144|2 - One to three times weekly|2 - One to three times weekly|38
145|2 - Parenteral nutrition (TPN or lipids)|2 - Parenteral nutrition (TPN or lipids)|38
146|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic) [ Go to M1620]|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic) [ Go|38
147|2 - Patient requires considerable assistance from another person to manage equipment, but independently completes portions of the task.|2 - Patient requires considerable assistance from another person to manage equipment, but independen|38
148|2 - Patient transferred to a noninstitutional hospice|2 - Patient transferred to a noninstitutional hospice|38
149|2 - Person residing in the home (EXCLUDING paid help)|2 - Person residing in the home (EXCLUDING paid help)|38
150|2 - Rehabilitation facility|2 - Rehabilitation facility|38
151|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifting of attention) or consistently requires low stimulus environment due to distractibility.|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifti|38
152|2 - Respite care|2 - Respite care|38
153|2 - Sense of failure or self reproach|2 - Sense of failure or self reproach|38
154|2 - Several times during day|2 - Several times during day|38
155|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonresponsive.|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonrespons|38
156|2 - Someone must assist the patient to groom self.|2 - Someone must assist the patient to groom self.|38
157|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|38
158|2 - Someone must help the patient put on upper body clothing.|2 - Someone must help the patient put on upper body clothing.|38
159|2 - Stage 2|2 - Stage 2|38
160|2 - Start of care - no further visits planned|2 - Start of care - no further visits planned|38
161|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitoring|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitori|38
162|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment regimen.|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment re|38
163|2 - Two|2 - Two|38
164|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistance due to cognitive or mental limitation.|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistanc|38
165|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|38
166|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assistance).|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assis|38
167|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home delivery.|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home deli|38
168|2 - Unable to prepare any light meals or reheat any delivered meals.|2 - Unable to prepare any light meals or reheat any delivered meals.|38
169|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|38
170|2 - UNABLE to take injectable medications unless administered by someone else.|2 - UNABLE to take injectable medications unless administered by someone else.|38
171|2 - UNABLE to take medication unless administered by someone else.|2 - UNABLE to take medication unless administered by someone else.|38
172|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|38
173|2 - Ventilator (continually or at night)|2 - Ventilator (continually or at night)|38
174|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less than 20 feet)|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less th|38
175|2 - With spouse or significant other|2 - With spouse or significant other|38
176|2 - Yes, assistance or services provided by family or friends|2 - Yes, assistance or services provided by family or friends|38
177|2-PT|2-PT|38
178|3 - Able to answer the telephone only some of the time or is able to carry on only a limited conversation.|3 - Able to answer the telephone only some of the time or is able to carry on only a limited convers|38
179|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube or gastrostomy.|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube|38
180|3 - Alcohol dependency|3 - Alcohol dependency|38
181|3 - All of the time|3 - All of the time|38
182|3 - Black or African-American|3 - Black or African-American|38
183|3 - Boarding home or rented room|3 - Boarding home or rented room|38
184|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment, clean/store/dispose of equipment or supplies).|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment,|38
185|3 -Able to walk only with the supervision or assistance of another person at all times.|3 -Able to walk only with the supervision or assistance of another person at all times.|38
186|3 - Continuous / Bi-level positive airway pressure|3 - Continuous / Bi-level positive airway pressure|38
187|3 - During the day and evening, but not constantly|3 - During the day and evening, but not constantly|38
188|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the alimentary canal)|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the|38
189|3 - Environmental support (e.g., housing, home maintenance)|3 - Environmental support (e.g., housing, home maintenance)|38
190|3 - Four to six times weekly|3 - Four to six times weekly|38
191|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessing by listener.  Speech limited to single words or short phrases.|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessin|38
192|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires multiple repetitions, restatements, demonstrations, additional time.|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires m|38
193|3 - Hopelessness|3 - Hopelessness|38
194|3 - Hospice care|3 - Hospice care|38
195|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|38
196|3 - Injury caused by fall or accident at home|3 - Injury caused by fall or accident at home|38
197|3 - Intractable pain|3 - Intractable pain|38
198|3 - Medicaid (traditional fee-for-service)|3 - Medicaid (traditional fee-for-service)|38
199|3 - Needs someone to do all shopping and errands.|3 - Needs someone to do all shopping and errands.|38
200|3 - Not healing|3 - Not healing|38
201|3 - Nursing home|3 - Nursing home|38
202|3 - Once daily|3 - Once daily|38
203|3 - Other family member|3 - Other family member|38
204|3 - Outpatient department/clinic emergency (includes urgicenter sites)|3 - Outpatient department/clinic emergency (includes urgicenter sites)|38
205|3 - Paid help|3 - Paid help|38
206|3 - Able to participate in bathing self in shower or tub, but requires presence of another person throughout the bath for assistance or supervision.|3 - Able to participate in bathing self in shower or tub, but requires presence of another person th|38
207|3 - Patient depends entirely upon another person to dress lower body.|3 - Patient depends entirely upon another person to dress lower body.|38
208|3 - Patient depends entirely upon another person to dress the upper body.|3 - Patient depends entirely upon another person to dress the upper body.|38
209|3 - Patient depends entirely upon someone else for grooming needs.|3 - Patient depends entirely upon someone else for grooming needs.|38
210|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone else to manage the equipment.|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone|38
211|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable to shift attention and recall directions more than half the time.|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable|38
212|3 - Respiratory problems (SOB, infection, obstruction)|3 - Respiratory problems (SOB, infection, obstruction)|38
213|3 - Resumption of care (after inpatient stay)|3 - Resumption of care (after inpatient stay)|38
214|3 - Several times each month|3 - Several times each month|38
215|3 - Skilled Nursing Facility|3 - Skilled Nursing Facility|38
216|3 - Stage 3|3 - Stage 3|38
217|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|38
218|3 - Three|3 - Three|38
219|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person throughout the process.|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person through|38
220|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal independently.|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal indep|38
221|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person.|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person|38
222|3 - Unknown because patient moved to a geographic location not served by this agency|3 - Unknown because patient moved to a geographic location not served by this agency|38
223|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|38
224|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|38
225|3 - With other family member|3 - With other family member|38
226|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home health services, homemaker assistance, transportation assistance, assisted living, board and care)|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home h|38
227|3-SLP/ST|3-SLP/ST|38
228|4 - At rest (during day or night)|4 - At rest (during day or night)|38
229|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|38
230|4 - Board and care or assisted living facility|4 - Board and care or assisted living facility|38
231|4 - Caregiver is completely dependent on someone else to manage all equipment.|4 - Caregiver is completely dependent on someone else to manage all equipment.|38
232|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|38
233|4 - Constantly|4 - Constantly|38
234|4 - Drug dependency|4 - Drug dependency|38
235|4 - Four or more|4 - Four or more|38
236|4 - Friend or neighbor or community or church member|4 - Friend or neighbor or community or church member|38
237|4 - Hispanic or Latino|4 - Hispanic or Latino|38
238|4 - Hospice|4 - Hospice|38
239|4 - Impaired decision-making|4 - Impaired decision-making|38
240|4 - Is totally dependent in toileting.|4 - Is totally dependent in toileting.|38
241|4 - Medicaid (HMO/managed care)|4 - Medicaid (HMO/managed care)|38
242|4 - None of the above|4 - None of the above|38
243|4 - Nursing home|4 - Nursing home|38
244|4 - On a daily basis|4 - On a daily basis|38
245|4 - Patient is completely dependent on someone else to manage all equipment.|4 - Patient is completely dependent on someone else to manage all equipment.|38
246|4 - Permanent placement|4 - Permanent placement|38
247|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, punches, dangerous maneuvers w/ wheelchair or other objects)|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, pu|38
248|4 - Psychosocial support (e.g., socialization, companionship, recreation)|4 - Psychosocial support (e.g., socialization, companionship, recreation)|38
249|4 - Recertification (follow-up) reassessment|4 - Recertification (follow-up) reassessment|38
250|4 - Recurrent thoughts of death|4 - Recurrent thoughts of death|38
251|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruction)|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruc|38
252|4 - Several times a week|4 - Several times a week|38
253|4 - Stage 4|4 - Stage 4|38
254|4 - Symptoms poorly controlled, history of rehospitalizations|4 - Symptoms poorly controlled, history of rehospitalizations|38
255|4 - Three or more times per week|4 - Three or more times per week|38
256|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetative state, or delirium.|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetati|38
257|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|38
258|4 - Unable to effectively participate in any housekeeping tasks.|4 - Unable to effectively participate in any housekeeping tasks.|38
259|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or unresponsive (e.g., speech is nonsensical or unintelligible).|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or u|38
260|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonresponsive.|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonr|38
261|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostomy.|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostom|38
262|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of devices at the sink, in chair, or on commode|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of|38
263|4 - With a friend|4 - With a friend|38
264|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|38
265|4-OT|4-OT|38
266|5 - Advocates or facilitates patient's participation in appropriate medical care|5 - Advocates or facilitates patient's participation in appropriate medical care|38
267|5 - At least daily|5 - At least daily|38
268|6 - Bedfast, unable to ambulate or be up in a chair.|6 - Bedfast, unable to ambulate or be up in a chair.|38
269|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|38
270|5 - Disruptive or socially inappropriate behavior|5 - Disruptive or socially inappropriate behavior|38
271|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|38
272|5 - Hypo/Hyperglycemia, diabetes out of control|5 - Hypo/Hyperglycemia, diabetes out of control|38
273|5 - More often than once daily|5 - More often than once daily|38
274|5 - Native Hawaiian or Pacific Islander|5 - Native Hawaiian or Pacific Islander|38
275|5 - None of the above|5 - None of the above|38
276|5 - One to two times per week|5 - One to two times per week|38
277|5 - Other|5 - Other|38
278|5 - Other follow-up|5 - Other follow-up|38
279|5 - Paid help|5 - Paid help|38
280|5 - Patient nonresponsive or unable to speak.|5 - Patient nonresponsive or unable to speak.|38
281|5 - Thoughts of suicide|5 - Thoughts of suicide|38
282|5 - Totally unable to use the telephone.|5 - Totally unable to use the telephone.|38
283|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|38
284|5 - Unable to take in nutrients orally or by tube feeding.|5 - Unable to take in nutrients orally or by tube feeding.|38
285|5 - Unsafe for care at home|5 - Unsafe for care at home|38
286|5 - With paid help (other than home care agency staff)|5 - With paid help (other than home care agency staff)|38
287|5 - Workers' compensation|5 - Workers' compensation|38
288|5 - Wound infection, deteriorating wound status, new lesion/ulcer|5 - Wound infection, deteriorating wound status, new lesion/ulcer|38
289|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|38
290|6 - Delusional, hallucinatory, or paranoid behavior|6 - Delusional, hallucinatory, or paranoid behavior|38
291|6 - Financial agent, power of attorney, or conservator of finance|6 - Financial agent, power of attorney, or conservator of finance|38
292|6 - GI bleeding, obstruction|6 - GI bleeding, obstruction|38
293|6 - Less often than weekly|6 - Less often than weekly|38
294|6 - Memory loss to the extent that supervision required|6 - Memory loss to the extent that supervision required|38
295|6 - None of the above feelings observed or reported|6 - None of the above feelings observed or reported|38
296|6 - Other|6 - Other|38
297|6 - Title programs (e.g., Title III, V, or XX)|6 - Title programs (e.g., Title III, V, or XX)|38
298|6 - Transferred to an inpatient facility - patient not discharged from agency|6 - Transferred to an inpatient facility - patient not discharged from agency|38
299|6 - White|6 - White|38
300|6 - With other than above|6 - With other than above|38
301|7 - Exacerbation of CHF, fluid overload, heart failure|7 - Exacerbation of CHF, fluid overload, heart failure|38
302|7 - Health care agent, conservator of person, or medical power of attorney|7 - Health care agent, conservator of person, or medical power of attorney|38
303|7 - Hypo/Hyperglycemia, diabetes out of control|7 - Hypo/Hyperglycemia, diabetes out of control|38
304|7 - None of the above|7 - None of the above|38
305|7 - None of the above behaviors demonstrated|7 - None of the above behaviors demonstrated|38
306|7 - Other government (e.g., TriCare, VA, etc.)|7 - Other government (e.g., TriCare, VA, etc.)|38
307|7 - Transferred to an inpatient facility - patient discharged from agency|7 - Transferred to an inpatient facility - patient discharged from agency|38
308|8 - Death at home|8 - Death at home|38
309|8 - GI bleeding, obstruction|8 - GI bleeding, obstruction|38
310|8 - Myocardial infarction, stroke|8 - Myocardial infarction, stroke|38
311|8 - Private insurance|8 - Private insurance|38
312|9 - Chemotherapy|9 - Chemotherapy|38
313|9 - Discharge from agency|9 - Discharge from agency|38
314|9 - Other than above reasons|9 - Other than above reasons|38
315|9 - Private HMO/managed care|9 - Private HMO/managed care|38
316|NA - No caregiver|NA - No caregiver|38
317|NA - No equipment of this type used in care.|NA - No equipment of this type used in care.|38
318|NA - No inhalant/mist medications prescribed.|NA - No inhalant/mist medications prescribed.|38
319|NA - No injectable medications prescribed.|NA - No injectable medications prescribed.|38
320|NA - No inpatient facility admission|NA - No inpatient facility admission|38
321|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|38
322|NA - No Medicaid|NA - No Medicaid|38
323|NA - No Medicare|NA - No Medicare|38
324|NA - No observable pressure ulcer or unhealed pressure ulcer|NA - No observable pressure ulcer or unhealed pressure ulcer|38
325|NA - No observable stasis ulcer|NA - No observable stasis ulcer|38
326|NA - No observable surgical wound|NA - No observable surgical wound|38
327|NA - No oral medications prescribed.|NA - No oral medications prescribed.|38
328|NA - Not applicable|NA - Not applicable|38
329|NA - Patient does not have a telephone.|NA - Patient does not have a telephone.|38
330|NA - Patient has ostomy for bowel elimination|NA - Patient has ostomy for bowel elimination|38
331|NA - Patient nonresponsive|NA - Patient nonresponsive|38
332|NA - Patient on prophylactic treatment|NA - Patient on prophylactic treatment|38
333|NA - Patient was not discharged from an inpatient facility [Go to M1016 ]|NA - Patient was not discharged from an inpatient facility [Go to M1016 ]|38
334|UK - Other unknown|UK - Other unknown|38
335|UK - Reason unknown|UK - Reason unknown|38
336|UK - Unknown|UK - Unknown|38
337|UK - Unknown or Not Available|UK - Unknown or Not Available|38
341|01 - Early|01 - Early|38
342|02 - Late|02 - Late|38
343|NA - Not Applicable. No case mix group defined for this assessment.|NA - Not Applicable. No case mix group defined for this assessment.|38
344|NA - No case mix group defined by this assessment.|NA - No case mix group defined by this assessment.|38
345|1 - Recent decline in mental, emotional, or behavioral status|1 - Recent decline in mental, emotional, or behavioral status|38
346|2 - Multiple hospitalizations (2 or more) in the past 12 months|2 - Multiple hospitalizations (2 or more) in the past 12 months|38
347|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|38
348|4 - Taking five or more medications|4 - Taking five or more medications|38
349|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|38
350|6 - Other|6 - Other|38
351|7 - None of the above|7 - None of the above|38
352|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond tho|38
353|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable without heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable wi|38
354|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious complications and death.|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious compl|38
355|3 - The patient has serious progressive conditions that could lead to death within a year.|3 - The patient has serious progressive conditions that could lead to death within a year.|38
356|UK - The patient+s situation is unknown or unclear.|UK - The patient+s situation is unknown or unclear.|38
357|1 - Yes [ Go to M1050 ]|1 - Yes [ Go to M1050 ]|38
358|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this influenza season. [ Go to M1050 ]|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this i|38
359|1 - Received from another health care provider (e.g., physician)|1 - Received from another health care provider (e.g., physician)|38
360|2 - Received from your agency previously during this year+s flu season|2 - Received from your agency previously during this year+s flu season|38
361|3 - Offered and declined|3 - Offered and declined|38
362|4 - Assessed and determined to have medical contraindication(s)|4 - Assessed and determined to have medical contraindication(s)|38
363|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|38
364|6 - Inability to obtain vaccine due to declared shortage|6 - Inability to obtain vaccine due to declared shortage|38
365|1 - Yes [ Go to M1500 at TRN; Go to M1230 at DC ]|1 - Yes [ Go to M1500 at TRN; Go to M1230 at DC ]|38
366|1 - Patient has received PPV in the past|1 - Patient has received PPV in the past|38
367|2 - Offered and declined|2 - Offered and declined|38
368|3 - Assessed and determined to have medical contraindication(s)|3 - Assessed and determined to have medical contraindication(s)|38
369|4 - Not indicated; patient does not meet age/condition guidelines for PPV|4 - Not indicated; patient does not meet age/condition guidelines for PPV|38
370|5 - None of the above|5 - None of the above|38
371|0 - Adequate: hears normal conversation without difficulty.|0 - Adequate: hears normal conversation without difficulty.|38
372|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to increase volume or speak distinctly.|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to in|38
373|2 - Severely Impaired: absence of useful hearing.|2 - Severely Impaired: absence of useful hearing.|38
374|UK - Unable to assess hearing.|UK - Unable to assess hearing.|38
375|0 - Understands: clear comprehension without cues or repetitions.|0 - Understands: clear comprehension without cues or repetitions.|38
376|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Requires cues at times to understand.|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Req|38
377|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequently requires cues to understand.|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequentl|38
378|3 - Rarely/Never Understands|3 - Rarely/Never Understands|38
379|UK - Unable to assess understanding.|UK - Unable to assess understanding.|38
380|0 - No standardized assessment conducted|0 - No standardized assessment conducted|38
381|1 - Yes, and it does not indicate severe pain|1 - Yes, and it does not indicate severe pain|38
382|2 - Yes, and it indicates severe pain|2 - Yes, and it indicates severe pain|38
383|0 - Patient has no pain|0 - Patient has no pain|38
384|1 - Patient has pain that does not interfere with activity or movement|1 - Patient has pain that does not interfere with activity or movement|38
385|2 - Less often than daily|2 - Less often than daily|38
386|3 - Daily, but not constantly|3 - Daily, but not constantly|38
387|4 - All of the time|4 - All of the time|38
388|0 - No assessment conducted [ Go to M1306 ]|0 - No assessment conducted [ Go to M1306 ]|38
389|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc., without use of standardized tool|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc.,|38
390|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|38
391|0 - No [ Go to M1322]|0 - No [ Go to M1322]|38
392|0 v Newly epithelialized|0 v Newly epithelialized|38
393|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|38
394|2 - Yes, patient has observable stasis ulcers ONLY|2 - Yes, patient has observable stasis ulcers ONLY|38
395|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable dressing) [Go to M1340]|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable|38
396|0 - No [ Go to M1350 ]|0 - No [ Go to M1350 ]|38
397|1 - Yes, patient has at least one (observable) surgical wound|1 - Yes, patient has at least one (observable) surgical wound|38
398|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1350 ]|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1350 ]|38
399|0 - Patient is not short of breath|0 - Patient is not short of breath|38
400|3 - Continuous Bi-level positive airway pressure|3 - Continuous Bi-level positive airway pressure|38
401|0 - No [ Go to M2004 at TRN; Go to M1600 at DC ]|0 - No [ Go to M2004 at TRN; Go to M1600 at DC ]|38
402|2 - Not assessed [Go to M2004 at TRN; Go to M1600 at DC ]|2 - Not assessed [Go to M2004 at TRN; Go to M1600 at DC ]|38
403|NA - Patient does not have diagnosis of heart failure [Go to M2004 at TRN; Go to M1600 at DC]|NA - Patient does not have diagnosis of heart failure [Go to M2004 at TRN; Go to M1600 at DC]|38
404|0 - No action taken|0 - No action taken|38
405|1 - Patient+s physician (or other primary care practitioner) contacted the same day|1 - Patient+s physician (or other primary care practitioner) contacted the same day|38
406|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|38
407|3 - Implement physician-ordered patient-specific established parameters for treatment|3 - Implement physician-ordered patient-specific established parameters for treatment|38
408|4 - Patient education or other clinical interventions|4 - Patient education or other clinical interventions|38
409|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequency, telehealth, etc.)|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequ|38
410|1 - Occasional stress incontinence|1 - Occasional stress incontinence|38
411|2 - During the night only|2 - During the night only|38
412|3 - During the day only|3 - During the day only|38
413|4 - During the day and night|4 - During the day and night|38
414|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|38
415|0 - Able to manage toileting hygiene and clothing management without assistance.|0 - Able to manage toileting hygiene and clothing management without assistance.|38
416|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implements are laid out for the patient.|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implemen|38
417|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|38
418|3 - Patient depends entirely upon another person to maintain toileting hygiene.|3 - Patient depends entirely upon another person to maintain toileting hygiene.|38
419|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independent|38
420|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface|38
421|0 - No multi-factor falls risk assessment conducted.|0 - No multi-factor falls risk assessment conducted.|38
422|1 - Yes, and it does not indicate a risk for falls.|1 - Yes, and it does not indicate a risk for falls.|38
423|2 - Yes, and it indicates a risk for falls.|2 - Yes, and it indicates a risk for falls.|38
424|0 - Not assessed/reviewed [ Go to M2010 ]|0 - Not assessed/reviewed [ Go to M2010 ]|38
425|1 - No problems found during review [ Go to M2010 ]|1 - No problems found during review [ Go to M2010 ]|38
426|2 - Problems found during review|2 - Problems found during review|38
427|NA - Patient is not taking any medications [ Go to M2040 ]|NA - Patient is not taking any medications [ Go to M2040 ]|38
428|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special precautions associated with all high-risk medications|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special p|38
429|NA - Patient not taking any drugs|NA - Patient not taking any drugs|38
430|2 - Able to take medication(s) at the correct times if given reminders by another person at the appropriate times|2 - Able to take medication(s) at the correct times if given reminders by another person at the appr|38
431|3 - Unable to take medication unless administered by another person.|3 - Unable to take medication unless administered by another person.|38
432|1 - At least daily|1 - At least daily|38
433|2 - Three or more times per week|2 - Three or more times per week|38
434|3 - One to two times per week|3 - One to two times per week|38
435|4 - Received, but less often than weekly|4 - Received, but less often than weekly|38
436|5 - No assistance received|5 - No assistance received|38
437|0 - No [Go to M2400]|0 - No [Go to M2400]|38
438|1 - Yes, used hospital emergency department WITHOUT hospital admission|1 - Yes, used hospital emergency department WITHOUT hospital admission|38
439|2 - Yes, used hospital emergency department WITH hospital admission|2 - Yes, used hospital emergency department WITH hospital admission|38
440|UK - Unknown [Go to M2400]|UK - Unknown [Go to M2400]|38
441|2 - Injury caused by fall|2 - Injury caused by fall|38
442|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|38
443|4 - Other respiratory problem|4 - Other respiratory problem|38
444|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|38
445|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|38
446|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|38
447|8 - Other heart disease|8 - Other heart disease|38
448|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|38
449|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|38
450|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|38
451|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|38
452|13 - Urinary tract infection|13 - Urinary tract infection|38
453|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|38
454|15 - Wound infection or deterioration|15 - Wound infection or deterioration|38
455|16 - Uncontrolled pain|16 - Uncontrolled pain|38
456|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|38
457|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|38
458|19 - Other than above reasons|19 - Other than above reasons|38
459|2 - Patient remained in the community (with formal assistive services)|2 - Patient remained in the community (with formal assistive services)|38
460|3 - Patient transferred to a noninstitutional hospice|3 - Patient transferred to a noninstitutional hospice|38
461|4 - Unknown because patient moved to a geographic location not served by this agency|4 - Unknown because patient moved to a geographic location not served by this agency|38
462|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|38
463|4 - Other respiratory problem|4 - Other respiratory problem|38
464|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|38
465|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|38
466|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|38
467|8 - Other heart disease|8 - Other heart disease|38
468|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|38
469|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|38
470|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|38
471|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|38
472|13 - Urinary tract infection|13 - Urinary tract infection|38
473|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|38
474|15 - Wound infection or deterioration|15 - Wound infection or deterioration|38
475|16 - Uncontrolled pain|16 - Uncontrolled pain|38
476|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|38
477|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|38
478|19 - Scheduled treatment or procedure|19 - Scheduled treatment or procedure|38
479|20 - Other than above reasons|20 - Other than above reasons|38
480|UK - Reason unknown [Go to M0903]|UK - Reason unknown [Go to M0903]|38
482|01 - Patient lives alone around the clock|01 - Patient lives alone around the clock|38
483|02 - Patient lives alone regular daytime|02 - Patient lives alone regular daytime|38
484|03 - Patient lives alone regular nighttime|03 - Patient lives alone regular nighttime|38
485|04 - Patient lives alone occassional/short term assistance|04 - Patient lives alone occassional/short term assistance|38
486|05 - Patient lives alone no assisstance available|05 - Patient lives alone no assisstance available|38
487|06 - Patient lives with other person(s) in the home around the clock|06 - Patient lives with other person(s) in the home around the clock|38
488|07 - Patient lives with other person(s) in the home regular daytime|07 - Patient lives with other person(s) in the home regular daytime|38
489|08 - Patient lives with other person(s) in the home regular nighttime|08 - Patient lives with other person(s) in the home regular nighttime|38
490|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|38
491|10 - Patient lives with other person(s) in the home no assistance available|10 - Patient lives with other person(s) in the home no assistance available|38
492|1 - Was present at the most recent SOC/ROC assessment|1 - Was present at the most recent SOC/ROC assessment|38
493|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|38
494|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|38
495|0 - Newly epithelialized|0 - Newly epithelialized|38
496|0 - No [ Go to M1340 ]|0 - No [ Go to M1340 ]|38
498|0 - Independent|0 - Independent|38
499|1 - Needed Some Help|1 - Needed Some Help|38
500|2 - Dependent|2 - Dependent|38
502|0 - No assistance needed in this area|0 - No assistance needed in this area|38
503|1 - Caregiver(s) currently provide assistance|1 - Caregiver(s) currently provide assistance|38
504|2 - Caregiver(s) need training/ supportive services to provide assistance|2 - Caregiver(s) need training/ supportive services to provide assistance|38
505|3 - Caregiver(s) not likely to provide assistance|3 - Caregiver(s) not likely to provide assistance|38
506|4 - Unclear if Caregiver(s) will provide assistance|4 - Unclear if Caregiver(s) will provide assistance|38
507|5 - Assistance needed, but no Caregiver(s) available|5 - Assistance needed, but no Caregiver(s) available|38
508|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will use standardized clinical guidelines accessible for all care providers to reference|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will|38
510|NA - Patient is not assessed to be at risk for falls|NA - Patient is not assessed to be at risk for falls|38
511|NA - Patient has no diagnosis or symptoms of depression|NA - Patient has no diagnosis or symptoms of depression|38
512|NA - No pain identified|NA - No pain identified|38
513|NA - Patient is not assessed to be at risk for pressure ulcers|NA - Patient is not assessed to be at risk for pressure ulcers|38
514|NA - Patient has no pressure ulcers with need for moist wound healing|NA - Patient has no pressure ulcers with need for moist wound healing|38
515|1 - Long-term nursing facility (NF)|1 - Long-term nursing facility (NF)|38
516|2 - Skilled nursing facility (SNF / TCU)|2 - Skilled nursing facility (SNF / TCU)|38
517|3 - Short stay acute hospital (IPP S)|3 - Short stay acute hospital (IPP S)|38
518|4 - Long-term care hospital (LTCH)|4 - Long-term care hospital (LTCH)|38
519|5 - Inpatient rehabilitation hospital or unit (IRF)|5 - Inpatient rehabilitation hospital or unit (IRF)|38
520|6 - Psychiatric hospital or unit|6 - Psychiatric hospital or unit|38
521|7 - Other|7 - Other|38
522|NA - Patient was not discharged from an inpatient facility [Goto M1016]|NA - Patient was not discharged from an inpatient facility [Goto M1016]|38
523|6 - Unable to participate effectively in bathing and is bathed totally by another person|6 - Unable to participate effectively in bathing and is bathed totally by another person|38
524|4 - Chairfast, unable to ambulate but is able to wheel self independently.|4 - Chairfast, unable to ambulate but is able to wheel self independently.|38
525|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask patient: "Over the last two weeks, how often have you been bothered by any of the following problems")|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask|38
526|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluation for depression.|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluat|38
527|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet criteria for further evaluation for depression.|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet|38
528|0 - Not at all  0 - 1 day|0 - Not at all  0 - 1 day|38
529|1 - Several days  2 - 6 days|1 - Several days  2 - 6 days|38
530|2 - More than half of the days  7 - 11 days|2 - More than half of the days  7 - 11 days|38
531|3 - Nearly every day  12 - 14 days|3 - Nearly every day  12 - 14 days|38
532|NA - N/A  Unable to respond|NA - N/A  Unable to respond|38
533|2 - Able to take medication(s) at the correct times if given reminders by another person based on the frequency of the injection|2 - Able to take medication(s) at the correct times if given reminders by another person based on th|38
534|3 - Unable to take injectable medication unless administered by another person.|3 - Unable to take injectable medication unless administered by another person.|38
547|NA - No clinically significant medication issues identified since the previous OASIS assessment|NA - No clinically significant medication issues identified since the previous OASIS assessment|38
552|1 - Hospital [ Go to M2430 ]|1 - Hospital [ Go to M2430 ]|38
553|2 - Rehabilitation facility [ Go to M0903 ]|2 - Rehabilitation facility [ Go to M0903 ]|38
554|3 - Nursing home [ Go to M2440 ]|3 - Nursing home [ Go to M2440 ]|38
555|4 - Hospice [ Go to M0903 ]|4 - Hospice [ Go to M0903 ]|38
2|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; OR (b) Is physically, cognitively, and mentally able to prepare light meals on a regular basis but has not routinely performed light meal preparation in the past (i.e., prior to this home care admission).|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; O|39
3|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and mentally able to perform all housekeeping tasks .|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and menta|39
4|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and mentally able to do laundry and access facilities.|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and menta|39
5|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying packages OR b) Physically, cognitively, and mentally able to take care of shopping, but has not done shopping in the past (i.e., prior to this home care admission).|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying|39
6|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|39
7|0 - Able to dial numbers and answer calls appropriately and as desired.|0 - Able to dial numbers and answer calls appropriately and as desired.|39
8|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body without assistance.|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body|39
9|0 - Able to get to and from the toilet and transfer independently with or without a device.|0 - Able to get to and from the toilet and transfer independently with or without a device.|39
10|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|39
11|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible public bus.|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible p|39
12|0 - Able to independently feed self.|0 - Able to independently feed self.|39
13|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|39
14|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct times.|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct ti|39
15|0 - Able to independently transfer.|0 - Able to independently transfer.|39
16|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without rail|39
17|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings|39
18|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|39
19|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions independently.|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions indep|39
20|0 - Asymptomatic, no treatment needed at this time|0 - Asymptomatic, no treatment needed at this time|39
21|0 - Caregiver manages all tasks related to equipment completely independently.|0 - Caregiver manages all tasks related to equipment completely independently.|39
22|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations with no observable impairment.|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations w|39
23|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|39
24|0 - Life expectancy is greater than 6 months|0 - Life expectancy is greater than 6 months|39
25|0 - Never|0 - Never|39
26|0 - Patient is not short of breath|0 - Patient is not short of breath|39
27|0 - No|0 - No|39
28|0 - No emergent care services|0 - No emergent care services|39
29|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [Goto M1620]|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [Goto M1620]|39
30|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and extended or abstract conversation.|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and exte|39
31|0 - No one person|0 - No one person|39
32|0 - None of the time|0 - None of the time|39
33|0 - None, no charge for current services|0 - None, no charge for current services|39
34|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|39
35|0 - Patient does NOT have an ostomy for bowel elimination.|0 - Patient does NOT have an ostomy for bowel elimination.|39
36|0 - Patient has no pain|0 - Patient has no pain|39
37|0 - Patient manages all tasks related to equipment completely independently.|0 - Patient manages all tasks related to equipment completely independently.|39
38|0 - Poor:  little or no recovery is expected and/or further decline is imminent|0 - Poor:  little or no recovery is expected and/or further decline is imminent|39
39|0 - Timed-voiding defers incontinence|0 - Timed-voiding defers incontinence|39
40|0 - Very rarely or never has bowel incontinence|0 - Very rarely or never has bowel incontinence|39
41|0 - Zero|0 - Zero|39
42|00 - No|00 - No|39
43|01 - Yes|01 - Yes|39
44|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or mental limitations, needs assistance with heavy laundry.|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or|39
45|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the patient.|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the|39
46|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|39
47|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or supervision from another person OR c) a liquid, pureed or ground meat diet.|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or su|39
48|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|39
49|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|39
50|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independently.|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independe|39
51|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only when assisted or accompanied by another person.|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only w|39
52|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepa|39
53|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance by another person OR b) given daily reminders.|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance b|39
54|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advan|39
55|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advan|39
56|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for the deaf) and call essential numbers.|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for t|39
57|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|39
58|1 - American Indian or Alaska Native|1 - American Indian or Alaska Native|39
59|1 - Depressed mood (e.g., feeling sad, tearful)|1 - Depressed mood (e.g., feeling sad, tearful)|39
60|1 - During the night only|1 - During the night only|39
61|1 - Fully granulating|1 - Fully granulating|39
62|1 - Good/Fair:  partial to full recovery is expected|1 - Good/Fair:  partial to full recovery is expected|39
63|1 - Good:  marked improvement in functional status is expected|1 - Good:  marked improvement in functional status is expected|39
64|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|39
65|1 - Smoking|1 - Smoking|39
66|1 - Hospital [ Go to M2430 ]|1 - Hospital [ Go to M2430 ]|39
67|1 - Hospital emergency room (includes 23-hour holding)|1 - Hospital emergency room (includes 23-hour holding)|39
68|1 - Hospitalization for EMERGENT (unscheduled) care|1 - Hospitalization for EMERGENT (unscheduled) care|39
69|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepared solutions), patient is able to manage all other aspects of equipment.|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepar|39
70|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|39
71|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|39
72|1 - In new or complex situations only|1 - In new or complex situations only|39
73|1 - Intravenous or infusion therapy (excludes TPN)|1 - Intravenous or infusion therapy (excludes TPN)|39
74|1 - Less often than daily|1 - Less often than daily|39
75|1 - Less than once a month|1 - Less than once a month|39
76|1 - Less than once weekly|1 - Less than once weekly|39
77|1 - Life expectancy is 6 months or fewer|1 - Life expectancy is 6 months or fewer|39
78|1 - Lives alone|1 - Lives alone|39
79|1 - Male|1 - Male|39
80|1 - Medicare (traditional fee-for-service)|1 - Medicare (traditional fee-for-service)|39
81|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of past 24 hours, significant memory loss so that supervision is required|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of pas|39
82|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors in word choice, grammar or speech intelligibility, needs minimal prompting or assistance).|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors i|39
83|1 - No assistance or services received|1 - No assistance or services received|39
84|1 - One|1 - One|39
85|1 - Oxygen (intermittent or continuous)|1 - Oxygen (intermittent or continuous)|39
86|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, and the surrounding layout, can count fingers at arm's length.|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, a|39
87|1 - Patient is incontinent|1 - Patient is incontinent|39
88|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|39
89|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical or treatment regimen.|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical|39
90|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient/couple/significant other)|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient|39
91|1 - Relatives, friends, or neighbors living outside the home|1 - Relatives, friends, or neighbors living outside the home|39
92|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions.|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions|39
93|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independentl|39
94|1 - Several times during day and night|1 - Several times during day and night|39
95|1 - Spouse or significant other|1 - Spouse or significant other|39
96|1 - Stage 1|1 - Stage 1|39
97|1 - Start of care - further visits planned|1 - Start of care - further visits planned|39
98|1 - Symptoms well controlled with current therapy|1 - Symptoms well controlled with current therapy|39
99|1 - Therapy services|1 - Therapy services|39
100|1 - Able to transfer with minimal human assistance or with use of an assistive device.|1 - Able to transfer with minimal human assistance or with use of an assistive device.|39
101|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitations.|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitatio|39
102|1 - Urinary incontinence|1 - Urinary incontinence|39
103|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and transfer.|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and|39
104|1 - When walking more than 20 feet, climbing stairs|1 - When walking more than 20 feet, climbing stairs|39
105|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary conversation. May need occasional repetition, extra time, or louder voice.|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary c|39
106|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting in and out of tub/shower|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting|39
107|1 - Yes|1 - Yes|39
108|1-RN|1-RN|39
109|10 - Discharge from agency - no visits completed after start/resumption of care assessment|10 - Discharge from agency - no visits completed after start/resumption of care assessment|39
110|10 - Scheduled surgical procedure|10 - Scheduled surgical procedure|39
111|10 - Self-pay|10 - Self-pay|39
112|11 - Other|11 - Other|39
113|11 - Urinary tract infection|11 - Urinary tract infection|39
114|12 - IV catheter-related infection|12 - IV catheter-related infection|39
115|13 - Deep vein thrombosis, pulmonary embolus|13 - Deep vein thrombosis, pulmonary embolus|39
116|14 - Uncontrolled pain|14 - Uncontrolled pain|39
117|15 - Psychotic episode|15 - Psychotic episode|39
118|16 - Other than above reasons|16 - Other than above reasons|39
119|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing calls.|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing|39
120|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another person.|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another pers|39
121|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface a|39
122|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for intermittent supervision or encouragement or reminders, OR (b) to get in and out of the shower or tub, OR (c) for washing difficult to reach areas.|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for inter|39
123|2 - Asian|2 - Asian|39
124|2 - Caregiver requires considerable assistance from another person to manage equipment, but independently completes significant portions of task.|2 - Caregiver requires considerable assistance from another person to manage equipment, but independ|39
125|2 - Daily, but not constantly|2 - Daily, but not constantly|39
126|2 - Daughter or son|2 - Daughter or son|39
127|2 - Doctor's office emergency visit/house call|2 - Doctor's office emergency visit/house call|39
128|2 - During the day and night|2 - During the day and night|39
129|2 - Early/partial granulation|2 - Early/partial granulation|39
130|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors in word choice, organization or speech intelligibility). Speaks in phrases or short sentences.|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors|39
131|2 - Family member's residence|2 - Family member's residence|39
132|2 - Female|2 - Female|39
133|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conversation, needs frequent prompting or assistance.|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conver|39
134|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|39
135|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|39
136|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately stop activities, jeopardizes safety through actions|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately st|39
137|2 - Indwelling/suprapubic catheter|2 - Indwelling/suprapubic catheter|39
138|2 - Injury caused by fall or accident at home|2 - Injury caused by fall or accident at home|39
139|2 - Medicare (HMO/managed care/Advantage plan)|2 - Medicare (HMO/managed care/Advantage plan)|39
140|2 - Nausea, dehydration, malnutrition, constipation, impaction|2 - Nausea, dehydration, malnutrition, constipation, impaction|39
141|2 - Obesity|2 - Obesity|39
142|2 - On awakening or at night only|2 - On awakening or at night only|39
143|2 - Once a month|2 - Once a month|39
144|2 - One to three times weekly|2 - One to three times weekly|39
145|2 - Parenteral nutrition (TPN or lipids)|2 - Parenteral nutrition (TPN or lipids)|39
146|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic) [ Go to M1620 ]|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic) [ Go|39
147|2 - Patient requires considerable assistance from another person to manage equipment, but independently completes portions of the task.|2 - Patient requires considerable assistance from another person to manage equipment, but independen|39
148|2 - Patient transferred to a noninstitutional hospice|2 - Patient transferred to a noninstitutional hospice|39
149|2 - Person residing in the home (EXCLUDING paid help)|2 - Person residing in the home (EXCLUDING paid help)|39
150|2 - Rehabilitation facility [ Go to M0903 ]|2 - Rehabilitation facility [ Go to M0903 ]|39
151|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifting of attention) or consistently requires low stimulus environment due to distractibility.|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifti|39
152|2 - Respite care|2 - Respite care|39
153|2 - Sense of failure or self reproach|2 - Sense of failure or self reproach|39
154|2 - Several times during day|2 - Several times during day|39
155|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonresponsive.|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonrespons|39
156|2 - Someone must assist the patient to groom self.|2 - Someone must assist the patient to groom self.|39
157|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|39
158|2 - Someone must help the patient put on upper body clothing.|2 - Someone must help the patient put on upper body clothing.|39
159|2 - Stage 2|2 - Stage 2|39
160|2 - Start of care - no further visits planned|2 - Start of care - no further visits planned|39
161|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitoring|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitori|39
162|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment regimen.|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment re|39
163|2 - Two|2 - Two|39
164|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistance due to cognitive or mental limitation.|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistanc|39
165|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|39
166|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assistance).|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assis|39
167|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home delivery.|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home deli|39
168|2 - Unable to prepare any light meals or reheat any delivered meals.|2 - Unable to prepare any light meals or reheat any delivered meals.|39
169|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|39
170|2 - UNABLE to take injectable medications unless administered by someone else.|2 - UNABLE to take injectable medications unless administered by someone else.|39
171|2 - UNABLE to take medication unless administered by someone else.|2 - UNABLE to take medication unless administered by someone else.|39
172|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|39
173|2 - Ventilator (continually or at night)|2 - Ventilator (continually or at night)|39
174|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less than 20 feet)|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less th|39
175|2 - With spouse or significant other|2 - With spouse or significant other|39
176|2 - Yes, assistance or services provided by family or friends|2 - Yes, assistance or services provided by family or friends|39
177|2-PT|2-PT|39
178|3 - Able to answer the telephone only some of the time or is able to carry on only a limited conversation.|3 - Able to answer the telephone only some of the time or is able to carry on only a limited convers|39
179|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube or gastrostomy.|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube|39
180|3 - Alcohol dependency|3 - Alcohol dependency|39
181|3 - All of the time|3 - All of the time|39
182|3 - Black or African-American|3 - Black or African-American|39
183|3 - Boarding home or rented room|3 - Boarding home or rented room|39
184|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment, clean/store/dispose of equipment or supplies).|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment,|39
185|3 -Able to walk only with the supervision or assistance of another person at all times.|3 -Able to walk only with the supervision or assistance of another person at all times.|39
186|3 - Continuous / Bi-level positive airway pressure|3 - Continuous / Bi-level positive airway pressure|39
187|3 - During the day and evening, but not constantly|3 - During the day and evening, but not constantly|39
188|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the alimentary canal)|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the|39
189|3 - Environmental support (e.g., housing, home maintenance)|3 - Environmental support (e.g., housing, home maintenance)|39
190|3 - Four to six times weekly|3 - Four to six times weekly|39
191|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessing by listener.  Speech limited to single words or short phrases.|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessin|39
192|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires multiple repetitions, restatements, demonstrations, additional time.|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires m|39
193|3 - Hopelessness|3 - Hopelessness|39
194|3 - Hospice care|3 - Hospice care|39
195|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|39
196|3 - Injury caused by fall or accident at home|3 - Injury caused by fall or accident at home|39
197|3 - Intractable pain|3 - Intractable pain|39
198|3 - Medicaid (traditional fee-for-service)|3 - Medicaid (traditional fee-for-service)|39
199|3 - Needs someone to do all shopping and errands.|3 - Needs someone to do all shopping and errands.|39
200|3 - Not healing|3 - Not healing|39
201|3 - Nursing home [ Go to M2440 ]|3 - Nursing home [ Go to M2440 ]|39
202|3 - Once daily|3 - Once daily|39
203|3 - Other family member|3 - Other family member|39
204|3 - Outpatient department/clinic emergency (includes urgicenter sites)|3 - Outpatient department/clinic emergency (includes urgicenter sites)|39
205|3 - Paid help|3 - Paid help|39
206|3 - Able to participate in bathing self in shower or tub, but requires presence of another person throughout the bath for assistance or supervision.|3 - Able to participate in bathing self in shower or tub, but requires presence of another person th|39
207|3 - Patient depends entirely upon another person to dress lower body.|3 - Patient depends entirely upon another person to dress lower body.|39
208|3 - Patient depends entirely upon another person to dress the upper body.|3 - Patient depends entirely upon another person to dress the upper body.|39
209|3 - Patient depends entirely upon someone else for grooming needs.|3 - Patient depends entirely upon someone else for grooming needs.|39
210|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone else to manage the equipment.|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone|39
211|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable to shift attention and recall directions more than half the time.|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable|39
212|3 - Respiratory problems (SOB, infection, obstruction)|3 - Respiratory problems (SOB, infection, obstruction)|39
213|3 - Resumption of care (after inpatient stay)|3 - Resumption of care (after inpatient stay)|39
214|3 - Several times each month|3 - Several times each month|39
215|3 - Skilled Nursing Facility|3 - Skilled Nursing Facility|39
216|3 - Stage 3|3 - Stage 3|39
217|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|39
218|3 - Three|3 - Three|39
219|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person throughout the process.|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person through|39
220|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal independently.|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal indep|39
221|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person.|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person|39
222|3 - Unknown because patient moved to a geographic location not served by this agency|3 - Unknown because patient moved to a geographic location not served by this agency|39
223|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|39
224|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|39
225|3 - With other family member|3 - With other family member|39
226|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home health services, homemaker assistance, transportation assistance, assisted living, board and care)|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home h|39
227|3-SLP/ST|3-SLP/ST|39
228|4 - At rest (during day or night)|4 - At rest (during day or night)|39
229|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|39
230|4 - Board and care or assisted living facility|4 - Board and care or assisted living facility|39
231|4 - Caregiver is completely dependent on someone else to manage all equipment.|4 - Caregiver is completely dependent on someone else to manage all equipment.|39
232|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|39
233|4 - Constantly|4 - Constantly|39
234|4 - Drug dependency|4 - Drug dependency|39
235|4 - Four or more|4 - Four or more|39
236|4 - Friend or neighbor or community or church member|4 - Friend or neighbor or community or church member|39
237|4 - Hispanic or Latino|4 - Hispanic or Latino|39
238|4 - Hospice [ Go to M0903 ]|4 - Hospice [ Go to M0903 ]|39
239|4 - Impaired decision-making|4 - Impaired decision-making|39
240|4 - Is totally dependent in toileting.|4 - Is totally dependent in toileting.|39
241|4 - Medicaid (HMO/managed care)|4 - Medicaid (HMO/managed care)|39
242|4 - None of the above|4 - None of the above|39
243|4 - Nursing home|4 - Nursing home|39
244|4 - On a daily basis|4 - On a daily basis|39
245|4 - Patient is completely dependent on someone else to manage all equipment.|4 - Patient is completely dependent on someone else to manage all equipment.|39
246|4 - Permanent placement|4 - Permanent placement|39
247|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, punches, dangerous maneuvers w/ wheelchair or other objects)|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, pu|39
248|4 - Psychosocial support (e.g., socialization, companionship, recreation)|4 - Psychosocial support (e.g., socialization, companionship, recreation)|39
249|4 - Recertification (follow-up) reassessment|4 - Recertification (follow-up) reassessment|39
250|4 - Recurrent thoughts of death|4 - Recurrent thoughts of death|39
251|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruction)|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruc|39
252|4 - Several times a week|4 - Several times a week|39
253|4 - Stage 4|4 - Stage 4|39
254|4 - Symptoms poorly controlled, history of re-hospitalizations|4 - Symptoms poorly controlled, history of re-hospitalizations|39
255|4 - Three or more times per week|4 - Three or more times per week|39
256|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetative state, or delirium.|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetati|39
257|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|39
258|4 - Unable to effectively participate in any housekeeping tasks.|4 - Unable to effectively participate in any housekeeping tasks.|39
259|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or unresponsive (e.g., speech is nonsensical or unintelligible).|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or u|39
260|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonresponsive.|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonr|39
261|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostomy.|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostom|39
262|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of devices at the sink, in chair, or on commode|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of|39
263|4 - With a friend|4 - With a friend|39
264|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|39
265|4-OT|4-OT|39
266|5 - Advocates or facilitates patient's participation in appropriate medical care|5 - Advocates or facilitates patient's participation in appropriate medical care|39
267|5 - At least daily|5 - At least daily|39
268|6 - Bedfast, unable to ambulate or be up in a chair.|6 - Bedfast, unable to ambulate or be up in a chair.|39
269|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|39
270|5 - Disruptive or socially inappropriate behavior|5 - Disruptive or socially inappropriate behavior|39
271|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|39
272|5 - Hypo/Hyperglycemia, diabetes out of control|5 - Hypo/Hyperglycemia, diabetes out of control|39
273|5 - More often than once daily|5 - More often than once daily|39
274|5 - Native Hawaiian or Pacific Islander|5 - Native Hawaiian or Pacific Islander|39
275|5 - None of the above|5 - None of the above|39
276|5 - One to two times per week|5 - One to two times per week|39
277|5 - Other|5 - Other|39
278|5 - Other follow-up|5 - Other follow-up|39
279|5 - Paid help|5 - Paid help|39
280|5 - Patient nonresponsive or unable to speak.|5 - Patient nonresponsive or unable to speak.|39
281|5 - Thoughts of suicide|5 - Thoughts of suicide|39
282|5 - Totally unable to use the telephone.|5 - Totally unable to use the telephone.|39
283|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|39
284|5 - Unable to take in nutrients orally or by tube feeding.|5 - Unable to take in nutrients orally or by tube feeding.|39
285|5 - Unsafe for care at home|5 - Unsafe for care at home|39
286|5 - With paid help (other than home care agency staff)|5 - With paid help (other than home care agency staff)|39
287|5 - Workers' compensation|5 - Workers' compensation|39
288|5 - Wound infection, deteriorating wound status, new lesion/ulcer|5 - Wound infection, deteriorating wound status, new lesion/ulcer|39
289|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|39
290|6 - Delusional, hallucinatory, or paranoid behavior|6 - Delusional, hallucinatory, or paranoid behavior|39
291|6 - Financial agent, power of attorney, or conservator of finance|6 - Financial agent, power of attorney, or conservator of finance|39
292|6 - GI bleeding, obstruction|6 - GI bleeding, obstruction|39
293|6 - Less often than weekly|6 - Less often than weekly|39
294|6 - Memory loss to the extent that supervision required|6 - Memory loss to the extent that supervision required|39
295|6 - None of the above feelings observed or reported|6 - None of the above feelings observed or reported|39
296|6 - Other|6 - Other|39
297|6 - Title programs (e.g., Title III, V, or XX)|6 - Title programs (e.g., Title III, V, or XX)|39
298|6 - Transferred to an inpatient facility - patient not discharged from agency|6 - Transferred to an inpatient facility - patient not discharged from agency|39
299|6 - White|6 - White|39
300|6 - With other than above|6 - With other than above|39
301|7 - Exacerbation of CHF, fluid overload, heart failure|7 - Exacerbation of CHF, fluid overload, heart failure|39
302|7 - Health care agent, conservator of person, or medical power of attorney|7 - Health care agent, conservator of person, or medical power of attorney|39
303|7 - Hypo/Hyperglycemia, diabetes out of control|7 - Hypo/Hyperglycemia, diabetes out of control|39
304|7 - None of the above|7 - None of the above|39
305|7 - None of the above behaviors demonstrated|7 - None of the above behaviors demonstrated|39
306|7 - Other government (e.g., TriCare, VA, etc.)|7 - Other government (e.g., TriCare, VA, etc.)|39
307|7 - Transferred to an inpatient facility - patient discharged from agency|7 - Transferred to an inpatient facility - patient discharged from agency|39
308|8 - Death at home|8 - Death at home|39
309|8 - GI bleeding, obstruction|8 - GI bleeding, obstruction|39
310|8 - Myocardial infarction, stroke|8 - Myocardial infarction, stroke|39
311|8 - Private insurance|8 - Private insurance|39
312|9 - Chemotherapy|9 - Chemotherapy|39
313|9 - Discharge from agency|9 - Discharge from agency|39
314|9 - Other than above reasons|9 - Other than above reasons|39
315|9 - Private HMO/managed care|9 - Private HMO/managed care|39
316|NA - No caregiver|NA - No caregiver|39
317|NA - No equipment of this type used in care.|NA - No equipment of this type used in care.|39
318|NA - No inhalant/mist medications prescribed.|NA - No inhalant/mist medications prescribed.|39
319|NA - No injectable medications prescribed.|NA - No injectable medications prescribed.|39
320|NA - No inpatient facility admission|NA - No inpatient facility admission|39
321|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|39
322|NA - No Medicaid|NA - No Medicaid|39
323|NA - No Medicare|NA - No Medicare|39
324|NA - No observable pressure ulcer|NA - No observable pressure ulcer|39
325|NA - No observable stasis ulcer|NA - No observable stasis ulcer|39
326|NA - No observable surgical wound|NA - No observable surgical wound|39
327|NA - No oral medications prescribed.|NA - No oral medications prescribed.|39
328|NA - Not applicable|NA - Not applicable|39
329|NA - Patient does not have a telephone.|NA - Patient does not have a telephone.|39
330|NA - Patient has ostomy for bowel elimination|NA - Patient has ostomy for bowel elimination|39
331|NA - Patient nonresponsive|NA - Patient nonresponsive|39
332|NA - Patient on prophylactic treatment|NA - Patient on prophylactic treatment|39
333|NA - Patient was not discharged from an inpatient facility [Go to M1016 ]|NA - Patient was not discharged from an inpatient facility [Go to M1016 ]|39
334|UK - Other unknown|UK - Other unknown|39
335|UK - Reason unknown|UK - Reason unknown|39
336|UK - Unknown|UK - Unknown|39
337|UK - Unknown or Not Available|UK - Unknown or Not Available|39
341|01 - Early|01 - Early|39
342|02 - Late|02 - Late|39
343|NA - Not Applicable. No case mix group defined for this assessment.|NA - Not Applicable. No case mix group defined for this assessment.|39
344|NA - No case mix group defined by this assessment.|NA - No case mix group defined by this assessment.|39
345|1 - Recent decline in mental, emotional, or behavioral status|1 - Recent decline in mental, emotional, or behavioral status|39
346|2 - Multiple hospitalizations (2 or more) in the past 12 months|2 - Multiple hospitalizations (2 or more) in the past 12 months|39
347|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|39
348|4 - Taking five or more medications|4 - Taking five or more medications|39
349|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|39
350|6 - Other|6 - Other|39
351|7 - None of the above|7 - None of the above|39
352|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond tho|39
353|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable without heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable wi|39
354|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious complications and death.|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious compl|39
355|3 - The patient has serious progressive conditions that could lead to death within a year.|3 - The patient has serious progressive conditions that could lead to death within a year.|39
356|UK - The patient+s situation is unknown or unclear.|UK - The patient+s situation is unknown or unclear.|39
357|1 - Yes [ Go to M1050 ]|1 - Yes [ Go to M1050 ]|39
358|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this influenza season. [ Go to M1050 ]|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this i|39
359|1 - Received from another health care provider (e.g., physician)|1 - Received from another health care provider (e.g., physician)|39
360|2 - Received from your agency previously during this year+s flu season|2 - Received from your agency previously during this year+s flu season|39
361|3 - Offered and declined|3 - Offered and declined|39
362|4 - Assessed and determined to have medical contraindication(s)|4 - Assessed and determined to have medical contraindication(s)|39
363|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|39
364|6 - Inability to obtain vaccine due to declared shortage|6 - Inability to obtain vaccine due to declared shortage|39
365|1 - Yes [ Go to M1500 at TRN; Go to M1230 at DC ]|1 - Yes [ Go to M1500 at TRN; Go to M1230 at DC ]|39
366|1 - Patient has received PPV in the past|1 - Patient has received PPV in the past|39
367|2 - Offered and declined|2 - Offered and declined|39
368|3 - Assessed and determined to have medical contraindication(s)|3 - Assessed and determined to have medical contraindication(s)|39
369|4 - Not indicated; patient does not meet age/condition guidelines for PPV|4 - Not indicated; patient does not meet age/condition guidelines for PPV|39
370|5 - None of the above|5 - None of the above|39
371|0 - Adequate: hears normal conversation without difficulty.|0 - Adequate: hears normal conversation without difficulty.|39
372|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to increase volume or speak distinctly.|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to in|39
373|2 - Severely Impaired: absence of useful hearing.|2 - Severely Impaired: absence of useful hearing.|39
374|UK - Unable to assess hearing.|UK - Unable to assess hearing.|39
375|0 - Understands: clear comprehension without cues or repetitions.|0 - Understands: clear comprehension without cues or repetitions.|39
376|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Requires cues at times to understand.|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Req|39
377|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequently requires cues to understand.|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequentl|39
378|3 - Rarely/Never Understands|3 - Rarely/Never Understands|39
379|UK - Unable to assess understanding.|UK - Unable to assess understanding.|39
380|0 - No standardized assessment conducted|0 - No standardized assessment conducted|39
381|1 - Yes, and it does not indicate severe pain|1 - Yes, and it does not indicate severe pain|39
382|2 - Yes, and it indicates severe pain|2 - Yes, and it indicates severe pain|39
383|0 - Patient has no pain|0 - Patient has no pain|39
384|1 - Patient has pain that does not interfere with activity or movement|1 - Patient has pain that does not interfere with activity or movement|39
385|2 - Less often than daily|2 - Less often than daily|39
386|3 - Daily, but not constantly|3 - Daily, but not constantly|39
387|4 - All of the time|4 - All of the time|39
388|0 - No assessment conducted [ Go to M1306 ]|0 - No assessment conducted [ Go to M1306 ]|39
389|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc., without use of standardized tool|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc.,|39
390|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|39
391|0 - No [ Go to M1322]|0 - No [ Go to M1322]|39
392|0 v Newly epithelialized|0 v Newly epithelialized|39
393|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|39
394|2 - Yes, patient has observable stasis ulcers ONLY|2 - Yes, patient has observable stasis ulcers ONLY|39
395|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable dressing) [Go to M1340]|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable|39
396|0 - No [ Go to M1350 ]|0 - No [ Go to M1350 ]|39
397|1 - Yes, patient has at least one (observable) surgical wound|1 - Yes, patient has at least one (observable) surgical wound|39
398|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1350 ]|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1350 ]|39
399|0 - Patient is not short of breath|0 - Patient is not short of breath|39
400|3 - Continuous Bi-level positive airway pressure|3 - Continuous Bi-level positive airway pressure|39
401|0 - No [ Go to M1732 at TRN; Go to M1600 at DC ]|0 - No [ Go to M1732 at TRN; Go to M1600 at DC ]|39
402|2 - Not assessed [Go to M1732 at TRN; Go to M1600 at DC ]|2 - Not assessed [Go to M1732 at TRN; Go to M1600 at DC ]|39
403|NA - Patient does not have diagnosis of heart failure [Go to M2004 at TRN; Go to M1600 at DC]|NA - Patient does not have diagnosis of heart failure [Go to M2004 at TRN; Go to M1600 at DC]|39
404|0 - No action taken|0 - No action taken|39
405|1 - Patient+s physician (or other primary care practitioner) contacted the same day|1 - Patient+s physician (or other primary care practitioner) contacted the same day|39
406|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|39
407|3 - Implement physician-ordered patient-specific established parameters for treatment|3 - Implement physician-ordered patient-specific established parameters for treatment|39
408|4 - Patient education or other clinical interventions|4 - Patient education or other clinical interventions|39
409|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequency, telehealth, etc.)|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequ|39
410|1 - Occasional stress incontinence|1 - Occasional stress incontinence|39
411|2 - During the night only|2 - During the night only|39
412|3 - During the day only|3 - During the day only|39
413|4 - During the day and night|4 - During the day and night|39
414|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|39
415|0 - Able to manage toileting hygiene and clothing management without assistance.|0 - Able to manage toileting hygiene and clothing management without assistance.|39
416|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implements are laid out for the patient.|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implemen|39
417|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|39
418|3 - Patient depends entirely upon another person to maintain toileting hygiene.|3 - Patient depends entirely upon another person to maintain toileting hygiene.|39
419|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independent|39
420|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface|39
421|0 - No multi-factor falls risk assessment conducted.|0 - No multi-factor falls risk assessment conducted.|39
422|1 - Yes, and it does not indicate a risk for falls.|1 - Yes, and it does not indicate a risk for falls.|39
423|2 - Yes, and it indicates a risk for falls.|2 - Yes, and it indicates a risk for falls.|39
424|0 - Not assessed/reviewed [ Go to M2010 ]|0 - Not assessed/reviewed [ Go to M2010 ]|39
425|1 - No problems found during review [ Go to M2010 ]|1 - No problems found during review [ Go to M2010 ]|39
426|2 - Problems found during review|2 - Problems found during review|39
427|NA - Patient is not taking any medications [ Go to M2040 ]|NA - Patient is not taking any medications [ Go to M2040 ]|39
428|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special precautions associated with all high-risk medications|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special p|39
429|NA - Patient not taking any drugs|NA - Patient not taking any drugs|39
430|2 - Able to take medication(s) at the correct times if given reminders by another person at the appropriate times|2 - Able to take medication(s) at the correct times if given reminders by another person at the appr|39
431|3 - Unable to take medication unless administered by another person.|3 - Unable to take medication unless administered by another person.|39
432|1 - At least daily|1 - At least daily|39
433|2 - Three or more times per week|2 - Three or more times per week|39
434|3 - One to two times per week|3 - One to two times per week|39
435|4 - Received, but less often than weekly|4 - Received, but less often than weekly|39
436|5 - No assistance received|5 - No assistance received|39
437|0 - No [Go to M2400]|0 - No [Go to M2400]|39
438|1 - Yes, used hospital emergency department WITHOUT hospital admission|1 - Yes, used hospital emergency department WITHOUT hospital admission|39
439|2 - Yes, used hospital emergency department WITH hospital admission|2 - Yes, used hospital emergency department WITH hospital admission|39
440|UK - Unknown [Go to M2400]|UK - Unknown [Go to M2400]|39
441|2 - Injury caused by fall|2 - Injury caused by fall|39
442|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|39
443|4 - Other respiratory problem|4 - Other respiratory problem|39
444|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|39
445|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|39
446|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|39
447|8 - Other heart disease|8 - Other heart disease|39
448|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|39
449|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|39
450|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|39
451|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|39
452|13 - Urinary tract infection|13 - Urinary tract infection|39
453|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|39
454|15 - Wound infection or deterioration|15 - Wound infection or deterioration|39
455|16 - Uncontrolled pain|16 - Uncontrolled pain|39
456|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|39
457|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|39
458|19 - Other than above reasons|19 - Other than above reasons|39
459|2 - Patient remained in the community (with formal assistive services)|2 - Patient remained in the community (with formal assistive services)|39
460|3 - Patient transferred to a noninstitutional hospice|3 - Patient transferred to a noninstitutional hospice|39
461|4 - Unknown because patient moved to a geographic location not served by this agency|4 - Unknown because patient moved to a geographic location not served by this agency|39
462|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|39
463|4 - Other respiratory problem|4 - Other respiratory problem|39
464|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|39
465|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|39
466|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|39
467|8 - Other heart disease|8 - Other heart disease|39
468|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|39
469|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|39
470|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|39
471|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|39
472|13 - Urinary tract infection|13 - Urinary tract infection|39
473|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|39
474|15 - Wound infection or deterioration|15 - Wound infection or deterioration|39
475|16 - Uncontrolled pain|16 - Uncontrolled pain|39
476|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|39
477|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|39
478|19 - Scheduled treatment or procedure|19 - Scheduled treatment or procedure|39
479|20 - Other than above reasons|20 - Other than above reasons|39
480|UK - Reason unknown [Go to M0903]|UK - Reason unknown [Go to M0903]|39
482|01 - Patient lives alone around the clock|01 - Patient lives alone around the clock|39
483|02 - Patient lives alone regular daytime|02 - Patient lives alone regular daytime|39
484|03 - Patient lives alone regular nighttime|03 - Patient lives alone regular nighttime|39
485|04 - Patient lives alone occassional/short term assistance|04 - Patient lives alone occassional/short term assistance|39
486|05 - Patient lives alone no assisstance available|05 - Patient lives alone no assisstance available|39
487|06 - Patient lives with other person(s) in the home around the clock|06 - Patient lives with other person(s) in the home around the clock|39
488|07 - Patient lives with other person(s) in the home regular daytime|07 - Patient lives with other person(s) in the home regular daytime|39
489|08 - Patient lives with other person(s) in the home regular nighttime|08 - Patient lives with other person(s) in the home regular nighttime|39
490|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|39
491|10 - Patient lives with other person(s) in the home no assistance available|10 - Patient lives with other person(s) in the home no assistance available|39
492|1 - Was present at the most recent SOC/ROC assessment [Goto M1308A1]|1 - Was present at the most recent SOC/ROC assessment [Goto M1308A1]|39
493|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|39
494|NA - No non-epithelialized Stage II pressure ulcers are present at discharge [Goto M1308A1]|NA - No non-epithelialized Stage II pressure ulcers are present at discharge [Goto M1308A1]|39
495|0 - Newly epithelialized|0 - Newly epithelialized|39
496|0 - No [ Go to M1340 ]|0 - No [ Go to M1340 ]|39
498|0 - Independent|0 - Independent|39
499|1 - Needed Some Help|1 - Needed Some Help|39
500|2 - Dependent|2 - Dependent|39
502|0 - No assistance needed in this area|0 - No assistance needed in this area|39
503|1 - Caregiver(s) currently provide assistance|1 - Caregiver(s) currently provide assistance|39
504|2 - Caregiver(s) need training/ supportive services to provide assistance|2 - Caregiver(s) need training/ supportive services to provide assistance|39
505|3 - Caregiver(s) not likely to provide assistance|3 - Caregiver(s) not likely to provide assistance|39
506|4 - Unclear if Caregiver(s) will provide assistance|4 - Unclear if Caregiver(s) will provide assistance|39
507|5 - Assistance needed, but no Caregiver(s) available|5 - Assistance needed, but no Caregiver(s) available|39
508|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will use standardized clinical guidelines accessible for all care providers to reference|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will|39
510|NA - Patient is not assessed to be at risk for falls|NA - Patient is not assessed to be at risk for falls|39
511|NA - Patient has no diagnosis or symptoms of depression|NA - Patient has no diagnosis or symptoms of depression|39
512|NA - No pain identified|NA - No pain identified|39
513|NA - Patient is not assessed to be at risk for pressure ulcers|NA - Patient is not assessed to be at risk for pressure ulcers|39
514|NA - Patient has no pressure ulcers with need for moist wound healing|NA - Patient has no pressure ulcers with need for moist wound healing|39
515|1 - Long-term nursing facility (NF)|1 - Long-term nursing facility (NF)|39
516|2 - Skilled nursing facility (SNF / TCU)|2 - Skilled nursing facility (SNF / TCU)|39
517|3 - Short stay acute hospital (IPP S)|3 - Short stay acute hospital (IPP S)|39
518|4 - Long-term care hospital (LTCH)|4 - Long-term care hospital (LTCH)|39
519|5 - Inpatient rehabilitation hospital or unit (IRF)|5 - Inpatient rehabilitation hospital or unit (IRF)|39
520|6 - Psychiatric hospital or unit|6 - Psychiatric hospital or unit|39
521|7 - Other|7 - Other|39
522|NA - Patient was not discharged from an inpatient facility [Goto M1016]|NA - Patient was not discharged from an inpatient facility [Goto M1016]|39
523|6 - Unable to participate effectively in bathing and is bathed totally by another person|6 - Unable to participate effectively in bathing and is bathed totally by another person|39
524|4 - Chairfast, unable to ambulate but is able to wheel self independently.|4 - Chairfast, unable to ambulate but is able to wheel self independently.|39
525|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask patient: "Over the last two weeks, how often have you been bothered by any of the following problems")  *Copyright+ Pfizer Inc. All rights reserved. Reproduced with permission.|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask|39
526|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluation for depression.|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluat|39
527|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet criteria for further evaluation for depression.|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet|39
528|0 - Not at all  0 - 1 day|0 - Not at all  0 - 1 day|39
529|1 - Several days  2 - 6 days|1 - Several days  2 - 6 days|39
530|2 - More than half of the days  7 - 11 days|2 - More than half of the days  7 - 11 days|39
531|3 - Nearly every day  12 - 14 days|3 - Nearly every day  12 - 14 days|39
532|NA - N/A  Unable to respond|NA - N/A  Unable to respond|39
533|2 - Able to take medication(s) at the correct times if given reminders by another person based on the frequency of the injection|2 - Able to take medication(s) at the correct times if given reminders by another person based on th|39
534|3 - Unable to take injectable medication unless administered by another person.|3 - Unable to take injectable medication unless administered by another person.|39
570|NA - No observable pressure ulcer or unhealed pressure ulcer|NA - No observable pressure ulcer or unhealed pressure ulcer|39
571|NA - No clinically significant medication issues identified since the previous OASIS assessment|NA - No clinically significant medication issues identified since the previous OASIS assessment|39
572|NA - Patient is not diabetic or is bilateral amputee|NA - Patient is not diabetic or is bilateral amputee|39
573|NA - Formal multi-factor Fall Risk Assessment indicates the patient was not at risk for falls since the last OASIS assessment|NA - Formal multi-factor Fall Risk Assessment indicates the patient was not at risk for falls since|39
574|NA - Formal assessment indicates patient did not meet criteria for depression AND patient did not have diagnosis of depression since the last OASIS assessment|NA - Formal assessment indicates patient did not meet criteria for depression AND patient did not ha|39
575|NA - Formal assessment did not indicate pain since the last OASIS assessment|NA - Formal assessment did not indicate pain since the last OASIS assessment|39
576|NA - Formal assessment indicates the patient was not at risk of pressure ulcers since the last OASIS assessment|NA - Formal assessment indicates the patient was not at risk of pressure ulcers since the last OASIS|39
577|NA - Dressings that support the principles of moist wound healing not indicated for this patient's pressure ulcers OR patient has no pressure ulcers with need for moist wound healing|NA - Dressings that support the principles of moist wound healing not indicated for this patient's p|39
578|1 - Patient remained in the community (without formal assistive services)|1 - Patient remained in the community (without formal assistive services)|39
579|2 - Patient remained in the community (with formal assistive services)|2 - Patient remained in the community (with formal assistive services)|39
580|3 - Patient transferred to a non-institutional hospice|3 - Patient transferred to a non-institutional hospice|39
581|4 - Unknown because patient moved to a geographic location not served by this agency|4 - Unknown because patient moved to a geographic location not served by this agency|39
2|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; OR (b) Is physically, cognitively, and mentally able to prepare light meals on a regular basis but has not routinely performed light meal preparation in the past (i.e., prior to this home care admission).|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; O|41
3|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and mentally able to perform all housekeeping tasks .|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and menta|41
4|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and mentally able to do laundry and access facilities.|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and menta|41
5|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying packages OR b) Physically, cognitively, and mentally able to take care of shopping, but has not done shopping in the past (i.e., prior to this home care admission).|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying|41
6|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|41
7|0 - Able to dial numbers and answer calls appropriately and as desired.|0 - Able to dial numbers and answer calls appropriately and as desired.|41
8|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body without assistance.|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body|41
9|0 - Able to get to and from the toilet and transfer independently with or without a device.|0 - Able to get to and from the toilet and transfer independently with or without a device.|41
10|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|41
11|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible public bus.|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible p|41
12|0 - Able to independently feed self.|0 - Able to independently feed self.|41
13|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|41
14|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct times.|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct ti|41
15|0 - Able to independently transfer.|0 - Able to independently transfer.|41
16|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without rail|41
17|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings|41
18|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|41
19|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions independently.|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions indep|41
20|0 - Asymptomatic, no treatment needed at this time|0 - Asymptomatic, no treatment needed at this time|41
21|0 - Caregiver manages all tasks related to equipment completely independently.|0 - Caregiver manages all tasks related to equipment completely independently.|41
22|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations with no observable impairment.|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations w|41
23|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|41
24|0 - Life expectancy is greater than 6 months|0 - Life expectancy is greater than 6 months|41
25|0 - Never|0 - Never|41
26|0 - Patient is not short of breath|0 - Patient is not short of breath|41
27|0 - No|0 - No|41
28|0 - No emergent care services|0 - No emergent care services|41
29|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [ Go to M1620 ]|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [ Go to M1620 ]|41
30|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and extended or abstract conversation.|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and exte|41
31|0 - No one person|0 - No one person|41
32|0 - None of the time|0 - None of the time|41
33|0 - None, no charge for current services|0 - None, no charge for current services|41
34|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|41
35|0 - Patient does NOT have an ostomy for bowel elimination.|0 - Patient does NOT have an ostomy for bowel elimination.|41
36|0 - Patient has no pain|0 - Patient has no pain|41
37|0 - Patient manages all tasks related to equipment completely independently.|0 - Patient manages all tasks related to equipment completely independently.|41
38|0 - Poor:  little or no recovery is expected and/or further decline is imminent|0 - Poor:  little or no recovery is expected and/or further decline is imminent|41
39|0 - Timed-voiding defers incontinence|0 - Timed-voiding defers incontinence|41
40|0 - Very rarely or never has bowel incontinence|0 - Very rarely or never has bowel incontinence|41
41|0 - Zero|0 - Zero|41
42|00 - No|00 - No|41
43|01 - Yes|01 - Yes|41
44|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or mental limitations, needs assistance with heavy laundry.|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or|41
45|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the patient.|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the|41
46|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|41
47|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or supervision from another person OR c) a liquid, pureed or ground meat diet.|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or su|41
48|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|41
49|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|41
50|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independently.|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independe|41
51|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only when assisted or accompanied by another person.|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only w|41
52|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepa|41
53|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance by another person OR b) given daily reminders.|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance b|41
54|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advan|41
55|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advan|41
56|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for the deaf) and call essential numbers.|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for t|41
57|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|41
58|1 - American Indian or Alaska Native|1 - American Indian or Alaska Native|41
59|1 - Depressed mood (e.g., feeling sad, tearful)|1 - Depressed mood (e.g., feeling sad, tearful)|41
60|1 - During the night only|1 - During the night only|41
61|1 - Fully granulating|1 - Fully granulating|41
62|1 - Good/Fair:  partial to full recovery is expected|1 - Good/Fair:  partial to full recovery is expected|41
63|1 - Good:  marked improvement in functional status is expected|1 - Good:  marked improvement in functional status is expected|41
64|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|41
65|1 - Smoking|1 - Smoking|41
66|1 - Hospital|1 - Hospital|41
67|1 - Hospital emergency room (includes 23-hour holding)|1 - Hospital emergency room (includes 23-hour holding)|41
68|1 - Hospitalization for EMERGENT (unscheduled) care|1 - Hospitalization for EMERGENT (unscheduled) care|41
69|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepared solutions), patient is able to manage all other aspects of equipment.|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepar|41
70|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|41
71|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|41
72|1 - In new or complex situations only|1 - In new or complex situations only|41
73|1 - Intravenous or infusion therapy (excludes TPN)|1 - Intravenous or infusion therapy (excludes TPN)|41
74|1 - Less often than daily|1 - Less often than daily|41
75|1 - Less than once a month|1 - Less than once a month|41
76|1 - Less than once weekly|1 - Less than once weekly|41
77|1 - Life expectancy is 6 months or fewer|1 - Life expectancy is 6 months or fewer|41
78|1 - Lives alone|1 - Lives alone|41
79|1 - Male|1 - Male|41
80|1 - Medicare (traditional fee-for-service)|1 - Medicare (traditional fee-for-service)|41
81|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of past 24 hours, significant memory loss so that supervision is required|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of pas|41
82|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors in word choice, grammar or speech intelligibility, needs minimal prompting or assistance).|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors i|41
83|1 - No assistance or services received|1 - No assistance or services received|41
84|1 - One|1 - One|41
85|1 - Oxygen (intermittent or continuous)|1 - Oxygen (intermittent or continuous)|41
86|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, and the surrounding layout, can count fingers at arm's length.|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, a|41
87|1 - Patient is incontinent|1 - Patient is incontinent|41
88|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|41
89|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical or treatment regimen.|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical|41
90|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient/couple/significant other)|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient|41
91|1 - Relatives, friends, or neighbors living outside the home|1 - Relatives, friends, or neighbors living outside the home|41
92|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions.|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions|41
93|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independentl|41
94|1 - Several times during day and night|1 - Several times during day and night|41
95|1 - Spouse or significant other|1 - Spouse or significant other|41
96|1 - Stage 1|1 - Stage 1|41
97|1 - Start of care - further visits planned|1 - Start of care - further visits planned|41
98|1 - Symptoms well controlled with current therapy|1 - Symptoms well controlled with current therapy|41
99|1 - Therapy services|1 - Therapy services|41
100|1 - Able to transfer with minimal human assistance or with use of an assistive device.|1 - Able to transfer with minimal human assistance or with use of an assistive device.|41
101|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitations.|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitatio|41
102|1 - Urinary incontinence|1 - Urinary incontinence|41
103|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and transfer.|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and|41
104|1 - When walking more than 20 feet, climbing stairs|1 - When walking more than 20 feet, climbing stairs|41
105|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary conversation. May need occasional repetition, extra time, or louder voice.|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary c|41
106|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting in and out of tub/shower|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting|41
107|1 - Yes|1 - Yes|41
108|1-RN|1-RN|41
109|10 - Discharge from agency - no visits completed after start/resumption of care assessment|10 - Discharge from agency - no visits completed after start/resumption of care assessment|41
110|10 - Scheduled surgical procedure|10 - Scheduled surgical procedure|41
111|10 - Self-pay|10 - Self-pay|41
112|11 - Other|11 - Other|41
113|11 - Urinary tract infection|11 - Urinary tract infection|41
114|12 - IV catheter-related infection|12 - IV catheter-related infection|41
115|13 - Deep vein thrombosis, pulmonary embolus|13 - Deep vein thrombosis, pulmonary embolus|41
116|14 - Uncontrolled pain|14 - Uncontrolled pain|41
117|15 - Psychotic episode|15 - Psychotic episode|41
118|16 - Other than above reasons|16 - Other than above reasons|41
119|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing calls.|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing|41
120|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another person.|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another pers|41
121|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface a|41
122|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for intermittent supervision or encouragement or reminders, OR (b) to get in and out of the shower or tub, OR (c) for washing difficult to reach areas.|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for inter|41
123|2 - Asian|2 - Asian|41
124|2 - Caregiver requires considerable assistance from another person to manage equipment, but independently completes significant portions of task.|2 - Caregiver requires considerable assistance from another person to manage equipment, but independ|41
125|2 - Daily, but not constantly|2 - Daily, but not constantly|41
126|2 - Daughter or son|2 - Daughter or son|41
127|2 - Doctor's office emergency visit/house call|2 - Doctor's office emergency visit/house call|41
128|2 - During the day and night|2 - During the day and night|41
129|2 - Early/partial granulation|2 - Early/partial granulation|41
130|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors in word choice, organization or speech intelligibility). Speaks in phrases or short sentences.|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors|41
131|2 - Family member's residence|2 - Family member's residence|41
132|2 - Female|2 - Female|41
133|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conversation, needs frequent prompting or assistance.|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conver|41
134|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|41
135|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|41
136|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately stop activities, jeopardizes safety through actions|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately st|41
137|2 - Indwelling/suprapubic catheter|2 - Indwelling/suprapubic catheter|41
138|2 - Injury caused by fall or accident at home|2 - Injury caused by fall or accident at home|41
139|2 - Medicare (HMO/managed care/Advantage plan)|2 - Medicare (HMO/managed care/Advantage plan)|41
140|2 - Nausea, dehydration, malnutrition, constipation, impaction|2 - Nausea, dehydration, malnutrition, constipation, impaction|41
141|2 - Obesity|2 - Obesity|41
142|2 - On awakening or at night only|2 - On awakening or at night only|41
143|2 - Once a month|2 - Once a month|41
144|2 - One to three times weekly|2 - One to three times weekly|41
145|2 - Parenteral nutrition (TPN or lipids)|2 - Parenteral nutrition (TPN or lipids)|41
146|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic)  [ Go to M1620 ]|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic)  [ Go|41
147|2 - Patient requires considerable assistance from another person to manage equipment, but independently completes portions of the task.|2 - Patient requires considerable assistance from another person to manage equipment, but independen|41
148|2 - Patient transferred to a noninstitutional hospice|2 - Patient transferred to a noninstitutional hospice|41
149|2 - Person residing in the home (EXCLUDING paid help)|2 - Person residing in the home (EXCLUDING paid help)|41
150|2 - Rehabilitation facility|2 - Rehabilitation facility|41
151|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifting of attention) or consistently requires low stimulus environment due to distractibility.|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifti|41
152|2 - Respite care|2 - Respite care|41
153|2 - Sense of failure or self reproach|2 - Sense of failure or self reproach|41
154|2 - Several times during day|2 - Several times during day|41
155|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonresponsive.|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonrespons|41
156|2 - Someone must assist the patient to groom self.|2 - Someone must assist the patient to groom self.|41
157|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|41
158|2 - Someone must help the patient put on upper body clothing.|2 - Someone must help the patient put on upper body clothing.|41
159|2 - Stage 2|2 - Stage 2|41
160|2 - Start of care - no further visits planned|2 - Start of care - no further visits planned|41
161|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitoring|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitori|41
162|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment regimen.|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment re|41
163|2 - Two|2 - Two|41
164|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistance due to cognitive or mental limitation.|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistanc|41
165|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|41
166|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assistance).|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assis|41
167|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home delivery.|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home deli|41
168|2 - Unable to prepare any light meals or reheat any delivered meals.|2 - Unable to prepare any light meals or reheat any delivered meals.|41
169|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|41
170|2 - UNABLE to take injectable medications unless administered by someone else.|2 - UNABLE to take injectable medications unless administered by someone else.|41
171|2 - UNABLE to take medication unless administered by someone else.|2 - UNABLE to take medication unless administered by someone else.|41
172|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|41
173|2 - Ventilator (continually or at night)|2 - Ventilator (continually or at night)|41
174|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less than 20 feet)|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less th|41
175|2 - With spouse or significant other|2 - With spouse or significant other|41
176|2 - Yes, assistance or services provided by family or friends|2 - Yes, assistance or services provided by family or friends|41
177|2-PT|2-PT|41
178|3 - Able to answer the telephone only some of the time or is able to carry on only a limited conversation.|3 - Able to answer the telephone only some of the time or is able to carry on only a limited convers|41
179|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube or gastrostomy.|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube|41
180|3 - Alcohol dependency|3 - Alcohol dependency|41
181|3 - All of the time|3 - All of the time|41
182|3 - Black or African-American|3 - Black or African-American|41
183|3 - Boarding home or rented room|3 - Boarding home or rented room|41
184|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment, clean/store/dispose of equipment or supplies).|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment,|41
185|3 -Able to walk only with the supervision or assistance of another person at all times.|3 -Able to walk only with the supervision or assistance of another person at all times.|41
186|3 - Continuous / Bi-level positive airway pressure|3 - Continuous / Bi-level positive airway pressure|41
187|3 - During the day and evening, but not constantly|3 - During the day and evening, but not constantly|41
188|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the alimentary canal)|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the|41
189|3 - Environmental support (e.g., housing, home maintenance)|3 - Environmental support (e.g., housing, home maintenance)|41
190|3 - Four to six times weekly|3 - Four to six times weekly|41
191|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessing by listener.  Speech limited to single words or short phrases.|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessin|41
192|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires multiple repetitions, restatements, demonstrations, additional time.|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires m|41
193|3 - Hopelessness|3 - Hopelessness|41
194|3 - Hospice care|3 - Hospice care|41
195|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|41
196|3 - Injury caused by fall or accident at home|3 - Injury caused by fall or accident at home|41
197|3 - Intractable pain|3 - Intractable pain|41
198|3 - Medicaid (traditional fee-for-service)|3 - Medicaid (traditional fee-for-service)|41
199|3 - Needs someone to do all shopping and errands.|3 - Needs someone to do all shopping and errands.|41
200|3 - Not healing|3 - Not healing|41
201|3 - Nursing home|3 - Nursing home|41
202|3 - Once daily|3 - Once daily|41
203|3 - Other family member|3 - Other family member|41
204|3 - Outpatient department/clinic emergency (includes urgicenter sites)|3 - Outpatient department/clinic emergency (includes urgicenter sites)|41
205|3 - Paid help|3 - Paid help|41
206|3 - Able to participate in bathing self in shower or tub, but requires presence of another person throughout the bath for assistance or supervision.|3 - Able to participate in bathing self in shower or tub, but requires presence of another person th|41
207|3 - Patient depends entirely upon another person to dress lower body.|3 - Patient depends entirely upon another person to dress lower body.|41
208|3 - Patient depends entirely upon another person to dress the upper body.|3 - Patient depends entirely upon another person to dress the upper body.|41
209|3 - Patient depends entirely upon someone else for grooming needs.|3 - Patient depends entirely upon someone else for grooming needs.|41
210|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone else to manage the equipment.|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone|41
211|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable to shift attention and recall directions more than half the time.|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable|41
212|3 - Respiratory problems (SOB, infection, obstruction)|3 - Respiratory problems (SOB, infection, obstruction)|41
213|3 - Resumption of care (after inpatient stay)|3 - Resumption of care (after inpatient stay)|41
214|3 - Several times each month|3 - Several times each month|41
215|3 - Skilled Nursing Facility|3 - Skilled Nursing Facility|41
216|3 - Stage 3|3 - Stage 3|41
217|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|41
218|3 - Three|3 - Three|41
219|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person throughout the process.|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person through|41
220|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal independently.|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal indep|41
221|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person.|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person|41
222|3 - Unknown because patient moved to a geographic location not served by this agency|3 - Unknown because patient moved to a geographic location not served by this agency|41
223|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|41
224|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|41
225|3 - With other family member|3 - With other family member|41
226|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home health services, homemaker assistance, transportation assistance, assisted living, board and care)|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home h|41
227|3-SLP/ST|3-SLP/ST|41
228|4 - At rest (during day or night)|4 - At rest (during day or night)|41
229|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|41
230|4 - Board and care or assisted living facility|4 - Board and care or assisted living facility|41
231|4 - Caregiver is completely dependent on someone else to manage all equipment.|4 - Caregiver is completely dependent on someone else to manage all equipment.|41
232|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|41
233|4 - Constantly|4 - Constantly|41
234|4 - Drug dependency|4 - Drug dependency|41
235|4 - Four or more|4 - Four or more|41
236|4 - Friend or neighbor or community or church member|4 - Friend or neighbor or community or church member|41
237|4 - Hispanic or Latino|4 - Hispanic or Latino|41
238|4 - Hospice|4 - Hospice|41
239|4 - Impaired decision-making|4 - Impaired decision-making|41
240|4 - Is totally dependent in toileting.|4 - Is totally dependent in toileting.|41
241|4 - Medicaid (HMO/managed care)|4 - Medicaid (HMO/managed care)|41
242|4 - None of the above|4 - None of the above|41
243|4 - Nursing home|4 - Nursing home|41
244|4 - On a daily basis|4 - On a daily basis|41
245|4 - Patient is completely dependent on someone else to manage all equipment.|4 - Patient is completely dependent on someone else to manage all equipment.|41
246|4 - Permanent placement|4 - Permanent placement|41
247|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, punches, dangerous maneuvers w/ wheelchair or other objects)|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, pu|41
248|4 - Psychosocial support (e.g., socialization, companionship, recreation)|4 - Psychosocial support (e.g., socialization, companionship, recreation)|41
249|4 - Recertification (follow-up) reassessment|4 - Recertification (follow-up) reassessment|41
250|4 - Recurrent thoughts of death|4 - Recurrent thoughts of death|41
251|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruction)|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruc|41
252|4 - Several times a week|4 - Several times a week|41
253|4 - Stage 4|4 - Stage 4|41
254|4 - Symptoms poorly controlled, history of re-hospitalizations|4 - Symptoms poorly controlled, history of re-hospitalizations|41
255|4 - Three or more times per week|4 - Three or more times per week|41
256|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetative state, or delirium.|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetati|41
257|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|41
258|4 - Unable to effectively participate in any housekeeping tasks.|4 - Unable to effectively participate in any housekeeping tasks.|41
259|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or unresponsive (e.g., speech is nonsensical or unintelligible).|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or u|41
260|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonresponsive.|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonr|41
261|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostomy.|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostom|41
262|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of devices at the sink, in chair, or on commode|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of|41
263|4 - With a friend|4 - With a friend|41
264|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|41
265|4-OT|4-OT|41
266|5 - Advocates or facilitates patient's participation in appropriate medical care|5 - Advocates or facilitates patient's participation in appropriate medical care|41
267|5 - At least daily|5 - At least daily|41
268|6 - Bedfast, unable to ambulate or be up in a chair.|6 - Bedfast, unable to ambulate or be up in a chair.|41
269|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|41
270|5 - Disruptive or socially inappropriate behavior|5 - Disruptive or socially inappropriate behavior|41
271|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|41
272|5 - Hypo/Hyperglycemia, diabetes out of control|5 - Hypo/Hyperglycemia, diabetes out of control|41
273|5 - More often than once daily|5 - More often than once daily|41
274|5 - Native Hawaiian or Pacific Islander|5 - Native Hawaiian or Pacific Islander|41
275|5 - None of the above|5 - None of the above|41
276|5 - One to two times per week|5 - One to two times per week|41
277|5 - Other|5 - Other|41
278|5 - Other follow-up|5 - Other follow-up|41
279|5 - Paid help|5 - Paid help|41
280|5 - Patient nonresponsive or unable to speak.|5 - Patient nonresponsive or unable to speak.|41
281|5 - Thoughts of suicide|5 - Thoughts of suicide|41
282|5 - Totally unable to use the telephone.|5 - Totally unable to use the telephone.|41
283|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|41
284|5 - Unable to take in nutrients orally or by tube feeding.|5 - Unable to take in nutrients orally or by tube feeding.|41
285|5 - Unsafe for care at home|5 - Unsafe for care at home|41
286|5 - With paid help (other than home care agency staff)|5 - With paid help (other than home care agency staff)|41
287|5 - Workers' compensation|5 - Workers' compensation|41
288|5 - Wound infection, deteriorating wound status, new lesion/ulcer|5 - Wound infection, deteriorating wound status, new lesion/ulcer|41
289|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|41
290|6 - Delusional, hallucinatory, or paranoid behavior|6 - Delusional, hallucinatory, or paranoid behavior|41
291|6 - Financial agent, power of attorney, or conservator of finance|6 - Financial agent, power of attorney, or conservator of finance|41
292|6 - GI bleeding, obstruction|6 - GI bleeding, obstruction|41
293|6 - Less often than weekly|6 - Less often than weekly|41
294|6 - Memory loss to the extent that supervision required|6 - Memory loss to the extent that supervision required|41
295|6 - None of the above feelings observed or reported|6 - None of the above feelings observed or reported|41
296|6 - Other|6 - Other|41
297|6 - Title programs (e.g., Title III, V, or XX)|6 - Title programs (e.g., Title III, V, or XX)|41
298|6 - Transferred to an inpatient facility - patient not discharged from agency|6 - Transferred to an inpatient facility - patient not discharged from agency|41
299|6 - White|6 - White|41
300|6 - With other than above|6 - With other than above|41
301|7 - Exacerbation of CHF, fluid overload, heart failure|7 - Exacerbation of CHF, fluid overload, heart failure|41
302|7 - Health care agent, conservator of person, or medical power of attorney|7 - Health care agent, conservator of person, or medical power of attorney|41
303|7 - Hypo/Hyperglycemia, diabetes out of control|7 - Hypo/Hyperglycemia, diabetes out of control|41
304|7 - None of the above|7 - None of the above|41
305|7 - None of the above behaviors demonstrated|7 - None of the above behaviors demonstrated|41
306|7 - Other government (e.g., TriCare, VA, etc.)|7 - Other government (e.g., TriCare, VA, etc.)|41
307|7 - Transferred to an inpatient facility - patient discharged from agency|7 - Transferred to an inpatient facility - patient discharged from agency|41
308|8 - Death at home|8 - Death at home|41
309|8 - GI bleeding, obstruction|8 - GI bleeding, obstruction|41
310|8 - Myocardial infarction, stroke|8 - Myocardial infarction, stroke|41
311|8 - Private insurance|8 - Private insurance|41
312|9 - Chemotherapy|9 - Chemotherapy|41
313|9 - Discharge from agency|9 - Discharge from agency|41
314|9 - Other than above reasons|9 - Other than above reasons|41
315|9 - Private HMO/managed care|9 - Private HMO/managed care|41
316|NA - No caregiver|NA - No caregiver|41
317|NA - No equipment of this type used in care.|NA - No equipment of this type used in care.|41
318|NA - No inhalant/mist medications prescribed.|NA - No inhalant/mist medications prescribed.|41
319|NA - No injectable medications prescribed.|NA - No injectable medications prescribed.|41
320|NA - No inpatient facility admission|NA - No inpatient facility admission|41
321|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|41
322|NA - No Medicaid|NA - No Medicaid|41
323|NA - No Medicare|NA - No Medicare|41
324|NA - No observable pressure ulcer|NA - No observable pressure ulcer|41
325|NA - No observable stasis ulcer|NA - No observable stasis ulcer|41
326|NA - No observable surgical wound|NA - No observable surgical wound|41
327|NA - No oral medications prescribed.|NA - No oral medications prescribed.|41
328|NA - Not applicable|NA - Not applicable|41
329|NA - Patient does not have a telephone.|NA - Patient does not have a telephone.|41
330|NA - Patient has ostomy for bowel elimination|NA - Patient has ostomy for bowel elimination|41
331|NA - Patient nonresponsive|NA - Patient nonresponsive|41
332|NA - Patient on prophylactic treatment|NA - Patient on prophylactic treatment|41
333|NA - Patient was not discharged from an inpatient facility [Go to M1016 ]|NA - Patient was not discharged from an inpatient facility [Go to M1016 ]|41
334|UK - Other unknown|UK - Other unknown|41
335|UK - Reason unknown|UK - Reason unknown|41
336|UK - Unknown|UK - Unknown|41
337|UK - Unknown or Not Available|UK - Unknown or Not Available|41
341|01 - Early|01 - Early|41
342|02 - Late|02 - Late|41
343|NA - Not Applicable. No case mix group defined for this assessment.|NA - Not Applicable. No case mix group defined for this assessment.|41
344|NA - No case mix group defined by this assessment.|NA - No case mix group defined by this assessment.|41
345|1 - Recent decline in mental, emotional, or behavioral status|1 - Recent decline in mental, emotional, or behavioral status|41
346|2 - Multiple hospitalizations (2 or more) in the past 12 months|2 - Multiple hospitalizations (2 or more) in the past 12 months|41
347|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|41
348|4 - Taking five or more medications|4 - Taking five or more medications|41
349|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|41
350|6 - Other|6 - Other|41
351|7 - None of the above|7 - None of the above|41
352|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond tho|41
353|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable without heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable wi|41
354|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious complications and death.|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious compl|41
355|3 - The patient has serious progressive conditions that could lead to death within a year.|3 - The patient has serious progressive conditions that could lead to death within a year.|41
356|UK - The patient+s situation is unknown or unclear.|UK - The patient+s situation is unknown or unclear.|41
357|1 - Yes [ Go to M1050 ]|1 - Yes [ Go to M1050 ]|41
358|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this influenza season. [ Go to M1050 ]|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this i|41
359|1 - Received from another health care provider (e.g., physician)|1 - Received from another health care provider (e.g., physician)|41
360|2 - Received from your agency previously during this year+s flu season|2 - Received from your agency previously during this year+s flu season|41
361|3 - Offered and declined|3 - Offered and declined|41
362|4 - Assessed and determined to have medical contraindication(s)|4 - Assessed and determined to have medical contraindication(s)|41
363|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|41
364|6 - Inability to obtain vaccine due to declared shortage|6 - Inability to obtain vaccine due to declared shortage|41
365|1 - Yes [ Go to M1500 at TRN; Go to M1230 at DC ]|1 - Yes [ Go to M1500 at TRN; Go to M1230 at DC ]|41
366|1 - Patient has received PPV in the past|1 - Patient has received PPV in the past|41
367|2 - Offered and declined|2 - Offered and declined|41
368|3 - Assessed and determined to have medical contraindication(s)|3 - Assessed and determined to have medical contraindication(s)|41
369|4 - Not indicated; patient does not meet age/condition guidelines for PPV|4 - Not indicated; patient does not meet age/condition guidelines for PPV|41
370|5 - None of the above|5 - None of the above|41
371|0 - Adequate: hears normal conversation without difficulty.|0 - Adequate: hears normal conversation without difficulty.|41
372|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to increase volume or speak distinctly.|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to in|41
373|2 - Severely Impaired: absence of useful hearing.|2 - Severely Impaired: absence of useful hearing.|41
374|UK - Unable to assess hearing.|UK - Unable to assess hearing.|41
375|0 - Understands: clear comprehension without cues or repetitions.|0 - Understands: clear comprehension without cues or repetitions.|41
376|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Requires cues at times to understand.|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Req|41
377|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequently requires cues to understand.|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequentl|41
378|3 - Rarely/Never Understands|3 - Rarely/Never Understands|41
379|UK - Unable to assess understanding.|UK - Unable to assess understanding.|41
380|0 - No standardized assessment conducted|0 - No standardized assessment conducted|41
381|1 - Yes, and it does not indicate severe pain|1 - Yes, and it does not indicate severe pain|41
382|2 - Yes, and it indicates severe pain|2 - Yes, and it indicates severe pain|41
383|0 - Patient has no pain|0 - Patient has no pain|41
384|1 - Patient has pain that does not interfere with activity or movement|1 - Patient has pain that does not interfere with activity or movement|41
385|2 - Less often than daily|2 - Less often than daily|41
386|3 - Daily, but not constantly|3 - Daily, but not constantly|41
387|4 - All of the time|4 - All of the time|41
388|0 - No assessment conducted [ Go to M1306 ]|0 - No assessment conducted [ Go to M1306 ]|41
389|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc., without use of standardized tool|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc.,|41
390|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|41
391|0 - No [ Go to M1322]|0 - No [ Go to M1322]|41
392|0 v Newly epithelialized|0 v Newly epithelialized|41
393|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|41
394|2 - Yes, patient has observable stasis ulcers ONLY|2 - Yes, patient has observable stasis ulcers ONLY|41
395|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable dressing) [Go to M1340]|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable|41
396|0 - No [ Go to M1350 ]|0 - No [ Go to M1350 ]|41
397|1 - Yes, patient has at least one (observable) surgical wound|1 - Yes, patient has at least one (observable) surgical wound|41
398|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1350 ]|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1350 ]|41
399|0 - Patient is not short of breath|0 - Patient is not short of breath|41
400|3 - Continuous Bi-level positive airway pressure|3 - Continuous Bi-level positive airway pressure|41
401|0 - No [ Go to M1732 at TRN; Go to M1600 at DC ]|0 - No [ Go to M1732 at TRN; Go to M1600 at DC ]|41
402|2 - Not assessed [Go to M1732 at TRN; Go to M1600 at DC ]|2 - Not assessed [Go to M1732 at TRN; Go to M1600 at DC ]|41
403|NA - Patient does not have diagnosis of heart failure [Go to M2004 at TRN; Go to M1600 at DC]|NA - Patient does not have diagnosis of heart failure [Go to M2004 at TRN; Go to M1600 at DC]|41
404|0 - No action taken|0 - No action taken|41
405|1 - Patient+s physician (or other primary care practitioner) contacted the same day|1 - Patient+s physician (or other primary care practitioner) contacted the same day|41
406|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|41
407|3 - Implement physician-ordered patient-specific established parameters for treatment|3 - Implement physician-ordered patient-specific established parameters for treatment|41
408|4 - Patient education or other clinical interventions|4 - Patient education or other clinical interventions|41
409|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequency, telehealth, etc.)|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequ|41
410|1 - Occasional stress incontinence|1 - Occasional stress incontinence|41
411|2 - During the night only|2 - During the night only|41
412|3 - During the day only|3 - During the day only|41
413|4 - During the day and night|4 - During the day and night|41
414|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|41
415|0 - Able to manage toileting hygiene and clothing management without assistance.|0 - Able to manage toileting hygiene and clothing management without assistance.|41
416|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implements are laid out for the patient.|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implemen|41
417|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|41
418|3 - Patient depends entirely upon another person to maintain toileting hygiene.|3 - Patient depends entirely upon another person to maintain toileting hygiene.|41
419|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independent|41
420|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface|41
421|0 - No multi-factor falls risk assessment conducted.|0 - No multi-factor falls risk assessment conducted.|41
422|1 - Yes, and it does not indicate a risk for falls.|1 - Yes, and it does not indicate a risk for falls.|41
423|2 - Yes, and it indicates a risk for falls.|2 - Yes, and it indicates a risk for falls.|41
424|0 - Not assessed/reviewed [ Go to M2010 ]|0 - Not assessed/reviewed [ Go to M2010 ]|41
425|1 - No problems found during review [ Go to M2010 ]|1 - No problems found during review [ Go to M2010 ]|41
426|2 - Problems found during review|2 - Problems found during review|41
427|NA - Patient is not taking any medications [ Go to M2040 ]|NA - Patient is not taking any medications [ Go to M2040 ]|41
428|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special precautions associated with all high-risk medications|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special p|41
429|NA - Patient not taking any drugs|NA - Patient not taking any drugs|41
430|2 - Able to take medication(s) at the correct times if given reminders by another person at the appropriate times|2 - Able to take medication(s) at the correct times if given reminders by another person at the appr|41
431|3 - Unable to take medication unless administered by another person.|3 - Unable to take medication unless administered by another person.|41
432|1 - At least daily|1 - At least daily|41
433|2 - Three or more times per week|2 - Three or more times per week|41
434|3 - One to two times per week|3 - One to two times per week|41
435|4 - Received, but less often than weekly|4 - Received, but less often than weekly|41
436|5 - No assistance received|5 - No assistance received|41
437|0 - No [Go to M2400]|0 - No [Go to M2400]|41
438|1 - Yes, used hospital emergency department WITHOUT hospital admission|1 - Yes, used hospital emergency department WITHOUT hospital admission|41
439|2 - Yes, used hospital emergency department WITH hospital admission|2 - Yes, used hospital emergency department WITH hospital admission|41
440|UK - Unknown [Go to M2400]|UK - Unknown [Go to M2400]|41
441|2 - Injury caused by fall|2 - Injury caused by fall|41
442|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|41
443|4 - Other respiratory problem|4 - Other respiratory problem|41
444|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|41
445|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|41
446|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|41
447|8 - Other heart disease|8 - Other heart disease|41
448|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|41
449|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|41
450|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|41
451|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|41
452|13 - Urinary tract infection|13 - Urinary tract infection|41
453|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|41
454|15 - Wound infection or deterioration|15 - Wound infection or deterioration|41
455|16 - Uncontrolled pain|16 - Uncontrolled pain|41
456|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|41
457|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|41
458|19 - Other than above reasons|19 - Other than above reasons|41
459|2 - Patient remained in the community (with formal assistive services)|2 - Patient remained in the community (with formal assistive services)|41
460|3 - Patient transferred to a noninstitutional hospice|3 - Patient transferred to a noninstitutional hospice|41
461|4 - Unknown because patient moved to a geographic location not served by this agency|4 - Unknown because patient moved to a geographic location not served by this agency|41
462|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|41
463|4 - Other respiratory problem|4 - Other respiratory problem|41
464|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|41
465|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|41
466|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|41
467|8 - Other heart disease|8 - Other heart disease|41
468|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|41
469|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|41
470|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|41
471|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|41
472|13 - Urinary tract infection|13 - Urinary tract infection|41
473|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|41
474|15 - Wound infection or deterioration|15 - Wound infection or deterioration|41
475|16 - Uncontrolled pain|16 - Uncontrolled pain|41
476|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|41
477|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|41
478|19 - Scheduled treatment or procedure|19 - Scheduled treatment or procedure|41
479|20 - Other than above reasons|20 - Other than above reasons|41
480|UK - Reason unknown [Go to M0903]|UK - Reason unknown [Go to M0903]|41
482|01 - Patient lives alone around the clock|01 - Patient lives alone around the clock|41
483|02 - Patient lives alone regular daytime|02 - Patient lives alone regular daytime|41
484|03 - Patient lives alone regular nighttime|03 - Patient lives alone regular nighttime|41
485|04 - Patient lives alone occassional/short term assistance|04 - Patient lives alone occassional/short term assistance|41
486|05 - Patient lives alone no assisstance available|05 - Patient lives alone no assisstance available|41
487|06 - Patient lives with other person(s) in the home around the clock|06 - Patient lives with other person(s) in the home around the clock|41
488|07 - Patient lives with other person(s) in the home regular daytime|07 - Patient lives with other person(s) in the home regular daytime|41
489|08 - Patient lives with other person(s) in the home regular nighttime|08 - Patient lives with other person(s) in the home regular nighttime|41
490|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|41
491|10 - Patient lives with other person(s) in the home no assistance available|10 - Patient lives with other person(s) in the home no assistance available|41
492|1 - Was present at the most recent SOC/ROC assessment|1 - Was present at the most recent SOC/ROC assessment|41
493|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|41
494|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|41
495|0 - Newly epithelialized|0 - Newly epithelialized|41
496|0 - No [ Go to M1340 ]|0 - No [ Go to M1340 ]|41
498|0 - Independent|0 - Independent|41
499|1 - Needed Some Help|1 - Needed Some Help|41
500|2 - Dependent|2 - Dependent|41
502|0 - No assistance needed in this area|0 - No assistance needed in this area|41
503|1 - Caregiver(s) currently provide assistance|1 - Caregiver(s) currently provide assistance|41
504|2 - Caregiver(s) need training/ supportive services to provide assistance|2 - Caregiver(s) need training/ supportive services to provide assistance|41
505|3 - Caregiver(s) not likely to provide assistance|3 - Caregiver(s) not likely to provide assistance|41
506|4 - Unclear if Caregiver(s) will provide assistance|4 - Unclear if Caregiver(s) will provide assistance|41
507|5 - Assistance needed, but no Caregiver(s) available|5 - Assistance needed, but no Caregiver(s) available|41
508|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will use standardized clinical guidelines accessible for all care providers to reference|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will|41
509|NA - Patient is not diabetic or is bilateral amputee|NA - Patient is not diabetic or is bilateral amputee|41
510|NA - Patient is not assessed to be at risk for falls|NA - Patient is not assessed to be at risk for falls|41
511|NA - Patient has no diagnosis or symptoms of depression|NA - Patient has no diagnosis or symptoms of depression|41
512|NA - No pain identified|NA - No pain identified|41
513|NA - Patient is not assessed to be at risk for pressure ulcers|NA - Patient is not assessed to be at risk for pressure ulcers|41
514|NA - Patient has no pressure ulcers with need for moist wound healing|NA - Patient has no pressure ulcers with need for moist wound healing|41
515|1 - Long-term nursing facility (NF)|1 - Long-term nursing facility (NF)|41
516|2 - Skilled nursing facility (SNF / TCU)|2 - Skilled nursing facility (SNF / TCU)|41
517|3 - Short stay acute hospital (IPP S)|3 - Short stay acute hospital (IPP S)|41
518|4 - Long-term care hospital (LTCH)|4 - Long-term care hospital (LTCH)|41
519|5 - Inpatient rehabilitation hospital or unit (IRF)|5 - Inpatient rehabilitation hospital or unit (IRF)|41
520|6 - Psychiatric hospital or unit|6 - Psychiatric hospital or unit|41
521|7 - Other|7 - Other|41
522|NA - Patient was not discharged from an inpatient facility [Go to M1016]|NA - Patient was not discharged from an inpatient facility [Go to M1016]|41
523|6 - Unable to participate effectively in bathing and is bathed totally by another person|6 - Unable to participate effectively in bathing and is bathed totally by another person|41
524|4 - Chairfast, unable to ambulate but is able to wheel self independently.|4 - Chairfast, unable to ambulate but is able to wheel self independently.|41
525|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask patient: "Over the last two weeks, how often have you been bothered by any of the following problems")  *Copyright+ Pfizer Inc. All rights reserved. Reproduced with permission.|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask|41
526|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluation for depression.|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluat|41
527|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet criteria for further evaluation for depression.|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet|41
528|0 - Not at all  0 - 1 day|0 - Not at all  0 - 1 day|41
529|1 - Several days  2 - 6 days|1 - Several days  2 - 6 days|41
530|2 - More than half of the days  7 - 11 days|2 - More than half of the days  7 - 11 days|41
531|3 - Nearly every day  12 - 14 days|3 - Nearly every day  12 - 14 days|41
532|NA - N/A  Unable to respond|NA - N/A  Unable to respond|41
533|2 - Able to take medication(s) at the correct times if given reminders by another person based on the frequency of the injection|2 - Able to take medication(s) at the correct times if given reminders by another person based on th|41
534|3 - Unable to take injectable medication unless administered by another person.|3 - Unable to take injectable medication unless administered by another person.|41
535|11 - Patient lives in congregate situation (e.g., assisted living) around the clock|11 - Patient lives in congregate situation (e.g., assisted living) around the clock|41
536|12 - Patient lives in congregate situation (e.g., assisted living) regular daytime|12 - Patient lives in congregate situation (e.g., assisted living) regular daytime|41
537|13 - Patient lives in congregate situation (e.g., assisted living) regular nighttime|13 - Patient lives in congregate situation (e.g., assisted living) regular nighttime|41
538|14 - Patient lives in congregate situation (e.g., assisted living) occasional / short-term assistance|14 - Patient lives in congregate situation (e.g., assisted living) occasional / short-term assistanc|41
539|15 - Patient lives in congregate situation (e.g., assisted living) no assistance available|15 - Patient lives in congregate situation (e.g., assisted living) no assistance available|41
545|NA - No observable pressure ulcer or unhealed pressure ulcer|NA - No observable pressure ulcer or unhealed pressure ulcer|41
582|NA - No specific SOC date ordered by physician|NA - No specific SOC date ordered by physician|41
585|UK - Inpatient Discharge Date Unknown|UK - Inpatient Discharge Date Unknown|41
600|1 - History of falls (2 or more falls - or any fall with an injury - in the past 12 months) |1 - History of falls (2 or more falls - or any fall with an injury - in the past 12 months) |41
602|2 - Unintentional weight loss of a total of 10 pounds or more in the past 12 months |2 - Unintentional weight loss of a total of 10 pounds or more in the past 12 months |41
604|3 - Multiple hospitalizations (2 or more) in the past 6 months|3 - Multiple hospitalizations (2 or more) in the past 6 months|41
606|4 - Multiple emergency department visits (2 or more) in the past 6 months|4 - Multiple emergency department visits (2 or more) in the past 6 months|41
608|5 - Decline in mental emotional or behavioral status in the past 3 months |5 - Decline in mental emotional or behavioral status in the past 3 months |41
610|6 - Reported or observed history of difficulty complying with any medical instructions (for example |6 - Reported or observed history of difficulty complying with any medical instructions (for example |41
612|7 - Currently taking 5 or more medications|7 - Currently taking 5 or more medications|41
614|8 - Currently reports exhaustion|8 - Currently reports exhaustion|41
616|9 - Other risk(s) not listed in 1 - 8|9 - Other risk(s) not listed in 1 - 8|41
618|10 - None of the above |10 - None of the above |41
632|0 - No assistance needed v patient is independent or does not have needs in this area|0 - No assistance needed v patient is independent or does not have needs in this area|41
633|1 - Non-agency caregiver(s) currently provide assistance |1 - Non-agency caregiver(s) currently provide assistance |41
634|2 - Non-agency caregiver(s) need training/ supportive services to provide assistance|2 - Non-agency caregiver(s) need training/ supportive services to provide assistance|41
635|3 - Non-agency caregiver(s) are not likely to provide assistance OR it is unclear if they will provide assistance|3 - Non-agency caregiver(s) are not likely to provide assistance OR unclear if will provide asst|41
636|4 - Assistance needed but no non-agency caregiver(s) available|4 - Assistance needed but no non-agency caregiver(s) available|41
2|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; OR (b) Is physically, cognitively, and mentally able to prepare light meals on a regular basis but has not routinely performed light meal preparation in the past (i.e., prior to this home care admission).|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; O|43
3|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and mentally able to perform all housekeeping tasks .|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and menta|43
4|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and mentally able to do laundry and access facilities.|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and menta|43
5|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying packages OR b) Physically, cognitively, and mentally able to take care of shopping, but has not done shopping in the past (i.e., prior to this home care admission).|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying|43
6|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|43
7|0 - Able to dial numbers and answer calls appropriately and as desired.|0 - Able to dial numbers and answer calls appropriately and as desired.|43
8|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body without assistance.|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body|43
9|0 - Able to get to and from the toilet and transfer independently with or without a device.|0 - Able to get to and from the toilet and transfer independently with or without a device.|43
10|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|43
11|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible public bus.|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible p|43
12|0 - Able to independently feed self.|0 - Able to independently feed self.|43
13|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|43
14|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct times.|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct ti|43
15|0 - Able to independently transfer.|0 - Able to independently transfer.|43
16|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without rail|43
17|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings|43
18|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|43
19|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions independently.|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions indep|43
20|0 - Asymptomatic, no treatment needed at this time|0 - Asymptomatic, no treatment needed at this time|43
21|0 - Caregiver manages all tasks related to equipment completely independently.|0 - Caregiver manages all tasks related to equipment completely independently.|43
22|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations with no observable impairment.|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations w|43
23|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|43
24|0 - Life expectancy is greater than 6 months|0 - Life expectancy is greater than 6 months|43
25|0 - Never|0 - Never|43
26|0 - Patient is not short of breath|0 - Patient is not short of breath|43
27|0 - No|0 - No|43
28|0 - No emergent care services|0 - No emergent care services|43
29|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [ Go to M1620 ]|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [ Go to M1620 ]|43
30|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and extended or abstract conversation.|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and exte|43
31|0 - No one person|0 - No one person|43
32|0 - None of the time|0 - None of the time|43
33|0 - None, no charge for current services|0 - None, no charge for current services|43
34|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|43
35|0 - Patient does NOT have an ostomy for bowel elimination.|0 - Patient does NOT have an ostomy for bowel elimination.|43
36|0 - Patient has no pain|0 - Patient has no pain|43
37|0 - Patient manages all tasks related to equipment completely independently.|0 - Patient manages all tasks related to equipment completely independently.|43
38|0 - Poor:  little or no recovery is expected and/or further decline is imminent|0 - Poor:  little or no recovery is expected and/or further decline is imminent|43
39|0 - Timed-voiding defers incontinence|0 - Timed-voiding defers incontinence|43
40|0 - Very rarely or never has bowel incontinence|0 - Very rarely or never has bowel incontinence|43
41|0 - Zero|0 - Zero|43
42|00 - No|00 - No|43
43|01 - Yes|01 - Yes|43
44|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or mental limitations, needs assistance with heavy laundry.|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or|43
45|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the patient.|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the|43
46|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|43
47|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or supervision from another person OR c) a liquid, pureed or ground meat diet.|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or su|43
48|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|43
49|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|43
50|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independently.|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independe|43
51|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only when assisted or accompanied by another person.|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only w|43
52|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepa|43
53|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance by another person OR b) given daily reminders.|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance b|43
54|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advan|43
55|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advan|43
56|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for the deaf) and call essential numbers.|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for t|43
57|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|43
58|1 - American Indian or Alaska Native|1 - American Indian or Alaska Native|43
59|1 - Depressed mood (e.g., feeling sad, tearful)|1 - Depressed mood (e.g., feeling sad, tearful)|43
60|1 - During the night only|1 - During the night only|43
61|1 - Fully granulating|1 - Fully granulating|43
62|1 - Good/Fair:  partial to full recovery is expected|1 - Good/Fair:  partial to full recovery is expected|43
63|1 - Good:  marked improvement in functional status is expected|1 - Good:  marked improvement in functional status is expected|43
64|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|43
65|1 - Smoking|1 - Smoking|43
66|1 - Hospital|1 - Hospital|43
67|1 - Hospital emergency room (includes 23-hour holding)|1 - Hospital emergency room (includes 23-hour holding)|43
68|1 - Hospitalization for EMERGENT (unscheduled) care|1 - Hospitalization for EMERGENT (unscheduled) care|43
69|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepared solutions), patient is able to manage all other aspects of equipment.|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepar|43
70|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|43
71|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|43
72|1 - In new or complex situations only|1 - In new or complex situations only|43
73|1 - Intravenous or infusion therapy (excludes TPN)|1 - Intravenous or infusion therapy (excludes TPN)|43
74|1 - Less often than daily|1 - Less often than daily|43
75|1 - Less than once a month|1 - Less than once a month|43
76|1 - Less than once weekly|1 - Less than once weekly|43
77|1 - Life expectancy is 6 months or fewer|1 - Life expectancy is 6 months or fewer|43
78|1 - Lives alone|1 - Lives alone|43
79|1 - Male|1 - Male|43
80|1 - Medicare (traditional fee-for-service)|1 - Medicare (traditional fee-for-service)|43
81|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of past 24 hours, significant memory loss so that supervision is required|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of pas|43
82|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors in word choice, grammar or speech intelligibility, needs minimal prompting or assistance).|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors i|43
83|1 - No assistance or services received|1 - No assistance or services received|43
84|1 - One|1 - One|43
85|1 - Oxygen (intermittent or continuous)|1 - Oxygen (intermittent or continuous)|43
86|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, and the surrounding layout, can count fingers at arm's length.|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, a|43
87|1 - Patient is incontinent|1 - Patient is incontinent|43
88|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|43
89|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical or treatment regimen.|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical|43
90|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient/couple/significant other)|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient|43
91|1 - Relatives, friends, or neighbors living outside the home|1 - Relatives, friends, or neighbors living outside the home|43
92|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions.|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions|43
93|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independentl|43
94|1 - Several times during day and night|1 - Several times during day and night|43
95|1 - Spouse or significant other|1 - Spouse or significant other|43
96|1 - Stage 1|1 - Stage 1|43
97|1 - Start of care - further visits planned|1 - Start of care - further visits planned|43
98|1 - Symptoms well controlled with current therapy|1 - Symptoms well controlled with current therapy|43
99|1 - Therapy services|1 - Therapy services|43
100|1 - Able to transfer with minimal human assistance or with use of an assistive device.|1 - Able to transfer with minimal human assistance or with use of an assistive device.|43
101|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitations.|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitatio|43
102|1 - Urinary incontinence|1 - Urinary incontinence|43
103|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and transfer.|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and|43
104|1 - When walking more than 20 feet, climbing stairs|1 - When walking more than 20 feet, climbing stairs|43
105|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary conversation. May need occasional repetition, extra time, or louder voice.|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary c|43
106|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting in and out of tub/shower|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting|43
107|1 - Yes|1 - Yes|43
108|1-RN|1-RN|43
109|10 - Discharge from agency - no visits completed after start/resumption of care assessment|10 - Discharge from agency - no visits completed after start/resumption of care assessment|43
110|10 - Scheduled surgical procedure|10 - Scheduled surgical procedure|43
111|10 - Self-pay|10 - Self-pay|43
112|11 - Other|11 - Other|43
113|11 - Urinary tract infection|11 - Urinary tract infection|43
114|12 - IV catheter-related infection|12 - IV catheter-related infection|43
115|13 - Deep vein thrombosis, pulmonary embolus|13 - Deep vein thrombosis, pulmonary embolus|43
116|14 - Uncontrolled pain|14 - Uncontrolled pain|43
117|15 - Psychotic episode|15 - Psychotic episode|43
118|16 - Other than above reasons|16 - Other than above reasons|43
119|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing calls.|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing|43
120|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another person.|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another pers|43
121|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface a|43
122|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for intermittent supervision or encouragement or reminders, OR (b) to get in and out of the shower or tub, OR (c) for washing difficult to reach areas.|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for inter|43
123|2 - Asian|2 - Asian|43
124|2 - Caregiver requires considerable assistance from another person to manage equipment, but independently completes significant portions of task.|2 - Caregiver requires considerable assistance from another person to manage equipment, but independ|43
125|2 - Daily, but not constantly|2 - Daily, but not constantly|43
126|2 - Daughter or son|2 - Daughter or son|43
127|2 - Doctor's office emergency visit/house call|2 - Doctor's office emergency visit/house call|43
128|2 - During the day and night|2 - During the day and night|43
129|2 - Early/partial granulation|2 - Early/partial granulation|43
130|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors in word choice, organization or speech intelligibility). Speaks in phrases or short sentences.|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors|43
131|2 - Family member's residence|2 - Family member's residence|43
132|2 - Female|2 - Female|43
133|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conversation, needs frequent prompting or assistance.|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conver|43
134|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|43
135|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|43
136|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately stop activities, jeopardizes safety through actions|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately st|43
137|2 - Indwelling/suprapubic catheter|2 - Indwelling/suprapubic catheter|43
138|2 - Injury caused by fall or accident at home|2 - Injury caused by fall or accident at home|43
139|2 - Medicare (HMO/managed care/Advantage plan)|2 - Medicare (HMO/managed care/Advantage plan)|43
140|2 - Nausea, dehydration, malnutrition, constipation, impaction|2 - Nausea, dehydration, malnutrition, constipation, impaction|43
141|2 - Obesity|2 - Obesity|43
142|2 - On awakening or at night only|2 - On awakening or at night only|43
143|2 - Once a month|2 - Once a month|43
144|2 - One to three times weekly|2 - One to three times weekly|43
145|2 - Parenteral nutrition (TPN or lipids)|2 - Parenteral nutrition (TPN or lipids)|43
146|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic)  [ Go to M1620 ]|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic)  [ Go|43
147|2 - Patient requires considerable assistance from another person to manage equipment, but independently completes portions of the task.|2 - Patient requires considerable assistance from another person to manage equipment, but independen|43
148|2 - Patient transferred to a noninstitutional hospice|2 - Patient transferred to a noninstitutional hospice|43
149|2 - Person residing in the home (EXCLUDING paid help)|2 - Person residing in the home (EXCLUDING paid help)|43
150|2 - Rehabilitation facility|2 - Rehabilitation facility|43
151|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifting of attention) or consistently requires low stimulus environment due to distractibility.|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifti|43
152|2 - Respite care|2 - Respite care|43
153|2 - Sense of failure or self reproach|2 - Sense of failure or self reproach|43
154|2 - Several times during day|2 - Several times during day|43
155|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonresponsive.|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonrespons|43
156|2 - Someone must assist the patient to groom self.|2 - Someone must assist the patient to groom self.|43
157|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|43
158|2 - Someone must help the patient put on upper body clothing.|2 - Someone must help the patient put on upper body clothing.|43
159|2 - Stage 2|2 - Stage 2|43
160|2 - Start of care - no further visits planned|2 - Start of care - no further visits planned|43
161|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitoring|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitori|43
162|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment regimen.|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment re|43
163|2 - Two|2 - Two|43
164|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistance due to cognitive or mental limitation.|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistanc|43
165|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|43
166|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assistance).|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assis|43
167|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home delivery.|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home deli|43
168|2 - Unable to prepare any light meals or reheat any delivered meals.|2 - Unable to prepare any light meals or reheat any delivered meals.|43
169|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|43
170|2 - UNABLE to take injectable medications unless administered by someone else.|2 - UNABLE to take injectable medications unless administered by someone else.|43
171|2 - UNABLE to take medication unless administered by someone else.|2 - UNABLE to take medication unless administered by someone else.|43
172|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|43
173|2 - Ventilator (continually or at night)|2 - Ventilator (continually or at night)|43
174|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less than 20 feet)|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less th|43
175|2 - With spouse or significant other|2 - With spouse or significant other|43
176|2 - Yes, assistance or services provided by family or friends|2 - Yes, assistance or services provided by family or friends|43
177|2-PT|2-PT|43
178|3 - Able to answer the telephone only some of the time or is able to carry on only a limited conversation.|3 - Able to answer the telephone only some of the time or is able to carry on only a limited convers|43
179|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube or gastrostomy.|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube|43
180|3 - Alcohol dependency|3 - Alcohol dependency|43
181|3 - All of the time|3 - All of the time|43
182|3 - Black or African-American|3 - Black or African-American|43
183|3 - Boarding home or rented room|3 - Boarding home or rented room|43
184|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment, clean/store/dispose of equipment or supplies).|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment,|43
185|3 -Able to walk only with the supervision or assistance of another person at all times.|3 -Able to walk only with the supervision or assistance of another person at all times.|43
186|3 - Continuous / Bi-level positive airway pressure|3 - Continuous / Bi-level positive airway pressure|43
187|3 - During the day and evening, but not constantly|3 - During the day and evening, but not constantly|43
188|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the alimentary canal)|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the|43
189|3 - Environmental support (e.g., housing, home maintenance)|3 - Environmental support (e.g., housing, home maintenance)|43
190|3 - Four to six times weekly|3 - Four to six times weekly|43
191|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessing by listener.  Speech limited to single words or short phrases.|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessin|43
192|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires multiple repetitions, restatements, demonstrations, additional time.|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires m|43
193|3 - Hopelessness|3 - Hopelessness|43
194|3 - Hospice care|3 - Hospice care|43
195|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|43
196|3 - Injury caused by fall or accident at home|3 - Injury caused by fall or accident at home|43
197|3 - Intractable pain|3 - Intractable pain|43
198|3 - Medicaid (traditional fee-for-service)|3 - Medicaid (traditional fee-for-service)|43
199|3 - Needs someone to do all shopping and errands.|3 - Needs someone to do all shopping and errands.|43
200|3 - Not healing|3 - Not healing|43
201|3 - Nursing home|3 - Nursing home|43
202|3 - Once daily|3 - Once daily|43
203|3 - Other family member|3 - Other family member|43
204|3 - Outpatient department/clinic emergency (includes urgicenter sites)|3 - Outpatient department/clinic emergency (includes urgicenter sites)|43
205|3 - Paid help|3 - Paid help|43
206|3 - Able to participate in bathing self in shower or tub, but requires presence of another person throughout the bath for assistance or supervision.|3 - Able to participate in bathing self in shower or tub, but requires presence of another person th|43
207|3 - Patient depends entirely upon another person to dress lower body.|3 - Patient depends entirely upon another person to dress lower body.|43
208|3 - Patient depends entirely upon another person to dress the upper body.|3 - Patient depends entirely upon another person to dress the upper body.|43
209|3 - Patient depends entirely upon someone else for grooming needs.|3 - Patient depends entirely upon someone else for grooming needs.|43
210|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone else to manage the equipment.|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone|43
211|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable to shift attention and recall directions more than half the time.|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable|43
212|3 - Respiratory problems (SOB, infection, obstruction)|3 - Respiratory problems (SOB, infection, obstruction)|43
213|3 - Resumption of care (after inpatient stay)|3 - Resumption of care (after inpatient stay)|43
214|3 - Several times each month|3 - Several times each month|43
215|3 - Skilled Nursing Facility|3 - Skilled Nursing Facility|43
216|3 - Stage 3|3 - Stage 3|43
217|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|43
218|3 - Three|3 - Three|43
219|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person throughout the process.|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person through|43
220|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal independently.|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal indep|43
221|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person.|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person|43
222|3 - Unknown because patient moved to a geographic location not served by this agency|3 - Unknown because patient moved to a geographic location not served by this agency|43
223|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|43
224|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|43
225|3 - With other family member|3 - With other family member|43
226|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home health services, homemaker assistance, transportation assistance, assisted living, board and care)|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home h|43
227|3-SLP/ST|3-SLP/ST|43
228|4 - At rest (during day or night)|4 - At rest (during day or night)|43
229|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|43
230|4 - Board and care or assisted living facility|4 - Board and care or assisted living facility|43
231|4 - Caregiver is completely dependent on someone else to manage all equipment.|4 - Caregiver is completely dependent on someone else to manage all equipment.|43
232|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|43
233|4 - Constantly|4 - Constantly|43
234|4 - Drug dependency|4 - Drug dependency|43
235|4 - Four or more|4 - Four or more|43
236|4 - Friend or neighbor or community or church member|4 - Friend or neighbor or community or church member|43
237|4 - Hispanic or Latino|4 - Hispanic or Latino|43
238|4 - Hospice|4 - Hospice|43
239|4 - Impaired decision-making|4 - Impaired decision-making|43
240|4 - Is totally dependent in toileting.|4 - Is totally dependent in toileting.|43
241|4 - Medicaid (HMO/managed care)|4 - Medicaid (HMO/managed care)|43
242|4 - None of the above|4 - None of the above|43
243|4 - Nursing home|4 - Nursing home|43
244|4 - On a daily basis|4 - On a daily basis|43
245|4 - Patient is completely dependent on someone else to manage all equipment.|4 - Patient is completely dependent on someone else to manage all equipment.|43
246|4 - Permanent placement|4 - Permanent placement|43
247|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, punches, dangerous maneuvers w/ wheelchair or other objects)|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, pu|43
248|4 - Psychosocial support (e.g., socialization, companionship, recreation)|4 - Psychosocial support (e.g., socialization, companionship, recreation)|43
249|4 - Recertification (follow-up) reassessment|4 - Recertification (follow-up) reassessment|43
250|4 - Recurrent thoughts of death|4 - Recurrent thoughts of death|43
251|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruction)|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruc|43
252|4 - Several times a week|4 - Several times a week|43
253|4 - Stage 4|4 - Stage 4|43
254|4 - Symptoms poorly controlled, history of re-hospitalizations|4 - Symptoms poorly controlled, history of re-hospitalizations|43
255|4 - Three or more times per week|4 - Three or more times per week|43
256|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetative state, or delirium.|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetati|43
257|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|43
258|4 - Unable to effectively participate in any housekeeping tasks.|4 - Unable to effectively participate in any housekeeping tasks.|43
259|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or unresponsive (e.g., speech is nonsensical or unintelligible).|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or u|43
260|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonresponsive.|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonr|43
261|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostomy.|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostom|43
262|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of devices at the sink, in chair, or on commode|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of|43
263|4 - With a friend|4 - With a friend|43
264|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|43
265|4-OT|4-OT|43
266|5 - Advocates or facilitates patient's participation in appropriate medical care|5 - Advocates or facilitates patient's participation in appropriate medical care|43
267|5 - At least daily|5 - At least daily|43
268|6 - Bedfast, unable to ambulate or be up in a chair.|6 - Bedfast, unable to ambulate or be up in a chair.|43
269|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|43
270|5 - Disruptive or socially inappropriate behavior|5 - Disruptive or socially inappropriate behavior|43
271|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|43
272|5 - Hypo/Hyperglycemia, diabetes out of control|5 - Hypo/Hyperglycemia, diabetes out of control|43
273|5 - More often than once daily|5 - More often than once daily|43
274|5 - Native Hawaiian or Pacific Islander|5 - Native Hawaiian or Pacific Islander|43
275|5 - None of the above|5 - None of the above|43
276|5 - One to two times per week|5 - One to two times per week|43
277|5 - Other|5 - Other|43
278|5 - Other follow-up|5 - Other follow-up|43
279|5 - Paid help|5 - Paid help|43
280|5 - Patient nonresponsive or unable to speak.|5 - Patient nonresponsive or unable to speak.|43
281|5 - Thoughts of suicide|5 - Thoughts of suicide|43
282|5 - Totally unable to use the telephone.|5 - Totally unable to use the telephone.|43
283|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|43
284|5 - Unable to take in nutrients orally or by tube feeding.|5 - Unable to take in nutrients orally or by tube feeding.|43
285|5 - Unsafe for care at home|5 - Unsafe for care at home|43
286|5 - With paid help (other than home care agency staff)|5 - With paid help (other than home care agency staff)|43
287|5 - Workers' compensation|5 - Workers' compensation|43
288|5 - Wound infection, deteriorating wound status, new lesion/ulcer|5 - Wound infection, deteriorating wound status, new lesion/ulcer|43
289|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|43
290|6 - Delusional, hallucinatory, or paranoid behavior|6 - Delusional, hallucinatory, or paranoid behavior|43
291|6 - Financial agent, power of attorney, or conservator of finance|6 - Financial agent, power of attorney, or conservator of finance|43
292|6 - GI bleeding, obstruction|6 - GI bleeding, obstruction|43
293|6 - Less often than weekly|6 - Less often than weekly|43
294|6 - Memory loss to the extent that supervision required|6 - Memory loss to the extent that supervision required|43
295|6 - None of the above feelings observed or reported|6 - None of the above feelings observed or reported|43
296|6 - Other|6 - Other|43
297|6 - Title programs (e.g., Title III, V, or XX)|6 - Title programs (e.g., Title III, V, or XX)|43
298|6 - Transferred to an inpatient facility - patient not discharged from agency|6 - Transferred to an inpatient facility - patient not discharged from agency|43
299|6 - White|6 - White|43
300|6 - With other than above|6 - With other than above|43
301|7 - Exacerbation of CHF, fluid overload, heart failure|7 - Exacerbation of CHF, fluid overload, heart failure|43
302|7 - Health care agent, conservator of person, or medical power of attorney|7 - Health care agent, conservator of person, or medical power of attorney|43
303|7 - Hypo/Hyperglycemia, diabetes out of control|7 - Hypo/Hyperglycemia, diabetes out of control|43
304|7 - None of the above|7 - None of the above|43
305|7 - None of the above behaviors demonstrated|7 - None of the above behaviors demonstrated|43
306|7 - Other government (e.g., TriCare, VA, etc.)|7 - Other government (e.g., TriCare, VA, etc.)|43
307|7 - Transferred to an inpatient facility - patient discharged from agency|7 - Transferred to an inpatient facility - patient discharged from agency|43
308|8 - Death at home|8 - Death at home|43
309|8 - GI bleeding, obstruction|8 - GI bleeding, obstruction|43
310|8 - Myocardial infarction, stroke|8 - Myocardial infarction, stroke|43
311|8 - Private insurance|8 - Private insurance|43
312|9 - Chemotherapy|9 - Chemotherapy|43
313|9 - Discharge from agency|9 - Discharge from agency|43
314|9 - Other than above reasons|9 - Other than above reasons|43
315|9 - Private HMO/managed care|9 - Private HMO/managed care|43
316|NA - No caregiver|NA - No caregiver|43
317|NA - No equipment of this type used in care.|NA - No equipment of this type used in care.|43
318|NA - No inhalant/mist medications prescribed.|NA - No inhalant/mist medications prescribed.|43
319|NA - No injectable medications prescribed.|NA - No injectable medications prescribed.|43
320|NA - No inpatient facility admission|NA - No inpatient facility admission|43
321|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|43
322|NA - No Medicaid|NA - No Medicaid|43
323|NA - No Medicare|NA - No Medicare|43
324|NA - No observable pressure ulcer or unhealed pressure ulcer|NA - No observable pressure ulcer or unhealed pressure ulcer|43
325|NA - No observable stasis ulcer|NA - No observable stasis ulcer|43
326|NA - No observable surgical wound|NA - No observable surgical wound|43
327|NA - No oral medications prescribed.|NA - No oral medications prescribed.|43
328|NA - Not applicable|NA - Not applicable|43
329|NA - Patient does not have a telephone.|NA - Patient does not have a telephone.|43
330|NA - Patient has ostomy for bowel elimination|NA - Patient has ostomy for bowel elimination|43
331|NA - Patient nonresponsive|NA - Patient nonresponsive|43
332|NA - Patient on prophylactic treatment|NA - Patient on prophylactic treatment|43
333|NA - Patient was not discharged from an inpatient facility [Go to M1016 ]|NA - Patient was not discharged from an inpatient facility [Go to M1016 ]|43
334|UK - Other unknown|UK - Other unknown|43
335|UK - Reason unknown|UK - Reason unknown|43
336|UK - Unknown|UK - Unknown|43
337|UK - Unknown or Not Available|UK - Unknown or Not Available|43
341|01 - Early|01 - Early|43
342|02 - Late|02 - Late|43
343|NA - Not Applicable. No case mix group defined for this assessment.|NA - Not Applicable. No case mix group defined for this assessment.|43
344|NA - No case mix group defined by this assessment.|NA - No case mix group defined by this assessment.|43
345|1 - Recent decline in mental, emotional, or behavioral status|1 - Recent decline in mental, emotional, or behavioral status|43
346|2 - Multiple hospitalizations (2 or more) in the past 12 months|2 - Multiple hospitalizations (2 or more) in the past 12 months|43
347|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|43
348|4 - Taking five or more medications|4 - Taking five or more medications|43
349|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|43
350|6 - Other|6 - Other|43
351|7 - None of the above|7 - None of the above|43
352|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond tho|43
353|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable without heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable wi|43
354|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious complications and death.|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious compl|43
355|3 - The patient has serious progressive conditions that could lead to death within a year.|3 - The patient has serious progressive conditions that could lead to death within a year.|43
356|UK - The patient+s situation is unknown or unclear.|UK - The patient+s situation is unknown or unclear.|43
357|1 - Yes [ Go to M1050 ]|1 - Yes [ Go to M1050 ]|43
358|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this influenza season. [ Go to M1050 ]|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this i|43
359|1 - Received from another health care provider (e.g., physician)|1 - Received from another health care provider (e.g., physician)|43
360|2 - Received from your agency previously during this year+s flu season|2 - Received from your agency previously during this year+s flu season|43
361|3 - Offered and declined|3 - Offered and declined|43
362|4 - Assessed and determined to have medical contraindication(s)|4 - Assessed and determined to have medical contraindication(s)|43
363|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|43
364|6 - Inability to obtain vaccine due to declared shortage|6 - Inability to obtain vaccine due to declared shortage|43
365|1 - Yes [ Go to M1500 at TRN; Go to M1230 at DC ]|1 - Yes [ Go to M1500 at TRN; Go to M1230 at DC ]|43
366|1 - Patient has received PPV in the past|1 - Patient has received PPV in the past|43
367|2 - Offered and declined|2 - Offered and declined|43
368|3 - Assessed and determined to have medical contraindication(s)|3 - Assessed and determined to have medical contraindication(s)|43
369|4 - Not indicated; patient does not meet age/condition guidelines for PPV|4 - Not indicated; patient does not meet age/condition guidelines for PPV|43
370|5 - None of the above|5 - None of the above|43
371|0 - Adequate: hears normal conversation without difficulty.|0 - Adequate: hears normal conversation without difficulty.|43
372|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to increase volume or speak distinctly.|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to in|43
373|2 - Severely Impaired: absence of useful hearing.|2 - Severely Impaired: absence of useful hearing.|43
374|UK - Unable to assess hearing.|UK - Unable to assess hearing.|43
375|0 - Understands: clear comprehension without cues or repetitions.|0 - Understands: clear comprehension without cues or repetitions.|43
376|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Requires cues at times to understand.|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Req|43
377|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequently requires cues to understand.|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequentl|43
378|3 - Rarely/Never Understands|3 - Rarely/Never Understands|43
379|UK - Unable to assess understanding.|UK - Unable to assess understanding.|43
380|0 - No standardized assessment conducted|0 - No standardized assessment conducted|43
381|1 - Yes, and it does not indicate severe pain|1 - Yes, and it does not indicate severe pain|43
382|2 - Yes, and it indicates severe pain|2 - Yes, and it indicates severe pain|43
383|0 - Patient has no pain|0 - Patient has no pain|43
384|1 - Patient has pain that does not interfere with activity or movement|1 - Patient has pain that does not interfere with activity or movement|43
385|2 - Less often than daily|2 - Less often than daily|43
386|3 - Daily, but not constantly|3 - Daily, but not constantly|43
387|4 - All of the time|4 - All of the time|43
388|0 - No assessment conducted [ Go to M1306 ]|0 - No assessment conducted [ Go to M1306 ]|43
389|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc., without use of standardized tool|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc.,|43
390|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|43
391|0 - No [ Go to M1322]|0 - No [ Go to M1322]|43
392|0 v Newly epithelialized|0 v Newly epithelialized|43
393|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|43
394|2 - Yes, patient has observable stasis ulcers ONLY|2 - Yes, patient has observable stasis ulcers ONLY|43
395|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable dressing) [Go to M1340]|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable|43
396|0 - No [ Go to M1350 ]|0 - No [ Go to M1350 ]|43
397|1 - Yes, patient has at least one (observable) surgical wound|1 - Yes, patient has at least one (observable) surgical wound|43
398|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1350 ]|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1350 ]|43
399|0 - Patient is not short of breath|0 - Patient is not short of breath|43
400|3 - Continuous Bi-level positive airway pressure|3 - Continuous Bi-level positive airway pressure|43
401|0 - No [ Go to M1732 at TRN; Go to M1600 at DC ]|0 - No [ Go to M1732 at TRN; Go to M1600 at DC ]|43
402|2 - Not assessed [Go to M1732 at TRN; Go to M1600 at DC ]|2 - Not assessed [Go to M1732 at TRN; Go to M1600 at DC ]|43
403|NA - Patient does not have diagnosis of heart failure [Go to M2004 at TRN; Go to M1600 at DC]|NA - Patient does not have diagnosis of heart failure [Go to M2004 at TRN; Go to M1600 at DC]|43
404|0 - No action taken|0 - No action taken|43
405|1 - Patient+s physician (or other primary care practitioner) contacted the same day|1 - Patient+s physician (or other primary care practitioner) contacted the same day|43
406|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|43
407|3 - Implement physician-ordered patient-specific established parameters for treatment|3 - Implement physician-ordered patient-specific established parameters for treatment|43
408|4 - Patient education or other clinical interventions|4 - Patient education or other clinical interventions|43
409|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequency, telehealth, etc.)|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequ|43
410|1 - Occasional stress incontinence|1 - Occasional stress incontinence|43
411|2 - During the night only|2 - During the night only|43
412|3 - During the day only|3 - During the day only|43
413|4 - During the day and night|4 - During the day and night|43
414|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|43
415|0 - Able to manage toileting hygiene and clothing management without assistance.|0 - Able to manage toileting hygiene and clothing management without assistance.|43
416|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implements are laid out for the patient.|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implemen|43
417|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|43
418|3 - Patient depends entirely upon another person to maintain toileting hygiene.|3 - Patient depends entirely upon another person to maintain toileting hygiene.|43
419|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independent|43
420|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface|43
421|0 - No multi-factor falls risk assessment conducted.|0 - No multi-factor falls risk assessment conducted.|43
422|1 - Yes, and it does not indicate a risk for falls.|1 - Yes, and it does not indicate a risk for falls.|43
423|2 - Yes, and it indicates a risk for falls.|2 - Yes, and it indicates a risk for falls.|43
424|0 - Not assessed/reviewed [ Go to M2010 ]|0 - Not assessed/reviewed [ Go to M2010 ]|43
425|1 - No problems found during review [ Go to M2010 ]|1 - No problems found during review [ Go to M2010 ]|43
426|2 - Problems found during review|2 - Problems found during review|43
427|NA - Patient is not taking any medications [ Go to M2040 ]|NA - Patient is not taking any medications [ Go to M2040 ]|43
428|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special precautions associated with all high-risk medications|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special p|43
429|NA - Patient not taking any drugs|NA - Patient not taking any drugs|43
430|2 - Able to take medication(s) at the correct times if given reminders by another person at the appropriate times|2 - Able to take medication(s) at the correct times if given reminders by another person at the appr|43
431|3 - Unable to take medication unless administered by another person.|3 - Unable to take medication unless administered by another person.|43
432|1 - At least daily|1 - At least daily|43
433|2 - Three or more times per week|2 - Three or more times per week|43
434|3 - One to two times per week|3 - One to two times per week|43
435|4 - Received, but less often than weekly|4 - Received, but less often than weekly|43
436|5 - No assistance received|5 - No assistance received|43
437|0 - No [Go to M2400]|0 - No [Go to M2400]|43
438|1 - Yes, used hospital emergency department WITHOUT hospital admission|1 - Yes, used hospital emergency department WITHOUT hospital admission|43
439|2 - Yes, used hospital emergency department WITH hospital admission|2 - Yes, used hospital emergency department WITH hospital admission|43
440|UK - Unknown [Go to M2400]|UK - Unknown [Go to M2400]|43
441|2 - Injury caused by fall|2 - Injury caused by fall|43
442|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|43
443|4 - Other respiratory problem|4 - Other respiratory problem|43
444|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|43
445|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|43
446|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|43
447|8 - Other heart disease|8 - Other heart disease|43
448|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|43
449|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|43
450|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|43
451|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|43
452|13 - Urinary tract infection|13 - Urinary tract infection|43
453|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|43
454|15 - Wound infection or deterioration|15 - Wound infection or deterioration|43
455|16 - Uncontrolled pain|16 - Uncontrolled pain|43
456|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|43
457|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|43
458|19 - Other than above reasons|19 - Other than above reasons|43
459|2 - Patient remained in the community (with formal assistive services)|2 - Patient remained in the community (with formal assistive services)|43
460|3 - Patient transferred to a noninstitutional hospice|3 - Patient transferred to a noninstitutional hospice|43
461|4 - Unknown because patient moved to a geographic location not served by this agency|4 - Unknown because patient moved to a geographic location not served by this agency|43
462|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|43
463|4 - Other respiratory problem|4 - Other respiratory problem|43
464|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|43
465|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|43
466|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|43
467|8 - Other heart disease|8 - Other heart disease|43
468|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|43
469|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|43
470|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|43
471|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|43
472|13 - Urinary tract infection|13 - Urinary tract infection|43
473|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|43
474|15 - Wound infection or deterioration|15 - Wound infection or deterioration|43
475|16 - Uncontrolled pain|16 - Uncontrolled pain|43
476|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|43
477|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|43
478|19 - Scheduled treatment or procedure|19 - Scheduled treatment or procedure|43
479|20 - Other than above reasons|20 - Other than above reasons|43
480|UK - Reason unknown [Go to M0903]|UK - Reason unknown [Go to M0903]|43
482|01 - Patient lives alone around the clock|01 - Patient lives alone around the clock|43
483|02 - Patient lives alone regular daytime|02 - Patient lives alone regular daytime|43
484|03 - Patient lives alone regular nighttime|03 - Patient lives alone regular nighttime|43
485|04 - Patient lives alone occassional/short term assistance|04 - Patient lives alone occassional/short term assistance|43
486|05 - Patient lives alone no assisstance available|05 - Patient lives alone no assisstance available|43
487|06 - Patient lives with other person(s) in the home around the clock|06 - Patient lives with other person(s) in the home around the clock|43
488|07 - Patient lives with other person(s) in the home regular daytime|07 - Patient lives with other person(s) in the home regular daytime|43
489|08 - Patient lives with other person(s) in the home regular nighttime|08 - Patient lives with other person(s) in the home regular nighttime|43
490|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|43
491|10 - Patient lives with other person(s) in the home no assistance available|10 - Patient lives with other person(s) in the home no assistance available|43
492|1 - Was present at the most recent SOC/ROC assessment|1 - Was present at the most recent SOC/ROC assessment|43
493|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|43
494|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|43
495|0 - Newly epithelialized|0 - Newly epithelialized|43
496|0 - No [ Go to M1340 ]|0 - No [ Go to M1340 ]|43
498|0 - Independent|0 - Independent|43
499|1 - Needed Some Help|1 - Needed Some Help|43
500|2 - Dependent|2 - Dependent|43
502|0 - No assistance needed in this area|0 - No assistance needed in this area|43
503|1 - Caregiver(s) currently provide assistance|1 - Caregiver(s) currently provide assistance|43
504|2 - Caregiver(s) need training/ supportive services to provide assistance|2 - Caregiver(s) need training/ supportive services to provide assistance|43
505|3 - Caregiver(s) not likely to provide assistance|3 - Caregiver(s) not likely to provide assistance|43
506|4 - Unclear if Caregiver(s) will provide assistance|4 - Unclear if Caregiver(s) will provide assistance|43
507|5 - Assistance needed, but no Caregiver(s) available|5 - Assistance needed, but no Caregiver(s) available|43
508|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will use standardized clinical guidelines accessible for all care providers to reference|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will|43
509|NA - Patient is not diabetic or is bilateral amputee|NA - Patient is not diabetic or is bilateral amputee|43
510|NA - Patient is not assessed to be at risk for falls|NA - Patient is not assessed to be at risk for falls|43
511|NA - Patient has no diagnosis or symptoms of depression|NA - Patient has no diagnosis or symptoms of depression|43
512|NA - No pain identified|NA - No pain identified|43
513|NA - Patient is not assessed to be at risk for pressure ulcers|NA - Patient is not assessed to be at risk for pressure ulcers|43
514|NA - Patient has no pressure ulcers with need for moist wound healing|NA - Patient has no pressure ulcers with need for moist wound healing|43
515|1 - Long-term nursing facility (NF)|1 - Long-term nursing facility (NF)|43
516|2 - Skilled nursing facility (SNF / TCU)|2 - Skilled nursing facility (SNF / TCU)|43
517|3 - Short stay acute hospital (IPP S)|3 - Short stay acute hospital (IPP S)|43
518|4 - Long-term care hospital (LTCH)|4 - Long-term care hospital (LTCH)|43
519|5 - Inpatient rehabilitation hospital or unit (IRF)|5 - Inpatient rehabilitation hospital or unit (IRF)|43
520|6 - Psychiatric hospital or unit|6 - Psychiatric hospital or unit|43
521|7 - Other|7 - Other|43
522|NA - Patient was not discharged from an inpatient facility [Go to M1016]|NA - Patient was not discharged from an inpatient facility [Go to M1016]|43
523|6 - Unable to participate effectively in bathing and is bathed totally by another person|6 - Unable to participate effectively in bathing and is bathed totally by another person|43
524|4 - Chairfast, unable to ambulate but is able to wheel self independently.|4 - Chairfast, unable to ambulate but is able to wheel self independently.|43
525|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask patient: "Over the last two weeks, how often have you been bothered by any of the following problems")  *Copyright+ Pfizer Inc. All rights reserved. Reproduced with permission.|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask|43
526|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluation for depression.|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluat|43
527|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet criteria for further evaluation for depression.|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet|43
528|0 - Not at all  0 - 1 day|0 - Not at all  0 - 1 day|43
529|1 - Several days  2 - 6 days|1 - Several days  2 - 6 days|43
530|2 - More than half of the days  7 - 11 days|2 - More than half of the days  7 - 11 days|43
531|3 - Nearly every day  12 - 14 days|3 - Nearly every day  12 - 14 days|43
532|NA - N/A  Unable to respond|NA - N/A  Unable to respond|43
533|2 - Able to take medication(s) at the correct times if given reminders by another person based on the frequency of the injection|2 - Able to take medication(s) at the correct times if given reminders by another person based on th|43
534|3 - Unable to take injectable medication unless administered by another person.|3 - Unable to take injectable medication unless administered by another person.|43
540|11 - Patient lives in congregate situation (e.g., assisted living) around the clock|11 - Patient lives in congregate situation (e.g., assisted living) around the clock|43
541|12 - Patient lives in congregate situation (e.g., assisted living) regular daytime|12 - Patient lives in congregate situation (e.g., assisted living) regular daytime|43
542|13 - Patient lives in congregate situation (e.g., assisted living) regular nighttime|13 - Patient lives in congregate situation (e.g., assisted living) regular nighttime|43
543|14 - Patient lives in congregate situation (e.g., assisted living) occasional / short-term assistance|14 - Patient lives in congregate situation (e.g., assisted living) occasional / short-term assistanc|43
544|15 - Patient lives in congregate situation (e.g., assisted living) no available assistance|15 - Patient lives in congregate situation (e.g., assisted living) no available assistance|43
546|NA - No observable pressure ulcer|NA - No observable pressure ulcer|43
583|NA - No specific SOC date ordered by physician|NA - No specific SOC date ordered by physician|43
586|UK - Inpatient Discharge Date Unknown|UK - Inpatient Discharge Date Unknown|43
601|1 - History of falls (2 or more falls - or any fall with an injury - in the past 12 months) |1 - History of falls (2 or more falls - or any fall with an injury - in the past 12 months) |43
603|2 - Unintentional weight loss of a total of 10 pounds or more in the past 12 months |2 - Unintentional weight loss of a total of 10 pounds or more in the past 12 months |43
605|3 - Multiple hospitalizations (2 or more) in the past 6 months|3 - Multiple hospitalizations (2 or more) in the past 6 months|43
607|4 - Multiple emergency department visits (2 or more) in the past 6 months|4 - Multiple emergency department visits (2 or more) in the past 6 months|43
609|5 - Decline in mental emotional or behavioral status in the past 3 months |5 - Decline in mental emotional or behavioral status in the past 3 months |43
611|6 - Reported or observed history of difficulty complying with any medical instructions (for example |6 - Reported or observed history of difficulty complying with any medical instructions (for example |43
613|7 - Currently taking 5 or more medications|7 - Currently taking 5 or more medications|43
615|8 - Currently reports exhaustion|8 - Currently reports exhaustion|43
617|9 - Other risk(s) not listed in 1 - 8|9 - Other risk(s) not listed in 1 - 8|43
619|10 - None of the above |10 - None of the above |43
632|0 - No assistance needed v patient is independent or does not have needs in this area|0 - No assistance needed v patient is independent or does not have needs in this area|43
633|1 - Non-agency caregiver(s) currently provide assistance |1 - Non-agency caregiver(s) currently provide assistance |43
634|2 - Non-agency caregiver(s) need training/ supportive services to provide assistance|2 - Non-agency caregiver(s) need training/ supportive services to provide assistance|43
635|3 - Non-agency caregiver(s) are not likely to provide assistance OR it is unclear if they will provide assistance|3 - Non-agency caregiver(s) are not likely to provide assistance OR unclear if will provide asst|43
636|4 - Assistance needed but no non-agency caregiver(s) available|4 - Assistance needed but no non-agency caregiver(s) available|43
2|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; OR (b) Is physically, cognitively, and mentally able to prepare light meals on a regular basis but has not routinely performed light meal preparation in the past (i.e., prior to this home care admission).|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; O|44
3|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and mentally able to perform all housekeeping tasks .|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and menta|44
4|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and mentally able to do laundry and access facilities.|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and menta|44
5|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying packages OR b) Physically, cognitively, and mentally able to take care of shopping, but has not done shopping in the past (i.e., prior to this home care admission).|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying|44
6|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|44
7|0 - Able to dial numbers and answer calls appropriately and as desired.|0 - Able to dial numbers and answer calls appropriately and as desired.|44
8|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body without assistance.|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body|44
9|0 - Able to get to and from the toilet and transfer independently with or without a device.|0 - Able to get to and from the toilet and transfer independently with or without a device.|44
10|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|44
11|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible public bus.|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible p|44
12|0 - Able to independently feed self.|0 - Able to independently feed self.|44
13|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|44
14|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct times.|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct ti|44
15|0 - Able to independently transfer.|0 - Able to independently transfer.|44
16|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without rail|44
17|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings|44
18|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|44
19|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions independently.|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions indep|44
20|0 - Asymptomatic, no treatment needed at this time|0 - Asymptomatic, no treatment needed at this time|44
21|0 - Caregiver manages all tasks related to equipment completely independently.|0 - Caregiver manages all tasks related to equipment completely independently.|44
22|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations with no observable impairment.|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations w|44
23|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|44
24|0 - Life expectancy is greater than 6 months|0 - Life expectancy is greater than 6 months|44
25|0 - Never|0 - Never|44
26|0 - Patient is not short of breath|0 - Patient is not short of breath|44
27|0 - No|0 - No|44
28|0 - No emergent care services|0 - No emergent care services|44
29|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [Goto M1620]|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [Goto M1620]|44
30|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and extended or abstract conversation.|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and exte|44
31|0 - No one person|0 - No one person|44
32|0 - None of the time|0 - None of the time|44
33|0 - None, no charge for current services|0 - None, no charge for current services|44
34|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|44
35|0 - Patient does NOT have an ostomy for bowel elimination.|0 - Patient does NOT have an ostomy for bowel elimination.|44
36|0 - Patient has no pain|0 - Patient has no pain|44
37|0 - Patient manages all tasks related to equipment completely independently.|0 - Patient manages all tasks related to equipment completely independently.|44
38|0 - Poor:  little or no recovery is expected and/or further decline is imminent|0 - Poor:  little or no recovery is expected and/or further decline is imminent|44
39|0 - Timed-voiding defers incontinence|0 - Timed-voiding defers incontinence|44
40|0 - Very rarely or never has bowel incontinence|0 - Very rarely or never has bowel incontinence|44
41|0 - Zero|0 - Zero|44
42|00 - No|00 - No|44
43|01 - Yes|01 - Yes|44
44|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or mental limitations, needs assistance with heavy laundry.|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or|44
45|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the patient.|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the|44
46|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|44
47|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or supervision from another person OR c) a liquid, pureed or ground meat diet.|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or su|44
48|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|44
49|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|44
50|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independently.|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independe|44
51|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only when assisted or accompanied by another person.|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only w|44
52|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepa|44
53|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance by another person OR b) given daily reminders.|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance b|44
54|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advan|44
55|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advan|44
56|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for the deaf) and call essential numbers.|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for t|44
57|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|44
58|1 - American Indian or Alaska Native|1 - American Indian or Alaska Native|44
59|1 - Depressed mood (e.g., feeling sad, tearful)|1 - Depressed mood (e.g., feeling sad, tearful)|44
60|1 - During the night only|1 - During the night only|44
61|1 - Fully granulating|1 - Fully granulating|44
62|1 - Good/Fair:  partial to full recovery is expected|1 - Good/Fair:  partial to full recovery is expected|44
63|1 - Good:  marked improvement in functional status is expected|1 - Good:  marked improvement in functional status is expected|44
64|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|44
65|1 - Smoking|1 - Smoking|44
66|1 - Hospital|1 - Hospital|44
67|1 - Hospital emergency room (includes 23-hour holding)|1 - Hospital emergency room (includes 23-hour holding)|44
68|1 - Hospitalization for EMERGENT (unscheduled) care|1 - Hospitalization for EMERGENT (unscheduled) care|44
69|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepared solutions), patient is able to manage all other aspects of equipment.|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepar|44
70|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|44
71|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|44
72|1 - In new or complex situations only|1 - In new or complex situations only|44
73|1 - Intravenous or infusion therapy (excludes TPN)|1 - Intravenous or infusion therapy (excludes TPN)|44
74|1 - Less often than daily|1 - Less often than daily|44
75|1 - Less than once a month|1 - Less than once a month|44
76|1 - Less than once weekly|1 - Less than once weekly|44
77|1 - Life expectancy is 6 months or fewer|1 - Life expectancy is 6 months or fewer|44
78|1 - Lives alone|1 - Lives alone|44
79|1 - Male|1 - Male|44
80|1 - Medicare (traditional fee-for-service)|1 - Medicare (traditional fee-for-service)|44
81|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of past 24 hours, significant memory loss so that supervision is required|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of pas|44
82|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors in word choice, grammar or speech intelligibility, needs minimal prompting or assistance).|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors i|44
83|1 - No assistance or services received|1 - No assistance or services received|44
84|1 - One|1 - One|44
85|1 - Oxygen (intermittent or continuous)|1 - Oxygen (intermittent or continuous)|44
86|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, and the surrounding layout, can count fingers at arm's length.|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, a|44
87|1 - Patient is incontinent|1 - Patient is incontinent|44
88|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|44
89|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical or treatment regimen.|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical|44
90|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient/couple/significant other)|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient|44
91|1 - Relatives, friends, or neighbors living outside the home|1 - Relatives, friends, or neighbors living outside the home|44
92|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions.|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions|44
93|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independentl|44
94|1 - Several times during day and night|1 - Several times during day and night|44
95|1 - Spouse or significant other|1 - Spouse or significant other|44
96|1 - Stage 1|1 - Stage 1|44
97|1 - Start of care - further visits planned|1 - Start of care - further visits planned|44
98|1 - Symptoms well controlled with current therapy|1 - Symptoms well controlled with current therapy|44
99|1 - Therapy services|1 - Therapy services|44
100|1 - Able to transfer with minimal human assistance or with use of an assistive device.|1 - Able to transfer with minimal human assistance or with use of an assistive device.|44
101|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitations.|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitatio|44
102|1 - Urinary incontinence|1 - Urinary incontinence|44
103|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and transfer.|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and|44
104|1 - When walking more than 20 feet, climbing stairs|1 - When walking more than 20 feet, climbing stairs|44
105|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary conversation. May need occasional repetition, extra time, or louder voice.|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary c|44
106|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting in and out of tub/shower|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting|44
107|1 - Yes|1 - Yes|44
108|1-RN|1-RN|44
109|10 - Discharge from agency - no visits completed after start/resumption of care assessment|10 - Discharge from agency - no visits completed after start/resumption of care assessment|44
110|10 - Scheduled surgical procedure|10 - Scheduled surgical procedure|44
111|10 - Self-pay|10 - Self-pay|44
112|11 - Other|11 - Other|44
113|11 - Urinary tract infection|11 - Urinary tract infection|44
114|12 - IV catheter-related infection|12 - IV catheter-related infection|44
115|13 - Deep vein thrombosis, pulmonary embolus|13 - Deep vein thrombosis, pulmonary embolus|44
116|14 - Uncontrolled pain|14 - Uncontrolled pain|44
117|15 - Psychotic episode|15 - Psychotic episode|44
118|16 - Other than above reasons|16 - Other than above reasons|44
119|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing calls.|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing|44
120|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another person.|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another pers|44
121|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface a|44
122|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for intermittent supervision or encouragement or reminders, OR (b) to get in and out of the shower or tub, OR (c) for washing difficult to reach areas.|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for inter|44
123|2 - Asian|2 - Asian|44
124|2 - Caregiver requires considerable assistance from another person to manage equipment, but independently completes significant portions of task.|2 - Caregiver requires considerable assistance from another person to manage equipment, but independ|44
125|2 - Daily, but not constantly|2 - Daily, but not constantly|44
126|2 - Daughter or son|2 - Daughter or son|44
127|2 - Doctor's office emergency visit/house call|2 - Doctor's office emergency visit/house call|44
128|2 - During the day and night|2 - During the day and night|44
129|2 - Early/partial granulation|2 - Early/partial granulation|44
130|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors in word choice, organization or speech intelligibility). Speaks in phrases or short sentences.|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors|44
131|2 - Family member's residence|2 - Family member's residence|44
132|2 - Female|2 - Female|44
133|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conversation, needs frequent prompting or assistance.|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conver|44
134|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|44
135|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|44
136|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately stop activities, jeopardizes safety through actions|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately st|44
137|2 - Indwelling/suprapubic catheter|2 - Indwelling/suprapubic catheter|44
138|2 - Injury caused by fall or accident at home|2 - Injury caused by fall or accident at home|44
139|2 - Medicare (HMO/managed care/Advantage plan)|2 - Medicare (HMO/managed care/Advantage plan)|44
140|2 - Nausea, dehydration, malnutrition, constipation, impaction|2 - Nausea, dehydration, malnutrition, constipation, impaction|44
141|2 - Obesity|2 - Obesity|44
142|2 - On awakening or at night only|2 - On awakening or at night only|44
143|2 - Once a month|2 - Once a month|44
144|2 - One to three times weekly|2 - One to three times weekly|44
145|2 - Parenteral nutrition (TPN or lipids)|2 - Parenteral nutrition (TPN or lipids)|44
146|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic) [ Go to M1620 ]|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic) [ Go|44
147|2 - Patient requires considerable assistance from another person to manage equipment, but independently completes portions of the task.|2 - Patient requires considerable assistance from another person to manage equipment, but independen|44
148|2 - Patient transferred to a noninstitutional hospice|2 - Patient transferred to a noninstitutional hospice|44
149|2 - Person residing in the home (EXCLUDING paid help)|2 - Person residing in the home (EXCLUDING paid help)|44
150|2 - Rehabilitation facility|2 - Rehabilitation facility|44
151|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifting of attention) or consistently requires low stimulus environment due to distractibility.|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifti|44
152|2 - Respite care|2 - Respite care|44
153|2 - Sense of failure or self reproach|2 - Sense of failure or self reproach|44
154|2 - Several times during day|2 - Several times during day|44
155|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonresponsive.|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonrespons|44
156|2 - Someone must assist the patient to groom self.|2 - Someone must assist the patient to groom self.|44
157|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|44
158|2 - Someone must help the patient put on upper body clothing.|2 - Someone must help the patient put on upper body clothing.|44
159|2 - Stage 2|2 - Stage 2|44
160|2 - Start of care - no further visits planned|2 - Start of care - no further visits planned|44
161|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitoring|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitori|44
162|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment regimen.|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment re|44
163|2 - Two|2 - Two|44
164|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistance due to cognitive or mental limitation.|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistanc|44
165|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|44
166|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assistance).|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assis|44
167|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home delivery.|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home deli|44
168|2 - Unable to prepare any light meals or reheat any delivered meals.|2 - Unable to prepare any light meals or reheat any delivered meals.|44
169|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|44
170|2 - UNABLE to take injectable medications unless administered by someone else.|2 - UNABLE to take injectable medications unless administered by someone else.|44
171|2 - UNABLE to take medication unless administered by someone else.|2 - UNABLE to take medication unless administered by someone else.|44
172|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|44
173|2 - Ventilator (continually or at night)|2 - Ventilator (continually or at night)|44
174|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less than 20 feet)|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less th|44
175|2 - With spouse or significant other|2 - With spouse or significant other|44
176|2 - Yes, assistance or services provided by family or friends|2 - Yes, assistance or services provided by family or friends|44
177|2-PT|2-PT|44
178|3 - Able to answer the telephone only some of the time or is able to carry on only a limited conversation.|3 - Able to answer the telephone only some of the time or is able to carry on only a limited convers|44
179|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube or gastrostomy.|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube|44
180|3 - Alcohol dependency|3 - Alcohol dependency|44
181|3 - All of the time|3 - All of the time|44
182|3 - Black or African-American|3 - Black or African-American|44
183|3 - Boarding home or rented room|3 - Boarding home or rented room|44
184|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment, clean/store/dispose of equipment or supplies).|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment,|44
185|3 -Able to walk only with the supervision or assistance of another person at all times.|3 -Able to walk only with the supervision or assistance of another person at all times.|44
186|3 - Continuous / Bi-level positive airway pressure|3 - Continuous / Bi-level positive airway pressure|44
187|3 - During the day and evening, but not constantly|3 - During the day and evening, but not constantly|44
188|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the alimentary canal)|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the|44
189|3 - Environmental support (e.g., housing, home maintenance)|3 - Environmental support (e.g., housing, home maintenance)|44
190|3 - Four to six times weekly|3 - Four to six times weekly|44
191|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessing by listener.  Speech limited to single words or short phrases.|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessin|44
192|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires multiple repetitions, restatements, demonstrations, additional time.|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires m|44
193|3 - Hopelessness|3 - Hopelessness|44
194|3 - Hospice care|3 - Hospice care|44
195|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|44
196|3 - Injury caused by fall or accident at home|3 - Injury caused by fall or accident at home|44
197|3 - Intractable pain|3 - Intractable pain|44
198|3 - Medicaid (traditional fee-for-service)|3 - Medicaid (traditional fee-for-service)|44
199|3 - Needs someone to do all shopping and errands.|3 - Needs someone to do all shopping and errands.|44
200|3 - Not healing|3 - Not healing|44
201|3 - Nursing home|3 - Nursing home|44
202|3 - Once daily|3 - Once daily|44
203|3 - Other family member|3 - Other family member|44
204|3 - Outpatient department/clinic emergency (includes urgicenter sites)|3 - Outpatient department/clinic emergency (includes urgicenter sites)|44
205|3 - Paid help|3 - Paid help|44
206|3 - Able to participate in bathing self in shower or tub, but requires presence of another person throughout the bath for assistance or supervision.|3 - Able to participate in bathing self in shower or tub, but requires presence of another person th|44
207|3 - Patient depends entirely upon another person to dress lower body.|3 - Patient depends entirely upon another person to dress lower body.|44
208|3 - Patient depends entirely upon another person to dress the upper body.|3 - Patient depends entirely upon another person to dress the upper body.|44
209|3 - Patient depends entirely upon someone else for grooming needs.|3 - Patient depends entirely upon someone else for grooming needs.|44
210|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone else to manage the equipment.|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone|44
211|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable to shift attention and recall directions more than half the time.|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable|44
212|3 - Respiratory problems (SOB, infection, obstruction)|3 - Respiratory problems (SOB, infection, obstruction)|44
213|3 - Resumption of care (after inpatient stay)|3 - Resumption of care (after inpatient stay)|44
214|3 - Several times each month|3 - Several times each month|44
215|3 - Skilled Nursing Facility|3 - Skilled Nursing Facility|44
216|3 - Stage 3|3 - Stage 3|44
217|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|44
218|3 - Three|3 - Three|44
219|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person throughout the process.|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person through|44
220|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal independently.|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal indep|44
221|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person.|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person|44
222|3 - Unknown because patient moved to a geographic location not served by this agency|3 - Unknown because patient moved to a geographic location not served by this agency|44
223|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|44
224|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|44
225|3 - With other family member|3 - With other family member|44
226|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home health services, homemaker assistance, transportation assistance, assisted living, board and care)|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home h|44
227|3-SLP/ST|3-SLP/ST|44
228|4 - At rest (during day or night)|4 - At rest (during day or night)|44
229|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|44
230|4 - Board and care or assisted living facility|4 - Board and care or assisted living facility|44
231|4 - Caregiver is completely dependent on someone else to manage all equipment.|4 - Caregiver is completely dependent on someone else to manage all equipment.|44
232|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|44
233|4 - Constantly|4 - Constantly|44
234|4 - Drug dependency|4 - Drug dependency|44
235|4 - Four or more|4 - Four or more|44
236|4 - Friend or neighbor or community or church member|4 - Friend or neighbor or community or church member|44
237|4 - Hispanic or Latino|4 - Hispanic or Latino|44
238|4 - Hospice|4 - Hospice|44
239|4 - Impaired decision-making|4 - Impaired decision-making|44
240|4 - Is totally dependent in toileting.|4 - Is totally dependent in toileting.|44
241|4 - Medicaid (HMO/managed care)|4 - Medicaid (HMO/managed care)|44
242|4 - None of the above|4 - None of the above|44
243|4 - Nursing home|4 - Nursing home|44
244|4 - On a daily basis|4 - On a daily basis|44
245|4 - Patient is completely dependent on someone else to manage all equipment.|4 - Patient is completely dependent on someone else to manage all equipment.|44
246|4 - Permanent placement|4 - Permanent placement|44
247|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, punches, dangerous maneuvers w/ wheelchair or other objects)|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, pu|44
248|4 - Psychosocial support (e.g., socialization, companionship, recreation)|4 - Psychosocial support (e.g., socialization, companionship, recreation)|44
249|4 - Recertification (follow-up) reassessment|4 - Recertification (follow-up) reassessment|44
250|4 - Recurrent thoughts of death|4 - Recurrent thoughts of death|44
251|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruction)|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruc|44
252|4 - Several times a week|4 - Several times a week|44
253|4 - Stage 4|4 - Stage 4|44
254|4 - Symptoms poorly controlled, history of re-hospitalizations|4 - Symptoms poorly controlled, history of re-hospitalizations|44
255|4 - Three or more times per week|4 - Three or more times per week|44
256|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetative state, or delirium.|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetati|44
257|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|44
258|4 - Unable to effectively participate in any housekeeping tasks.|4 - Unable to effectively participate in any housekeeping tasks.|44
259|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or unresponsive (e.g., speech is nonsensical or unintelligible).|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or u|44
260|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonresponsive.|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonr|44
261|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostomy.|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostom|44
262|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of devices at the sink, in chair, or on commode|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of|44
263|4 - With a friend|4 - With a friend|44
264|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|44
265|4-OT|4-OT|44
266|5 - Advocates or facilitates patient's participation in appropriate medical care|5 - Advocates or facilitates patient's participation in appropriate medical care|44
267|5 - At least daily|5 - At least daily|44
268|6 - Bedfast, unable to ambulate or be up in a chair.|6 - Bedfast, unable to ambulate or be up in a chair.|44
269|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|44
270|5 - Disruptive or socially inappropriate behavior|5 - Disruptive or socially inappropriate behavior|44
271|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|44
272|5 - Hypo/Hyperglycemia, diabetes out of control|5 - Hypo/Hyperglycemia, diabetes out of control|44
273|5 - More often than once daily|5 - More often than once daily|44
274|5 - Native Hawaiian or Pacific Islander|5 - Native Hawaiian or Pacific Islander|44
275|5 - None of the above|5 - None of the above|44
276|5 - One to two times per week|5 - One to two times per week|44
277|5 - Other|5 - Other|44
278|5 - Other follow-up|5 - Other follow-up|44
279|5 - Paid help|5 - Paid help|44
280|5 - Patient nonresponsive or unable to speak.|5 - Patient nonresponsive or unable to speak.|44
281|5 - Thoughts of suicide|5 - Thoughts of suicide|44
282|5 - Totally unable to use the telephone.|5 - Totally unable to use the telephone.|44
283|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|44
284|5 - Unable to take in nutrients orally or by tube feeding.|5 - Unable to take in nutrients orally or by tube feeding.|44
285|5 - Unsafe for care at home|5 - Unsafe for care at home|44
286|5 - With paid help (other than home care agency staff)|5 - With paid help (other than home care agency staff)|44
287|5 - Workers' compensation|5 - Workers' compensation|44
288|5 - Wound infection, deteriorating wound status, new lesion/ulcer|5 - Wound infection, deteriorating wound status, new lesion/ulcer|44
289|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|44
290|6 - Delusional, hallucinatory, or paranoid behavior|6 - Delusional, hallucinatory, or paranoid behavior|44
291|6 - Financial agent, power of attorney, or conservator of finance|6 - Financial agent, power of attorney, or conservator of finance|44
292|6 - GI bleeding, obstruction|6 - GI bleeding, obstruction|44
293|6 - Less often than weekly|6 - Less often than weekly|44
294|6 - Memory loss to the extent that supervision required|6 - Memory loss to the extent that supervision required|44
295|6 - None of the above feelings observed or reported|6 - None of the above feelings observed or reported|44
296|6 - Other|6 - Other|44
297|6 - Title programs (e.g., Title III, V, or XX)|6 - Title programs (e.g., Title III, V, or XX)|44
298|6 - Transferred to an inpatient facility - patient not discharged from agency|6 - Transferred to an inpatient facility - patient not discharged from agency|44
299|6 - White|6 - White|44
300|6 - With other than above|6 - With other than above|44
301|7 - Exacerbation of CHF, fluid overload, heart failure|7 - Exacerbation of CHF, fluid overload, heart failure|44
302|7 - Health care agent, conservator of person, or medical power of attorney|7 - Health care agent, conservator of person, or medical power of attorney|44
303|7 - Hypo/Hyperglycemia, diabetes out of control|7 - Hypo/Hyperglycemia, diabetes out of control|44
304|7 - None of the above|7 - None of the above|44
305|7 - None of the above behaviors demonstrated|7 - None of the above behaviors demonstrated|44
306|7 - Other government (e.g., TriCare, VA, etc.)|7 - Other government (e.g., TriCare, VA, etc.)|44
307|7 - Transferred to an inpatient facility - patient discharged from agency|7 - Transferred to an inpatient facility - patient discharged from agency|44
308|8 - Death at home|8 - Death at home|44
309|8 - GI bleeding, obstruction|8 - GI bleeding, obstruction|44
310|8 - Myocardial infarction, stroke|8 - Myocardial infarction, stroke|44
311|8 - Private insurance|8 - Private insurance|44
312|9 - Chemotherapy|9 - Chemotherapy|44
313|9 - Discharge from agency|9 - Discharge from agency|44
314|9 - Other than above reasons|9 - Other than above reasons|44
315|9 - Private HMO/managed care|9 - Private HMO/managed care|44
316|NA - No caregiver|NA - No caregiver|44
317|NA - No equipment of this type used in care.|NA - No equipment of this type used in care.|44
318|NA - No inhalant/mist medications prescribed.|NA - No inhalant/mist medications prescribed.|44
319|NA - No injectable medications prescribed.|NA - No injectable medications prescribed.|44
320|NA - No inpatient facility admission|NA - No inpatient facility admission|44
321|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|44
322|NA - No Medicaid|NA - No Medicaid|44
323|NA - No Medicare|NA - No Medicare|44
324|NA - No observable pressure ulcer or unhealed pressure ulcer|NA - No observable pressure ulcer or unhealed pressure ulcer|44
325|NA - No observable stasis ulcer|NA - No observable stasis ulcer|44
326|NA - No observable surgical wound|NA - No observable surgical wound|44
327|NA - No oral medications prescribed.|NA - No oral medications prescribed.|44
328|NA - Not applicable|NA - Not applicable|44
329|NA - Patient does not have a telephone.|NA - Patient does not have a telephone.|44
330|NA - Patient has ostomy for bowel elimination|NA - Patient has ostomy for bowel elimination|44
331|NA - Patient nonresponsive|NA - Patient nonresponsive|44
332|NA - Patient on prophylactic treatment|NA - Patient on prophylactic treatment|44
333|NA - Patient was not discharged from an inpatient facility [Go to M1016 ]|NA - Patient was not discharged from an inpatient facility [Go to M1016 ]|44
334|UK - Other unknown|UK - Other unknown|44
335|UK - Reason unknown|UK - Reason unknown|44
336|UK - Unknown|UK - Unknown|44
337|UK - Unknown or Not Available|UK - Unknown or Not Available|44
341|01 - Early|01 - Early|44
342|02 - Late|02 - Late|44
343|NA - Not Applicable. No case mix group defined for this assessment.|NA - Not Applicable. No case mix group defined for this assessment.|44
344|NA - No case mix group defined by this assessment.|NA - No case mix group defined by this assessment.|44
345|1 - Recent decline in mental, emotional, or behavioral status|1 - Recent decline in mental, emotional, or behavioral status|44
346|2 - Multiple hospitalizations (2 or more) in the past 12 months|2 - Multiple hospitalizations (2 or more) in the past 12 months|44
347|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|44
348|4 - Taking five or more medications|4 - Taking five or more medications|44
349|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|44
350|6 - Other|6 - Other|44
351|7 - None of the above|7 - None of the above|44
352|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond tho|44
353|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable without heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable wi|44
354|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious complications and death.|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious compl|44
355|3 - The patient has serious progressive conditions that could lead to death within a year.|3 - The patient has serious progressive conditions that could lead to death within a year.|44
356|UK - The patient+s situation is unknown or unclear.|UK - The patient+s situation is unknown or unclear.|44
357|1 - Yes [ Go to M1050 ]|1 - Yes [ Go to M1050 ]|44
358|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this influenza season. [ Go to M1050 ]|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this i|44
359|1 - Received from another health care provider (e.g., physician)|1 - Received from another health care provider (e.g., physician)|44
360|2 - Received from your agency previously during this year+s flu season|2 - Received from your agency previously during this year+s flu season|44
361|3 - Offered and declined|3 - Offered and declined|44
362|4 - Assessed and determined to have medical contraindication(s)|4 - Assessed and determined to have medical contraindication(s)|44
363|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|44
364|6 - Inability to obtain vaccine due to declared shortage|6 - Inability to obtain vaccine due to declared shortage|44
365|1 - Yes [ Go to M1500 at TRN; Go to M1230 at DC ]|1 - Yes [ Go to M1500 at TRN; Go to M1230 at DC ]|44
366|1 - Patient has received PPV in the past|1 - Patient has received PPV in the past|44
367|2 - Offered and declined|2 - Offered and declined|44
368|3 - Assessed and determined to have medical contraindication(s)|3 - Assessed and determined to have medical contraindication(s)|44
369|4 - Not indicated; patient does not meet age/condition guidelines for PPV|4 - Not indicated; patient does not meet age/condition guidelines for PPV|44
370|5 - None of the above|5 - None of the above|44
371|0 - Adequate: hears normal conversation without difficulty.|0 - Adequate: hears normal conversation without difficulty.|44
372|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to increase volume or speak distinctly.|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to in|44
373|2 - Severely Impaired: absence of useful hearing.|2 - Severely Impaired: absence of useful hearing.|44
374|UK - Unable to assess hearing.|UK - Unable to assess hearing.|44
375|0 - Understands: clear comprehension without cues or repetitions.|0 - Understands: clear comprehension without cues or repetitions.|44
376|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Requires cues at times to understand.|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Req|44
377|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequently requires cues to understand.|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequentl|44
378|3 - Rarely/Never Understands|3 - Rarely/Never Understands|44
379|UK - Unable to assess understanding.|UK - Unable to assess understanding.|44
380|0 - No standardized assessment conducted|0 - No standardized assessment conducted|44
381|1 - Yes, and it does not indicate severe pain|1 - Yes, and it does not indicate severe pain|44
382|2 - Yes, and it indicates severe pain|2 - Yes, and it indicates severe pain|44
383|0 - Patient has no pain|0 - Patient has no pain|44
384|1 - Patient has pain that does not interfere with activity or movement|1 - Patient has pain that does not interfere with activity or movement|44
385|2 - Less often than daily|2 - Less often than daily|44
386|3 - Daily, but not constantly|3 - Daily, but not constantly|44
387|4 - All of the time|4 - All of the time|44
388|0 - No assessment conducted [ Go to M1306 ]|0 - No assessment conducted [ Go to M1306 ]|44
389|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc., without use of standardized tool|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc.,|44
390|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|44
391|0 - No [ Go to M1322]|0 - No [ Go to M1322]|44
392|0 v Newly epithelialized|0 v Newly epithelialized|44
393|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|44
394|2 - Yes, patient has observable stasis ulcers ONLY|2 - Yes, patient has observable stasis ulcers ONLY|44
395|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable dressing) [Go to M1340]|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable|44
396|0 - No [ Go to M1350 ]|0 - No [ Go to M1350 ]|44
397|1 - Yes, patient has at least one (observable) surgical wound|1 - Yes, patient has at least one (observable) surgical wound|44
398|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1350 ]|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1350 ]|44
399|0 - Patient is not short of breath|0 - Patient is not short of breath|44
400|3 - Continuous Bi-level positive airway pressure|3 - Continuous Bi-level positive airway pressure|44
401|0 - No [ Go to M1732 at TRN; Go to M1600 at DC ]|0 - No [ Go to M1732 at TRN; Go to M1600 at DC ]|44
402|2 - Not assessed [Go to M1732 at TRN; Go to M1600 at DC ]|2 - Not assessed [Go to M1732 at TRN; Go to M1600 at DC ]|44
403|NA - Patient does not have diagnosis of heart failure [Go to M2004 at TRN; Go to M1600 at DC]|NA - Patient does not have diagnosis of heart failure [Go to M2004 at TRN; Go to M1600 at DC]|44
404|0 - No action taken|0 - No action taken|44
405|1 - Patient+s physician (or other primary care practitioner) contacted the same day|1 - Patient+s physician (or other primary care practitioner) contacted the same day|44
406|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|44
407|3 - Implement physician-ordered patient-specific established parameters for treatment|3 - Implement physician-ordered patient-specific established parameters for treatment|44
408|4 - Patient education or other clinical interventions|4 - Patient education or other clinical interventions|44
409|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequency, telehealth, etc.)|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequ|44
410|1 - Occasional stress incontinence|1 - Occasional stress incontinence|44
411|2 - During the night only|2 - During the night only|44
412|3 - During the day only|3 - During the day only|44
413|4 - During the day and night|4 - During the day and night|44
414|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|44
415|0 - Able to manage toileting hygiene and clothing management without assistance.|0 - Able to manage toileting hygiene and clothing management without assistance.|44
416|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implements are laid out for the patient.|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implemen|44
417|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|44
418|3 - Patient depends entirely upon another person to maintain toileting hygiene.|3 - Patient depends entirely upon another person to maintain toileting hygiene.|44
419|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independent|44
420|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface|44
421|0 - No multi-factor falls risk assessment conducted.|0 - No multi-factor falls risk assessment conducted.|44
422|1 - Yes, and it does not indicate a risk for falls.|1 - Yes, and it does not indicate a risk for falls.|44
423|2 - Yes, and it indicates a risk for falls.|2 - Yes, and it indicates a risk for falls.|44
424|0 - Not assessed/reviewed [ Go to M2010 ]|0 - Not assessed/reviewed [ Go to M2010 ]|44
425|1 - No problems found during review [ Go to M2010 ]|1 - No problems found during review [ Go to M2010 ]|44
426|2 - Problems found during review|2 - Problems found during review|44
427|NA - Patient is not taking any medications [ Go to M2040 ]|NA - Patient is not taking any medications [ Go to M2040 ]|44
428|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special precautions associated with all high-risk medications|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special p|44
429|NA - Patient not taking any drugs|NA - Patient not taking any drugs|44
430|2 - Able to take medication(s) at the correct times if given reminders by another person at the appropriate times|2 - Able to take medication(s) at the correct times if given reminders by another person at the appr|44
431|3 - Unable to take medication unless administered by another person.|3 - Unable to take medication unless administered by another person.|44
432|1 - At least daily|1 - At least daily|44
433|2 - Three or more times per week|2 - Three or more times per week|44
434|3 - One to two times per week|3 - One to two times per week|44
435|4 - Received, but less often than weekly|4 - Received, but less often than weekly|44
436|5 - No assistance received|5 - No assistance received|44
437|0 - No [Go to M2400]|0 - No [Go to M2400]|44
438|1 - Yes, used hospital emergency department WITHOUT hospital admission|1 - Yes, used hospital emergency department WITHOUT hospital admission|44
439|2 - Yes, used hospital emergency department WITH hospital admission|2 - Yes, used hospital emergency department WITH hospital admission|44
440|UK - Unknown [Go to M2400]|UK - Unknown [Go to M2400]|44
441|2 - Injury caused by fall|2 - Injury caused by fall|44
442|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|44
443|4 - Other respiratory problem|4 - Other respiratory problem|44
444|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|44
445|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|44
446|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|44
447|8 - Other heart disease|8 - Other heart disease|44
448|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|44
449|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|44
450|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|44
451|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|44
452|13 - Urinary tract infection|13 - Urinary tract infection|44
453|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|44
454|15 - Wound infection or deterioration|15 - Wound infection or deterioration|44
455|16 - Uncontrolled pain|16 - Uncontrolled pain|44
456|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|44
457|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|44
458|19 - Other than above reasons|19 - Other than above reasons|44
459|2 - Patient remained in the community (with formal assistive services)|2 - Patient remained in the community (with formal assistive services)|44
460|3 - Patient transferred to a noninstitutional hospice|3 - Patient transferred to a noninstitutional hospice|44
461|4 - Unknown because patient moved to a geographic location not served by this agency|4 - Unknown because patient moved to a geographic location not served by this agency|44
462|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|44
463|4 - Other respiratory problem|4 - Other respiratory problem|44
464|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|44
465|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|44
466|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|44
467|8 - Other heart disease|8 - Other heart disease|44
468|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|44
469|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|44
470|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|44
471|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|44
472|13 - Urinary tract infection|13 - Urinary tract infection|44
473|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|44
474|15 - Wound infection or deterioration|15 - Wound infection or deterioration|44
475|16 - Uncontrolled pain|16 - Uncontrolled pain|44
476|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|44
477|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|44
478|19 - Scheduled treatment or procedure|19 - Scheduled treatment or procedure|44
479|20 - Other than above reasons|20 - Other than above reasons|44
480|UK - Reason unknown [Go to M0903]|UK - Reason unknown [Go to M0903]|44
482|01 - Patient lives alone around the clock|01 - Patient lives alone around the clock|44
483|02 - Patient lives alone regular daytime|02 - Patient lives alone regular daytime|44
484|03 - Patient lives alone regular nighttime|03 - Patient lives alone regular nighttime|44
485|04 - Patient lives alone occassional/short term assistance|04 - Patient lives alone occassional/short term assistance|44
486|05 - Patient lives alone no assisstance available|05 - Patient lives alone no assisstance available|44
487|06 - Patient lives with other person(s) in the home around the clock|06 - Patient lives with other person(s) in the home around the clock|44
488|07 - Patient lives with other person(s) in the home regular daytime|07 - Patient lives with other person(s) in the home regular daytime|44
489|08 - Patient lives with other person(s) in the home regular nighttime|08 - Patient lives with other person(s) in the home regular nighttime|44
490|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|44
491|10 - Patient lives with other person(s) in the home no assistance available|10 - Patient lives with other person(s) in the home no assistance available|44
492|1 - Was present at the most recent SOC/ROC assessment|1 - Was present at the most recent SOC/ROC assessment|44
493|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|44
494|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|44
495|0 - Newly epithelialized|0 - Newly epithelialized|44
496|0 - No [ Go to M1340 ]|0 - No [ Go to M1340 ]|44
498|0 - Independent|0 - Independent|44
499|1 - Needed Some Help|1 - Needed Some Help|44
500|2 - Dependent|2 - Dependent|44
502|0 - No assistance needed in this area|0 - No assistance needed in this area|44
503|1 - Caregiver(s) currently provide assistance|1 - Caregiver(s) currently provide assistance|44
504|2 - Caregiver(s) need training/ supportive services to provide assistance|2 - Caregiver(s) need training/ supportive services to provide assistance|44
505|3 - Caregiver(s) not likely to provide assistance|3 - Caregiver(s) not likely to provide assistance|44
506|4 - Unclear if Caregiver(s) will provide assistance|4 - Unclear if Caregiver(s) will provide assistance|44
507|5 - Assistance needed, but no Caregiver(s) available|5 - Assistance needed, but no Caregiver(s) available|44
508|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will use standardized clinical guidelines accessible for all care providers to reference|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will|44
510|NA - Patient is not assessed to be at risk for falls|NA - Patient is not assessed to be at risk for falls|44
511|NA - Patient has no diagnosis or symptoms of depression|NA - Patient has no diagnosis or symptoms of depression|44
512|NA - No pain identified|NA - No pain identified|44
513|NA - Patient is not assessed to be at risk for pressure ulcers|NA - Patient is not assessed to be at risk for pressure ulcers|44
514|NA - Patient has no pressure ulcers with need for moist wound healing|NA - Patient has no pressure ulcers with need for moist wound healing|44
515|1 - Long-term nursing facility (NF)|1 - Long-term nursing facility (NF)|44
516|2 - Skilled nursing facility (SNF / TCU)|2 - Skilled nursing facility (SNF / TCU)|44
517|3 - Short stay acute hospital (IPP S)|3 - Short stay acute hospital (IPP S)|44
518|4 - Long-term care hospital (LTCH)|4 - Long-term care hospital (LTCH)|44
519|5 - Inpatient rehabilitation hospital or unit (IRF)|5 - Inpatient rehabilitation hospital or unit (IRF)|44
520|6 - Psychiatric hospital or unit|6 - Psychiatric hospital or unit|44
521|7 - Other|7 - Other|44
522|NA - Patient was not discharged from an inpatient facility [Goto M1016]|NA - Patient was not discharged from an inpatient facility [Goto M1016]|44
523|6 - Unable to participate effectively in bathing and is bathed totally by another person|6 - Unable to participate effectively in bathing and is bathed totally by another person|44
524|4 - Chairfast, unable to ambulate but is able to wheel self independently.|4 - Chairfast, unable to ambulate but is able to wheel self independently.|44
525|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask patient: "Over the last two weeks, how often have you been bothered by any of the following problems")  *Copyright+ Pfizer Inc. All rights reserved. Reproduced with permission.|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask|44
526|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluation for depression.|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluat|44
527|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet criteria for further evaluation for depression.|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet|44
528|0 - Not at all  0 - 1 day|0 - Not at all  0 - 1 day|44
529|1 - Several days  2 - 6 days|1 - Several days  2 - 6 days|44
530|2 - More than half of the days  7 - 11 days|2 - More than half of the days  7 - 11 days|44
531|3 - Nearly every day  12 - 14 days|3 - Nearly every day  12 - 14 days|44
532|NA - N/A  Unable to respond|NA - N/A  Unable to respond|44
533|2 - Able to take medication(s) at the correct times if given reminders by another person based on the frequency of the injection|2 - Able to take medication(s) at the correct times if given reminders by another person based on th|44
534|3 - Unable to take injectable medication unless administered by another person.|3 - Unable to take injectable medication unless administered by another person.|44
2|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; OR (b) Is physically, cognitively, and mentally able to prepare light meals on a regular basis but has not routinely performed light meal preparation in the past (i.e., prior to this home care admission).|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; O|45
3|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and mentally able to perform all housekeeping tasks .|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and menta|45
4|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and mentally able to do laundry and access facilities.|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and menta|45
5|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying packages OR b) Physically, cognitively, and mentally able to take care of shopping, but has not done shopping in the past (i.e., prior to this home care admission).|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying|45
6|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|45
7|0 - Able to dial numbers and answer calls appropriately and as desired.|0 - Able to dial numbers and answer calls appropriately and as desired.|45
8|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body without assistance.|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body|45
9|0 - Able to get to and from the toilet and transfer independently with or without a device.|0 - Able to get to and from the toilet and transfer independently with or without a device.|45
10|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|45
11|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible public bus.|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible p|45
12|0 - Able to independently feed self.|0 - Able to independently feed self.|45
13|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|45
14|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct times.|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct ti|45
15|0 - Able to independently transfer.|0 - Able to independently transfer.|45
16|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without rail|45
17|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings|45
18|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|45
19|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions independently.|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions indep|45
20|0 - Asymptomatic, no treatment needed at this time|0 - Asymptomatic, no treatment needed at this time|45
21|0 - Caregiver manages all tasks related to equipment completely independently.|0 - Caregiver manages all tasks related to equipment completely independently.|45
22|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations with no observable impairment.|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations w|45
23|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|45
24|0 - Life expectancy is greater than 6 months|0 - Life expectancy is greater than 6 months|45
25|0 - Never|0 - Never|45
26|0 - Patient is not short of breath|0 - Patient is not short of breath|45
27|0 - No|0 - No|45
28|0 - No emergent care services|0 - No emergent care services|45
29|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [Goto M1620]|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [Goto M1620]|45
30|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and extended or abstract conversation.|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and exte|45
31|0 - No one person|0 - No one person|45
32|0 - None of the time|0 - None of the time|45
33|0 - None, no charge for current services|0 - None, no charge for current services|45
34|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|45
35|0 - Patient does NOT have an ostomy for bowel elimination.|0 - Patient does NOT have an ostomy for bowel elimination.|45
36|0 - Patient has no pain|0 - Patient has no pain|45
37|0 - Patient manages all tasks related to equipment completely independently.|0 - Patient manages all tasks related to equipment completely independently.|45
38|0 - Poor:  little or no recovery is expected and/or further decline is imminent|0 - Poor:  little or no recovery is expected and/or further decline is imminent|45
39|0 - Timed-voiding defers incontinence|0 - Timed-voiding defers incontinence|45
40|0 - Very rarely or never has bowel incontinence|0 - Very rarely or never has bowel incontinence|45
41|0 - Zero|0 - Zero|45
42|00 - No|00 - No|45
43|01 - Yes|01 - Yes|45
44|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or mental limitations, needs assistance with heavy laundry.|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or|45
45|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the patient.|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the|45
46|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|45
47|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or supervision from another person OR c) a liquid, pureed or ground meat diet.|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or su|45
48|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|45
49|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|45
50|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independently.|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independe|45
51|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only when assisted or accompanied by another person.|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only w|45
52|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepa|45
53|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance by another person OR b) given daily reminders.|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance b|45
54|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advan|45
55|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advan|45
56|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for the deaf) and call essential numbers.|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for t|45
57|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|45
58|1 - American Indian or Alaska Native|1 - American Indian or Alaska Native|45
59|1 - Depressed mood (e.g., feeling sad, tearful)|1 - Depressed mood (e.g., feeling sad, tearful)|45
60|1 - During the night only|1 - During the night only|45
61|1 - Fully granulating|1 - Fully granulating|45
62|1 - Good/Fair:  partial to full recovery is expected|1 - Good/Fair:  partial to full recovery is expected|45
63|1 - Good:  marked improvement in functional status is expected|1 - Good:  marked improvement in functional status is expected|45
64|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|45
65|1 - Smoking|1 - Smoking|45
66|1 - Hospital|1 - Hospital|45
67|1 - Hospital emergency room (includes 23-hour holding)|1 - Hospital emergency room (includes 23-hour holding)|45
68|1 - Hospitalization for EMERGENT (unscheduled) care|1 - Hospitalization for EMERGENT (unscheduled) care|45
69|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepared solutions), patient is able to manage all other aspects of equipment.|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepar|45
70|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|45
71|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|45
72|1 - In new or complex situations only|1 - In new or complex situations only|45
73|1 - Intravenous or infusion therapy (excludes TPN)|1 - Intravenous or infusion therapy (excludes TPN)|45
74|1 - Less often than daily|1 - Less often than daily|45
75|1 - Less than once a month|1 - Less than once a month|45
76|1 - Less than once weekly|1 - Less than once weekly|45
77|1 - Life expectancy is 6 months or fewer|1 - Life expectancy is 6 months or fewer|45
78|1 - Lives alone|1 - Lives alone|45
79|1 - Male|1 - Male|45
80|1 - Medicare (traditional fee-for-service)|1 - Medicare (traditional fee-for-service)|45
81|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of past 24 hours, significant memory loss so that supervision is required|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of pas|45
82|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors in word choice, grammar or speech intelligibility, needs minimal prompting or assistance).|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors i|45
83|1 - No assistance or services received|1 - No assistance or services received|45
84|1 - One|1 - One|45
85|1 - Oxygen (intermittent or continuous)|1 - Oxygen (intermittent or continuous)|45
86|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, and the surrounding layout, can count fingers at arm's length.|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, a|45
87|1 - Patient is incontinent|1 - Patient is incontinent|45
88|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|45
89|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical or treatment regimen.|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical|45
90|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient/couple/significant other)|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient|45
91|1 - Relatives, friends, or neighbors living outside the home|1 - Relatives, friends, or neighbors living outside the home|45
92|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions.|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions|45
93|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independentl|45
94|1 - Several times during day and night|1 - Several times during day and night|45
95|1 - Spouse or significant other|1 - Spouse or significant other|45
96|1 - Stage 1|1 - Stage 1|45
97|1 - Start of care - further visits planned|1 - Start of care - further visits planned|45
98|1 - Symptoms well controlled with current therapy|1 - Symptoms well controlled with current therapy|45
99|1 - Therapy services|1 - Therapy services|45
100|1 - Able to transfer with minimal human assistance or with use of an assistive device.|1 - Able to transfer with minimal human assistance or with use of an assistive device.|45
101|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitations.|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitatio|45
102|1 - Urinary incontinence|1 - Urinary incontinence|45
103|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and transfer.|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and|45
104|1 - When walking more than 20 feet, climbing stairs|1 - When walking more than 20 feet, climbing stairs|45
105|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary conversation. May need occasional repetition, extra time, or louder voice.|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary c|45
106|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting in and out of tub/shower|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting|45
107|1 - Yes|1 - Yes|45
108|1-RN|1-RN|45
109|10 - Discharge from agency - no visits completed after start/resumption of care assessment|10 - Discharge from agency - no visits completed after start/resumption of care assessment|45
110|10 - Scheduled surgical procedure|10 - Scheduled surgical procedure|45
111|10 - Self-pay|10 - Self-pay|45
112|11 - Other|11 - Other|45
113|11 - Urinary tract infection|11 - Urinary tract infection|45
114|12 - IV catheter-related infection|12 - IV catheter-related infection|45
115|13 - Deep vein thrombosis, pulmonary embolus|13 - Deep vein thrombosis, pulmonary embolus|45
116|14 - Uncontrolled pain|14 - Uncontrolled pain|45
117|15 - Psychotic episode|15 - Psychotic episode|45
118|16 - Other than above reasons|16 - Other than above reasons|45
119|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing calls.|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing|45
120|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another person.|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another pers|45
121|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface a|45
122|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for intermittent supervision or encouragement or reminders, OR (b) to get in and out of the shower or tub, OR (c) for washing difficult to reach areas.|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for inter|45
123|2 - Asian|2 - Asian|45
124|2 - Caregiver requires considerable assistance from another person to manage equipment, but independently completes significant portions of task.|2 - Caregiver requires considerable assistance from another person to manage equipment, but independ|45
125|2 - Daily, but not constantly|2 - Daily, but not constantly|45
126|2 - Daughter or son|2 - Daughter or son|45
127|2 - Doctor's office emergency visit/house call|2 - Doctor's office emergency visit/house call|45
128|2 - During the day and night|2 - During the day and night|45
129|2 - Early/partial granulation|2 - Early/partial granulation|45
130|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors in word choice, organization or speech intelligibility). Speaks in phrases or short sentences.|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors|45
131|2 - Family member's residence|2 - Family member's residence|45
132|2 - Female|2 - Female|45
133|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conversation, needs frequent prompting or assistance.|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conver|45
134|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|45
135|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|45
136|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately stop activities, jeopardizes safety through actions|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately st|45
137|2 - Indwelling/suprapubic catheter|2 - Indwelling/suprapubic catheter|45
138|2 - Injury caused by fall or accident at home|2 - Injury caused by fall or accident at home|45
139|2 - Medicare (HMO/managed care/Advantage plan)|2 - Medicare (HMO/managed care/Advantage plan)|45
140|2 - Nausea, dehydration, malnutrition, constipation, impaction|2 - Nausea, dehydration, malnutrition, constipation, impaction|45
141|2 - Obesity|2 - Obesity|45
142|2 - On awakening or at night only|2 - On awakening or at night only|45
143|2 - Once a month|2 - Once a month|45
144|2 - One to three times weekly|2 - One to three times weekly|45
145|2 - Parenteral nutrition (TPN or lipids)|2 - Parenteral nutrition (TPN or lipids)|45
146|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic) [ Go to M1620 ]|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic) [ Go|45
147|2 - Patient requires considerable assistance from another person to manage equipment, but independently completes portions of the task.|2 - Patient requires considerable assistance from another person to manage equipment, but independen|45
148|2 - Patient transferred to a noninstitutional hospice|2 - Patient transferred to a noninstitutional hospice|45
149|2 - Person residing in the home (EXCLUDING paid help)|2 - Person residing in the home (EXCLUDING paid help)|45
150|2 - Rehabilitation facility|2 - Rehabilitation facility|45
151|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifting of attention) or consistently requires low stimulus environment due to distractibility.|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifti|45
152|2 - Respite care|2 - Respite care|45
153|2 - Sense of failure or self reproach|2 - Sense of failure or self reproach|45
154|2 - Several times during day|2 - Several times during day|45
155|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonresponsive.|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonrespons|45
156|2 - Someone must assist the patient to groom self.|2 - Someone must assist the patient to groom self.|45
157|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|45
158|2 - Someone must help the patient put on upper body clothing.|2 - Someone must help the patient put on upper body clothing.|45
159|2 - Stage 2|2 - Stage 2|45
160|2 - Start of care - no further visits planned|2 - Start of care - no further visits planned|45
161|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitoring|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitori|45
162|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment regimen.|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment re|45
163|2 - Two|2 - Two|45
164|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistance due to cognitive or mental limitation.|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistanc|45
165|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|45
166|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assistance).|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assis|45
167|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home delivery.|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home deli|45
168|2 - Unable to prepare any light meals or reheat any delivered meals.|2 - Unable to prepare any light meals or reheat any delivered meals.|45
169|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|45
170|2 - UNABLE to take injectable medications unless administered by someone else.|2 - UNABLE to take injectable medications unless administered by someone else.|45
171|2 - UNABLE to take medication unless administered by someone else.|2 - UNABLE to take medication unless administered by someone else.|45
172|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|45
173|2 - Ventilator (continually or at night)|2 - Ventilator (continually or at night)|45
174|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less than 20 feet)|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less th|45
175|2 - With spouse or significant other|2 - With spouse or significant other|45
176|2 - Yes, assistance or services provided by family or friends|2 - Yes, assistance or services provided by family or friends|45
177|2-PT|2-PT|45
178|3 - Able to answer the telephone only some of the time or is able to carry on only a limited conversation.|3 - Able to answer the telephone only some of the time or is able to carry on only a limited convers|45
179|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube or gastrostomy.|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube|45
180|3 - Alcohol dependency|3 - Alcohol dependency|45
181|3 - All of the time|3 - All of the time|45
182|3 - Black or African-American|3 - Black or African-American|45
183|3 - Boarding home or rented room|3 - Boarding home or rented room|45
184|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment, clean/store/dispose of equipment or supplies).|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment,|45
185|3 -Able to walk only with the supervision or assistance of another person at all times.|3 -Able to walk only with the supervision or assistance of another person at all times.|45
186|3 - Continuous / Bi-level positive airway pressure|3 - Continuous / Bi-level positive airway pressure|45
187|3 - During the day and evening, but not constantly|3 - During the day and evening, but not constantly|45
188|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the alimentary canal)|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the|45
189|3 - Environmental support (e.g., housing, home maintenance)|3 - Environmental support (e.g., housing, home maintenance)|45
190|3 - Four to six times weekly|3 - Four to six times weekly|45
191|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessing by listener.  Speech limited to single words or short phrases.|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessin|45
192|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires multiple repetitions, restatements, demonstrations, additional time.|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires m|45
193|3 - Hopelessness|3 - Hopelessness|45
194|3 - Hospice care|3 - Hospice care|45
195|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|45
196|3 - Injury caused by fall or accident at home|3 - Injury caused by fall or accident at home|45
197|3 - Intractable pain|3 - Intractable pain|45
198|3 - Medicaid (traditional fee-for-service)|3 - Medicaid (traditional fee-for-service)|45
199|3 - Needs someone to do all shopping and errands.|3 - Needs someone to do all shopping and errands.|45
200|3 - Not healing|3 - Not healing|45
201|3 - Nursing home|3 - Nursing home|45
202|3 - Once daily|3 - Once daily|45
203|3 - Other family member|3 - Other family member|45
204|3 - Outpatient department/clinic emergency (includes urgicenter sites)|3 - Outpatient department/clinic emergency (includes urgicenter sites)|45
205|3 - Paid help|3 - Paid help|45
206|3 - Able to participate in bathing self in shower or tub, but requires presence of another person throughout the bath for assistance or supervision.|3 - Able to participate in bathing self in shower or tub, but requires presence of another person th|45
207|3 - Patient depends entirely upon another person to dress lower body.|3 - Patient depends entirely upon another person to dress lower body.|45
208|3 - Patient depends entirely upon another person to dress the upper body.|3 - Patient depends entirely upon another person to dress the upper body.|45
209|3 - Patient depends entirely upon someone else for grooming needs.|3 - Patient depends entirely upon someone else for grooming needs.|45
210|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone else to manage the equipment.|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone|45
211|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable to shift attention and recall directions more than half the time.|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable|45
212|3 - Respiratory problems (SOB, infection, obstruction)|3 - Respiratory problems (SOB, infection, obstruction)|45
213|3 - Resumption of care (after inpatient stay)|3 - Resumption of care (after inpatient stay)|45
214|3 - Several times each month|3 - Several times each month|45
215|3 - Skilled Nursing Facility|3 - Skilled Nursing Facility|45
216|3 - Stage 3|3 - Stage 3|45
217|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|45
218|3 - Three|3 - Three|45
219|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person throughout the process.|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person through|45
220|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal independently.|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal indep|45
221|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person.|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person|45
222|3 - Unknown because patient moved to a geographic location not served by this agency|3 - Unknown because patient moved to a geographic location not served by this agency|45
223|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|45
224|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|45
225|3 - With other family member|3 - With other family member|45
226|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home health services, homemaker assistance, transportation assistance, assisted living, board and care)|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home h|45
227|3-SLP/ST|3-SLP/ST|45
228|4 - At rest (during day or night)|4 - At rest (during day or night)|45
229|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|45
230|4 - Board and care or assisted living facility|4 - Board and care or assisted living facility|45
231|4 - Caregiver is completely dependent on someone else to manage all equipment.|4 - Caregiver is completely dependent on someone else to manage all equipment.|45
232|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|45
233|4 - Constantly|4 - Constantly|45
234|4 - Drug dependency|4 - Drug dependency|45
235|4 - Four or more|4 - Four or more|45
236|4 - Friend or neighbor or community or church member|4 - Friend or neighbor or community or church member|45
237|4 - Hispanic or Latino|4 - Hispanic or Latino|45
238|4 - Hospice|4 - Hospice|45
239|4 - Impaired decision-making|4 - Impaired decision-making|45
240|4 - Is totally dependent in toileting.|4 - Is totally dependent in toileting.|45
241|4 - Medicaid (HMO/managed care)|4 - Medicaid (HMO/managed care)|45
242|4 - None of the above|4 - None of the above|45
243|4 - Nursing home|4 - Nursing home|45
244|4 - On a daily basis|4 - On a daily basis|45
245|4 - Patient is completely dependent on someone else to manage all equipment.|4 - Patient is completely dependent on someone else to manage all equipment.|45
246|4 - Permanent placement|4 - Permanent placement|45
247|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, punches, dangerous maneuvers w/ wheelchair or other objects)|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, pu|45
248|4 - Psychosocial support (e.g., socialization, companionship, recreation)|4 - Psychosocial support (e.g., socialization, companionship, recreation)|45
249|4 - Recertification (follow-up) reassessment|4 - Recertification (follow-up) reassessment|45
250|4 - Recurrent thoughts of death|4 - Recurrent thoughts of death|45
251|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruction)|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruc|45
252|4 - Several times a week|4 - Several times a week|45
253|4 - Stage 4|4 - Stage 4|45
254|4 - Symptoms poorly controlled, history of re-hospitalizations|4 - Symptoms poorly controlled, history of re-hospitalizations|45
255|4 - Three or more times per week|4 - Three or more times per week|45
256|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetative state, or delirium.|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetati|45
257|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|45
258|4 - Unable to effectively participate in any housekeeping tasks.|4 - Unable to effectively participate in any housekeeping tasks.|45
259|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or unresponsive (e.g., speech is nonsensical or unintelligible).|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or u|45
260|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonresponsive.|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonr|45
261|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostomy.|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostom|45
262|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of devices at the sink, in chair, or on commode|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of|45
263|4 - With a friend|4 - With a friend|45
264|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|45
265|4-OT|4-OT|45
266|5 - Advocates or facilitates patient's participation in appropriate medical care|5 - Advocates or facilitates patient's participation in appropriate medical care|45
267|5 - At least daily|5 - At least daily|45
268|6 - Bedfast, unable to ambulate or be up in a chair.|6 - Bedfast, unable to ambulate or be up in a chair.|45
269|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|45
270|5 - Disruptive or socially inappropriate behavior|5 - Disruptive or socially inappropriate behavior|45
271|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|45
272|5 - Hypo/Hyperglycemia, diabetes out of control|5 - Hypo/Hyperglycemia, diabetes out of control|45
273|5 - More often than once daily|5 - More often than once daily|45
274|5 - Native Hawaiian or Pacific Islander|5 - Native Hawaiian or Pacific Islander|45
275|5 - None of the above|5 - None of the above|45
276|5 - One to two times per week|5 - One to two times per week|45
277|5 - Other|5 - Other|45
278|5 - Other follow-up|5 - Other follow-up|45
279|5 - Paid help|5 - Paid help|45
280|5 - Patient nonresponsive or unable to speak.|5 - Patient nonresponsive or unable to speak.|45
281|5 - Thoughts of suicide|5 - Thoughts of suicide|45
282|5 - Totally unable to use the telephone.|5 - Totally unable to use the telephone.|45
283|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|45
284|5 - Unable to take in nutrients orally or by tube feeding.|5 - Unable to take in nutrients orally or by tube feeding.|45
285|5 - Unsafe for care at home|5 - Unsafe for care at home|45
286|5 - With paid help (other than home care agency staff)|5 - With paid help (other than home care agency staff)|45
287|5 - Workers' compensation|5 - Workers' compensation|45
288|5 - Wound infection, deteriorating wound status, new lesion/ulcer|5 - Wound infection, deteriorating wound status, new lesion/ulcer|45
289|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|45
290|6 - Delusional, hallucinatory, or paranoid behavior|6 - Delusional, hallucinatory, or paranoid behavior|45
291|6 - Financial agent, power of attorney, or conservator of finance|6 - Financial agent, power of attorney, or conservator of finance|45
292|6 - GI bleeding, obstruction|6 - GI bleeding, obstruction|45
293|6 - Less often than weekly|6 - Less often than weekly|45
294|6 - Memory loss to the extent that supervision required|6 - Memory loss to the extent that supervision required|45
295|6 - None of the above feelings observed or reported|6 - None of the above feelings observed or reported|45
296|6 - Other|6 - Other|45
297|6 - Title programs (e.g., Title III, V, or XX)|6 - Title programs (e.g., Title III, V, or XX)|45
298|6 - Transferred to an inpatient facility - patient not discharged from agency|6 - Transferred to an inpatient facility - patient not discharged from agency|45
299|6 - White|6 - White|45
300|6 - With other than above|6 - With other than above|45
301|7 - Exacerbation of CHF, fluid overload, heart failure|7 - Exacerbation of CHF, fluid overload, heart failure|45
302|7 - Health care agent, conservator of person, or medical power of attorney|7 - Health care agent, conservator of person, or medical power of attorney|45
303|7 - Hypo/Hyperglycemia, diabetes out of control|7 - Hypo/Hyperglycemia, diabetes out of control|45
304|7 - None of the above|7 - None of the above|45
305|7 - None of the above behaviors demonstrated|7 - None of the above behaviors demonstrated|45
306|7 - Other government (e.g., TriCare, VA, etc.)|7 - Other government (e.g., TriCare, VA, etc.)|45
307|7 - Transferred to an inpatient facility - patient discharged from agency|7 - Transferred to an inpatient facility - patient discharged from agency|45
308|8 - Death at home|8 - Death at home|45
309|8 - GI bleeding, obstruction|8 - GI bleeding, obstruction|45
310|8 - Myocardial infarction, stroke|8 - Myocardial infarction, stroke|45
311|8 - Private insurance|8 - Private insurance|45
312|9 - Chemotherapy|9 - Chemotherapy|45
313|9 - Discharge from agency|9 - Discharge from agency|45
314|9 - Other than above reasons|9 - Other than above reasons|45
315|9 - Private HMO/managed care|9 - Private HMO/managed care|45
316|NA - No caregiver|NA - No caregiver|45
317|NA - No equipment of this type used in care.|NA - No equipment of this type used in care.|45
318|NA - No inhalant/mist medications prescribed.|NA - No inhalant/mist medications prescribed.|45
319|NA - No injectable medications prescribed.|NA - No injectable medications prescribed.|45
320|NA - No inpatient facility admission|NA - No inpatient facility admission|45
321|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|45
322|NA - No Medicaid|NA - No Medicaid|45
323|NA - No Medicare|NA - No Medicare|45
324|NA - No observable pressure ulcer or unhealed pressure ulcer|NA - No observable pressure ulcer or unhealed pressure ulcer|45
325|NA - No observable stasis ulcer|NA - No observable stasis ulcer|45
326|NA - No observable surgical wound|NA - No observable surgical wound|45
327|NA - No oral medications prescribed.|NA - No oral medications prescribed.|45
328|NA - Not applicable|NA - Not applicable|45
329|NA - Patient does not have a telephone.|NA - Patient does not have a telephone.|45
330|NA - Patient has ostomy for bowel elimination|NA - Patient has ostomy for bowel elimination|45
331|NA - Patient nonresponsive|NA - Patient nonresponsive|45
332|NA - Patient on prophylactic treatment|NA - Patient on prophylactic treatment|45
333|NA - Patient was not discharged from an inpatient facility [Go to M1016 ]|NA - Patient was not discharged from an inpatient facility [Go to M1016 ]|45
334|UK - Other unknown|UK - Other unknown|45
335|UK - Reason unknown|UK - Reason unknown|45
336|UK - Unknown|UK - Unknown|45
337|UK - Unknown or Not Available|UK - Unknown or Not Available|45
341|01 - Early|01 - Early|45
342|02 - Late|02 - Late|45
343|NA - Not Applicable. No case mix group defined for this assessment.|NA - Not Applicable. No case mix group defined for this assessment.|45
344|NA - No case mix group defined by this assessment.|NA - No case mix group defined by this assessment.|45
345|1 - Recent decline in mental, emotional, or behavioral status|1 - Recent decline in mental, emotional, or behavioral status|45
346|2 - Multiple hospitalizations (2 or more) in the past 12 months|2 - Multiple hospitalizations (2 or more) in the past 12 months|45
347|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|45
348|4 - Taking five or more medications|4 - Taking five or more medications|45
349|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|45
350|6 - Other|6 - Other|45
351|7 - None of the above|7 - None of the above|45
352|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond tho|45
353|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable without heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable wi|45
354|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious complications and death.|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious compl|45
355|3 - The patient has serious progressive conditions that could lead to death within a year.|3 - The patient has serious progressive conditions that could lead to death within a year.|45
356|UK - The patient+s situation is unknown or unclear.|UK - The patient+s situation is unknown or unclear.|45
357|1 - Yes [ Go to M1050 ]|1 - Yes [ Go to M1050 ]|45
358|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this influenza season. [ Go to M1050 ]|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this i|45
359|1 - Received from another health care provider (e.g., physician)|1 - Received from another health care provider (e.g., physician)|45
360|2 - Received from your agency previously during this year+s flu season|2 - Received from your agency previously during this year+s flu season|45
361|3 - Offered and declined|3 - Offered and declined|45
362|4 - Assessed and determined to have medical contraindication(s)|4 - Assessed and determined to have medical contraindication(s)|45
363|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|45
364|6 - Inability to obtain vaccine due to declared shortage|6 - Inability to obtain vaccine due to declared shortage|45
365|1 - Yes [ Go to M1500 at TRN; Go to M1230 at DC ]|1 - Yes [ Go to M1500 at TRN; Go to M1230 at DC ]|45
366|1 - Patient has received PPV in the past|1 - Patient has received PPV in the past|45
367|2 - Offered and declined|2 - Offered and declined|45
368|3 - Assessed and determined to have medical contraindication(s)|3 - Assessed and determined to have medical contraindication(s)|45
369|4 - Not indicated; patient does not meet age/condition guidelines for PPV|4 - Not indicated; patient does not meet age/condition guidelines for PPV|45
370|5 - None of the above|5 - None of the above|45
371|0 - Adequate: hears normal conversation without difficulty.|0 - Adequate: hears normal conversation without difficulty.|45
372|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to increase volume or speak distinctly.|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to in|45
373|2 - Severely Impaired: absence of useful hearing.|2 - Severely Impaired: absence of useful hearing.|45
374|UK - Unable to assess hearing.|UK - Unable to assess hearing.|45
375|0 - Understands: clear comprehension without cues or repetitions.|0 - Understands: clear comprehension without cues or repetitions.|45
376|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Requires cues at times to understand.|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Req|45
377|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequently requires cues to understand.|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequentl|45
378|3 - Rarely/Never Understands|3 - Rarely/Never Understands|45
379|UK - Unable to assess understanding.|UK - Unable to assess understanding.|45
380|0 - No standardized assessment conducted|0 - No standardized assessment conducted|45
381|1 - Yes, and it does not indicate severe pain|1 - Yes, and it does not indicate severe pain|45
382|2 - Yes, and it indicates severe pain|2 - Yes, and it indicates severe pain|45
383|0 - Patient has no pain|0 - Patient has no pain|45
384|1 - Patient has pain that does not interfere with activity or movement|1 - Patient has pain that does not interfere with activity or movement|45
385|2 - Less often than daily|2 - Less often than daily|45
386|3 - Daily, but not constantly|3 - Daily, but not constantly|45
387|4 - All of the time|4 - All of the time|45
388|0 - No assessment conducted [ Go to M1306 ]|0 - No assessment conducted [ Go to M1306 ]|45
389|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc., without use of standardized tool|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc.,|45
390|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|45
391|0 - No [ Go to M1322]|0 - No [ Go to M1322]|45
392|0 v Newly epithelialized|0 v Newly epithelialized|45
393|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|45
394|2 - Yes, patient has observable stasis ulcers ONLY|2 - Yes, patient has observable stasis ulcers ONLY|45
395|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable dressing) [Go to M1340]|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable|45
396|0 - No [ Go to M1350 ]|0 - No [ Go to M1350 ]|45
397|1 - Yes, patient has at least one (observable) surgical wound|1 - Yes, patient has at least one (observable) surgical wound|45
398|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1350 ]|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1350 ]|45
399|0 - Patient is not short of breath|0 - Patient is not short of breath|45
400|3 - Continuous Bi-level positive airway pressure|3 - Continuous Bi-level positive airway pressure|45
401|0 - No [ Go to M1732 at TRN; Go to M1600 at DC ]|0 - No [ Go to M1732 at TRN; Go to M1600 at DC ]|45
402|2 - Not assessed [Go to M1732 at TRN; Go to M1600 at DC ]|2 - Not assessed [Go to M1732 at TRN; Go to M1600 at DC ]|45
403|NA - Patient does not have diagnosis of heart failure [Go to M2004 at TRN; Go to M1600 at DC]|NA - Patient does not have diagnosis of heart failure [Go to M2004 at TRN; Go to M1600 at DC]|45
404|0 - No action taken|0 - No action taken|45
405|1 - Patient+s physician (or other primary care practitioner) contacted the same day|1 - Patient+s physician (or other primary care practitioner) contacted the same day|45
406|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|45
407|3 - Implement physician-ordered patient-specific established parameters for treatment|3 - Implement physician-ordered patient-specific established parameters for treatment|45
408|4 - Patient education or other clinical interventions|4 - Patient education or other clinical interventions|45
409|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequency, telehealth, etc.)|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequ|45
410|1 - Occasional stress incontinence|1 - Occasional stress incontinence|45
411|2 - During the night only|2 - During the night only|45
412|3 - During the day only|3 - During the day only|45
413|4 - During the day and night|4 - During the day and night|45
414|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|45
415|0 - Able to manage toileting hygiene and clothing management without assistance.|0 - Able to manage toileting hygiene and clothing management without assistance.|45
416|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implements are laid out for the patient.|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implemen|45
417|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|45
418|3 - Patient depends entirely upon another person to maintain toileting hygiene.|3 - Patient depends entirely upon another person to maintain toileting hygiene.|45
419|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independent|45
420|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface|45
421|0 - No multi-factor falls risk assessment conducted.|0 - No multi-factor falls risk assessment conducted.|45
422|1 - Yes, and it does not indicate a risk for falls.|1 - Yes, and it does not indicate a risk for falls.|45
423|2 - Yes, and it indicates a risk for falls.|2 - Yes, and it indicates a risk for falls.|45
424|0 - Not assessed/reviewed [ Go to M2010 ]|0 - Not assessed/reviewed [ Go to M2010 ]|45
425|1 - No problems found during review [ Go to M2010 ]|1 - No problems found during review [ Go to M2010 ]|45
426|2 - Problems found during review|2 - Problems found during review|45
427|NA - Patient is not taking any medications [ Go to M2040 ]|NA - Patient is not taking any medications [ Go to M2040 ]|45
428|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special precautions associated with all high-risk medications|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special p|45
429|NA - Patient not taking any drugs|NA - Patient not taking any drugs|45
430|2 - Able to take medication(s) at the correct times if given reminders by another person at the appropriate times|2 - Able to take medication(s) at the correct times if given reminders by another person at the appr|45
431|3 - Unable to take medication unless administered by another person.|3 - Unable to take medication unless administered by another person.|45
432|1 - At least daily|1 - At least daily|45
433|2 - Three or more times per week|2 - Three or more times per week|45
434|3 - One to two times per week|3 - One to two times per week|45
435|4 - Received, but less often than weekly|4 - Received, but less often than weekly|45
436|5 - No assistance received|5 - No assistance received|45
437|0 - No [Go to M2400]|0 - No [Go to M2400]|45
438|1 - Yes, used hospital emergency department WITHOUT hospital admission|1 - Yes, used hospital emergency department WITHOUT hospital admission|45
439|2 - Yes, used hospital emergency department WITH hospital admission|2 - Yes, used hospital emergency department WITH hospital admission|45
440|UK - Unknown [Go to M2400]|UK - Unknown [Go to M2400]|45
441|2 - Injury caused by fall|2 - Injury caused by fall|45
442|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|45
443|4 - Other respiratory problem|4 - Other respiratory problem|45
444|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|45
445|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|45
446|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|45
447|8 - Other heart disease|8 - Other heart disease|45
448|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|45
449|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|45
450|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|45
451|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|45
452|13 - Urinary tract infection|13 - Urinary tract infection|45
453|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|45
454|15 - Wound infection or deterioration|15 - Wound infection or deterioration|45
455|16 - Uncontrolled pain|16 - Uncontrolled pain|45
456|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|45
457|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|45
458|19 - Other than above reasons|19 - Other than above reasons|45
459|2 - Patient remained in the community (with formal assistive services)|2 - Patient remained in the community (with formal assistive services)|45
460|3 - Patient transferred to a noninstitutional hospice|3 - Patient transferred to a noninstitutional hospice|45
461|4 - Unknown because patient moved to a geographic location not served by this agency|4 - Unknown because patient moved to a geographic location not served by this agency|45
462|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|45
463|4 - Other respiratory problem|4 - Other respiratory problem|45
464|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|45
465|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|45
466|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|45
467|8 - Other heart disease|8 - Other heart disease|45
468|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|45
469|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|45
470|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|45
471|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|45
472|13 - Urinary tract infection|13 - Urinary tract infection|45
473|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|45
474|15 - Wound infection or deterioration|15 - Wound infection or deterioration|45
475|16 - Uncontrolled pain|16 - Uncontrolled pain|45
476|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|45
477|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|45
478|19 - Scheduled treatment or procedure|19 - Scheduled treatment or procedure|45
479|20 - Other than above reasons|20 - Other than above reasons|45
480|UK - Reason unknown [Go to M0903]|UK - Reason unknown [Go to M0903]|45
482|01 - Patient lives alone around the clock|01 - Patient lives alone around the clock|45
483|02 - Patient lives alone regular daytime|02 - Patient lives alone regular daytime|45
484|03 - Patient lives alone regular nighttime|03 - Patient lives alone regular nighttime|45
485|04 - Patient lives alone occassional/short term assistance|04 - Patient lives alone occassional/short term assistance|45
486|05 - Patient lives alone no assisstance available|05 - Patient lives alone no assisstance available|45
487|06 - Patient lives with other person(s) in the home around the clock|06 - Patient lives with other person(s) in the home around the clock|45
488|07 - Patient lives with other person(s) in the home regular daytime|07 - Patient lives with other person(s) in the home regular daytime|45
489|08 - Patient lives with other person(s) in the home regular nighttime|08 - Patient lives with other person(s) in the home regular nighttime|45
490|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|45
491|10 - Patient lives with other person(s) in the home no assistance available|10 - Patient lives with other person(s) in the home no assistance available|45
492|1 - Was present at the most recent SOC/ROC assessment|1 - Was present at the most recent SOC/ROC assessment|45
493|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|45
494|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|45
495|0 - Newly epithelialized|0 - Newly epithelialized|45
496|0 - No [ Go to M1340 ]|0 - No [ Go to M1340 ]|45
498|0 - Independent|0 - Independent|45
499|1 - Needed Some Help|1 - Needed Some Help|45
500|2 - Dependent|2 - Dependent|45
502|0 - No assistance needed in this area|0 - No assistance needed in this area|45
503|1 - Caregiver(s) currently provide assistance|1 - Caregiver(s) currently provide assistance|45
504|2 - Caregiver(s) need training/ supportive services to provide assistance|2 - Caregiver(s) need training/ supportive services to provide assistance|45
505|3 - Caregiver(s) not likely to provide assistance|3 - Caregiver(s) not likely to provide assistance|45
506|4 - Unclear if Caregiver(s) will provide assistance|4 - Unclear if Caregiver(s) will provide assistance|45
507|5 - Assistance needed, but no Caregiver(s) available|5 - Assistance needed, but no Caregiver(s) available|45
508|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will use standardized clinical guidelines accessible for all care providers to reference|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will|45
510|NA - Patient is not assessed to be at risk for falls|NA - Patient is not assessed to be at risk for falls|45
511|NA - Patient has no diagnosis or symptoms of depression|NA - Patient has no diagnosis or symptoms of depression|45
512|NA - No pain identified|NA - No pain identified|45
513|NA - Patient is not assessed to be at risk for pressure ulcers|NA - Patient is not assessed to be at risk for pressure ulcers|45
514|NA - Patient has no pressure ulcers with need for moist wound healing|NA - Patient has no pressure ulcers with need for moist wound healing|45
515|1 - Long-term nursing facility (NF)|1 - Long-term nursing facility (NF)|45
516|2 - Skilled nursing facility (SNF / TCU)|2 - Skilled nursing facility (SNF / TCU)|45
517|3 - Short stay acute hospital (IPP S)|3 - Short stay acute hospital (IPP S)|45
518|4 - Long-term care hospital (LTCH)|4 - Long-term care hospital (LTCH)|45
519|5 - Inpatient rehabilitation hospital or unit (IRF)|5 - Inpatient rehabilitation hospital or unit (IRF)|45
520|6 - Psychiatric hospital or unit|6 - Psychiatric hospital or unit|45
521|7 - Other|7 - Other|45
522|NA - Patient was not discharged from an inpatient facility [Goto M1016]|NA - Patient was not discharged from an inpatient facility [Goto M1016]|45
523|6 - Unable to participate effectively in bathing and is bathed totally by another person|6 - Unable to participate effectively in bathing and is bathed totally by another person|45
524|4 - Chairfast, unable to ambulate but is able to wheel self independently.|4 - Chairfast, unable to ambulate but is able to wheel self independently.|45
525|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask patient: "Over the last two weeks, how often have you been bothered by any of the following problems")   *Copyright+ Pfizer Inc. All rights reserved. Reproduced with permission.|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask|45
526|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluation for depression.|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluat|45
527|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet criteria for further evaluation for depression.|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet|45
528|0 - Not at all  0 - 1 day|0 - Not at all  0 - 1 day|45
529|1 - Several days  2 - 6 days|1 - Several days  2 - 6 days|45
530|2 - More than half of the days  7 - 11 days|2 - More than half of the days  7 - 11 days|45
531|3 - Nearly every day  12 - 14 days|3 - Nearly every day  12 - 14 days|45
532|NA - N/A  Unable to respond|NA - N/A  Unable to respond|45
533|2 - Able to take medication(s) at the correct times if given reminders by another person based on the frequency of the injection|2 - Able to take medication(s) at the correct times if given reminders by another person based on th|45
534|3 - Unable to take injectable medication unless administered by another person.|3 - Unable to take injectable medication unless administered by another person.|45
2|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; OR (b) Is physically, cognitively, and mentally able to prepare light meals on a regular basis but has not routinely performed light meal preparation in the past (i.e., prior to this home care admission).|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; O|46
3|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and mentally able to perform all housekeeping tasks .|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and menta|46
4|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and mentally able to do laundry and access facilities.|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and menta|46
5|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying packages OR b) Physically, cognitively, and mentally able to take care of shopping, but has not done shopping in the past (i.e., prior to this home care admission).|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying|46
6|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|46
7|0 - Able to dial numbers and answer calls appropriately and as desired.|0 - Able to dial numbers and answer calls appropriately and as desired.|46
8|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body without assistance.|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body|46
9|0 - Able to get to and from the toilet and transfer independently with or without a device.|0 - Able to get to and from the toilet and transfer independently with or without a device.|46
10|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|46
11|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible public bus.|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible p|46
12|0 - Able to independently feed self.|0 - Able to independently feed self.|46
13|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|46
14|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct times.|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct ti|46
15|0 - Able to independently transfer.|0 - Able to independently transfer.|46
16|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without rail|46
17|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings|46
18|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|46
19|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions independently.|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions indep|46
20|0 - Asymptomatic, no treatment needed at this time|0 - Asymptomatic, no treatment needed at this time|46
21|0 - Caregiver manages all tasks related to equipment completely independently.|0 - Caregiver manages all tasks related to equipment completely independently.|46
22|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations with no observable impairment.|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations w|46
23|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|46
24|0 - Life expectancy is greater than 6 months|0 - Life expectancy is greater than 6 months|46
25|0 - Never|0 - Never|46
26|0 - Patient is not short of breath|0 - Patient is not short of breath|46
27|0 - No|0 - No|46
28|0 - No emergent care services|0 - No emergent care services|46
29|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [Goto 1620]|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [Goto 1620]|46
30|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and extended or abstract conversation.|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and exte|46
31|0 - No one person|0 - No one person|46
32|0 - None of the time|0 - None of the time|46
33|0 - None, no charge for current services|0 - None, no charge for current services|46
34|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|46
35|0 - Patient does NOT have an ostomy for bowel elimination.|0 - Patient does NOT have an ostomy for bowel elimination.|46
36|0 - Patient has no pain|0 - Patient has no pain|46
37|0 - Patient manages all tasks related to equipment completely independently.|0 - Patient manages all tasks related to equipment completely independently.|46
38|0 - Poor:  little or no recovery is expected and/or further decline is imminent|0 - Poor:  little or no recovery is expected and/or further decline is imminent|46
39|0 - Timed-voiding defers incontinence|0 - Timed-voiding defers incontinence|46
40|0 - Very rarely or never has bowel incontinence|0 - Very rarely or never has bowel incontinence|46
41|0 - Zero|0 - Zero|46
42|00 - No|00 - No|46
43|01 - Yes|01 - Yes|46
44|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or mental limitations, needs assistance with heavy laundry.|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or|46
45|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the patient.|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the|46
46|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|46
47|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or supervision from another person OR c) a liquid, pureed or ground meat diet.|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or su|46
48|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|46
49|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|46
50|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independently.|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independe|46
51|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only when assisted or accompanied by another person.|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only w|46
52|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepa|46
53|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance by another person OR b) given daily reminders.|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance b|46
54|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advan|46
55|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advan|46
56|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for the deaf) and call essential numbers.|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for t|46
57|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|46
58|1 - American Indian or Alaska Native|1 - American Indian or Alaska Native|46
59|1 - Depressed mood (e.g., feeling sad, tearful)|1 - Depressed mood (e.g., feeling sad, tearful)|46
60|1 - During the night only|1 - During the night only|46
61|1 - Fully granulating|1 - Fully granulating|46
62|1 - Good/Fair:  partial to full recovery is expected|1 - Good/Fair:  partial to full recovery is expected|46
63|1 - Good:  marked improvement in functional status is expected|1 - Good:  marked improvement in functional status is expected|46
64|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|46
65|1 - Smoking|1 - Smoking|46
66|1 - Hospital|1 - Hospital|46
67|1 - Hospital emergency room (includes 23-hour holding)|1 - Hospital emergency room (includes 23-hour holding)|46
68|1 - Hospitalization for EMERGENT (unscheduled) care|1 - Hospitalization for EMERGENT (unscheduled) care|46
69|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepared solutions), patient is able to manage all other aspects of equipment.|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepar|46
70|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|46
71|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|46
72|1 - In new or complex situations only|1 - In new or complex situations only|46
73|1 - Intravenous or infusion therapy (excludes TPN)|1 - Intravenous or infusion therapy (excludes TPN)|46
74|1 - Less often than daily|1 - Less often than daily|46
75|1 - Less than once a month|1 - Less than once a month|46
76|1 - Less than once weekly|1 - Less than once weekly|46
77|1 - Life expectancy is 6 months or fewer|1 - Life expectancy is 6 months or fewer|46
78|1 - Lives alone|1 - Lives alone|46
79|1 - Male|1 - Male|46
80|1 - Medicare (traditional fee-for-service)|1 - Medicare (traditional fee-for-service)|46
81|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of past 24 hours, significant memory loss so that supervision is required|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of pas|46
82|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors in word choice, grammar or speech intelligibility, needs minimal prompting or assistance).|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors i|46
83|1 - No assistance or services received|1 - No assistance or services received|46
84|1 - One|1 - One|46
85|1 - Oxygen (intermittent or continuous)|1 - Oxygen (intermittent or continuous)|46
86|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, and the surrounding layout, can count fingers at arm's length.|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, a|46
87|1 - Patient is incontinent|1 - Patient is incontinent|46
88|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|46
89|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical or treatment regimen.|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical|46
90|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient/couple/significant other)|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient|46
91|1 - Relatives, friends, or neighbors living outside the home|1 - Relatives, friends, or neighbors living outside the home|46
92|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions.|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions|46
93|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independentl|46
94|1 - Several times during day and night|1 - Several times during day and night|46
95|1 - Spouse or significant other|1 - Spouse or significant other|46
96|1 - Stage 1|1 - Stage 1|46
97|1 - Start of care - further visits planned|1 - Start of care - further visits planned|46
98|1 - Symptoms well controlled with current therapy|1 - Symptoms well controlled with current therapy|46
99|1 - Therapy services|1 - Therapy services|46
100|1 - Able to transfer with minimal human assistance or with use of an assistive device.|1 - Able to transfer with minimal human assistance or with use of an assistive device.|46
101|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitations.|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitatio|46
102|1 - Urinary incontinence|1 - Urinary incontinence|46
103|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and transfer.|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and|46
104|1 - When walking more than 20 feet, climbing stairs|1 - When walking more than 20 feet, climbing stairs|46
105|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary conversation. May need occasional repetition, extra time, or louder voice.|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary c|46
106|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting in and out of tub/shower|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting|46
107|1 - Yes|1 - Yes|46
108|1-RN|1-RN|46
109|10 - Discharge from agency - no visits completed after start/resumption of care assessment|10 - Discharge from agency - no visits completed after start/resumption of care assessment|46
110|10 - Scheduled surgical procedure|10 - Scheduled surgical procedure|46
111|10 - Self-pay|10 - Self-pay|46
112|11 - Other|11 - Other|46
113|11 - Urinary tract infection|11 - Urinary tract infection|46
114|12 - IV catheter-related infection|12 - IV catheter-related infection|46
115|13 - Deep vein thrombosis, pulmonary embolus|13 - Deep vein thrombosis, pulmonary embolus|46
116|14 - Uncontrolled pain|14 - Uncontrolled pain|46
117|15 - Psychotic episode|15 - Psychotic episode|46
118|16 - Other than above reasons|16 - Other than above reasons|46
119|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing calls.|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing|46
120|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another person.|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another pers|46
121|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface a|46
122|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for intermittent supervision or encouragement or reminders, OR (b) to get in and out of the shower or tub, OR (c) for washing difficult to reach areas.|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for inter|46
123|2 - Asian|2 - Asian|46
124|2 - Caregiver requires considerable assistance from another person to manage equipment, but independently completes significant portions of task.|2 - Caregiver requires considerable assistance from another person to manage equipment, but independ|46
125|2 - Daily, but not constantly|2 - Daily, but not constantly|46
126|2 - Daughter or son|2 - Daughter or son|46
127|2 - Doctor's office emergency visit/house call|2 - Doctor's office emergency visit/house call|46
128|2 - During the day and night|2 - During the day and night|46
129|2 - Early/partial granulation|2 - Early/partial granulation|46
130|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors in word choice, organization or speech intelligibility). Speaks in phrases or short sentences.|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors|46
131|2 - Family member's residence|2 - Family member's residence|46
132|2 - Female|2 - Female|46
133|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conversation, needs frequent prompting or assistance.|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conver|46
134|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|46
135|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|46
136|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately stop activities, jeopardizes safety through actions|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately st|46
137|2 - Indwelling/suprapubic catheter|2 - Indwelling/suprapubic catheter|46
138|2 - Injury caused by fall|2 - Injury caused by fall|46
139|2 - Medicare (HMO/managed care/Advantage plan)|2 - Medicare (HMO/managed care/Advantage plan)|46
140|2 - Nausea, dehydration, malnutrition, constipation, impaction|2 - Nausea, dehydration, malnutrition, constipation, impaction|46
141|2 - Obesity|2 - Obesity|46
142|2 - On awakening or at night only|2 - On awakening or at night only|46
143|2 - Once a month|2 - Once a month|46
144|2 - One to three times weekly|2 - One to three times weekly|46
145|2 - Parenteral nutrition (TPN or lipids)|2 - Parenteral nutrition (TPN or lipids)|46
146|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic) [ Go to M1620]|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic) [ Go|46
147|2 - Patient requires considerable assistance from another person to manage equipment, but independently completes portions of the task.|2 - Patient requires considerable assistance from another person to manage equipment, but independen|46
148|2 - Patient transferred to a noninstitutional hospice|2 - Patient transferred to a noninstitutional hospice|46
149|2 - Person residing in the home (EXCLUDING paid help)|2 - Person residing in the home (EXCLUDING paid help)|46
150|2 - Rehabilitation facility|2 - Rehabilitation facility|46
151|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifting of attention) or consistently requires low stimulus environment due to distractibility.|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifti|46
152|2 - Respite care|2 - Respite care|46
153|2 - Sense of failure or self reproach|2 - Sense of failure or self reproach|46
154|2 - Several times during day|2 - Several times during day|46
155|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonresponsive.|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonrespons|46
156|2 - Someone must assist the patient to groom self.|2 - Someone must assist the patient to groom self.|46
157|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|46
158|2 - Someone must help the patient put on upper body clothing.|2 - Someone must help the patient put on upper body clothing.|46
159|2 - Stage 2|2 - Stage 2|46
160|2 - Start of care - no further visits planned|2 - Start of care - no further visits planned|46
161|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitoring|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitori|46
162|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment regimen.|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment re|46
163|2 - Two|2 - Two|46
164|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistance due to cognitive or mental limitation.|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistanc|46
165|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|46
166|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assistance).|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assis|46
167|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home delivery.|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home deli|46
168|2 - Unable to prepare any light meals or reheat any delivered meals.|2 - Unable to prepare any light meals or reheat any delivered meals.|46
169|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|46
170|2 - UNABLE to take injectable medications unless administered by someone else.|2 - UNABLE to take injectable medications unless administered by someone else.|46
171|2 - UNABLE to take medication unless administered by someone else.|2 - UNABLE to take medication unless administered by someone else.|46
172|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|46
173|2 - Ventilator (continually or at night)|2 - Ventilator (continually or at night)|46
174|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less than 20 feet)|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less th|46
175|2 - With spouse or significant other|2 - With spouse or significant other|46
176|2 - Yes, assistance or services provided by family or friends|2 - Yes, assistance or services provided by family or friends|46
177|2-PT|2-PT|46
178|3 - Able to answer the telephone only some of the time or is able to carry on only a limited conversation.|3 - Able to answer the telephone only some of the time or is able to carry on only a limited convers|46
179|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube or gastrostomy.|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube|46
180|3 - Alcohol dependency|3 - Alcohol dependency|46
181|3 - All of the time|3 - All of the time|46
182|3 - Black or African-American|3 - Black or African-American|46
183|3 - Boarding home or rented room|3 - Boarding home or rented room|46
184|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment, clean/store/dispose of equipment or supplies).|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment,|46
185|3 -Able to walk only with the supervision or assistance of another person at all times.|3 -Able to walk only with the supervision or assistance of another person at all times.|46
186|3 - Continuous / Bi-level positive airway pressure|3 - Continuous / Bi-level positive airway pressure|46
187|3 - During the day and evening, but not constantly|3 - During the day and evening, but not constantly|46
188|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the alimentary canal)|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the|46
189|3 - Environmental support (e.g., housing, home maintenance)|3 - Environmental support (e.g., housing, home maintenance)|46
190|3 - Four to six times weekly|3 - Four to six times weekly|46
191|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessing by listener.  Speech limited to single words or short phrases.|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessin|46
192|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires multiple repetitions, restatements, demonstrations, additional time.|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires m|46
193|3 - Hopelessness|3 - Hopelessness|46
194|3 - Hospice care|3 - Hospice care|46
195|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|46
196|3 - Injury caused by fall or accident at home|3 - Injury caused by fall or accident at home|46
197|3 - Intractable pain|3 - Intractable pain|46
198|3 - Medicaid (traditional fee-for-service)|3 - Medicaid (traditional fee-for-service)|46
199|3 - Needs someone to do all shopping and errands.|3 - Needs someone to do all shopping and errands.|46
200|3 - Not healing|3 - Not healing|46
201|3 - Nursing home|3 - Nursing home|46
202|3 - Once daily|3 - Once daily|46
203|3 - Other family member|3 - Other family member|46
204|3 - Outpatient department/clinic emergency (includes urgicenter sites)|3 - Outpatient department/clinic emergency (includes urgicenter sites)|46
205|3 - Paid help|3 - Paid help|46
206|3 - Able to participate in bathing self in shower or tub, but requires presence of another person throughout the bath for assistance or supervision.|3 - Able to participate in bathing self in shower or tub, but requires presence of another person th|46
207|3 - Patient depends entirely upon another person to dress lower body.|3 - Patient depends entirely upon another person to dress lower body.|46
208|3 - Patient depends entirely upon another person to dress the upper body.|3 - Patient depends entirely upon another person to dress the upper body.|46
209|3 - Patient depends entirely upon someone else for grooming needs.|3 - Patient depends entirely upon someone else for grooming needs.|46
210|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone else to manage the equipment.|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone|46
211|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable to shift attention and recall directions more than half the time.|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable|46
212|3 - Respiratory problems (SOB, infection, obstruction)|3 - Respiratory problems (SOB, infection, obstruction)|46
213|3 - Resumption of care (after inpatient stay)|3 - Resumption of care (after inpatient stay)|46
214|3 - Several times each month|3 - Several times each month|46
215|3 - Skilled Nursing Facility|3 - Skilled Nursing Facility|46
216|3 - Stage 3|3 - Stage 3|46
217|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|46
218|3 - Three|3 - Three|46
219|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person throughout the process.|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person through|46
220|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal independently.|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal indep|46
221|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person.|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person|46
222|3 - Unknown because patient moved to a geographic location not served by this agency|3 - Unknown because patient moved to a geographic location not served by this agency|46
223|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|46
224|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|46
225|3 - With other family member|3 - With other family member|46
226|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home health services, homemaker assistance, transportation assistance, assisted living, board and care)|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home h|46
227|3-SLP/ST|3-SLP/ST|46
228|4 - At rest (during day or night)|4 - At rest (during day or night)|46
229|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|46
230|4 - Board and care or assisted living facility|4 - Board and care or assisted living facility|46
231|4 - Caregiver is completely dependent on someone else to manage all equipment.|4 - Caregiver is completely dependent on someone else to manage all equipment.|46
232|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|46
233|4 - Constantly|4 - Constantly|46
234|4 - Drug dependency|4 - Drug dependency|46
235|4 - Four or more|4 - Four or more|46
236|4 - Friend or neighbor or community or church member|4 - Friend or neighbor or community or church member|46
237|4 - Hispanic or Latino|4 - Hispanic or Latino|46
238|4 - Hospice|4 - Hospice|46
239|4 - Impaired decision-making|4 - Impaired decision-making|46
240|4 - Is totally dependent in toileting.|4 - Is totally dependent in toileting.|46
241|4 - Medicaid (HMO/managed care)|4 - Medicaid (HMO/managed care)|46
242|4 - None of the above|4 - None of the above|46
243|4 - Nursing home|4 - Nursing home|46
244|4 - On a daily basis|4 - On a daily basis|46
245|4 - Patient is completely dependent on someone else to manage all equipment.|4 - Patient is completely dependent on someone else to manage all equipment.|46
246|4 - Permanent placement|4 - Permanent placement|46
247|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, punches, dangerous maneuvers w/ wheelchair or other objects)|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, pu|46
248|4 - Psychosocial support (e.g., socialization, companionship, recreation)|4 - Psychosocial support (e.g., socialization, companionship, recreation)|46
249|4 - Recertification (follow-up) reassessment|4 - Recertification (follow-up) reassessment|46
250|4 - Recurrent thoughts of death|4 - Recurrent thoughts of death|46
251|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruction)|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruc|46
252|4 - Several times a week|4 - Several times a week|46
253|4 - Stage 4|4 - Stage 4|46
254|4 - Symptoms poorly controlled, history of rehospitalizations|4 - Symptoms poorly controlled, history of rehospitalizations|46
255|4 - Three or more times per week|4 - Three or more times per week|46
256|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetative state, or delirium.|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetati|46
257|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|46
258|4 - Unable to effectively participate in any housekeeping tasks.|4 - Unable to effectively participate in any housekeeping tasks.|46
259|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or unresponsive (e.g., speech is nonsensical or unintelligible).|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or u|46
260|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonresponsive.|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonr|46
261|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostomy.|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostom|46
262|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of devices at the sink, in chair, or on commode|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of|46
263|4 - With a friend|4 - With a friend|46
264|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|46
265|4-OT|4-OT|46
266|5 - Advocates or facilitates patient's participation in appropriate medical care|5 - Advocates or facilitates patient's participation in appropriate medical care|46
267|5 - At least daily|5 - At least daily|46
268|6 - Bedfast, unable to ambulate or be up in a chair.|6 - Bedfast, unable to ambulate or be up in a chair.|46
269|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|46
270|5 - Disruptive or socially inappropriate behavior|5 - Disruptive or socially inappropriate behavior|46
271|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|46
272|5 - Hypo/Hyperglycemia, diabetes out of control|5 - Hypo/Hyperglycemia, diabetes out of control|46
273|5 - More often than once daily|5 - More often than once daily|46
274|5 - Native Hawaiian or Pacific Islander|5 - Native Hawaiian or Pacific Islander|46
275|5 - None of the above|5 - None of the above|46
276|5 - One to two times per week|5 - One to two times per week|46
277|5 - Other|5 - Other|46
278|5 - Other follow-up|5 - Other follow-up|46
279|5 - Paid help|5 - Paid help|46
280|5 - Patient nonresponsive or unable to speak.|5 - Patient nonresponsive or unable to speak.|46
281|5 - Thoughts of suicide|5 - Thoughts of suicide|46
282|5 - Totally unable to use the telephone.|5 - Totally unable to use the telephone.|46
283|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|46
284|5 - Unable to take in nutrients orally or by tube feeding.|5 - Unable to take in nutrients orally or by tube feeding.|46
285|5 - Unsafe for care at home|5 - Unsafe for care at home|46
286|5 - With paid help (other than home care agency staff)|5 - With paid help (other than home care agency staff)|46
287|5 - Workers' compensation|5 - Workers' compensation|46
288|5 - Wound infection, deteriorating wound status, new lesion/ulcer|5 - Wound infection, deteriorating wound status, new lesion/ulcer|46
289|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|46
290|6 - Delusional, hallucinatory, or paranoid behavior|6 - Delusional, hallucinatory, or paranoid behavior|46
291|6 - Financial agent, power of attorney, or conservator of finance|6 - Financial agent, power of attorney, or conservator of finance|46
292|6 - GI bleeding, obstruction|6 - GI bleeding, obstruction|46
293|6 - Less often than weekly|6 - Less often than weekly|46
294|6 - Memory loss to the extent that supervision required|6 - Memory loss to the extent that supervision required|46
295|6 - None of the above feelings observed or reported|6 - None of the above feelings observed or reported|46
296|6 - Other|6 - Other|46
297|6 - Title programs (e.g., Title III, V, or XX)|6 - Title programs (e.g., Title III, V, or XX)|46
298|6 - Transferred to an inpatient facility - patient not discharged from agency|6 - Transferred to an inpatient facility - patient not discharged from agency|46
299|6 - White|6 - White|46
300|6 - With other than above|6 - With other than above|46
301|7 - Exacerbation of CHF, fluid overload, heart failure|7 - Exacerbation of CHF, fluid overload, heart failure|46
302|7 - Health care agent, conservator of person, or medical power of attorney|7 - Health care agent, conservator of person, or medical power of attorney|46
303|7 - Hypo/Hyperglycemia, diabetes out of control|7 - Hypo/Hyperglycemia, diabetes out of control|46
304|7 - None of the above|7 - None of the above|46
305|7 - None of the above behaviors demonstrated|7 - None of the above behaviors demonstrated|46
306|7 - Other government (e.g., TriCare, VA, etc.)|7 - Other government (e.g., TriCare, VA, etc.)|46
307|7 - Transferred to an inpatient facility - patient discharged from agency|7 - Transferred to an inpatient facility - patient discharged from agency|46
308|8 - Death at home|8 - Death at home|46
309|8 - GI bleeding, obstruction|8 - GI bleeding, obstruction|46
310|8 - Myocardial infarction, stroke|8 - Myocardial infarction, stroke|46
311|8 - Private insurance|8 - Private insurance|46
312|9 - Chemotherapy|9 - Chemotherapy|46
313|9 - Discharge from agency|9 - Discharge from agency|46
314|9 - Other than above reasons|9 - Other than above reasons|46
315|9 - Private HMO/managed care|9 - Private HMO/managed care|46
316|NA - No caregiver|NA - No caregiver|46
317|NA - No equipment of this type used in care.|NA - No equipment of this type used in care.|46
318|NA - No inhalant/mist medications prescribed.|NA - No inhalant/mist medications prescribed.|46
319|NA - No injectable medications prescribed.|NA - No injectable medications prescribed.|46
320|NA - No inpatient facility admission|NA - No inpatient facility admission|46
321|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|46
322|NA - No Medicaid|NA - No Medicaid|46
323|NA - No Medicare|NA - No Medicare|46
324|NA - No observable pressure ulcer or unhealed pressure ulcer|NA - No observable pressure ulcer or unhealed pressure ulcer|46
325|NA - No observable stasis ulcer|NA - No observable stasis ulcer|46
326|NA - No observable surgical wound|NA - No observable surgical wound|46
327|NA - No oral medications prescribed.|NA - No oral medications prescribed.|46
328|NA - Not applicable|NA - Not applicable|46
329|NA - Patient does not have a telephone.|NA - Patient does not have a telephone.|46
330|NA - Patient has ostomy for bowel elimination|NA - Patient has ostomy for bowel elimination|46
331|NA - Patient nonresponsive|NA - Patient nonresponsive|46
332|NA - Patient on prophylactic treatment|NA - Patient on prophylactic treatment|46
333|NA - Patient was not discharged from an inpatient facility [Go to M1016 ]|NA - Patient was not discharged from an inpatient facility [Go to M1016 ]|46
334|UK - Other unknown|UK - Other unknown|46
335|UK - Reason unknown|UK - Reason unknown|46
336|UK - Unknown|UK - Unknown|46
337|UK - Unknown or Not Available|UK - Unknown or Not Available|46
341|01 - Early|01 - Early|46
342|02 - Late|02 - Late|46
343|NA - Not Applicable. No case mix group defined for this assessment.|NA - Not Applicable. No case mix group defined for this assessment.|46
344|NA - No case mix group defined by this assessment.|NA - No case mix group defined by this assessment.|46
345|1 - Recent decline in mental, emotional, or behavioral status|1 - Recent decline in mental, emotional, or behavioral status|46
346|2 - Multiple hospitalizations (2 or more) in the past 12 months|2 - Multiple hospitalizations (2 or more) in the past 12 months|46
347|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|46
348|4 - Taking five or more medications|4 - Taking five or more medications|46
349|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|46
350|6 - Other|6 - Other|46
351|7 - None of the above|7 - None of the above|46
352|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond tho|46
353|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable without heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable wi|46
354|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious complications and death.|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious compl|46
355|3 - The patient has serious progressive conditions that could lead to death within a year.|3 - The patient has serious progressive conditions that could lead to death within a year.|46
356|UK - The patient+s situation is unknown or unclear.|UK - The patient+s situation is unknown or unclear.|46
357|0 - No [ Go to M1051 ]|0 - No [ Go to M1051 ]|46
358|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this influenza season. [ Go to M1050 ]|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this i|46
359|1 - Received from another health care provider (e.g., physician)|1 - Received from another health care provider (e.g., physician)|46
360|2 - Received from your agency previously during this year+s flu season|2 - Received from your agency previously during this year+s flu season|46
361|3 - Offered and declined|3 - Offered and declined|46
362|4 - Assessed and determined to have medical contraindication(s)|4 - Assessed and determined to have medical contraindication(s)|46
363|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|46
364|6 - Inability to obtain vaccine due to declared shortage|6 - Inability to obtain vaccine due to declared shortage|46
365|1 - Yes [ Go to M1500 at TRN; Go to M1230 at DC ]|1 - Yes [ Go to M1500 at TRN; Go to M1230 at DC ]|46
366|1 - Patient has received PPV in the past|1 - Patient has received PPV in the past|46
367|2 - Offered and declined|2 - Offered and declined|46
368|3 - Assessed and determined to have medical contraindication(s)|3 - Assessed and determined to have medical contraindication(s)|46
369|4 - Not indicated; patient does not meet age/condition guidelines for PPV|4 - Not indicated; patient does not meet age/condition guidelines for PPV|46
370|5 - None of the above|5 - None of the above|46
371|0 - Adequate: hears normal conversation without difficulty.|0 - Adequate: hears normal conversation without difficulty.|46
372|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to increase volume or speak distinctly.|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to in|46
373|2 - Severely Impaired: absence of useful hearing.|2 - Severely Impaired: absence of useful hearing.|46
374|UK - Unable to assess hearing.|UK - Unable to assess hearing.|46
375|0 - Understands: clear comprehension without cues or repetitions.|0 - Understands: clear comprehension without cues or repetitions.|46
376|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Requires cues at times to understand.|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Req|46
377|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequently requires cues to understand.|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequentl|46
378|3 - Rarely/Never Understands|3 - Rarely/Never Understands|46
379|UK - Unable to assess understanding.|UK - Unable to assess understanding.|46
380|0 - No standardized assessment conducted|0 - No standardized assessment conducted|46
381|1 - Yes, and it does not indicate severe pain|1 - Yes, and it does not indicate severe pain|46
382|2 - Yes, and it indicates severe pain|2 - Yes, and it indicates severe pain|46
383|0 - Patient has no pain|0 - Patient has no pain|46
384|1 - Patient has pain that does not interfere with activity or movement|1 - Patient has pain that does not interfere with activity or movement|46
385|2 - Less often than daily|2 - Less often than daily|46
386|3 - Daily, but not constantly|3 - Daily, but not constantly|46
387|4 - All of the time|4 - All of the time|46
388|0 - No assessment conducted [ Go to M1306 ]|0 - No assessment conducted [ Go to M1306 ]|46
389|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc., without use of standardized tool|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc.,|46
390|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|46
391|0 - No [ Go to M1322]|0 - No [ Go to M1322]|46
392|0 v Newly epithelialized|0 v Newly epithelialized|46
393|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|46
394|2 - Yes, patient has observable stasis ulcers ONLY|2 - Yes, patient has observable stasis ulcers ONLY|46
395|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable dressing) [Go to M1340]|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable|46
396|0 - No [ Go to M1350 ]|0 - No [ Go to M1350 ]|46
397|1 - Yes, patient has at least one (observable) surgical wound|1 - Yes, patient has at least one (observable) surgical wound|46
398|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1350 ]|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1350 ]|46
399|0 - Patient is not short of breath|0 - Patient is not short of breath|46
400|3 - Continuous Bi-level positive airway pressure|3 - Continuous Bi-level positive airway pressure|46
401|0 - No [ Go to M2004 at TRN; Go to M1600 at DC ]|0 - No [ Go to M2004 at TRN; Go to M1600 at DC ]|46
402|2 - Not assessed [Go to M2004 at TRN; Go to M1600 at DC ]|2 - Not assessed [Go to M2004 at TRN; Go to M1600 at DC ]|46
403|NA - Patient does not have diagnosis of heart failure [Go to M2004 at TRN; Go to M1600 at DC]|NA - Patient does not have diagnosis of heart failure [Go to M2004 at TRN; Go to M1600 at DC]|46
404|0 - No action taken|0 - No action taken|46
405|1 - Patient+s physician (or other primary care practitioner) contacted the same day|1 - Patient+s physician (or other primary care practitioner) contacted the same day|46
406|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|46
407|3 - Implement physician-ordered patient-specific established parameters for treatment|3 - Implement physician-ordered patient-specific established parameters for treatment|46
408|4 - Patient education or other clinical interventions|4 - Patient education or other clinical interventions|46
409|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequency, telehealth, etc.)|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequ|46
410|1 - Occasional stress incontinence|1 - Occasional stress incontinence|46
411|2 - During the night only|2 - During the night only|46
412|3 - During the day only|3 - During the day only|46
413|4 - During the day and night|4 - During the day and night|46
414|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|46
415|0 - Able to manage toileting hygiene and clothing management without assistance.|0 - Able to manage toileting hygiene and clothing management without assistance.|46
416|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implements are laid out for the patient.|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implemen|46
417|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|46
418|3 - Patient depends entirely upon another person to maintain toileting hygiene.|3 - Patient depends entirely upon another person to maintain toileting hygiene.|46
419|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independent|46
420|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface|46
421|0 - No multi-factor falls risk assessment conducted.|0 - No multi-factor falls risk assessment conducted.|46
422|1 - Yes, and it does not indicate a risk for falls.|1 - Yes, and it does not indicate a risk for falls.|46
423|2 - Yes, and it indicates a risk for falls.|2 - Yes, and it indicates a risk for falls.|46
424|0 - Not assessed/reviewed [ Go to M2010 ]|0 - Not assessed/reviewed [ Go to M2010 ]|46
425|1 - No problems found during review [ Go to M2010 ]|1 - No problems found during review [ Go to M2010 ]|46
426|2 - Problems found during review|2 - Problems found during review|46
427|NA - Patient is not taking any medications [ Go to M2040 ]|NA - Patient is not taking any medications [ Go to M2040 ]|46
428|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special precautions associated with all high-risk medications|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special p|46
429|NA - Patient not taking any drugs|NA - Patient not taking any drugs|46
430|2 - Able to take medication(s) at the correct times if given reminders by another person at the appropriate times|2 - Able to take medication(s) at the correct times if given reminders by another person at the appr|46
431|3 - Unable to take medication unless administered by another person.|3 - Unable to take medication unless administered by another person.|46
432|1 - At least daily|1 - At least daily|46
433|2 - Three or more times per week|2 - Three or more times per week|46
434|3 - One to two times per week|3 - One to two times per week|46
435|4 - Received, but less often than weekly|4 - Received, but less often than weekly|46
436|5 - No assistance received|5 - No assistance received|46
437|0 - No [Go to M2400]|0 - No [Go to M2400]|46
438|1 - Yes, used hospital emergency department WITHOUT hospital admission|1 - Yes, used hospital emergency department WITHOUT hospital admission|46
439|2 - Yes, used hospital emergency department WITH hospital admission|2 - Yes, used hospital emergency department WITH hospital admission|46
440|UK - Unknown [Go to M2400]|UK - Unknown [Go to M2400]|46
441|2 - Injury caused by fall|2 - Injury caused by fall|46
442|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|46
443|4 - Other respiratory problem|4 - Other respiratory problem|46
444|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|46
445|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|46
446|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|46
447|8 - Other heart disease|8 - Other heart disease|46
448|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|46
449|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|46
450|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|46
451|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|46
452|13 - Urinary tract infection|13 - Urinary tract infection|46
453|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|46
454|15 - Wound infection or deterioration|15 - Wound infection or deterioration|46
455|16 - Uncontrolled pain|16 - Uncontrolled pain|46
456|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|46
457|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|46
458|19 - Other than above reasons|19 - Other than above reasons|46
459|2 - Patient remained in the community (with formal assistive services)|2 - Patient remained in the community (with formal assistive services)|46
460|3 - Patient transferred to a noninstitutional hospice|3 - Patient transferred to a noninstitutional hospice|46
461|4 - Unknown because patient moved to a geographic location not served by this agency|4 - Unknown because patient moved to a geographic location not served by this agency|46
462|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|46
463|4 - Other respiratory problem|4 - Other respiratory problem|46
464|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|46
465|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|46
466|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|46
467|8 - Other heart disease|8 - Other heart disease|46
468|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|46
469|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|46
470|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|46
471|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|46
472|13 - Urinary tract infection|13 - Urinary tract infection|46
473|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|46
474|15 - Wound infection or deterioration|15 - Wound infection or deterioration|46
475|16 - Uncontrolled pain|16 - Uncontrolled pain|46
476|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|46
477|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|46
478|19 - Scheduled treatment or procedure|19 - Scheduled treatment or procedure|46
479|20 - Other than above reasons|20 - Other than above reasons|46
480|UK - Reason unknown [Go to M0903]|UK - Reason unknown [Go to M0903]|46
482|01 - Patient lives alone around the clock|01 - Patient lives alone around the clock|46
483|02 - Patient lives alone regular daytime|02 - Patient lives alone regular daytime|46
484|03 - Patient lives alone regular nighttime|03 - Patient lives alone regular nighttime|46
485|04 - Patient lives alone occassional/short term assistance|04 - Patient lives alone occassional/short term assistance|46
486|05 - Patient lives alone no assisstance available|05 - Patient lives alone no assisstance available|46
487|06 - Patient lives with other person(s) in the home around the clock|06 - Patient lives with other person(s) in the home around the clock|46
488|07 - Patient lives with other person(s) in the home regular daytime|07 - Patient lives with other person(s) in the home regular daytime|46
489|08 - Patient lives with other person(s) in the home regular nighttime|08 - Patient lives with other person(s) in the home regular nighttime|46
490|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|46
491|10 - Patient lives with other person(s) in the home no assistance available|10 - Patient lives with other person(s) in the home no assistance available|46
492|1 - Was present at the most recent SOC/ROC assessment|1 - Was present at the most recent SOC/ROC assessment|46
493|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|46
494|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|46
495|0 - Newly epithelialized|0 - Newly epithelialized|46
496|0 - No [ Go to M1340 ]|0 - No [ Go to M1340 ]|46
498|0 - Independent|0 - Independent|46
499|1 - Needed Some Help|1 - Needed Some Help|46
500|2 - Dependent|2 - Dependent|46
502|0 - No assistance needed in this area|0 - No assistance needed in this area|46
503|1 - Caregiver(s) currently provide assistance|1 - Caregiver(s) currently provide assistance|46
504|2 - Caregiver(s) need training/ supportive services to provide assistance|2 - Caregiver(s) need training/ supportive services to provide assistance|46
505|3 - Caregiver(s) not likely to provide assistance|3 - Caregiver(s) not likely to provide assistance|46
506|4 - Unclear if Caregiver(s) will provide assistance|4 - Unclear if Caregiver(s) will provide assistance|46
507|5 - Assistance needed, but no Caregiver(s) available|5 - Assistance needed, but no Caregiver(s) available|46
508|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will use standardized clinical guidelines accessible for all care providers to reference|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will|46
510|NA - Patient is not assessed to be at risk for falls|NA - Patient is not assessed to be at risk for falls|46
511|NA - Patient has no diagnosis or symptoms of depression|NA - Patient has no diagnosis or symptoms of depression|46
512|NA - No pain identified|NA - No pain identified|46
513|NA - Patient is not assessed to be at risk for pressure ulcers|NA - Patient is not assessed to be at risk for pressure ulcers|46
514|NA - Patient has no pressure ulcers with need for moist wound healing|NA - Patient has no pressure ulcers with need for moist wound healing|46
515|1 - Long-term nursing facility (NF)|1 - Long-term nursing facility (NF)|46
516|2 - Skilled nursing facility (SNF / TCU)|2 - Skilled nursing facility (SNF / TCU)|46
517|3 - Short stay acute hospital (IPP S)|3 - Short stay acute hospital (IPP S)|46
518|4 - Long-term care hospital (LTCH)|4 - Long-term care hospital (LTCH)|46
519|5 - Inpatient rehabilitation hospital or unit (IRF)|5 - Inpatient rehabilitation hospital or unit (IRF)|46
520|6 - Psychiatric hospital or unit|6 - Psychiatric hospital or unit|46
521|7 - Other|7 - Other|46
522|NA - Patient was not discharged from an inpatient facility [Goto M1016]|NA - Patient was not discharged from an inpatient facility [Goto M1016]|46
523|6 - Unable to participate effectively in bathing and is bathed totally by another person|6 - Unable to participate effectively in bathing and is bathed totally by another person|46
524|4 - Chairfast, unable to ambulate but is able to wheel self independently.|4 - Chairfast, unable to ambulate but is able to wheel self independently.|46
525|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask patient: "Over the last two weeks, how often have you been bothered by any of the following problems")|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask|46
526|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluation for depression.|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluat|46
527|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet criteria for further evaluation for depression.|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet|46
528|0 - Not at all  0 - 1 day|0 - Not at all  0 - 1 day|46
529|1 - Several days  2 - 6 days|1 - Several days  2 - 6 days|46
530|2 - More than half of the days  7 - 11 days|2 - More than half of the days  7 - 11 days|46
531|3 - Nearly every day  12 - 14 days|3 - Nearly every day  12 - 14 days|46
532|NA - N/A  Unable to respond|NA - N/A  Unable to respond|46
533|2 - Able to take medication(s) at the correct times if given reminders by another person based on the frequency of the injection|2 - Able to take medication(s) at the correct times if given reminders by another person based on th|46
534|3 - Unable to take injectable medication unless administered by another person.|3 - Unable to take injectable medication unless administered by another person.|46
547|NA - No clinically significant medication issues identified since the previous OASIS assessment|NA - No clinically significant medication issues identified since the previous OASIS assessment|46
552|1 - Hospital [ Go to M2430 ]|1 - Hospital [ Go to M2430 ]|46
553|2 - Rehabilitation facility [ Go to M0903 ]|2 - Rehabilitation facility [ Go to M0903 ]|46
554|3 - Nursing home [ Go to M2440 ]|3 - Nursing home [ Go to M2440 ]|46
555|4 - Hospice [ Go to M0903 ]|4 - Hospice [ Go to M0903 ]|46
557|NA - Patient is not diabetic or is bilateral amputee|NA - Patient is not diabetic or is bilateral amputee|46
558|NA - Formal multi-factor Fall Risk Assessment indicates the patient was not at risk for falls since the last OASIS assessment|NA - Formal multi-factor Fall Risk Assessment indicates the patient was not at risk for falls since|46
559|NA - Formal assessment indicates patient did not meet criteria for depression AND patient did not have diagnosis of depression since the last OASIS assessment|NA - Formal assessment indicates patient did not meet criteria for depression AND patient did not ha|46
560|NA - Formal assessment did not indicate pain since the last OASIS assessment|NA - Formal assessment did not indicate pain since the last OASIS assessment|46
561|NA - Formal assessment indicates the patient was not at risk of pressure ulcers since the last OASIS assessment|NA - Formal assessment indicates the patient was not at risk of pressure ulcers since the last OASIS|46
562|NA - Dressings that support the principles of moist wound healing not indicated for this patient's pressure ulcers OR patient has no pressure ulcers with need for moist wound healing|NA - Dressings that support the principles of moist wound healing not indicated for this patient's p|46
620|1 - Yes; received from your agency during this episode of care (SOC/ROC to Transfer/Discharge)|1 - Yes; received from your agency during this episode of care (SOC/ROC to Transfer/Discharge)|46
621|2 - Yes; received from your agency during a prior episode of care (SOC/ROC to Transfer/Discharge)|2 - Yes; received from your agency during a prior episode of care (SOC/ROC to Transfer/Discharge)|46
622|3 - Yes; received from another health care provider (for example physician pharmacist)|3 - Yes; received from another health care provider (for example physician pharmacist)|46
623|4 - No; patient offered and declined |4 - No; patient offered and declined |46
624|5 - No; patient assessed and determined to have medical contraindication(s)|5 - No; patient assessed and determined to have medical contraindication(s)|46
625|6 - No; not indicated - patient does not meet age/condition guidelines for influenza vaccine|6 - No; not indicated - patient does not meet age/condition guidelines for influenza vaccine|46
626|7 - No; inability to obtain vaccine due to declared shortage |7 - No; inability to obtain vaccine due to declared shortage |46
627|8 - No; patient did not receive the vaccine due to reasons other than those listed in responses 4 v 7. |8 - No; patient did not receive the vaccine due to reasons other than those listed in responses 4v7.|46
628|1 - Offered and declined|1 - Offered and declined|46
629|2 - Assessed and determined to have medical contraindication(s) |2 - Assessed and determined to have medical contraindication(s) |46
630|3 - Not indicated; patient does not meet age/condition guidelines for Pneumococcal Vaccine|3 - Not indicated; patient does not meet age/condition guidelines for Pneumococcal Vaccine|46
631|4 - None of the above|4 - None of the above|46
2|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; OR (b) Is physically, cognitively, and mentally able to prepare light meals on a regular basis but has not routinely performed light meal preparation in the past (i.e., prior to this home care admission).|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; O|47
3|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and mentally able to perform all housekeeping tasks .|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and menta|47
4|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and mentally able to do laundry and access facilities.|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and menta|47
5|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying packages OR b) Physically, cognitively, and mentally able to take care of shopping, but has not done shopping in the past (i.e., prior to this home care admission).|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying|47
6|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|47
7|0 - Able to dial numbers and answer calls appropriately and as desired.|0 - Able to dial numbers and answer calls appropriately and as desired.|47
8|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body without assistance.|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body|47
9|0 - Able to get to and from the toilet and transfer independently with or without a device.|0 - Able to get to and from the toilet and transfer independently with or without a device.|47
10|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|47
11|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible public bus.|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible p|47
12|0 - Able to independently feed self.|0 - Able to independently feed self.|47
13|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|47
14|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct times.|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct ti|47
15|0 - Able to independently transfer.|0 - Able to independently transfer.|47
16|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without rail|47
17|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings|47
18|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|47
19|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions independently.|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions indep|47
20|0 - Asymptomatic, no treatment needed at this time|0 - Asymptomatic, no treatment needed at this time|47
21|0 - Caregiver manages all tasks related to equipment completely independently.|0 - Caregiver manages all tasks related to equipment completely independently.|47
22|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations with no observable impairment.|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations w|47
23|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|47
24|0 - Life expectancy is greater than 6 months|0 - Life expectancy is greater than 6 months|47
25|0 - Never|0 - Never|47
26|0 - Patient is not short of breath|0 - Patient is not short of breath|47
27|0 - No|0 - No|47
28|0 - No emergent care services|0 - No emergent care services|47
29|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [Goto 1620]|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [Goto 1620]|47
30|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and extended or abstract conversation.|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and exte|47
31|0 - No one person|0 - No one person|47
32|0 - None of the time|0 - None of the time|47
33|0 - None, no charge for current services|0 - None, no charge for current services|47
34|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|47
35|0 - Patient does NOT have an ostomy for bowel elimination.|0 - Patient does NOT have an ostomy for bowel elimination.|47
36|0 - Patient has no pain|0 - Patient has no pain|47
37|0 - Patient manages all tasks related to equipment completely independently.|0 - Patient manages all tasks related to equipment completely independently.|47
38|0 - Poor:  little or no recovery is expected and/or further decline is imminent|0 - Poor:  little or no recovery is expected and/or further decline is imminent|47
39|0 - Timed-voiding defers incontinence|0 - Timed-voiding defers incontinence|47
40|0 - Very rarely or never has bowel incontinence|0 - Very rarely or never has bowel incontinence|47
41|0 - Zero|0 - Zero|47
42|00 - No|00 - No|47
43|01 - Yes|01 - Yes|47
44|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or mental limitations, needs assistance with heavy laundry.|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or|47
45|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the patient.|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the|47
46|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|47
47|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or supervision from another person OR c) a liquid, pureed or ground meat diet.|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or su|47
48|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|47
49|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|47
50|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independently.|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independe|47
51|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only when assisted or accompanied by another person.|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only w|47
52|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepa|47
53|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance by another person OR b) given daily reminders.|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance b|47
54|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advan|47
55|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advan|47
56|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for the deaf) and call essential numbers.|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for t|47
57|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|47
58|1 - American Indian or Alaska Native|1 - American Indian or Alaska Native|47
59|1 - Depressed mood (e.g., feeling sad, tearful)|1 - Depressed mood (e.g., feeling sad, tearful)|47
60|1 - During the night only|1 - During the night only|47
61|1 - Fully granulating|1 - Fully granulating|47
62|1 - Good/Fair:  partial to full recovery is expected|1 - Good/Fair:  partial to full recovery is expected|47
63|1 - Good:  marked improvement in functional status is expected|1 - Good:  marked improvement in functional status is expected|47
64|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|47
65|1 - Smoking|1 - Smoking|47
66|1 - Hospital|1 - Hospital|47
67|1 - Hospital emergency room (includes 23-hour holding)|1 - Hospital emergency room (includes 23-hour holding)|47
68|1 - Hospitalization for EMERGENT (unscheduled) care|1 - Hospitalization for EMERGENT (unscheduled) care|47
69|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepared solutions), patient is able to manage all other aspects of equipment.|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepar|47
70|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|47
71|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|47
72|1 - In new or complex situations only|1 - In new or complex situations only|47
73|1 - Intravenous or infusion therapy (excludes TPN)|1 - Intravenous or infusion therapy (excludes TPN)|47
74|1 - Less often than daily|1 - Less often than daily|47
75|1 - Less than once a month|1 - Less than once a month|47
76|1 - Less than once weekly|1 - Less than once weekly|47
77|1 - Life expectancy is 6 months or fewer|1 - Life expectancy is 6 months or fewer|47
78|1 - Lives alone|1 - Lives alone|47
79|1 - Male|1 - Male|47
80|1 - Medicare (traditional fee-for-service)|1 - Medicare (traditional fee-for-service)|47
81|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of past 24 hours, significant memory loss so that supervision is required|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of pas|47
82|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors in word choice, grammar or speech intelligibility, needs minimal prompting or assistance).|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors i|47
83|1 - No assistance or services received|1 - No assistance or services received|47
84|1 - One|1 - One|47
85|1 - Oxygen (intermittent or continuous)|1 - Oxygen (intermittent or continuous)|47
86|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, and the surrounding layout, can count fingers at arm's length.|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, a|47
87|1 - Patient is incontinent|1 - Patient is incontinent|47
88|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|47
89|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical or treatment regimen.|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical|47
90|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient/couple/significant other)|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient|47
91|1 - Relatives, friends, or neighbors living outside the home|1 - Relatives, friends, or neighbors living outside the home|47
92|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions.|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions|47
93|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independentl|47
94|1 - Several times during day and night|1 - Several times during day and night|47
95|1 - Spouse or significant other|1 - Spouse or significant other|47
96|1 - Stage 1|1 - Stage 1|47
97|1 - Start of care - further visits planned|1 - Start of care - further visits planned|47
98|1 - Symptoms well controlled with current therapy|1 - Symptoms well controlled with current therapy|47
99|1 - Therapy services|1 - Therapy services|47
100|1 - Able to transfer with minimal human assistance or with use of an assistive device.|1 - Able to transfer with minimal human assistance or with use of an assistive device.|47
101|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitations.|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitatio|47
102|1 - Urinary incontinence|1 - Urinary incontinence|47
103|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and transfer.|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and|47
104|1 - When walking more than 20 feet, climbing stairs|1 - When walking more than 20 feet, climbing stairs|47
105|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary conversation. May need occasional repetition, extra time, or louder voice.|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary c|47
106|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting in and out of tub/shower|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting|47
107|1 - Yes|1 - Yes|47
108|1-RN|1-RN|47
109|10 - Discharge from agency - no visits completed after start/resumption of care assessment|10 - Discharge from agency - no visits completed after start/resumption of care assessment|47
110|10 - Scheduled surgical procedure|10 - Scheduled surgical procedure|47
111|10 - Self-pay|10 - Self-pay|47
112|11 - Other|11 - Other|47
113|11 - Urinary tract infection|11 - Urinary tract infection|47
114|12 - IV catheter-related infection|12 - IV catheter-related infection|47
115|13 - Deep vein thrombosis, pulmonary embolus|13 - Deep vein thrombosis, pulmonary embolus|47
116|14 - Uncontrolled pain|14 - Uncontrolled pain|47
117|15 - Psychotic episode|15 - Psychotic episode|47
118|16 - Other than above reasons|16 - Other than above reasons|47
119|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing calls.|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing|47
120|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another person.|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another pers|47
121|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface a|47
122|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for intermittent supervision or encouragement or reminders, OR (b) to get in and out of the shower or tub, OR (c) for washing difficult to reach areas.|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for inter|47
123|2 - Asian|2 - Asian|47
124|2 - Caregiver requires considerable assistance from another person to manage equipment, but independently completes significant portions of task.|2 - Caregiver requires considerable assistance from another person to manage equipment, but independ|47
125|2 - Daily, but not constantly|2 - Daily, but not constantly|47
126|2 - Daughter or son|2 - Daughter or son|47
127|2 - Doctor's office emergency visit/house call|2 - Doctor's office emergency visit/house call|47
128|2 - During the day and night|2 - During the day and night|47
129|2 - Early/partial granulation|2 - Early/partial granulation|47
130|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors in word choice, organization or speech intelligibility). Speaks in phrases or short sentences.|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors|47
131|2 - Family member's residence|2 - Family member's residence|47
132|2 - Female|2 - Female|47
133|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conversation, needs frequent prompting or assistance.|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conver|47
134|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|47
135|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|47
136|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately stop activities, jeopardizes safety through actions|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately st|47
137|2 - Indwelling/suprapubic catheter|2 - Indwelling/suprapubic catheter|47
138|2 - Injury caused by fall|2 - Injury caused by fall|47
139|2 - Medicare (HMO/managed care/Advantage plan)|2 - Medicare (HMO/managed care/Advantage plan)|47
140|2 - Nausea, dehydration, malnutrition, constipation, impaction|2 - Nausea, dehydration, malnutrition, constipation, impaction|47
141|2 - Obesity|2 - Obesity|47
142|2 - On awakening or at night only|2 - On awakening or at night only|47
143|2 - Once a month|2 - Once a month|47
144|2 - One to three times weekly|2 - One to three times weekly|47
145|2 - Parenteral nutrition (TPN or lipids)|2 - Parenteral nutrition (TPN or lipids)|47
146|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic) [ Go to M1620]|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic) [ Go|47
147|2 - Patient requires considerable assistance from another person to manage equipment, but independently completes portions of the task.|2 - Patient requires considerable assistance from another person to manage equipment, but independen|47
148|2 - Patient transferred to a noninstitutional hospice|2 - Patient transferred to a noninstitutional hospice|47
149|2 - Person residing in the home (EXCLUDING paid help)|2 - Person residing in the home (EXCLUDING paid help)|47
150|2 - Rehabilitation facility|2 - Rehabilitation facility|47
151|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifting of attention) or consistently requires low stimulus environment due to distractibility.|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifti|47
152|2 - Respite care|2 - Respite care|47
153|2 - Sense of failure or self reproach|2 - Sense of failure or self reproach|47
154|2 - Several times during day|2 - Several times during day|47
155|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonresponsive.|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonrespons|47
156|2 - Someone must assist the patient to groom self.|2 - Someone must assist the patient to groom self.|47
157|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|47
158|2 - Someone must help the patient put on upper body clothing.|2 - Someone must help the patient put on upper body clothing.|47
159|2 - Stage 2|2 - Stage 2|47
160|2 - Start of care - no further visits planned|2 - Start of care - no further visits planned|47
161|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitoring|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitori|47
162|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment regimen.|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment re|47
163|2 - Two|2 - Two|47
164|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistance due to cognitive or mental limitation.|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistanc|47
165|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|47
166|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assistance).|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assis|47
167|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home delivery.|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home deli|47
168|2 - Unable to prepare any light meals or reheat any delivered meals.|2 - Unable to prepare any light meals or reheat any delivered meals.|47
169|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|47
170|2 - UNABLE to take injectable medications unless administered by someone else.|2 - UNABLE to take injectable medications unless administered by someone else.|47
171|2 - UNABLE to take medication unless administered by someone else.|2 - UNABLE to take medication unless administered by someone else.|47
172|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|47
173|2 - Ventilator (continually or at night)|2 - Ventilator (continually or at night)|47
174|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less than 20 feet)|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less th|47
175|2 - With spouse or significant other|2 - With spouse or significant other|47
176|2 - Yes, assistance or services provided by family or friends|2 - Yes, assistance or services provided by family or friends|47
177|2-PT|2-PT|47
178|3 - Able to answer the telephone only some of the time or is able to carry on only a limited conversation.|3 - Able to answer the telephone only some of the time or is able to carry on only a limited convers|47
179|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube or gastrostomy.|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube|47
180|3 - Alcohol dependency|3 - Alcohol dependency|47
181|3 - All of the time|3 - All of the time|47
182|3 - Black or African-American|3 - Black or African-American|47
183|3 - Boarding home or rented room|3 - Boarding home or rented room|47
184|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment, clean/store/dispose of equipment or supplies).|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment,|47
185|3 -Able to walk only with the supervision or assistance of another person at all times.|3 -Able to walk only with the supervision or assistance of another person at all times.|47
186|3 - Continuous / Bi-level positive airway pressure|3 - Continuous / Bi-level positive airway pressure|47
187|3 - During the day and evening, but not constantly|3 - During the day and evening, but not constantly|47
188|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the alimentary canal)|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the|47
189|3 - Environmental support (e.g., housing, home maintenance)|3 - Environmental support (e.g., housing, home maintenance)|47
190|3 - Four to six times weekly|3 - Four to six times weekly|47
191|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessing by listener.  Speech limited to single words or short phrases.|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessin|47
192|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires multiple repetitions, restatements, demonstrations, additional time.|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires m|47
193|3 - Hopelessness|3 - Hopelessness|47
194|3 - Hospice care|3 - Hospice care|47
195|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|47
196|3 - Injury caused by fall or accident at home|3 - Injury caused by fall or accident at home|47
197|3 - Intractable pain|3 - Intractable pain|47
198|3 - Medicaid (traditional fee-for-service)|3 - Medicaid (traditional fee-for-service)|47
199|3 - Needs someone to do all shopping and errands.|3 - Needs someone to do all shopping and errands.|47
200|3 - Not healing|3 - Not healing|47
201|3 - Nursing home|3 - Nursing home|47
202|3 - Once daily|3 - Once daily|47
203|3 - Other family member|3 - Other family member|47
204|3 - Outpatient department/clinic emergency (includes urgicenter sites)|3 - Outpatient department/clinic emergency (includes urgicenter sites)|47
205|3 - Paid help|3 - Paid help|47
206|3 - Able to participate in bathing self in shower or tub, but requires presence of another person throughout the bath for assistance or supervision.|3 - Able to participate in bathing self in shower or tub, but requires presence of another person th|47
207|3 - Patient depends entirely upon another person to dress lower body.|3 - Patient depends entirely upon another person to dress lower body.|47
208|3 - Patient depends entirely upon another person to dress the upper body.|3 - Patient depends entirely upon another person to dress the upper body.|47
209|3 - Patient depends entirely upon someone else for grooming needs.|3 - Patient depends entirely upon someone else for grooming needs.|47
210|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone else to manage the equipment.|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone|47
211|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable to shift attention and recall directions more than half the time.|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable|47
212|3 - Respiratory problems (SOB, infection, obstruction)|3 - Respiratory problems (SOB, infection, obstruction)|47
213|3 - Resumption of care (after inpatient stay)|3 - Resumption of care (after inpatient stay)|47
214|3 - Several times each month|3 - Several times each month|47
215|3 - Skilled Nursing Facility|3 - Skilled Nursing Facility|47
216|3 - Stage 3|3 - Stage 3|47
217|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|47
218|3 - Three|3 - Three|47
219|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person throughout the process.|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person through|47
220|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal independently.|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal indep|47
221|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person.|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person|47
222|3 - Unknown because patient moved to a geographic location not served by this agency|3 - Unknown because patient moved to a geographic location not served by this agency|47
223|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|47
224|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|47
225|3 - With other family member|3 - With other family member|47
226|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home health services, homemaker assistance, transportation assistance, assisted living, board and care)|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home h|47
227|3-SLP/ST|3-SLP/ST|47
228|4 - At rest (during day or night)|4 - At rest (during day or night)|47
229|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|47
230|4 - Board and care or assisted living facility|4 - Board and care or assisted living facility|47
231|4 - Caregiver is completely dependent on someone else to manage all equipment.|4 - Caregiver is completely dependent on someone else to manage all equipment.|47
232|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|47
233|4 - Constantly|4 - Constantly|47
234|4 - Drug dependency|4 - Drug dependency|47
235|4 - Four or more|4 - Four or more|47
236|4 - Friend or neighbor or community or church member|4 - Friend or neighbor or community or church member|47
237|4 - Hispanic or Latino|4 - Hispanic or Latino|47
238|4 - Hospice|4 - Hospice|47
239|4 - Impaired decision-making|4 - Impaired decision-making|47
240|4 - Is totally dependent in toileting.|4 - Is totally dependent in toileting.|47
241|4 - Medicaid (HMO/managed care)|4 - Medicaid (HMO/managed care)|47
242|4 - None of the above|4 - None of the above|47
243|4 - Nursing home|4 - Nursing home|47
244|4 - On a daily basis|4 - On a daily basis|47
245|4 - Patient is completely dependent on someone else to manage all equipment.|4 - Patient is completely dependent on someone else to manage all equipment.|47
246|4 - Permanent placement|4 - Permanent placement|47
247|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, punches, dangerous maneuvers w/ wheelchair or other objects)|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, pu|47
248|4 - Psychosocial support (e.g., socialization, companionship, recreation)|4 - Psychosocial support (e.g., socialization, companionship, recreation)|47
249|4 - Recertification (follow-up) reassessment|4 - Recertification (follow-up) reassessment|47
250|4 - Recurrent thoughts of death|4 - Recurrent thoughts of death|47
251|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruction)|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruc|47
252|4 - Several times a week|4 - Several times a week|47
253|4 - Stage 4|4 - Stage 4|47
254|4 - Symptoms poorly controlled, history of rehospitalizations|4 - Symptoms poorly controlled, history of rehospitalizations|47
255|4 - Three or more times per week|4 - Three or more times per week|47
256|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetative state, or delirium.|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetati|47
257|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|47
258|4 - Unable to effectively participate in any housekeeping tasks.|4 - Unable to effectively participate in any housekeeping tasks.|47
259|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or unresponsive (e.g., speech is nonsensical or unintelligible).|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or u|47
260|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonresponsive.|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonr|47
261|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostomy.|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostom|47
262|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of devices at the sink, in chair, or on commode|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of|47
263|4 - With a friend|4 - With a friend|47
264|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|47
265|4-OT|4-OT|47
266|5 - Advocates or facilitates patient's participation in appropriate medical care|5 - Advocates or facilitates patient's participation in appropriate medical care|47
267|5 - At least daily|5 - At least daily|47
268|6 - Bedfast, unable to ambulate or be up in a chair.|6 - Bedfast, unable to ambulate or be up in a chair.|47
269|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|47
270|5 - Disruptive or socially inappropriate behavior|5 - Disruptive or socially inappropriate behavior|47
271|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|47
272|5 - Hypo/Hyperglycemia, diabetes out of control|5 - Hypo/Hyperglycemia, diabetes out of control|47
273|5 - More often than once daily|5 - More often than once daily|47
274|5 - Native Hawaiian or Pacific Islander|5 - Native Hawaiian or Pacific Islander|47
275|5 - None of the above|5 - None of the above|47
276|5 - One to two times per week|5 - One to two times per week|47
277|5 - Other|5 - Other|47
278|5 - Other follow-up|5 - Other follow-up|47
279|5 - Paid help|5 - Paid help|47
280|5 - Patient nonresponsive or unable to speak.|5 - Patient nonresponsive or unable to speak.|47
281|5 - Thoughts of suicide|5 - Thoughts of suicide|47
282|5 - Totally unable to use the telephone.|5 - Totally unable to use the telephone.|47
283|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|47
284|5 - Unable to take in nutrients orally or by tube feeding.|5 - Unable to take in nutrients orally or by tube feeding.|47
285|5 - Unsafe for care at home|5 - Unsafe for care at home|47
286|5 - With paid help (other than home care agency staff)|5 - With paid help (other than home care agency staff)|47
287|5 - Workers' compensation|5 - Workers' compensation|47
288|5 - Wound infection, deteriorating wound status, new lesion/ulcer|5 - Wound infection, deteriorating wound status, new lesion/ulcer|47
289|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|47
290|6 - Delusional, hallucinatory, or paranoid behavior|6 - Delusional, hallucinatory, or paranoid behavior|47
291|6 - Financial agent, power of attorney, or conservator of finance|6 - Financial agent, power of attorney, or conservator of finance|47
292|6 - GI bleeding, obstruction|6 - GI bleeding, obstruction|47
293|6 - Less often than weekly|6 - Less often than weekly|47
294|6 - Memory loss to the extent that supervision required|6 - Memory loss to the extent that supervision required|47
295|6 - None of the above feelings observed or reported|6 - None of the above feelings observed or reported|47
296|6 - Other|6 - Other|47
297|6 - Title programs (e.g., Title III, V, or XX)|6 - Title programs (e.g., Title III, V, or XX)|47
298|6 - Transferred to an inpatient facility - patient not discharged from agency|6 - Transferred to an inpatient facility - patient not discharged from agency|47
299|6 - White|6 - White|47
300|6 - With other than above|6 - With other than above|47
301|7 - Exacerbation of CHF, fluid overload, heart failure|7 - Exacerbation of CHF, fluid overload, heart failure|47
302|7 - Health care agent, conservator of person, or medical power of attorney|7 - Health care agent, conservator of person, or medical power of attorney|47
303|7 - Hypo/Hyperglycemia, diabetes out of control|7 - Hypo/Hyperglycemia, diabetes out of control|47
304|7 - None of the above|7 - None of the above|47
305|7 - None of the above behaviors demonstrated|7 - None of the above behaviors demonstrated|47
306|7 - Other government (e.g., TriCare, VA, etc.)|7 - Other government (e.g., TriCare, VA, etc.)|47
307|7 - Transferred to an inpatient facility - patient discharged from agency|7 - Transferred to an inpatient facility - patient discharged from agency|47
308|8 - Death at home|8 - Death at home|47
309|8 - GI bleeding, obstruction|8 - GI bleeding, obstruction|47
310|8 - Myocardial infarction, stroke|8 - Myocardial infarction, stroke|47
311|8 - Private insurance|8 - Private insurance|47
312|9 - Chemotherapy|9 - Chemotherapy|47
313|9 - Discharge from agency|9 - Discharge from agency|47
314|9 - Other than above reasons|9 - Other than above reasons|47
315|9 - Private HMO/managed care|9 - Private HMO/managed care|47
316|NA - No caregiver|NA - No caregiver|47
317|NA - No equipment of this type used in care.|NA - No equipment of this type used in care.|47
318|NA - No inhalant/mist medications prescribed.|NA - No inhalant/mist medications prescribed.|47
319|NA - No injectable medications prescribed.|NA - No injectable medications prescribed.|47
320|NA - No inpatient facility admission|NA - No inpatient facility admission|47
321|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|47
322|NA - No Medicaid|NA - No Medicaid|47
323|NA - No Medicare|NA - No Medicare|47
324|NA - No observable pressure ulcer or unhealed pressure ulcer|NA - No observable pressure ulcer or unhealed pressure ulcer|47
325|NA - No observable stasis ulcer|NA - No observable stasis ulcer|47
326|NA - No observable surgical wound|NA - No observable surgical wound|47
327|NA - No oral medications prescribed.|NA - No oral medications prescribed.|47
328|NA - Not applicable|NA - Not applicable|47
329|NA - Patient does not have a telephone.|NA - Patient does not have a telephone.|47
330|NA - Patient has ostomy for bowel elimination|NA - Patient has ostomy for bowel elimination|47
331|NA - Patient nonresponsive|NA - Patient nonresponsive|47
332|NA - Patient on prophylactic treatment|NA - Patient on prophylactic treatment|47
333|NA - Patient was not discharged from an inpatient facility [Go to M1016 ]|NA - Patient was not discharged from an inpatient facility [Go to M1016 ]|47
334|UK - Other unknown|UK - Other unknown|47
335|UK - Reason unknown|UK - Reason unknown|47
336|UK - Unknown|UK - Unknown|47
337|UK - Unknown or Not Available|UK - Unknown or Not Available|47
341|01 - Early|01 - Early|47
342|02 - Late|02 - Late|47
343|NA - Not Applicable. No case mix group defined for this assessment.|NA - Not Applicable. No case mix group defined for this assessment.|47
344|NA - No case mix group defined by this assessment.|NA - No case mix group defined by this assessment.|47
345|1 - Recent decline in mental, emotional, or behavioral status|1 - Recent decline in mental, emotional, or behavioral status|47
346|2 - Multiple hospitalizations (2 or more) in the past 12 months|2 - Multiple hospitalizations (2 or more) in the past 12 months|47
347|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|47
348|4 - Taking five or more medications|4 - Taking five or more medications|47
349|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|47
350|6 - Other|6 - Other|47
351|7 - None of the above|7 - None of the above|47
352|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond tho|47
353|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable without heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable wi|47
354|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious complications and death.|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious compl|47
355|3 - The patient has serious progressive conditions that could lead to death within a year.|3 - The patient has serious progressive conditions that could lead to death within a year.|47
356|UK - The patient+s situation is unknown or unclear.|UK - The patient+s situation is unknown or unclear.|47
357|0 - No [ Go to M1051 ]|0 - No [ Go to M1051 ]|47
358|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this influenza season. [ Go to M1050 ]|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this i|47
359|1 - Received from another health care provider (e.g., physician)|1 - Received from another health care provider (e.g., physician)|47
360|2 - Received from your agency previously during this year+s flu season|2 - Received from your agency previously during this year+s flu season|47
361|3 - Offered and declined|3 - Offered and declined|47
362|4 - Assessed and determined to have medical contraindication(s)|4 - Assessed and determined to have medical contraindication(s)|47
363|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|47
364|6 - Inability to obtain vaccine due to declared shortage|6 - Inability to obtain vaccine due to declared shortage|47
365|1 - Yes [ Go to M1500 at TRN; Go to M1230 at DC ]|1 - Yes [ Go to M1500 at TRN; Go to M1230 at DC ]|47
366|1 - Patient has received PPV in the past|1 - Patient has received PPV in the past|47
367|2 - Offered and declined|2 - Offered and declined|47
368|3 - Assessed and determined to have medical contraindication(s)|3 - Assessed and determined to have medical contraindication(s)|47
369|4 - Not indicated; patient does not meet age/condition guidelines for PPV|4 - Not indicated; patient does not meet age/condition guidelines for PPV|47
370|5 - None of the above|5 - None of the above|47
371|0 - Adequate: hears normal conversation without difficulty.|0 - Adequate: hears normal conversation without difficulty.|47
372|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to increase volume or speak distinctly.|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to in|47
373|2 - Severely Impaired: absence of useful hearing.|2 - Severely Impaired: absence of useful hearing.|47
374|UK - Unable to assess hearing.|UK - Unable to assess hearing.|47
375|0 - Understands: clear comprehension without cues or repetitions.|0 - Understands: clear comprehension without cues or repetitions.|47
376|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Requires cues at times to understand.|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Req|47
377|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequently requires cues to understand.|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequentl|47
378|3 - Rarely/Never Understands|3 - Rarely/Never Understands|47
379|UK - Unable to assess understanding.|UK - Unable to assess understanding.|47
380|0 - No standardized assessment conducted|0 - No standardized assessment conducted|47
381|1 - Yes, and it does not indicate severe pain|1 - Yes, and it does not indicate severe pain|47
382|2 - Yes, and it indicates severe pain|2 - Yes, and it indicates severe pain|47
383|0 - Patient has no pain|0 - Patient has no pain|47
384|1 - Patient has pain that does not interfere with activity or movement|1 - Patient has pain that does not interfere with activity or movement|47
385|2 - Less often than daily|2 - Less often than daily|47
386|3 - Daily, but not constantly|3 - Daily, but not constantly|47
387|4 - All of the time|4 - All of the time|47
388|0 - No assessment conducted [ Go to M1306 ]|0 - No assessment conducted [ Go to M1306 ]|47
389|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc., without use of standardized tool|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc.,|47
390|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|47
391|0 - No [ Go to M1322]|0 - No [ Go to M1322]|47
392|0 v Newly epithelialized|0 v Newly epithelialized|47
393|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|47
394|2 - Yes, patient has observable stasis ulcers ONLY|2 - Yes, patient has observable stasis ulcers ONLY|47
395|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable dressing) [Go to M1340]|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable|47
396|0 - No [ Go to M1350 ]|0 - No [ Go to M1350 ]|47
397|1 - Yes, patient has at least one (observable) surgical wound|1 - Yes, patient has at least one (observable) surgical wound|47
398|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1350 ]|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1350 ]|47
399|0 - Patient is not short of breath|0 - Patient is not short of breath|47
400|3 - Continuous Bi-level positive airway pressure|3 - Continuous Bi-level positive airway pressure|47
401|0 - No [ Go to M2004 at TRN; Go to M1600 at DC ]|0 - No [ Go to M2004 at TRN; Go to M1600 at DC ]|47
402|2 - Not assessed [Go to M2004 at TRN; Go to M1600 at DC ]|2 - Not assessed [Go to M2004 at TRN; Go to M1600 at DC ]|47
403|NA - Patient does not have diagnosis of heart failure [Go to M2004 at TRN; Go to M1600 at DC]|NA - Patient does not have diagnosis of heart failure [Go to M2004 at TRN; Go to M1600 at DC]|47
404|0 - No action taken|0 - No action taken|47
405|1 - Patient+s physician (or other primary care practitioner) contacted the same day|1 - Patient+s physician (or other primary care practitioner) contacted the same day|47
406|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|47
407|3 - Implement physician-ordered patient-specific established parameters for treatment|3 - Implement physician-ordered patient-specific established parameters for treatment|47
408|4 - Patient education or other clinical interventions|4 - Patient education or other clinical interventions|47
409|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequency, telehealth, etc.)|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequ|47
410|1 - Occasional stress incontinence|1 - Occasional stress incontinence|47
411|2 - During the night only|2 - During the night only|47
412|3 - During the day only|3 - During the day only|47
413|4 - During the day and night|4 - During the day and night|47
414|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|47
415|0 - Able to manage toileting hygiene and clothing management without assistance.|0 - Able to manage toileting hygiene and clothing management without assistance.|47
416|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implements are laid out for the patient.|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implemen|47
417|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|47
418|3 - Patient depends entirely upon another person to maintain toileting hygiene.|3 - Patient depends entirely upon another person to maintain toileting hygiene.|47
419|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independent|47
420|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface|47
421|0 - No multi-factor falls risk assessment conducted.|0 - No multi-factor falls risk assessment conducted.|47
422|1 - Yes, and it does not indicate a risk for falls.|1 - Yes, and it does not indicate a risk for falls.|47
423|2 - Yes, and it indicates a risk for falls.|2 - Yes, and it indicates a risk for falls.|47
424|0 - Not assessed/reviewed [ Go to M2010 ]|0 - Not assessed/reviewed [ Go to M2010 ]|47
425|1 - No problems found during review [ Go to M2010 ]|1 - No problems found during review [ Go to M2010 ]|47
426|2 - Problems found during review|2 - Problems found during review|47
427|NA - Patient is not taking any medications [ Go to M2040 ]|NA - Patient is not taking any medications [ Go to M2040 ]|47
428|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special precautions associated with all high-risk medications|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special p|47
429|NA - Patient not taking any drugs|NA - Patient not taking any drugs|47
430|2 - Able to take medication(s) at the correct times if given reminders by another person at the appropriate times|2 - Able to take medication(s) at the correct times if given reminders by another person at the appr|47
431|3 - Unable to take medication unless administered by another person.|3 - Unable to take medication unless administered by another person.|47
432|1 - At least daily|1 - At least daily|47
433|2 - Three or more times per week|2 - Three or more times per week|47
434|3 - One to two times per week|3 - One to two times per week|47
435|4 - Received, but less often than weekly|4 - Received, but less often than weekly|47
436|5 - No assistance received|5 - No assistance received|47
437|0 - No [Go to M2400]|0 - No [Go to M2400]|47
438|1 - Yes, used hospital emergency department WITHOUT hospital admission|1 - Yes, used hospital emergency department WITHOUT hospital admission|47
439|2 - Yes, used hospital emergency department WITH hospital admission|2 - Yes, used hospital emergency department WITH hospital admission|47
440|UK - Unknown [Go to M2400]|UK - Unknown [Go to M2400]|47
441|2 - Injury caused by fall|2 - Injury caused by fall|47
442|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|47
443|4 - Other respiratory problem|4 - Other respiratory problem|47
444|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|47
445|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|47
446|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|47
447|8 - Other heart disease|8 - Other heart disease|47
448|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|47
449|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|47
450|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|47
451|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|47
452|13 - Urinary tract infection|13 - Urinary tract infection|47
453|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|47
454|15 - Wound infection or deterioration|15 - Wound infection or deterioration|47
455|16 - Uncontrolled pain|16 - Uncontrolled pain|47
456|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|47
457|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|47
458|19 - Other than above reasons|19 - Other than above reasons|47
459|2 - Patient remained in the community (with formal assistive services)|2 - Patient remained in the community (with formal assistive services)|47
460|3 - Patient transferred to a noninstitutional hospice|3 - Patient transferred to a noninstitutional hospice|47
461|4 - Unknown because patient moved to a geographic location not served by this agency|4 - Unknown because patient moved to a geographic location not served by this agency|47
462|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|47
463|4 - Other respiratory problem|4 - Other respiratory problem|47
464|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|47
465|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|47
466|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|47
467|8 - Other heart disease|8 - Other heart disease|47
468|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|47
469|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|47
470|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|47
471|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|47
472|13 - Urinary tract infection|13 - Urinary tract infection|47
473|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|47
474|15 - Wound infection or deterioration|15 - Wound infection or deterioration|47
475|16 - Uncontrolled pain|16 - Uncontrolled pain|47
476|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|47
477|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|47
478|19 - Scheduled treatment or procedure|19 - Scheduled treatment or procedure|47
479|20 - Other than above reasons|20 - Other than above reasons|47
480|UK - Reason unknown [Go to M0903]|UK - Reason unknown [Go to M0903]|47
482|01 - Patient lives alone around the clock|01 - Patient lives alone around the clock|47
483|02 - Patient lives alone regular daytime|02 - Patient lives alone regular daytime|47
484|03 - Patient lives alone regular nighttime|03 - Patient lives alone regular nighttime|47
485|04 - Patient lives alone occassional/short term assistance|04 - Patient lives alone occassional/short term assistance|47
486|05 - Patient lives alone no assisstance available|05 - Patient lives alone no assisstance available|47
487|06 - Patient lives with other person(s) in the home around the clock|06 - Patient lives with other person(s) in the home around the clock|47
488|07 - Patient lives with other person(s) in the home regular daytime|07 - Patient lives with other person(s) in the home regular daytime|47
489|08 - Patient lives with other person(s) in the home regular nighttime|08 - Patient lives with other person(s) in the home regular nighttime|47
490|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|47
491|10 - Patient lives with other person(s) in the home no assistance available|10 - Patient lives with other person(s) in the home no assistance available|47
492|1 - Was present at the most recent SOC/ROC assessment|1 - Was present at the most recent SOC/ROC assessment|47
493|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|47
494|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|47
495|0 - Newly epithelialized|0 - Newly epithelialized|47
496|0 - No [ Go to M1340 ]|0 - No [ Go to M1340 ]|47
498|0 - Independent|0 - Independent|47
499|1 - Needed Some Help|1 - Needed Some Help|47
500|2 - Dependent|2 - Dependent|47
502|0 - No assistance needed in this area|0 - No assistance needed in this area|47
503|1 - Caregiver(s) currently provide assistance|1 - Caregiver(s) currently provide assistance|47
504|2 - Caregiver(s) need training/ supportive services to provide assistance|2 - Caregiver(s) need training/ supportive services to provide assistance|47
505|3 - Caregiver(s) not likely to provide assistance|3 - Caregiver(s) not likely to provide assistance|47
506|4 - Unclear if Caregiver(s) will provide assistance|4 - Unclear if Caregiver(s) will provide assistance|47
507|5 - Assistance needed, but no Caregiver(s) available|5 - Assistance needed, but no Caregiver(s) available|47
508|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will use standardized clinical guidelines accessible for all care providers to reference|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will|47
510|NA - Patient is not assessed to be at risk for falls|NA - Patient is not assessed to be at risk for falls|47
511|NA - Patient has no diagnosis or symptoms of depression|NA - Patient has no diagnosis or symptoms of depression|47
512|NA - No pain identified|NA - No pain identified|47
513|NA - Patient is not assessed to be at risk for pressure ulcers|NA - Patient is not assessed to be at risk for pressure ulcers|47
514|NA - Patient has no pressure ulcers with need for moist wound healing|NA - Patient has no pressure ulcers with need for moist wound healing|47
515|1 - Long-term nursing facility (NF)|1 - Long-term nursing facility (NF)|47
516|2 - Skilled nursing facility (SNF / TCU)|2 - Skilled nursing facility (SNF / TCU)|47
517|3 - Short stay acute hospital (IPP S)|3 - Short stay acute hospital (IPP S)|47
518|4 - Long-term care hospital (LTCH)|4 - Long-term care hospital (LTCH)|47
519|5 - Inpatient rehabilitation hospital or unit (IRF)|5 - Inpatient rehabilitation hospital or unit (IRF)|47
520|6 - Psychiatric hospital or unit|6 - Psychiatric hospital or unit|47
521|7 - Other|7 - Other|47
522|NA - Patient was not discharged from an inpatient facility [Goto M1016]|NA - Patient was not discharged from an inpatient facility [Goto M1016]|47
523|6 - Unable to participate effectively in bathing and is bathed totally by another person|6 - Unable to participate effectively in bathing and is bathed totally by another person|47
524|4 - Chairfast, unable to ambulate but is able to wheel self independently.|4 - Chairfast, unable to ambulate but is able to wheel self independently.|47
525|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask patient: "Over the last two weeks, how often have you been bothered by any of the following problems")|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask|47
526|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluation for depression.|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluat|47
527|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet criteria for further evaluation for depression.|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet|47
528|0 - Not at all  0 - 1 day|0 - Not at all  0 - 1 day|47
529|1 - Several days  2 - 6 days|1 - Several days  2 - 6 days|47
530|2 - More than half of the days  7 - 11 days|2 - More than half of the days  7 - 11 days|47
531|3 - Nearly every day  12 - 14 days|3 - Nearly every day  12 - 14 days|47
532|NA - N/A  Unable to respond|NA - N/A  Unable to respond|47
533|2 - Able to take medication(s) at the correct times if given reminders by another person based on the frequency of the injection|2 - Able to take medication(s) at the correct times if given reminders by another person based on th|47
534|3 - Unable to take injectable medication unless administered by another person.|3 - Unable to take injectable medication unless administered by another person.|47
547|NA - No clinically significant medication issues identified since the previous OASIS assessment|NA - No clinically significant medication issues identified since the previous OASIS assessment|47
552|1 - Hospital [ Go to M2430 ]|1 - Hospital [ Go to M2430 ]|47
553|2 - Rehabilitation facility [ Go to M0903 ]|2 - Rehabilitation facility [ Go to M0903 ]|47
554|3 - Nursing home [ Go to M2440 ]|3 - Nursing home [ Go to M2440 ]|47
555|4 - Hospice [ Go to M0903 ]|4 - Hospice [ Go to M0903 ]|47
564|NA - Patient is not diabetic or is bilateral amputee|NA - Patient is not diabetic or is bilateral amputee|47
565|NA - Formal multi-factor Fall Risk Assessment indicates the patient was not at risk for falls since the last OASIS assessment|NA - Formal multi-factor Fall Risk Assessment indicates the patient was not at risk for falls since|47
566|NA - Formal assessment indicates patient did not meet criteria for depression AND patient did not have diagnosis of depression since the last OASIS assessment|NA - Formal assessment indicates patient did not meet criteria for depression AND patient did not ha|47
567|NA - Formal assessment did not indicate pain since the last OASIS assessment|NA - Formal assessment did not indicate pain since the last OASIS assessment|47
568|NA - Formal assessment indicates the patient was not at risk of pressure ulcers since the last OASIS assessment|NA - Formal assessment indicates the patient was not at risk of pressure ulcers since the last OASIS|47
569|NA - Dressings that support the principles of moist wound healing not indicated for this patient's pressure ulcers OR patient has no pressure ulcers with need for moist wound healing|NA - Dressings that support the principles of moist wound healing not indicated for this patient's p|47
620|1 - Yes; received from your agency during this episode of care (SOC/ROC to Transfer/Discharge)|1 - Yes; received from your agency during this episode of care (SOC/ROC to Transfer/Discharge)|47
621|2 - Yes; received from your agency during a prior episode of care (SOC/ROC to Transfer/Discharge)|2 - Yes; received from your agency during a prior episode of care (SOC/ROC to Transfer/Discharge)|47
622|3 - Yes; received from another health care provider (for example physician pharmacist)|3 - Yes; received from another health care provider (for example physician pharmacist)|47
623|4 - No; patient offered and declined |4 - No; patient offered and declined |47
624|5 - No; patient assessed and determined to have medical contraindication(s)|5 - No; patient assessed and determined to have medical contraindication(s)|47
625|6 - No; not indicated - patient does not meet age/condition guidelines for influenza vaccine|6 - No; not indicated - patient does not meet age/condition guidelines for influenza vaccine|47
626|7 - No; inability to obtain vaccine due to declared shortage |7 - No; inability to obtain vaccine due to declared shortage |47
627|8 - No; patient did not receive the vaccine due to reasons other than those listed in responses 4 v 7. |8 - No; patient did not receive the vaccine due to reasons other than those listed in responses 4v7.|47
628|1 - Offered and declined|1 - Offered and declined|47
629|2 - Assessed and determined to have medical contraindication(s) |2 - Assessed and determined to have medical contraindication(s) |47
630|3 - Not indicated; patient does not meet age/condition guidelines for Pneumococcal Vaccine|3 - Not indicated; patient does not meet age/condition guidelines for Pneumococcal Vaccine|47
631|4 - None of the above|4 - None of the above|47
2|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; OR (b) Is physically, cognitively, and mentally able to prepare light meals on a regular basis but has not routinely performed light meal preparation in the past (i.e., prior to this home care admission).|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; O|48
3|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and mentally able to perform all housekeeping tasks .|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and menta|48
4|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and mentally able to do laundry and access facilities.|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and menta|48
5|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying packages OR b) Physically, cognitively, and mentally able to take care of shopping, but has not done shopping in the past (i.e., prior to this home care admission).|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying|48
6|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|48
7|0 - Able to dial numbers and answer calls appropriately and as desired.|0 - Able to dial numbers and answer calls appropriately and as desired.|48
8|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body without assistance.|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body|48
9|0 - Able to get to and from the toilet and transfer independently with or without a device.|0 - Able to get to and from the toilet and transfer independently with or without a device.|48
10|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|48
11|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible public bus.|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible p|48
12|0 - Able to independently feed self.|0 - Able to independently feed self.|48
13|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|48
14|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct times.|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct ti|48
15|0 - Able to independently transfer.|0 - Able to independently transfer.|48
16|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without rail|48
17|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings|48
18|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|48
19|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions independently.|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions indep|48
20|0 - Asymptomatic, no treatment needed at this time|0 - Asymptomatic, no treatment needed at this time|48
21|0 - Caregiver manages all tasks related to equipment completely independently.|0 - Caregiver manages all tasks related to equipment completely independently.|48
22|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations with no observable impairment.|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations w|48
23|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|48
24|0 - Life expectancy is greater than 6 months|0 - Life expectancy is greater than 6 months|48
25|0 - Never|0 - Never|48
26|0 - Patient is not short of breath|0 - Patient is not short of breath|48
27|0 - No|0 - No|48
28|0 - No emergent care services|0 - No emergent care services|48
29|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [Goto 1620]|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [Goto 1620]|48
30|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and extended or abstract conversation.|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and exte|48
31|0 - No one person|0 - No one person|48
32|0 - None of the time|0 - None of the time|48
33|0 - None, no charge for current services|0 - None, no charge for current services|48
34|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|48
35|0 - Patient does NOT have an ostomy for bowel elimination.|0 - Patient does NOT have an ostomy for bowel elimination.|48
36|0 - Patient has no pain|0 - Patient has no pain|48
37|0 - Patient manages all tasks related to equipment completely independently.|0 - Patient manages all tasks related to equipment completely independently.|48
38|0 - Poor:  little or no recovery is expected and/or further decline is imminent|0 - Poor:  little or no recovery is expected and/or further decline is imminent|48
39|0 - Timed-voiding defers incontinence|0 - Timed-voiding defers incontinence|48
40|0 - Very rarely or never has bowel incontinence|0 - Very rarely or never has bowel incontinence|48
41|0 - Zero|0 - Zero|48
42|00 - No|00 - No|48
43|01 - Yes|01 - Yes|48
44|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or mental limitations, needs assistance with heavy laundry.|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or|48
45|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the patient.|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the|48
46|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|48
47|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or supervision from another person OR c) a liquid, pureed or ground meat diet.|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or su|48
48|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|48
49|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|48
50|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independently.|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independe|48
51|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only when assisted or accompanied by another person.|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only w|48
52|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepa|48
53|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance by another person OR b) given daily reminders.|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance b|48
54|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advan|48
55|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advan|48
56|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for the deaf) and call essential numbers.|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for t|48
57|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|48
58|1 - American Indian or Alaska Native|1 - American Indian or Alaska Native|48
59|1 - Depressed mood (e.g., feeling sad, tearful)|1 - Depressed mood (e.g., feeling sad, tearful)|48
60|1 - During the night only|1 - During the night only|48
61|1 - Fully granulating|1 - Fully granulating|48
62|1 - Good/Fair:  partial to full recovery is expected|1 - Good/Fair:  partial to full recovery is expected|48
63|1 - Good:  marked improvement in functional status is expected|1 - Good:  marked improvement in functional status is expected|48
64|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|48
65|1 - Smoking|1 - Smoking|48
66|1 - Hospital|1 - Hospital|48
67|1 - Hospital emergency room (includes 23-hour holding)|1 - Hospital emergency room (includes 23-hour holding)|48
68|1 - Hospitalization for EMERGENT (unscheduled) care|1 - Hospitalization for EMERGENT (unscheduled) care|48
69|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepared solutions), patient is able to manage all other aspects of equipment.|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepar|48
70|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|48
71|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|48
72|1 - In new or complex situations only|1 - In new or complex situations only|48
73|1 - Intravenous or infusion therapy (excludes TPN)|1 - Intravenous or infusion therapy (excludes TPN)|48
74|1 - Less often than daily|1 - Less often than daily|48
75|1 - Less than once a month|1 - Less than once a month|48
76|1 - Less than once weekly|1 - Less than once weekly|48
77|1 - Life expectancy is 6 months or fewer|1 - Life expectancy is 6 months or fewer|48
78|1 - Lives alone|1 - Lives alone|48
79|1 - Male|1 - Male|48
80|1 - Medicare (traditional fee-for-service)|1 - Medicare (traditional fee-for-service)|48
81|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of past 24 hours, significant memory loss so that supervision is required|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of pas|48
82|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors in word choice, grammar or speech intelligibility, needs minimal prompting or assistance).|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors i|48
83|1 - No assistance or services received|1 - No assistance or services received|48
84|1 - One|1 - One|48
85|1 - Oxygen (intermittent or continuous)|1 - Oxygen (intermittent or continuous)|48
86|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, and the surrounding layout, can count fingers at arm's length.|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, a|48
87|1 - Patient is incontinent|1 - Patient is incontinent|48
88|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|48
89|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical or treatment regimen.|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical|48
90|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient/couple/significant other)|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient|48
91|1 - Relatives, friends, or neighbors living outside the home|1 - Relatives, friends, or neighbors living outside the home|48
92|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions.|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions|48
93|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independentl|48
94|1 - Several times during day and night|1 - Several times during day and night|48
95|1 - Spouse or significant other|1 - Spouse or significant other|48
96|1 - Stage 1|1 - Stage 1|48
97|1 - Start of care - further visits planned|1 - Start of care - further visits planned|48
98|1 - Symptoms well controlled with current therapy|1 - Symptoms well controlled with current therapy|48
99|1 - Therapy services|1 - Therapy services|48
100|1 - Able to transfer with minimal human assistance or with use of an assistive device.|1 - Able to transfer with minimal human assistance or with use of an assistive device.|48
101|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitations.|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitatio|48
102|1 - Urinary incontinence|1 - Urinary incontinence|48
103|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and transfer.|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and|48
104|1 - When walking more than 20 feet, climbing stairs|1 - When walking more than 20 feet, climbing stairs|48
105|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary conversation. May need occasional repetition, extra time, or louder voice.|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary c|48
106|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting in and out of tub/shower|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting|48
107|1 - Yes|1 - Yes|48
108|1-RN|1-RN|48
109|10 - Discharge from agency - no visits completed after start/resumption of care assessment|10 - Discharge from agency - no visits completed after start/resumption of care assessment|48
110|10 - Scheduled surgical procedure|10 - Scheduled surgical procedure|48
111|10 - Self-pay|10 - Self-pay|48
112|11 - Other|11 - Other|48
113|11 - Urinary tract infection|11 - Urinary tract infection|48
114|12 - IV catheter-related infection|12 - IV catheter-related infection|48
115|13 - Deep vein thrombosis, pulmonary embolus|13 - Deep vein thrombosis, pulmonary embolus|48
116|14 - Uncontrolled pain|14 - Uncontrolled pain|48
117|15 - Psychotic episode|15 - Psychotic episode|48
118|16 - Other than above reasons|16 - Other than above reasons|48
119|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing calls.|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing|48
120|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another person.|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another pers|48
121|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface a|48
122|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for intermittent supervision or encouragement or reminders, OR (b) to get in and out of the shower or tub, OR (c) for washing difficult to reach areas.|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for inter|48
123|2 - Asian|2 - Asian|48
124|2 - Caregiver requires considerable assistance from another person to manage equipment, but independently completes significant portions of task.|2 - Caregiver requires considerable assistance from another person to manage equipment, but independ|48
125|2 - Daily, but not constantly|2 - Daily, but not constantly|48
126|2 - Daughter or son|2 - Daughter or son|48
127|2 - Doctor's office emergency visit/house call|2 - Doctor's office emergency visit/house call|48
128|2 - During the day and night|2 - During the day and night|48
129|2 - Early/partial granulation|2 - Early/partial granulation|48
130|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors in word choice, organization or speech intelligibility). Speaks in phrases or short sentences.|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors|48
131|2 - Family member's residence|2 - Family member's residence|48
132|2 - Female|2 - Female|48
133|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conversation, needs frequent prompting or assistance.|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conver|48
134|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|48
135|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|48
136|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately stop activities, jeopardizes safety through actions|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately st|48
137|2 - Indwelling/suprapubic catheter|2 - Indwelling/suprapubic catheter|48
138|2 - Injury caused by fall or accident at home|2 - Injury caused by fall or accident at home|48
139|2 - Medicare (HMO/managed care/Advantage plan)|2 - Medicare (HMO/managed care/Advantage plan)|48
140|2 - Nausea, dehydration, malnutrition, constipation, impaction|2 - Nausea, dehydration, malnutrition, constipation, impaction|48
141|2 - Obesity|2 - Obesity|48
142|2 - On awakening or at night only|2 - On awakening or at night only|48
143|2 - Once a month|2 - Once a month|48
144|2 - One to three times weekly|2 - One to three times weekly|48
145|2 - Parenteral nutrition (TPN or lipids)|2 - Parenteral nutrition (TPN or lipids)|48
146|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic) [ Go to M1620]|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic) [ Go|48
147|2 - Patient requires considerable assistance from another person to manage equipment, but independently completes portions of the task.|2 - Patient requires considerable assistance from another person to manage equipment, but independen|48
148|2 - Patient transferred to a noninstitutional hospice|2 - Patient transferred to a noninstitutional hospice|48
149|2 - Person residing in the home (EXCLUDING paid help)|2 - Person residing in the home (EXCLUDING paid help)|48
150|2 - Rehabilitation facility|2 - Rehabilitation facility|48
151|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifting of attention) or consistently requires low stimulus environment due to distractibility.|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifti|48
152|2 - Respite care|2 - Respite care|48
153|2 - Sense of failure or self reproach|2 - Sense of failure or self reproach|48
154|2 - Several times during day|2 - Several times during day|48
155|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonresponsive.|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonrespons|48
156|2 - Someone must assist the patient to groom self.|2 - Someone must assist the patient to groom self.|48
157|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|48
158|2 - Someone must help the patient put on upper body clothing.|2 - Someone must help the patient put on upper body clothing.|48
159|2 - Stage 2|2 - Stage 2|48
160|2 - Start of care - no further visits planned|2 - Start of care - no further visits planned|48
161|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitoring|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitori|48
162|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment regimen.|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment re|48
163|2 - Two|2 - Two|48
164|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistance due to cognitive or mental limitation.|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistanc|48
165|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|48
166|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assistance).|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assis|48
167|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home delivery.|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home deli|48
168|2 - Unable to prepare any light meals or reheat any delivered meals.|2 - Unable to prepare any light meals or reheat any delivered meals.|48
169|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|48
170|2 - UNABLE to take injectable medications unless administered by someone else.|2 - UNABLE to take injectable medications unless administered by someone else.|48
171|2 - UNABLE to take medication unless administered by someone else.|2 - UNABLE to take medication unless administered by someone else.|48
172|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|48
173|2 - Ventilator (continually or at night)|2 - Ventilator (continually or at night)|48
174|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less than 20 feet)|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less th|48
175|2 - With spouse or significant other|2 - With spouse or significant other|48
176|2 - Yes, assistance or services provided by family or friends|2 - Yes, assistance or services provided by family or friends|48
177|2-PT|2-PT|48
178|3 - Able to answer the telephone only some of the time or is able to carry on only a limited conversation.|3 - Able to answer the telephone only some of the time or is able to carry on only a limited convers|48
179|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube or gastrostomy.|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube|48
180|3 - Alcohol dependency|3 - Alcohol dependency|48
181|3 - All of the time|3 - All of the time|48
182|3 - Black or African-American|3 - Black or African-American|48
183|3 - Boarding home or rented room|3 - Boarding home or rented room|48
184|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment, clean/store/dispose of equipment or supplies).|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment,|48
185|3 -Able to walk only with the supervision or assistance of another person at all times.|3 -Able to walk only with the supervision or assistance of another person at all times.|48
186|3 - Continuous / Bi-level positive airway pressure|3 - Continuous / Bi-level positive airway pressure|48
187|3 - During the day and evening, but not constantly|3 - During the day and evening, but not constantly|48
188|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the alimentary canal)|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the|48
189|3 - Environmental support (e.g., housing, home maintenance)|3 - Environmental support (e.g., housing, home maintenance)|48
190|3 - Four to six times weekly|3 - Four to six times weekly|48
191|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessing by listener.  Speech limited to single words or short phrases.|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessin|48
192|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires multiple repetitions, restatements, demonstrations, additional time.|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires m|48
193|3 - Hopelessness|3 - Hopelessness|48
194|3 - Hospice care|3 - Hospice care|48
195|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|48
196|3 - Injury caused by fall or accident at home|3 - Injury caused by fall or accident at home|48
197|3 - Intractable pain|3 - Intractable pain|48
198|3 - Medicaid (traditional fee-for-service)|3 - Medicaid (traditional fee-for-service)|48
199|3 - Needs someone to do all shopping and errands.|3 - Needs someone to do all shopping and errands.|48
200|3 - Not healing|3 - Not healing|48
201|3 - Nursing home|3 - Nursing home|48
202|3 - Once daily|3 - Once daily|48
203|3 - Other family member|3 - Other family member|48
204|3 - Outpatient department/clinic emergency (includes urgicenter sites)|3 - Outpatient department/clinic emergency (includes urgicenter sites)|48
205|3 - Paid help|3 - Paid help|48
206|3 - Able to participate in bathing self in shower or tub, but requires presence of another person throughout the bath for assistance or supervision.|3 - Able to participate in bathing self in shower or tub, but requires presence of another person th|48
207|3 - Patient depends entirely upon another person to dress lower body.|3 - Patient depends entirely upon another person to dress lower body.|48
208|3 - Patient depends entirely upon another person to dress the upper body.|3 - Patient depends entirely upon another person to dress the upper body.|48
209|3 - Patient depends entirely upon someone else for grooming needs.|3 - Patient depends entirely upon someone else for grooming needs.|48
210|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone else to manage the equipment.|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone|48
211|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable to shift attention and recall directions more than half the time.|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable|48
212|3 - Respiratory problems (SOB, infection, obstruction)|3 - Respiratory problems (SOB, infection, obstruction)|48
213|3 - Resumption of care (after inpatient stay)|3 - Resumption of care (after inpatient stay)|48
214|3 - Several times each month|3 - Several times each month|48
215|3 - Skilled Nursing Facility|3 - Skilled Nursing Facility|48
216|3 - Stage 3|3 - Stage 3|48
217|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|48
218|3 - Three|3 - Three|48
219|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person throughout the process.|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person through|48
220|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal independently.|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal indep|48
221|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person.|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person|48
222|3 - Unknown because patient moved to a geographic location not served by this agency|3 - Unknown because patient moved to a geographic location not served by this agency|48
223|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|48
224|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|48
225|3 - With other family member|3 - With other family member|48
226|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home health services, homemaker assistance, transportation assistance, assisted living, board and care)|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home h|48
227|3-SLP/ST|3-SLP/ST|48
228|4 - At rest (during day or night)|4 - At rest (during day or night)|48
229|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|48
230|4 - Board and care or assisted living facility|4 - Board and care or assisted living facility|48
231|4 - Caregiver is completely dependent on someone else to manage all equipment.|4 - Caregiver is completely dependent on someone else to manage all equipment.|48
232|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|48
233|4 - Constantly|4 - Constantly|48
234|4 - Drug dependency|4 - Drug dependency|48
235|4 - Four or more|4 - Four or more|48
236|4 - Friend or neighbor or community or church member|4 - Friend or neighbor or community or church member|48
237|4 - Hispanic or Latino|4 - Hispanic or Latino|48
238|4 - Hospice|4 - Hospice|48
239|4 - Impaired decision-making|4 - Impaired decision-making|48
240|4 - Is totally dependent in toileting.|4 - Is totally dependent in toileting.|48
241|4 - Medicaid (HMO/managed care)|4 - Medicaid (HMO/managed care)|48
242|4 - None of the above|4 - None of the above|48
243|4 - Nursing home|4 - Nursing home|48
244|4 - On a daily basis|4 - On a daily basis|48
245|4 - Patient is completely dependent on someone else to manage all equipment.|4 - Patient is completely dependent on someone else to manage all equipment.|48
246|4 - Permanent placement|4 - Permanent placement|48
247|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, punches, dangerous maneuvers w/ wheelchair or other objects)|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, pu|48
248|4 - Psychosocial support (e.g., socialization, companionship, recreation)|4 - Psychosocial support (e.g., socialization, companionship, recreation)|48
249|4 - Recertification (follow-up) reassessment|4 - Recertification (follow-up) reassessment|48
250|4 - Recurrent thoughts of death|4 - Recurrent thoughts of death|48
251|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruction)|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruc|48
252|4 - Several times a week|4 - Several times a week|48
253|4 - Stage 4|4 - Stage 4|48
254|4 - Symptoms poorly controlled, history of rehospitalizations|4 - Symptoms poorly controlled, history of rehospitalizations|48
255|4 - Three or more times per week|4 - Three or more times per week|48
256|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetative state, or delirium.|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetati|48
257|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|48
258|4 - Unable to effectively participate in any housekeeping tasks.|4 - Unable to effectively participate in any housekeeping tasks.|48
259|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or unresponsive (e.g., speech is nonsensical or unintelligible).|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or u|48
260|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonresponsive.|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonr|48
261|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostomy.|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostom|48
262|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of devices at the sink, in chair, or on commode|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of|48
263|4 - With a friend|4 - With a friend|48
264|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|48
265|4-OT|4-OT|48
266|5 - Advocates or facilitates patient's participation in appropriate medical care|5 - Advocates or facilitates patient's participation in appropriate medical care|48
267|5 - At least daily|5 - At least daily|48
268|6 - Bedfast, unable to ambulate or be up in a chair.|6 - Bedfast, unable to ambulate or be up in a chair.|48
269|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|48
270|5 - Disruptive or socially inappropriate behavior|5 - Disruptive or socially inappropriate behavior|48
271|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|48
272|5 - Hypo/Hyperglycemia, diabetes out of control|5 - Hypo/Hyperglycemia, diabetes out of control|48
273|5 - More often than once daily|5 - More often than once daily|48
274|5 - Native Hawaiian or Pacific Islander|5 - Native Hawaiian or Pacific Islander|48
275|5 - None of the above|5 - None of the above|48
276|5 - One to two times per week|5 - One to two times per week|48
277|5 - Other|5 - Other|48
278|5 - Other follow-up|5 - Other follow-up|48
279|5 - Paid help|5 - Paid help|48
280|5 - Patient nonresponsive or unable to speak.|5 - Patient nonresponsive or unable to speak.|48
281|5 - Thoughts of suicide|5 - Thoughts of suicide|48
282|5 - Totally unable to use the telephone.|5 - Totally unable to use the telephone.|48
283|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|48
284|5 - Unable to take in nutrients orally or by tube feeding.|5 - Unable to take in nutrients orally or by tube feeding.|48
285|5 - Unsafe for care at home|5 - Unsafe for care at home|48
286|5 - With paid help (other than home care agency staff)|5 - With paid help (other than home care agency staff)|48
287|5 - Workers' compensation|5 - Workers' compensation|48
288|5 - Wound infection, deteriorating wound status, new lesion/ulcer|5 - Wound infection, deteriorating wound status, new lesion/ulcer|48
289|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|48
290|6 - Delusional, hallucinatory, or paranoid behavior|6 - Delusional, hallucinatory, or paranoid behavior|48
291|6 - Financial agent, power of attorney, or conservator of finance|6 - Financial agent, power of attorney, or conservator of finance|48
292|6 - GI bleeding, obstruction|6 - GI bleeding, obstruction|48
293|6 - Less often than weekly|6 - Less often than weekly|48
294|6 - Memory loss to the extent that supervision required|6 - Memory loss to the extent that supervision required|48
295|6 - None of the above feelings observed or reported|6 - None of the above feelings observed or reported|48
296|6 - Other|6 - Other|48
297|6 - Title programs (e.g., Title III, V, or XX)|6 - Title programs (e.g., Title III, V, or XX)|48
298|6 - Transferred to an inpatient facility - patient not discharged from agency|6 - Transferred to an inpatient facility - patient not discharged from agency|48
299|6 - White|6 - White|48
300|6 - With other than above|6 - With other than above|48
301|7 - Exacerbation of CHF, fluid overload, heart failure|7 - Exacerbation of CHF, fluid overload, heart failure|48
302|7 - Health care agent, conservator of person, or medical power of attorney|7 - Health care agent, conservator of person, or medical power of attorney|48
303|7 - Hypo/Hyperglycemia, diabetes out of control|7 - Hypo/Hyperglycemia, diabetes out of control|48
304|7 - None of the above|7 - None of the above|48
305|7 - None of the above behaviors demonstrated|7 - None of the above behaviors demonstrated|48
306|7 - Other government (e.g., TriCare, VA, etc.)|7 - Other government (e.g., TriCare, VA, etc.)|48
307|7 - Transferred to an inpatient facility - patient discharged from agency|7 - Transferred to an inpatient facility - patient discharged from agency|48
308|8 - Death at home|8 - Death at home|48
309|8 - GI bleeding, obstruction|8 - GI bleeding, obstruction|48
310|8 - Myocardial infarction, stroke|8 - Myocardial infarction, stroke|48
311|8 - Private insurance|8 - Private insurance|48
312|9 - Chemotherapy|9 - Chemotherapy|48
313|9 - Discharge from agency|9 - Discharge from agency|48
314|9 - Other than above reasons|9 - Other than above reasons|48
315|9 - Private HMO/managed care|9 - Private HMO/managed care|48
316|NA - No caregiver|NA - No caregiver|48
317|NA - No equipment of this type used in care.|NA - No equipment of this type used in care.|48
318|NA - No inhalant/mist medications prescribed.|NA - No inhalant/mist medications prescribed.|48
319|NA - No injectable medications prescribed.|NA - No injectable medications prescribed.|48
320|NA - No inpatient facility admission|NA - No inpatient facility admission|48
321|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|48
322|NA - No Medicaid|NA - No Medicaid|48
323|NA - No Medicare|NA - No Medicare|48
324|NA - No observable pressure ulcer or unhealed pressure ulcer|NA - No observable pressure ulcer or unhealed pressure ulcer|48
325|NA - No observable stasis ulcer|NA - No observable stasis ulcer|48
326|NA - No observable surgical wound|NA - No observable surgical wound|48
327|NA - No oral medications prescribed.|NA - No oral medications prescribed.|48
328|NA - Not applicable|NA - Not applicable|48
329|NA - Patient does not have a telephone.|NA - Patient does not have a telephone.|48
330|NA - Patient has ostomy for bowel elimination|NA - Patient has ostomy for bowel elimination|48
331|NA - Patient nonresponsive|NA - Patient nonresponsive|48
332|NA - Patient on prophylactic treatment|NA - Patient on prophylactic treatment|48
333|NA - Patient was not discharged from an inpatient facility [Go to M1016 ]|NA - Patient was not discharged from an inpatient facility [Go to M1016 ]|48
334|UK - Other unknown|UK - Other unknown|48
335|UK - Reason unknown|UK - Reason unknown|48
336|UK - Unknown|UK - Unknown|48
337|UK - Unknown or Not Available|UK - Unknown or Not Available|48
341|01 - Early|01 - Early|48
342|02 - Late|02 - Late|48
343|NA - Not Applicable. No case mix group defined for this assessment.|NA - Not Applicable. No case mix group defined for this assessment.|48
344|NA - No case mix group defined by this assessment.|NA - No case mix group defined by this assessment.|48
345|1 - Recent decline in mental, emotional, or behavioral status|1 - Recent decline in mental, emotional, or behavioral status|48
346|2 - Multiple hospitalizations (2 or more) in the past 12 months|2 - Multiple hospitalizations (2 or more) in the past 12 months|48
347|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|48
348|4 - Taking five or more medications|4 - Taking five or more medications|48
349|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|48
350|6 - Other|6 - Other|48
351|7 - None of the above|7 - None of the above|48
352|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond tho|48
353|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable without heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable wi|48
354|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious complications and death.|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious compl|48
355|3 - The patient has serious progressive conditions that could lead to death within a year.|3 - The patient has serious progressive conditions that could lead to death within a year.|48
356|UK - The patient+s situation is unknown or unclear.|UK - The patient+s situation is unknown or unclear.|48
357|1 - Yes [ Go to M1050 ]|1 - Yes [ Go to M1050 ]|48
358|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this influenza season. [ Go to M1050 ]|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this i|48
359|1 - Received from another health care provider (e.g., physician)|1 - Received from another health care provider (e.g., physician)|48
360|2 - Received from your agency previously during this year+s flu season|2 - Received from your agency previously during this year+s flu season|48
361|3 - Offered and declined|3 - Offered and declined|48
362|4 - Assessed and determined to have medical contraindication(s)|4 - Assessed and determined to have medical contraindication(s)|48
363|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|48
364|6 - Inability to obtain vaccine due to declared shortage|6 - Inability to obtain vaccine due to declared shortage|48
365|1 - Yes [ Go to M1500 at TRN; Go to M1230 at DC ]|1 - Yes [ Go to M1500 at TRN; Go to M1230 at DC ]|48
366|1 - Patient has received PPV in the past|1 - Patient has received PPV in the past|48
367|2 - Offered and declined|2 - Offered and declined|48
368|3 - Assessed and determined to have medical contraindication(s)|3 - Assessed and determined to have medical contraindication(s)|48
369|4 - Not indicated; patient does not meet age/condition guidelines for PPV|4 - Not indicated; patient does not meet age/condition guidelines for PPV|48
370|5 - None of the above|5 - None of the above|48
371|0 - Adequate: hears normal conversation without difficulty.|0 - Adequate: hears normal conversation without difficulty.|48
372|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to increase volume or speak distinctly.|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to in|48
373|2 - Severely Impaired: absence of useful hearing.|2 - Severely Impaired: absence of useful hearing.|48
374|UK - Unable to assess hearing.|UK - Unable to assess hearing.|48
375|0 - Understands: clear comprehension without cues or repetitions.|0 - Understands: clear comprehension without cues or repetitions.|48
376|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Requires cues at times to understand.|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Req|48
377|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequently requires cues to understand.|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequentl|48
378|3 - Rarely/Never Understands|3 - Rarely/Never Understands|48
379|UK - Unable to assess understanding.|UK - Unable to assess understanding.|48
380|0 - No standardized assessment conducted|0 - No standardized assessment conducted|48
381|1 - Yes, and it does not indicate severe pain|1 - Yes, and it does not indicate severe pain|48
382|2 - Yes, and it indicates severe pain|2 - Yes, and it indicates severe pain|48
383|0 - Patient has no pain|0 - Patient has no pain|48
384|1 - Patient has pain that does not interfere with activity or movement|1 - Patient has pain that does not interfere with activity or movement|48
385|2 - Less often than daily|2 - Less often than daily|48
386|3 - Daily, but not constantly|3 - Daily, but not constantly|48
387|4 - All of the time|4 - All of the time|48
388|0 - No assessment conducted [ Go to M1306 ]|0 - No assessment conducted [ Go to M1306 ]|48
389|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc., without use of standardized tool|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc.,|48
390|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|48
391|0 - No [ Go to M1322]|0 - No [ Go to M1322]|48
392|0 v Newly epithelialized|0 v Newly epithelialized|48
393|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|48
394|2 - Yes, patient has observable stasis ulcers ONLY|2 - Yes, patient has observable stasis ulcers ONLY|48
395|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable dressing) [Go to M1340]|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable|48
396|0 - No [ Go to M1350 ]|0 - No [ Go to M1350 ]|48
397|1 - Yes, patient has at least one (observable) surgical wound|1 - Yes, patient has at least one (observable) surgical wound|48
398|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1350 ]|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1350 ]|48
399|0 - Patient is not short of breath|0 - Patient is not short of breath|48
400|3 - Continuous Bi-level positive airway pressure|3 - Continuous Bi-level positive airway pressure|48
401|0 - No [ Go to M2004 at TRN; Go to M1600 at DC ]|0 - No [ Go to M2004 at TRN; Go to M1600 at DC ]|48
402|2 - Not assessed [Go to M2004 at TRN; Go to M1600 at DC ]|2 - Not assessed [Go to M2004 at TRN; Go to M1600 at DC ]|48
403|NA - Patient does not have diagnosis of heart failure [Go to M2004 at TRN; Go to M1600 at DC]|NA - Patient does not have diagnosis of heart failure [Go to M2004 at TRN; Go to M1600 at DC]|48
404|0 - No action taken|0 - No action taken|48
405|1 - Patient+s physician (or other primary care practitioner) contacted the same day|1 - Patient+s physician (or other primary care practitioner) contacted the same day|48
406|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|48
407|3 - Implement physician-ordered patient-specific established parameters for treatment|3 - Implement physician-ordered patient-specific established parameters for treatment|48
408|4 - Patient education or other clinical interventions|4 - Patient education or other clinical interventions|48
409|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequency, telehealth, etc.)|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequ|48
410|1 - Occasional stress incontinence|1 - Occasional stress incontinence|48
411|2 - During the night only|2 - During the night only|48
412|3 - During the day only|3 - During the day only|48
413|4 - During the day and night|4 - During the day and night|48
414|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|48
415|0 - Able to manage toileting hygiene and clothing management without assistance.|0 - Able to manage toileting hygiene and clothing management without assistance.|48
416|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implements are laid out for the patient.|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implemen|48
417|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|48
418|3 - Patient depends entirely upon another person to maintain toileting hygiene.|3 - Patient depends entirely upon another person to maintain toileting hygiene.|48
419|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independent|48
420|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface|48
421|0 - No multi-factor falls risk assessment conducted.|0 - No multi-factor falls risk assessment conducted.|48
422|1 - Yes, and it does not indicate a risk for falls.|1 - Yes, and it does not indicate a risk for falls.|48
423|2 - Yes, and it indicates a risk for falls.|2 - Yes, and it indicates a risk for falls.|48
424|0 - Not assessed/reviewed [ Go to M2010 ]|0 - Not assessed/reviewed [ Go to M2010 ]|48
425|1 - No problems found during review [ Go to M2010 ]|1 - No problems found during review [ Go to M2010 ]|48
426|2 - Problems found during review|2 - Problems found during review|48
427|NA - Patient is not taking any medications [ Go to M2040 ]|NA - Patient is not taking any medications [ Go to M2040 ]|48
428|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special precautions associated with all high-risk medications|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special p|48
429|NA - Patient not taking any drugs|NA - Patient not taking any drugs|48
430|2 - Able to take medication(s) at the correct times if given reminders by another person at the appropriate times|2 - Able to take medication(s) at the correct times if given reminders by another person at the appr|48
431|3 - Unable to take medication unless administered by another person.|3 - Unable to take medication unless administered by another person.|48
432|1 - At least daily|1 - At least daily|48
433|2 - Three or more times per week|2 - Three or more times per week|48
434|3 - One to two times per week|3 - One to two times per week|48
435|4 - Received, but less often than weekly|4 - Received, but less often than weekly|48
436|5 - No assistance received|5 - No assistance received|48
437|0 - No [Go to M2400]|0 - No [Go to M2400]|48
438|1 - Yes, used hospital emergency department WITHOUT hospital admission|1 - Yes, used hospital emergency department WITHOUT hospital admission|48
439|2 - Yes, used hospital emergency department WITH hospital admission|2 - Yes, used hospital emergency department WITH hospital admission|48
440|UK - Unknown [Go to M2400]|UK - Unknown [Go to M2400]|48
441|2 - Injury caused by fall|2 - Injury caused by fall|48
442|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|48
443|4 - Other respiratory problem|4 - Other respiratory problem|48
444|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|48
445|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|48
446|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|48
447|8 - Other heart disease|8 - Other heart disease|48
448|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|48
449|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|48
450|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|48
451|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|48
452|13 - Urinary tract infection|13 - Urinary tract infection|48
453|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|48
454|15 - Wound infection or deterioration|15 - Wound infection or deterioration|48
455|16 - Uncontrolled pain|16 - Uncontrolled pain|48
456|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|48
457|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|48
458|19 - Other than above reasons|19 - Other than above reasons|48
459|2 - Patient remained in the community (with formal assistive services)|2 - Patient remained in the community (with formal assistive services)|48
460|3 - Patient transferred to a noninstitutional hospice|3 - Patient transferred to a noninstitutional hospice|48
461|4 - Unknown because patient moved to a geographic location not served by this agency|4 - Unknown because patient moved to a geographic location not served by this agency|48
462|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|48
463|4 - Other respiratory problem|4 - Other respiratory problem|48
464|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|48
465|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|48
466|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|48
467|8 - Other heart disease|8 - Other heart disease|48
468|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|48
469|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|48
470|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|48
471|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|48
472|13 - Urinary tract infection|13 - Urinary tract infection|48
473|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|48
474|15 - Wound infection or deterioration|15 - Wound infection or deterioration|48
475|16 - Uncontrolled pain|16 - Uncontrolled pain|48
476|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|48
477|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|48
478|19 - Scheduled treatment or procedure|19 - Scheduled treatment or procedure|48
479|20 - Other than above reasons|20 - Other than above reasons|48
480|UK - Reason unknown [Go to M0903]|UK - Reason unknown [Go to M0903]|48
482|01 - Patient lives alone around the clock|01 - Patient lives alone around the clock|48
483|02 - Patient lives alone regular daytime|02 - Patient lives alone regular daytime|48
484|03 - Patient lives alone regular nighttime|03 - Patient lives alone regular nighttime|48
485|04 - Patient lives alone occassional/short term assistance|04 - Patient lives alone occassional/short term assistance|48
486|05 - Patient lives alone no assisstance available|05 - Patient lives alone no assisstance available|48
487|06 - Patient lives with other person(s) in the home around the clock|06 - Patient lives with other person(s) in the home around the clock|48
488|07 - Patient lives with other person(s) in the home regular daytime|07 - Patient lives with other person(s) in the home regular daytime|48
489|08 - Patient lives with other person(s) in the home regular nighttime|08 - Patient lives with other person(s) in the home regular nighttime|48
490|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|48
491|10 - Patient lives with other person(s) in the home no assistance available|10 - Patient lives with other person(s) in the home no assistance available|48
492|1 - Was present at the most recent SOC/ROC assessment|1 - Was present at the most recent SOC/ROC assessment|48
493|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|48
494|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|48
495|0 - Newly epithelialized|0 - Newly epithelialized|48
496|0 - No [ Go to M1340 ]|0 - No [ Go to M1340 ]|48
498|0 - Independent|0 - Independent|48
499|1 - Needed Some Help|1 - Needed Some Help|48
500|2 - Dependent|2 - Dependent|48
502|0 - No assistance needed in this area|0 - No assistance needed in this area|48
503|1 - Caregiver(s) currently provide assistance|1 - Caregiver(s) currently provide assistance|48
504|2 - Caregiver(s) need training/ supportive services to provide assistance|2 - Caregiver(s) need training/ supportive services to provide assistance|48
505|3 - Caregiver(s) not likely to provide assistance|3 - Caregiver(s) not likely to provide assistance|48
506|4 - Unclear if Caregiver(s) will provide assistance|4 - Unclear if Caregiver(s) will provide assistance|48
507|5 - Assistance needed, but no Caregiver(s) available|5 - Assistance needed, but no Caregiver(s) available|48
508|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will use standardized clinical guidelines accessible for all care providers to reference|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will|48
510|NA - Patient is not assessed to be at risk for falls|NA - Patient is not assessed to be at risk for falls|48
511|NA - Patient has no diagnosis or symptoms of depression|NA - Patient has no diagnosis or symptoms of depression|48
512|NA - No pain identified|NA - No pain identified|48
513|NA - Patient is not assessed to be at risk for pressure ulcers|NA - Patient is not assessed to be at risk for pressure ulcers|48
514|NA - Patient has no pressure ulcers with need for moist wound healing|NA - Patient has no pressure ulcers with need for moist wound healing|48
515|1 - Long-term nursing facility (NF)|1 - Long-term nursing facility (NF)|48
516|2 - Skilled nursing facility (SNF / TCU)|2 - Skilled nursing facility (SNF / TCU)|48
517|3 - Short stay acute hospital (IPP S)|3 - Short stay acute hospital (IPP S)|48
518|4 - Long-term care hospital (LTCH)|4 - Long-term care hospital (LTCH)|48
519|5 - Inpatient rehabilitation hospital or unit (IRF)|5 - Inpatient rehabilitation hospital or unit (IRF)|48
520|6 - Psychiatric hospital or unit|6 - Psychiatric hospital or unit|48
521|7 - Other|7 - Other|48
522|NA - Patient was not discharged from an inpatient facility [Goto M1016]|NA - Patient was not discharged from an inpatient facility [Goto M1016]|48
523|6 - Unable to participate effectively in bathing and is bathed totally by another person|6 - Unable to participate effectively in bathing and is bathed totally by another person|48
524|4 - Chairfast, unable to ambulate but is able to wheel self independently.|4 - Chairfast, unable to ambulate but is able to wheel self independently.|48
525|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask patient: "Over the last two weeks, how often have you been bothered by any of the following problems")|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask|48
526|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluation for depression.|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluat|48
527|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet criteria for further evaluation for depression.|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet|48
528|0 - Not at all  0 - 1 day|0 - Not at all  0 - 1 day|48
529|1 - Several days  2 - 6 days|1 - Several days  2 - 6 days|48
530|2 - More than half of the days  7 - 11 days|2 - More than half of the days  7 - 11 days|48
531|3 - Nearly every day  12 - 14 days|3 - Nearly every day  12 - 14 days|48
532|NA - N/A  Unable to respond|NA - N/A  Unable to respond|48
533|2 - Able to take medication(s) at the correct times if given reminders by another person based on the frequency of the injection|2 - Able to take medication(s) at the correct times if given reminders by another person based on th|48
534|3 - Unable to take injectable medication unless administered by another person.|3 - Unable to take injectable medication unless administered by another person.|48
547|NA - No clinically significant medication issues identified since the previous OASIS assessment|NA - No clinically significant medication issues identified since the previous OASIS assessment|48
552|1 - Hospital [ Go to M2430 ]|1 - Hospital [ Go to M2430 ]|48
553|2 - Rehabilitation facility [ Go to M0903 ]|2 - Rehabilitation facility [ Go to M0903 ]|48
554|3 - Nursing home [ Go to M2440 ]|3 - Nursing home [ Go to M2440 ]|48
555|4 - Hospice [ Go to M0903 ]|4 - Hospice [ Go to M0903 ]|48
2|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; OR (b) Is physically, cognitively, and mentally able to prepare light meals on a regular basis but has not routinely performed light meal preparation in the past (i.e., prior to this home care admission).|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; O|49
3|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and mentally able to perform all housekeeping tasks .|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and menta|49
4|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and mentally able to do laundry and access facilities.|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and menta|49
5|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying packages OR b) Physically, cognitively, and mentally able to take care of shopping, but has not done shopping in the past (i.e., prior to this home care admission).|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying|49
6|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|49
7|0 - Able to dial numbers and answer calls appropriately and as desired.|0 - Able to dial numbers and answer calls appropriately and as desired.|49
8|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body without assistance.|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body|49
9|0 - Able to get to and from the toilet and transfer independently with or without a device.|0 - Able to get to and from the toilet and transfer independently with or without a device.|49
10|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|49
11|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible public bus.|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible p|49
12|0 - Able to independently feed self.|0 - Able to independently feed self.|49
13|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|49
14|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct times.|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct ti|49
15|0 - Able to independently transfer.|0 - Able to independently transfer.|49
16|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without rail|49
17|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings|49
18|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|49
19|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions independently.|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions indep|49
20|0 - Asymptomatic, no treatment needed at this time|0 - Asymptomatic, no treatment needed at this time|49
21|0 - Caregiver manages all tasks related to equipment completely independently.|0 - Caregiver manages all tasks related to equipment completely independently.|49
22|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations with no observable impairment.|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations w|49
23|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|49
24|0 - Life expectancy is greater than 6 months|0 - Life expectancy is greater than 6 months|49
25|0 - Never|0 - Never|49
26|0 - Patient is not short of breath|0 - Patient is not short of breath|49
27|0 - No|0 - No|49
28|0 - No emergent care services|0 - No emergent care services|49
29|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [Goto M1620]|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [Goto M1620]|49
30|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and extended or abstract conversation.|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and exte|49
31|0 - No one person|0 - No one person|49
32|0 - None of the time|0 - None of the time|49
33|0 - None, no charge for current services|0 - None, no charge for current services|49
34|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|49
35|0 - Patient does NOT have an ostomy for bowel elimination.|0 - Patient does NOT have an ostomy for bowel elimination.|49
36|0 - Patient has no pain|0 - Patient has no pain|49
37|0 - Patient manages all tasks related to equipment completely independently.|0 - Patient manages all tasks related to equipment completely independently.|49
38|0 - Poor:  little or no recovery is expected and/or further decline is imminent|0 - Poor:  little or no recovery is expected and/or further decline is imminent|49
39|0 - Timed-voiding defers incontinence|0 - Timed-voiding defers incontinence|49
40|0 - Very rarely or never has bowel incontinence|0 - Very rarely or never has bowel incontinence|49
41|0 - Zero|0 - Zero|49
42|00 - No|00 - No|49
43|01 - Yes|01 - Yes|49
44|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or mental limitations, needs assistance with heavy laundry.|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or|49
45|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the patient.|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the|49
46|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|49
47|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or supervision from another person OR c) a liquid, pureed or ground meat diet.|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or su|49
48|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|49
49|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|49
50|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independently.|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independe|49
51|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only when assisted or accompanied by another person.|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only w|49
52|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepa|49
53|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance by another person OR b) given daily reminders.|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance b|49
54|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advan|49
55|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advan|49
56|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for the deaf) and call essential numbers.|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for t|49
57|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|49
58|1 - American Indian or Alaska Native|1 - American Indian or Alaska Native|49
59|1 - Depressed mood (e.g., feeling sad, tearful)|1 - Depressed mood (e.g., feeling sad, tearful)|49
60|1 - During the night only|1 - During the night only|49
61|1 - Fully granulating|1 - Fully granulating|49
62|1 - Good/Fair:  partial to full recovery is expected|1 - Good/Fair:  partial to full recovery is expected|49
63|1 - Good:  marked improvement in functional status is expected|1 - Good:  marked improvement in functional status is expected|49
64|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|49
65|1 - Smoking|1 - Smoking|49
66|1 - Hospital [ Go to M2430 ]|1 - Hospital [ Go to M2430 ]|49
67|1 - Hospital emergency room (includes 23-hour holding)|1 - Hospital emergency room (includes 23-hour holding)|49
68|1 - Hospitalization for EMERGENT (unscheduled) care|1 - Hospitalization for EMERGENT (unscheduled) care|49
69|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepared solutions), patient is able to manage all other aspects of equipment.|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepar|49
70|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|49
71|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|49
72|1 - In new or complex situations only|1 - In new or complex situations only|49
73|1 - Intravenous or infusion therapy (excludes TPN)|1 - Intravenous or infusion therapy (excludes TPN)|49
74|1 - Less often than daily|1 - Less often than daily|49
75|1 - Less than once a month|1 - Less than once a month|49
76|1 - Less than once weekly|1 - Less than once weekly|49
77|1 - Life expectancy is 6 months or fewer|1 - Life expectancy is 6 months or fewer|49
78|1 - Lives alone|1 - Lives alone|49
79|1 - Male|1 - Male|49
80|1 - Medicare (traditional fee-for-service)|1 - Medicare (traditional fee-for-service)|49
81|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of past 24 hours, significant memory loss so that supervision is required|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of pas|49
82|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors in word choice, grammar or speech intelligibility, needs minimal prompting or assistance).|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors i|49
83|1 - No assistance or services received|1 - No assistance or services received|49
84|1 - One|1 - One|49
85|1 - Oxygen (intermittent or continuous)|1 - Oxygen (intermittent or continuous)|49
86|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, and the surrounding layout, can count fingers at arm's length.|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, a|49
87|1 - Patient is incontinent|1 - Patient is incontinent|49
88|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|49
89|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical or treatment regimen.|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical|49
90|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient/couple/significant other)|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient|49
91|1 - Relatives, friends, or neighbors living outside the home|1 - Relatives, friends, or neighbors living outside the home|49
92|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions.|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions|49
93|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independentl|49
94|1 - Several times during day and night|1 - Several times during day and night|49
95|1 - Spouse or significant other|1 - Spouse or significant other|49
96|1 - Stage 1|1 - Stage 1|49
97|1 - Start of care - further visits planned|1 - Start of care - further visits planned|49
98|1 - Symptoms well controlled with current therapy|1 - Symptoms well controlled with current therapy|49
99|1 - Therapy services|1 - Therapy services|49
100|1 - Able to transfer with minimal human assistance or with use of an assistive device.|1 - Able to transfer with minimal human assistance or with use of an assistive device.|49
101|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitations.|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitatio|49
102|1 - Urinary incontinence|1 - Urinary incontinence|49
103|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and transfer.|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and|49
104|1 - When walking more than 20 feet, climbing stairs|1 - When walking more than 20 feet, climbing stairs|49
105|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary conversation. May need occasional repetition, extra time, or louder voice.|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary c|49
106|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting in and out of tub/shower|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting|49
107|1 - Yes|1 - Yes|49
108|1-RN|1-RN|49
109|10 - Discharge from agency - no visits completed after start/resumption of care assessment|10 - Discharge from agency - no visits completed after start/resumption of care assessment|49
110|10 - Scheduled surgical procedure|10 - Scheduled surgical procedure|49
111|10 - Self-pay|10 - Self-pay|49
112|11 - Other|11 - Other|49
113|11 - Urinary tract infection|11 - Urinary tract infection|49
114|12 - IV catheter-related infection|12 - IV catheter-related infection|49
115|13 - Deep vein thrombosis, pulmonary embolus|13 - Deep vein thrombosis, pulmonary embolus|49
116|14 - Uncontrolled pain|14 - Uncontrolled pain|49
117|15 - Psychotic episode|15 - Psychotic episode|49
118|16 - Other than above reasons|16 - Other than above reasons|49
119|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing calls.|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing|49
120|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another person.|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another pers|49
121|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface a|49
122|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for intermittent supervision or encouragement or reminders, OR (b) to get in and out of the shower or tub, OR (c) for washing difficult to reach areas.|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for inter|49
123|2 - Asian|2 - Asian|49
124|2 - Caregiver requires considerable assistance from another person to manage equipment, but independently completes significant portions of task.|2 - Caregiver requires considerable assistance from another person to manage equipment, but independ|49
125|2 - Daily, but not constantly|2 - Daily, but not constantly|49
126|2 - Daughter or son|2 - Daughter or son|49
127|2 - Doctor's office emergency visit/house call|2 - Doctor's office emergency visit/house call|49
128|2 - During the day and night|2 - During the day and night|49
129|2 - Early/partial granulation|2 - Early/partial granulation|49
130|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors in word choice, organization or speech intelligibility). Speaks in phrases or short sentences.|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors|49
131|2 - Family member's residence|2 - Family member's residence|49
132|2 - Female|2 - Female|49
133|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conversation, needs frequent prompting or assistance.|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conver|49
134|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|49
135|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|49
136|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately stop activities, jeopardizes safety through actions|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately st|49
137|2 - Indwelling/suprapubic catheter|2 - Indwelling/suprapubic catheter|49
138|2 - Injury caused by fall or accident at home|2 - Injury caused by fall or accident at home|49
139|2 - Medicare (HMO/managed care/Advantage plan)|2 - Medicare (HMO/managed care/Advantage plan)|49
140|2 - Nausea, dehydration, malnutrition, constipation, impaction|2 - Nausea, dehydration, malnutrition, constipation, impaction|49
141|2 - Obesity|2 - Obesity|49
142|2 - On awakening or at night only|2 - On awakening or at night only|49
143|2 - Once a month|2 - Once a month|49
144|2 - One to three times weekly|2 - One to three times weekly|49
145|2 - Parenteral nutrition (TPN or lipids)|2 - Parenteral nutrition (TPN or lipids)|49
146|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic) [ Go to M1620 ]|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic) [ Go|49
147|2 - Patient requires considerable assistance from another person to manage equipment, but independently completes portions of the task.|2 - Patient requires considerable assistance from another person to manage equipment, but independen|49
148|2 - Patient transferred to a noninstitutional hospice|2 - Patient transferred to a noninstitutional hospice|49
149|2 - Person residing in the home (EXCLUDING paid help)|2 - Person residing in the home (EXCLUDING paid help)|49
150|2 - Rehabilitation facility [ Go to M0903 ]|2 - Rehabilitation facility [ Go to M0903 ]|49
151|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifting of attention) or consistently requires low stimulus environment due to distractibility.|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifti|49
152|2 - Respite care|2 - Respite care|49
153|2 - Sense of failure or self reproach|2 - Sense of failure or self reproach|49
154|2 - Several times during day|2 - Several times during day|49
155|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonresponsive.|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonrespons|49
156|2 - Someone must assist the patient to groom self.|2 - Someone must assist the patient to groom self.|49
157|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|49
158|2 - Someone must help the patient put on upper body clothing.|2 - Someone must help the patient put on upper body clothing.|49
159|2 - Stage 2|2 - Stage 2|49
160|2 - Start of care - no further visits planned|2 - Start of care - no further visits planned|49
161|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitoring|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitori|49
162|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment regimen.|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment re|49
163|2 - Two|2 - Two|49
164|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistance due to cognitive or mental limitation.|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistanc|49
165|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|49
166|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assistance).|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assis|49
167|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home delivery.|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home deli|49
168|2 - Unable to prepare any light meals or reheat any delivered meals.|2 - Unable to prepare any light meals or reheat any delivered meals.|49
169|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|49
170|2 - UNABLE to take injectable medications unless administered by someone else.|2 - UNABLE to take injectable medications unless administered by someone else.|49
171|2 - UNABLE to take medication unless administered by someone else.|2 - UNABLE to take medication unless administered by someone else.|49
172|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|49
173|2 - Ventilator (continually or at night)|2 - Ventilator (continually or at night)|49
174|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less than 20 feet)|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less th|49
175|2 - With spouse or significant other|2 - With spouse or significant other|49
176|2 - Yes, assistance or services provided by family or friends|2 - Yes, assistance or services provided by family or friends|49
177|2-PT|2-PT|49
178|3 - Able to answer the telephone only some of the time or is able to carry on only a limited conversation.|3 - Able to answer the telephone only some of the time or is able to carry on only a limited convers|49
179|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube or gastrostomy.|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube|49
180|3 - Alcohol dependency|3 - Alcohol dependency|49
181|3 - All of the time|3 - All of the time|49
182|3 - Black or African-American|3 - Black or African-American|49
183|3 - Boarding home or rented room|3 - Boarding home or rented room|49
184|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment, clean/store/dispose of equipment or supplies).|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment,|49
185|3 -Able to walk only with the supervision or assistance of another person at all times.|3 -Able to walk only with the supervision or assistance of another person at all times.|49
186|3 - Continuous / Bi-level positive airway pressure|3 - Continuous / Bi-level positive airway pressure|49
187|3 - During the day and evening, but not constantly|3 - During the day and evening, but not constantly|49
188|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the alimentary canal)|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the|49
189|3 - Environmental support (e.g., housing, home maintenance)|3 - Environmental support (e.g., housing, home maintenance)|49
190|3 - Four to six times weekly|3 - Four to six times weekly|49
191|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessing by listener.  Speech limited to single words or short phrases.|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessin|49
192|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires multiple repetitions, restatements, demonstrations, additional time.|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires m|49
193|3 - Hopelessness|3 - Hopelessness|49
194|3 - Hospice care|3 - Hospice care|49
195|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|49
196|3 - Injury caused by fall or accident at home|3 - Injury caused by fall or accident at home|49
197|3 - Intractable pain|3 - Intractable pain|49
198|3 - Medicaid (traditional fee-for-service)|3 - Medicaid (traditional fee-for-service)|49
199|3 - Needs someone to do all shopping and errands.|3 - Needs someone to do all shopping and errands.|49
200|3 - Not healing|3 - Not healing|49
201|3 - Nursing home [ Go to M2440 ]|3 - Nursing home [ Go to M2440 ]|49
202|3 - Once daily|3 - Once daily|49
203|3 - Other family member|3 - Other family member|49
204|3 - Outpatient department/clinic emergency (includes urgicenter sites)|3 - Outpatient department/clinic emergency (includes urgicenter sites)|49
205|3 - Paid help|3 - Paid help|49
206|3 - Able to participate in bathing self in shower or tub, but requires presence of another person throughout the bath for assistance or supervision.|3 - Able to participate in bathing self in shower or tub, but requires presence of another person th|49
207|3 - Patient depends entirely upon another person to dress lower body.|3 - Patient depends entirely upon another person to dress lower body.|49
208|3 - Patient depends entirely upon another person to dress the upper body.|3 - Patient depends entirely upon another person to dress the upper body.|49
209|3 - Patient depends entirely upon someone else for grooming needs.|3 - Patient depends entirely upon someone else for grooming needs.|49
210|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone else to manage the equipment.|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone|49
211|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable to shift attention and recall directions more than half the time.|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable|49
212|3 - Respiratory problems (SOB, infection, obstruction)|3 - Respiratory problems (SOB, infection, obstruction)|49
213|3 - Resumption of care (after inpatient stay)|3 - Resumption of care (after inpatient stay)|49
214|3 - Several times each month|3 - Several times each month|49
215|3 - Skilled Nursing Facility|3 - Skilled Nursing Facility|49
216|3 - Stage 3|3 - Stage 3|49
217|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|49
218|3 - Three|3 - Three|49
219|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person throughout the process.|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person through|49
220|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal independently.|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal indep|49
221|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person.|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person|49
222|3 - Unknown because patient moved to a geographic location not served by this agency|3 - Unknown because patient moved to a geographic location not served by this agency|49
223|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|49
224|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|49
225|3 - With other family member|3 - With other family member|49
226|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home health services, homemaker assistance, transportation assistance, assisted living, board and care)|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home h|49
227|3-SLP/ST|3-SLP/ST|49
228|4 - At rest (during day or night)|4 - At rest (during day or night)|49
229|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|49
230|4 - Board and care or assisted living facility|4 - Board and care or assisted living facility|49
231|4 - Caregiver is completely dependent on someone else to manage all equipment.|4 - Caregiver is completely dependent on someone else to manage all equipment.|49
232|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|49
233|4 - Constantly|4 - Constantly|49
234|4 - Drug dependency|4 - Drug dependency|49
235|4 - Four or more|4 - Four or more|49
236|4 - Friend or neighbor or community or church member|4 - Friend or neighbor or community or church member|49
237|4 - Hispanic or Latino|4 - Hispanic or Latino|49
238|4 - Hospice [ Go to M0903 ]|4 - Hospice [ Go to M0903 ]|49
239|4 - Impaired decision-making|4 - Impaired decision-making|49
240|4 - Is totally dependent in toileting.|4 - Is totally dependent in toileting.|49
241|4 - Medicaid (HMO/managed care)|4 - Medicaid (HMO/managed care)|49
242|4 - None of the above|4 - None of the above|49
243|4 - Nursing home|4 - Nursing home|49
244|4 - On a daily basis|4 - On a daily basis|49
245|4 - Patient is completely dependent on someone else to manage all equipment.|4 - Patient is completely dependent on someone else to manage all equipment.|49
246|4 - Permanent placement|4 - Permanent placement|49
247|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, punches, dangerous maneuvers w/ wheelchair or other objects)|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, pu|49
248|4 - Psychosocial support (e.g., socialization, companionship, recreation)|4 - Psychosocial support (e.g., socialization, companionship, recreation)|49
249|4 - Recertification (follow-up) reassessment|4 - Recertification (follow-up) reassessment|49
250|4 - Recurrent thoughts of death|4 - Recurrent thoughts of death|49
251|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruction)|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruc|49
252|4 - Several times a week|4 - Several times a week|49
253|4 - Stage 4|4 - Stage 4|49
254|4 - Symptoms poorly controlled, history of re-hospitalizations|4 - Symptoms poorly controlled, history of re-hospitalizations|49
255|4 - Three or more times per week|4 - Three or more times per week|49
256|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetative state, or delirium.|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetati|49
257|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|49
258|4 - Unable to effectively participate in any housekeeping tasks.|4 - Unable to effectively participate in any housekeeping tasks.|49
259|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or unresponsive (e.g., speech is nonsensical or unintelligible).|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or u|49
260|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonresponsive.|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonr|49
261|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostomy.|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostom|49
262|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of devices at the sink, in chair, or on commode|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of|49
263|4 - With a friend|4 - With a friend|49
264|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|49
265|4-OT|4-OT|49
266|5 - Advocates or facilitates patient's participation in appropriate medical care|5 - Advocates or facilitates patient's participation in appropriate medical care|49
267|5 - At least daily|5 - At least daily|49
268|6 - Bedfast, unable to ambulate or be up in a chair.|6 - Bedfast, unable to ambulate or be up in a chair.|49
269|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|49
270|5 - Disruptive or socially inappropriate behavior|5 - Disruptive or socially inappropriate behavior|49
271|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|49
272|5 - Hypo/Hyperglycemia, diabetes out of control|5 - Hypo/Hyperglycemia, diabetes out of control|49
273|5 - More often than once daily|5 - More often than once daily|49
274|5 - Native Hawaiian or Pacific Islander|5 - Native Hawaiian or Pacific Islander|49
275|5 - None of the above|5 - None of the above|49
276|5 - One to two times per week|5 - One to two times per week|49
277|5 - Other|5 - Other|49
278|5 - Other follow-up|5 - Other follow-up|49
279|5 - Paid help|5 - Paid help|49
280|5 - Patient nonresponsive or unable to speak.|5 - Patient nonresponsive or unable to speak.|49
281|5 - Thoughts of suicide|5 - Thoughts of suicide|49
282|5 - Totally unable to use the telephone.|5 - Totally unable to use the telephone.|49
283|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|49
284|5 - Unable to take in nutrients orally or by tube feeding.|5 - Unable to take in nutrients orally or by tube feeding.|49
285|5 - Unsafe for care at home|5 - Unsafe for care at home|49
286|5 - With paid help (other than home care agency staff)|5 - With paid help (other than home care agency staff)|49
287|5 - Workers' compensation|5 - Workers' compensation|49
288|5 - Wound infection, deteriorating wound status, new lesion/ulcer|5 - Wound infection, deteriorating wound status, new lesion/ulcer|49
289|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|49
290|6 - Delusional, hallucinatory, or paranoid behavior|6 - Delusional, hallucinatory, or paranoid behavior|49
291|6 - Financial agent, power of attorney, or conservator of finance|6 - Financial agent, power of attorney, or conservator of finance|49
292|6 - GI bleeding, obstruction|6 - GI bleeding, obstruction|49
293|6 - Less often than weekly|6 - Less often than weekly|49
294|6 - Memory loss to the extent that supervision required|6 - Memory loss to the extent that supervision required|49
295|6 - None of the above feelings observed or reported|6 - None of the above feelings observed or reported|49
296|6 - Other|6 - Other|49
297|6 - Title programs (e.g., Title III, V, or XX)|6 - Title programs (e.g., Title III, V, or XX)|49
298|6 - Transferred to an inpatient facility - patient not discharged from agency|6 - Transferred to an inpatient facility - patient not discharged from agency|49
299|6 - White|6 - White|49
300|6 - With other than above|6 - With other than above|49
301|7 - Exacerbation of CHF, fluid overload, heart failure|7 - Exacerbation of CHF, fluid overload, heart failure|49
302|7 - Health care agent, conservator of person, or medical power of attorney|7 - Health care agent, conservator of person, or medical power of attorney|49
303|7 - Hypo/Hyperglycemia, diabetes out of control|7 - Hypo/Hyperglycemia, diabetes out of control|49
304|7 - None of the above|7 - None of the above|49
305|7 - None of the above behaviors demonstrated|7 - None of the above behaviors demonstrated|49
306|7 - Other government (e.g., TriCare, VA, etc.)|7 - Other government (e.g., TriCare, VA, etc.)|49
307|7 - Transferred to an inpatient facility - patient discharged from agency|7 - Transferred to an inpatient facility - patient discharged from agency|49
308|8 - Death at home|8 - Death at home|49
309|8 - GI bleeding, obstruction|8 - GI bleeding, obstruction|49
310|8 - Myocardial infarction, stroke|8 - Myocardial infarction, stroke|49
311|8 - Private insurance|8 - Private insurance|49
312|9 - Chemotherapy|9 - Chemotherapy|49
313|9 - Discharge from agency|9 - Discharge from agency|49
314|9 - Other than above reasons|9 - Other than above reasons|49
315|9 - Private HMO/managed care|9 - Private HMO/managed care|49
316|NA - No caregiver|NA - No caregiver|49
317|NA - No equipment of this type used in care.|NA - No equipment of this type used in care.|49
318|NA - No inhalant/mist medications prescribed.|NA - No inhalant/mist medications prescribed.|49
319|NA - No injectable medications prescribed.|NA - No injectable medications prescribed.|49
320|NA - No inpatient facility admission|NA - No inpatient facility admission|49
321|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|49
322|NA - No Medicaid|NA - No Medicaid|49
323|NA - No Medicare|NA - No Medicare|49
324|NA - No observable pressure ulcer|NA - No observable pressure ulcer|49
325|NA - No observable stasis ulcer|NA - No observable stasis ulcer|49
326|NA - No observable surgical wound|NA - No observable surgical wound|49
327|NA - No oral medications prescribed.|NA - No oral medications prescribed.|49
328|NA - Not applicable|NA - Not applicable|49
329|NA - Patient does not have a telephone.|NA - Patient does not have a telephone.|49
330|NA - Patient has ostomy for bowel elimination|NA - Patient has ostomy for bowel elimination|49
331|NA - Patient nonresponsive|NA - Patient nonresponsive|49
332|NA - Patient on prophylactic treatment|NA - Patient on prophylactic treatment|49
333|NA - Patient was not discharged from an inpatient facility [Go to M1016 ]|NA - Patient was not discharged from an inpatient facility [Go to M1016 ]|49
334|UK - Other unknown|UK - Other unknown|49
335|UK - Reason unknown|UK - Reason unknown|49
336|UK - Unknown|UK - Unknown|49
337|UK - Unknown or Not Available|UK - Unknown or Not Available|49
341|01 - Early|01 - Early|49
342|02 - Late|02 - Late|49
343|NA - Not Applicable. No case mix group defined for this assessment.|NA - Not Applicable. No case mix group defined for this assessment.|49
344|NA - No case mix group defined by this assessment.|NA - No case mix group defined by this assessment.|49
345|1 - Recent decline in mental, emotional, or behavioral status|1 - Recent decline in mental, emotional, or behavioral status|49
346|2 - Multiple hospitalizations (2 or more) in the past 12 months|2 - Multiple hospitalizations (2 or more) in the past 12 months|49
347|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|49
348|4 - Taking five or more medications|4 - Taking five or more medications|49
349|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|49
350|6 - Other|6 - Other|49
351|7 - None of the above|7 - None of the above|49
352|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond tho|49
353|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable without heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable wi|49
354|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious complications and death.|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious compl|49
355|3 - The patient has serious progressive conditions that could lead to death within a year.|3 - The patient has serious progressive conditions that could lead to death within a year.|49
356|UK - The patient+s situation is unknown or unclear.|UK - The patient+s situation is unknown or unclear.|49
357|0 - No [ Go to M1051 ]|0 - No [ Go to M1051 ]|49
358|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this influenza season. [ Go to M1050 ]|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this i|49
359|1 - Received from another health care provider (e.g., physician)|1 - Received from another health care provider (e.g., physician)|49
360|2 - Received from your agency previously during this year+s flu season|2 - Received from your agency previously during this year+s flu season|49
361|3 - Offered and declined|3 - Offered and declined|49
362|4 - Assessed and determined to have medical contraindication(s)|4 - Assessed and determined to have medical contraindication(s)|49
363|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|49
364|6 - Inability to obtain vaccine due to declared shortage|6 - Inability to obtain vaccine due to declared shortage|49
365|1 - Yes [ Go to M1500 at TRN; Go to M1230 at DC ]|1 - Yes [ Go to M1500 at TRN; Go to M1230 at DC ]|49
366|1 - Patient has received PPV in the past|1 - Patient has received PPV in the past|49
367|2 - Offered and declined|2 - Offered and declined|49
368|3 - Assessed and determined to have medical contraindication(s)|3 - Assessed and determined to have medical contraindication(s)|49
369|4 - Not indicated; patient does not meet age/condition guidelines for PPV|4 - Not indicated; patient does not meet age/condition guidelines for PPV|49
370|5 - None of the above|5 - None of the above|49
371|0 - Adequate: hears normal conversation without difficulty.|0 - Adequate: hears normal conversation without difficulty.|49
372|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to increase volume or speak distinctly.|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to in|49
373|2 - Severely Impaired: absence of useful hearing.|2 - Severely Impaired: absence of useful hearing.|49
374|UK - Unable to assess hearing.|UK - Unable to assess hearing.|49
375|0 - Understands: clear comprehension without cues or repetitions.|0 - Understands: clear comprehension without cues or repetitions.|49
376|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Requires cues at times to understand.|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Req|49
377|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequently requires cues to understand.|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequentl|49
378|3 - Rarely/Never Understands|3 - Rarely/Never Understands|49
379|UK - Unable to assess understanding.|UK - Unable to assess understanding.|49
380|0 - No standardized assessment conducted|0 - No standardized assessment conducted|49
381|1 - Yes, and it does not indicate severe pain|1 - Yes, and it does not indicate severe pain|49
382|2 - Yes, and it indicates severe pain|2 - Yes, and it indicates severe pain|49
383|0 - Patient has no pain|0 - Patient has no pain|49
384|1 - Patient has pain that does not interfere with activity or movement|1 - Patient has pain that does not interfere with activity or movement|49
385|2 - Less often than daily|2 - Less often than daily|49
386|3 - Daily, but not constantly|3 - Daily, but not constantly|49
387|4 - All of the time|4 - All of the time|49
388|0 - No assessment conducted [ Go to M1306 ]|0 - No assessment conducted [ Go to M1306 ]|49
389|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc., without use of standardized tool|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc.,|49
390|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|49
391|0 - No [ Go to M1322]|0 - No [ Go to M1322]|49
392|0 v Newly epithelialized|0 v Newly epithelialized|49
393|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|49
394|2 - Yes, patient has observable stasis ulcers ONLY|2 - Yes, patient has observable stasis ulcers ONLY|49
395|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable dressing) [Go to M1340]|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable|49
396|0 - No [ Go to M1350 ]|0 - No [ Go to M1350 ]|49
397|1 - Yes, patient has at least one (observable) surgical wound|1 - Yes, patient has at least one (observable) surgical wound|49
398|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1350 ]|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1350 ]|49
399|0 - Patient is not short of breath|0 - Patient is not short of breath|49
400|3 - Continuous Bi-level positive airway pressure|3 - Continuous Bi-level positive airway pressure|49
401|0 - No [ Go to M1732 at TRN; Go to M1600 at DC ]|0 - No [ Go to M1732 at TRN; Go to M1600 at DC ]|49
402|2 - Not assessed [Go to M1732 at TRN; Go to M1600 at DC ]|2 - Not assessed [Go to M1732 at TRN; Go to M1600 at DC ]|49
403|NA - Patient does not have diagnosis of heart failure [Go to M2004 at TRN; Go to M1600 at DC]|NA - Patient does not have diagnosis of heart failure [Go to M2004 at TRN; Go to M1600 at DC]|49
404|0 - No action taken|0 - No action taken|49
405|1 - Patient+s physician (or other primary care practitioner) contacted the same day|1 - Patient+s physician (or other primary care practitioner) contacted the same day|49
406|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|49
407|3 - Implement physician-ordered patient-specific established parameters for treatment|3 - Implement physician-ordered patient-specific established parameters for treatment|49
408|4 - Patient education or other clinical interventions|4 - Patient education or other clinical interventions|49
409|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequency, telehealth, etc.)|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequ|49
410|1 - Occasional stress incontinence|1 - Occasional stress incontinence|49
411|2 - During the night only|2 - During the night only|49
412|3 - During the day only|3 - During the day only|49
413|4 - During the day and night|4 - During the day and night|49
414|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|49
415|0 - Able to manage toileting hygiene and clothing management without assistance.|0 - Able to manage toileting hygiene and clothing management without assistance.|49
416|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implements are laid out for the patient.|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implemen|49
417|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|49
418|3 - Patient depends entirely upon another person to maintain toileting hygiene.|3 - Patient depends entirely upon another person to maintain toileting hygiene.|49
419|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independent|49
420|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface|49
421|0 - No multi-factor falls risk assessment conducted.|0 - No multi-factor falls risk assessment conducted.|49
422|1 - Yes, and it does not indicate a risk for falls.|1 - Yes, and it does not indicate a risk for falls.|49
423|2 - Yes, and it indicates a risk for falls.|2 - Yes, and it indicates a risk for falls.|49
424|0 - Not assessed/reviewed [ Go to M2010 ]|0 - Not assessed/reviewed [ Go to M2010 ]|49
425|1 - No problems found during review [ Go to M2010 ]|1 - No problems found during review [ Go to M2010 ]|49
426|2 - Problems found during review|2 - Problems found during review|49
427|NA - Patient is not taking any medications [ Go to M2040 ]|NA - Patient is not taking any medications [ Go to M2040 ]|49
428|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special precautions associated with all high-risk medications|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special p|49
429|NA - Patient not taking any drugs|NA - Patient not taking any drugs|49
430|2 - Able to take medication(s) at the correct times if given reminders by another person at the appropriate times|2 - Able to take medication(s) at the correct times if given reminders by another person at the appr|49
431|3 - Unable to take medication unless administered by another person.|3 - Unable to take medication unless administered by another person.|49
432|1 - At least daily|1 - At least daily|49
433|2 - Three or more times per week|2 - Three or more times per week|49
434|3 - One to two times per week|3 - One to two times per week|49
435|4 - Received, but less often than weekly|4 - Received, but less often than weekly|49
436|5 - No assistance received|5 - No assistance received|49
437|0 - No [Go to M2400]|0 - No [Go to M2400]|49
438|1 - Yes, used hospital emergency department WITHOUT hospital admission|1 - Yes, used hospital emergency department WITHOUT hospital admission|49
439|2 - Yes, used hospital emergency department WITH hospital admission|2 - Yes, used hospital emergency department WITH hospital admission|49
440|UK - Unknown [Go to M2400]|UK - Unknown [Go to M2400]|49
441|2 - Injury caused by fall|2 - Injury caused by fall|49
442|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|49
443|4 - Other respiratory problem|4 - Other respiratory problem|49
444|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|49
445|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|49
446|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|49
447|8 - Other heart disease|8 - Other heart disease|49
448|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|49
449|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|49
450|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|49
451|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|49
452|13 - Urinary tract infection|13 - Urinary tract infection|49
453|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|49
454|15 - Wound infection or deterioration|15 - Wound infection or deterioration|49
455|16 - Uncontrolled pain|16 - Uncontrolled pain|49
456|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|49
457|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|49
458|19 - Other than above reasons|19 - Other than above reasons|49
459|2 - Patient remained in the community (with formal assistive services)|2 - Patient remained in the community (with formal assistive services)|49
460|3 - Patient transferred to a noninstitutional hospice|3 - Patient transferred to a noninstitutional hospice|49
461|4 - Unknown because patient moved to a geographic location not served by this agency|4 - Unknown because patient moved to a geographic location not served by this agency|49
462|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|49
463|4 - Other respiratory problem|4 - Other respiratory problem|49
464|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|49
465|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|49
466|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|49
467|8 - Other heart disease|8 - Other heart disease|49
468|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|49
469|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|49
470|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|49
471|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|49
472|13 - Urinary tract infection|13 - Urinary tract infection|49
473|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|49
474|15 - Wound infection or deterioration|15 - Wound infection or deterioration|49
475|16 - Uncontrolled pain|16 - Uncontrolled pain|49
476|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|49
477|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|49
478|19 - Scheduled treatment or procedure|19 - Scheduled treatment or procedure|49
479|20 - Other than above reasons|20 - Other than above reasons|49
480|UK - Reason unknown [Go to M0903]|UK - Reason unknown [Go to M0903]|49
482|01 - Patient lives alone around the clock|01 - Patient lives alone around the clock|49
483|02 - Patient lives alone regular daytime|02 - Patient lives alone regular daytime|49
484|03 - Patient lives alone regular nighttime|03 - Patient lives alone regular nighttime|49
485|04 - Patient lives alone occassional/short term assistance|04 - Patient lives alone occassional/short term assistance|49
486|05 - Patient lives alone no assisstance available|05 - Patient lives alone no assisstance available|49
487|06 - Patient lives with other person(s) in the home around the clock|06 - Patient lives with other person(s) in the home around the clock|49
488|07 - Patient lives with other person(s) in the home regular daytime|07 - Patient lives with other person(s) in the home regular daytime|49
489|08 - Patient lives with other person(s) in the home regular nighttime|08 - Patient lives with other person(s) in the home regular nighttime|49
490|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|49
491|10 - Patient lives with other person(s) in the home no assistance available|10 - Patient lives with other person(s) in the home no assistance available|49
492|1 - Was present at the most recent SOC/ROC assessment [Goto M1308A1]|1 - Was present at the most recent SOC/ROC assessment [Goto M1308A1]|49
493|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|49
494|NA - No non-epithelialized Stage II pressure ulcers are present at discharge [Goto M1308A1]|NA - No non-epithelialized Stage II pressure ulcers are present at discharge [Goto M1308A1]|49
495|0 - Newly epithelialized|0 - Newly epithelialized|49
496|0 - No [ Go to M1340 ]|0 - No [ Go to M1340 ]|49
498|0 - Independent|0 - Independent|49
499|1 - Needed Some Help|1 - Needed Some Help|49
500|2 - Dependent|2 - Dependent|49
502|0 - No assistance needed in this area|0 - No assistance needed in this area|49
503|1 - Caregiver(s) currently provide assistance|1 - Caregiver(s) currently provide assistance|49
504|2 - Caregiver(s) need training/ supportive services to provide assistance|2 - Caregiver(s) need training/ supportive services to provide assistance|49
505|3 - Caregiver(s) not likely to provide assistance|3 - Caregiver(s) not likely to provide assistance|49
506|4 - Unclear if Caregiver(s) will provide assistance|4 - Unclear if Caregiver(s) will provide assistance|49
507|5 - Assistance needed, but no Caregiver(s) available|5 - Assistance needed, but no Caregiver(s) available|49
508|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will use standardized clinical guidelines accessible for all care providers to reference|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will|49
510|NA - Patient is not assessed to be at risk for falls|NA - Patient is not assessed to be at risk for falls|49
511|NA - Patient has no diagnosis or symptoms of depression|NA - Patient has no diagnosis or symptoms of depression|49
512|NA - No pain identified|NA - No pain identified|49
513|NA - Patient is not assessed to be at risk for pressure ulcers|NA - Patient is not assessed to be at risk for pressure ulcers|49
514|NA - Patient has no pressure ulcers with need for moist wound healing|NA - Patient has no pressure ulcers with need for moist wound healing|49
515|1 - Long-term nursing facility (NF)|1 - Long-term nursing facility (NF)|49
516|2 - Skilled nursing facility (SNF / TCU)|2 - Skilled nursing facility (SNF / TCU)|49
517|3 - Short stay acute hospital (IPP S)|3 - Short stay acute hospital (IPP S)|49
518|4 - Long-term care hospital (LTCH)|4 - Long-term care hospital (LTCH)|49
519|5 - Inpatient rehabilitation hospital or unit (IRF)|5 - Inpatient rehabilitation hospital or unit (IRF)|49
520|6 - Psychiatric hospital or unit|6 - Psychiatric hospital or unit|49
521|7 - Other|7 - Other|49
522|NA - Patient was not discharged from an inpatient facility [Goto M1016]|NA - Patient was not discharged from an inpatient facility [Goto M1016]|49
523|6 - Unable to participate effectively in bathing and is bathed totally by another person|6 - Unable to participate effectively in bathing and is bathed totally by another person|49
524|4 - Chairfast, unable to ambulate but is able to wheel self independently.|4 - Chairfast, unable to ambulate but is able to wheel self independently.|49
525|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask patient: "Over the last two weeks, how often have you been bothered by any of the following problems")  *Copyright+ Pfizer Inc. All rights reserved. Reproduced with permission.|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask|49
526|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluation for depression.|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluat|49
527|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet criteria for further evaluation for depression.|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet|49
528|0 - Not at all  0 - 1 day|0 - Not at all  0 - 1 day|49
529|1 - Several days  2 - 6 days|1 - Several days  2 - 6 days|49
530|2 - More than half of the days  7 - 11 days|2 - More than half of the days  7 - 11 days|49
531|3 - Nearly every day  12 - 14 days|3 - Nearly every day  12 - 14 days|49
532|NA - N/A  Unable to respond|NA - N/A  Unable to respond|49
533|2 - Able to take medication(s) at the correct times if given reminders by another person based on the frequency of the injection|2 - Able to take medication(s) at the correct times if given reminders by another person based on th|49
534|3 - Unable to take injectable medication unless administered by another person.|3 - Unable to take injectable medication unless administered by another person.|49
570|NA - No observable pressure ulcer or unhealed pressure ulcer|NA - No observable pressure ulcer or unhealed pressure ulcer|49
571|NA - No clinically significant medication issues identified since the previous OASIS assessment|NA - No clinically significant medication issues identified since the previous OASIS assessment|49
572|NA - Patient is not diabetic or is bilateral amputee|NA - Patient is not diabetic or is bilateral amputee|49
573|NA - Formal multi-factor Fall Risk Assessment indicates the patient was not at risk for falls since the last OASIS assessment|NA - Formal multi-factor Fall Risk Assessment indicates the patient was not at risk for falls since|49
574|NA - Formal assessment indicates patient did not meet criteria for depression AND patient did not have diagnosis of depression since the last OASIS assessment|NA - Formal assessment indicates patient did not meet criteria for depression AND patient did not ha|49
575|NA - Formal assessment did not indicate pain since the last OASIS assessment|NA - Formal assessment did not indicate pain since the last OASIS assessment|49
576|NA - Formal assessment indicates the patient was not at risk of pressure ulcers since the last OASIS assessment|NA - Formal assessment indicates the patient was not at risk of pressure ulcers since the last OASIS|49
577|NA - Dressings that support the principles of moist wound healing not indicated for this patient's pressure ulcers OR patient has no pressure ulcers with need for moist wound healing|NA - Dressings that support the principles of moist wound healing not indicated for this patient's p|49
578|1 - Patient remained in the community (without formal assistive services)|1 - Patient remained in the community (without formal assistive services)|49
579|2 - Patient remained in the community (with formal assistive services)|2 - Patient remained in the community (with formal assistive services)|49
580|3 - Patient transferred to a non-institutional hospice|3 - Patient transferred to a non-institutional hospice|49
581|4 - Unknown because patient moved to a geographic location not served by this agency|4 - Unknown because patient moved to a geographic location not served by this agency|49
620|1 - Yes; received from your agency during this episode of care (SOC/ROC to Transfer/Discharge)|1 - Yes; received from your agency during this episode of care (SOC/ROC to Transfer/Discharge)|49
621|2 - Yes; received from your agency during a prior episode of care (SOC/ROC to Transfer/Discharge)|2 - Yes; received from your agency during a prior episode of care (SOC/ROC to Transfer/Discharge)|49
622|3 - Yes; received from another health care provider (for example physician pharmacist)|3 - Yes; received from another health care provider (for example physician pharmacist)|49
623|4 - No; patient offered and declined |4 - No; patient offered and declined |49
624|5 - No; patient assessed and determined to have medical contraindication(s)|5 - No; patient assessed and determined to have medical contraindication(s)|49
625|6 - No; not indicated - patient does not meet age/condition guidelines for influenza vaccine|6 - No; not indicated - patient does not meet age/condition guidelines for influenza vaccine|49
626|7 - No; inability to obtain vaccine due to declared shortage |7 - No; inability to obtain vaccine due to declared shortage |49
627|8 - No; patient did not receive the vaccine due to reasons other than those listed in responses 4 v 7. |8 - No; patient did not receive the vaccine due to reasons other than those listed in responses 4v7.|49
628|1 - Offered and declined|1 - Offered and declined|49
629|2 - Assessed and determined to have medical contraindication(s) |2 - Assessed and determined to have medical contraindication(s) |49
630|3 - Not indicated; patient does not meet age/condition guidelines for Pneumococcal Vaccine|3 - Not indicated; patient does not meet age/condition guidelines for Pneumococcal Vaccine|49
631|4 - None of the above|4 - None of the above|49
632|0 - No assistance needed v patient is independent or does not have needs in this area|0 - No assistance needed v patient is independent or does not have needs in this area|49
633|1 - Non-agency caregiver(s) currently provide assistance |1 - Non-agency caregiver(s) currently provide assistance |49
634|2 - Non-agency caregiver(s) need training/ supportive services to provide assistance|2 - Non-agency caregiver(s) need training/ supportive services to provide assistance|49
635|3 - Non-agency caregiver(s) are not likely to provide assistance OR it is unclear if they will provide assistance|3 - Non-agency caregiver(s) are not likely to provide assistance OR unclear if will provide asst|49
636|4 - Assistance needed but no non-agency caregiver(s) available|4 - Assistance needed but no non-agency caregiver(s) available|49
2|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; OR (b) Is physically, cognitively, and mentally able to prepare light meals on a regular basis but has not routinely performed light meal preparation in the past (i.e., prior to this home care admission).|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; O|51
3|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and mentally able to perform all housekeeping tasks .|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and menta|51
4|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and mentally able to do laundry and access facilities.|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and menta|51
5|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying packages OR b) Physically, cognitively, and mentally able to take care of shopping, but has not done shopping in the past (i.e., prior to this home care admission).|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying|51
6|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|51
7|0 - Able to dial numbers and answer calls appropriately and as desired.|0 - Able to dial numbers and answer calls appropriately and as desired.|51
8|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body without assistance.|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body|51
9|0 - Able to get to and from the toilet and transfer independently with or without a device.|0 - Able to get to and from the toilet and transfer independently with or without a device.|51
10|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|51
11|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible public bus.|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible p|51
12|0 - Able to independently feed self.|0 - Able to independently feed self.|51
13|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|51
14|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct times.|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct ti|51
15|0 - Able to independently transfer.|0 - Able to independently transfer.|51
16|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without rail|51
17|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings|51
18|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|51
19|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions independently.|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions indep|51
20|0 - Asymptomatic, no treatment needed at this time|0 - Asymptomatic, no treatment needed at this time|51
21|0 - Caregiver manages all tasks related to equipment completely independently.|0 - Caregiver manages all tasks related to equipment completely independently.|51
22|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations with no observable impairment.|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations w|51
23|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|51
24|0 - Life expectancy is greater than 6 months|0 - Life expectancy is greater than 6 months|51
25|0 - Never|0 - Never|51
26|0 - Patient is not short of breath|0 - Patient is not short of breath|51
27|0 - No|0 - No|51
28|0 - No emergent care services|0 - No emergent care services|51
29|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [ Go to M1620 ]|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [ Go to M1620 ]|51
30|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and extended or abstract conversation.|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and exte|51
31|0 - No one person|0 - No one person|51
32|0 - None of the time|0 - None of the time|51
33|0 - None, no charge for current services|0 - None, no charge for current services|51
34|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|51
35|0 - Patient does NOT have an ostomy for bowel elimination.|0 - Patient does NOT have an ostomy for bowel elimination.|51
36|0 - Patient has no pain|0 - Patient has no pain|51
37|0 - Patient manages all tasks related to equipment completely independently.|0 - Patient manages all tasks related to equipment completely independently.|51
38|0 - Poor:  little or no recovery is expected and/or further decline is imminent|0 - Poor:  little or no recovery is expected and/or further decline is imminent|51
39|0 - Timed-voiding defers incontinence|0 - Timed-voiding defers incontinence|51
40|0 - Very rarely or never has bowel incontinence|0 - Very rarely or never has bowel incontinence|51
41|0 - Zero|0 - Zero|51
42|00 - No|00 - No|51
43|01 - Yes|01 - Yes|51
44|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or mental limitations, needs assistance with heavy laundry.|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or|51
45|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the patient.|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the|51
46|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|51
47|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or supervision from another person OR c) a liquid, pureed or ground meat diet.|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or su|51
48|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|51
49|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|51
50|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independently.|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independe|51
51|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only when assisted or accompanied by another person.|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only w|51
52|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepa|51
53|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance by another person OR b) given daily reminders.|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance b|51
54|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advan|51
55|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advan|51
56|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for the deaf) and call essential numbers.|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for t|51
57|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|51
58|1 - American Indian or Alaska Native|1 - American Indian or Alaska Native|51
59|1 - Depressed mood (e.g., feeling sad, tearful)|1 - Depressed mood (e.g., feeling sad, tearful)|51
60|1 - During the night only|1 - During the night only|51
61|1 - Fully granulating|1 - Fully granulating|51
62|1 - Good/Fair:  partial to full recovery is expected|1 - Good/Fair:  partial to full recovery is expected|51
63|1 - Good:  marked improvement in functional status is expected|1 - Good:  marked improvement in functional status is expected|51
64|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|51
65|1 - Smoking|1 - Smoking|51
66|1 - Hospital|1 - Hospital|51
67|1 - Hospital emergency room (includes 23-hour holding)|1 - Hospital emergency room (includes 23-hour holding)|51
68|1 - Hospitalization for EMERGENT (unscheduled) care|1 - Hospitalization for EMERGENT (unscheduled) care|51
69|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepared solutions), patient is able to manage all other aspects of equipment.|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepar|51
70|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|51
71|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|51
72|1 - In new or complex situations only|1 - In new or complex situations only|51
73|1 - Intravenous or infusion therapy (excludes TPN)|1 - Intravenous or infusion therapy (excludes TPN)|51
74|1 - Less often than daily|1 - Less often than daily|51
75|1 - Less than once a month|1 - Less than once a month|51
76|1 - Less than once weekly|1 - Less than once weekly|51
77|1 - Life expectancy is 6 months or fewer|1 - Life expectancy is 6 months or fewer|51
78|1 - Lives alone|1 - Lives alone|51
79|1 - Male|1 - Male|51
80|1 - Medicare (traditional fee-for-service)|1 - Medicare (traditional fee-for-service)|51
81|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of past 24 hours, significant memory loss so that supervision is required|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of pas|51
82|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors in word choice, grammar or speech intelligibility, needs minimal prompting or assistance).|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors i|51
83|1 - No assistance or services received|1 - No assistance or services received|51
84|1 - One|1 - One|51
85|1 - Oxygen (intermittent or continuous)|1 - Oxygen (intermittent or continuous)|51
86|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, and the surrounding layout, can count fingers at arm's length.|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, a|51
87|1 - Patient is incontinent|1 - Patient is incontinent|51
88|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|51
89|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical or treatment regimen.|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical|51
90|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient/couple/significant other)|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient|51
91|1 - Relatives, friends, or neighbors living outside the home|1 - Relatives, friends, or neighbors living outside the home|51
92|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions.|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions|51
93|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independentl|51
94|1 - Several times during day and night|1 - Several times during day and night|51
95|1 - Spouse or significant other|1 - Spouse or significant other|51
96|1 - Stage 1|1 - Stage 1|51
97|1 - Start of care - further visits planned|1 - Start of care - further visits planned|51
98|1 - Symptoms well controlled with current therapy|1 - Symptoms well controlled with current therapy|51
99|1 - Therapy services|1 - Therapy services|51
100|1 - Able to transfer with minimal human assistance or with use of an assistive device.|1 - Able to transfer with minimal human assistance or with use of an assistive device.|51
101|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitations.|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitatio|51
102|1 - Urinary incontinence|1 - Urinary incontinence|51
103|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and transfer.|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and|51
104|1 - When walking more than 20 feet, climbing stairs|1 - When walking more than 20 feet, climbing stairs|51
105|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary conversation. May need occasional repetition, extra time, or louder voice.|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary c|51
106|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting in and out of tub/shower|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting|51
107|1 - Yes|1 - Yes|51
108|1-RN|1-RN|51
109|10 - Discharge from agency - no visits completed after start/resumption of care assessment|10 - Discharge from agency - no visits completed after start/resumption of care assessment|51
110|10 - Scheduled surgical procedure|10 - Scheduled surgical procedure|51
111|10 - Self-pay|10 - Self-pay|51
112|11 - Other|11 - Other|51
113|11 - Urinary tract infection|11 - Urinary tract infection|51
114|12 - IV catheter-related infection|12 - IV catheter-related infection|51
115|13 - Deep vein thrombosis, pulmonary embolus|13 - Deep vein thrombosis, pulmonary embolus|51
116|14 - Uncontrolled pain|14 - Uncontrolled pain|51
117|15 - Psychotic episode|15 - Psychotic episode|51
118|16 - Other than above reasons|16 - Other than above reasons|51
119|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing calls.|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing|51
120|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another person.|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another pers|51
121|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface a|51
122|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for intermittent supervision or encouragement or reminders, OR (b) to get in and out of the shower or tub, OR (c) for washing difficult to reach areas.|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for inter|51
123|2 - Asian|2 - Asian|51
124|2 - Caregiver requires considerable assistance from another person to manage equipment, but independently completes significant portions of task.|2 - Caregiver requires considerable assistance from another person to manage equipment, but independ|51
125|2 - Daily, but not constantly|2 - Daily, but not constantly|51
126|2 - Daughter or son|2 - Daughter or son|51
127|2 - Doctor's office emergency visit/house call|2 - Doctor's office emergency visit/house call|51
128|2 - During the day and night|2 - During the day and night|51
129|2 - Early/partial granulation|2 - Early/partial granulation|51
130|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors in word choice, organization or speech intelligibility). Speaks in phrases or short sentences.|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors|51
131|2 - Family member's residence|2 - Family member's residence|51
132|2 - Female|2 - Female|51
133|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conversation, needs frequent prompting or assistance.|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conver|51
134|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|51
135|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|51
136|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately stop activities, jeopardizes safety through actions|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately st|51
137|2 - Indwelling/suprapubic catheter|2 - Indwelling/suprapubic catheter|51
138|2 - Injury caused by fall or accident at home|2 - Injury caused by fall or accident at home|51
139|2 - Medicare (HMO/managed care/Advantage plan)|2 - Medicare (HMO/managed care/Advantage plan)|51
140|2 - Nausea, dehydration, malnutrition, constipation, impaction|2 - Nausea, dehydration, malnutrition, constipation, impaction|51
141|2 - Obesity|2 - Obesity|51
142|2 - On awakening or at night only|2 - On awakening or at night only|51
143|2 - Once a month|2 - Once a month|51
144|2 - One to three times weekly|2 - One to three times weekly|51
145|2 - Parenteral nutrition (TPN or lipids)|2 - Parenteral nutrition (TPN or lipids)|51
146|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic)  [ Go to M1620 ]|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic)  [ Go|51
147|2 - Patient requires considerable assistance from another person to manage equipment, but independently completes portions of the task.|2 - Patient requires considerable assistance from another person to manage equipment, but independen|51
148|2 - Patient transferred to a noninstitutional hospice|2 - Patient transferred to a noninstitutional hospice|51
149|2 - Person residing in the home (EXCLUDING paid help)|2 - Person residing in the home (EXCLUDING paid help)|51
150|2 - Rehabilitation facility|2 - Rehabilitation facility|51
151|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifting of attention) or consistently requires low stimulus environment due to distractibility.|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifti|51
152|2 - Respite care|2 - Respite care|51
153|2 - Sense of failure or self reproach|2 - Sense of failure or self reproach|51
154|2 - Several times during day|2 - Several times during day|51
155|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonresponsive.|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonrespons|51
156|2 - Someone must assist the patient to groom self.|2 - Someone must assist the patient to groom self.|51
157|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|51
158|2 - Someone must help the patient put on upper body clothing.|2 - Someone must help the patient put on upper body clothing.|51
159|2 - Stage 2|2 - Stage 2|51
160|2 - Start of care - no further visits planned|2 - Start of care - no further visits planned|51
161|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitoring|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitori|51
162|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment regimen.|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment re|51
163|2 - Two|2 - Two|51
164|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistance due to cognitive or mental limitation.|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistanc|51
165|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|51
166|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assistance).|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assis|51
167|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home delivery.|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home deli|51
168|2 - Unable to prepare any light meals or reheat any delivered meals.|2 - Unable to prepare any light meals or reheat any delivered meals.|51
169|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|51
170|2 - UNABLE to take injectable medications unless administered by someone else.|2 - UNABLE to take injectable medications unless administered by someone else.|51
171|2 - UNABLE to take medication unless administered by someone else.|2 - UNABLE to take medication unless administered by someone else.|51
172|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|51
173|2 - Ventilator (continually or at night)|2 - Ventilator (continually or at night)|51
174|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less than 20 feet)|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less th|51
175|2 - With spouse or significant other|2 - With spouse or significant other|51
176|2 - Yes, assistance or services provided by family or friends|2 - Yes, assistance or services provided by family or friends|51
177|2-PT|2-PT|51
178|3 - Able to answer the telephone only some of the time or is able to carry on only a limited conversation.|3 - Able to answer the telephone only some of the time or is able to carry on only a limited convers|51
179|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube or gastrostomy.|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube|51
180|3 - Alcohol dependency|3 - Alcohol dependency|51
181|3 - All of the time|3 - All of the time|51
182|3 - Black or African-American|3 - Black or African-American|51
183|3 - Boarding home or rented room|3 - Boarding home or rented room|51
184|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment, clean/store/dispose of equipment or supplies).|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment,|51
185|3 -Able to walk only with the supervision or assistance of another person at all times.|3 -Able to walk only with the supervision or assistance of another person at all times.|51
186|3 - Continuous / Bi-level positive airway pressure|3 - Continuous / Bi-level positive airway pressure|51
187|3 - During the day and evening, but not constantly|3 - During the day and evening, but not constantly|51
188|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the alimentary canal)|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the|51
189|3 - Environmental support (e.g., housing, home maintenance)|3 - Environmental support (e.g., housing, home maintenance)|51
190|3 - Four to six times weekly|3 - Four to six times weekly|51
191|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessing by listener.  Speech limited to single words or short phrases.|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessin|51
192|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires multiple repetitions, restatements, demonstrations, additional time.|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires m|51
193|3 - Hopelessness|3 - Hopelessness|51
194|3 - Hospice care|3 - Hospice care|51
195|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|51
196|3 - Injury caused by fall or accident at home|3 - Injury caused by fall or accident at home|51
197|3 - Intractable pain|3 - Intractable pain|51
198|3 - Medicaid (traditional fee-for-service)|3 - Medicaid (traditional fee-for-service)|51
199|3 - Needs someone to do all shopping and errands.|3 - Needs someone to do all shopping and errands.|51
200|3 - Not healing|3 - Not healing|51
201|3 - Nursing home|3 - Nursing home|51
202|3 - Once daily|3 - Once daily|51
203|3 - Other family member|3 - Other family member|51
204|3 - Outpatient department/clinic emergency (includes urgicenter sites)|3 - Outpatient department/clinic emergency (includes urgicenter sites)|51
205|3 - Paid help|3 - Paid help|51
206|3 - Able to participate in bathing self in shower or tub, but requires presence of another person throughout the bath for assistance or supervision.|3 - Able to participate in bathing self in shower or tub, but requires presence of another person th|51
207|3 - Patient depends entirely upon another person to dress lower body.|3 - Patient depends entirely upon another person to dress lower body.|51
208|3 - Patient depends entirely upon another person to dress the upper body.|3 - Patient depends entirely upon another person to dress the upper body.|51
209|3 - Patient depends entirely upon someone else for grooming needs.|3 - Patient depends entirely upon someone else for grooming needs.|51
210|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone else to manage the equipment.|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone|51
211|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable to shift attention and recall directions more than half the time.|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable|51
212|3 - Respiratory problems (SOB, infection, obstruction)|3 - Respiratory problems (SOB, infection, obstruction)|51
213|3 - Resumption of care (after inpatient stay)|3 - Resumption of care (after inpatient stay)|51
214|3 - Several times each month|3 - Several times each month|51
215|3 - Skilled Nursing Facility|3 - Skilled Nursing Facility|51
216|3 - Stage 3|3 - Stage 3|51
217|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|51
218|3 - Three|3 - Three|51
219|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person throughout the process.|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person through|51
220|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal independently.|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal indep|51
221|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person.|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person|51
222|3 - Unknown because patient moved to a geographic location not served by this agency|3 - Unknown because patient moved to a geographic location not served by this agency|51
223|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|51
224|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|51
225|3 - With other family member|3 - With other family member|51
226|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home health services, homemaker assistance, transportation assistance, assisted living, board and care)|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home h|51
227|3-SLP/ST|3-SLP/ST|51
228|4 - At rest (during day or night)|4 - At rest (during day or night)|51
229|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|51
230|4 - Board and care or assisted living facility|4 - Board and care or assisted living facility|51
231|4 - Caregiver is completely dependent on someone else to manage all equipment.|4 - Caregiver is completely dependent on someone else to manage all equipment.|51
232|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|51
233|4 - Constantly|4 - Constantly|51
234|4 - Drug dependency|4 - Drug dependency|51
235|4 - Four or more|4 - Four or more|51
236|4 - Friend or neighbor or community or church member|4 - Friend or neighbor or community or church member|51
237|4 - Hispanic or Latino|4 - Hispanic or Latino|51
238|4 - Hospice|4 - Hospice|51
239|4 - Impaired decision-making|4 - Impaired decision-making|51
240|4 - Is totally dependent in toileting.|4 - Is totally dependent in toileting.|51
241|4 - Medicaid (HMO/managed care)|4 - Medicaid (HMO/managed care)|51
242|4 - None of the above|4 - None of the above|51
243|4 - Nursing home|4 - Nursing home|51
244|4 - On a daily basis|4 - On a daily basis|51
245|4 - Patient is completely dependent on someone else to manage all equipment.|4 - Patient is completely dependent on someone else to manage all equipment.|51
246|4 - Permanent placement|4 - Permanent placement|51
247|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, punches, dangerous maneuvers w/ wheelchair or other objects)|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, pu|51
248|4 - Psychosocial support (e.g., socialization, companionship, recreation)|4 - Psychosocial support (e.g., socialization, companionship, recreation)|51
249|4 - Recertification (follow-up) reassessment|4 - Recertification (follow-up) reassessment|51
250|4 - Recurrent thoughts of death|4 - Recurrent thoughts of death|51
251|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruction)|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruc|51
252|4 - Several times a week|4 - Several times a week|51
253|4 - Stage 4|4 - Stage 4|51
254|4 - Symptoms poorly controlled, history of re-hospitalizations|4 - Symptoms poorly controlled, history of re-hospitalizations|51
255|4 - Three or more times per week|4 - Three or more times per week|51
256|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetative state, or delirium.|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetati|51
257|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|51
258|4 - Unable to effectively participate in any housekeeping tasks.|4 - Unable to effectively participate in any housekeeping tasks.|51
259|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or unresponsive (e.g., speech is nonsensical or unintelligible).|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or u|51
260|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonresponsive.|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonr|51
261|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostomy.|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostom|51
262|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of devices at the sink, in chair, or on commode|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of|51
263|4 - With a friend|4 - With a friend|51
264|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|51
265|4-OT|4-OT|51
266|5 - Advocates or facilitates patient's participation in appropriate medical care|5 - Advocates or facilitates patient's participation in appropriate medical care|51
267|5 - At least daily|5 - At least daily|51
268|6 - Bedfast, unable to ambulate or be up in a chair.|6 - Bedfast, unable to ambulate or be up in a chair.|51
269|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|51
270|5 - Disruptive or socially inappropriate behavior|5 - Disruptive or socially inappropriate behavior|51
271|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|51
272|5 - Hypo/Hyperglycemia, diabetes out of control|5 - Hypo/Hyperglycemia, diabetes out of control|51
273|5 - More often than once daily|5 - More often than once daily|51
274|5 - Native Hawaiian or Pacific Islander|5 - Native Hawaiian or Pacific Islander|51
275|5 - None of the above|5 - None of the above|51
276|5 - One to two times per week|5 - One to two times per week|51
277|5 - Other|5 - Other|51
278|5 - Other follow-up|5 - Other follow-up|51
279|5 - Paid help|5 - Paid help|51
280|5 - Patient nonresponsive or unable to speak.|5 - Patient nonresponsive or unable to speak.|51
281|5 - Thoughts of suicide|5 - Thoughts of suicide|51
282|5 - Totally unable to use the telephone.|5 - Totally unable to use the telephone.|51
283|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|51
284|5 - Unable to take in nutrients orally or by tube feeding.|5 - Unable to take in nutrients orally or by tube feeding.|51
285|5 - Unsafe for care at home|5 - Unsafe for care at home|51
286|5 - With paid help (other than home care agency staff)|5 - With paid help (other than home care agency staff)|51
287|5 - Workers' compensation|5 - Workers' compensation|51
288|5 - Wound infection, deteriorating wound status, new lesion/ulcer|5 - Wound infection, deteriorating wound status, new lesion/ulcer|51
289|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|51
290|6 - Delusional, hallucinatory, or paranoid behavior|6 - Delusional, hallucinatory, or paranoid behavior|51
291|6 - Financial agent, power of attorney, or conservator of finance|6 - Financial agent, power of attorney, or conservator of finance|51
292|6 - GI bleeding, obstruction|6 - GI bleeding, obstruction|51
293|6 - Less often than weekly|6 - Less often than weekly|51
294|6 - Memory loss to the extent that supervision required|6 - Memory loss to the extent that supervision required|51
295|6 - None of the above feelings observed or reported|6 - None of the above feelings observed or reported|51
296|6 - Other|6 - Other|51
297|6 - Title programs (e.g., Title III, V, or XX)|6 - Title programs (e.g., Title III, V, or XX)|51
298|6 - Transferred to an inpatient facility - patient not discharged from agency|6 - Transferred to an inpatient facility - patient not discharged from agency|51
299|6 - White|6 - White|51
300|6 - With other than above|6 - With other than above|51
301|7 - Exacerbation of CHF, fluid overload, heart failure|7 - Exacerbation of CHF, fluid overload, heart failure|51
302|7 - Health care agent, conservator of person, or medical power of attorney|7 - Health care agent, conservator of person, or medical power of attorney|51
303|7 - Hypo/Hyperglycemia, diabetes out of control|7 - Hypo/Hyperglycemia, diabetes out of control|51
304|7 - None of the above|7 - None of the above|51
305|7 - None of the above behaviors demonstrated|7 - None of the above behaviors demonstrated|51
306|7 - Other government (e.g., TriCare, VA, etc.)|7 - Other government (e.g., TriCare, VA, etc.)|51
307|7 - Transferred to an inpatient facility - patient discharged from agency|7 - Transferred to an inpatient facility - patient discharged from agency|51
308|8 - Death at home|8 - Death at home|51
309|8 - GI bleeding, obstruction|8 - GI bleeding, obstruction|51
310|8 - Myocardial infarction, stroke|8 - Myocardial infarction, stroke|51
311|8 - Private insurance|8 - Private insurance|51
312|9 - Chemotherapy|9 - Chemotherapy|51
313|9 - Discharge from agency|9 - Discharge from agency|51
314|9 - Other than above reasons|9 - Other than above reasons|51
315|9 - Private HMO/managed care|9 - Private HMO/managed care|51
316|NA - No caregiver|NA - No caregiver|51
317|NA - No equipment of this type used in care.|NA - No equipment of this type used in care.|51
318|NA - No inhalant/mist medications prescribed.|NA - No inhalant/mist medications prescribed.|51
319|NA - No injectable medications prescribed.|NA - No injectable medications prescribed.|51
320|NA - No inpatient facility admission|NA - No inpatient facility admission|51
321|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|51
322|NA - No Medicaid|NA - No Medicaid|51
323|NA - No Medicare|NA - No Medicare|51
324|NA - No observable pressure ulcer|NA - No observable pressure ulcer|51
325|NA - No observable stasis ulcer|NA - No observable stasis ulcer|51
326|NA - No observable surgical wound|NA - No observable surgical wound|51
327|NA - No oral medications prescribed.|NA - No oral medications prescribed.|51
328|NA - Not applicable|NA - Not applicable|51
329|NA - Patient does not have a telephone.|NA - Patient does not have a telephone.|51
330|NA - Patient has ostomy for bowel elimination|NA - Patient has ostomy for bowel elimination|51
331|NA - Patient nonresponsive|NA - Patient nonresponsive|51
332|NA - Patient on prophylactic treatment|NA - Patient on prophylactic treatment|51
333|NA - Patient was not discharged from an inpatient facility [Go to M1017]|NA - Patient was not discharged from an inpatient facility [Go to M1017]|51
334|UK - Other unknown|UK - Other unknown|51
335|UK - Reason unknown|UK - Reason unknown|51
336|UK - Unknown|UK - Unknown|51
337|UK - Unknown or Not Available|UK - Unknown or Not Available|51
341|01 - Early|01 - Early|51
342|02 - Late|02 - Late|51
343|NA - Not Applicable. No case mix group defined for this assessment.|NA - Not Applicable. No case mix group defined for this assessment.|51
344|NA - No case mix group defined by this assessment.|NA - No case mix group defined by this assessment.|51
345|1 - Recent decline in mental, emotional, or behavioral status|1 - Recent decline in mental, emotional, or behavioral status|51
346|2 - Multiple hospitalizations (2 or more) in the past 12 months|2 - Multiple hospitalizations (2 or more) in the past 12 months|51
347|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|51
348|4 - Taking five or more medications|4 - Taking five or more medications|51
349|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|51
350|6 - Other|6 - Other|51
351|7 - None of the above|7 - None of the above|51
352|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond tho|51
353|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable without heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable wi|51
354|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious complications and death.|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious compl|51
355|3 - The patient has serious progressive conditions that could lead to death within a year.|3 - The patient has serious progressive conditions that could lead to death within a year.|51
356|UK - The patient+s situation is unknown or unclear.|UK - The patient+s situation is unknown or unclear.|51
357|1 - Yes [ Go to M1050 ]|1 - Yes [ Go to M1050 ]|51
358|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this influenza season. [ Go to M1050 ]|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this i|51
359|1 - Received from another health care provider (e.g., physician)|1 - Received from another health care provider (e.g., physician)|51
360|2 - Received from your agency previously during this year+s flu season|2 - Received from your agency previously during this year+s flu season|51
361|3 - Offered and declined|3 - Offered and declined|51
362|4 - Assessed and determined to have medical contraindication(s)|4 - Assessed and determined to have medical contraindication(s)|51
363|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|51
364|6 - Inability to obtain vaccine due to declared shortage|6 - Inability to obtain vaccine due to declared shortage|51
365|1 - Yes [ Go to M1500 at TRN; Go to M1230 at DC ]|1 - Yes [ Go to M1500 at TRN; Go to M1230 at DC ]|51
366|1 - Patient has received PPV in the past|1 - Patient has received PPV in the past|51
367|2 - Offered and declined|2 - Offered and declined|51
368|3 - Assessed and determined to have medical contraindication(s)|3 - Assessed and determined to have medical contraindication(s)|51
369|4 - Not indicated; patient does not meet age/condition guidelines for PPV|4 - Not indicated; patient does not meet age/condition guidelines for PPV|51
370|5 - None of the above|5 - None of the above|51
371|0 - Adequate: hears normal conversation without difficulty.|0 - Adequate: hears normal conversation without difficulty.|51
372|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to increase volume or speak distinctly.|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to in|51
373|2 - Severely Impaired: absence of useful hearing.|2 - Severely Impaired: absence of useful hearing.|51
374|UK - Unable to assess hearing.|UK - Unable to assess hearing.|51
375|0 - Understands: clear comprehension without cues or repetitions.|0 - Understands: clear comprehension without cues or repetitions.|51
376|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Requires cues at times to understand.|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Req|51
377|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequently requires cues to understand.|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequentl|51
378|3 - Rarely/Never Understands|3 - Rarely/Never Understands|51
379|UK - Unable to assess understanding.|UK - Unable to assess understanding.|51
380|0 - No standardized assessment conducted|0 - No standardized assessment conducted|51
381|1 - Yes, and it does not indicate severe pain|1 - Yes, and it does not indicate severe pain|51
382|2 - Yes, and it indicates severe pain|2 - Yes, and it indicates severe pain|51
383|0 - Patient has no pain|0 - Patient has no pain|51
384|1 - Patient has pain that does not interfere with activity or movement|1 - Patient has pain that does not interfere with activity or movement|51
385|2 - Less often than daily|2 - Less often than daily|51
386|3 - Daily, but not constantly|3 - Daily, but not constantly|51
387|4 - All of the time|4 - All of the time|51
388|0 - No assessment conducted [ Go to M1306 ]|0 - No assessment conducted [ Go to M1306 ]|51
389|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc., without use of standardized tool|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc.,|51
390|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|51
391|0 - No [ Go to M1322]|0 - No [ Go to M1322]|51
392|0 v Newly epithelialized|0 v Newly epithelialized|51
393|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|51
394|2 - Yes, patient has observable stasis ulcers ONLY|2 - Yes, patient has observable stasis ulcers ONLY|51
395|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable dressing) [Go to M1340]|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable|51
396|0 - No [ Go to M1350 ]|0 - No [ Go to M1350 ]|51
397|1 - Yes, patient has at least one (observable) surgical wound|1 - Yes, patient has at least one (observable) surgical wound|51
398|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1350 ]|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1350 ]|51
399|0 - Patient is not short of breath|0 - Patient is not short of breath|51
400|3 - Continuous Bi-level positive airway pressure|3 - Continuous Bi-level positive airway pressure|51
401|0 - No [ Go to M1732 at TRN; Go to M1600 at DC ]|0 - No [ Go to M1732 at TRN; Go to M1600 at DC ]|51
402|2 - Not assessed [Go to M1732 at TRN; Go to M1600 at DC ]|2 - Not assessed [Go to M1732 at TRN; Go to M1600 at DC ]|51
403|NA - Patient does not have diagnosis of heart failure [Go to M2004 at TRN; Go to M1600 at DC]|NA - Patient does not have diagnosis of heart failure [Go to M2004 at TRN; Go to M1600 at DC]|51
404|0 - No action taken|0 - No action taken|51
405|1 - Patient+s physician (or other primary care practitioner) contacted the same day|1 - Patient+s physician (or other primary care practitioner) contacted the same day|51
406|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|51
407|3 - Implement physician-ordered patient-specific established parameters for treatment|3 - Implement physician-ordered patient-specific established parameters for treatment|51
408|4 - Patient education or other clinical interventions|4 - Patient education or other clinical interventions|51
409|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequency, telehealth, etc.)|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequ|51
410|1 - Occasional stress incontinence|1 - Occasional stress incontinence|51
411|2 - During the night only|2 - During the night only|51
412|3 - During the day only|3 - During the day only|51
413|4 - During the day and night|4 - During the day and night|51
414|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|51
415|0 - Able to manage toileting hygiene and clothing management without assistance.|0 - Able to manage toileting hygiene and clothing management without assistance.|51
416|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implements are laid out for the patient.|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implemen|51
417|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|51
418|3 - Patient depends entirely upon another person to maintain toileting hygiene.|3 - Patient depends entirely upon another person to maintain toileting hygiene.|51
419|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independent|51
420|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface|51
421|0 - No multi-factor falls risk assessment conducted.|0 - No multi-factor falls risk assessment conducted.|51
422|1 - Yes, and it does not indicate a risk for falls.|1 - Yes, and it does not indicate a risk for falls.|51
423|2 - Yes, and it indicates a risk for falls.|2 - Yes, and it indicates a risk for falls.|51
424|0 - Not assessed/reviewed [ Go to M2010 ]|0 - Not assessed/reviewed [ Go to M2010 ]|51
425|1 - No problems found during review [ Go to M2010 ]|1 - No problems found during review [ Go to M2010 ]|51
426|2 - Problems found during review|2 - Problems found during review|51
427|NA - Patient is not taking any medications [ Go to M2040 ]|NA - Patient is not taking any medications [ Go to M2040 ]|51
428|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special precautions associated with all high-risk medications|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special p|51
429|NA - Patient not taking any drugs|NA - Patient not taking any drugs|51
430|2 - Able to take medication(s) at the correct times if given reminders by another person at the appropriate times|2 - Able to take medication(s) at the correct times if given reminders by another person at the appr|51
431|3 - Unable to take medication unless administered by another person.|3 - Unable to take medication unless administered by another person.|51
432|1 - At least daily|1 - At least daily|51
433|2 - Three or more times per week|2 - Three or more times per week|51
434|3 - One to two times per week|3 - One to two times per week|51
435|4 - Received, but less often than weekly|4 - Received, but less often than weekly|51
436|5 - No assistance received|5 - No assistance received|51
437|0 - No [Go to M2400]|0 - No [Go to M2400]|51
438|1 - Yes, used hospital emergency department WITHOUT hospital admission|1 - Yes, used hospital emergency department WITHOUT hospital admission|51
439|2 - Yes, used hospital emergency department WITH hospital admission|2 - Yes, used hospital emergency department WITH hospital admission|51
440|UK - Unknown [Go to M2400]|UK - Unknown [Go to M2400]|51
441|2 - Injury caused by fall|2 - Injury caused by fall|51
442|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|51
443|4 - Other respiratory problem|4 - Other respiratory problem|51
444|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|51
445|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|51
446|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|51
447|8 - Other heart disease|8 - Other heart disease|51
448|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|51
449|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|51
450|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|51
451|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|51
452|13 - Urinary tract infection|13 - Urinary tract infection|51
453|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|51
454|15 - Wound infection or deterioration|15 - Wound infection or deterioration|51
455|16 - Uncontrolled pain|16 - Uncontrolled pain|51
456|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|51
457|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|51
458|19 - Other than above reasons|19 - Other than above reasons|51
459|2 - Patient remained in the community (with formal assistive services)|2 - Patient remained in the community (with formal assistive services)|51
460|3 - Patient transferred to a noninstitutional hospice|3 - Patient transferred to a noninstitutional hospice|51
461|4 - Unknown because patient moved to a geographic location not served by this agency|4 - Unknown because patient moved to a geographic location not served by this agency|51
462|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|51
463|4 - Other respiratory problem|4 - Other respiratory problem|51
464|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|51
465|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|51
466|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|51
467|8 - Other heart disease|8 - Other heart disease|51
468|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|51
469|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|51
470|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|51
471|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|51
472|13 - Urinary tract infection|13 - Urinary tract infection|51
473|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|51
474|15 - Wound infection or deterioration|15 - Wound infection or deterioration|51
475|16 - Uncontrolled pain|16 - Uncontrolled pain|51
476|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|51
477|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|51
478|19 - Scheduled treatment or procedure|19 - Scheduled treatment or procedure|51
479|20 - Other than above reasons|20 - Other than above reasons|51
480|UK - Reason unknown [Go to M0903]|UK - Reason unknown [Go to M0903]|51
482|01 - Patient lives alone around the clock|01 - Patient lives alone around the clock|51
483|02 - Patient lives alone regular daytime|02 - Patient lives alone regular daytime|51
484|03 - Patient lives alone regular nighttime|03 - Patient lives alone regular nighttime|51
485|04 - Patient lives alone occassional/short term assistance|04 - Patient lives alone occassional/short term assistance|51
486|05 - Patient lives alone no assisstance available|05 - Patient lives alone no assisstance available|51
487|06 - Patient lives with other person(s) in the home around the clock|06 - Patient lives with other person(s) in the home around the clock|51
488|07 - Patient lives with other person(s) in the home regular daytime|07 - Patient lives with other person(s) in the home regular daytime|51
489|08 - Patient lives with other person(s) in the home regular nighttime|08 - Patient lives with other person(s) in the home regular nighttime|51
490|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|51
491|10 - Patient lives with other person(s) in the home no assistance available|10 - Patient lives with other person(s) in the home no assistance available|51
492|1 - Was present at the most recent SOC/ROC assessment|1 - Was present at the most recent SOC/ROC assessment|51
493|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|51
494|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|51
495|0 - Newly epithelialized|0 - Newly epithelialized|51
496|0 - No [ Go to M1340 ]|0 - No [ Go to M1340 ]|51
498|0 - Independent|0 - Independent|51
499|1 - Needed Some Help|1 - Needed Some Help|51
500|2 - Dependent|2 - Dependent|51
502|0 - No assistance needed in this area|0 - No assistance needed in this area|51
503|1 - Caregiver(s) currently provide assistance|1 - Caregiver(s) currently provide assistance|51
504|2 - Caregiver(s) need training/ supportive services to provide assistance|2 - Caregiver(s) need training/ supportive services to provide assistance|51
505|3 - Caregiver(s) not likely to provide assistance|3 - Caregiver(s) not likely to provide assistance|51
506|4 - Unclear if Caregiver(s) will provide assistance|4 - Unclear if Caregiver(s) will provide assistance|51
507|5 - Assistance needed, but no Caregiver(s) available|5 - Assistance needed, but no Caregiver(s) available|51
508|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will use standardized clinical guidelines accessible for all care providers to reference|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will|51
509|NA - Patient is not diabetic or is bilateral amputee|NA - Patient is not diabetic or is bilateral amputee|51
510|NA - Patient is not assessed to be at risk for falls|NA - Patient is not assessed to be at risk for falls|51
511|NA - Patient has no diagnosis or symptoms of depression|NA - Patient has no diagnosis or symptoms of depression|51
512|NA - No pain identified|NA - No pain identified|51
513|NA - Patient is not assessed to be at risk for pressure ulcers|NA - Patient is not assessed to be at risk for pressure ulcers|51
514|NA - Patient has no pressure ulcers with need for moist wound healing|NA - Patient has no pressure ulcers with need for moist wound healing|51
515|1 - Long-term nursing facility (NF)|1 - Long-term nursing facility (NF)|51
516|2 - Skilled nursing facility (SNF / TCU)|2 - Skilled nursing facility (SNF / TCU)|51
517|3 - Short stay acute hospital (IPP S)|3 - Short stay acute hospital (IPP S)|51
518|4 - Long-term care hospital (LTCH)|4 - Long-term care hospital (LTCH)|51
519|5 - Inpatient rehabilitation hospital or unit (IRF)|5 - Inpatient rehabilitation hospital or unit (IRF)|51
520|6 - Psychiatric hospital or unit|6 - Psychiatric hospital or unit|51
521|7 - Other|7 - Other|51
522|NA - Patient was not discharged from an inpatient facility [Go to M1017]|NA - Patient was not discharged from an inpatient facility [Go to M1017]|51
523|6 - Unable to participate effectively in bathing and is bathed totally by another person|6 - Unable to participate effectively in bathing and is bathed totally by another person|51
524|4 - Chairfast, unable to ambulate but is able to wheel self independently.|4 - Chairfast, unable to ambulate but is able to wheel self independently.|51
525|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask patient: "Over the last two weeks, how often have you been bothered by any of the following problems")  *Copyright+ Pfizer Inc. All rights reserved. Reproduced with permission.|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask|51
526|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluation for depression.|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluat|51
527|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet criteria for further evaluation for depression.|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet|51
528|0 - Not at all  0 - 1 day|0 - Not at all  0 - 1 day|51
529|1 - Several days  2 - 6 days|1 - Several days  2 - 6 days|51
530|2 - More than half of the days  7 - 11 days|2 - More than half of the days  7 - 11 days|51
531|3 - Nearly every day  12 - 14 days|3 - Nearly every day  12 - 14 days|51
532|NA - N/A  Unable to respond|NA - N/A  Unable to respond|51
533|2 - Able to take medication(s) at the correct times if given reminders by another person based on the frequency of the injection|2 - Able to take medication(s) at the correct times if given reminders by another person based on th|51
534|3 - Unable to take injectable medication unless administered by another person.|3 - Unable to take injectable medication unless administered by another person.|51
535|11 - Patient lives in congregate situation (e.g., assisted living) around the clock|11 - Patient lives in congregate situation (e.g., assisted living) around the clock|51
536|12 - Patient lives in congregate situation (e.g., assisted living) regular daytime|12 - Patient lives in congregate situation (e.g., assisted living) regular daytime|51
537|13 - Patient lives in congregate situation (e.g., assisted living) regular nighttime|13 - Patient lives in congregate situation (e.g., assisted living) regular nighttime|51
538|14 - Patient lives in congregate situation (e.g., assisted living) occasional / short-term assistance|14 - Patient lives in congregate situation (e.g., assisted living) occasional / short-term assistanc|51
539|15 - Patient lives in congregate situation (e.g., assisted living) no assistance available|15 - Patient lives in congregate situation (e.g., assisted living) no assistance available|51
545|NA - No observable pressure ulcer or unhealed pressure ulcer|NA - No observable pressure ulcer or unhealed pressure ulcer|51
582|NA - No specific SOC date ordered by physician|NA - No specific SOC date ordered by physician|51
585|UK - Inpatient Discharge Date Unknown|UK - Inpatient Discharge Date Unknown|51
600|1 - History of falls (2 or more falls - or any fall with an injury - in the past 12 months) |1 - History of falls (2 or more falls - or any fall with an injury - in the past 12 months) |51
602|2 - Unintentional weight loss of a total of 10 pounds or more in the past 12 months |2 - Unintentional weight loss of a total of 10 pounds or more in the past 12 months |51
604|3 - Multiple hospitalizations (2 or more) in the past 6 months|3 - Multiple hospitalizations (2 or more) in the past 6 months|51
606|4 - Multiple emergency department visits (2 or more) in the past 6 months|4 - Multiple emergency department visits (2 or more) in the past 6 months|51
608|5 - Decline in mental emotional or behavioral status in the past 3 months |5 - Decline in mental emotional or behavioral status in the past 3 months |51
610|6 - Reported or observed history of difficulty complying with any medical instructions (for example |6 - Reported or observed history of difficulty complying with any medical instructions (for example |51
612|7 - Currently taking 5 or more medications|7 - Currently taking 5 or more medications|51
614|8 - Currently reports exhaustion|8 - Currently reports exhaustion|51
616|9 - Other risk(s) not listed in 1 - 8|9 - Other risk(s) not listed in 1 - 8|51
618|10 - None of the above |10 - None of the above |51
632|0 - No assistance needed v patient is independent or does not have needs in this area|0 - No assistance needed v patient is independent or does not have needs in this area|51
633|1 - Non-agency caregiver(s) currently provide assistance |1 - Non-agency caregiver(s) currently provide assistance |51
634|2 - Non-agency caregiver(s) need training/ supportive services to provide assistance|2 - Non-agency caregiver(s) need training/ supportive services to provide assistance|51
635|3 - Non-agency caregiver(s) are not likely to provide assistance OR it is unclear if they will provide assistance|3 - Non-agency caregiver(s) are not likely to provide assistance OR unclear if will provide asst|51
636|4 - Assistance needed but no non-agency caregiver(s) available|4 - Assistance needed but no non-agency caregiver(s) available|51
2|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; OR (b) Is physically, cognitively, and mentally able to prepare light meals on a regular basis but has not routinely performed light meal preparation in the past (i.e., prior to this home care admission).|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; O|53
3|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and mentally able to perform all housekeeping tasks .|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and menta|53
4|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and mentally able to do laundry and access facilities.|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and menta|53
5|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying packages OR b) Physically, cognitively, and mentally able to take care of shopping, but has not done shopping in the past (i.e., prior to this home care admission).|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying|53
6|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|53
7|0 - Able to dial numbers and answer calls appropriately and as desired.|0 - Able to dial numbers and answer calls appropriately and as desired.|53
8|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body without assistance.|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body|53
9|0 - Able to get to and from the toilet and transfer independently with or without a device.|0 - Able to get to and from the toilet and transfer independently with or without a device.|53
10|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|53
11|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible public bus.|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible p|53
12|0 - Able to independently feed self.|0 - Able to independently feed self.|53
13|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|53
14|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct times.|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct ti|53
15|0 - Able to independently transfer.|0 - Able to independently transfer.|53
16|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without rail|53
17|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings|53
18|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|53
19|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions independently.|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions indep|53
20|0 - Asymptomatic, no treatment needed at this time|0 - Asymptomatic, no treatment needed at this time|53
21|0 - Caregiver manages all tasks related to equipment completely independently.|0 - Caregiver manages all tasks related to equipment completely independently.|53
22|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations with no observable impairment.|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations w|53
23|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|53
24|0 - Life expectancy is greater than 6 months|0 - Life expectancy is greater than 6 months|53
25|0 - Never|0 - Never|53
26|0 - Patient is not short of breath|0 - Patient is not short of breath|53
27|0 - No|0 - No|53
28|0 - No emergent care services|0 - No emergent care services|53
29|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [ Go to M1620 ]|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [ Go to M1620 ]|53
30|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and extended or abstract conversation.|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and exte|53
31|0 - No one person|0 - No one person|53
32|0 - None of the time|0 - None of the time|53
33|0 - None, no charge for current services|0 - None, no charge for current services|53
34|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|53
35|0 - Patient does NOT have an ostomy for bowel elimination.|0 - Patient does NOT have an ostomy for bowel elimination.|53
36|0 - Patient has no pain|0 - Patient has no pain|53
37|0 - Patient manages all tasks related to equipment completely independently.|0 - Patient manages all tasks related to equipment completely independently.|53
38|0 - Poor:  little or no recovery is expected and/or further decline is imminent|0 - Poor:  little or no recovery is expected and/or further decline is imminent|53
39|0 - Timed-voiding defers incontinence|0 - Timed-voiding defers incontinence|53
40|0 - Very rarely or never has bowel incontinence|0 - Very rarely or never has bowel incontinence|53
41|0 - Zero|0 - Zero|53
42|00 - No|00 - No|53
43|01 - Yes|01 - Yes|53
44|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or mental limitations, needs assistance with heavy laundry.|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or|53
45|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the patient.|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the|53
46|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|53
47|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or supervision from another person OR c) a liquid, pureed or ground meat diet.|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or su|53
48|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|53
49|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|53
50|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independently.|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independe|53
51|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only when assisted or accompanied by another person.|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only w|53
52|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepa|53
53|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance by another person OR b) given daily reminders.|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance b|53
54|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advan|53
55|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advan|53
56|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for the deaf) and call essential numbers.|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for t|53
57|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|53
58|1 - American Indian or Alaska Native|1 - American Indian or Alaska Native|53
59|1 - Depressed mood (e.g., feeling sad, tearful)|1 - Depressed mood (e.g., feeling sad, tearful)|53
60|1 - During the night only|1 - During the night only|53
61|1 - Fully granulating|1 - Fully granulating|53
62|1 - Good/Fair:  partial to full recovery is expected|1 - Good/Fair:  partial to full recovery is expected|53
63|1 - Good:  marked improvement in functional status is expected|1 - Good:  marked improvement in functional status is expected|53
64|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|53
65|1 - Smoking|1 - Smoking|53
66|1 - Hospital|1 - Hospital|53
67|1 - Hospital emergency room (includes 23-hour holding)|1 - Hospital emergency room (includes 23-hour holding)|53
68|1 - Hospitalization for EMERGENT (unscheduled) care|1 - Hospitalization for EMERGENT (unscheduled) care|53
69|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepared solutions), patient is able to manage all other aspects of equipment.|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepar|53
70|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|53
71|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|53
72|1 - In new or complex situations only|1 - In new or complex situations only|53
73|1 - Intravenous or infusion therapy (excludes TPN)|1 - Intravenous or infusion therapy (excludes TPN)|53
74|1 - Less often than daily|1 - Less often than daily|53
75|1 - Less than once a month|1 - Less than once a month|53
76|1 - Less than once weekly|1 - Less than once weekly|53
77|1 - Life expectancy is 6 months or fewer|1 - Life expectancy is 6 months or fewer|53
78|1 - Lives alone|1 - Lives alone|53
79|1 - Male|1 - Male|53
80|1 - Medicare (traditional fee-for-service)|1 - Medicare (traditional fee-for-service)|53
81|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of past 24 hours, significant memory loss so that supervision is required|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of pas|53
82|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors in word choice, grammar or speech intelligibility, needs minimal prompting or assistance).|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors i|53
83|1 - No assistance or services received|1 - No assistance or services received|53
84|1 - One|1 - One|53
85|1 - Oxygen (intermittent or continuous)|1 - Oxygen (intermittent or continuous)|53
86|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, and the surrounding layout, can count fingers at arm's length.|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, a|53
87|1 - Patient is incontinent|1 - Patient is incontinent|53
88|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|53
89|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical or treatment regimen.|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical|53
90|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient/couple/significant other)|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient|53
91|1 - Relatives, friends, or neighbors living outside the home|1 - Relatives, friends, or neighbors living outside the home|53
92|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions.|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions|53
93|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independentl|53
94|1 - Several times during day and night|1 - Several times during day and night|53
95|1 - Spouse or significant other|1 - Spouse or significant other|53
96|1 - Stage 1|1 - Stage 1|53
97|1 - Start of care - further visits planned|1 - Start of care - further visits planned|53
98|1 - Symptoms well controlled with current therapy|1 - Symptoms well controlled with current therapy|53
99|1 - Therapy services|1 - Therapy services|53
100|1 - Able to transfer with minimal human assistance or with use of an assistive device.|1 - Able to transfer with minimal human assistance or with use of an assistive device.|53
101|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitations.|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitatio|53
102|1 - Urinary incontinence|1 - Urinary incontinence|53
103|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and transfer.|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and|53
104|1 - When walking more than 20 feet, climbing stairs|1 - When walking more than 20 feet, climbing stairs|53
105|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary conversation. May need occasional repetition, extra time, or louder voice.|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary c|53
106|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting in and out of tub/shower|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting|53
107|1 - Yes|1 - Yes|53
108|1-RN|1-RN|53
109|10 - Discharge from agency - no visits completed after start/resumption of care assessment|10 - Discharge from agency - no visits completed after start/resumption of care assessment|53
110|10 - Scheduled surgical procedure|10 - Scheduled surgical procedure|53
111|10 - Self-pay|10 - Self-pay|53
112|11 - Other|11 - Other|53
113|11 - Urinary tract infection|11 - Urinary tract infection|53
114|12 - IV catheter-related infection|12 - IV catheter-related infection|53
115|13 - Deep vein thrombosis, pulmonary embolus|13 - Deep vein thrombosis, pulmonary embolus|53
116|14 - Uncontrolled pain|14 - Uncontrolled pain|53
117|15 - Psychotic episode|15 - Psychotic episode|53
118|16 - Other than above reasons|16 - Other than above reasons|53
119|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing calls.|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing|53
120|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another person.|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another pers|53
121|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface a|53
122|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for intermittent supervision or encouragement or reminders, OR (b) to get in and out of the shower or tub, OR (c) for washing difficult to reach areas.|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for inter|53
123|2 - Asian|2 - Asian|53
124|2 - Caregiver requires considerable assistance from another person to manage equipment, but independently completes significant portions of task.|2 - Caregiver requires considerable assistance from another person to manage equipment, but independ|53
125|2 - Daily, but not constantly|2 - Daily, but not constantly|53
126|2 - Daughter or son|2 - Daughter or son|53
127|2 - Doctor's office emergency visit/house call|2 - Doctor's office emergency visit/house call|53
128|2 - During the day and night|2 - During the day and night|53
129|2 - Early/partial granulation|2 - Early/partial granulation|53
130|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors in word choice, organization or speech intelligibility). Speaks in phrases or short sentences.|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors|53
131|2 - Family member's residence|2 - Family member's residence|53
132|2 - Female|2 - Female|53
133|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conversation, needs frequent prompting or assistance.|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conver|53
134|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|53
135|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|53
136|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately stop activities, jeopardizes safety through actions|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately st|53
137|2 - Indwelling/suprapubic catheter|2 - Indwelling/suprapubic catheter|53
138|2 - Injury caused by fall or accident at home|2 - Injury caused by fall or accident at home|53
139|2 - Medicare (HMO/managed care/Advantage plan)|2 - Medicare (HMO/managed care/Advantage plan)|53
140|2 - Nausea, dehydration, malnutrition, constipation, impaction|2 - Nausea, dehydration, malnutrition, constipation, impaction|53
141|2 - Obesity|2 - Obesity|53
142|2 - On awakening or at night only|2 - On awakening or at night only|53
143|2 - Once a month|2 - Once a month|53
144|2 - One to three times weekly|2 - One to three times weekly|53
145|2 - Parenteral nutrition (TPN or lipids)|2 - Parenteral nutrition (TPN or lipids)|53
146|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic)  [ Go to M1620 ]|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic)  [ Go|53
147|2 - Patient requires considerable assistance from another person to manage equipment, but independently completes portions of the task.|2 - Patient requires considerable assistance from another person to manage equipment, but independen|53
148|2 - Patient transferred to a noninstitutional hospice|2 - Patient transferred to a noninstitutional hospice|53
149|2 - Person residing in the home (EXCLUDING paid help)|2 - Person residing in the home (EXCLUDING paid help)|53
150|2 - Rehabilitation facility|2 - Rehabilitation facility|53
151|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifting of attention) or consistently requires low stimulus environment due to distractibility.|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifti|53
152|2 - Respite care|2 - Respite care|53
153|2 - Sense of failure or self reproach|2 - Sense of failure or self reproach|53
154|2 - Several times during day|2 - Several times during day|53
155|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonresponsive.|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonrespons|53
156|2 - Someone must assist the patient to groom self.|2 - Someone must assist the patient to groom self.|53
157|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|53
158|2 - Someone must help the patient put on upper body clothing.|2 - Someone must help the patient put on upper body clothing.|53
159|2 - Stage 2|2 - Stage 2|53
160|2 - Start of care - no further visits planned|2 - Start of care - no further visits planned|53
161|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitoring|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitori|53
162|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment regimen.|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment re|53
163|2 - Two|2 - Two|53
164|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistance due to cognitive or mental limitation.|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistanc|53
165|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|53
166|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assistance).|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assis|53
167|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home delivery.|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home deli|53
168|2 - Unable to prepare any light meals or reheat any delivered meals.|2 - Unable to prepare any light meals or reheat any delivered meals.|53
169|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|53
170|2 - UNABLE to take injectable medications unless administered by someone else.|2 - UNABLE to take injectable medications unless administered by someone else.|53
171|2 - UNABLE to take medication unless administered by someone else.|2 - UNABLE to take medication unless administered by someone else.|53
172|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|53
173|2 - Ventilator (continually or at night)|2 - Ventilator (continually or at night)|53
174|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less than 20 feet)|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less th|53
175|2 - With spouse or significant other|2 - With spouse or significant other|53
176|2 - Yes, assistance or services provided by family or friends|2 - Yes, assistance or services provided by family or friends|53
177|2-PT|2-PT|53
178|3 - Able to answer the telephone only some of the time or is able to carry on only a limited conversation.|3 - Able to answer the telephone only some of the time or is able to carry on only a limited convers|53
179|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube or gastrostomy.|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube|53
180|3 - Alcohol dependency|3 - Alcohol dependency|53
181|3 - All of the time|3 - All of the time|53
182|3 - Black or African-American|3 - Black or African-American|53
183|3 - Boarding home or rented room|3 - Boarding home or rented room|53
184|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment, clean/store/dispose of equipment or supplies).|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment,|53
185|3 -Able to walk only with the supervision or assistance of another person at all times.|3 -Able to walk only with the supervision or assistance of another person at all times.|53
186|3 - Continuous / Bi-level positive airway pressure|3 - Continuous / Bi-level positive airway pressure|53
187|3 - During the day and evening, but not constantly|3 - During the day and evening, but not constantly|53
188|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the alimentary canal)|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the|53
189|3 - Environmental support (e.g., housing, home maintenance)|3 - Environmental support (e.g., housing, home maintenance)|53
190|3 - Four to six times weekly|3 - Four to six times weekly|53
191|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessing by listener.  Speech limited to single words or short phrases.|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessin|53
192|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires multiple repetitions, restatements, demonstrations, additional time.|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires m|53
193|3 - Hopelessness|3 - Hopelessness|53
194|3 - Hospice care|3 - Hospice care|53
195|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|53
196|3 - Injury caused by fall or accident at home|3 - Injury caused by fall or accident at home|53
197|3 - Intractable pain|3 - Intractable pain|53
198|3 - Medicaid (traditional fee-for-service)|3 - Medicaid (traditional fee-for-service)|53
199|3 - Needs someone to do all shopping and errands.|3 - Needs someone to do all shopping and errands.|53
200|3 - Not healing|3 - Not healing|53
201|3 - Nursing home|3 - Nursing home|53
202|3 - Once daily|3 - Once daily|53
203|3 - Other family member|3 - Other family member|53
204|3 - Outpatient department/clinic emergency (includes urgicenter sites)|3 - Outpatient department/clinic emergency (includes urgicenter sites)|53
205|3 - Paid help|3 - Paid help|53
206|3 - Able to participate in bathing self in shower or tub, but requires presence of another person throughout the bath for assistance or supervision.|3 - Able to participate in bathing self in shower or tub, but requires presence of another person th|53
207|3 - Patient depends entirely upon another person to dress lower body.|3 - Patient depends entirely upon another person to dress lower body.|53
208|3 - Patient depends entirely upon another person to dress the upper body.|3 - Patient depends entirely upon another person to dress the upper body.|53
209|3 - Patient depends entirely upon someone else for grooming needs.|3 - Patient depends entirely upon someone else for grooming needs.|53
210|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone else to manage the equipment.|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone|53
211|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable to shift attention and recall directions more than half the time.|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable|53
212|3 - Respiratory problems (SOB, infection, obstruction)|3 - Respiratory problems (SOB, infection, obstruction)|53
213|3 - Resumption of care (after inpatient stay)|3 - Resumption of care (after inpatient stay)|53
214|3 - Several times each month|3 - Several times each month|53
215|3 - Skilled Nursing Facility|3 - Skilled Nursing Facility|53
216|3 - Stage 3|3 - Stage 3|53
217|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|53
218|3 - Three|3 - Three|53
219|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person throughout the process.|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person through|53
220|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal independently.|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal indep|53
221|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person.|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person|53
222|3 - Unknown because patient moved to a geographic location not served by this agency|3 - Unknown because patient moved to a geographic location not served by this agency|53
223|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|53
224|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|53
225|3 - With other family member|3 - With other family member|53
226|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home health services, homemaker assistance, transportation assistance, assisted living, board and care)|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home h|53
227|3-SLP/ST|3-SLP/ST|53
228|4 - At rest (during day or night)|4 - At rest (during day or night)|53
229|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|53
230|4 - Board and care or assisted living facility|4 - Board and care or assisted living facility|53
231|4 - Caregiver is completely dependent on someone else to manage all equipment.|4 - Caregiver is completely dependent on someone else to manage all equipment.|53
232|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|53
233|4 - Constantly|4 - Constantly|53
234|4 - Drug dependency|4 - Drug dependency|53
235|4 - Four or more|4 - Four or more|53
236|4 - Friend or neighbor or community or church member|4 - Friend or neighbor or community or church member|53
237|4 - Hispanic or Latino|4 - Hispanic or Latino|53
238|4 - Hospice|4 - Hospice|53
239|4 - Impaired decision-making|4 - Impaired decision-making|53
240|4 - Is totally dependent in toileting.|4 - Is totally dependent in toileting.|53
241|4 - Medicaid (HMO/managed care)|4 - Medicaid (HMO/managed care)|53
242|4 - None of the above|4 - None of the above|53
243|4 - Nursing home|4 - Nursing home|53
244|4 - On a daily basis|4 - On a daily basis|53
245|4 - Patient is completely dependent on someone else to manage all equipment.|4 - Patient is completely dependent on someone else to manage all equipment.|53
246|4 - Permanent placement|4 - Permanent placement|53
247|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, punches, dangerous maneuvers w/ wheelchair or other objects)|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, pu|53
248|4 - Psychosocial support (e.g., socialization, companionship, recreation)|4 - Psychosocial support (e.g., socialization, companionship, recreation)|53
249|4 - Recertification (follow-up) reassessment|4 - Recertification (follow-up) reassessment|53
250|4 - Recurrent thoughts of death|4 - Recurrent thoughts of death|53
251|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruction)|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruc|53
252|4 - Several times a week|4 - Several times a week|53
253|4 - Stage 4|4 - Stage 4|53
254|4 - Symptoms poorly controlled, history of re-hospitalizations|4 - Symptoms poorly controlled, history of re-hospitalizations|53
255|4 - Three or more times per week|4 - Three or more times per week|53
256|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetative state, or delirium.|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetati|53
257|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|53
258|4 - Unable to effectively participate in any housekeeping tasks.|4 - Unable to effectively participate in any housekeeping tasks.|53
259|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or unresponsive (e.g., speech is nonsensical or unintelligible).|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or u|53
260|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonresponsive.|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonr|53
261|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostomy.|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostom|53
262|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of devices at the sink, in chair, or on commode|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of|53
263|4 - With a friend|4 - With a friend|53
264|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|53
265|4-OT|4-OT|53
266|5 - Advocates or facilitates patient's participation in appropriate medical care|5 - Advocates or facilitates patient's participation in appropriate medical care|53
267|5 - At least daily|5 - At least daily|53
268|6 - Bedfast, unable to ambulate or be up in a chair.|6 - Bedfast, unable to ambulate or be up in a chair.|53
269|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|53
270|5 - Disruptive or socially inappropriate behavior|5 - Disruptive or socially inappropriate behavior|53
271|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|53
272|5 - Hypo/Hyperglycemia, diabetes out of control|5 - Hypo/Hyperglycemia, diabetes out of control|53
273|5 - More often than once daily|5 - More often than once daily|53
274|5 - Native Hawaiian or Pacific Islander|5 - Native Hawaiian or Pacific Islander|53
275|5 - None of the above|5 - None of the above|53
276|5 - One to two times per week|5 - One to two times per week|53
277|5 - Other|5 - Other|53
278|5 - Other follow-up|5 - Other follow-up|53
279|5 - Paid help|5 - Paid help|53
280|5 - Patient nonresponsive or unable to speak.|5 - Patient nonresponsive or unable to speak.|53
281|5 - Thoughts of suicide|5 - Thoughts of suicide|53
282|5 - Totally unable to use the telephone.|5 - Totally unable to use the telephone.|53
283|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|53
284|5 - Unable to take in nutrients orally or by tube feeding.|5 - Unable to take in nutrients orally or by tube feeding.|53
285|5 - Unsafe for care at home|5 - Unsafe for care at home|53
286|5 - With paid help (other than home care agency staff)|5 - With paid help (other than home care agency staff)|53
287|5 - Workers' compensation|5 - Workers' compensation|53
288|5 - Wound infection, deteriorating wound status, new lesion/ulcer|5 - Wound infection, deteriorating wound status, new lesion/ulcer|53
289|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|53
290|6 - Delusional, hallucinatory, or paranoid behavior|6 - Delusional, hallucinatory, or paranoid behavior|53
291|6 - Financial agent, power of attorney, or conservator of finance|6 - Financial agent, power of attorney, or conservator of finance|53
292|6 - GI bleeding, obstruction|6 - GI bleeding, obstruction|53
293|6 - Less often than weekly|6 - Less often than weekly|53
294|6 - Memory loss to the extent that supervision required|6 - Memory loss to the extent that supervision required|53
295|6 - None of the above feelings observed or reported|6 - None of the above feelings observed or reported|53
296|6 - Other|6 - Other|53
297|6 - Title programs (e.g., Title III, V, or XX)|6 - Title programs (e.g., Title III, V, or XX)|53
298|6 - Transferred to an inpatient facility - patient not discharged from agency|6 - Transferred to an inpatient facility - patient not discharged from agency|53
299|6 - White|6 - White|53
300|6 - With other than above|6 - With other than above|53
301|7 - Exacerbation of CHF, fluid overload, heart failure|7 - Exacerbation of CHF, fluid overload, heart failure|53
302|7 - Health care agent, conservator of person, or medical power of attorney|7 - Health care agent, conservator of person, or medical power of attorney|53
303|7 - Hypo/Hyperglycemia, diabetes out of control|7 - Hypo/Hyperglycemia, diabetes out of control|53
304|7 - None of the above|7 - None of the above|53
305|7 - None of the above behaviors demonstrated|7 - None of the above behaviors demonstrated|53
306|7 - Other government (e.g., TriCare, VA, etc.)|7 - Other government (e.g., TriCare, VA, etc.)|53
307|7 - Transferred to an inpatient facility - patient discharged from agency|7 - Transferred to an inpatient facility - patient discharged from agency|53
308|8 - Death at home|8 - Death at home|53
309|8 - GI bleeding, obstruction|8 - GI bleeding, obstruction|53
310|8 - Myocardial infarction, stroke|8 - Myocardial infarction, stroke|53
311|8 - Private insurance|8 - Private insurance|53
312|9 - Chemotherapy|9 - Chemotherapy|53
313|9 - Discharge from agency|9 - Discharge from agency|53
314|9 - Other than above reasons|9 - Other than above reasons|53
315|9 - Private HMO/managed care|9 - Private HMO/managed care|53
316|NA - No caregiver|NA - No caregiver|53
317|NA - No equipment of this type used in care.|NA - No equipment of this type used in care.|53
318|NA - No inhalant/mist medications prescribed.|NA - No inhalant/mist medications prescribed.|53
319|NA - No injectable medications prescribed.|NA - No injectable medications prescribed.|53
320|NA - No inpatient facility admission|NA - No inpatient facility admission|53
321|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|53
322|NA - No Medicaid|NA - No Medicaid|53
323|NA - No Medicare|NA - No Medicare|53
324|NA - No observable pressure ulcer or unhealed pressure ulcer|NA - No observable pressure ulcer or unhealed pressure ulcer|53
325|NA - No observable stasis ulcer|NA - No observable stasis ulcer|53
326|NA - No observable surgical wound|NA - No observable surgical wound|53
327|NA - No oral medications prescribed.|NA - No oral medications prescribed.|53
328|NA - Not applicable|NA - Not applicable|53
329|NA - Patient does not have a telephone.|NA - Patient does not have a telephone.|53
330|NA - Patient has ostomy for bowel elimination|NA - Patient has ostomy for bowel elimination|53
331|NA - Patient nonresponsive|NA - Patient nonresponsive|53
332|NA - Patient on prophylactic treatment|NA - Patient on prophylactic treatment|53
333|NA - Patient was not discharged from an inpatient facility [Go to M1017]|NA - Patient was not discharged from an inpatient facility [Go to M1017]|53
334|UK - Other unknown|UK - Other unknown|53
335|UK - Reason unknown|UK - Reason unknown|53
336|UK - Unknown|UK - Unknown|53
337|UK - Unknown or Not Available|UK - Unknown or Not Available|53
341|01 - Early|01 - Early|53
342|02 - Late|02 - Late|53
343|NA - Not Applicable. No case mix group defined for this assessment.|NA - Not Applicable. No case mix group defined for this assessment.|53
344|NA - No case mix group defined by this assessment.|NA - No case mix group defined by this assessment.|53
345|1 - Recent decline in mental, emotional, or behavioral status|1 - Recent decline in mental, emotional, or behavioral status|53
346|2 - Multiple hospitalizations (2 or more) in the past 12 months|2 - Multiple hospitalizations (2 or more) in the past 12 months|53
347|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|53
348|4 - Taking five or more medications|4 - Taking five or more medications|53
349|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|53
350|6 - Other|6 - Other|53
351|7 - None of the above|7 - None of the above|53
352|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond tho|53
353|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable without heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable wi|53
354|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious complications and death.|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious compl|53
355|3 - The patient has serious progressive conditions that could lead to death within a year.|3 - The patient has serious progressive conditions that could lead to death within a year.|53
356|UK - The patient+s situation is unknown or unclear.|UK - The patient+s situation is unknown or unclear.|53
357|1 - Yes [ Go to M1050 ]|1 - Yes [ Go to M1050 ]|53
358|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this influenza season. [ Go to M1050 ]|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this i|53
359|1 - Received from another health care provider (e.g., physician)|1 - Received from another health care provider (e.g., physician)|53
360|2 - Received from your agency previously during this year+s flu season|2 - Received from your agency previously during this year+s flu season|53
361|3 - Offered and declined|3 - Offered and declined|53
362|4 - Assessed and determined to have medical contraindication(s)|4 - Assessed and determined to have medical contraindication(s)|53
363|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|53
364|6 - Inability to obtain vaccine due to declared shortage|6 - Inability to obtain vaccine due to declared shortage|53
365|1 - Yes [ Go to M1500 at TRN; Go to M1230 at DC ]|1 - Yes [ Go to M1500 at TRN; Go to M1230 at DC ]|53
366|1 - Patient has received PPV in the past|1 - Patient has received PPV in the past|53
367|2 - Offered and declined|2 - Offered and declined|53
368|3 - Assessed and determined to have medical contraindication(s)|3 - Assessed and determined to have medical contraindication(s)|53
369|4 - Not indicated; patient does not meet age/condition guidelines for PPV|4 - Not indicated; patient does not meet age/condition guidelines for PPV|53
370|5 - None of the above|5 - None of the above|53
371|0 - Adequate: hears normal conversation without difficulty.|0 - Adequate: hears normal conversation without difficulty.|53
372|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to increase volume or speak distinctly.|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to in|53
373|2 - Severely Impaired: absence of useful hearing.|2 - Severely Impaired: absence of useful hearing.|53
374|UK - Unable to assess hearing.|UK - Unable to assess hearing.|53
375|0 - Understands: clear comprehension without cues or repetitions.|0 - Understands: clear comprehension without cues or repetitions.|53
376|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Requires cues at times to understand.|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Req|53
377|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequently requires cues to understand.|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequentl|53
378|3 - Rarely/Never Understands|3 - Rarely/Never Understands|53
379|UK - Unable to assess understanding.|UK - Unable to assess understanding.|53
380|0 - No standardized assessment conducted|0 - No standardized assessment conducted|53
381|1 - Yes, and it does not indicate severe pain|1 - Yes, and it does not indicate severe pain|53
382|2 - Yes, and it indicates severe pain|2 - Yes, and it indicates severe pain|53
383|0 - Patient has no pain|0 - Patient has no pain|53
384|1 - Patient has pain that does not interfere with activity or movement|1 - Patient has pain that does not interfere with activity or movement|53
385|2 - Less often than daily|2 - Less often than daily|53
386|3 - Daily, but not constantly|3 - Daily, but not constantly|53
387|4 - All of the time|4 - All of the time|53
388|0 - No assessment conducted [ Go to M1306 ]|0 - No assessment conducted [ Go to M1306 ]|53
389|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc., without use of standardized tool|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc.,|53
390|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|53
391|0 - No [ Go to M1322]|0 - No [ Go to M1322]|53
392|0 v Newly epithelialized|0 v Newly epithelialized|53
393|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|53
394|2 - Yes, patient has observable stasis ulcers ONLY|2 - Yes, patient has observable stasis ulcers ONLY|53
395|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable dressing) [Go to M1340]|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable|53
396|0 - No [ Go to M1350 ]|0 - No [ Go to M1350 ]|53
397|1 - Yes, patient has at least one (observable) surgical wound|1 - Yes, patient has at least one (observable) surgical wound|53
398|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1350 ]|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1350 ]|53
399|0 - Patient is not short of breath|0 - Patient is not short of breath|53
400|3 - Continuous Bi-level positive airway pressure|3 - Continuous Bi-level positive airway pressure|53
401|0 - No [ Go to M1732 at TRN; Go to M1600 at DC ]|0 - No [ Go to M1732 at TRN; Go to M1600 at DC ]|53
402|2 - Not assessed [Go to M1732 at TRN; Go to M1600 at DC ]|2 - Not assessed [Go to M1732 at TRN; Go to M1600 at DC ]|53
403|NA - Patient does not have diagnosis of heart failure [Go to M2004 at TRN; Go to M1600 at DC]|NA - Patient does not have diagnosis of heart failure [Go to M2004 at TRN; Go to M1600 at DC]|53
404|0 - No action taken|0 - No action taken|53
405|1 - Patient+s physician (or other primary care practitioner) contacted the same day|1 - Patient+s physician (or other primary care practitioner) contacted the same day|53
406|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|53
407|3 - Implement physician-ordered patient-specific established parameters for treatment|3 - Implement physician-ordered patient-specific established parameters for treatment|53
408|4 - Patient education or other clinical interventions|4 - Patient education or other clinical interventions|53
409|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequency, telehealth, etc.)|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequ|53
410|1 - Occasional stress incontinence|1 - Occasional stress incontinence|53
411|2 - During the night only|2 - During the night only|53
412|3 - During the day only|3 - During the day only|53
413|4 - During the day and night|4 - During the day and night|53
414|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|53
415|0 - Able to manage toileting hygiene and clothing management without assistance.|0 - Able to manage toileting hygiene and clothing management without assistance.|53
416|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implements are laid out for the patient.|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implemen|53
417|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|53
418|3 - Patient depends entirely upon another person to maintain toileting hygiene.|3 - Patient depends entirely upon another person to maintain toileting hygiene.|53
419|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independent|53
420|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface|53
421|0 - No multi-factor falls risk assessment conducted.|0 - No multi-factor falls risk assessment conducted.|53
422|1 - Yes, and it does not indicate a risk for falls.|1 - Yes, and it does not indicate a risk for falls.|53
423|2 - Yes, and it indicates a risk for falls.|2 - Yes, and it indicates a risk for falls.|53
424|0 - Not assessed/reviewed [ Go to M2010 ]|0 - Not assessed/reviewed [ Go to M2010 ]|53
425|1 - No problems found during review [ Go to M2010 ]|1 - No problems found during review [ Go to M2010 ]|53
426|2 - Problems found during review|2 - Problems found during review|53
427|NA - Patient is not taking any medications [ Go to M2040 ]|NA - Patient is not taking any medications [ Go to M2040 ]|53
428|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special precautions associated with all high-risk medications|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special p|53
429|NA - Patient not taking any drugs|NA - Patient not taking any drugs|53
430|2 - Able to take medication(s) at the correct times if given reminders by another person at the appropriate times|2 - Able to take medication(s) at the correct times if given reminders by another person at the appr|53
431|3 - Unable to take medication unless administered by another person.|3 - Unable to take medication unless administered by another person.|53
432|1 - At least daily|1 - At least daily|53
433|2 - Three or more times per week|2 - Three or more times per week|53
434|3 - One to two times per week|3 - One to two times per week|53
435|4 - Received, but less often than weekly|4 - Received, but less often than weekly|53
436|5 - No assistance received|5 - No assistance received|53
437|0 - No [Go to M2400]|0 - No [Go to M2400]|53
438|1 - Yes, used hospital emergency department WITHOUT hospital admission|1 - Yes, used hospital emergency department WITHOUT hospital admission|53
439|2 - Yes, used hospital emergency department WITH hospital admission|2 - Yes, used hospital emergency department WITH hospital admission|53
440|UK - Unknown [Go to M2400]|UK - Unknown [Go to M2400]|53
441|2 - Injury caused by fall|2 - Injury caused by fall|53
442|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|53
443|4 - Other respiratory problem|4 - Other respiratory problem|53
444|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|53
445|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|53
446|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|53
447|8 - Other heart disease|8 - Other heart disease|53
448|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|53
449|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|53
450|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|53
451|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|53
452|13 - Urinary tract infection|13 - Urinary tract infection|53
453|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|53
454|15 - Wound infection or deterioration|15 - Wound infection or deterioration|53
455|16 - Uncontrolled pain|16 - Uncontrolled pain|53
456|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|53
457|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|53
458|19 - Other than above reasons|19 - Other than above reasons|53
459|2 - Patient remained in the community (with formal assistive services)|2 - Patient remained in the community (with formal assistive services)|53
460|3 - Patient transferred to a noninstitutional hospice|3 - Patient transferred to a noninstitutional hospice|53
461|4 - Unknown because patient moved to a geographic location not served by this agency|4 - Unknown because patient moved to a geographic location not served by this agency|53
462|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|53
463|4 - Other respiratory problem|4 - Other respiratory problem|53
464|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|53
465|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|53
466|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|53
467|8 - Other heart disease|8 - Other heart disease|53
468|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|53
469|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|53
470|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|53
471|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|53
472|13 - Urinary tract infection|13 - Urinary tract infection|53
473|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|53
474|15 - Wound infection or deterioration|15 - Wound infection or deterioration|53
475|16 - Uncontrolled pain|16 - Uncontrolled pain|53
476|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|53
477|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|53
478|19 - Scheduled treatment or procedure|19 - Scheduled treatment or procedure|53
479|20 - Other than above reasons|20 - Other than above reasons|53
480|UK - Reason unknown [Go to M0903]|UK - Reason unknown [Go to M0903]|53
482|01 - Patient lives alone around the clock|01 - Patient lives alone around the clock|53
483|02 - Patient lives alone regular daytime|02 - Patient lives alone regular daytime|53
484|03 - Patient lives alone regular nighttime|03 - Patient lives alone regular nighttime|53
485|04 - Patient lives alone occassional/short term assistance|04 - Patient lives alone occassional/short term assistance|53
486|05 - Patient lives alone no assisstance available|05 - Patient lives alone no assisstance available|53
487|06 - Patient lives with other person(s) in the home around the clock|06 - Patient lives with other person(s) in the home around the clock|53
488|07 - Patient lives with other person(s) in the home regular daytime|07 - Patient lives with other person(s) in the home regular daytime|53
489|08 - Patient lives with other person(s) in the home regular nighttime|08 - Patient lives with other person(s) in the home regular nighttime|53
490|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|53
491|10 - Patient lives with other person(s) in the home no assistance available|10 - Patient lives with other person(s) in the home no assistance available|53
492|1 - Was present at the most recent SOC/ROC assessment|1 - Was present at the most recent SOC/ROC assessment|53
493|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|53
494|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|53
495|0 - Newly epithelialized|0 - Newly epithelialized|53
496|0 - No [ Go to M1340 ]|0 - No [ Go to M1340 ]|53
498|0 - Independent|0 - Independent|53
499|1 - Needed Some Help|1 - Needed Some Help|53
500|2 - Dependent|2 - Dependent|53
502|0 - No assistance needed in this area|0 - No assistance needed in this area|53
503|1 - Caregiver(s) currently provide assistance|1 - Caregiver(s) currently provide assistance|53
504|2 - Caregiver(s) need training/ supportive services to provide assistance|2 - Caregiver(s) need training/ supportive services to provide assistance|53
505|3 - Caregiver(s) not likely to provide assistance|3 - Caregiver(s) not likely to provide assistance|53
506|4 - Unclear if Caregiver(s) will provide assistance|4 - Unclear if Caregiver(s) will provide assistance|53
507|5 - Assistance needed, but no Caregiver(s) available|5 - Assistance needed, but no Caregiver(s) available|53
508|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will use standardized clinical guidelines accessible for all care providers to reference|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will|53
509|NA - Patient is not diabetic or is bilateral amputee|NA - Patient is not diabetic or is bilateral amputee|53
510|NA - Patient is not assessed to be at risk for falls|NA - Patient is not assessed to be at risk for falls|53
511|NA - Patient has no diagnosis or symptoms of depression|NA - Patient has no diagnosis or symptoms of depression|53
512|NA - No pain identified|NA - No pain identified|53
513|NA - Patient is not assessed to be at risk for pressure ulcers|NA - Patient is not assessed to be at risk for pressure ulcers|53
514|NA - Patient has no pressure ulcers with need for moist wound healing|NA - Patient has no pressure ulcers with need for moist wound healing|53
515|1 - Long-term nursing facility (NF)|1 - Long-term nursing facility (NF)|53
516|2 - Skilled nursing facility (SNF / TCU)|2 - Skilled nursing facility (SNF / TCU)|53
517|3 - Short stay acute hospital (IPP S)|3 - Short stay acute hospital (IPP S)|53
518|4 - Long-term care hospital (LTCH)|4 - Long-term care hospital (LTCH)|53
519|5 - Inpatient rehabilitation hospital or unit (IRF)|5 - Inpatient rehabilitation hospital or unit (IRF)|53
520|6 - Psychiatric hospital or unit|6 - Psychiatric hospital or unit|53
521|7 - Other|7 - Other|53
522|NA - Patient was not discharged from an inpatient facility [Go to M1017]|NA - Patient was not discharged from an inpatient facility [Go to M1017]|53
523|6 - Unable to participate effectively in bathing and is bathed totally by another person|6 - Unable to participate effectively in bathing and is bathed totally by another person|53
524|4 - Chairfast, unable to ambulate but is able to wheel self independently.|4 - Chairfast, unable to ambulate but is able to wheel self independently.|53
525|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask patient: "Over the last two weeks, how often have you been bothered by any of the following problems")  *Copyright+ Pfizer Inc. All rights reserved. Reproduced with permission.|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask|53
526|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluation for depression.|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluat|53
527|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet criteria for further evaluation for depression.|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet|53
528|0 - Not at all  0 - 1 day|0 - Not at all  0 - 1 day|53
529|1 - Several days  2 - 6 days|1 - Several days  2 - 6 days|53
530|2 - More than half of the days  7 - 11 days|2 - More than half of the days  7 - 11 days|53
531|3 - Nearly every day  12 - 14 days|3 - Nearly every day  12 - 14 days|53
532|NA - N/A  Unable to respond|NA - N/A  Unable to respond|53
533|2 - Able to take medication(s) at the correct times if given reminders by another person based on the frequency of the injection|2 - Able to take medication(s) at the correct times if given reminders by another person based on th|53
534|3 - Unable to take injectable medication unless administered by another person.|3 - Unable to take injectable medication unless administered by another person.|53
540|11 - Patient lives in congregate situation (e.g., assisted living) around the clock|11 - Patient lives in congregate situation (e.g., assisted living) around the clock|53
541|12 - Patient lives in congregate situation (e.g., assisted living) regular daytime|12 - Patient lives in congregate situation (e.g., assisted living) regular daytime|53
542|13 - Patient lives in congregate situation (e.g., assisted living) regular nighttime|13 - Patient lives in congregate situation (e.g., assisted living) regular nighttime|53
543|14 - Patient lives in congregate situation (e.g., assisted living) occasional / short-term assistance|14 - Patient lives in congregate situation (e.g., assisted living) occasional / short-term assistanc|53
544|15 - Patient lives in congregate situation (e.g., assisted living) no available assistance|15 - Patient lives in congregate situation (e.g., assisted living) no available assistance|53
546|NA - No observable pressure ulcer|NA - No observable pressure ulcer|53
583|NA - No specific SOC date ordered by physician|NA - No specific SOC date ordered by physician|53
586|UK - Inpatient Discharge Date Unknown|UK - Inpatient Discharge Date Unknown|53
601|1 - History of falls (2 or more falls - or any fall with an injury - in the past 12 months) |1 - History of falls (2 or more falls - or any fall with an injury - in the past 12 months) |53
603|2 - Unintentional weight loss of a total of 10 pounds or more in the past 12 months |2 - Unintentional weight loss of a total of 10 pounds or more in the past 12 months |53
605|3 - Multiple hospitalizations (2 or more) in the past 6 months|3 - Multiple hospitalizations (2 or more) in the past 6 months|53
607|4 - Multiple emergency department visits (2 or more) in the past 6 months|4 - Multiple emergency department visits (2 or more) in the past 6 months|53
609|5 - Decline in mental emotional or behavioral status in the past 3 months |5 - Decline in mental emotional or behavioral status in the past 3 months |53
611|6 - Reported or observed history of difficulty complying with any medical instructions (for example |6 - Reported or observed history of difficulty complying with any medical instructions (for example |53
613|7 - Currently taking 5 or more medications|7 - Currently taking 5 or more medications|53
615|8 - Currently reports exhaustion|8 - Currently reports exhaustion|53
617|9 - Other risk(s) not listed in 1 - 8|9 - Other risk(s) not listed in 1 - 8|53
619|10 - None of the above |10 - None of the above |53
632|0 - No assistance needed v patient is independent or does not have needs in this area|0 - No assistance needed v patient is independent or does not have needs in this area|53
633|1 - Non-agency caregiver(s) currently provide assistance |1 - Non-agency caregiver(s) currently provide assistance |53
634|2 - Non-agency caregiver(s) need training/ supportive services to provide assistance|2 - Non-agency caregiver(s) need training/ supportive services to provide assistance|53
635|3 - Non-agency caregiver(s) are not likely to provide assistance OR it is unclear if they will provide assistance|3 - Non-agency caregiver(s) are not likely to provide assistance OR unclear if will provide asst|53
636|4 - Assistance needed but no non-agency caregiver(s) available|4 - Assistance needed but no non-agency caregiver(s) available|53
2|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; OR (b) Is physically, cognitively, and mentally able to prepare light meals on a regular basis but has not routinely performed light meal preparation in the past (i.e., prior to this home care admission).|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; O|54
3|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and mentally able to perform all housekeeping tasks .|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and menta|54
4|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and mentally able to do laundry and access facilities.|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and menta|54
5|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying packages OR b) Physically, cognitively, and mentally able to take care of shopping, but has not done shopping in the past (i.e., prior to this home care admission).|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying|54
6|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|54
7|0 - Able to dial numbers and answer calls appropriately and as desired.|0 - Able to dial numbers and answer calls appropriately and as desired.|54
8|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body without assistance.|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body|54
9|0 - Able to get to and from the toilet and transfer independently with or without a device.|0 - Able to get to and from the toilet and transfer independently with or without a device.|54
10|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|54
11|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible public bus.|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible p|54
12|0 - Able to independently feed self.|0 - Able to independently feed self.|54
13|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|54
14|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct times.|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct ti|54
15|0 - Able to independently transfer.|0 - Able to independently transfer.|54
16|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without rail|54
17|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings|54
18|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|54
19|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions independently.|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions indep|54
20|0 - Asymptomatic, no treatment needed at this time|0 - Asymptomatic, no treatment needed at this time|54
21|0 - Caregiver manages all tasks related to equipment completely independently.|0 - Caregiver manages all tasks related to equipment completely independently.|54
22|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations with no observable impairment.|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations w|54
23|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|54
24|0 - Life expectancy is greater than 6 months|0 - Life expectancy is greater than 6 months|54
25|0 - Never|0 - Never|54
26|0 - Patient is not short of breath|0 - Patient is not short of breath|54
27|0 - No|0 - No|54
28|0 - No emergent care services|0 - No emergent care services|54
29|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [Goto M1620]|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [Goto M1620]|54
30|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and extended or abstract conversation.|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and exte|54
31|0 - No one person|0 - No one person|54
32|0 - None of the time|0 - None of the time|54
33|0 - None, no charge for current services|0 - None, no charge for current services|54
34|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|54
35|0 - Patient does NOT have an ostomy for bowel elimination.|0 - Patient does NOT have an ostomy for bowel elimination.|54
36|0 - Patient has no pain|0 - Patient has no pain|54
37|0 - Patient manages all tasks related to equipment completely independently.|0 - Patient manages all tasks related to equipment completely independently.|54
38|0 - Poor:  little or no recovery is expected and/or further decline is imminent|0 - Poor:  little or no recovery is expected and/or further decline is imminent|54
39|0 - Timed-voiding defers incontinence|0 - Timed-voiding defers incontinence|54
40|0 - Very rarely or never has bowel incontinence|0 - Very rarely or never has bowel incontinence|54
41|0 - Zero|0 - Zero|54
42|00 - No|00 - No|54
43|01 - Yes|01 - Yes|54
44|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or mental limitations, needs assistance with heavy laundry.|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or|54
45|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the patient.|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the|54
46|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|54
47|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or supervision from another person OR c) a liquid, pureed or ground meat diet.|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or su|54
48|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|54
49|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|54
50|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independently.|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independe|54
51|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only when assisted or accompanied by another person.|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only w|54
52|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepa|54
53|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance by another person OR b) given daily reminders.|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance b|54
54|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advan|54
55|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advan|54
56|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for the deaf) and call essential numbers.|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for t|54
57|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|54
58|1 - American Indian or Alaska Native|1 - American Indian or Alaska Native|54
59|1 - Depressed mood (e.g., feeling sad, tearful)|1 - Depressed mood (e.g., feeling sad, tearful)|54
60|1 - During the night only|1 - During the night only|54
61|1 - Fully granulating|1 - Fully granulating|54
62|1 - Good/Fair:  partial to full recovery is expected|1 - Good/Fair:  partial to full recovery is expected|54
63|1 - Good:  marked improvement in functional status is expected|1 - Good:  marked improvement in functional status is expected|54
64|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|54
65|1 - Smoking|1 - Smoking|54
66|1 - Hospital|1 - Hospital|54
67|1 - Hospital emergency room (includes 23-hour holding)|1 - Hospital emergency room (includes 23-hour holding)|54
68|1 - Hospitalization for EMERGENT (unscheduled) care|1 - Hospitalization for EMERGENT (unscheduled) care|54
69|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepared solutions), patient is able to manage all other aspects of equipment.|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepar|54
70|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|54
71|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|54
72|1 - In new or complex situations only|1 - In new or complex situations only|54
73|1 - Intravenous or infusion therapy (excludes TPN)|1 - Intravenous or infusion therapy (excludes TPN)|54
74|1 - Less often than daily|1 - Less often than daily|54
75|1 - Less than once a month|1 - Less than once a month|54
76|1 - Less than once weekly|1 - Less than once weekly|54
77|1 - Life expectancy is 6 months or fewer|1 - Life expectancy is 6 months or fewer|54
78|1 - Lives alone|1 - Lives alone|54
79|1 - Male|1 - Male|54
80|1 - Medicare (traditional fee-for-service)|1 - Medicare (traditional fee-for-service)|54
81|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of past 24 hours, significant memory loss so that supervision is required|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of pas|54
82|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors in word choice, grammar or speech intelligibility, needs minimal prompting or assistance).|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors i|54
83|1 - No assistance or services received|1 - No assistance or services received|54
84|1 - One|1 - One|54
85|1 - Oxygen (intermittent or continuous)|1 - Oxygen (intermittent or continuous)|54
86|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, and the surrounding layout, can count fingers at arm's length.|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, a|54
87|1 - Patient is incontinent|1 - Patient is incontinent|54
88|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|54
89|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical or treatment regimen.|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical|54
90|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient/couple/significant other)|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient|54
91|1 - Relatives, friends, or neighbors living outside the home|1 - Relatives, friends, or neighbors living outside the home|54
92|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions.|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions|54
93|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independentl|54
94|1 - Several times during day and night|1 - Several times during day and night|54
95|1 - Spouse or significant other|1 - Spouse or significant other|54
96|1 - Stage 1|1 - Stage 1|54
97|1 - Start of care - further visits planned|1 - Start of care - further visits planned|54
98|1 - Symptoms well controlled with current therapy|1 - Symptoms well controlled with current therapy|54
99|1 - Therapy services|1 - Therapy services|54
100|1 - Able to transfer with minimal human assistance or with use of an assistive device.|1 - Able to transfer with minimal human assistance or with use of an assistive device.|54
101|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitations.|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitatio|54
102|1 - Urinary incontinence|1 - Urinary incontinence|54
103|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and transfer.|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and|54
104|1 - When walking more than 20 feet, climbing stairs|1 - When walking more than 20 feet, climbing stairs|54
105|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary conversation. May need occasional repetition, extra time, or louder voice.|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary c|54
106|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting in and out of tub/shower|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting|54
107|1 - Yes|1 - Yes|54
108|1-RN|1-RN|54
109|10 - Discharge from agency - no visits completed after start/resumption of care assessment|10 - Discharge from agency - no visits completed after start/resumption of care assessment|54
110|10 - Scheduled surgical procedure|10 - Scheduled surgical procedure|54
111|10 - Self-pay|10 - Self-pay|54
112|11 - Other|11 - Other|54
113|11 - Urinary tract infection|11 - Urinary tract infection|54
114|12 - IV catheter-related infection|12 - IV catheter-related infection|54
115|13 - Deep vein thrombosis, pulmonary embolus|13 - Deep vein thrombosis, pulmonary embolus|54
116|14 - Uncontrolled pain|14 - Uncontrolled pain|54
117|15 - Psychotic episode|15 - Psychotic episode|54
118|16 - Other than above reasons|16 - Other than above reasons|54
119|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing calls.|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing|54
120|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another person.|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another pers|54
121|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface a|54
122|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for intermittent supervision or encouragement or reminders, OR (b) to get in and out of the shower or tub, OR (c) for washing difficult to reach areas.|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for inter|54
123|2 - Asian|2 - Asian|54
124|2 - Caregiver requires considerable assistance from another person to manage equipment, but independently completes significant portions of task.|2 - Caregiver requires considerable assistance from another person to manage equipment, but independ|54
125|2 - Daily, but not constantly|2 - Daily, but not constantly|54
126|2 - Daughter or son|2 - Daughter or son|54
127|2 - Doctor's office emergency visit/house call|2 - Doctor's office emergency visit/house call|54
128|2 - During the day and night|2 - During the day and night|54
129|2 - Early/partial granulation|2 - Early/partial granulation|54
130|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors in word choice, organization or speech intelligibility). Speaks in phrases or short sentences.|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors|54
131|2 - Family member's residence|2 - Family member's residence|54
132|2 - Female|2 - Female|54
133|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conversation, needs frequent prompting or assistance.|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conver|54
134|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|54
135|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|54
136|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately stop activities, jeopardizes safety through actions|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately st|54
137|2 - Indwelling/suprapubic catheter|2 - Indwelling/suprapubic catheter|54
138|2 - Injury caused by fall or accident at home|2 - Injury caused by fall or accident at home|54
139|2 - Medicare (HMO/managed care/Advantage plan)|2 - Medicare (HMO/managed care/Advantage plan)|54
140|2 - Nausea, dehydration, malnutrition, constipation, impaction|2 - Nausea, dehydration, malnutrition, constipation, impaction|54
141|2 - Obesity|2 - Obesity|54
142|2 - On awakening or at night only|2 - On awakening or at night only|54
143|2 - Once a month|2 - Once a month|54
144|2 - One to three times weekly|2 - One to three times weekly|54
145|2 - Parenteral nutrition (TPN or lipids)|2 - Parenteral nutrition (TPN or lipids)|54
146|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic) [ Go to M1620 ]|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic) [ Go|54
147|2 - Patient requires considerable assistance from another person to manage equipment, but independently completes portions of the task.|2 - Patient requires considerable assistance from another person to manage equipment, but independen|54
148|2 - Patient transferred to a noninstitutional hospice|2 - Patient transferred to a noninstitutional hospice|54
149|2 - Person residing in the home (EXCLUDING paid help)|2 - Person residing in the home (EXCLUDING paid help)|54
150|2 - Rehabilitation facility|2 - Rehabilitation facility|54
151|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifting of attention) or consistently requires low stimulus environment due to distractibility.|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifti|54
152|2 - Respite care|2 - Respite care|54
153|2 - Sense of failure or self reproach|2 - Sense of failure or self reproach|54
154|2 - Several times during day|2 - Several times during day|54
155|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonresponsive.|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonrespons|54
156|2 - Someone must assist the patient to groom self.|2 - Someone must assist the patient to groom self.|54
157|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|54
158|2 - Someone must help the patient put on upper body clothing.|2 - Someone must help the patient put on upper body clothing.|54
159|2 - Stage 2|2 - Stage 2|54
160|2 - Start of care - no further visits planned|2 - Start of care - no further visits planned|54
161|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitoring|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitori|54
162|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment regimen.|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment re|54
163|2 - Two|2 - Two|54
164|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistance due to cognitive or mental limitation.|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistanc|54
165|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|54
166|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assistance).|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assis|54
167|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home delivery.|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home deli|54
168|2 - Unable to prepare any light meals or reheat any delivered meals.|2 - Unable to prepare any light meals or reheat any delivered meals.|54
169|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|54
170|2 - UNABLE to take injectable medications unless administered by someone else.|2 - UNABLE to take injectable medications unless administered by someone else.|54
171|2 - UNABLE to take medication unless administered by someone else.|2 - UNABLE to take medication unless administered by someone else.|54
172|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|54
173|2 - Ventilator (continually or at night)|2 - Ventilator (continually or at night)|54
174|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less than 20 feet)|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less th|54
175|2 - With spouse or significant other|2 - With spouse or significant other|54
176|2 - Yes, assistance or services provided by family or friends|2 - Yes, assistance or services provided by family or friends|54
177|2-PT|2-PT|54
178|3 - Able to answer the telephone only some of the time or is able to carry on only a limited conversation.|3 - Able to answer the telephone only some of the time or is able to carry on only a limited convers|54
179|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube or gastrostomy.|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube|54
180|3 - Alcohol dependency|3 - Alcohol dependency|54
181|3 - All of the time|3 - All of the time|54
182|3 - Black or African-American|3 - Black or African-American|54
183|3 - Boarding home or rented room|3 - Boarding home or rented room|54
184|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment, clean/store/dispose of equipment or supplies).|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment,|54
185|3 -Able to walk only with the supervision or assistance of another person at all times.|3 -Able to walk only with the supervision or assistance of another person at all times.|54
186|3 - Continuous / Bi-level positive airway pressure|3 - Continuous / Bi-level positive airway pressure|54
187|3 - During the day and evening, but not constantly|3 - During the day and evening, but not constantly|54
188|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the alimentary canal)|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the|54
189|3 - Environmental support (e.g., housing, home maintenance)|3 - Environmental support (e.g., housing, home maintenance)|54
190|3 - Four to six times weekly|3 - Four to six times weekly|54
191|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessing by listener.  Speech limited to single words or short phrases.|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessin|54
192|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires multiple repetitions, restatements, demonstrations, additional time.|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires m|54
193|3 - Hopelessness|3 - Hopelessness|54
194|3 - Hospice care|3 - Hospice care|54
195|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|54
196|3 - Injury caused by fall or accident at home|3 - Injury caused by fall or accident at home|54
197|3 - Intractable pain|3 - Intractable pain|54
198|3 - Medicaid (traditional fee-for-service)|3 - Medicaid (traditional fee-for-service)|54
199|3 - Needs someone to do all shopping and errands.|3 - Needs someone to do all shopping and errands.|54
200|3 - Not healing|3 - Not healing|54
201|3 - Nursing home|3 - Nursing home|54
202|3 - Once daily|3 - Once daily|54
203|3 - Other family member|3 - Other family member|54
204|3 - Outpatient department/clinic emergency (includes urgicenter sites)|3 - Outpatient department/clinic emergency (includes urgicenter sites)|54
205|3 - Paid help|3 - Paid help|54
206|3 - Able to participate in bathing self in shower or tub, but requires presence of another person throughout the bath for assistance or supervision.|3 - Able to participate in bathing self in shower or tub, but requires presence of another person th|54
207|3 - Patient depends entirely upon another person to dress lower body.|3 - Patient depends entirely upon another person to dress lower body.|54
208|3 - Patient depends entirely upon another person to dress the upper body.|3 - Patient depends entirely upon another person to dress the upper body.|54
209|3 - Patient depends entirely upon someone else for grooming needs.|3 - Patient depends entirely upon someone else for grooming needs.|54
210|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone else to manage the equipment.|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone|54
211|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable to shift attention and recall directions more than half the time.|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable|54
212|3 - Respiratory problems (SOB, infection, obstruction)|3 - Respiratory problems (SOB, infection, obstruction)|54
213|3 - Resumption of care (after inpatient stay)|3 - Resumption of care (after inpatient stay)|54
214|3 - Several times each month|3 - Several times each month|54
215|3 - Skilled Nursing Facility|3 - Skilled Nursing Facility|54
216|3 - Stage 3|3 - Stage 3|54
217|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|54
218|3 - Three|3 - Three|54
219|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person throughout the process.|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person through|54
220|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal independently.|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal indep|54
221|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person.|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person|54
222|3 - Unknown because patient moved to a geographic location not served by this agency|3 - Unknown because patient moved to a geographic location not served by this agency|54
223|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|54
224|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|54
225|3 - With other family member|3 - With other family member|54
226|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home health services, homemaker assistance, transportation assistance, assisted living, board and care)|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home h|54
227|3-SLP/ST|3-SLP/ST|54
228|4 - At rest (during day or night)|4 - At rest (during day or night)|54
229|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|54
230|4 - Board and care or assisted living facility|4 - Board and care or assisted living facility|54
231|4 - Caregiver is completely dependent on someone else to manage all equipment.|4 - Caregiver is completely dependent on someone else to manage all equipment.|54
232|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|54
233|4 - Constantly|4 - Constantly|54
234|4 - Drug dependency|4 - Drug dependency|54
235|4 - Four or more|4 - Four or more|54
236|4 - Friend or neighbor or community or church member|4 - Friend or neighbor or community or church member|54
237|4 - Hispanic or Latino|4 - Hispanic or Latino|54
238|4 - Hospice|4 - Hospice|54
239|4 - Impaired decision-making|4 - Impaired decision-making|54
240|4 - Is totally dependent in toileting.|4 - Is totally dependent in toileting.|54
241|4 - Medicaid (HMO/managed care)|4 - Medicaid (HMO/managed care)|54
242|4 - None of the above|4 - None of the above|54
243|4 - Nursing home|4 - Nursing home|54
244|4 - On a daily basis|4 - On a daily basis|54
245|4 - Patient is completely dependent on someone else to manage all equipment.|4 - Patient is completely dependent on someone else to manage all equipment.|54
246|4 - Permanent placement|4 - Permanent placement|54
247|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, punches, dangerous maneuvers w/ wheelchair or other objects)|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, pu|54
248|4 - Psychosocial support (e.g., socialization, companionship, recreation)|4 - Psychosocial support (e.g., socialization, companionship, recreation)|54
249|4 - Recertification (follow-up) reassessment|4 - Recertification (follow-up) reassessment|54
250|4 - Recurrent thoughts of death|4 - Recurrent thoughts of death|54
251|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruction)|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruc|54
252|4 - Several times a week|4 - Several times a week|54
253|4 - Stage 4|4 - Stage 4|54
254|4 - Symptoms poorly controlled, history of re-hospitalizations|4 - Symptoms poorly controlled, history of re-hospitalizations|54
255|4 - Three or more times per week|4 - Three or more times per week|54
256|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetative state, or delirium.|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetati|54
257|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|54
258|4 - Unable to effectively participate in any housekeeping tasks.|4 - Unable to effectively participate in any housekeeping tasks.|54
259|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or unresponsive (e.g., speech is nonsensical or unintelligible).|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or u|54
260|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonresponsive.|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonr|54
261|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostomy.|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostom|54
262|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of devices at the sink, in chair, or on commode|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of|54
263|4 - With a friend|4 - With a friend|54
264|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|54
265|4-OT|4-OT|54
266|5 - Advocates or facilitates patient's participation in appropriate medical care|5 - Advocates or facilitates patient's participation in appropriate medical care|54
267|5 - At least daily|5 - At least daily|54
268|6 - Bedfast, unable to ambulate or be up in a chair.|6 - Bedfast, unable to ambulate or be up in a chair.|54
269|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|54
270|5 - Disruptive or socially inappropriate behavior|5 - Disruptive or socially inappropriate behavior|54
271|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|54
272|5 - Hypo/Hyperglycemia, diabetes out of control|5 - Hypo/Hyperglycemia, diabetes out of control|54
273|5 - More often than once daily|5 - More often than once daily|54
274|5 - Native Hawaiian or Pacific Islander|5 - Native Hawaiian or Pacific Islander|54
275|5 - None of the above|5 - None of the above|54
276|5 - One to two times per week|5 - One to two times per week|54
277|5 - Other|5 - Other|54
278|5 - Other follow-up|5 - Other follow-up|54
279|5 - Paid help|5 - Paid help|54
280|5 - Patient nonresponsive or unable to speak.|5 - Patient nonresponsive or unable to speak.|54
281|5 - Thoughts of suicide|5 - Thoughts of suicide|54
282|5 - Totally unable to use the telephone.|5 - Totally unable to use the telephone.|54
283|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|54
284|5 - Unable to take in nutrients orally or by tube feeding.|5 - Unable to take in nutrients orally or by tube feeding.|54
285|5 - Unsafe for care at home|5 - Unsafe for care at home|54
286|5 - With paid help (other than home care agency staff)|5 - With paid help (other than home care agency staff)|54
287|5 - Workers' compensation|5 - Workers' compensation|54
288|5 - Wound infection, deteriorating wound status, new lesion/ulcer|5 - Wound infection, deteriorating wound status, new lesion/ulcer|54
289|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|54
290|6 - Delusional, hallucinatory, or paranoid behavior|6 - Delusional, hallucinatory, or paranoid behavior|54
291|6 - Financial agent, power of attorney, or conservator of finance|6 - Financial agent, power of attorney, or conservator of finance|54
292|6 - GI bleeding, obstruction|6 - GI bleeding, obstruction|54
293|6 - Less often than weekly|6 - Less often than weekly|54
294|6 - Memory loss to the extent that supervision required|6 - Memory loss to the extent that supervision required|54
295|6 - None of the above feelings observed or reported|6 - None of the above feelings observed or reported|54
296|6 - Other|6 - Other|54
297|6 - Title programs (e.g., Title III, V, or XX)|6 - Title programs (e.g., Title III, V, or XX)|54
298|6 - Transferred to an inpatient facility - patient not discharged from agency|6 - Transferred to an inpatient facility - patient not discharged from agency|54
299|6 - White|6 - White|54
300|6 - With other than above|6 - With other than above|54
301|7 - Exacerbation of CHF, fluid overload, heart failure|7 - Exacerbation of CHF, fluid overload, heart failure|54
302|7 - Health care agent, conservator of person, or medical power of attorney|7 - Health care agent, conservator of person, or medical power of attorney|54
303|7 - Hypo/Hyperglycemia, diabetes out of control|7 - Hypo/Hyperglycemia, diabetes out of control|54
304|7 - None of the above|7 - None of the above|54
305|7 - None of the above behaviors demonstrated|7 - None of the above behaviors demonstrated|54
306|7 - Other government (e.g., TriCare, VA, etc.)|7 - Other government (e.g., TriCare, VA, etc.)|54
307|7 - Transferred to an inpatient facility - patient discharged from agency|7 - Transferred to an inpatient facility - patient discharged from agency|54
308|8 - Death at home|8 - Death at home|54
309|8 - GI bleeding, obstruction|8 - GI bleeding, obstruction|54
310|8 - Myocardial infarction, stroke|8 - Myocardial infarction, stroke|54
311|8 - Private insurance|8 - Private insurance|54
312|9 - Chemotherapy|9 - Chemotherapy|54
313|9 - Discharge from agency|9 - Discharge from agency|54
314|9 - Other than above reasons|9 - Other than above reasons|54
315|9 - Private HMO/managed care|9 - Private HMO/managed care|54
316|NA - No caregiver|NA - No caregiver|54
317|NA - No equipment of this type used in care.|NA - No equipment of this type used in care.|54
318|NA - No inhalant/mist medications prescribed.|NA - No inhalant/mist medications prescribed.|54
319|NA - No injectable medications prescribed.|NA - No injectable medications prescribed.|54
320|NA - No inpatient facility admission|NA - No inpatient facility admission|54
321|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|54
322|NA - No Medicaid|NA - No Medicaid|54
323|NA - No Medicare|NA - No Medicare|54
324|NA - No observable pressure ulcer or unhealed pressure ulcer|NA - No observable pressure ulcer or unhealed pressure ulcer|54
325|NA - No observable stasis ulcer|NA - No observable stasis ulcer|54
326|NA - No observable surgical wound|NA - No observable surgical wound|54
327|NA - No oral medications prescribed.|NA - No oral medications prescribed.|54
328|NA - Not applicable|NA - Not applicable|54
329|NA - Patient does not have a telephone.|NA - Patient does not have a telephone.|54
330|NA - Patient has ostomy for bowel elimination|NA - Patient has ostomy for bowel elimination|54
331|NA - Patient nonresponsive|NA - Patient nonresponsive|54
332|NA - Patient on prophylactic treatment|NA - Patient on prophylactic treatment|54
333|NA - Patient was not discharged from an inpatient facility [Go to M1017]|NA - Patient was not discharged from an inpatient facility [Go to M1017]|54
334|UK - Other unknown|UK - Other unknown|54
335|UK - Reason unknown|UK - Reason unknown|54
336|UK - Unknown|UK - Unknown|54
337|UK - Unknown or Not Available|UK - Unknown or Not Available|54
341|01 - Early|01 - Early|54
342|02 - Late|02 - Late|54
343|NA - Not Applicable. No case mix group defined for this assessment.|NA - Not Applicable. No case mix group defined for this assessment.|54
344|NA - No case mix group defined by this assessment.|NA - No case mix group defined by this assessment.|54
345|1 - Recent decline in mental, emotional, or behavioral status|1 - Recent decline in mental, emotional, or behavioral status|54
346|2 - Multiple hospitalizations (2 or more) in the past 12 months|2 - Multiple hospitalizations (2 or more) in the past 12 months|54
347|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|54
348|4 - Taking five or more medications|4 - Taking five or more medications|54
349|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|54
350|6 - Other|6 - Other|54
351|7 - None of the above|7 - None of the above|54
352|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond tho|54
353|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable without heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable wi|54
354|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious complications and death.|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious compl|54
355|3 - The patient has serious progressive conditions that could lead to death within a year.|3 - The patient has serious progressive conditions that could lead to death within a year.|54
356|UK - The patient+s situation is unknown or unclear.|UK - The patient+s situation is unknown or unclear.|54
357|1 - Yes [ Go to M1050 ]|1 - Yes [ Go to M1050 ]|54
358|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this influenza season. [ Go to M1050 ]|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this i|54
359|1 - Received from another health care provider (e.g., physician)|1 - Received from another health care provider (e.g., physician)|54
360|2 - Received from your agency previously during this year+s flu season|2 - Received from your agency previously during this year+s flu season|54
361|3 - Offered and declined|3 - Offered and declined|54
362|4 - Assessed and determined to have medical contraindication(s)|4 - Assessed and determined to have medical contraindication(s)|54
363|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|54
364|6 - Inability to obtain vaccine due to declared shortage|6 - Inability to obtain vaccine due to declared shortage|54
365|1 - Yes [ Go to M1500 at TRN; Go to M1230 at DC ]|1 - Yes [ Go to M1500 at TRN; Go to M1230 at DC ]|54
366|1 - Patient has received PPV in the past|1 - Patient has received PPV in the past|54
367|2 - Offered and declined|2 - Offered and declined|54
368|3 - Assessed and determined to have medical contraindication(s)|3 - Assessed and determined to have medical contraindication(s)|54
369|4 - Not indicated; patient does not meet age/condition guidelines for PPV|4 - Not indicated; patient does not meet age/condition guidelines for PPV|54
370|5 - None of the above|5 - None of the above|54
371|0 - Adequate: hears normal conversation without difficulty.|0 - Adequate: hears normal conversation without difficulty.|54
372|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to increase volume or speak distinctly.|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to in|54
373|2 - Severely Impaired: absence of useful hearing.|2 - Severely Impaired: absence of useful hearing.|54
374|UK - Unable to assess hearing.|UK - Unable to assess hearing.|54
375|0 - Understands: clear comprehension without cues or repetitions.|0 - Understands: clear comprehension without cues or repetitions.|54
376|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Requires cues at times to understand.|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Req|54
377|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequently requires cues to understand.|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequentl|54
378|3 - Rarely/Never Understands|3 - Rarely/Never Understands|54
379|UK - Unable to assess understanding.|UK - Unable to assess understanding.|54
380|0 - No standardized assessment conducted|0 - No standardized assessment conducted|54
381|1 - Yes, and it does not indicate severe pain|1 - Yes, and it does not indicate severe pain|54
382|2 - Yes, and it indicates severe pain|2 - Yes, and it indicates severe pain|54
383|0 - Patient has no pain|0 - Patient has no pain|54
384|1 - Patient has pain that does not interfere with activity or movement|1 - Patient has pain that does not interfere with activity or movement|54
385|2 - Less often than daily|2 - Less often than daily|54
386|3 - Daily, but not constantly|3 - Daily, but not constantly|54
387|4 - All of the time|4 - All of the time|54
388|0 - No assessment conducted [ Go to M1306 ]|0 - No assessment conducted [ Go to M1306 ]|54
389|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc., without use of standardized tool|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc.,|54
390|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|54
391|0 - No [ Go to M1322]|0 - No [ Go to M1322]|54
392|0 v Newly epithelialized|0 v Newly epithelialized|54
393|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|54
394|2 - Yes, patient has observable stasis ulcers ONLY|2 - Yes, patient has observable stasis ulcers ONLY|54
395|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable dressing) [Go to M1340]|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable|54
396|0 - No [ Go to M1400 ]|0 - No [ Go to M1400 ]|54
397|1 - Yes, patient has at least one (observable) surgical wound|1 - Yes, patient has at least one (observable) surgical wound|54
398|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1400 ]|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1400 ]|54
399|0 - Patient is not short of breath|0 - Patient is not short of breath|54
400|3 - Continuous Bi-level positive airway pressure|3 - Continuous Bi-level positive airway pressure|54
401|0 - No [ Go to M1732 at TRN; Go to M1600 at DC ]|0 - No [ Go to M1732 at TRN; Go to M1600 at DC ]|54
402|2 - Not assessed [Go to M1732 at TRN; Go to M1600 at DC ]|2 - Not assessed [Go to M1732 at TRN; Go to M1600 at DC ]|54
403|NA - Patient does not have diagnosis of heart failure [Go to M2004 at TRN; Go to M1600 at DC]|NA - Patient does not have diagnosis of heart failure [Go to M2004 at TRN; Go to M1600 at DC]|54
404|0 - No action taken|0 - No action taken|54
405|1 - Patient+s physician (or other primary care practitioner) contacted the same day|1 - Patient+s physician (or other primary care practitioner) contacted the same day|54
406|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|54
407|3 - Implement physician-ordered patient-specific established parameters for treatment|3 - Implement physician-ordered patient-specific established parameters for treatment|54
408|4 - Patient education or other clinical interventions|4 - Patient education or other clinical interventions|54
409|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequency, telehealth, etc.)|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequ|54
410|1 - Occasional stress incontinence|1 - Occasional stress incontinence|54
411|2 - During the night only|2 - During the night only|54
412|3 - During the day only|3 - During the day only|54
413|4 - During the day and night|4 - During the day and night|54
414|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|54
415|0 - Able to manage toileting hygiene and clothing management without assistance.|0 - Able to manage toileting hygiene and clothing management without assistance.|54
416|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implements are laid out for the patient.|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implemen|54
417|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|54
418|3 - Patient depends entirely upon another person to maintain toileting hygiene.|3 - Patient depends entirely upon another person to maintain toileting hygiene.|54
419|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independent|54
420|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface|54
421|0 - No multi-factor falls risk assessment conducted.|0 - No multi-factor falls risk assessment conducted.|54
422|1 - Yes, and it does not indicate a risk for falls.|1 - Yes, and it does not indicate a risk for falls.|54
423|2 - Yes, and it indicates a risk for falls.|2 - Yes, and it indicates a risk for falls.|54
424|0 - Not assessed/reviewed [ Go to M2010 ]|0 - Not assessed/reviewed [ Go to M2010 ]|54
425|1 - No problems found during review [ Go to M2010 ]|1 - No problems found during review [ Go to M2010 ]|54
426|2 - Problems found during review|2 - Problems found during review|54
427|NA - Patient is not taking any medications [ Go to M2040 ]|NA - Patient is not taking any medications [ Go to M2040 ]|54
428|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special precautions associated with all high-risk medications|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special p|54
429|NA - Patient not taking any drugs|NA - Patient not taking any drugs|54
430|2 - Able to take medication(s) at the correct times if given reminders by another person at the appropriate times|2 - Able to take medication(s) at the correct times if given reminders by another person at the appr|54
431|3 - Unable to take medication unless administered by another person.|3 - Unable to take medication unless administered by another person.|54
432|1 - At least daily|1 - At least daily|54
433|2 - Three or more times per week|2 - Three or more times per week|54
434|3 - One to two times per week|3 - One to two times per week|54
435|4 - Received, but less often than weekly|4 - Received, but less often than weekly|54
436|5 - No assistance received|5 - No assistance received|54
437|0 - No [Go to M2400]|0 - No [Go to M2400]|54
438|1 - Yes, used hospital emergency department WITHOUT hospital admission|1 - Yes, used hospital emergency department WITHOUT hospital admission|54
439|2 - Yes, used hospital emergency department WITH hospital admission|2 - Yes, used hospital emergency department WITH hospital admission|54
440|UK - Unknown [Go to M2400]|UK - Unknown [Go to M2400]|54
441|2 - Injury caused by fall|2 - Injury caused by fall|54
442|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|54
443|4 - Other respiratory problem|4 - Other respiratory problem|54
444|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|54
445|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|54
446|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|54
447|8 - Other heart disease|8 - Other heart disease|54
448|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|54
449|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|54
450|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|54
451|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|54
452|13 - Urinary tract infection|13 - Urinary tract infection|54
453|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|54
454|15 - Wound infection or deterioration|15 - Wound infection or deterioration|54
455|16 - Uncontrolled pain|16 - Uncontrolled pain|54
456|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|54
457|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|54
458|19 - Other than above reasons|19 - Other than above reasons|54
459|2 - Patient remained in the community (with formal assistive services)|2 - Patient remained in the community (with formal assistive services)|54
460|3 - Patient transferred to a noninstitutional hospice|3 - Patient transferred to a noninstitutional hospice|54
461|4 - Unknown because patient moved to a geographic location not served by this agency|4 - Unknown because patient moved to a geographic location not served by this agency|54
462|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|54
463|4 - Other respiratory problem|4 - Other respiratory problem|54
464|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|54
465|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|54
466|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|54
467|8 - Other heart disease|8 - Other heart disease|54
468|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|54
469|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|54
470|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|54
471|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|54
472|13 - Urinary tract infection|13 - Urinary tract infection|54
473|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|54
474|15 - Wound infection or deterioration|15 - Wound infection or deterioration|54
475|16 - Uncontrolled pain|16 - Uncontrolled pain|54
476|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|54
477|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|54
478|19 - Scheduled treatment or procedure|19 - Scheduled treatment or procedure|54
479|20 - Other than above reasons|20 - Other than above reasons|54
480|UK - Reason unknown [Go to M0903]|UK - Reason unknown [Go to M0903]|54
482|01 - Patient lives alone around the clock|01 - Patient lives alone around the clock|54
483|02 - Patient lives alone regular daytime|02 - Patient lives alone regular daytime|54
484|03 - Patient lives alone regular nighttime|03 - Patient lives alone regular nighttime|54
485|04 - Patient lives alone occassional/short term assistance|04 - Patient lives alone occassional/short term assistance|54
486|05 - Patient lives alone no assisstance available|05 - Patient lives alone no assisstance available|54
487|06 - Patient lives with other person(s) in the home around the clock|06 - Patient lives with other person(s) in the home around the clock|54
488|07 - Patient lives with other person(s) in the home regular daytime|07 - Patient lives with other person(s) in the home regular daytime|54
489|08 - Patient lives with other person(s) in the home regular nighttime|08 - Patient lives with other person(s) in the home regular nighttime|54
490|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|54
491|10 - Patient lives with other person(s) in the home no assistance available|10 - Patient lives with other person(s) in the home no assistance available|54
492|1 - Was present at the most recent SOC/ROC assessment|1 - Was present at the most recent SOC/ROC assessment|54
493|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|54
494|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|54
495|0 - Newly epithelialized|0 - Newly epithelialized|54
496|0 - No [ Go to M1340 ]|0 - No [ Go to M1340 ]|54
498|0 - Independent|0 - Independent|54
499|1 - Needed Some Help|1 - Needed Some Help|54
500|2 - Dependent|2 - Dependent|54
502|0 - No assistance needed in this area|0 - No assistance needed in this area|54
503|1 - Caregiver(s) currently provide assistance|1 - Caregiver(s) currently provide assistance|54
504|2 - Caregiver(s) need training/ supportive services to provide assistance|2 - Caregiver(s) need training/ supportive services to provide assistance|54
505|3 - Caregiver(s) not likely to provide assistance|3 - Caregiver(s) not likely to provide assistance|54
506|4 - Unclear if Caregiver(s) will provide assistance|4 - Unclear if Caregiver(s) will provide assistance|54
507|5 - Assistance needed, but no Caregiver(s) available|5 - Assistance needed, but no Caregiver(s) available|54
508|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will use standardized clinical guidelines accessible for all care providers to reference|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will|54
510|NA - Patient is not assessed to be at risk for falls|NA - Patient is not assessed to be at risk for falls|54
511|NA - Patient has no diagnosis or symptoms of depression|NA - Patient has no diagnosis or symptoms of depression|54
512|NA - No pain identified|NA - No pain identified|54
513|NA - Patient is not assessed to be at risk for pressure ulcers|NA - Patient is not assessed to be at risk for pressure ulcers|54
514|NA - Patient has no pressure ulcers with need for moist wound healing|NA - Patient has no pressure ulcers with need for moist wound healing|54
515|1 - Long-term nursing facility (NF)|1 - Long-term nursing facility (NF)|54
516|2 - Skilled nursing facility (SNF / TCU)|2 - Skilled nursing facility (SNF / TCU)|54
517|3 - Short stay acute hospital (IPP S)|3 - Short stay acute hospital (IPP S)|54
518|4 - Long-term care hospital (LTCH)|4 - Long-term care hospital (LTCH)|54
519|5 - Inpatient rehabilitation hospital or unit (IRF)|5 - Inpatient rehabilitation hospital or unit (IRF)|54
520|6 - Psychiatric hospital or unit|6 - Psychiatric hospital or unit|54
521|7 - Other|7 - Other|54
522|NA - Patient was not discharged from an inpatient facility [Go to M1017]|NA - Patient was not discharged from an inpatient facility [Go to M1017]|54
523|6 - Unable to participate effectively in bathing and is bathed totally by another person|6 - Unable to participate effectively in bathing and is bathed totally by another person|54
524|4 - Chairfast, unable to ambulate but is able to wheel self independently.|4 - Chairfast, unable to ambulate but is able to wheel self independently.|54
525|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask patient: "Over the last two weeks, how often have you been bothered by any of the following problems")  *Copyright+ Pfizer Inc. All rights reserved. Reproduced with permission.|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask|54
526|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluation for depression.|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluat|54
527|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet criteria for further evaluation for depression.|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet|54
528|0 - Not at all  0 - 1 day|0 - Not at all  0 - 1 day|54
529|1 - Several days  2 - 6 days|1 - Several days  2 - 6 days|54
530|2 - More than half of the days  7 - 11 days|2 - More than half of the days  7 - 11 days|54
531|3 - Nearly every day  12 - 14 days|3 - Nearly every day  12 - 14 days|54
532|NA - N/A  Unable to respond|NA - N/A  Unable to respond|54
533|2 - Able to take medication(s) at the correct times if given reminders by another person based on the frequency of the injection|2 - Able to take medication(s) at the correct times if given reminders by another person based on th|54
534|3 - Unable to take injectable medication unless administered by another person.|3 - Unable to take injectable medication unless administered by another person.|54
535|UK - Inpatient Discharge Date Unknown|UK - Inpatient Discharge Date Unknown|54
538|NA - Inpatient stay within last 14 days Not Applicable|NA - Inpatient stay within last 14 days Not Applicable|54
2|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; OR (b) Is physically, cognitively, and mentally able to prepare light meals on a regular basis but has not routinely performed light meal preparation in the past (i.e., prior to this home care admission).|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; O|55
3|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and mentally able to perform all housekeeping tasks .|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and menta|55
4|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and mentally able to do laundry and access facilities.|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and menta|55
5|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying packages OR b) Physically, cognitively, and mentally able to take care of shopping, but has not done shopping in the past (i.e., prior to this home care admission).|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying|55
6|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|55
7|0 - Able to dial numbers and answer calls appropriately and as desired.|0 - Able to dial numbers and answer calls appropriately and as desired.|55
8|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body without assistance.|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body|55
9|0 - Able to get to and from the toilet and transfer independently with or without a device.|0 - Able to get to and from the toilet and transfer independently with or without a device.|55
10|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|55
11|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible public bus.|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible p|55
12|0 - Able to independently feed self.|0 - Able to independently feed self.|55
13|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|55
14|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct times.|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct ti|55
15|0 - Able to independently transfer.|0 - Able to independently transfer.|55
16|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without rail|55
17|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings|55
18|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|55
19|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions independently.|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions indep|55
20|0 - Asymptomatic, no treatment needed at this time|0 - Asymptomatic, no treatment needed at this time|55
21|0 - Caregiver manages all tasks related to equipment completely independently.|0 - Caregiver manages all tasks related to equipment completely independently.|55
22|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations with no observable impairment.|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations w|55
23|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|55
24|0 - Life expectancy is greater than 6 months|0 - Life expectancy is greater than 6 months|55
25|0 - Never|0 - Never|55
26|0 - Patient is not short of breath|0 - Patient is not short of breath|55
27|0 - No|0 - No|55
28|0 - No emergent care services|0 - No emergent care services|55
29|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [Goto M1620]|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [Goto M1620]|55
30|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and extended or abstract conversation.|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and exte|55
31|0 - No one person|0 - No one person|55
32|0 - None of the time|0 - None of the time|55
33|0 - None, no charge for current services|0 - None, no charge for current services|55
34|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|55
35|0 - Patient does NOT have an ostomy for bowel elimination.|0 - Patient does NOT have an ostomy for bowel elimination.|55
36|0 - Patient has no pain|0 - Patient has no pain|55
37|0 - Patient manages all tasks related to equipment completely independently.|0 - Patient manages all tasks related to equipment completely independently.|55
38|0 - Poor:  little or no recovery is expected and/or further decline is imminent|0 - Poor:  little or no recovery is expected and/or further decline is imminent|55
39|0 - Timed-voiding defers incontinence|0 - Timed-voiding defers incontinence|55
40|0 - Very rarely or never has bowel incontinence|0 - Very rarely or never has bowel incontinence|55
41|0 - Zero|0 - Zero|55
42|00 - No|00 - No|55
43|01 - Yes|01 - Yes|55
44|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or mental limitations, needs assistance with heavy laundry.|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or|55
45|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the patient.|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the|55
46|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|55
47|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or supervision from another person OR c) a liquid, pureed or ground meat diet.|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or su|55
48|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|55
49|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|55
50|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independently.|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independe|55
51|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only when assisted or accompanied by another person.|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only w|55
52|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepa|55
53|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance by another person OR b) given daily reminders.|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance b|55
54|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advan|55
55|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advan|55
56|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for the deaf) and call essential numbers.|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for t|55
57|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|55
58|1 - American Indian or Alaska Native|1 - American Indian or Alaska Native|55
59|1 - Depressed mood (e.g., feeling sad, tearful)|1 - Depressed mood (e.g., feeling sad, tearful)|55
60|1 - During the night only|1 - During the night only|55
61|1 - Fully granulating|1 - Fully granulating|55
62|1 - Good/Fair:  partial to full recovery is expected|1 - Good/Fair:  partial to full recovery is expected|55
63|1 - Good:  marked improvement in functional status is expected|1 - Good:  marked improvement in functional status is expected|55
64|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|55
65|1 - Smoking|1 - Smoking|55
66|1 - Hospital|1 - Hospital|55
67|1 - Hospital emergency room (includes 23-hour holding)|1 - Hospital emergency room (includes 23-hour holding)|55
68|1 - Hospitalization for EMERGENT (unscheduled) care|1 - Hospitalization for EMERGENT (unscheduled) care|55
69|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepared solutions), patient is able to manage all other aspects of equipment.|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepar|55
70|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|55
71|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|55
72|1 - In new or complex situations only|1 - In new or complex situations only|55
73|1 - Intravenous or infusion therapy (excludes TPN)|1 - Intravenous or infusion therapy (excludes TPN)|55
74|1 - Less often than daily|1 - Less often than daily|55
75|1 - Less than once a month|1 - Less than once a month|55
76|1 - Less than once weekly|1 - Less than once weekly|55
77|1 - Life expectancy is 6 months or fewer|1 - Life expectancy is 6 months or fewer|55
78|1 - Lives alone|1 - Lives alone|55
79|1 - Male|1 - Male|55
80|1 - Medicare (traditional fee-for-service)|1 - Medicare (traditional fee-for-service)|55
81|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of past 24 hours, significant memory loss so that supervision is required|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of pas|55
82|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors in word choice, grammar or speech intelligibility, needs minimal prompting or assistance).|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors i|55
83|1 - No assistance or services received|1 - No assistance or services received|55
84|1 - One|1 - One|55
85|1 - Oxygen (intermittent or continuous)|1 - Oxygen (intermittent or continuous)|55
86|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, and the surrounding layout, can count fingers at arm's length.|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, a|55
87|1 - Patient is incontinent|1 - Patient is incontinent|55
88|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|55
89|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical or treatment regimen.|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical|55
90|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient/couple/significant other)|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient|55
91|1 - Relatives, friends, or neighbors living outside the home|1 - Relatives, friends, or neighbors living outside the home|55
92|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions.|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions|55
93|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independentl|55
94|1 - Several times during day and night|1 - Several times during day and night|55
95|1 - Spouse or significant other|1 - Spouse or significant other|55
96|1 - Stage 1|1 - Stage 1|55
97|1 - Start of care - further visits planned|1 - Start of care - further visits planned|55
98|1 - Symptoms well controlled with current therapy|1 - Symptoms well controlled with current therapy|55
99|1 - Therapy services|1 - Therapy services|55
100|1 - Able to transfer with minimal human assistance or with use of an assistive device.|1 - Able to transfer with minimal human assistance or with use of an assistive device.|55
101|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitations.|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitatio|55
102|1 - Urinary incontinence|1 - Urinary incontinence|55
103|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and transfer.|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and|55
104|1 - When walking more than 20 feet, climbing stairs|1 - When walking more than 20 feet, climbing stairs|55
105|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary conversation. May need occasional repetition, extra time, or louder voice.|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary c|55
106|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting in and out of tub/shower|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting|55
107|1 - Yes|1 - Yes|55
108|1-RN|1-RN|55
109|10 - Discharge from agency - no visits completed after start/resumption of care assessment|10 - Discharge from agency - no visits completed after start/resumption of care assessment|55
110|10 - Scheduled surgical procedure|10 - Scheduled surgical procedure|55
111|10 - Self-pay|10 - Self-pay|55
112|11 - Other|11 - Other|55
113|11 - Urinary tract infection|11 - Urinary tract infection|55
114|12 - IV catheter-related infection|12 - IV catheter-related infection|55
115|13 - Deep vein thrombosis, pulmonary embolus|13 - Deep vein thrombosis, pulmonary embolus|55
116|14 - Uncontrolled pain|14 - Uncontrolled pain|55
117|15 - Psychotic episode|15 - Psychotic episode|55
118|16 - Other than above reasons|16 - Other than above reasons|55
119|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing calls.|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing|55
120|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another person.|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another pers|55
121|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface a|55
122|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for intermittent supervision or encouragement or reminders, OR (b) to get in and out of the shower or tub, OR (c) for washing difficult to reach areas.|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for inter|55
123|2 - Asian|2 - Asian|55
124|2 - Caregiver requires considerable assistance from another person to manage equipment, but independently completes significant portions of task.|2 - Caregiver requires considerable assistance from another person to manage equipment, but independ|55
125|2 - Daily, but not constantly|2 - Daily, but not constantly|55
126|2 - Daughter or son|2 - Daughter or son|55
127|2 - Doctor's office emergency visit/house call|2 - Doctor's office emergency visit/house call|55
128|2 - During the day and night|2 - During the day and night|55
129|2 - Early/partial granulation|2 - Early/partial granulation|55
130|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors in word choice, organization or speech intelligibility). Speaks in phrases or short sentences.|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors|55
131|2 - Family member's residence|2 - Family member's residence|55
132|2 - Female|2 - Female|55
133|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conversation, needs frequent prompting or assistance.|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conver|55
134|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|55
135|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|55
136|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately stop activities, jeopardizes safety through actions|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately st|55
137|2 - Indwelling/suprapubic catheter|2 - Indwelling/suprapubic catheter|55
138|2 - Injury caused by fall or accident at home|2 - Injury caused by fall or accident at home|55
139|2 - Medicare (HMO/managed care/Advantage plan)|2 - Medicare (HMO/managed care/Advantage plan)|55
140|2 - Nausea, dehydration, malnutrition, constipation, impaction|2 - Nausea, dehydration, malnutrition, constipation, impaction|55
141|2 - Obesity|2 - Obesity|55
142|2 - On awakening or at night only|2 - On awakening or at night only|55
143|2 - Once a month|2 - Once a month|55
144|2 - One to three times weekly|2 - One to three times weekly|55
145|2 - Parenteral nutrition (TPN or lipids)|2 - Parenteral nutrition (TPN or lipids)|55
146|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic) [ Go to M1620 ]|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic) [ Go|55
147|2 - Patient requires considerable assistance from another person to manage equipment, but independently completes portions of the task.|2 - Patient requires considerable assistance from another person to manage equipment, but independen|55
148|2 - Patient transferred to a noninstitutional hospice|2 - Patient transferred to a noninstitutional hospice|55
149|2 - Person residing in the home (EXCLUDING paid help)|2 - Person residing in the home (EXCLUDING paid help)|55
150|2 - Rehabilitation facility|2 - Rehabilitation facility|55
151|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifting of attention) or consistently requires low stimulus environment due to distractibility.|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifti|55
152|2 - Respite care|2 - Respite care|55
153|2 - Sense of failure or self reproach|2 - Sense of failure or self reproach|55
154|2 - Several times during day|2 - Several times during day|55
155|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonresponsive.|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonrespons|55
156|2 - Someone must assist the patient to groom self.|2 - Someone must assist the patient to groom self.|55
157|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|55
158|2 - Someone must help the patient put on upper body clothing.|2 - Someone must help the patient put on upper body clothing.|55
159|2 - Stage 2|2 - Stage 2|55
160|2 - Start of care - no further visits planned|2 - Start of care - no further visits planned|55
161|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitoring|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitori|55
162|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment regimen.|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment re|55
163|2 - Two|2 - Two|55
164|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistance due to cognitive or mental limitation.|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistanc|55
165|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|55
166|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assistance).|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assis|55
167|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home delivery.|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home deli|55
168|2 - Unable to prepare any light meals or reheat any delivered meals.|2 - Unable to prepare any light meals or reheat any delivered meals.|55
169|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|55
170|2 - UNABLE to take injectable medications unless administered by someone else.|2 - UNABLE to take injectable medications unless administered by someone else.|55
171|2 - UNABLE to take medication unless administered by someone else.|2 - UNABLE to take medication unless administered by someone else.|55
172|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|55
173|2 - Ventilator (continually or at night)|2 - Ventilator (continually or at night)|55
174|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less than 20 feet)|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less th|55
175|2 - With spouse or significant other|2 - With spouse or significant other|55
176|2 - Yes, assistance or services provided by family or friends|2 - Yes, assistance or services provided by family or friends|55
177|2-PT|2-PT|55
178|3 - Able to answer the telephone only some of the time or is able to carry on only a limited conversation.|3 - Able to answer the telephone only some of the time or is able to carry on only a limited convers|55
179|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube or gastrostomy.|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube|55
180|3 - Alcohol dependency|3 - Alcohol dependency|55
181|3 - All of the time|3 - All of the time|55
182|3 - Black or African-American|3 - Black or African-American|55
183|3 - Boarding home or rented room|3 - Boarding home or rented room|55
184|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment, clean/store/dispose of equipment or supplies).|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment,|55
185|3 -Able to walk only with the supervision or assistance of another person at all times.|3 -Able to walk only with the supervision or assistance of another person at all times.|55
186|3 - Continuous / Bi-level positive airway pressure|3 - Continuous / Bi-level positive airway pressure|55
187|3 - During the day and evening, but not constantly|3 - During the day and evening, but not constantly|55
188|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the alimentary canal)|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the|55
189|3 - Environmental support (e.g., housing, home maintenance)|3 - Environmental support (e.g., housing, home maintenance)|55
190|3 - Four to six times weekly|3 - Four to six times weekly|55
191|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessing by listener.  Speech limited to single words or short phrases.|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessin|55
192|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires multiple repetitions, restatements, demonstrations, additional time.|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires m|55
193|3 - Hopelessness|3 - Hopelessness|55
194|3 - Hospice care|3 - Hospice care|55
195|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|55
196|3 - Injury caused by fall or accident at home|3 - Injury caused by fall or accident at home|55
197|3 - Intractable pain|3 - Intractable pain|55
198|3 - Medicaid (traditional fee-for-service)|3 - Medicaid (traditional fee-for-service)|55
199|3 - Needs someone to do all shopping and errands.|3 - Needs someone to do all shopping and errands.|55
200|3 - Not healing|3 - Not healing|55
201|3 - Nursing home|3 - Nursing home|55
202|3 - Once daily|3 - Once daily|55
203|3 - Other family member|3 - Other family member|55
204|3 - Outpatient department/clinic emergency (includes urgicenter sites)|3 - Outpatient department/clinic emergency (includes urgicenter sites)|55
205|3 - Paid help|3 - Paid help|55
206|3 - Able to participate in bathing self in shower or tub, but requires presence of another person throughout the bath for assistance or supervision.|3 - Able to participate in bathing self in shower or tub, but requires presence of another person th|55
207|3 - Patient depends entirely upon another person to dress lower body.|3 - Patient depends entirely upon another person to dress lower body.|55
208|3 - Patient depends entirely upon another person to dress the upper body.|3 - Patient depends entirely upon another person to dress the upper body.|55
209|3 - Patient depends entirely upon someone else for grooming needs.|3 - Patient depends entirely upon someone else for grooming needs.|55
210|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone else to manage the equipment.|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone|55
211|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable to shift attention and recall directions more than half the time.|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable|55
212|3 - Respiratory problems (SOB, infection, obstruction)|3 - Respiratory problems (SOB, infection, obstruction)|55
213|3 - Resumption of care (after inpatient stay)|3 - Resumption of care (after inpatient stay)|55
214|3 - Several times each month|3 - Several times each month|55
215|3 - Skilled Nursing Facility|3 - Skilled Nursing Facility|55
216|3 - Stage 3|3 - Stage 3|55
217|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|55
218|3 - Three|3 - Three|55
219|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person throughout the process.|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person through|55
220|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal independently.|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal indep|55
221|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person.|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person|55
222|3 - Unknown because patient moved to a geographic location not served by this agency|3 - Unknown because patient moved to a geographic location not served by this agency|55
223|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|55
224|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|55
225|3 - With other family member|3 - With other family member|55
226|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home health services, homemaker assistance, transportation assistance, assisted living, board and care)|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home h|55
227|3-SLP/ST|3-SLP/ST|55
228|4 - At rest (during day or night)|4 - At rest (during day or night)|55
229|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|55
230|4 - Board and care or assisted living facility|4 - Board and care or assisted living facility|55
231|4 - Caregiver is completely dependent on someone else to manage all equipment.|4 - Caregiver is completely dependent on someone else to manage all equipment.|55
232|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|55
233|4 - Constantly|4 - Constantly|55
234|4 - Drug dependency|4 - Drug dependency|55
235|4 - Four or more|4 - Four or more|55
236|4 - Friend or neighbor or community or church member|4 - Friend or neighbor or community or church member|55
237|4 - Hispanic or Latino|4 - Hispanic or Latino|55
238|4 - Hospice|4 - Hospice|55
239|4 - Impaired decision-making|4 - Impaired decision-making|55
240|4 - Is totally dependent in toileting.|4 - Is totally dependent in toileting.|55
241|4 - Medicaid (HMO/managed care)|4 - Medicaid (HMO/managed care)|55
242|4 - None of the above|4 - None of the above|55
243|4 - Nursing home|4 - Nursing home|55
244|4 - On a daily basis|4 - On a daily basis|55
245|4 - Patient is completely dependent on someone else to manage all equipment.|4 - Patient is completely dependent on someone else to manage all equipment.|55
246|4 - Permanent placement|4 - Permanent placement|55
247|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, punches, dangerous maneuvers w/ wheelchair or other objects)|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, pu|55
248|4 - Psychosocial support (e.g., socialization, companionship, recreation)|4 - Psychosocial support (e.g., socialization, companionship, recreation)|55
249|4 - Recertification (follow-up) reassessment|4 - Recertification (follow-up) reassessment|55
250|4 - Recurrent thoughts of death|4 - Recurrent thoughts of death|55
251|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruction)|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruc|55
252|4 - Several times a week|4 - Several times a week|55
253|4 - Stage 4|4 - Stage 4|55
254|4 - Symptoms poorly controlled, history of re-hospitalizations|4 - Symptoms poorly controlled, history of re-hospitalizations|55
255|4 - Three or more times per week|4 - Three or more times per week|55
256|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetative state, or delirium.|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetati|55
257|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|55
258|4 - Unable to effectively participate in any housekeeping tasks.|4 - Unable to effectively participate in any housekeeping tasks.|55
259|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or unresponsive (e.g., speech is nonsensical or unintelligible).|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or u|55
260|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonresponsive.|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonr|55
261|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostomy.|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostom|55
262|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of devices at the sink, in chair, or on commode|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of|55
263|4 - With a friend|4 - With a friend|55
264|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|55
265|4-OT|4-OT|55
266|5 - Advocates or facilitates patient's participation in appropriate medical care|5 - Advocates or facilitates patient's participation in appropriate medical care|55
267|5 - At least daily|5 - At least daily|55
268|6 - Bedfast, unable to ambulate or be up in a chair.|6 - Bedfast, unable to ambulate or be up in a chair.|55
269|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|55
270|5 - Disruptive or socially inappropriate behavior|5 - Disruptive or socially inappropriate behavior|55
271|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|55
272|5 - Hypo/Hyperglycemia, diabetes out of control|5 - Hypo/Hyperglycemia, diabetes out of control|55
273|5 - More often than once daily|5 - More often than once daily|55
274|5 - Native Hawaiian or Pacific Islander|5 - Native Hawaiian or Pacific Islander|55
275|5 - None of the above|5 - None of the above|55
276|5 - One to two times per week|5 - One to two times per week|55
277|5 - Other|5 - Other|55
278|5 - Other follow-up|5 - Other follow-up|55
279|5 - Paid help|5 - Paid help|55
280|5 - Patient nonresponsive or unable to speak.|5 - Patient nonresponsive or unable to speak.|55
281|5 - Thoughts of suicide|5 - Thoughts of suicide|55
282|5 - Totally unable to use the telephone.|5 - Totally unable to use the telephone.|55
283|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|55
284|5 - Unable to take in nutrients orally or by tube feeding.|5 - Unable to take in nutrients orally or by tube feeding.|55
285|5 - Unsafe for care at home|5 - Unsafe for care at home|55
286|5 - With paid help (other than home care agency staff)|5 - With paid help (other than home care agency staff)|55
287|5 - Workers' compensation|5 - Workers' compensation|55
288|5 - Wound infection, deteriorating wound status, new lesion/ulcer|5 - Wound infection, deteriorating wound status, new lesion/ulcer|55
289|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|55
290|6 - Delusional, hallucinatory, or paranoid behavior|6 - Delusional, hallucinatory, or paranoid behavior|55
291|6 - Financial agent, power of attorney, or conservator of finance|6 - Financial agent, power of attorney, or conservator of finance|55
292|6 - GI bleeding, obstruction|6 - GI bleeding, obstruction|55
293|6 - Less often than weekly|6 - Less often than weekly|55
294|6 - Memory loss to the extent that supervision required|6 - Memory loss to the extent that supervision required|55
295|6 - None of the above feelings observed or reported|6 - None of the above feelings observed or reported|55
296|6 - Other|6 - Other|55
297|6 - Title programs (e.g., Title III, V, or XX)|6 - Title programs (e.g., Title III, V, or XX)|55
298|6 - Transferred to an inpatient facility - patient not discharged from agency|6 - Transferred to an inpatient facility - patient not discharged from agency|55
299|6 - White|6 - White|55
300|6 - With other than above|6 - With other than above|55
301|7 - Exacerbation of CHF, fluid overload, heart failure|7 - Exacerbation of CHF, fluid overload, heart failure|55
302|7 - Health care agent, conservator of person, or medical power of attorney|7 - Health care agent, conservator of person, or medical power of attorney|55
303|7 - Hypo/Hyperglycemia, diabetes out of control|7 - Hypo/Hyperglycemia, diabetes out of control|55
304|7 - None of the above|7 - None of the above|55
305|7 - None of the above behaviors demonstrated|7 - None of the above behaviors demonstrated|55
306|7 - Other government (e.g., TriCare, VA, etc.)|7 - Other government (e.g., TriCare, VA, etc.)|55
307|7 - Transferred to an inpatient facility - patient discharged from agency|7 - Transferred to an inpatient facility - patient discharged from agency|55
308|8 - Death at home|8 - Death at home|55
309|8 - GI bleeding, obstruction|8 - GI bleeding, obstruction|55
310|8 - Myocardial infarction, stroke|8 - Myocardial infarction, stroke|55
311|8 - Private insurance|8 - Private insurance|55
312|9 - Chemotherapy|9 - Chemotherapy|55
313|9 - Discharge from agency|9 - Discharge from agency|55
314|9 - Other than above reasons|9 - Other than above reasons|55
315|9 - Private HMO/managed care|9 - Private HMO/managed care|55
316|NA - No caregiver|NA - No caregiver|55
317|NA - No equipment of this type used in care.|NA - No equipment of this type used in care.|55
318|NA - No inhalant/mist medications prescribed.|NA - No inhalant/mist medications prescribed.|55
319|NA - No injectable medications prescribed.|NA - No injectable medications prescribed.|55
320|NA - No inpatient facility admission|NA - No inpatient facility admission|55
321|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|55
322|NA - No Medicaid|NA - No Medicaid|55
323|NA - No Medicare|NA - No Medicare|55
324|NA - No observable pressure ulcer or unhealed pressure ulcer|NA - No observable pressure ulcer or unhealed pressure ulcer|55
325|NA - No observable stasis ulcer|NA - No observable stasis ulcer|55
326|NA - No observable surgical wound|NA - No observable surgical wound|55
327|NA - No oral medications prescribed.|NA - No oral medications prescribed.|55
328|NA - Not applicable|NA - Not applicable|55
329|NA - Patient does not have a telephone.|NA - Patient does not have a telephone.|55
330|NA - Patient has ostomy for bowel elimination|NA - Patient has ostomy for bowel elimination|55
331|NA - Patient nonresponsive|NA - Patient nonresponsive|55
332|NA - Patient on prophylactic treatment|NA - Patient on prophylactic treatment|55
333|NA - Patient was not discharged from an inpatient facility [Go to M1017]|NA - Patient was not discharged from an inpatient facility [Go to M1017]|55
334|UK - Other unknown|UK - Other unknown|55
335|UK - Reason unknown|UK - Reason unknown|55
336|UK - Unknown|UK - Unknown|55
337|UK - Unknown or Not Available|UK - Unknown or Not Available|55
341|01 - Early|01 - Early|55
342|02 - Late|02 - Late|55
343|NA - Not Applicable. No case mix group defined for this assessment.|NA - Not Applicable. No case mix group defined for this assessment.|55
344|NA - No case mix group defined by this assessment.|NA - No case mix group defined by this assessment.|55
345|1 - Recent decline in mental, emotional, or behavioral status|1 - Recent decline in mental, emotional, or behavioral status|55
346|2 - Multiple hospitalizations (2 or more) in the past 12 months|2 - Multiple hospitalizations (2 or more) in the past 12 months|55
347|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|55
348|4 - Taking five or more medications|4 - Taking five or more medications|55
349|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|55
350|6 - Other|6 - Other|55
351|7 - None of the above|7 - None of the above|55
352|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond tho|55
353|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable without heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable wi|55
354|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious complications and death.|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious compl|55
355|3 - The patient has serious progressive conditions that could lead to death within a year.|3 - The patient has serious progressive conditions that could lead to death within a year.|55
356|UK - The patient+s situation is unknown or unclear.|UK - The patient+s situation is unknown or unclear.|55
357|1 - Yes [ Go to M1050 ]|1 - Yes [ Go to M1050 ]|55
358|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this influenza season. [ Go to M1050 ]|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this i|55
359|1 - Received from another health care provider (e.g., physician)|1 - Received from another health care provider (e.g., physician)|55
360|2 - Received from your agency previously during this year+s flu season|2 - Received from your agency previously during this year+s flu season|55
361|3 - Offered and declined|3 - Offered and declined|55
362|4 - Assessed and determined to have medical contraindication(s)|4 - Assessed and determined to have medical contraindication(s)|55
363|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|55
364|6 - Inability to obtain vaccine due to declared shortage|6 - Inability to obtain vaccine due to declared shortage|55
365|1 - Yes [ Go to M1500 at TRN; Go to M1230 at DC ]|1 - Yes [ Go to M1500 at TRN; Go to M1230 at DC ]|55
366|1 - Patient has received PPV in the past|1 - Patient has received PPV in the past|55
367|2 - Offered and declined|2 - Offered and declined|55
368|3 - Assessed and determined to have medical contraindication(s)|3 - Assessed and determined to have medical contraindication(s)|55
369|4 - Not indicated; patient does not meet age/condition guidelines for PPV|4 - Not indicated; patient does not meet age/condition guidelines for PPV|55
370|5 - None of the above|5 - None of the above|55
371|0 - Adequate: hears normal conversation without difficulty.|0 - Adequate: hears normal conversation without difficulty.|55
372|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to increase volume or speak distinctly.|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to in|55
373|2 - Severely Impaired: absence of useful hearing.|2 - Severely Impaired: absence of useful hearing.|55
374|UK - Unable to assess hearing.|UK - Unable to assess hearing.|55
375|0 - Understands: clear comprehension without cues or repetitions.|0 - Understands: clear comprehension without cues or repetitions.|55
376|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Requires cues at times to understand.|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Req|55
377|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequently requires cues to understand.|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequentl|55
378|3 - Rarely/Never Understands|3 - Rarely/Never Understands|55
379|UK - Unable to assess understanding.|UK - Unable to assess understanding.|55
380|0 - No standardized assessment conducted|0 - No standardized assessment conducted|55
381|1 - Yes, and it does not indicate severe pain|1 - Yes, and it does not indicate severe pain|55
382|2 - Yes, and it indicates severe pain|2 - Yes, and it indicates severe pain|55
383|0 - Patient has no pain|0 - Patient has no pain|55
384|1 - Patient has pain that does not interfere with activity or movement|1 - Patient has pain that does not interfere with activity or movement|55
385|2 - Less often than daily|2 - Less often than daily|55
386|3 - Daily, but not constantly|3 - Daily, but not constantly|55
387|4 - All of the time|4 - All of the time|55
388|0 - No assessment conducted [ Go to M1306 ]|0 - No assessment conducted [ Go to M1306 ]|55
389|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc., without use of standardized tool|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc.,|55
390|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|55
391|0 - No [ Go to M1322]|0 - No [ Go to M1322]|55
392|0 v Newly epithelialized|0 v Newly epithelialized|55
393|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|55
394|2 - Yes, patient has observable stasis ulcers ONLY|2 - Yes, patient has observable stasis ulcers ONLY|55
395|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable dressing) [Go to M1340]|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable|55
396|0 - No [ Go to M1400 ]|0 - No [ Go to M1400 ]|55
397|1 - Yes, patient has at least one (observable) surgical wound|1 - Yes, patient has at least one (observable) surgical wound|55
398|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1400 ]|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1400 ]|55
399|0 - Patient is not short of breath|0 - Patient is not short of breath|55
400|3 - Continuous Bi-level positive airway pressure|3 - Continuous Bi-level positive airway pressure|55
401|0 - No [ Go to M1732 at TRN; Go to M1600 at DC ]|0 - No [ Go to M1732 at TRN; Go to M1600 at DC ]|55
402|2 - Not assessed [Go to M1732 at TRN; Go to M1600 at DC ]|2 - Not assessed [Go to M1732 at TRN; Go to M1600 at DC ]|55
403|NA - Patient does not have diagnosis of heart failure [Go to M2004 at TRN; Go to M1600 at DC]|NA - Patient does not have diagnosis of heart failure [Go to M2004 at TRN; Go to M1600 at DC]|55
404|0 - No action taken|0 - No action taken|55
405|1 - Patient+s physician (or other primary care practitioner) contacted the same day|1 - Patient+s physician (or other primary care practitioner) contacted the same day|55
406|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|55
407|3 - Implement physician-ordered patient-specific established parameters for treatment|3 - Implement physician-ordered patient-specific established parameters for treatment|55
408|4 - Patient education or other clinical interventions|4 - Patient education or other clinical interventions|55
409|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequency, telehealth, etc.)|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequ|55
410|1 - Occasional stress incontinence|1 - Occasional stress incontinence|55
411|2 - During the night only|2 - During the night only|55
412|3 - During the day only|3 - During the day only|55
413|4 - During the day and night|4 - During the day and night|55
414|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|55
415|0 - Able to manage toileting hygiene and clothing management without assistance.|0 - Able to manage toileting hygiene and clothing management without assistance.|55
416|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implements are laid out for the patient.|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implemen|55
417|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|55
418|3 - Patient depends entirely upon another person to maintain toileting hygiene.|3 - Patient depends entirely upon another person to maintain toileting hygiene.|55
419|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independent|55
420|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface|55
421|0 - No multi-factor falls risk assessment conducted.|0 - No multi-factor falls risk assessment conducted.|55
422|1 - Yes, and it does not indicate a risk for falls.|1 - Yes, and it does not indicate a risk for falls.|55
423|2 - Yes, and it indicates a risk for falls.|2 - Yes, and it indicates a risk for falls.|55
424|0 - Not assessed/reviewed [ Go to M2010 ]|0 - Not assessed/reviewed [ Go to M2010 ]|55
425|1 - No problems found during review [ Go to M2010 ]|1 - No problems found during review [ Go to M2010 ]|55
426|2 - Problems found during review|2 - Problems found during review|55
427|NA - Patient is not taking any medications [ Go to M2040 ]|NA - Patient is not taking any medications [ Go to M2040 ]|55
428|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special precautions associated with all high-risk medications|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special p|55
429|NA - Patient not taking any drugs|NA - Patient not taking any drugs|55
430|2 - Able to take medication(s) at the correct times if given reminders by another person at the appropriate times|2 - Able to take medication(s) at the correct times if given reminders by another person at the appr|55
431|3 - Unable to take medication unless administered by another person.|3 - Unable to take medication unless administered by another person.|55
432|1 - At least daily|1 - At least daily|55
433|2 - Three or more times per week|2 - Three or more times per week|55
434|3 - One to two times per week|3 - One to two times per week|55
435|4 - Received, but less often than weekly|4 - Received, but less often than weekly|55
436|5 - No assistance received|5 - No assistance received|55
437|0 - No [Go to M2400]|0 - No [Go to M2400]|55
438|1 - Yes, used hospital emergency department WITHOUT hospital admission|1 - Yes, used hospital emergency department WITHOUT hospital admission|55
439|2 - Yes, used hospital emergency department WITH hospital admission|2 - Yes, used hospital emergency department WITH hospital admission|55
440|UK - Unknown [Go to M2400]|UK - Unknown [Go to M2400]|55
441|2 - Injury caused by fall|2 - Injury caused by fall|55
442|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|55
443|4 - Other respiratory problem|4 - Other respiratory problem|55
444|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|55
445|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|55
446|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|55
447|8 - Other heart disease|8 - Other heart disease|55
448|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|55
449|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|55
450|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|55
451|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|55
452|13 - Urinary tract infection|13 - Urinary tract infection|55
453|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|55
454|15 - Wound infection or deterioration|15 - Wound infection or deterioration|55
455|16 - Uncontrolled pain|16 - Uncontrolled pain|55
456|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|55
457|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|55
458|19 - Other than above reasons|19 - Other than above reasons|55
459|2 - Patient remained in the community (with formal assistive services)|2 - Patient remained in the community (with formal assistive services)|55
460|3 - Patient transferred to a noninstitutional hospice|3 - Patient transferred to a noninstitutional hospice|55
461|4 - Unknown because patient moved to a geographic location not served by this agency|4 - Unknown because patient moved to a geographic location not served by this agency|55
462|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|55
463|4 - Other respiratory problem|4 - Other respiratory problem|55
464|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|55
465|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|55
466|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|55
467|8 - Other heart disease|8 - Other heart disease|55
468|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|55
469|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|55
470|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|55
471|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|55
472|13 - Urinary tract infection|13 - Urinary tract infection|55
473|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|55
474|15 - Wound infection or deterioration|15 - Wound infection or deterioration|55
475|16 - Uncontrolled pain|16 - Uncontrolled pain|55
476|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|55
477|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|55
478|19 - Scheduled treatment or procedure|19 - Scheduled treatment or procedure|55
479|20 - Other than above reasons|20 - Other than above reasons|55
480|UK - Reason unknown [Go to M0903]|UK - Reason unknown [Go to M0903]|55
482|01 - Patient lives alone around the clock|01 - Patient lives alone around the clock|55
483|02 - Patient lives alone regular daytime|02 - Patient lives alone regular daytime|55
484|03 - Patient lives alone regular nighttime|03 - Patient lives alone regular nighttime|55
485|04 - Patient lives alone occassional/short term assistance|04 - Patient lives alone occassional/short term assistance|55
486|05 - Patient lives alone no assisstance available|05 - Patient lives alone no assisstance available|55
487|06 - Patient lives with other person(s) in the home around the clock|06 - Patient lives with other person(s) in the home around the clock|55
488|07 - Patient lives with other person(s) in the home regular daytime|07 - Patient lives with other person(s) in the home regular daytime|55
489|08 - Patient lives with other person(s) in the home regular nighttime|08 - Patient lives with other person(s) in the home regular nighttime|55
490|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|55
491|10 - Patient lives with other person(s) in the home no assistance available|10 - Patient lives with other person(s) in the home no assistance available|55
492|1 - Was present at the most recent SOC/ROC assessment|1 - Was present at the most recent SOC/ROC assessment|55
493|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|55
494|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|55
495|0 - Newly epithelialized|0 - Newly epithelialized|55
496|0 - No [ Go to M1340 ]|0 - No [ Go to M1340 ]|55
498|0 - Independent|0 - Independent|55
499|1 - Needed Some Help|1 - Needed Some Help|55
500|2 - Dependent|2 - Dependent|55
502|0 - No assistance needed in this area|0 - No assistance needed in this area|55
503|1 - Caregiver(s) currently provide assistance|1 - Caregiver(s) currently provide assistance|55
504|2 - Caregiver(s) need training/ supportive services to provide assistance|2 - Caregiver(s) need training/ supportive services to provide assistance|55
505|3 - Caregiver(s) not likely to provide assistance|3 - Caregiver(s) not likely to provide assistance|55
506|4 - Unclear if Caregiver(s) will provide assistance|4 - Unclear if Caregiver(s) will provide assistance|55
507|5 - Assistance needed, but no Caregiver(s) available|5 - Assistance needed, but no Caregiver(s) available|55
508|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will use standardized clinical guidelines accessible for all care providers to reference|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will|55
510|NA - Patient is not assessed to be at risk for falls|NA - Patient is not assessed to be at risk for falls|55
511|NA - Patient has no diagnosis or symptoms of depression|NA - Patient has no diagnosis or symptoms of depression|55
512|NA - No pain identified|NA - No pain identified|55
513|NA - Patient is not assessed to be at risk for pressure ulcers|NA - Patient is not assessed to be at risk for pressure ulcers|55
514|NA - Patient has no pressure ulcers with need for moist wound healing|NA - Patient has no pressure ulcers with need for moist wound healing|55
515|1 - Long-term nursing facility (NF)|1 - Long-term nursing facility (NF)|55
516|2 - Skilled nursing facility (SNF / TCU)|2 - Skilled nursing facility (SNF / TCU)|55
517|3 - Short stay acute hospital (IPP S)|3 - Short stay acute hospital (IPP S)|55
518|4 - Long-term care hospital (LTCH)|4 - Long-term care hospital (LTCH)|55
519|5 - Inpatient rehabilitation hospital or unit (IRF)|5 - Inpatient rehabilitation hospital or unit (IRF)|55
520|6 - Psychiatric hospital or unit|6 - Psychiatric hospital or unit|55
521|7 - Other|7 - Other|55
522|NA - Patient was not discharged from an inpatient facility [Go to M1017]|NA - Patient was not discharged from an inpatient facility [Go to M1017]|55
523|6 - Unable to participate effectively in bathing and is bathed totally by another person|6 - Unable to participate effectively in bathing and is bathed totally by another person|55
524|4 - Chairfast, unable to ambulate but is able to wheel self independently.|4 - Chairfast, unable to ambulate but is able to wheel self independently.|55
525|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask patient: "Over the last two weeks, how often have you been bothered by any of the following problems")   *Copyright+ Pfizer Inc. All rights reserved. Reproduced with permission.|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask|55
526|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluation for depression.|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluat|55
527|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet criteria for further evaluation for depression.|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet|55
528|0 - Not at all  0 - 1 day|0 - Not at all  0 - 1 day|55
529|1 - Several days  2 - 6 days|1 - Several days  2 - 6 days|55
530|2 - More than half of the days  7 - 11 days|2 - More than half of the days  7 - 11 days|55
531|3 - Nearly every day  12 - 14 days|3 - Nearly every day  12 - 14 days|55
532|NA - N/A  Unable to respond|NA - N/A  Unable to respond|55
533|2 - Able to take medication(s) at the correct times if given reminders by another person based on the frequency of the injection|2 - Able to take medication(s) at the correct times if given reminders by another person based on th|55
534|3 - Unable to take injectable medication unless administered by another person.|3 - Unable to take injectable medication unless administered by another person.|55
536|UK - Inpatient Discharge Date Unknown|UK - Inpatient Discharge Date Unknown|55
537|NA - Inpatient stay within last 14 days Not Applicable|NA - Inpatient stay within last 14 days Not Applicable|55
2|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; OR (b) Is physically, cognitively, and mentally able to prepare light meals on a regular basis but has not routinely performed light meal preparation in the past (i.e., prior to this home care admission).|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; O|56
3|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and mentally able to perform all housekeeping tasks .|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and menta|56
4|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and mentally able to do laundry and access facilities.|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and menta|56
5|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying packages OR b) Physically, cognitively, and mentally able to take care of shopping, but has not done shopping in the past (i.e., prior to this home care admission).|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying|56
6|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|56
7|0 - Able to dial numbers and answer calls appropriately and as desired.|0 - Able to dial numbers and answer calls appropriately and as desired.|56
8|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body without assistance.|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body|56
9|0 - Able to get to and from the toilet and transfer independently with or without a device.|0 - Able to get to and from the toilet and transfer independently with or without a device.|56
10|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|56
11|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible public bus.|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible p|56
12|0 - Able to independently feed self.|0 - Able to independently feed self.|56
13|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|56
14|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct times.|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct ti|56
15|0 - Able to independently transfer.|0 - Able to independently transfer.|56
16|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without rail|56
17|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings|56
18|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|56
19|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions independently.|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions indep|56
20|0 - Asymptomatic, no treatment needed at this time|0 - Asymptomatic, no treatment needed at this time|56
21|0 - Caregiver manages all tasks related to equipment completely independently.|0 - Caregiver manages all tasks related to equipment completely independently.|56
22|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations with no observable impairment.|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations w|56
23|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|56
24|0 - Life expectancy is greater than 6 months|0 - Life expectancy is greater than 6 months|56
25|0 - Never|0 - Never|56
26|0 - Patient is not short of breath|0 - Patient is not short of breath|56
27|0 - No|0 - No|56
28|0 - No emergent care services|0 - No emergent care services|56
29|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [Goto 1620]|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [Goto 1620]|56
30|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and extended or abstract conversation.|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and exte|56
31|0 - No one person|0 - No one person|56
32|0 - None of the time|0 - None of the time|56
33|0 - None, no charge for current services|0 - None, no charge for current services|56
34|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|56
35|0 - Patient does NOT have an ostomy for bowel elimination.|0 - Patient does NOT have an ostomy for bowel elimination.|56
36|0 - Patient has no pain|0 - Patient has no pain|56
37|0 - Patient manages all tasks related to equipment completely independently.|0 - Patient manages all tasks related to equipment completely independently.|56
38|0 - Poor:  little or no recovery is expected and/or further decline is imminent|0 - Poor:  little or no recovery is expected and/or further decline is imminent|56
39|0 - Timed-voiding defers incontinence|0 - Timed-voiding defers incontinence|56
40|0 - Very rarely or never has bowel incontinence|0 - Very rarely or never has bowel incontinence|56
41|0 - Zero|0 - Zero|56
42|00 - No|00 - No|56
43|01 - Yes|01 - Yes|56
44|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or mental limitations, needs assistance with heavy laundry.|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or|56
45|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the patient.|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the|56
46|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|56
47|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or supervision from another person OR c) a liquid, pureed or ground meat diet.|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or su|56
48|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|56
49|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|56
50|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independently.|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independe|56
51|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only when assisted or accompanied by another person.|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only w|56
52|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepa|56
53|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance by another person OR b) given daily reminders.|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance b|56
54|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advan|56
55|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advan|56
56|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for the deaf) and call essential numbers.|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for t|56
57|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|56
58|1 - American Indian or Alaska Native|1 - American Indian or Alaska Native|56
59|1 - Depressed mood (e.g., feeling sad, tearful)|1 - Depressed mood (e.g., feeling sad, tearful)|56
60|1 - During the night only|1 - During the night only|56
61|1 - Fully granulating|1 - Fully granulating|56
62|1 - Good/Fair:  partial to full recovery is expected|1 - Good/Fair:  partial to full recovery is expected|56
63|1 - Good:  marked improvement in functional status is expected|1 - Good:  marked improvement in functional status is expected|56
64|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|56
65|1 - Smoking|1 - Smoking|56
66|1 - Hospital|1 - Hospital|56
67|1 - Hospital emergency room (includes 23-hour holding)|1 - Hospital emergency room (includes 23-hour holding)|56
68|1 - Hospitalization for EMERGENT (unscheduled) care|1 - Hospitalization for EMERGENT (unscheduled) care|56
69|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepared solutions), patient is able to manage all other aspects of equipment.|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepar|56
70|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|56
71|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|56
72|1 - In new or complex situations only|1 - In new or complex situations only|56
73|1 - Intravenous or infusion therapy (excludes TPN)|1 - Intravenous or infusion therapy (excludes TPN)|56
74|1 - Less often than daily|1 - Less often than daily|56
75|1 - Less than once a month|1 - Less than once a month|56
76|1 - Less than once weekly|1 - Less than once weekly|56
77|1 - Life expectancy is 6 months or fewer|1 - Life expectancy is 6 months or fewer|56
78|1 - Lives alone|1 - Lives alone|56
79|1 - Male|1 - Male|56
80|1 - Medicare (traditional fee-for-service)|1 - Medicare (traditional fee-for-service)|56
81|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of past 24 hours, significant memory loss so that supervision is required|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of pas|56
82|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors in word choice, grammar or speech intelligibility, needs minimal prompting or assistance).|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors i|56
83|1 - No assistance or services received|1 - No assistance or services received|56
84|1 - One|1 - One|56
85|1 - Oxygen (intermittent or continuous)|1 - Oxygen (intermittent or continuous)|56
86|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, and the surrounding layout, can count fingers at arm's length.|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, a|56
87|1 - Patient is incontinent|1 - Patient is incontinent|56
88|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|56
89|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical or treatment regimen.|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical|56
90|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient/couple/significant other)|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient|56
91|1 - Relatives, friends, or neighbors living outside the home|1 - Relatives, friends, or neighbors living outside the home|56
92|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions.|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions|56
93|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independentl|56
94|1 - Several times during day and night|1 - Several times during day and night|56
95|1 - Spouse or significant other|1 - Spouse or significant other|56
96|1 - Stage 1|1 - Stage 1|56
97|1 - Start of care - further visits planned|1 - Start of care - further visits planned|56
98|1 - Symptoms well controlled with current therapy|1 - Symptoms well controlled with current therapy|56
99|1 - Therapy services|1 - Therapy services|56
100|1 - Able to transfer with minimal human assistance or with use of an assistive device.|1 - Able to transfer with minimal human assistance or with use of an assistive device.|56
101|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitations.|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitatio|56
102|1 - Urinary incontinence|1 - Urinary incontinence|56
103|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and transfer.|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and|56
104|1 - When walking more than 20 feet, climbing stairs|1 - When walking more than 20 feet, climbing stairs|56
105|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary conversation. May need occasional repetition, extra time, or louder voice.|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary c|56
106|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting in and out of tub/shower|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting|56
107|1 - Yes|1 - Yes|56
108|1-RN|1-RN|56
109|10 - Discharge from agency - no visits completed after start/resumption of care assessment|10 - Discharge from agency - no visits completed after start/resumption of care assessment|56
110|10 - Scheduled surgical procedure|10 - Scheduled surgical procedure|56
111|10 - Self-pay|10 - Self-pay|56
112|11 - Other|11 - Other|56
113|11 - Urinary tract infection|11 - Urinary tract infection|56
114|12 - IV catheter-related infection|12 - IV catheter-related infection|56
115|13 - Deep vein thrombosis, pulmonary embolus|13 - Deep vein thrombosis, pulmonary embolus|56
116|14 - Uncontrolled pain|14 - Uncontrolled pain|56
117|15 - Psychotic episode|15 - Psychotic episode|56
118|16 - Other than above reasons|16 - Other than above reasons|56
119|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing calls.|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing|56
120|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another person.|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another pers|56
121|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface a|56
122|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for intermittent supervision or encouragement or reminders, OR (b) to get in and out of the shower or tub, OR (c) for washing difficult to reach areas.|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for inter|56
123|2 - Asian|2 - Asian|56
124|2 - Caregiver requires considerable assistance from another person to manage equipment, but independently completes significant portions of task.|2 - Caregiver requires considerable assistance from another person to manage equipment, but independ|56
125|2 - Daily, but not constantly|2 - Daily, but not constantly|56
126|2 - Daughter or son|2 - Daughter or son|56
127|2 - Doctor's office emergency visit/house call|2 - Doctor's office emergency visit/house call|56
128|2 - During the day and night|2 - During the day and night|56
129|2 - Early/partial granulation|2 - Early/partial granulation|56
130|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors in word choice, organization or speech intelligibility). Speaks in phrases or short sentences.|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors|56
131|2 - Family member's residence|2 - Family member's residence|56
132|2 - Female|2 - Female|56
133|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conversation, needs frequent prompting or assistance.|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conver|56
134|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|56
135|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|56
136|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately stop activities, jeopardizes safety through actions|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately st|56
137|2 - Indwelling/suprapubic catheter|2 - Indwelling/suprapubic catheter|56
138|2 - Injury caused by fall|2 - Injury caused by fall|56
139|2 - Medicare (HMO/managed care/Advantage plan)|2 - Medicare (HMO/managed care/Advantage plan)|56
140|2 - Nausea, dehydration, malnutrition, constipation, impaction|2 - Nausea, dehydration, malnutrition, constipation, impaction|56
141|2 - Obesity|2 - Obesity|56
142|2 - On awakening or at night only|2 - On awakening or at night only|56
143|2 - Once a month|2 - Once a month|56
144|2 - One to three times weekly|2 - One to three times weekly|56
145|2 - Parenteral nutrition (TPN or lipids)|2 - Parenteral nutrition (TPN or lipids)|56
146|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic) [ Go to M1620]|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic) [ Go|56
147|2 - Patient requires considerable assistance from another person to manage equipment, but independently completes portions of the task.|2 - Patient requires considerable assistance from another person to manage equipment, but independen|56
148|2 - Patient transferred to a noninstitutional hospice|2 - Patient transferred to a noninstitutional hospice|56
149|2 - Person residing in the home (EXCLUDING paid help)|2 - Person residing in the home (EXCLUDING paid help)|56
150|2 - Rehabilitation facility|2 - Rehabilitation facility|56
151|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifting of attention) or consistently requires low stimulus environment due to distractibility.|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifti|56
152|2 - Respite care|2 - Respite care|56
153|2 - Sense of failure or self reproach|2 - Sense of failure or self reproach|56
154|2 - Several times during day|2 - Several times during day|56
155|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonresponsive.|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonrespons|56
156|2 - Someone must assist the patient to groom self.|2 - Someone must assist the patient to groom self.|56
157|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|56
158|2 - Someone must help the patient put on upper body clothing.|2 - Someone must help the patient put on upper body clothing.|56
159|2 - Stage 2|2 - Stage 2|56
160|2 - Start of care - no further visits planned|2 - Start of care - no further visits planned|56
161|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitoring|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitori|56
162|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment regimen.|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment re|56
163|2 - Two|2 - Two|56
164|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistance due to cognitive or mental limitation.|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistanc|56
165|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|56
166|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assistance).|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assis|56
167|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home delivery.|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home deli|56
168|2 - Unable to prepare any light meals or reheat any delivered meals.|2 - Unable to prepare any light meals or reheat any delivered meals.|56
169|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|56
170|2 - UNABLE to take injectable medications unless administered by someone else.|2 - UNABLE to take injectable medications unless administered by someone else.|56
171|2 - UNABLE to take medication unless administered by someone else.|2 - UNABLE to take medication unless administered by someone else.|56
172|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|56
173|2 - Ventilator (continually or at night)|2 - Ventilator (continually or at night)|56
174|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less than 20 feet)|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less th|56
175|2 - With spouse or significant other|2 - With spouse or significant other|56
176|2 - Yes, assistance or services provided by family or friends|2 - Yes, assistance or services provided by family or friends|56
177|2-PT|2-PT|56
178|3 - Able to answer the telephone only some of the time or is able to carry on only a limited conversation.|3 - Able to answer the telephone only some of the time or is able to carry on only a limited convers|56
179|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube or gastrostomy.|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube|56
180|3 - Alcohol dependency|3 - Alcohol dependency|56
181|3 - All of the time|3 - All of the time|56
182|3 - Black or African-American|3 - Black or African-American|56
183|3 - Boarding home or rented room|3 - Boarding home or rented room|56
184|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment, clean/store/dispose of equipment or supplies).|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment,|56
185|3 -Able to walk only with the supervision or assistance of another person at all times.|3 -Able to walk only with the supervision or assistance of another person at all times.|56
186|3 - Continuous / Bi-level positive airway pressure|3 - Continuous / Bi-level positive airway pressure|56
187|3 - During the day and evening, but not constantly|3 - During the day and evening, but not constantly|56
188|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the alimentary canal)|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the|56
189|3 - Environmental support (e.g., housing, home maintenance)|3 - Environmental support (e.g., housing, home maintenance)|56
190|3 - Four to six times weekly|3 - Four to six times weekly|56
191|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessing by listener.  Speech limited to single words or short phrases.|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessin|56
192|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires multiple repetitions, restatements, demonstrations, additional time.|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires m|56
193|3 - Hopelessness|3 - Hopelessness|56
194|3 - Hospice care|3 - Hospice care|56
195|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|56
196|3 - Injury caused by fall or accident at home|3 - Injury caused by fall or accident at home|56
197|3 - Intractable pain|3 - Intractable pain|56
198|3 - Medicaid (traditional fee-for-service)|3 - Medicaid (traditional fee-for-service)|56
199|3 - Needs someone to do all shopping and errands.|3 - Needs someone to do all shopping and errands.|56
200|3 - Not healing|3 - Not healing|56
201|3 - Nursing home|3 - Nursing home|56
202|3 - Once daily|3 - Once daily|56
203|3 - Other family member|3 - Other family member|56
204|3 - Outpatient department/clinic emergency (includes urgicenter sites)|3 - Outpatient department/clinic emergency (includes urgicenter sites)|56
205|3 - Paid help|3 - Paid help|56
206|3 - Able to participate in bathing self in shower or tub, but requires presence of another person throughout the bath for assistance or supervision.|3 - Able to participate in bathing self in shower or tub, but requires presence of another person th|56
207|3 - Patient depends entirely upon another person to dress lower body.|3 - Patient depends entirely upon another person to dress lower body.|56
208|3 - Patient depends entirely upon another person to dress the upper body.|3 - Patient depends entirely upon another person to dress the upper body.|56
209|3 - Patient depends entirely upon someone else for grooming needs.|3 - Patient depends entirely upon someone else for grooming needs.|56
210|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone else to manage the equipment.|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone|56
211|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable to shift attention and recall directions more than half the time.|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable|56
212|3 - Respiratory problems (SOB, infection, obstruction)|3 - Respiratory problems (SOB, infection, obstruction)|56
213|3 - Resumption of care (after inpatient stay)|3 - Resumption of care (after inpatient stay)|56
214|3 - Several times each month|3 - Several times each month|56
215|3 - Skilled Nursing Facility|3 - Skilled Nursing Facility|56
216|3 - Stage 3|3 - Stage 3|56
217|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|56
218|3 - Three|3 - Three|56
219|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person throughout the process.|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person through|56
220|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal independently.|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal indep|56
221|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person.|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person|56
222|3 - Unknown because patient moved to a geographic location not served by this agency|3 - Unknown because patient moved to a geographic location not served by this agency|56
223|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|56
224|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|56
225|3 - With other family member|3 - With other family member|56
226|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home health services, homemaker assistance, transportation assistance, assisted living, board and care)|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home h|56
227|3-SLP/ST|3-SLP/ST|56
228|4 - At rest (during day or night)|4 - At rest (during day or night)|56
229|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|56
230|4 - Board and care or assisted living facility|4 - Board and care or assisted living facility|56
231|4 - Caregiver is completely dependent on someone else to manage all equipment.|4 - Caregiver is completely dependent on someone else to manage all equipment.|56
232|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|56
233|4 - Constantly|4 - Constantly|56
234|4 - Drug dependency|4 - Drug dependency|56
235|4 - Four or more|4 - Four or more|56
236|4 - Friend or neighbor or community or church member|4 - Friend or neighbor or community or church member|56
237|4 - Hispanic or Latino|4 - Hispanic or Latino|56
238|4 - Hospice|4 - Hospice|56
239|4 - Impaired decision-making|4 - Impaired decision-making|56
240|4 - Is totally dependent in toileting.|4 - Is totally dependent in toileting.|56
241|4 - Medicaid (HMO/managed care)|4 - Medicaid (HMO/managed care)|56
242|4 - None of the above|4 - None of the above|56
243|4 - Nursing home|4 - Nursing home|56
244|4 - On a daily basis|4 - On a daily basis|56
245|4 - Patient is completely dependent on someone else to manage all equipment.|4 - Patient is completely dependent on someone else to manage all equipment.|56
246|4 - Permanent placement|4 - Permanent placement|56
247|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, punches, dangerous maneuvers w/ wheelchair or other objects)|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, pu|56
248|4 - Psychosocial support (e.g., socialization, companionship, recreation)|4 - Psychosocial support (e.g., socialization, companionship, recreation)|56
249|4 - Recertification (follow-up) reassessment|4 - Recertification (follow-up) reassessment|56
250|4 - Recurrent thoughts of death|4 - Recurrent thoughts of death|56
251|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruction)|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruc|56
252|4 - Several times a week|4 - Several times a week|56
253|4 - Stage 4|4 - Stage 4|56
254|4 - Symptoms poorly controlled, history of rehospitalizations|4 - Symptoms poorly controlled, history of rehospitalizations|56
255|4 - Three or more times per week|4 - Three or more times per week|56
256|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetative state, or delirium.|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetati|56
257|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|56
258|4 - Unable to effectively participate in any housekeeping tasks.|4 - Unable to effectively participate in any housekeeping tasks.|56
259|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or unresponsive (e.g., speech is nonsensical or unintelligible).|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or u|56
260|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonresponsive.|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonr|56
261|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostomy.|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostom|56
262|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of devices at the sink, in chair, or on commode|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of|56
263|4 - With a friend|4 - With a friend|56
264|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|56
265|4-OT|4-OT|56
266|5 - Advocates or facilitates patient's participation in appropriate medical care|5 - Advocates or facilitates patient's participation in appropriate medical care|56
267|5 - At least daily|5 - At least daily|56
268|6 - Bedfast, unable to ambulate or be up in a chair.|6 - Bedfast, unable to ambulate or be up in a chair.|56
269|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|56
270|5 - Disruptive or socially inappropriate behavior|5 - Disruptive or socially inappropriate behavior|56
271|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|56
272|5 - Hypo/Hyperglycemia, diabetes out of control|5 - Hypo/Hyperglycemia, diabetes out of control|56
273|5 - More often than once daily|5 - More often than once daily|56
274|5 - Native Hawaiian or Pacific Islander|5 - Native Hawaiian or Pacific Islander|56
275|5 - None of the above|5 - None of the above|56
276|5 - One to two times per week|5 - One to two times per week|56
277|5 - Other|5 - Other|56
278|5 - Other follow-up|5 - Other follow-up|56
279|5 - Paid help|5 - Paid help|56
280|5 - Patient nonresponsive or unable to speak.|5 - Patient nonresponsive or unable to speak.|56
281|5 - Thoughts of suicide|5 - Thoughts of suicide|56
282|5 - Totally unable to use the telephone.|5 - Totally unable to use the telephone.|56
283|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|56
284|5 - Unable to take in nutrients orally or by tube feeding.|5 - Unable to take in nutrients orally or by tube feeding.|56
285|5 - Unsafe for care at home|5 - Unsafe for care at home|56
286|5 - With paid help (other than home care agency staff)|5 - With paid help (other than home care agency staff)|56
287|5 - Workers' compensation|5 - Workers' compensation|56
288|5 - Wound infection, deteriorating wound status, new lesion/ulcer|5 - Wound infection, deteriorating wound status, new lesion/ulcer|56
289|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|56
290|6 - Delusional, hallucinatory, or paranoid behavior|6 - Delusional, hallucinatory, or paranoid behavior|56
291|6 - Financial agent, power of attorney, or conservator of finance|6 - Financial agent, power of attorney, or conservator of finance|56
292|6 - GI bleeding, obstruction|6 - GI bleeding, obstruction|56
293|6 - Less often than weekly|6 - Less often than weekly|56
294|6 - Memory loss to the extent that supervision required|6 - Memory loss to the extent that supervision required|56
295|6 - None of the above feelings observed or reported|6 - None of the above feelings observed or reported|56
296|6 - Other|6 - Other|56
297|6 - Title programs (e.g., Title III, V, or XX)|6 - Title programs (e.g., Title III, V, or XX)|56
298|6 - Transferred to an inpatient facility - patient not discharged from agency|6 - Transferred to an inpatient facility - patient not discharged from agency|56
299|6 - White|6 - White|56
300|6 - With other than above|6 - With other than above|56
301|7 - Exacerbation of CHF, fluid overload, heart failure|7 - Exacerbation of CHF, fluid overload, heart failure|56
302|7 - Health care agent, conservator of person, or medical power of attorney|7 - Health care agent, conservator of person, or medical power of attorney|56
303|7 - Hypo/Hyperglycemia, diabetes out of control|7 - Hypo/Hyperglycemia, diabetes out of control|56
304|7 - None of the above|7 - None of the above|56
305|7 - None of the above behaviors demonstrated|7 - None of the above behaviors demonstrated|56
306|7 - Other government (e.g., TriCare, VA, etc.)|7 - Other government (e.g., TriCare, VA, etc.)|56
307|7 - Transferred to an inpatient facility - patient discharged from agency|7 - Transferred to an inpatient facility - patient discharged from agency|56
308|8 - Death at home|8 - Death at home|56
309|8 - GI bleeding, obstruction|8 - GI bleeding, obstruction|56
310|8 - Myocardial infarction, stroke|8 - Myocardial infarction, stroke|56
311|8 - Private insurance|8 - Private insurance|56
312|9 - Chemotherapy|9 - Chemotherapy|56
313|9 - Discharge from agency|9 - Discharge from agency|56
314|9 - Other than above reasons|9 - Other than above reasons|56
315|9 - Private HMO/managed care|9 - Private HMO/managed care|56
316|NA - No caregiver|NA - No caregiver|56
317|NA - No equipment of this type used in care.|NA - No equipment of this type used in care.|56
318|NA - No inhalant/mist medications prescribed.|NA - No inhalant/mist medications prescribed.|56
319|NA - No injectable medications prescribed.|NA - No injectable medications prescribed.|56
320|NA - No inpatient facility admission|NA - No inpatient facility admission|56
321|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|56
322|NA - No Medicaid|NA - No Medicaid|56
323|NA - No Medicare|NA - No Medicare|56
324|NA - No observable pressure ulcer or unhealed pressure ulcer|NA - No observable pressure ulcer or unhealed pressure ulcer|56
325|NA - No observable stasis ulcer|NA - No observable stasis ulcer|56
326|NA - No observable surgical wound|NA - No observable surgical wound|56
327|NA - No oral medications prescribed.|NA - No oral medications prescribed.|56
328|NA - Not applicable|NA - Not applicable|56
329|NA - Patient does not have a telephone.|NA - Patient does not have a telephone.|56
330|NA - Patient has ostomy for bowel elimination|NA - Patient has ostomy for bowel elimination|56
331|NA - Patient nonresponsive|NA - Patient nonresponsive|56
332|NA - Patient on prophylactic treatment|NA - Patient on prophylactic treatment|56
333|NA - Patient was not discharged from an inpatient facility [Go to M1017]|NA - Patient was not discharged from an inpatient facility [Go to M1017]|56
334|UK - Other unknown|UK - Other unknown|56
335|UK - Reason unknown|UK - Reason unknown|56
336|UK - Unknown|UK - Unknown|56
337|UK - Unknown or Not Available|UK - Unknown or Not Available|56
341|01 - Early|01 - Early|56
342|02 - Late|02 - Late|56
343|NA - Not Applicable. No case mix group defined for this assessment.|NA - Not Applicable. No case mix group defined for this assessment.|56
344|NA - No case mix group defined by this assessment.|NA - No case mix group defined by this assessment.|56
345|1 - Recent decline in mental, emotional, or behavioral status|1 - Recent decline in mental, emotional, or behavioral status|56
346|2 - Multiple hospitalizations (2 or more) in the past 12 months|2 - Multiple hospitalizations (2 or more) in the past 12 months|56
347|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|56
348|4 - Taking five or more medications|4 - Taking five or more medications|56
349|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|56
350|6 - Other|6 - Other|56
351|7 - None of the above|7 - None of the above|56
352|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond tho|56
353|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable without heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable wi|56
354|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious complications and death.|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious compl|56
355|3 - The patient has serious progressive conditions that could lead to death within a year.|3 - The patient has serious progressive conditions that could lead to death within a year.|56
356|UK - The patient+s situation is unknown or unclear.|UK - The patient+s situation is unknown or unclear.|56
357|0 - No [ Go to M1051 ]|0 - No [ Go to M1051 ]|56
358|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this influenza season. [ Go to M1050 ]|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this i|56
359|1 - Received from another health care provider (e.g., physician)|1 - Received from another health care provider (e.g., physician)|56
360|2 - Received from your agency previously during this year+s flu season|2 - Received from your agency previously during this year+s flu season|56
361|3 - Offered and declined|3 - Offered and declined|56
362|4 - Assessed and determined to have medical contraindication(s)|4 - Assessed and determined to have medical contraindication(s)|56
363|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|56
364|6 - Inability to obtain vaccine due to declared shortage|6 - Inability to obtain vaccine due to declared shortage|56
365|1 - Yes [ Go to M1500 at TRN; Go to M1230 at DC ]|1 - Yes [ Go to M1500 at TRN; Go to M1230 at DC ]|56
366|1 - Patient has received PPV in the past|1 - Patient has received PPV in the past|56
367|2 - Offered and declined|2 - Offered and declined|56
368|3 - Assessed and determined to have medical contraindication(s)|3 - Assessed and determined to have medical contraindication(s)|56
369|4 - Not indicated; patient does not meet age/condition guidelines for PPV|4 - Not indicated; patient does not meet age/condition guidelines for PPV|56
370|5 - None of the above|5 - None of the above|56
371|0 - Adequate: hears normal conversation without difficulty.|0 - Adequate: hears normal conversation without difficulty.|56
372|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to increase volume or speak distinctly.|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to in|56
373|2 - Severely Impaired: absence of useful hearing.|2 - Severely Impaired: absence of useful hearing.|56
374|UK - Unable to assess hearing.|UK - Unable to assess hearing.|56
375|0 - Understands: clear comprehension without cues or repetitions.|0 - Understands: clear comprehension without cues or repetitions.|56
376|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Requires cues at times to understand.|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Req|56
377|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequently requires cues to understand.|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequentl|56
378|3 - Rarely/Never Understands|3 - Rarely/Never Understands|56
379|UK - Unable to assess understanding.|UK - Unable to assess understanding.|56
380|0 - No standardized assessment conducted|0 - No standardized assessment conducted|56
381|1 - Yes, and it does not indicate severe pain|1 - Yes, and it does not indicate severe pain|56
382|2 - Yes, and it indicates severe pain|2 - Yes, and it indicates severe pain|56
383|0 - Patient has no pain|0 - Patient has no pain|56
384|1 - Patient has pain that does not interfere with activity or movement|1 - Patient has pain that does not interfere with activity or movement|56
385|2 - Less often than daily|2 - Less often than daily|56
386|3 - Daily, but not constantly|3 - Daily, but not constantly|56
387|4 - All of the time|4 - All of the time|56
388|0 - No assessment conducted [ Go to M1306 ]|0 - No assessment conducted [ Go to M1306 ]|56
389|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc., without use of standardized tool|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc.,|56
390|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|56
391|0 - No [ Go to M1322]|0 - No [ Go to M1322]|56
392|0 v Newly epithelialized|0 v Newly epithelialized|56
393|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|56
394|2 - Yes, patient has observable stasis ulcers ONLY|2 - Yes, patient has observable stasis ulcers ONLY|56
395|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable dressing) [Go to M1340]|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable|56
396|0 - No [ Go to M1350 ]|0 - No [ Go to M1350 ]|56
397|1 - Yes, patient has at least one (observable) surgical wound|1 - Yes, patient has at least one (observable) surgical wound|56
398|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1350 ]|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1350 ]|56
399|0 - Patient is not short of breath|0 - Patient is not short of breath|56
400|3 - Continuous Bi-level positive airway pressure|3 - Continuous Bi-level positive airway pressure|56
401|0 - No [ Go to M2004 at TRN; Go to M1600 at DC ]|0 - No [ Go to M2004 at TRN; Go to M1600 at DC ]|56
402|2 - Not assessed [Go to M2004 at TRN; Go to M1600 at DC ]|2 - Not assessed [Go to M2004 at TRN; Go to M1600 at DC ]|56
403|NA - Patient does not have diagnosis of heart failure [Go to M2004 at TRN; Go to M1600 at DC]|NA - Patient does not have diagnosis of heart failure [Go to M2004 at TRN; Go to M1600 at DC]|56
404|0 - No action taken|0 - No action taken|56
405|1 - Patient+s physician (or other primary care practitioner) contacted the same day|1 - Patient+s physician (or other primary care practitioner) contacted the same day|56
406|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|56
407|3 - Implement physician-ordered patient-specific established parameters for treatment|3 - Implement physician-ordered patient-specific established parameters for treatment|56
408|4 - Patient education or other clinical interventions|4 - Patient education or other clinical interventions|56
409|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequency, telehealth, etc.)|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequ|56
410|1 - Occasional stress incontinence|1 - Occasional stress incontinence|56
411|2 - During the night only|2 - During the night only|56
412|3 - During the day only|3 - During the day only|56
413|4 - During the day and night|4 - During the day and night|56
414|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|56
415|0 - Able to manage toileting hygiene and clothing management without assistance.|0 - Able to manage toileting hygiene and clothing management without assistance.|56
416|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implements are laid out for the patient.|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implemen|56
417|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|56
418|3 - Patient depends entirely upon another person to maintain toileting hygiene.|3 - Patient depends entirely upon another person to maintain toileting hygiene.|56
419|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independent|56
420|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface|56
421|0 - No multi-factor falls risk assessment conducted.|0 - No multi-factor falls risk assessment conducted.|56
422|1 - Yes, and it does not indicate a risk for falls.|1 - Yes, and it does not indicate a risk for falls.|56
423|2 - Yes, and it indicates a risk for falls.|2 - Yes, and it indicates a risk for falls.|56
424|0 - Not assessed/reviewed [ Go to M2010 ]|0 - Not assessed/reviewed [ Go to M2010 ]|56
425|1 - No problems found during review [ Go to M2010 ]|1 - No problems found during review [ Go to M2010 ]|56
426|2 - Problems found during review|2 - Problems found during review|56
427|NA - Patient is not taking any medications [ Go to M2040 ]|NA - Patient is not taking any medications [ Go to M2040 ]|56
428|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special precautions associated with all high-risk medications|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special p|56
429|NA - Patient not taking any drugs|NA - Patient not taking any drugs|56
430|2 - Able to take medication(s) at the correct times if given reminders by another person at the appropriate times|2 - Able to take medication(s) at the correct times if given reminders by another person at the appr|56
431|3 - Unable to take medication unless administered by another person.|3 - Unable to take medication unless administered by another person.|56
432|1 - At least daily|1 - At least daily|56
433|2 - Three or more times per week|2 - Three or more times per week|56
434|3 - One to two times per week|3 - One to two times per week|56
435|4 - Received, but less often than weekly|4 - Received, but less often than weekly|56
436|5 - No assistance received|5 - No assistance received|56
437|0 - No [Go to M2400]|0 - No [Go to M2400]|56
438|1 - Yes, used hospital emergency department WITHOUT hospital admission|1 - Yes, used hospital emergency department WITHOUT hospital admission|56
439|2 - Yes, used hospital emergency department WITH hospital admission|2 - Yes, used hospital emergency department WITH hospital admission|56
440|UK - Unknown [Go to M2400]|UK - Unknown [Go to M2400]|56
441|2 - Injury caused by fall|2 - Injury caused by fall|56
442|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|56
443|4 - Other respiratory problem|4 - Other respiratory problem|56
444|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|56
445|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|56
446|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|56
447|8 - Other heart disease|8 - Other heart disease|56
448|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|56
449|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|56
450|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|56
451|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|56
452|13 - Urinary tract infection|13 - Urinary tract infection|56
453|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|56
454|15 - Wound infection or deterioration|15 - Wound infection or deterioration|56
455|16 - Uncontrolled pain|16 - Uncontrolled pain|56
456|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|56
457|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|56
458|19 - Other than above reasons|19 - Other than above reasons|56
459|2 - Patient remained in the community (with formal assistive services)|2 - Patient remained in the community (with formal assistive services)|56
460|3 - Patient transferred to a noninstitutional hospice|3 - Patient transferred to a noninstitutional hospice|56
461|4 - Unknown because patient moved to a geographic location not served by this agency|4 - Unknown because patient moved to a geographic location not served by this agency|56
462|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|56
463|4 - Other respiratory problem|4 - Other respiratory problem|56
464|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|56
465|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|56
466|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|56
467|8 - Other heart disease|8 - Other heart disease|56
468|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|56
469|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|56
470|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|56
471|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|56
472|13 - Urinary tract infection|13 - Urinary tract infection|56
473|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|56
474|15 - Wound infection or deterioration|15 - Wound infection or deterioration|56
475|16 - Uncontrolled pain|16 - Uncontrolled pain|56
476|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|56
477|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|56
478|19 - Scheduled treatment or procedure|19 - Scheduled treatment or procedure|56
479|20 - Other than above reasons|20 - Other than above reasons|56
480|UK - Reason unknown [Go to M0903]|UK - Reason unknown [Go to M0903]|56
482|01 - Patient lives alone around the clock|01 - Patient lives alone around the clock|56
483|02 - Patient lives alone regular daytime|02 - Patient lives alone regular daytime|56
484|03 - Patient lives alone regular nighttime|03 - Patient lives alone regular nighttime|56
485|04 - Patient lives alone occassional/short term assistance|04 - Patient lives alone occassional/short term assistance|56
486|05 - Patient lives alone no assisstance available|05 - Patient lives alone no assisstance available|56
487|06 - Patient lives with other person(s) in the home around the clock|06 - Patient lives with other person(s) in the home around the clock|56
488|07 - Patient lives with other person(s) in the home regular daytime|07 - Patient lives with other person(s) in the home regular daytime|56
489|08 - Patient lives with other person(s) in the home regular nighttime|08 - Patient lives with other person(s) in the home regular nighttime|56
490|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|56
491|10 - Patient lives with other person(s) in the home no assistance available|10 - Patient lives with other person(s) in the home no assistance available|56
492|1 - Was present at the most recent SOC/ROC assessment|1 - Was present at the most recent SOC/ROC assessment|56
493|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|56
494|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|56
495|0 - Newly epithelialized|0 - Newly epithelialized|56
496|0 - No [ Go to M1340 ]|0 - No [ Go to M1340 ]|56
498|0 - Independent|0 - Independent|56
499|1 - Needed Some Help|1 - Needed Some Help|56
500|2 - Dependent|2 - Dependent|56
502|0 - No assistance needed in this area|0 - No assistance needed in this area|56
503|1 - Caregiver(s) currently provide assistance|1 - Caregiver(s) currently provide assistance|56
504|2 - Caregiver(s) need training/ supportive services to provide assistance|2 - Caregiver(s) need training/ supportive services to provide assistance|56
505|3 - Caregiver(s) not likely to provide assistance|3 - Caregiver(s) not likely to provide assistance|56
506|4 - Unclear if Caregiver(s) will provide assistance|4 - Unclear if Caregiver(s) will provide assistance|56
507|5 - Assistance needed, but no Caregiver(s) available|5 - Assistance needed, but no Caregiver(s) available|56
508|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will use standardized clinical guidelines accessible for all care providers to reference|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will|56
510|NA - Patient is not assessed to be at risk for falls|NA - Patient is not assessed to be at risk for falls|56
511|NA - Patient has no diagnosis or symptoms of depression|NA - Patient has no diagnosis or symptoms of depression|56
512|NA - No pain identified|NA - No pain identified|56
513|NA - Patient is not assessed to be at risk for pressure ulcers|NA - Patient is not assessed to be at risk for pressure ulcers|56
514|NA - Patient has no pressure ulcers with need for moist wound healing|NA - Patient has no pressure ulcers with need for moist wound healing|56
515|1 - Long-term nursing facility (NF)|1 - Long-term nursing facility (NF)|56
516|2 - Skilled nursing facility (SNF / TCU)|2 - Skilled nursing facility (SNF / TCU)|56
517|3 - Short stay acute hospital (IPP S)|3 - Short stay acute hospital (IPP S)|56
518|4 - Long-term care hospital (LTCH)|4 - Long-term care hospital (LTCH)|56
519|5 - Inpatient rehabilitation hospital or unit (IRF)|5 - Inpatient rehabilitation hospital or unit (IRF)|56
520|6 - Psychiatric hospital or unit|6 - Psychiatric hospital or unit|56
521|7 - Other|7 - Other|56
522|NA - Patient was not discharged from an inpatient facility [Go to M1017]|NA - Patient was not discharged from an inpatient facility [Go to M1017]|56
523|6 - Unable to participate effectively in bathing and is bathed totally by another person|6 - Unable to participate effectively in bathing and is bathed totally by another person|56
524|4 - Chairfast, unable to ambulate but is able to wheel self independently.|4 - Chairfast, unable to ambulate but is able to wheel self independently.|56
525|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask patient: "Over the last two weeks, how often have you been bothered by any of the following problems")|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask|56
526|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluation for depression.|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluat|56
527|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet criteria for further evaluation for depression.|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet|56
528|0 - Not at all  0 - 1 day|0 - Not at all  0 - 1 day|56
529|1 - Several days  2 - 6 days|1 - Several days  2 - 6 days|56
530|2 - More than half of the days  7 - 11 days|2 - More than half of the days  7 - 11 days|56
531|3 - Nearly every day  12 - 14 days|3 - Nearly every day  12 - 14 days|56
532|NA - N/A  Unable to respond|NA - N/A  Unable to respond|56
533|2 - Able to take medication(s) at the correct times if given reminders by another person based on the frequency of the injection|2 - Able to take medication(s) at the correct times if given reminders by another person based on th|56
534|3 - Unable to take injectable medication unless administered by another person.|3 - Unable to take injectable medication unless administered by another person.|56
547|NA - No clinically significant medication issues identified since the previous OASIS assessment|NA - No clinically significant medication issues identified since the previous OASIS assessment|56
552|1 - Hospital [ Go to M2430 ]|1 - Hospital [ Go to M2430 ]|56
553|2 - Rehabilitation facility [ Go to M0903 ]|2 - Rehabilitation facility [ Go to M0903 ]|56
554|3 - Nursing home [ Go to M2440 ]|3 - Nursing home [ Go to M2440 ]|56
555|4 - Hospice [ Go to M0903 ]|4 - Hospice [ Go to M0903 ]|56
557|NA - Patient is not diabetic or is bilateral amputee|NA - Patient is not diabetic or is bilateral amputee|56
558|NA - Formal multi-factor Fall Risk Assessment indicates the patient was not at risk for falls since the last OASIS assessment|NA - Formal multi-factor Fall Risk Assessment indicates the patient was not at risk for falls since|56
559|NA - Formal assessment indicates patient did not meet criteria for depression AND patient did not have diagnosis of depression since the last OASIS assessment|NA - Formal assessment indicates patient did not meet criteria for depression AND patient did not ha|56
560|NA - Formal assessment did not indicate pain since the last OASIS assessment|NA - Formal assessment did not indicate pain since the last OASIS assessment|56
561|NA - Formal assessment indicates the patient was not at risk of pressure ulcers since the last OASIS assessment|NA - Formal assessment indicates the patient was not at risk of pressure ulcers since the last OASIS|56
562|NA - Dressings that support the principles of moist wound healing not indicated for this patient's pressure ulcers OR patient has no pressure ulcers with need for moist wound healing|NA - Dressings that support the principles of moist wound healing not indicated for this patient's p|56
620|1 - Yes; received from your agency during this episode of care (SOC/ROC to Transfer/Discharge)|1 - Yes; received from your agency during this episode of care (SOC/ROC to Transfer/Discharge)|56
621|2 - Yes; received from your agency during a prior episode of care (SOC/ROC to Transfer/Discharge)|2 - Yes; received from your agency during a prior episode of care (SOC/ROC to Transfer/Discharge)|56
622|3 - Yes; received from another health care provider (for example physician pharmacist)|3 - Yes; received from another health care provider (for example physician pharmacist)|56
623|4 - No; patient offered and declined |4 - No; patient offered and declined |56
624|5 - No; patient assessed and determined to have medical contraindication(s)|5 - No; patient assessed and determined to have medical contraindication(s)|56
625|6 - No; not indicated - patient does not meet age/condition guidelines for influenza vaccine|6 - No; not indicated - patient does not meet age/condition guidelines for influenza vaccine|56
626|7 - No; inability to obtain vaccine due to declared shortage |7 - No; inability to obtain vaccine due to declared shortage |56
627|8 - No; patient did not receive the vaccine due to reasons other than those listed in responses 4 v 7. |8 - No; patient did not receive the vaccine due to reasons other than those listed in responses 4v7.|56
628|1 - Offered and declined|1 - Offered and declined|56
629|2 - Assessed and determined to have medical contraindication(s) |2 - Assessed and determined to have medical contraindication(s) |56
630|3 - Not indicated; patient does not meet age/condition guidelines for Pneumococcal Vaccine|3 - Not indicated; patient does not meet age/condition guidelines for Pneumococcal Vaccine|56
631|4 - None of the above|4 - None of the above|56
2|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; OR (b) Is physically, cognitively, and mentally able to prepare light meals on a regular basis but has not routinely performed light meal preparation in the past (i.e., prior to this home care admission).|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; O|57
3|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and mentally able to perform all housekeeping tasks .|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and menta|57
4|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and mentally able to do laundry and access facilities.|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and menta|57
5|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying packages OR b) Physically, cognitively, and mentally able to take care of shopping, but has not done shopping in the past (i.e., prior to this home care admission).|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying|57
6|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|57
7|0 - Able to dial numbers and answer calls appropriately and as desired.|0 - Able to dial numbers and answer calls appropriately and as desired.|57
8|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body without assistance.|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body|57
9|0 - Able to get to and from the toilet and transfer independently with or without a device.|0 - Able to get to and from the toilet and transfer independently with or without a device.|57
10|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|57
11|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible public bus.|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible p|57
12|0 - Able to independently feed self.|0 - Able to independently feed self.|57
13|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|57
14|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct times.|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct ti|57
15|0 - Able to independently transfer.|0 - Able to independently transfer.|57
16|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without rail|57
17|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings|57
18|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|57
19|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions independently.|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions indep|57
20|0 - Asymptomatic, no treatment needed at this time|0 - Asymptomatic, no treatment needed at this time|57
21|0 - Caregiver manages all tasks related to equipment completely independently.|0 - Caregiver manages all tasks related to equipment completely independently.|57
22|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations with no observable impairment.|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations w|57
23|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|57
24|0 - Life expectancy is greater than 6 months|0 - Life expectancy is greater than 6 months|57
25|0 - Never|0 - Never|57
26|0 - Patient is not short of breath|0 - Patient is not short of breath|57
27|0 - No|0 - No|57
28|0 - No emergent care services|0 - No emergent care services|57
29|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [Goto 1620]|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [Goto 1620]|57
30|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and extended or abstract conversation.|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and exte|57
31|0 - No one person|0 - No one person|57
32|0 - None of the time|0 - None of the time|57
33|0 - None, no charge for current services|0 - None, no charge for current services|57
34|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|57
35|0 - Patient does NOT have an ostomy for bowel elimination.|0 - Patient does NOT have an ostomy for bowel elimination.|57
36|0 - Patient has no pain|0 - Patient has no pain|57
37|0 - Patient manages all tasks related to equipment completely independently.|0 - Patient manages all tasks related to equipment completely independently.|57
38|0 - Poor:  little or no recovery is expected and/or further decline is imminent|0 - Poor:  little or no recovery is expected and/or further decline is imminent|57
39|0 - Timed-voiding defers incontinence|0 - Timed-voiding defers incontinence|57
40|0 - Very rarely or never has bowel incontinence|0 - Very rarely or never has bowel incontinence|57
41|0 - Zero|0 - Zero|57
42|00 - No|00 - No|57
43|01 - Yes|01 - Yes|57
44|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or mental limitations, needs assistance with heavy laundry.|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or|57
45|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the patient.|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the|57
46|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|57
47|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or supervision from another person OR c) a liquid, pureed or ground meat diet.|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or su|57
48|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|57
49|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|57
50|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independently.|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independe|57
51|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only when assisted or accompanied by another person.|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only w|57
52|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepa|57
53|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance by another person OR b) given daily reminders.|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance b|57
54|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advan|57
55|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advan|57
56|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for the deaf) and call essential numbers.|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for t|57
57|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|57
58|1 - American Indian or Alaska Native|1 - American Indian or Alaska Native|57
59|1 - Depressed mood (e.g., feeling sad, tearful)|1 - Depressed mood (e.g., feeling sad, tearful)|57
60|1 - During the night only|1 - During the night only|57
61|1 - Fully granulating|1 - Fully granulating|57
62|1 - Good/Fair:  partial to full recovery is expected|1 - Good/Fair:  partial to full recovery is expected|57
63|1 - Good:  marked improvement in functional status is expected|1 - Good:  marked improvement in functional status is expected|57
64|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|57
65|1 - Smoking|1 - Smoking|57
66|1 - Hospital|1 - Hospital|57
67|1 - Hospital emergency room (includes 23-hour holding)|1 - Hospital emergency room (includes 23-hour holding)|57
68|1 - Hospitalization for EMERGENT (unscheduled) care|1 - Hospitalization for EMERGENT (unscheduled) care|57
69|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepared solutions), patient is able to manage all other aspects of equipment.|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepar|57
70|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|57
71|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|57
72|1 - In new or complex situations only|1 - In new or complex situations only|57
73|1 - Intravenous or infusion therapy (excludes TPN)|1 - Intravenous or infusion therapy (excludes TPN)|57
74|1 - Less often than daily|1 - Less often than daily|57
75|1 - Less than once a month|1 - Less than once a month|57
76|1 - Less than once weekly|1 - Less than once weekly|57
77|1 - Life expectancy is 6 months or fewer|1 - Life expectancy is 6 months or fewer|57
78|1 - Lives alone|1 - Lives alone|57
79|1 - Male|1 - Male|57
80|1 - Medicare (traditional fee-for-service)|1 - Medicare (traditional fee-for-service)|57
81|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of past 24 hours, significant memory loss so that supervision is required|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of pas|57
82|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors in word choice, grammar or speech intelligibility, needs minimal prompting or assistance).|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors i|57
83|1 - No assistance or services received|1 - No assistance or services received|57
84|1 - One|1 - One|57
85|1 - Oxygen (intermittent or continuous)|1 - Oxygen (intermittent or continuous)|57
86|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, and the surrounding layout, can count fingers at arm's length.|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, a|57
87|1 - Patient is incontinent|1 - Patient is incontinent|57
88|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|57
89|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical or treatment regimen.|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical|57
90|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient/couple/significant other)|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient|57
91|1 - Relatives, friends, or neighbors living outside the home|1 - Relatives, friends, or neighbors living outside the home|57
92|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions.|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions|57
93|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independentl|57
94|1 - Several times during day and night|1 - Several times during day and night|57
95|1 - Spouse or significant other|1 - Spouse or significant other|57
96|1 - Stage 1|1 - Stage 1|57
97|1 - Start of care - further visits planned|1 - Start of care - further visits planned|57
98|1 - Symptoms well controlled with current therapy|1 - Symptoms well controlled with current therapy|57
99|1 - Therapy services|1 - Therapy services|57
100|1 - Able to transfer with minimal human assistance or with use of an assistive device.|1 - Able to transfer with minimal human assistance or with use of an assistive device.|57
101|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitations.|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitatio|57
102|1 - Urinary incontinence|1 - Urinary incontinence|57
103|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and transfer.|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and|57
104|1 - When walking more than 20 feet, climbing stairs|1 - When walking more than 20 feet, climbing stairs|57
105|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary conversation. May need occasional repetition, extra time, or louder voice.|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary c|57
106|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting in and out of tub/shower|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting|57
107|1 - Yes|1 - Yes|57
108|1-RN|1-RN|57
109|10 - Discharge from agency - no visits completed after start/resumption of care assessment|10 - Discharge from agency - no visits completed after start/resumption of care assessment|57
110|10 - Scheduled surgical procedure|10 - Scheduled surgical procedure|57
111|10 - Self-pay|10 - Self-pay|57
112|11 - Other|11 - Other|57
113|11 - Urinary tract infection|11 - Urinary tract infection|57
114|12 - IV catheter-related infection|12 - IV catheter-related infection|57
115|13 - Deep vein thrombosis, pulmonary embolus|13 - Deep vein thrombosis, pulmonary embolus|57
116|14 - Uncontrolled pain|14 - Uncontrolled pain|57
117|15 - Psychotic episode|15 - Psychotic episode|57
118|16 - Other than above reasons|16 - Other than above reasons|57
119|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing calls.|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing|57
120|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another person.|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another pers|57
121|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface a|57
122|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for intermittent supervision or encouragement or reminders, OR (b) to get in and out of the shower or tub, OR (c) for washing difficult to reach areas.|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for inter|57
123|2 - Asian|2 - Asian|57
124|2 - Caregiver requires considerable assistance from another person to manage equipment, but independently completes significant portions of task.|2 - Caregiver requires considerable assistance from another person to manage equipment, but independ|57
125|2 - Daily, but not constantly|2 - Daily, but not constantly|57
126|2 - Daughter or son|2 - Daughter or son|57
127|2 - Doctor's office emergency visit/house call|2 - Doctor's office emergency visit/house call|57
128|2 - During the day and night|2 - During the day and night|57
129|2 - Early/partial granulation|2 - Early/partial granulation|57
130|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors in word choice, organization or speech intelligibility). Speaks in phrases or short sentences.|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors|57
131|2 - Family member's residence|2 - Family member's residence|57
132|2 - Female|2 - Female|57
133|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conversation, needs frequent prompting or assistance.|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conver|57
134|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|57
135|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|57
136|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately stop activities, jeopardizes safety through actions|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately st|57
137|2 - Indwelling/suprapubic catheter|2 - Indwelling/suprapubic catheter|57
138|2 - Injury caused by fall|2 - Injury caused by fall|57
139|2 - Medicare (HMO/managed care/Advantage plan)|2 - Medicare (HMO/managed care/Advantage plan)|57
140|2 - Nausea, dehydration, malnutrition, constipation, impaction|2 - Nausea, dehydration, malnutrition, constipation, impaction|57
141|2 - Obesity|2 - Obesity|57
142|2 - On awakening or at night only|2 - On awakening or at night only|57
143|2 - Once a month|2 - Once a month|57
144|2 - One to three times weekly|2 - One to three times weekly|57
145|2 - Parenteral nutrition (TPN or lipids)|2 - Parenteral nutrition (TPN or lipids)|57
146|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic) [ Go to M1620]|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic) [ Go|57
147|2 - Patient requires considerable assistance from another person to manage equipment, but independently completes portions of the task.|2 - Patient requires considerable assistance from another person to manage equipment, but independen|57
148|2 - Patient transferred to a noninstitutional hospice|2 - Patient transferred to a noninstitutional hospice|57
149|2 - Person residing in the home (EXCLUDING paid help)|2 - Person residing in the home (EXCLUDING paid help)|57
150|2 - Rehabilitation facility|2 - Rehabilitation facility|57
151|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifting of attention) or consistently requires low stimulus environment due to distractibility.|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifti|57
152|2 - Respite care|2 - Respite care|57
153|2 - Sense of failure or self reproach|2 - Sense of failure or self reproach|57
154|2 - Several times during day|2 - Several times during day|57
155|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonresponsive.|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonrespons|57
156|2 - Someone must assist the patient to groom self.|2 - Someone must assist the patient to groom self.|57
157|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|57
158|2 - Someone must help the patient put on upper body clothing.|2 - Someone must help the patient put on upper body clothing.|57
159|2 - Stage 2|2 - Stage 2|57
160|2 - Start of care - no further visits planned|2 - Start of care - no further visits planned|57
161|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitoring|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitori|57
162|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment regimen.|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment re|57
163|2 - Two|2 - Two|57
164|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistance due to cognitive or mental limitation.|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistanc|57
165|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|57
166|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assistance).|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assis|57
167|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home delivery.|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home deli|57
168|2 - Unable to prepare any light meals or reheat any delivered meals.|2 - Unable to prepare any light meals or reheat any delivered meals.|57
169|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|57
170|2 - UNABLE to take injectable medications unless administered by someone else.|2 - UNABLE to take injectable medications unless administered by someone else.|57
171|2 - UNABLE to take medication unless administered by someone else.|2 - UNABLE to take medication unless administered by someone else.|57
172|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|57
173|2 - Ventilator (continually or at night)|2 - Ventilator (continually or at night)|57
174|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less than 20 feet)|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less th|57
175|2 - With spouse or significant other|2 - With spouse or significant other|57
176|2 - Yes, assistance or services provided by family or friends|2 - Yes, assistance or services provided by family or friends|57
177|2-PT|2-PT|57
178|3 - Able to answer the telephone only some of the time or is able to carry on only a limited conversation.|3 - Able to answer the telephone only some of the time or is able to carry on only a limited convers|57
179|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube or gastrostomy.|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube|57
180|3 - Alcohol dependency|3 - Alcohol dependency|57
181|3 - All of the time|3 - All of the time|57
182|3 - Black or African-American|3 - Black or African-American|57
183|3 - Boarding home or rented room|3 - Boarding home or rented room|57
184|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment, clean/store/dispose of equipment or supplies).|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment,|57
185|3 -Able to walk only with the supervision or assistance of another person at all times.|3 -Able to walk only with the supervision or assistance of another person at all times.|57
186|3 - Continuous / Bi-level positive airway pressure|3 - Continuous / Bi-level positive airway pressure|57
187|3 - During the day and evening, but not constantly|3 - During the day and evening, but not constantly|57
188|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the alimentary canal)|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the|57
189|3 - Environmental support (e.g., housing, home maintenance)|3 - Environmental support (e.g., housing, home maintenance)|57
190|3 - Four to six times weekly|3 - Four to six times weekly|57
191|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessing by listener.  Speech limited to single words or short phrases.|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessin|57
192|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires multiple repetitions, restatements, demonstrations, additional time.|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires m|57
193|3 - Hopelessness|3 - Hopelessness|57
194|3 - Hospice care|3 - Hospice care|57
195|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|57
196|3 - Injury caused by fall or accident at home|3 - Injury caused by fall or accident at home|57
197|3 - Intractable pain|3 - Intractable pain|57
198|3 - Medicaid (traditional fee-for-service)|3 - Medicaid (traditional fee-for-service)|57
199|3 - Needs someone to do all shopping and errands.|3 - Needs someone to do all shopping and errands.|57
200|3 - Not healing|3 - Not healing|57
201|3 - Nursing home|3 - Nursing home|57
202|3 - Once daily|3 - Once daily|57
203|3 - Other family member|3 - Other family member|57
204|3 - Outpatient department/clinic emergency (includes urgicenter sites)|3 - Outpatient department/clinic emergency (includes urgicenter sites)|57
205|3 - Paid help|3 - Paid help|57
206|3 - Able to participate in bathing self in shower or tub, but requires presence of another person throughout the bath for assistance or supervision.|3 - Able to participate in bathing self in shower or tub, but requires presence of another person th|57
207|3 - Patient depends entirely upon another person to dress lower body.|3 - Patient depends entirely upon another person to dress lower body.|57
208|3 - Patient depends entirely upon another person to dress the upper body.|3 - Patient depends entirely upon another person to dress the upper body.|57
209|3 - Patient depends entirely upon someone else for grooming needs.|3 - Patient depends entirely upon someone else for grooming needs.|57
210|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone else to manage the equipment.|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone|57
211|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable to shift attention and recall directions more than half the time.|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable|57
212|3 - Respiratory problems (SOB, infection, obstruction)|3 - Respiratory problems (SOB, infection, obstruction)|57
213|3 - Resumption of care (after inpatient stay)|3 - Resumption of care (after inpatient stay)|57
214|3 - Several times each month|3 - Several times each month|57
215|3 - Skilled Nursing Facility|3 - Skilled Nursing Facility|57
216|3 - Stage 3|3 - Stage 3|57
217|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|57
218|3 - Three|3 - Three|57
219|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person throughout the process.|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person through|57
220|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal independently.|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal indep|57
221|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person.|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person|57
222|3 - Unknown because patient moved to a geographic location not served by this agency|3 - Unknown because patient moved to a geographic location not served by this agency|57
223|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|57
224|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|57
225|3 - With other family member|3 - With other family member|57
226|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home health services, homemaker assistance, transportation assistance, assisted living, board and care)|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home h|57
227|3-SLP/ST|3-SLP/ST|57
228|4 - At rest (during day or night)|4 - At rest (during day or night)|57
229|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|57
230|4 - Board and care or assisted living facility|4 - Board and care or assisted living facility|57
231|4 - Caregiver is completely dependent on someone else to manage all equipment.|4 - Caregiver is completely dependent on someone else to manage all equipment.|57
232|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|57
233|4 - Constantly|4 - Constantly|57
234|4 - Drug dependency|4 - Drug dependency|57
235|4 - Four or more|4 - Four or more|57
236|4 - Friend or neighbor or community or church member|4 - Friend or neighbor or community or church member|57
237|4 - Hispanic or Latino|4 - Hispanic or Latino|57
238|4 - Hospice|4 - Hospice|57
239|4 - Impaired decision-making|4 - Impaired decision-making|57
240|4 - Is totally dependent in toileting.|4 - Is totally dependent in toileting.|57
241|4 - Medicaid (HMO/managed care)|4 - Medicaid (HMO/managed care)|57
242|4 - None of the above|4 - None of the above|57
243|4 - Nursing home|4 - Nursing home|57
244|4 - On a daily basis|4 - On a daily basis|57
245|4 - Patient is completely dependent on someone else to manage all equipment.|4 - Patient is completely dependent on someone else to manage all equipment.|57
246|4 - Permanent placement|4 - Permanent placement|57
247|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, punches, dangerous maneuvers w/ wheelchair or other objects)|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, pu|57
248|4 - Psychosocial support (e.g., socialization, companionship, recreation)|4 - Psychosocial support (e.g., socialization, companionship, recreation)|57
249|4 - Recertification (follow-up) reassessment|4 - Recertification (follow-up) reassessment|57
250|4 - Recurrent thoughts of death|4 - Recurrent thoughts of death|57
251|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruction)|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruc|57
252|4 - Several times a week|4 - Several times a week|57
253|4 - Stage 4|4 - Stage 4|57
254|4 - Symptoms poorly controlled, history of rehospitalizations|4 - Symptoms poorly controlled, history of rehospitalizations|57
255|4 - Three or more times per week|4 - Three or more times per week|57
256|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetative state, or delirium.|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetati|57
257|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|57
258|4 - Unable to effectively participate in any housekeeping tasks.|4 - Unable to effectively participate in any housekeeping tasks.|57
259|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or unresponsive (e.g., speech is nonsensical or unintelligible).|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or u|57
260|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonresponsive.|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonr|57
261|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostomy.|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostom|57
262|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of devices at the sink, in chair, or on commode|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of|57
263|4 - With a friend|4 - With a friend|57
264|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|57
265|4-OT|4-OT|57
266|5 - Advocates or facilitates patient's participation in appropriate medical care|5 - Advocates or facilitates patient's participation in appropriate medical care|57
267|5 - At least daily|5 - At least daily|57
268|6 - Bedfast, unable to ambulate or be up in a chair.|6 - Bedfast, unable to ambulate or be up in a chair.|57
269|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|57
270|5 - Disruptive or socially inappropriate behavior|5 - Disruptive or socially inappropriate behavior|57
271|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|57
272|5 - Hypo/Hyperglycemia, diabetes out of control|5 - Hypo/Hyperglycemia, diabetes out of control|57
273|5 - More often than once daily|5 - More often than once daily|57
274|5 - Native Hawaiian or Pacific Islander|5 - Native Hawaiian or Pacific Islander|57
275|5 - None of the above|5 - None of the above|57
276|5 - One to two times per week|5 - One to two times per week|57
277|5 - Other|5 - Other|57
278|5 - Other follow-up|5 - Other follow-up|57
279|5 - Paid help|5 - Paid help|57
280|5 - Patient nonresponsive or unable to speak.|5 - Patient nonresponsive or unable to speak.|57
281|5 - Thoughts of suicide|5 - Thoughts of suicide|57
282|5 - Totally unable to use the telephone.|5 - Totally unable to use the telephone.|57
283|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|57
284|5 - Unable to take in nutrients orally or by tube feeding.|5 - Unable to take in nutrients orally or by tube feeding.|57
285|5 - Unsafe for care at home|5 - Unsafe for care at home|57
286|5 - With paid help (other than home care agency staff)|5 - With paid help (other than home care agency staff)|57
287|5 - Workers' compensation|5 - Workers' compensation|57
288|5 - Wound infection, deteriorating wound status, new lesion/ulcer|5 - Wound infection, deteriorating wound status, new lesion/ulcer|57
289|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|57
290|6 - Delusional, hallucinatory, or paranoid behavior|6 - Delusional, hallucinatory, or paranoid behavior|57
291|6 - Financial agent, power of attorney, or conservator of finance|6 - Financial agent, power of attorney, or conservator of finance|57
292|6 - GI bleeding, obstruction|6 - GI bleeding, obstruction|57
293|6 - Less often than weekly|6 - Less often than weekly|57
294|6 - Memory loss to the extent that supervision required|6 - Memory loss to the extent that supervision required|57
295|6 - None of the above feelings observed or reported|6 - None of the above feelings observed or reported|57
296|6 - Other|6 - Other|57
297|6 - Title programs (e.g., Title III, V, or XX)|6 - Title programs (e.g., Title III, V, or XX)|57
298|6 - Transferred to an inpatient facility - patient not discharged from agency|6 - Transferred to an inpatient facility - patient not discharged from agency|57
299|6 - White|6 - White|57
300|6 - With other than above|6 - With other than above|57
301|7 - Exacerbation of CHF, fluid overload, heart failure|7 - Exacerbation of CHF, fluid overload, heart failure|57
302|7 - Health care agent, conservator of person, or medical power of attorney|7 - Health care agent, conservator of person, or medical power of attorney|57
303|7 - Hypo/Hyperglycemia, diabetes out of control|7 - Hypo/Hyperglycemia, diabetes out of control|57
304|7 - None of the above|7 - None of the above|57
305|7 - None of the above behaviors demonstrated|7 - None of the above behaviors demonstrated|57
306|7 - Other government (e.g., TriCare, VA, etc.)|7 - Other government (e.g., TriCare, VA, etc.)|57
307|7 - Transferred to an inpatient facility - patient discharged from agency|7 - Transferred to an inpatient facility - patient discharged from agency|57
308|8 - Death at home|8 - Death at home|57
309|8 - GI bleeding, obstruction|8 - GI bleeding, obstruction|57
310|8 - Myocardial infarction, stroke|8 - Myocardial infarction, stroke|57
311|8 - Private insurance|8 - Private insurance|57
312|9 - Chemotherapy|9 - Chemotherapy|57
313|9 - Discharge from agency|9 - Discharge from agency|57
314|9 - Other than above reasons|9 - Other than above reasons|57
315|9 - Private HMO/managed care|9 - Private HMO/managed care|57
316|NA - No caregiver|NA - No caregiver|57
317|NA - No equipment of this type used in care.|NA - No equipment of this type used in care.|57
318|NA - No inhalant/mist medications prescribed.|NA - No inhalant/mist medications prescribed.|57
319|NA - No injectable medications prescribed.|NA - No injectable medications prescribed.|57
320|NA - No inpatient facility admission|NA - No inpatient facility admission|57
321|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|57
322|NA - No Medicaid|NA - No Medicaid|57
323|NA - No Medicare|NA - No Medicare|57
324|NA - No observable pressure ulcer or unhealed pressure ulcer|NA - No observable pressure ulcer or unhealed pressure ulcer|57
325|NA - No observable stasis ulcer|NA - No observable stasis ulcer|57
326|NA - No observable surgical wound|NA - No observable surgical wound|57
327|NA - No oral medications prescribed.|NA - No oral medications prescribed.|57
328|NA - Not applicable|NA - Not applicable|57
329|NA - Patient does not have a telephone.|NA - Patient does not have a telephone.|57
330|NA - Patient has ostomy for bowel elimination|NA - Patient has ostomy for bowel elimination|57
331|NA - Patient nonresponsive|NA - Patient nonresponsive|57
332|NA - Patient on prophylactic treatment|NA - Patient on prophylactic treatment|57
333|NA - Patient was not discharged from an inpatient facility [Go to M1017]|NA - Patient was not discharged from an inpatient facility [Go to M1017]|57
334|UK - Other unknown|UK - Other unknown|57
335|UK - Reason unknown|UK - Reason unknown|57
336|UK - Unknown|UK - Unknown|57
337|UK - Unknown or Not Available|UK - Unknown or Not Available|57
341|01 - Early|01 - Early|57
342|02 - Late|02 - Late|57
343|NA - Not Applicable. No case mix group defined for this assessment.|NA - Not Applicable. No case mix group defined for this assessment.|57
344|NA - No case mix group defined by this assessment.|NA - No case mix group defined by this assessment.|57
345|1 - Recent decline in mental, emotional, or behavioral status|1 - Recent decline in mental, emotional, or behavioral status|57
346|2 - Multiple hospitalizations (2 or more) in the past 12 months|2 - Multiple hospitalizations (2 or more) in the past 12 months|57
347|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|57
348|4 - Taking five or more medications|4 - Taking five or more medications|57
349|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|57
350|6 - Other|6 - Other|57
351|7 - None of the above|7 - None of the above|57
352|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond tho|57
353|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable without heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable wi|57
354|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious complications and death.|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious compl|57
355|3 - The patient has serious progressive conditions that could lead to death within a year.|3 - The patient has serious progressive conditions that could lead to death within a year.|57
356|UK - The patient+s situation is unknown or unclear.|UK - The patient+s situation is unknown or unclear.|57
357|0 - No [ Go to M1051 ]|0 - No [ Go to M1051 ]|57
358|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this influenza season. [ Go to M1050 ]|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this i|57
359|1 - Received from another health care provider (e.g., physician)|1 - Received from another health care provider (e.g., physician)|57
360|2 - Received from your agency previously during this year+s flu season|2 - Received from your agency previously during this year+s flu season|57
361|3 - Offered and declined|3 - Offered and declined|57
362|4 - Assessed and determined to have medical contraindication(s)|4 - Assessed and determined to have medical contraindication(s)|57
363|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|57
364|6 - Inability to obtain vaccine due to declared shortage|6 - Inability to obtain vaccine due to declared shortage|57
365|1 - Yes [ Go to M1500 at TRN; Go to M1230 at DC ]|1 - Yes [ Go to M1500 at TRN; Go to M1230 at DC ]|57
366|1 - Patient has received PPV in the past|1 - Patient has received PPV in the past|57
367|2 - Offered and declined|2 - Offered and declined|57
368|3 - Assessed and determined to have medical contraindication(s)|3 - Assessed and determined to have medical contraindication(s)|57
369|4 - Not indicated; patient does not meet age/condition guidelines for PPV|4 - Not indicated; patient does not meet age/condition guidelines for PPV|57
370|5 - None of the above|5 - None of the above|57
371|0 - Adequate: hears normal conversation without difficulty.|0 - Adequate: hears normal conversation without difficulty.|57
372|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to increase volume or speak distinctly.|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to in|57
373|2 - Severely Impaired: absence of useful hearing.|2 - Severely Impaired: absence of useful hearing.|57
374|UK - Unable to assess hearing.|UK - Unable to assess hearing.|57
375|0 - Understands: clear comprehension without cues or repetitions.|0 - Understands: clear comprehension without cues or repetitions.|57
376|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Requires cues at times to understand.|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Req|57
377|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequently requires cues to understand.|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequentl|57
378|3 - Rarely/Never Understands|3 - Rarely/Never Understands|57
379|UK - Unable to assess understanding.|UK - Unable to assess understanding.|57
380|0 - No standardized assessment conducted|0 - No standardized assessment conducted|57
381|1 - Yes, and it does not indicate severe pain|1 - Yes, and it does not indicate severe pain|57
382|2 - Yes, and it indicates severe pain|2 - Yes, and it indicates severe pain|57
383|0 - Patient has no pain|0 - Patient has no pain|57
384|1 - Patient has pain that does not interfere with activity or movement|1 - Patient has pain that does not interfere with activity or movement|57
385|2 - Less often than daily|2 - Less often than daily|57
386|3 - Daily, but not constantly|3 - Daily, but not constantly|57
387|4 - All of the time|4 - All of the time|57
388|0 - No assessment conducted [ Go to M1306 ]|0 - No assessment conducted [ Go to M1306 ]|57
389|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc., without use of standardized tool|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc.,|57
390|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|57
391|0 - No [ Go to M1322]|0 - No [ Go to M1322]|57
392|0 v Newly epithelialized|0 v Newly epithelialized|57
393|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|57
394|2 - Yes, patient has observable stasis ulcers ONLY|2 - Yes, patient has observable stasis ulcers ONLY|57
395|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable dressing) [Go to M1340]|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable|57
396|0 - No [ Go to M1350 ]|0 - No [ Go to M1350 ]|57
397|1 - Yes, patient has at least one (observable) surgical wound|1 - Yes, patient has at least one (observable) surgical wound|57
398|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1350 ]|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1350 ]|57
399|0 - Patient is not short of breath|0 - Patient is not short of breath|57
400|3 - Continuous Bi-level positive airway pressure|3 - Continuous Bi-level positive airway pressure|57
401|0 - No [ Go to M2004 at TRN; Go to M1600 at DC ]|0 - No [ Go to M2004 at TRN; Go to M1600 at DC ]|57
402|2 - Not assessed [Go to M2004 at TRN; Go to M1600 at DC ]|2 - Not assessed [Go to M2004 at TRN; Go to M1600 at DC ]|57
403|NA - Patient does not have diagnosis of heart failure [Go to M2004 at TRN; Go to M1600 at DC]|NA - Patient does not have diagnosis of heart failure [Go to M2004 at TRN; Go to M1600 at DC]|57
404|0 - No action taken|0 - No action taken|57
405|1 - Patient+s physician (or other primary care practitioner) contacted the same day|1 - Patient+s physician (or other primary care practitioner) contacted the same day|57
406|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|57
407|3 - Implement physician-ordered patient-specific established parameters for treatment|3 - Implement physician-ordered patient-specific established parameters for treatment|57
408|4 - Patient education or other clinical interventions|4 - Patient education or other clinical interventions|57
409|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequency, telehealth, etc.)|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequ|57
410|1 - Occasional stress incontinence|1 - Occasional stress incontinence|57
411|2 - During the night only|2 - During the night only|57
412|3 - During the day only|3 - During the day only|57
413|4 - During the day and night|4 - During the day and night|57
414|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|57
415|0 - Able to manage toileting hygiene and clothing management without assistance.|0 - Able to manage toileting hygiene and clothing management without assistance.|57
416|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implements are laid out for the patient.|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implemen|57
417|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|57
418|3 - Patient depends entirely upon another person to maintain toileting hygiene.|3 - Patient depends entirely upon another person to maintain toileting hygiene.|57
419|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independent|57
420|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface|57
421|0 - No multi-factor falls risk assessment conducted.|0 - No multi-factor falls risk assessment conducted.|57
422|1 - Yes, and it does not indicate a risk for falls.|1 - Yes, and it does not indicate a risk for falls.|57
423|2 - Yes, and it indicates a risk for falls.|2 - Yes, and it indicates a risk for falls.|57
424|0 - Not assessed/reviewed [ Go to M2010 ]|0 - Not assessed/reviewed [ Go to M2010 ]|57
425|1 - No problems found during review [ Go to M2010 ]|1 - No problems found during review [ Go to M2010 ]|57
426|2 - Problems found during review|2 - Problems found during review|57
427|NA - Patient is not taking any medications [ Go to M2040 ]|NA - Patient is not taking any medications [ Go to M2040 ]|57
428|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special precautions associated with all high-risk medications|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special p|57
429|NA - Patient not taking any drugs|NA - Patient not taking any drugs|57
430|2 - Able to take medication(s) at the correct times if given reminders by another person at the appropriate times|2 - Able to take medication(s) at the correct times if given reminders by another person at the appr|57
431|3 - Unable to take medication unless administered by another person.|3 - Unable to take medication unless administered by another person.|57
432|1 - At least daily|1 - At least daily|57
433|2 - Three or more times per week|2 - Three or more times per week|57
434|3 - One to two times per week|3 - One to two times per week|57
435|4 - Received, but less often than weekly|4 - Received, but less often than weekly|57
436|5 - No assistance received|5 - No assistance received|57
437|0 - No [Go to M2400]|0 - No [Go to M2400]|57
438|1 - Yes, used hospital emergency department WITHOUT hospital admission|1 - Yes, used hospital emergency department WITHOUT hospital admission|57
439|2 - Yes, used hospital emergency department WITH hospital admission|2 - Yes, used hospital emergency department WITH hospital admission|57
440|UK - Unknown [Go to M2400]|UK - Unknown [Go to M2400]|57
441|2 - Injury caused by fall|2 - Injury caused by fall|57
442|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|57
443|4 - Other respiratory problem|4 - Other respiratory problem|57
444|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|57
445|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|57
446|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|57
447|8 - Other heart disease|8 - Other heart disease|57
448|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|57
449|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|57
450|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|57
451|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|57
452|13 - Urinary tract infection|13 - Urinary tract infection|57
453|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|57
454|15 - Wound infection or deterioration|15 - Wound infection or deterioration|57
455|16 - Uncontrolled pain|16 - Uncontrolled pain|57
456|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|57
457|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|57
458|19 - Other than above reasons|19 - Other than above reasons|57
459|2 - Patient remained in the community (with formal assistive services)|2 - Patient remained in the community (with formal assistive services)|57
460|3 - Patient transferred to a noninstitutional hospice|3 - Patient transferred to a noninstitutional hospice|57
461|4 - Unknown because patient moved to a geographic location not served by this agency|4 - Unknown because patient moved to a geographic location not served by this agency|57
462|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|57
463|4 - Other respiratory problem|4 - Other respiratory problem|57
464|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|57
465|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|57
466|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|57
467|8 - Other heart disease|8 - Other heart disease|57
468|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|57
469|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|57
470|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|57
471|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|57
472|13 - Urinary tract infection|13 - Urinary tract infection|57
473|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|57
474|15 - Wound infection or deterioration|15 - Wound infection or deterioration|57
475|16 - Uncontrolled pain|16 - Uncontrolled pain|57
476|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|57
477|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|57
478|19 - Scheduled treatment or procedure|19 - Scheduled treatment or procedure|57
479|20 - Other than above reasons|20 - Other than above reasons|57
480|UK - Reason unknown [Go to M0903]|UK - Reason unknown [Go to M0903]|57
482|01 - Patient lives alone around the clock|01 - Patient lives alone around the clock|57
483|02 - Patient lives alone regular daytime|02 - Patient lives alone regular daytime|57
484|03 - Patient lives alone regular nighttime|03 - Patient lives alone regular nighttime|57
485|04 - Patient lives alone occassional/short term assistance|04 - Patient lives alone occassional/short term assistance|57
486|05 - Patient lives alone no assisstance available|05 - Patient lives alone no assisstance available|57
487|06 - Patient lives with other person(s) in the home around the clock|06 - Patient lives with other person(s) in the home around the clock|57
488|07 - Patient lives with other person(s) in the home regular daytime|07 - Patient lives with other person(s) in the home regular daytime|57
489|08 - Patient lives with other person(s) in the home regular nighttime|08 - Patient lives with other person(s) in the home regular nighttime|57
490|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|57
491|10 - Patient lives with other person(s) in the home no assistance available|10 - Patient lives with other person(s) in the home no assistance available|57
492|1 - Was present at the most recent SOC/ROC assessment|1 - Was present at the most recent SOC/ROC assessment|57
493|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|57
494|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|57
495|0 - Newly epithelialized|0 - Newly epithelialized|57
496|0 - No [ Go to M1340 ]|0 - No [ Go to M1340 ]|57
498|0 - Independent|0 - Independent|57
499|1 - Needed Some Help|1 - Needed Some Help|57
500|2 - Dependent|2 - Dependent|57
502|0 - No assistance needed in this area|0 - No assistance needed in this area|57
503|1 - Caregiver(s) currently provide assistance|1 - Caregiver(s) currently provide assistance|57
504|2 - Caregiver(s) need training/ supportive services to provide assistance|2 - Caregiver(s) need training/ supportive services to provide assistance|57
505|3 - Caregiver(s) not likely to provide assistance|3 - Caregiver(s) not likely to provide assistance|57
506|4 - Unclear if Caregiver(s) will provide assistance|4 - Unclear if Caregiver(s) will provide assistance|57
507|5 - Assistance needed, but no Caregiver(s) available|5 - Assistance needed, but no Caregiver(s) available|57
508|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will use standardized clinical guidelines accessible for all care providers to reference|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will|57
510|NA - Patient is not assessed to be at risk for falls|NA - Patient is not assessed to be at risk for falls|57
511|NA - Patient has no diagnosis or symptoms of depression|NA - Patient has no diagnosis or symptoms of depression|57
512|NA - No pain identified|NA - No pain identified|57
513|NA - Patient is not assessed to be at risk for pressure ulcers|NA - Patient is not assessed to be at risk for pressure ulcers|57
514|NA - Patient has no pressure ulcers with need for moist wound healing|NA - Patient has no pressure ulcers with need for moist wound healing|57
515|1 - Long-term nursing facility (NF)|1 - Long-term nursing facility (NF)|57
516|2 - Skilled nursing facility (SNF / TCU)|2 - Skilled nursing facility (SNF / TCU)|57
517|3 - Short stay acute hospital (IPP S)|3 - Short stay acute hospital (IPP S)|57
518|4 - Long-term care hospital (LTCH)|4 - Long-term care hospital (LTCH)|57
519|5 - Inpatient rehabilitation hospital or unit (IRF)|5 - Inpatient rehabilitation hospital or unit (IRF)|57
520|6 - Psychiatric hospital or unit|6 - Psychiatric hospital or unit|57
521|7 - Other|7 - Other|57
522|NA - Patient was not discharged from an inpatient facility [Go to M1017]|NA - Patient was not discharged from an inpatient facility [Go to M1017]|57
523|6 - Unable to participate effectively in bathing and is bathed totally by another person|6 - Unable to participate effectively in bathing and is bathed totally by another person|57
524|4 - Chairfast, unable to ambulate but is able to wheel self independently.|4 - Chairfast, unable to ambulate but is able to wheel self independently.|57
525|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask patient: "Over the last two weeks, how often have you been bothered by any of the following problems")|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask|57
526|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluation for depression.|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluat|57
527|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet criteria for further evaluation for depression.|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet|57
528|0 - Not at all  0 - 1 day|0 - Not at all  0 - 1 day|57
529|1 - Several days  2 - 6 days|1 - Several days  2 - 6 days|57
530|2 - More than half of the days  7 - 11 days|2 - More than half of the days  7 - 11 days|57
531|3 - Nearly every day  12 - 14 days|3 - Nearly every day  12 - 14 days|57
532|NA - N/A  Unable to respond|NA - N/A  Unable to respond|57
533|2 - Able to take medication(s) at the correct times if given reminders by another person based on the frequency of the injection|2 - Able to take medication(s) at the correct times if given reminders by another person based on th|57
534|3 - Unable to take injectable medication unless administered by another person.|3 - Unable to take injectable medication unless administered by another person.|57
547|NA - No clinically significant medication issues identified since the previous OASIS assessment|NA - No clinically significant medication issues identified since the previous OASIS assessment|57
552|1 - Hospital [ Go to M2430 ]|1 - Hospital [ Go to M2430 ]|57
553|2 - Rehabilitation facility [ Go to M0903 ]|2 - Rehabilitation facility [ Go to M0903 ]|57
554|3 - Nursing home [ Go to M2440 ]|3 - Nursing home [ Go to M2440 ]|57
555|4 - Hospice [ Go to M0903 ]|4 - Hospice [ Go to M0903 ]|57
564|NA - Patient is not diabetic or is bilateral amputee|NA - Patient is not diabetic or is bilateral amputee|57
565|NA - Formal multi-factor Fall Risk Assessment indicates the patient was not at risk for falls since the last OASIS assessment|NA - Formal multi-factor Fall Risk Assessment indicates the patient was not at risk for falls since|57
566|NA - Formal assessment indicates patient did not meet criteria for depression AND patient did not have diagnosis of depression since the last OASIS assessment|NA - Formal assessment indicates patient did not meet criteria for depression AND patient did not ha|57
567|NA - Formal assessment did not indicate pain since the last OASIS assessment|NA - Formal assessment did not indicate pain since the last OASIS assessment|57
568|NA - Formal assessment indicates the patient was not at risk of pressure ulcers since the last OASIS assessment|NA - Formal assessment indicates the patient was not at risk of pressure ulcers since the last OASIS|57
569|NA - Dressings that support the principles of moist wound healing not indicated for this patient's pressure ulcers OR patient has no pressure ulcers with need for moist wound healing|NA - Dressings that support the principles of moist wound healing not indicated for this patient's p|57
620|1 - Yes; received from your agency during this episode of care (SOC/ROC to Transfer/Discharge)|1 - Yes; received from your agency during this episode of care (SOC/ROC to Transfer/Discharge)|57
621|2 - Yes; received from your agency during a prior episode of care (SOC/ROC to Transfer/Discharge)|2 - Yes; received from your agency during a prior episode of care (SOC/ROC to Transfer/Discharge)|57
622|3 - Yes; received from another health care provider (for example physician pharmacist)|3 - Yes; received from another health care provider (for example physician pharmacist)|57
623|4 - No; patient offered and declined |4 - No; patient offered and declined |57
624|5 - No; patient assessed and determined to have medical contraindication(s)|5 - No; patient assessed and determined to have medical contraindication(s)|57
625|6 - No; not indicated - patient does not meet age/condition guidelines for influenza vaccine|6 - No; not indicated - patient does not meet age/condition guidelines for influenza vaccine|57
626|7 - No; inability to obtain vaccine due to declared shortage |7 - No; inability to obtain vaccine due to declared shortage |57
627|8 - No; patient did not receive the vaccine due to reasons other than those listed in responses 4 v 7. |8 - No; patient did not receive the vaccine due to reasons other than those listed in responses 4v7.|57
628|1 - Offered and declined|1 - Offered and declined|57
629|2 - Assessed and determined to have medical contraindication(s) |2 - Assessed and determined to have medical contraindication(s) |57
630|3 - Not indicated; patient does not meet age/condition guidelines for Pneumococcal Vaccine|3 - Not indicated; patient does not meet age/condition guidelines for Pneumococcal Vaccine|57
631|4 - None of the above|4 - None of the above|57
2|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; OR (b) Is physically, cognitively, and mentally able to prepare light meals on a regular basis but has not routinely performed light meal preparation in the past (i.e., prior to this home care admission).|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; O|58
3|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and mentally able to perform all housekeeping tasks .|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and menta|58
4|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and mentally able to do laundry and access facilities.|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and menta|58
5|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying packages OR b) Physically, cognitively, and mentally able to take care of shopping, but has not done shopping in the past (i.e., prior to this home care admission).|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying|58
6|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|58
7|0 - Able to dial numbers and answer calls appropriately and as desired.|0 - Able to dial numbers and answer calls appropriately and as desired.|58
8|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body without assistance.|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body|58
9|0 - Able to get to and from the toilet and transfer independently with or without a device.|0 - Able to get to and from the toilet and transfer independently with or without a device.|58
10|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|58
11|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible public bus.|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible p|58
12|0 - Able to independently feed self.|0 - Able to independently feed self.|58
13|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|58
14|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct times.|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct ti|58
15|0 - Able to independently transfer.|0 - Able to independently transfer.|58
16|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without rail|58
17|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings|58
18|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|58
19|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions independently.|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions indep|58
20|0 - Asymptomatic, no treatment needed at this time|0 - Asymptomatic, no treatment needed at this time|58
21|0 - Caregiver manages all tasks related to equipment completely independently.|0 - Caregiver manages all tasks related to equipment completely independently.|58
22|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations with no observable impairment.|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations w|58
23|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|58
24|0 - Life expectancy is greater than 6 months|0 - Life expectancy is greater than 6 months|58
25|0 - Never|0 - Never|58
26|0 - Patient is not short of breath|0 - Patient is not short of breath|58
27|0 - No|0 - No|58
28|0 - No emergent care services|0 - No emergent care services|58
29|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [Goto 1620]|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [Goto 1620]|58
30|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and extended or abstract conversation.|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and exte|58
31|0 - No one person|0 - No one person|58
32|0 - None of the time|0 - None of the time|58
33|0 - None, no charge for current services|0 - None, no charge for current services|58
34|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|58
35|0 - Patient does NOT have an ostomy for bowel elimination.|0 - Patient does NOT have an ostomy for bowel elimination.|58
36|0 - Patient has no pain|0 - Patient has no pain|58
37|0 - Patient manages all tasks related to equipment completely independently.|0 - Patient manages all tasks related to equipment completely independently.|58
38|0 - Poor:  little or no recovery is expected and/or further decline is imminent|0 - Poor:  little or no recovery is expected and/or further decline is imminent|58
39|0 - Timed-voiding defers incontinence|0 - Timed-voiding defers incontinence|58
40|0 - Very rarely or never has bowel incontinence|0 - Very rarely or never has bowel incontinence|58
41|0 - Zero|0 - Zero|58
42|00 - No|00 - No|58
43|01 - Yes|01 - Yes|58
44|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or mental limitations, needs assistance with heavy laundry.|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or|58
45|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the patient.|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the|58
46|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|58
47|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or supervision from another person OR c) a liquid, pureed or ground meat diet.|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or su|58
48|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|58
49|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|58
50|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independently.|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independe|58
51|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only when assisted or accompanied by another person.|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only w|58
52|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepa|58
53|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance by another person OR b) given daily reminders.|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance b|58
54|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advan|58
55|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advan|58
56|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for the deaf) and call essential numbers.|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for t|58
57|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|58
58|1 - American Indian or Alaska Native|1 - American Indian or Alaska Native|58
59|1 - Depressed mood (e.g., feeling sad, tearful)|1 - Depressed mood (e.g., feeling sad, tearful)|58
60|1 - During the night only|1 - During the night only|58
61|1 - Fully granulating|1 - Fully granulating|58
62|1 - Good/Fair:  partial to full recovery is expected|1 - Good/Fair:  partial to full recovery is expected|58
63|1 - Good:  marked improvement in functional status is expected|1 - Good:  marked improvement in functional status is expected|58
64|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|58
65|1 - Smoking|1 - Smoking|58
66|1 - Hospital|1 - Hospital|58
67|1 - Hospital emergency room (includes 23-hour holding)|1 - Hospital emergency room (includes 23-hour holding)|58
68|1 - Hospitalization for EMERGENT (unscheduled) care|1 - Hospitalization for EMERGENT (unscheduled) care|58
69|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepared solutions), patient is able to manage all other aspects of equipment.|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepar|58
70|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|58
71|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|58
72|1 - In new or complex situations only|1 - In new or complex situations only|58
73|1 - Intravenous or infusion therapy (excludes TPN)|1 - Intravenous or infusion therapy (excludes TPN)|58
74|1 - Less often than daily|1 - Less often than daily|58
75|1 - Less than once a month|1 - Less than once a month|58
76|1 - Less than once weekly|1 - Less than once weekly|58
77|1 - Life expectancy is 6 months or fewer|1 - Life expectancy is 6 months or fewer|58
78|1 - Lives alone|1 - Lives alone|58
79|1 - Male|1 - Male|58
80|1 - Medicare (traditional fee-for-service)|1 - Medicare (traditional fee-for-service)|58
81|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of past 24 hours, significant memory loss so that supervision is required|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of pas|58
82|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors in word choice, grammar or speech intelligibility, needs minimal prompting or assistance).|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors i|58
83|1 - No assistance or services received|1 - No assistance or services received|58
84|1 - One|1 - One|58
85|1 - Oxygen (intermittent or continuous)|1 - Oxygen (intermittent or continuous)|58
86|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, and the surrounding layout, can count fingers at arm's length.|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, a|58
87|1 - Patient is incontinent|1 - Patient is incontinent|58
88|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|58
89|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical or treatment regimen.|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical|58
90|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient/couple/significant other)|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient|58
91|1 - Relatives, friends, or neighbors living outside the home|1 - Relatives, friends, or neighbors living outside the home|58
92|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions.|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions|58
93|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independentl|58
94|1 - Several times during day and night|1 - Several times during day and night|58
95|1 - Spouse or significant other|1 - Spouse or significant other|58
96|1 - Stage 1|1 - Stage 1|58
97|1 - Start of care - further visits planned|1 - Start of care - further visits planned|58
98|1 - Symptoms well controlled with current therapy|1 - Symptoms well controlled with current therapy|58
99|1 - Therapy services|1 - Therapy services|58
100|1 - Able to transfer with minimal human assistance or with use of an assistive device.|1 - Able to transfer with minimal human assistance or with use of an assistive device.|58
101|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitations.|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitatio|58
102|1 - Urinary incontinence|1 - Urinary incontinence|58
103|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and transfer.|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and|58
104|1 - When walking more than 20 feet, climbing stairs|1 - When walking more than 20 feet, climbing stairs|58
105|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary conversation. May need occasional repetition, extra time, or louder voice.|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary c|58
106|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting in and out of tub/shower|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting|58
107|1 - Yes|1 - Yes|58
108|1-RN|1-RN|58
109|10 - Discharge from agency - no visits completed after start/resumption of care assessment|10 - Discharge from agency - no visits completed after start/resumption of care assessment|58
110|10 - Scheduled surgical procedure|10 - Scheduled surgical procedure|58
111|10 - Self-pay|10 - Self-pay|58
112|11 - Other|11 - Other|58
113|11 - Urinary tract infection|11 - Urinary tract infection|58
114|12 - IV catheter-related infection|12 - IV catheter-related infection|58
115|13 - Deep vein thrombosis, pulmonary embolus|13 - Deep vein thrombosis, pulmonary embolus|58
116|14 - Uncontrolled pain|14 - Uncontrolled pain|58
117|15 - Psychotic episode|15 - Psychotic episode|58
118|16 - Other than above reasons|16 - Other than above reasons|58
119|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing calls.|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing|58
120|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another person.|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another pers|58
121|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface a|58
122|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for intermittent supervision or encouragement or reminders, OR (b) to get in and out of the shower or tub, OR (c) for washing difficult to reach areas.|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for inter|58
123|2 - Asian|2 - Asian|58
124|2 - Caregiver requires considerable assistance from another person to manage equipment, but independently completes significant portions of task.|2 - Caregiver requires considerable assistance from another person to manage equipment, but independ|58
125|2 - Daily, but not constantly|2 - Daily, but not constantly|58
126|2 - Daughter or son|2 - Daughter or son|58
127|2 - Doctor's office emergency visit/house call|2 - Doctor's office emergency visit/house call|58
128|2 - During the day and night|2 - During the day and night|58
129|2 - Early/partial granulation|2 - Early/partial granulation|58
130|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors in word choice, organization or speech intelligibility). Speaks in phrases or short sentences.|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors|58
131|2 - Family member's residence|2 - Family member's residence|58
132|2 - Female|2 - Female|58
133|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conversation, needs frequent prompting or assistance.|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conver|58
134|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|58
135|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|58
136|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately stop activities, jeopardizes safety through actions|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately st|58
137|2 - Indwelling/suprapubic catheter|2 - Indwelling/suprapubic catheter|58
138|2 - Injury caused by fall or accident at home|2 - Injury caused by fall or accident at home|58
139|2 - Medicare (HMO/managed care/Advantage plan)|2 - Medicare (HMO/managed care/Advantage plan)|58
140|2 - Nausea, dehydration, malnutrition, constipation, impaction|2 - Nausea, dehydration, malnutrition, constipation, impaction|58
141|2 - Obesity|2 - Obesity|58
142|2 - On awakening or at night only|2 - On awakening or at night only|58
143|2 - Once a month|2 - Once a month|58
144|2 - One to three times weekly|2 - One to three times weekly|58
145|2 - Parenteral nutrition (TPN or lipids)|2 - Parenteral nutrition (TPN or lipids)|58
146|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic) [ Go to M1620]|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic) [ Go|58
147|2 - Patient requires considerable assistance from another person to manage equipment, but independently completes portions of the task.|2 - Patient requires considerable assistance from another person to manage equipment, but independen|58
148|2 - Patient transferred to a noninstitutional hospice|2 - Patient transferred to a noninstitutional hospice|58
149|2 - Person residing in the home (EXCLUDING paid help)|2 - Person residing in the home (EXCLUDING paid help)|58
150|2 - Rehabilitation facility|2 - Rehabilitation facility|58
151|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifting of attention) or consistently requires low stimulus environment due to distractibility.|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifti|58
152|2 - Respite care|2 - Respite care|58
153|2 - Sense of failure or self reproach|2 - Sense of failure or self reproach|58
154|2 - Several times during day|2 - Several times during day|58
155|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonresponsive.|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonrespons|58
156|2 - Someone must assist the patient to groom self.|2 - Someone must assist the patient to groom self.|58
157|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|58
158|2 - Someone must help the patient put on upper body clothing.|2 - Someone must help the patient put on upper body clothing.|58
159|2 - Stage 2|2 - Stage 2|58
160|2 - Start of care - no further visits planned|2 - Start of care - no further visits planned|58
161|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitoring|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitori|58
162|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment regimen.|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment re|58
163|2 - Two|2 - Two|58
164|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistance due to cognitive or mental limitation.|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistanc|58
165|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|58
166|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assistance).|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assis|58
167|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home delivery.|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home deli|58
168|2 - Unable to prepare any light meals or reheat any delivered meals.|2 - Unable to prepare any light meals or reheat any delivered meals.|58
169|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|58
170|2 - UNABLE to take injectable medications unless administered by someone else.|2 - UNABLE to take injectable medications unless administered by someone else.|58
171|2 - UNABLE to take medication unless administered by someone else.|2 - UNABLE to take medication unless administered by someone else.|58
172|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|58
173|2 - Ventilator (continually or at night)|2 - Ventilator (continually or at night)|58
174|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less than 20 feet)|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less th|58
175|2 - With spouse or significant other|2 - With spouse or significant other|58
176|2 - Yes, assistance or services provided by family or friends|2 - Yes, assistance or services provided by family or friends|58
177|2-PT|2-PT|58
178|3 - Able to answer the telephone only some of the time or is able to carry on only a limited conversation.|3 - Able to answer the telephone only some of the time or is able to carry on only a limited convers|58
179|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube or gastrostomy.|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube|58
180|3 - Alcohol dependency|3 - Alcohol dependency|58
181|3 - All of the time|3 - All of the time|58
182|3 - Black or African-American|3 - Black or African-American|58
183|3 - Boarding home or rented room|3 - Boarding home or rented room|58
184|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment, clean/store/dispose of equipment or supplies).|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment,|58
185|3 -Able to walk only with the supervision or assistance of another person at all times.|3 -Able to walk only with the supervision or assistance of another person at all times.|58
186|3 - Continuous / Bi-level positive airway pressure|3 - Continuous / Bi-level positive airway pressure|58
187|3 - During the day and evening, but not constantly|3 - During the day and evening, but not constantly|58
188|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the alimentary canal)|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the|58
189|3 - Environmental support (e.g., housing, home maintenance)|3 - Environmental support (e.g., housing, home maintenance)|58
190|3 - Four to six times weekly|3 - Four to six times weekly|58
191|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessing by listener.  Speech limited to single words or short phrases.|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessin|58
192|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires multiple repetitions, restatements, demonstrations, additional time.|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires m|58
193|3 - Hopelessness|3 - Hopelessness|58
194|3 - Hospice care|3 - Hospice care|58
195|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|58
196|3 - Injury caused by fall or accident at home|3 - Injury caused by fall or accident at home|58
197|3 - Intractable pain|3 - Intractable pain|58
198|3 - Medicaid (traditional fee-for-service)|3 - Medicaid (traditional fee-for-service)|58
199|3 - Needs someone to do all shopping and errands.|3 - Needs someone to do all shopping and errands.|58
200|3 - Not healing|3 - Not healing|58
201|3 - Nursing home|3 - Nursing home|58
202|3 - Once daily|3 - Once daily|58
203|3 - Other family member|3 - Other family member|58
204|3 - Outpatient department/clinic emergency (includes urgicenter sites)|3 - Outpatient department/clinic emergency (includes urgicenter sites)|58
205|3 - Paid help|3 - Paid help|58
206|3 - Able to participate in bathing self in shower or tub, but requires presence of another person throughout the bath for assistance or supervision.|3 - Able to participate in bathing self in shower or tub, but requires presence of another person th|58
207|3 - Patient depends entirely upon another person to dress lower body.|3 - Patient depends entirely upon another person to dress lower body.|58
208|3 - Patient depends entirely upon another person to dress the upper body.|3 - Patient depends entirely upon another person to dress the upper body.|58
209|3 - Patient depends entirely upon someone else for grooming needs.|3 - Patient depends entirely upon someone else for grooming needs.|58
210|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone else to manage the equipment.|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone|58
211|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable to shift attention and recall directions more than half the time.|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable|58
212|3 - Respiratory problems (SOB, infection, obstruction)|3 - Respiratory problems (SOB, infection, obstruction)|58
213|3 - Resumption of care (after inpatient stay)|3 - Resumption of care (after inpatient stay)|58
214|3 - Several times each month|3 - Several times each month|58
215|3 - Skilled Nursing Facility|3 - Skilled Nursing Facility|58
216|3 - Stage 3|3 - Stage 3|58
217|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|58
218|3 - Three|3 - Three|58
219|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person throughout the process.|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person through|58
220|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal independently.|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal indep|58
221|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person.|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person|58
222|3 - Unknown because patient moved to a geographic location not served by this agency|3 - Unknown because patient moved to a geographic location not served by this agency|58
223|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|58
224|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|58
225|3 - With other family member|3 - With other family member|58
226|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home health services, homemaker assistance, transportation assistance, assisted living, board and care)|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home h|58
227|3-SLP/ST|3-SLP/ST|58
228|4 - At rest (during day or night)|4 - At rest (during day or night)|58
229|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|58
230|4 - Board and care or assisted living facility|4 - Board and care or assisted living facility|58
231|4 - Caregiver is completely dependent on someone else to manage all equipment.|4 - Caregiver is completely dependent on someone else to manage all equipment.|58
232|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|58
233|4 - Constantly|4 - Constantly|58
234|4 - Drug dependency|4 - Drug dependency|58
235|4 - Four or more|4 - Four or more|58
236|4 - Friend or neighbor or community or church member|4 - Friend or neighbor or community or church member|58
237|4 - Hispanic or Latino|4 - Hispanic or Latino|58
238|4 - Hospice|4 - Hospice|58
239|4 - Impaired decision-making|4 - Impaired decision-making|58
240|4 - Is totally dependent in toileting.|4 - Is totally dependent in toileting.|58
241|4 - Medicaid (HMO/managed care)|4 - Medicaid (HMO/managed care)|58
242|4 - None of the above|4 - None of the above|58
243|4 - Nursing home|4 - Nursing home|58
244|4 - On a daily basis|4 - On a daily basis|58
245|4 - Patient is completely dependent on someone else to manage all equipment.|4 - Patient is completely dependent on someone else to manage all equipment.|58
246|4 - Permanent placement|4 - Permanent placement|58
247|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, punches, dangerous maneuvers w/ wheelchair or other objects)|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, pu|58
248|4 - Psychosocial support (e.g., socialization, companionship, recreation)|4 - Psychosocial support (e.g., socialization, companionship, recreation)|58
249|4 - Recertification (follow-up) reassessment|4 - Recertification (follow-up) reassessment|58
250|4 - Recurrent thoughts of death|4 - Recurrent thoughts of death|58
251|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruction)|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruc|58
252|4 - Several times a week|4 - Several times a week|58
253|4 - Stage 4|4 - Stage 4|58
254|4 - Symptoms poorly controlled, history of rehospitalizations|4 - Symptoms poorly controlled, history of rehospitalizations|58
255|4 - Three or more times per week|4 - Three or more times per week|58
256|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetative state, or delirium.|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetati|58
257|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|58
258|4 - Unable to effectively participate in any housekeeping tasks.|4 - Unable to effectively participate in any housekeeping tasks.|58
259|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or unresponsive (e.g., speech is nonsensical or unintelligible).|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or u|58
260|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonresponsive.|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonr|58
261|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostomy.|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostom|58
262|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of devices at the sink, in chair, or on commode|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of|58
263|4 - With a friend|4 - With a friend|58
264|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|58
265|4-OT|4-OT|58
266|5 - Advocates or facilitates patient's participation in appropriate medical care|5 - Advocates or facilitates patient's participation in appropriate medical care|58
267|5 - At least daily|5 - At least daily|58
268|6 - Bedfast, unable to ambulate or be up in a chair.|6 - Bedfast, unable to ambulate or be up in a chair.|58
269|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|58
270|5 - Disruptive or socially inappropriate behavior|5 - Disruptive or socially inappropriate behavior|58
271|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|58
272|5 - Hypo/Hyperglycemia, diabetes out of control|5 - Hypo/Hyperglycemia, diabetes out of control|58
273|5 - More often than once daily|5 - More often than once daily|58
274|5 - Native Hawaiian or Pacific Islander|5 - Native Hawaiian or Pacific Islander|58
275|5 - None of the above|5 - None of the above|58
276|5 - One to two times per week|5 - One to two times per week|58
277|5 - Other|5 - Other|58
278|5 - Other follow-up|5 - Other follow-up|58
279|5 - Paid help|5 - Paid help|58
280|5 - Patient nonresponsive or unable to speak.|5 - Patient nonresponsive or unable to speak.|58
281|5 - Thoughts of suicide|5 - Thoughts of suicide|58
282|5 - Totally unable to use the telephone.|5 - Totally unable to use the telephone.|58
283|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|58
284|5 - Unable to take in nutrients orally or by tube feeding.|5 - Unable to take in nutrients orally or by tube feeding.|58
285|5 - Unsafe for care at home|5 - Unsafe for care at home|58
286|5 - With paid help (other than home care agency staff)|5 - With paid help (other than home care agency staff)|58
287|5 - Workers' compensation|5 - Workers' compensation|58
288|5 - Wound infection, deteriorating wound status, new lesion/ulcer|5 - Wound infection, deteriorating wound status, new lesion/ulcer|58
289|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|58
290|6 - Delusional, hallucinatory, or paranoid behavior|6 - Delusional, hallucinatory, or paranoid behavior|58
291|6 - Financial agent, power of attorney, or conservator of finance|6 - Financial agent, power of attorney, or conservator of finance|58
292|6 - GI bleeding, obstruction|6 - GI bleeding, obstruction|58
293|6 - Less often than weekly|6 - Less often than weekly|58
294|6 - Memory loss to the extent that supervision required|6 - Memory loss to the extent that supervision required|58
295|6 - None of the above feelings observed or reported|6 - None of the above feelings observed or reported|58
296|6 - Other|6 - Other|58
297|6 - Title programs (e.g., Title III, V, or XX)|6 - Title programs (e.g., Title III, V, or XX)|58
298|6 - Transferred to an inpatient facility - patient not discharged from agency|6 - Transferred to an inpatient facility - patient not discharged from agency|58
299|6 - White|6 - White|58
300|6 - With other than above|6 - With other than above|58
301|7 - Exacerbation of CHF, fluid overload, heart failure|7 - Exacerbation of CHF, fluid overload, heart failure|58
302|7 - Health care agent, conservator of person, or medical power of attorney|7 - Health care agent, conservator of person, or medical power of attorney|58
303|7 - Hypo/Hyperglycemia, diabetes out of control|7 - Hypo/Hyperglycemia, diabetes out of control|58
304|7 - None of the above|7 - None of the above|58
305|7 - None of the above behaviors demonstrated|7 - None of the above behaviors demonstrated|58
306|7 - Other government (e.g., TriCare, VA, etc.)|7 - Other government (e.g., TriCare, VA, etc.)|58
307|7 - Transferred to an inpatient facility - patient discharged from agency|7 - Transferred to an inpatient facility - patient discharged from agency|58
308|8 - Death at home|8 - Death at home|58
309|8 - GI bleeding, obstruction|8 - GI bleeding, obstruction|58
310|8 - Myocardial infarction, stroke|8 - Myocardial infarction, stroke|58
311|8 - Private insurance|8 - Private insurance|58
312|9 - Chemotherapy|9 - Chemotherapy|58
313|9 - Discharge from agency|9 - Discharge from agency|58
314|9 - Other than above reasons|9 - Other than above reasons|58
315|9 - Private HMO/managed care|9 - Private HMO/managed care|58
316|NA - No caregiver|NA - No caregiver|58
317|NA - No equipment of this type used in care.|NA - No equipment of this type used in care.|58
318|NA - No inhalant/mist medications prescribed.|NA - No inhalant/mist medications prescribed.|58
319|NA - No injectable medications prescribed.|NA - No injectable medications prescribed.|58
320|NA - No inpatient facility admission|NA - No inpatient facility admission|58
321|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|58
322|NA - No Medicaid|NA - No Medicaid|58
323|NA - No Medicare|NA - No Medicare|58
324|NA - No observable pressure ulcer or unhealed pressure ulcer|NA - No observable pressure ulcer or unhealed pressure ulcer|58
325|NA - No observable stasis ulcer|NA - No observable stasis ulcer|58
326|NA - No observable surgical wound|NA - No observable surgical wound|58
327|NA - No oral medications prescribed.|NA - No oral medications prescribed.|58
328|NA - Not applicable|NA - Not applicable|58
329|NA - Patient does not have a telephone.|NA - Patient does not have a telephone.|58
330|NA - Patient has ostomy for bowel elimination|NA - Patient has ostomy for bowel elimination|58
331|NA - Patient nonresponsive|NA - Patient nonresponsive|58
332|NA - Patient on prophylactic treatment|NA - Patient on prophylactic treatment|58
333|NA - Patient was not discharged from an inpatient facility [Go to M1017]|NA - Patient was not discharged from an inpatient facility [Go to M1017]|58
334|UK - Other unknown|UK - Other unknown|58
335|UK - Reason unknown|UK - Reason unknown|58
336|UK - Unknown|UK - Unknown|58
337|UK - Unknown or Not Available|UK - Unknown or Not Available|58
341|01 - Early|01 - Early|58
342|02 - Late|02 - Late|58
343|NA - Not Applicable. No case mix group defined for this assessment.|NA - Not Applicable. No case mix group defined for this assessment.|58
344|NA - No case mix group defined by this assessment.|NA - No case mix group defined by this assessment.|58
345|1 - Recent decline in mental, emotional, or behavioral status|1 - Recent decline in mental, emotional, or behavioral status|58
346|2 - Multiple hospitalizations (2 or more) in the past 12 months|2 - Multiple hospitalizations (2 or more) in the past 12 months|58
347|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|58
348|4 - Taking five or more medications|4 - Taking five or more medications|58
349|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|58
350|6 - Other|6 - Other|58
351|7 - None of the above|7 - None of the above|58
352|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond tho|58
353|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable without heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable wi|58
354|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious complications and death.|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious compl|58
355|3 - The patient has serious progressive conditions that could lead to death within a year.|3 - The patient has serious progressive conditions that could lead to death within a year.|58
356|UK - The patient+s situation is unknown or unclear.|UK - The patient+s situation is unknown or unclear.|58
357|1 - Yes [ Go to M1050 ]|1 - Yes [ Go to M1050 ]|58
358|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this influenza season. [ Go to M1050 ]|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this i|58
359|1 - Received from another health care provider (e.g., physician)|1 - Received from another health care provider (e.g., physician)|58
360|2 - Received from your agency previously during this year+s flu season|2 - Received from your agency previously during this year+s flu season|58
361|3 - Offered and declined|3 - Offered and declined|58
362|4 - Assessed and determined to have medical contraindication(s)|4 - Assessed and determined to have medical contraindication(s)|58
363|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|58
364|6 - Inability to obtain vaccine due to declared shortage|6 - Inability to obtain vaccine due to declared shortage|58
365|1 - Yes [ Go to M1500 at TRN; Go to M1230 at DC ]|1 - Yes [ Go to M1500 at TRN; Go to M1230 at DC ]|58
366|1 - Patient has received PPV in the past|1 - Patient has received PPV in the past|58
367|2 - Offered and declined|2 - Offered and declined|58
368|3 - Assessed and determined to have medical contraindication(s)|3 - Assessed and determined to have medical contraindication(s)|58
369|4 - Not indicated; patient does not meet age/condition guidelines for PPV|4 - Not indicated; patient does not meet age/condition guidelines for PPV|58
370|5 - None of the above|5 - None of the above|58
371|0 - Adequate: hears normal conversation without difficulty.|0 - Adequate: hears normal conversation without difficulty.|58
372|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to increase volume or speak distinctly.|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to in|58
373|2 - Severely Impaired: absence of useful hearing.|2 - Severely Impaired: absence of useful hearing.|58
374|UK - Unable to assess hearing.|UK - Unable to assess hearing.|58
375|0 - Understands: clear comprehension without cues or repetitions.|0 - Understands: clear comprehension without cues or repetitions.|58
376|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Requires cues at times to understand.|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Req|58
377|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequently requires cues to understand.|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequentl|58
378|3 - Rarely/Never Understands|3 - Rarely/Never Understands|58
379|UK - Unable to assess understanding.|UK - Unable to assess understanding.|58
380|0 - No standardized assessment conducted|0 - No standardized assessment conducted|58
381|1 - Yes, and it does not indicate severe pain|1 - Yes, and it does not indicate severe pain|58
382|2 - Yes, and it indicates severe pain|2 - Yes, and it indicates severe pain|58
383|0 - Patient has no pain|0 - Patient has no pain|58
384|1 - Patient has pain that does not interfere with activity or movement|1 - Patient has pain that does not interfere with activity or movement|58
385|2 - Less often than daily|2 - Less often than daily|58
386|3 - Daily, but not constantly|3 - Daily, but not constantly|58
387|4 - All of the time|4 - All of the time|58
388|0 - No assessment conducted [ Go to M1306 ]|0 - No assessment conducted [ Go to M1306 ]|58
389|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc., without use of standardized tool|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc.,|58
390|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|58
391|0 - No [ Go to M1322]|0 - No [ Go to M1322]|58
392|0 v Newly epithelialized|0 v Newly epithelialized|58
393|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|58
394|2 - Yes, patient has observable stasis ulcers ONLY|2 - Yes, patient has observable stasis ulcers ONLY|58
395|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable dressing) [Go to M1340]|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable|58
396|0 - No [ Go to M1350 ]|0 - No [ Go to M1350 ]|58
397|1 - Yes, patient has at least one (observable) surgical wound|1 - Yes, patient has at least one (observable) surgical wound|58
398|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1350 ]|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1350 ]|58
399|0 - Patient is not short of breath|0 - Patient is not short of breath|58
400|3 - Continuous Bi-level positive airway pressure|3 - Continuous Bi-level positive airway pressure|58
401|0 - No [ Go to M2004 at TRN; Go to M1600 at DC ]|0 - No [ Go to M2004 at TRN; Go to M1600 at DC ]|58
402|2 - Not assessed [Go to M2004 at TRN; Go to M1600 at DC ]|2 - Not assessed [Go to M2004 at TRN; Go to M1600 at DC ]|58
403|NA - Patient does not have diagnosis of heart failure [Go to M2004 at TRN; Go to M1600 at DC]|NA - Patient does not have diagnosis of heart failure [Go to M2004 at TRN; Go to M1600 at DC]|58
404|0 - No action taken|0 - No action taken|58
405|1 - Patient+s physician (or other primary care practitioner) contacted the same day|1 - Patient+s physician (or other primary care practitioner) contacted the same day|58
406|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|58
407|3 - Implement physician-ordered patient-specific established parameters for treatment|3 - Implement physician-ordered patient-specific established parameters for treatment|58
408|4 - Patient education or other clinical interventions|4 - Patient education or other clinical interventions|58
409|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequency, telehealth, etc.)|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequ|58
410|1 - Occasional stress incontinence|1 - Occasional stress incontinence|58
411|2 - During the night only|2 - During the night only|58
412|3 - During the day only|3 - During the day only|58
413|4 - During the day and night|4 - During the day and night|58
414|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|58
415|0 - Able to manage toileting hygiene and clothing management without assistance.|0 - Able to manage toileting hygiene and clothing management without assistance.|58
416|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implements are laid out for the patient.|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implemen|58
417|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|58
418|3 - Patient depends entirely upon another person to maintain toileting hygiene.|3 - Patient depends entirely upon another person to maintain toileting hygiene.|58
419|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independent|58
420|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface|58
421|0 - No multi-factor falls risk assessment conducted.|0 - No multi-factor falls risk assessment conducted.|58
422|1 - Yes, and it does not indicate a risk for falls.|1 - Yes, and it does not indicate a risk for falls.|58
423|2 - Yes, and it indicates a risk for falls.|2 - Yes, and it indicates a risk for falls.|58
424|0 - Not assessed/reviewed [ Go to M2010 ]|0 - Not assessed/reviewed [ Go to M2010 ]|58
425|1 - No problems found during review [ Go to M2010 ]|1 - No problems found during review [ Go to M2010 ]|58
426|2 - Problems found during review|2 - Problems found during review|58
427|NA - Patient is not taking any medications [ Go to M2040 ]|NA - Patient is not taking any medications [ Go to M2040 ]|58
428|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special precautions associated with all high-risk medications|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special p|58
429|NA - Patient not taking any drugs|NA - Patient not taking any drugs|58
430|2 - Able to take medication(s) at the correct times if given reminders by another person at the appropriate times|2 - Able to take medication(s) at the correct times if given reminders by another person at the appr|58
431|3 - Unable to take medication unless administered by another person.|3 - Unable to take medication unless administered by another person.|58
432|1 - At least daily|1 - At least daily|58
433|2 - Three or more times per week|2 - Three or more times per week|58
434|3 - One to two times per week|3 - One to two times per week|58
435|4 - Received, but less often than weekly|4 - Received, but less often than weekly|58
436|5 - No assistance received|5 - No assistance received|58
437|0 - No [Go to M2400]|0 - No [Go to M2400]|58
438|1 - Yes, used hospital emergency department WITHOUT hospital admission|1 - Yes, used hospital emergency department WITHOUT hospital admission|58
439|2 - Yes, used hospital emergency department WITH hospital admission|2 - Yes, used hospital emergency department WITH hospital admission|58
440|UK - Unknown [Go to M2400]|UK - Unknown [Go to M2400]|58
441|2 - Injury caused by fall|2 - Injury caused by fall|58
442|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|58
443|4 - Other respiratory problem|4 - Other respiratory problem|58
444|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|58
445|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|58
446|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|58
447|8 - Other heart disease|8 - Other heart disease|58
448|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|58
449|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|58
450|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|58
451|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|58
452|13 - Urinary tract infection|13 - Urinary tract infection|58
453|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|58
454|15 - Wound infection or deterioration|15 - Wound infection or deterioration|58
455|16 - Uncontrolled pain|16 - Uncontrolled pain|58
456|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|58
457|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|58
458|19 - Other than above reasons|19 - Other than above reasons|58
459|2 - Patient remained in the community (with formal assistive services)|2 - Patient remained in the community (with formal assistive services)|58
460|3 - Patient transferred to a noninstitutional hospice|3 - Patient transferred to a noninstitutional hospice|58
461|4 - Unknown because patient moved to a geographic location not served by this agency|4 - Unknown because patient moved to a geographic location not served by this agency|58
462|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|58
463|4 - Other respiratory problem|4 - Other respiratory problem|58
464|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|58
465|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|58
466|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|58
467|8 - Other heart disease|8 - Other heart disease|58
468|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|58
469|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|58
470|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|58
471|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|58
472|13 - Urinary tract infection|13 - Urinary tract infection|58
473|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|58
474|15 - Wound infection or deterioration|15 - Wound infection or deterioration|58
475|16 - Uncontrolled pain|16 - Uncontrolled pain|58
476|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|58
477|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|58
478|19 - Scheduled treatment or procedure|19 - Scheduled treatment or procedure|58
479|20 - Other than above reasons|20 - Other than above reasons|58
480|UK - Reason unknown [Go to M0903]|UK - Reason unknown [Go to M0903]|58
482|01 - Patient lives alone around the clock|01 - Patient lives alone around the clock|58
483|02 - Patient lives alone regular daytime|02 - Patient lives alone regular daytime|58
484|03 - Patient lives alone regular nighttime|03 - Patient lives alone regular nighttime|58
485|04 - Patient lives alone occassional/short term assistance|04 - Patient lives alone occassional/short term assistance|58
486|05 - Patient lives alone no assisstance available|05 - Patient lives alone no assisstance available|58
487|06 - Patient lives with other person(s) in the home around the clock|06 - Patient lives with other person(s) in the home around the clock|58
488|07 - Patient lives with other person(s) in the home regular daytime|07 - Patient lives with other person(s) in the home regular daytime|58
489|08 - Patient lives with other person(s) in the home regular nighttime|08 - Patient lives with other person(s) in the home regular nighttime|58
490|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|58
491|10 - Patient lives with other person(s) in the home no assistance available|10 - Patient lives with other person(s) in the home no assistance available|58
492|1 - Was present at the most recent SOC/ROC assessment|1 - Was present at the most recent SOC/ROC assessment|58
493|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|58
494|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|58
495|0 - Newly epithelialized|0 - Newly epithelialized|58
496|0 - No [ Go to M1340 ]|0 - No [ Go to M1340 ]|58
498|0 - Independent|0 - Independent|58
499|1 - Needed Some Help|1 - Needed Some Help|58
500|2 - Dependent|2 - Dependent|58
502|0 - No assistance needed in this area|0 - No assistance needed in this area|58
503|1 - Caregiver(s) currently provide assistance|1 - Caregiver(s) currently provide assistance|58
504|2 - Caregiver(s) need training/ supportive services to provide assistance|2 - Caregiver(s) need training/ supportive services to provide assistance|58
505|3 - Caregiver(s) not likely to provide assistance|3 - Caregiver(s) not likely to provide assistance|58
506|4 - Unclear if Caregiver(s) will provide assistance|4 - Unclear if Caregiver(s) will provide assistance|58
507|5 - Assistance needed, but no Caregiver(s) available|5 - Assistance needed, but no Caregiver(s) available|58
508|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will use standardized clinical guidelines accessible for all care providers to reference|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will|58
510|NA - Patient is not assessed to be at risk for falls|NA - Patient is not assessed to be at risk for falls|58
511|NA - Patient has no diagnosis or symptoms of depression|NA - Patient has no diagnosis or symptoms of depression|58
512|NA - No pain identified|NA - No pain identified|58
513|NA - Patient is not assessed to be at risk for pressure ulcers|NA - Patient is not assessed to be at risk for pressure ulcers|58
514|NA - Patient has no pressure ulcers with need for moist wound healing|NA - Patient has no pressure ulcers with need for moist wound healing|58
515|1 - Long-term nursing facility (NF)|1 - Long-term nursing facility (NF)|58
516|2 - Skilled nursing facility (SNF / TCU)|2 - Skilled nursing facility (SNF / TCU)|58
517|3 - Short stay acute hospital (IPP S)|3 - Short stay acute hospital (IPP S)|58
518|4 - Long-term care hospital (LTCH)|4 - Long-term care hospital (LTCH)|58
519|5 - Inpatient rehabilitation hospital or unit (IRF)|5 - Inpatient rehabilitation hospital or unit (IRF)|58
520|6 - Psychiatric hospital or unit|6 - Psychiatric hospital or unit|58
521|7 - Other|7 - Other|58
522|NA - Patient was not discharged from an inpatient facility [Go to M1017]|NA - Patient was not discharged from an inpatient facility [Go to M1017]|58
523|6 - Unable to participate effectively in bathing and is bathed totally by another person|6 - Unable to participate effectively in bathing and is bathed totally by another person|58
524|4 - Chairfast, unable to ambulate but is able to wheel self independently.|4 - Chairfast, unable to ambulate but is able to wheel self independently.|58
525|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask patient: "Over the last two weeks, how often have you been bothered by any of the following problems")|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask|58
526|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluation for depression.|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluat|58
527|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet criteria for further evaluation for depression.|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet|58
528|0 - Not at all  0 - 1 day|0 - Not at all  0 - 1 day|58
529|1 - Several days  2 - 6 days|1 - Several days  2 - 6 days|58
530|2 - More than half of the days  7 - 11 days|2 - More than half of the days  7 - 11 days|58
531|3 - Nearly every day  12 - 14 days|3 - Nearly every day  12 - 14 days|58
532|NA - N/A  Unable to respond|NA - N/A  Unable to respond|58
533|2 - Able to take medication(s) at the correct times if given reminders by another person based on the frequency of the injection|2 - Able to take medication(s) at the correct times if given reminders by another person based on th|58
534|3 - Unable to take injectable medication unless administered by another person.|3 - Unable to take injectable medication unless administered by another person.|58
547|NA - No clinically significant medication issues identified since the previous OASIS assessment|NA - No clinically significant medication issues identified since the previous OASIS assessment|58
552|1 - Hospital [ Go to M2430 ]|1 - Hospital [ Go to M2430 ]|58
553|2 - Rehabilitation facility [ Go to M0903 ]|2 - Rehabilitation facility [ Go to M0903 ]|58
554|3 - Nursing home [ Go to M2440 ]|3 - Nursing home [ Go to M2440 ]|58
555|4 - Hospice [ Go to M0903 ]|4 - Hospice [ Go to M0903 ]|58
2|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; OR (b) Is physically, cognitively, and mentally able to prepare light meals on a regular basis but has not routinely performed light meal preparation in the past (i.e., prior to this home care admission).|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; O|59
3|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and mentally able to perform all housekeeping tasks .|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and menta|59
4|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and mentally able to do laundry and access facilities.|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and menta|59
5|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying packages OR b) Physically, cognitively, and mentally able to take care of shopping, but has not done shopping in the past (i.e., prior to this home care admission).|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying|59
6|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|59
7|0 - Able to dial numbers and answer calls appropriately and as desired.|0 - Able to dial numbers and answer calls appropriately and as desired.|59
8|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body without assistance.|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body|59
9|0 - Able to get to and from the toilet and transfer independently with or without a device.|0 - Able to get to and from the toilet and transfer independently with or without a device.|59
10|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|59
11|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible public bus.|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible p|59
12|0 - Able to independently feed self.|0 - Able to independently feed self.|59
13|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|59
14|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct times.|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct ti|59
15|0 - Able to independently transfer.|0 - Able to independently transfer.|59
16|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without rail|59
17|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings|59
18|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|59
19|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions independently.|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions indep|59
20|0 - Asymptomatic, no treatment needed at this time|0 - Asymptomatic, no treatment needed at this time|59
21|0 - Caregiver manages all tasks related to equipment completely independently.|0 - Caregiver manages all tasks related to equipment completely independently.|59
22|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations with no observable impairment.|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations w|59
23|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|59
24|0 - Life expectancy is greater than 6 months|0 - Life expectancy is greater than 6 months|59
25|0 - Never|0 - Never|59
26|0 - Patient is not short of breath|0 - Patient is not short of breath|59
27|0 - No|0 - No|59
28|0 - No emergent care services|0 - No emergent care services|59
29|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [Goto M1620]|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [Goto M1620]|59
30|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and extended or abstract conversation.|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and exte|59
31|0 - No one person|0 - No one person|59
32|0 - None of the time|0 - None of the time|59
33|0 - None, no charge for current services|0 - None, no charge for current services|59
34|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|59
35|0 - Patient does NOT have an ostomy for bowel elimination.|0 - Patient does NOT have an ostomy for bowel elimination.|59
36|0 - Patient has no pain|0 - Patient has no pain|59
37|0 - Patient manages all tasks related to equipment completely independently.|0 - Patient manages all tasks related to equipment completely independently.|59
38|0 - Poor:  little or no recovery is expected and/or further decline is imminent|0 - Poor:  little or no recovery is expected and/or further decline is imminent|59
39|0 - Timed-voiding defers incontinence|0 - Timed-voiding defers incontinence|59
40|0 - Very rarely or never has bowel incontinence|0 - Very rarely or never has bowel incontinence|59
41|0 - Zero|0 - Zero|59
42|00 - No|00 - No|59
43|01 - Yes|01 - Yes|59
44|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or mental limitations, needs assistance with heavy laundry.|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or|59
45|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the patient.|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the|59
46|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|59
47|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or supervision from another person OR c) a liquid, pureed or ground meat diet.|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or su|59
48|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|59
49|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|59
50|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independently.|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independe|59
51|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only when assisted or accompanied by another person.|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only w|59
52|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepa|59
53|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance by another person OR b) given daily reminders.|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance b|59
54|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advan|59
55|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advan|59
56|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for the deaf) and call essential numbers.|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for t|59
57|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|59
58|1 - American Indian or Alaska Native|1 - American Indian or Alaska Native|59
59|1 - Depressed mood (e.g., feeling sad, tearful)|1 - Depressed mood (e.g., feeling sad, tearful)|59
60|1 - During the night only|1 - During the night only|59
61|1 - Fully granulating|1 - Fully granulating|59
62|1 - Good/Fair:  partial to full recovery is expected|1 - Good/Fair:  partial to full recovery is expected|59
63|1 - Good:  marked improvement in functional status is expected|1 - Good:  marked improvement in functional status is expected|59
64|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|59
65|1 - Smoking|1 - Smoking|59
66|1 - Hospital [ Go to M2430 ]|1 - Hospital [ Go to M2430 ]|59
67|1 - Hospital emergency room (includes 23-hour holding)|1 - Hospital emergency room (includes 23-hour holding)|59
68|1 - Hospitalization for EMERGENT (unscheduled) care|1 - Hospitalization for EMERGENT (unscheduled) care|59
69|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepared solutions), patient is able to manage all other aspects of equipment.|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepar|59
70|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|59
71|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|59
72|1 - In new or complex situations only|1 - In new or complex situations only|59
73|1 - Intravenous or infusion therapy (excludes TPN)|1 - Intravenous or infusion therapy (excludes TPN)|59
74|1 - Less often than daily|1 - Less often than daily|59
75|1 - Less than once a month|1 - Less than once a month|59
76|1 - Less than once weekly|1 - Less than once weekly|59
77|1 - Life expectancy is 6 months or fewer|1 - Life expectancy is 6 months or fewer|59
78|1 - Lives alone|1 - Lives alone|59
79|1 - Male|1 - Male|59
80|1 - Medicare (traditional fee-for-service)|1 - Medicare (traditional fee-for-service)|59
81|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of past 24 hours, significant memory loss so that supervision is required|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of pas|59
82|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors in word choice, grammar or speech intelligibility, needs minimal prompting or assistance).|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors i|59
83|1 - No assistance or services received|1 - No assistance or services received|59
84|1 - One|1 - One|59
85|1 - Oxygen (intermittent or continuous)|1 - Oxygen (intermittent or continuous)|59
86|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, and the surrounding layout, can count fingers at arm's length.|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, a|59
87|1 - Patient is incontinent|1 - Patient is incontinent|59
88|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|59
89|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical or treatment regimen.|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical|59
90|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient/couple/significant other)|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient|59
91|1 - Relatives, friends, or neighbors living outside the home|1 - Relatives, friends, or neighbors living outside the home|59
92|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions.|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions|59
93|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independentl|59
94|1 - Several times during day and night|1 - Several times during day and night|59
95|1 - Spouse or significant other|1 - Spouse or significant other|59
96|1 - Stage 1|1 - Stage 1|59
97|1 - Start of care - further visits planned|1 - Start of care - further visits planned|59
98|1 - Symptoms well controlled with current therapy|1 - Symptoms well controlled with current therapy|59
99|1 - Therapy services|1 - Therapy services|59
100|1 - Able to transfer with minimal human assistance or with use of an assistive device.|1 - Able to transfer with minimal human assistance or with use of an assistive device.|59
101|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitations.|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitatio|59
102|1 - Urinary incontinence|1 - Urinary incontinence|59
103|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and transfer.|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and|59
104|1 - When walking more than 20 feet, climbing stairs|1 - When walking more than 20 feet, climbing stairs|59
105|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary conversation. May need occasional repetition, extra time, or louder voice.|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary c|59
106|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting in and out of tub/shower|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting|59
107|1 - Yes|1 - Yes|59
108|1-RN|1-RN|59
109|10 - Discharge from agency - no visits completed after start/resumption of care assessment|10 - Discharge from agency - no visits completed after start/resumption of care assessment|59
110|10 - Scheduled surgical procedure|10 - Scheduled surgical procedure|59
111|10 - Self-pay|10 - Self-pay|59
112|11 - Other|11 - Other|59
113|11 - Urinary tract infection|11 - Urinary tract infection|59
114|12 - IV catheter-related infection|12 - IV catheter-related infection|59
115|13 - Deep vein thrombosis, pulmonary embolus|13 - Deep vein thrombosis, pulmonary embolus|59
116|14 - Uncontrolled pain|14 - Uncontrolled pain|59
117|15 - Psychotic episode|15 - Psychotic episode|59
118|16 - Other than above reasons|16 - Other than above reasons|59
119|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing calls.|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing|59
120|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another person.|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another pers|59
121|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface a|59
122|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for intermittent supervision or encouragement or reminders, OR (b) to get in and out of the shower or tub, OR (c) for washing difficult to reach areas.|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for inter|59
123|2 - Asian|2 - Asian|59
124|2 - Caregiver requires considerable assistance from another person to manage equipment, but independently completes significant portions of task.|2 - Caregiver requires considerable assistance from another person to manage equipment, but independ|59
125|2 - Daily, but not constantly|2 - Daily, but not constantly|59
126|2 - Daughter or son|2 - Daughter or son|59
127|2 - Doctor's office emergency visit/house call|2 - Doctor's office emergency visit/house call|59
128|2 - During the day and night|2 - During the day and night|59
129|2 - Early/partial granulation|2 - Early/partial granulation|59
130|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors in word choice, organization or speech intelligibility). Speaks in phrases or short sentences.|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors|59
131|2 - Family member's residence|2 - Family member's residence|59
132|2 - Female|2 - Female|59
133|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conversation, needs frequent prompting or assistance.|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conver|59
134|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|59
135|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|59
136|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately stop activities, jeopardizes safety through actions|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately st|59
137|2 - Indwelling/suprapubic catheter|2 - Indwelling/suprapubic catheter|59
138|2 - Injury caused by fall or accident at home|2 - Injury caused by fall or accident at home|59
139|2 - Medicare (HMO/managed care/Advantage plan)|2 - Medicare (HMO/managed care/Advantage plan)|59
140|2 - Nausea, dehydration, malnutrition, constipation, impaction|2 - Nausea, dehydration, malnutrition, constipation, impaction|59
141|2 - Obesity|2 - Obesity|59
142|2 - On awakening or at night only|2 - On awakening or at night only|59
143|2 - Once a month|2 - Once a month|59
144|2 - One to three times weekly|2 - One to three times weekly|59
145|2 - Parenteral nutrition (TPN or lipids)|2 - Parenteral nutrition (TPN or lipids)|59
146|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic) [ Go to M1620 ]|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic) [ Go|59
147|2 - Patient requires considerable assistance from another person to manage equipment, but independently completes portions of the task.|2 - Patient requires considerable assistance from another person to manage equipment, but independen|59
148|2 - Patient transferred to a noninstitutional hospice|2 - Patient transferred to a noninstitutional hospice|59
149|2 - Person residing in the home (EXCLUDING paid help)|2 - Person residing in the home (EXCLUDING paid help)|59
150|2 - Rehabilitation facility [ Go to M0903 ]|2 - Rehabilitation facility [ Go to M0903 ]|59
151|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifting of attention) or consistently requires low stimulus environment due to distractibility.|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifti|59
152|2 - Respite care|2 - Respite care|59
153|2 - Sense of failure or self reproach|2 - Sense of failure or self reproach|59
154|2 - Several times during day|2 - Several times during day|59
155|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonresponsive.|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonrespons|59
156|2 - Someone must assist the patient to groom self.|2 - Someone must assist the patient to groom self.|59
157|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|59
158|2 - Someone must help the patient put on upper body clothing.|2 - Someone must help the patient put on upper body clothing.|59
159|2 - Stage 2|2 - Stage 2|59
160|2 - Start of care - no further visits planned|2 - Start of care - no further visits planned|59
161|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitoring|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitori|59
162|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment regimen.|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment re|59
163|2 - Two|2 - Two|59
164|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistance due to cognitive or mental limitation.|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistanc|59
165|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|59
166|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assistance).|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assis|59
167|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home delivery.|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home deli|59
168|2 - Unable to prepare any light meals or reheat any delivered meals.|2 - Unable to prepare any light meals or reheat any delivered meals.|59
169|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|59
170|2 - UNABLE to take injectable medications unless administered by someone else.|2 - UNABLE to take injectable medications unless administered by someone else.|59
171|2 - UNABLE to take medication unless administered by someone else.|2 - UNABLE to take medication unless administered by someone else.|59
172|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|59
173|2 - Ventilator (continually or at night)|2 - Ventilator (continually or at night)|59
174|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less than 20 feet)|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less th|59
175|2 - With spouse or significant other|2 - With spouse or significant other|59
176|2 - Yes, assistance or services provided by family or friends|2 - Yes, assistance or services provided by family or friends|59
177|2-PT|2-PT|59
178|3 - Able to answer the telephone only some of the time or is able to carry on only a limited conversation.|3 - Able to answer the telephone only some of the time or is able to carry on only a limited convers|59
179|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube or gastrostomy.|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube|59
180|3 - Alcohol dependency|3 - Alcohol dependency|59
181|3 - All of the time|3 - All of the time|59
182|3 - Black or African-American|3 - Black or African-American|59
183|3 - Boarding home or rented room|3 - Boarding home or rented room|59
184|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment, clean/store/dispose of equipment or supplies).|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment,|59
185|3 -Able to walk only with the supervision or assistance of another person at all times.|3 -Able to walk only with the supervision or assistance of another person at all times.|59
186|3 - Continuous / Bi-level positive airway pressure|3 - Continuous / Bi-level positive airway pressure|59
187|3 - During the day and evening, but not constantly|3 - During the day and evening, but not constantly|59
188|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the alimentary canal)|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the|59
189|3 - Environmental support (e.g., housing, home maintenance)|3 - Environmental support (e.g., housing, home maintenance)|59
190|3 - Four to six times weekly|3 - Four to six times weekly|59
191|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessing by listener.  Speech limited to single words or short phrases.|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessin|59
192|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires multiple repetitions, restatements, demonstrations, additional time.|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires m|59
193|3 - Hopelessness|3 - Hopelessness|59
194|3 - Hospice care|3 - Hospice care|59
195|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|59
196|3 - Injury caused by fall or accident at home|3 - Injury caused by fall or accident at home|59
197|3 - Intractable pain|3 - Intractable pain|59
198|3 - Medicaid (traditional fee-for-service)|3 - Medicaid (traditional fee-for-service)|59
199|3 - Needs someone to do all shopping and errands.|3 - Needs someone to do all shopping and errands.|59
200|3 - Not healing|3 - Not healing|59
201|3 - Nursing home [ Go to M2440 ]|3 - Nursing home [ Go to M2440 ]|59
202|3 - Once daily|3 - Once daily|59
203|3 - Other family member|3 - Other family member|59
204|3 - Outpatient department/clinic emergency (includes urgicenter sites)|3 - Outpatient department/clinic emergency (includes urgicenter sites)|59
205|3 - Paid help|3 - Paid help|59
206|3 - Able to participate in bathing self in shower or tub, but requires presence of another person throughout the bath for assistance or supervision.|3 - Able to participate in bathing self in shower or tub, but requires presence of another person th|59
207|3 - Patient depends entirely upon another person to dress lower body.|3 - Patient depends entirely upon another person to dress lower body.|59
208|3 - Patient depends entirely upon another person to dress the upper body.|3 - Patient depends entirely upon another person to dress the upper body.|59
209|3 - Patient depends entirely upon someone else for grooming needs.|3 - Patient depends entirely upon someone else for grooming needs.|59
210|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone else to manage the equipment.|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone|59
211|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable to shift attention and recall directions more than half the time.|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable|59
212|3 - Respiratory problems (SOB, infection, obstruction)|3 - Respiratory problems (SOB, infection, obstruction)|59
213|3 - Resumption of care (after inpatient stay)|3 - Resumption of care (after inpatient stay)|59
214|3 - Several times each month|3 - Several times each month|59
215|3 - Skilled Nursing Facility|3 - Skilled Nursing Facility|59
216|3 - Stage 3|3 - Stage 3|59
217|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|59
218|3 - Three|3 - Three|59
219|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person throughout the process.|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person through|59
220|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal independently.|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal indep|59
221|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person.|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person|59
222|3 - Unknown because patient moved to a geographic location not served by this agency|3 - Unknown because patient moved to a geographic location not served by this agency|59
223|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|59
224|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|59
225|3 - With other family member|3 - With other family member|59
226|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home health services, homemaker assistance, transportation assistance, assisted living, board and care)|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home h|59
227|3-SLP/ST|3-SLP/ST|59
228|4 - At rest (during day or night)|4 - At rest (during day or night)|59
229|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|59
230|4 - Board and care or assisted living facility|4 - Board and care or assisted living facility|59
231|4 - Caregiver is completely dependent on someone else to manage all equipment.|4 - Caregiver is completely dependent on someone else to manage all equipment.|59
232|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|59
233|4 - Constantly|4 - Constantly|59
234|4 - Drug dependency|4 - Drug dependency|59
235|4 - Four or more|4 - Four or more|59
236|4 - Friend or neighbor or community or church member|4 - Friend or neighbor or community or church member|59
237|4 - Hispanic or Latino|4 - Hispanic or Latino|59
238|4 - Hospice [ Go to M0903 ]|4 - Hospice [ Go to M0903 ]|59
239|4 - Impaired decision-making|4 - Impaired decision-making|59
240|4 - Is totally dependent in toileting.|4 - Is totally dependent in toileting.|59
241|4 - Medicaid (HMO/managed care)|4 - Medicaid (HMO/managed care)|59
242|4 - None of the above|4 - None of the above|59
243|4 - Nursing home|4 - Nursing home|59
244|4 - On a daily basis|4 - On a daily basis|59
245|4 - Patient is completely dependent on someone else to manage all equipment.|4 - Patient is completely dependent on someone else to manage all equipment.|59
246|4 - Permanent placement|4 - Permanent placement|59
247|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, punches, dangerous maneuvers w/ wheelchair or other objects)|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, pu|59
248|4 - Psychosocial support (e.g., socialization, companionship, recreation)|4 - Psychosocial support (e.g., socialization, companionship, recreation)|59
249|4 - Recertification (follow-up) reassessment|4 - Recertification (follow-up) reassessment|59
250|4 - Recurrent thoughts of death|4 - Recurrent thoughts of death|59
251|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruction)|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruc|59
252|4 - Several times a week|4 - Several times a week|59
253|4 - Stage 4|4 - Stage 4|59
254|4 - Symptoms poorly controlled, history of re-hospitalizations|4 - Symptoms poorly controlled, history of re-hospitalizations|59
255|4 - Three or more times per week|4 - Three or more times per week|59
256|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetative state, or delirium.|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetati|59
257|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|59
258|4 - Unable to effectively participate in any housekeeping tasks.|4 - Unable to effectively participate in any housekeeping tasks.|59
259|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or unresponsive (e.g., speech is nonsensical or unintelligible).|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or u|59
260|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonresponsive.|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonr|59
261|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostomy.|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostom|59
262|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of devices at the sink, in chair, or on commode|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of|59
263|4 - With a friend|4 - With a friend|59
264|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|59
265|4-OT|4-OT|59
266|5 - Advocates or facilitates patient's participation in appropriate medical care|5 - Advocates or facilitates patient's participation in appropriate medical care|59
267|5 - At least daily|5 - At least daily|59
268|6 - Bedfast, unable to ambulate or be up in a chair.|6 - Bedfast, unable to ambulate or be up in a chair.|59
269|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|59
270|5 - Disruptive or socially inappropriate behavior|5 - Disruptive or socially inappropriate behavior|59
271|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|59
272|5 - Hypo/Hyperglycemia, diabetes out of control|5 - Hypo/Hyperglycemia, diabetes out of control|59
273|5 - More often than once daily|5 - More often than once daily|59
274|5 - Native Hawaiian or Pacific Islander|5 - Native Hawaiian or Pacific Islander|59
275|5 - None of the above|5 - None of the above|59
276|5 - One to two times per week|5 - One to two times per week|59
277|5 - Other|5 - Other|59
278|5 - Other follow-up|5 - Other follow-up|59
279|5 - Paid help|5 - Paid help|59
280|5 - Patient nonresponsive or unable to speak.|5 - Patient nonresponsive or unable to speak.|59
281|5 - Thoughts of suicide|5 - Thoughts of suicide|59
282|5 - Totally unable to use the telephone.|5 - Totally unable to use the telephone.|59
283|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|59
284|5 - Unable to take in nutrients orally or by tube feeding.|5 - Unable to take in nutrients orally or by tube feeding.|59
285|5 - Unsafe for care at home|5 - Unsafe for care at home|59
286|5 - With paid help (other than home care agency staff)|5 - With paid help (other than home care agency staff)|59
287|5 - Workers' compensation|5 - Workers' compensation|59
288|5 - Wound infection, deteriorating wound status, new lesion/ulcer|5 - Wound infection, deteriorating wound status, new lesion/ulcer|59
289|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|59
290|6 - Delusional, hallucinatory, or paranoid behavior|6 - Delusional, hallucinatory, or paranoid behavior|59
291|6 - Financial agent, power of attorney, or conservator of finance|6 - Financial agent, power of attorney, or conservator of finance|59
292|6 - GI bleeding, obstruction|6 - GI bleeding, obstruction|59
293|6 - Less often than weekly|6 - Less often than weekly|59
294|6 - Memory loss to the extent that supervision required|6 - Memory loss to the extent that supervision required|59
295|6 - None of the above feelings observed or reported|6 - None of the above feelings observed or reported|59
296|6 - Other|6 - Other|59
297|6 - Title programs (e.g., Title III, V, or XX)|6 - Title programs (e.g., Title III, V, or XX)|59
298|6 - Transferred to an inpatient facility - patient not discharged from agency|6 - Transferred to an inpatient facility - patient not discharged from agency|59
299|6 - White|6 - White|59
300|6 - With other than above|6 - With other than above|59
301|7 - Exacerbation of CHF, fluid overload, heart failure|7 - Exacerbation of CHF, fluid overload, heart failure|59
302|7 - Health care agent, conservator of person, or medical power of attorney|7 - Health care agent, conservator of person, or medical power of attorney|59
303|7 - Hypo/Hyperglycemia, diabetes out of control|7 - Hypo/Hyperglycemia, diabetes out of control|59
304|7 - None of the above|7 - None of the above|59
305|7 - None of the above behaviors demonstrated|7 - None of the above behaviors demonstrated|59
306|7 - Other government (e.g., TriCare, VA, etc.)|7 - Other government (e.g., TriCare, VA, etc.)|59
307|7 - Transferred to an inpatient facility - patient discharged from agency|7 - Transferred to an inpatient facility - patient discharged from agency|59
308|8 - Death at home|8 - Death at home|59
309|8 - GI bleeding, obstruction|8 - GI bleeding, obstruction|59
310|8 - Myocardial infarction, stroke|8 - Myocardial infarction, stroke|59
311|8 - Private insurance|8 - Private insurance|59
312|9 - Chemotherapy|9 - Chemotherapy|59
313|9 - Discharge from agency|9 - Discharge from agency|59
314|9 - Other than above reasons|9 - Other than above reasons|59
315|9 - Private HMO/managed care|9 - Private HMO/managed care|59
316|NA - No caregiver|NA - No caregiver|59
317|NA - No equipment of this type used in care.|NA - No equipment of this type used in care.|59
318|NA - No inhalant/mist medications prescribed.|NA - No inhalant/mist medications prescribed.|59
319|NA - No injectable medications prescribed.|NA - No injectable medications prescribed.|59
320|NA - No inpatient facility admission|NA - No inpatient facility admission|59
321|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|59
322|NA - No Medicaid|NA - No Medicaid|59
323|NA - No Medicare|NA - No Medicare|59
324|NA - No observable pressure ulcer|NA - No observable pressure ulcer|59
325|NA - No observable stasis ulcer|NA - No observable stasis ulcer|59
326|NA - No observable surgical wound|NA - No observable surgical wound|59
327|NA - No oral medications prescribed.|NA - No oral medications prescribed.|59
328|NA - Not applicable|NA - Not applicable|59
329|NA - Patient does not have a telephone.|NA - Patient does not have a telephone.|59
330|NA - Patient has ostomy for bowel elimination|NA - Patient has ostomy for bowel elimination|59
331|NA - Patient nonresponsive|NA - Patient nonresponsive|59
332|NA - Patient on prophylactic treatment|NA - Patient on prophylactic treatment|59
333|NA - Patient was not discharged from an inpatient facility [Go to M1017]|NA - Patient was not discharged from an inpatient facility [Go to M1017]|59
334|UK - Other unknown|UK - Other unknown|59
335|UK - Reason unknown|UK - Reason unknown|59
336|UK - Unknown|UK - Unknown|59
337|UK - Unknown or Not Available|UK - Unknown or Not Available|59
341|01 - Early|01 - Early|59
342|02 - Late|02 - Late|59
343|NA - Not Applicable. No case mix group defined for this assessment.|NA - Not Applicable. No case mix group defined for this assessment.|59
344|NA - No case mix group defined by this assessment.|NA - No case mix group defined by this assessment.|59
345|1 - Recent decline in mental, emotional, or behavioral status|1 - Recent decline in mental, emotional, or behavioral status|59
346|2 - Multiple hospitalizations (2 or more) in the past 12 months|2 - Multiple hospitalizations (2 or more) in the past 12 months|59
347|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|59
348|4 - Taking five or more medications|4 - Taking five or more medications|59
349|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|59
350|6 - Other|6 - Other|59
351|7 - None of the above|7 - None of the above|59
352|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond tho|59
353|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable without heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable wi|59
354|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious complications and death.|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious compl|59
355|3 - The patient has serious progressive conditions that could lead to death within a year.|3 - The patient has serious progressive conditions that could lead to death within a year.|59
356|UK - The patient+s situation is unknown or unclear.|UK - The patient+s situation is unknown or unclear.|59
357|0 - No [ Go to M1051 ]|0 - No [ Go to M1051 ]|59
358|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this influenza season. [ Go to M1050 ]|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this i|59
359|1 - Received from another health care provider (e.g., physician)|1 - Received from another health care provider (e.g., physician)|59
360|2 - Received from your agency previously during this year+s flu season|2 - Received from your agency previously during this year+s flu season|59
361|3 - Offered and declined|3 - Offered and declined|59
362|4 - Assessed and determined to have medical contraindication(s)|4 - Assessed and determined to have medical contraindication(s)|59
363|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|59
364|6 - Inability to obtain vaccine due to declared shortage|6 - Inability to obtain vaccine due to declared shortage|59
365|1 - Yes [ Go to M1500 at TRN; Go to M1230 at DC ]|1 - Yes [ Go to M1500 at TRN; Go to M1230 at DC ]|59
366|1 - Patient has received PPV in the past|1 - Patient has received PPV in the past|59
367|2 - Offered and declined|2 - Offered and declined|59
368|3 - Assessed and determined to have medical contraindication(s)|3 - Assessed and determined to have medical contraindication(s)|59
369|4 - Not indicated; patient does not meet age/condition guidelines for PPV|4 - Not indicated; patient does not meet age/condition guidelines for PPV|59
370|5 - None of the above|5 - None of the above|59
371|0 - Adequate: hears normal conversation without difficulty.|0 - Adequate: hears normal conversation without difficulty.|59
372|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to increase volume or speak distinctly.|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to in|59
373|2 - Severely Impaired: absence of useful hearing.|2 - Severely Impaired: absence of useful hearing.|59
374|UK - Unable to assess hearing.|UK - Unable to assess hearing.|59
375|0 - Understands: clear comprehension without cues or repetitions.|0 - Understands: clear comprehension without cues or repetitions.|59
376|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Requires cues at times to understand.|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Req|59
377|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequently requires cues to understand.|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequentl|59
378|3 - Rarely/Never Understands|3 - Rarely/Never Understands|59
379|UK - Unable to assess understanding.|UK - Unable to assess understanding.|59
380|0 - No standardized assessment conducted|0 - No standardized assessment conducted|59
381|1 - Yes, and it does not indicate severe pain|1 - Yes, and it does not indicate severe pain|59
382|2 - Yes, and it indicates severe pain|2 - Yes, and it indicates severe pain|59
383|0 - Patient has no pain|0 - Patient has no pain|59
384|1 - Patient has pain that does not interfere with activity or movement|1 - Patient has pain that does not interfere with activity or movement|59
385|2 - Less often than daily|2 - Less often than daily|59
386|3 - Daily, but not constantly|3 - Daily, but not constantly|59
387|4 - All of the time|4 - All of the time|59
388|0 - No assessment conducted [ Go to M1306 ]|0 - No assessment conducted [ Go to M1306 ]|59
389|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc., without use of standardized tool|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc.,|59
390|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|59
391|0 - No [ Go to M1322]|0 - No [ Go to M1322]|59
392|0 v Newly epithelialized|0 v Newly epithelialized|59
393|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|59
394|2 - Yes, patient has observable stasis ulcers ONLY|2 - Yes, patient has observable stasis ulcers ONLY|59
395|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable dressing) [Go to M1340]|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable|59
396|0 - No [ Go to M1400 ]|0 - No [ Go to M1400 ]|59
397|1 - Yes, patient has at least one (observable) surgical wound|1 - Yes, patient has at least one (observable) surgical wound|59
398|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1400 ]|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1400 ]|59
399|0 - Patient is not short of breath|0 - Patient is not short of breath|59
400|3 - Continuous Bi-level positive airway pressure|3 - Continuous Bi-level positive airway pressure|59
401|0 - No [ Go to M1732 at TRN; Go to M1600 at DC ]|0 - No [ Go to M1732 at TRN; Go to M1600 at DC ]|59
402|2 - Not assessed [Go to M1732 at TRN; Go to M1600 at DC ]|2 - Not assessed [Go to M1732 at TRN; Go to M1600 at DC ]|59
403|NA - Patient does not have diagnosis of heart failure [Go to M2004 at TRN; Go to M1600 at DC]|NA - Patient does not have diagnosis of heart failure [Go to M2004 at TRN; Go to M1600 at DC]|59
404|0 - No action taken|0 - No action taken|59
405|1 - Patient+s physician (or other primary care practitioner) contacted the same day|1 - Patient+s physician (or other primary care practitioner) contacted the same day|59
406|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|59
407|3 - Implement physician-ordered patient-specific established parameters for treatment|3 - Implement physician-ordered patient-specific established parameters for treatment|59
408|4 - Patient education or other clinical interventions|4 - Patient education or other clinical interventions|59
409|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequency, telehealth, etc.)|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequ|59
410|1 - Occasional stress incontinence|1 - Occasional stress incontinence|59
411|2 - During the night only|2 - During the night only|59
412|3 - During the day only|3 - During the day only|59
413|4 - During the day and night|4 - During the day and night|59
414|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|59
415|0 - Able to manage toileting hygiene and clothing management without assistance.|0 - Able to manage toileting hygiene and clothing management without assistance.|59
416|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implements are laid out for the patient.|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implemen|59
417|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|59
418|3 - Patient depends entirely upon another person to maintain toileting hygiene.|3 - Patient depends entirely upon another person to maintain toileting hygiene.|59
419|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independent|59
420|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface|59
421|0 - No multi-factor falls risk assessment conducted.|0 - No multi-factor falls risk assessment conducted.|59
422|1 - Yes, and it does not indicate a risk for falls.|1 - Yes, and it does not indicate a risk for falls.|59
423|2 - Yes, and it indicates a risk for falls.|2 - Yes, and it indicates a risk for falls.|59
424|0 - Not assessed/reviewed [ Go to M2010 ]|0 - Not assessed/reviewed [ Go to M2010 ]|59
425|1 - No problems found during review [ Go to M2010 ]|1 - No problems found during review [ Go to M2010 ]|59
426|2 - Problems found during review|2 - Problems found during review|59
427|NA - Patient is not taking any medications [ Go to M2040 ]|NA - Patient is not taking any medications [ Go to M2040 ]|59
428|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special precautions associated with all high-risk medications|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special p|59
429|NA - Patient not taking any drugs|NA - Patient not taking any drugs|59
430|2 - Able to take medication(s) at the correct times if given reminders by another person at the appropriate times|2 - Able to take medication(s) at the correct times if given reminders by another person at the appr|59
431|3 - Unable to take medication unless administered by another person.|3 - Unable to take medication unless administered by another person.|59
432|1 - At least daily|1 - At least daily|59
433|2 - Three or more times per week|2 - Three or more times per week|59
434|3 - One to two times per week|3 - One to two times per week|59
435|4 - Received, but less often than weekly|4 - Received, but less often than weekly|59
436|5 - No assistance received|5 - No assistance received|59
437|0 - No [Go to M2400]|0 - No [Go to M2400]|59
438|1 - Yes, used hospital emergency department WITHOUT hospital admission|1 - Yes, used hospital emergency department WITHOUT hospital admission|59
439|2 - Yes, used hospital emergency department WITH hospital admission|2 - Yes, used hospital emergency department WITH hospital admission|59
440|UK - Unknown [Go to M2400]|UK - Unknown [Go to M2400]|59
441|2 - Injury caused by fall|2 - Injury caused by fall|59
442|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|59
443|4 - Other respiratory problem|4 - Other respiratory problem|59
444|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|59
445|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|59
446|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|59
447|8 - Other heart disease|8 - Other heart disease|59
448|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|59
449|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|59
450|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|59
451|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|59
452|13 - Urinary tract infection|13 - Urinary tract infection|59
453|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|59
454|15 - Wound infection or deterioration|15 - Wound infection or deterioration|59
455|16 - Uncontrolled pain|16 - Uncontrolled pain|59
456|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|59
457|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|59
458|19 - Other than above reasons|19 - Other than above reasons|59
459|2 - Patient remained in the community (with formal assistive services)|2 - Patient remained in the community (with formal assistive services)|59
460|3 - Patient transferred to a noninstitutional hospice|3 - Patient transferred to a noninstitutional hospice|59
461|4 - Unknown because patient moved to a geographic location not served by this agency|4 - Unknown because patient moved to a geographic location not served by this agency|59
462|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|59
463|4 - Other respiratory problem|4 - Other respiratory problem|59
464|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|59
465|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|59
466|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|59
467|8 - Other heart disease|8 - Other heart disease|59
468|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|59
469|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|59
470|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|59
471|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|59
472|13 - Urinary tract infection|13 - Urinary tract infection|59
473|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|59
474|15 - Wound infection or deterioration|15 - Wound infection or deterioration|59
475|16 - Uncontrolled pain|16 - Uncontrolled pain|59
476|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|59
477|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|59
478|19 - Scheduled treatment or procedure|19 - Scheduled treatment or procedure|59
479|20 - Other than above reasons|20 - Other than above reasons|59
480|UK - Reason unknown [Go to M0903]|UK - Reason unknown [Go to M0903]|59
482|01 - Patient lives alone around the clock|01 - Patient lives alone around the clock|59
483|02 - Patient lives alone regular daytime|02 - Patient lives alone regular daytime|59
484|03 - Patient lives alone regular nighttime|03 - Patient lives alone regular nighttime|59
485|04 - Patient lives alone occassional/short term assistance|04 - Patient lives alone occassional/short term assistance|59
486|05 - Patient lives alone no assisstance available|05 - Patient lives alone no assisstance available|59
487|06 - Patient lives with other person(s) in the home around the clock|06 - Patient lives with other person(s) in the home around the clock|59
488|07 - Patient lives with other person(s) in the home regular daytime|07 - Patient lives with other person(s) in the home regular daytime|59
489|08 - Patient lives with other person(s) in the home regular nighttime|08 - Patient lives with other person(s) in the home regular nighttime|59
490|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|59
491|10 - Patient lives with other person(s) in the home no assistance available|10 - Patient lives with other person(s) in the home no assistance available|59
492|1 - Was present at the most recent SOC/ROC assessment [Goto M1308A1]|1 - Was present at the most recent SOC/ROC assessment [Goto M1308A1]|59
493|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|59
494|NA - No non-epithelialized Stage II pressure ulcers are present at discharge [Goto M1308A1]|NA - No non-epithelialized Stage II pressure ulcers are present at discharge [Goto M1308A1]|59
495|0 - Newly epithelialized|0 - Newly epithelialized|59
496|0 - No [ Go to M1340 ]|0 - No [ Go to M1340 ]|59
498|0 - Independent|0 - Independent|59
499|1 - Needed Some Help|1 - Needed Some Help|59
500|2 - Dependent|2 - Dependent|59
502|0 - No assistance needed in this area|0 - No assistance needed in this area|59
503|1 - Caregiver(s) currently provide assistance|1 - Caregiver(s) currently provide assistance|59
504|2 - Caregiver(s) need training/ supportive services to provide assistance|2 - Caregiver(s) need training/ supportive services to provide assistance|59
505|3 - Caregiver(s) not likely to provide assistance|3 - Caregiver(s) not likely to provide assistance|59
506|4 - Unclear if Caregiver(s) will provide assistance|4 - Unclear if Caregiver(s) will provide assistance|59
507|5 - Assistance needed, but no Caregiver(s) available|5 - Assistance needed, but no Caregiver(s) available|59
508|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will use standardized clinical guidelines accessible for all care providers to reference|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will|59
510|NA - Patient is not assessed to be at risk for falls|NA - Patient is not assessed to be at risk for falls|59
511|NA - Patient has no diagnosis or symptoms of depression|NA - Patient has no diagnosis or symptoms of depression|59
512|NA - No pain identified|NA - No pain identified|59
513|NA - Patient is not assessed to be at risk for pressure ulcers|NA - Patient is not assessed to be at risk for pressure ulcers|59
514|NA - Patient has no pressure ulcers with need for moist wound healing|NA - Patient has no pressure ulcers with need for moist wound healing|59
515|1 - Long-term nursing facility (NF)|1 - Long-term nursing facility (NF)|59
516|2 - Skilled nursing facility (SNF / TCU)|2 - Skilled nursing facility (SNF / TCU)|59
517|3 - Short stay acute hospital (IPP S)|3 - Short stay acute hospital (IPP S)|59
518|4 - Long-term care hospital (LTCH)|4 - Long-term care hospital (LTCH)|59
519|5 - Inpatient rehabilitation hospital or unit (IRF)|5 - Inpatient rehabilitation hospital or unit (IRF)|59
520|6 - Psychiatric hospital or unit|6 - Psychiatric hospital or unit|59
521|7 - Other|7 - Other|59
522|NA - Patient was not discharged from an inpatient facility [Go to M1017]|NA - Patient was not discharged from an inpatient facility [Go to M1017]|59
523|6 - Unable to participate effectively in bathing and is bathed totally by another person|6 - Unable to participate effectively in bathing and is bathed totally by another person|59
524|4 - Chairfast, unable to ambulate but is able to wheel self independently.|4 - Chairfast, unable to ambulate but is able to wheel self independently.|59
525|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask patient: "Over the last two weeks, how often have you been bothered by any of the following problems")  *Copyright+ Pfizer Inc. All rights reserved. Reproduced with permission.|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask|59
526|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluation for depression.|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluat|59
527|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet criteria for further evaluation for depression.|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet|59
528|0 - Not at all  0 - 1 day|0 - Not at all  0 - 1 day|59
529|1 - Several days  2 - 6 days|1 - Several days  2 - 6 days|59
530|2 - More than half of the days  7 - 11 days|2 - More than half of the days  7 - 11 days|59
531|3 - Nearly every day  12 - 14 days|3 - Nearly every day  12 - 14 days|59
532|NA - N/A  Unable to respond|NA - N/A  Unable to respond|59
533|2 - Able to take medication(s) at the correct times if given reminders by another person based on the frequency of the injection|2 - Able to take medication(s) at the correct times if given reminders by another person based on th|59
534|3 - Unable to take injectable medication unless administered by another person.|3 - Unable to take injectable medication unless administered by another person.|59
570|NA - No observable pressure ulcer or unhealed pressure ulcer|NA - No observable pressure ulcer or unhealed pressure ulcer|59
571|NA - No clinically significant medication issues identified since the previous OASIS assessment|NA - No clinically significant medication issues identified since the previous OASIS assessment|59
572|NA - Patient is not diabetic or is bilateral amputee|NA - Patient is not diabetic or is bilateral amputee|59
573|NA - Formal multi-factor Fall Risk Assessment indicates the patient was not at risk for falls since the last OASIS assessment|NA - Formal multi-factor Fall Risk Assessment indicates the patient was not at risk for falls since|59
574|NA - Formal assessment indicates patient did not meet criteria for depression AND patient did not have diagnosis of depression since the last OASIS assessment|NA - Formal assessment indicates patient did not meet criteria for depression AND patient did not ha|59
575|NA - Formal assessment did not indicate pain since the last OASIS assessment|NA - Formal assessment did not indicate pain since the last OASIS assessment|59
576|NA - Formal assessment indicates the patient was not at risk of pressure ulcers since the last OASIS assessment|NA - Formal assessment indicates the patient was not at risk of pressure ulcers since the last OASIS|59
577|NA - Dressings that support the principles of moist wound healing not indicated for this patient's pressure ulcers OR patient has no pressure ulcers with need for moist wound healing|NA - Dressings that support the principles of moist wound healing not indicated for this patient's p|59
578|1 - Patient remained in the community (without formal assistive services)|1 - Patient remained in the community (without formal assistive services)|59
579|2 - Patient remained in the community (with formal assistive services)|2 - Patient remained in the community (with formal assistive services)|59
580|3 - Patient transferred to a non-institutional hospice|3 - Patient transferred to a non-institutional hospice|59
581|4 - Unknown because patient moved to a geographic location not served by this agency|4 - Unknown because patient moved to a geographic location not served by this agency|59
620|1 - Yes; received from your agency during this episode of care (SOC/ROC to Transfer/Discharge)|1 - Yes; received from your agency during this episode of care (SOC/ROC to Transfer/Discharge)|59
621|2 - Yes; received from your agency during a prior episode of care (SOC/ROC to Transfer/Discharge)|2 - Yes; received from your agency during a prior episode of care (SOC/ROC to Transfer/Discharge)|59
622|3 - Yes; received from another health care provider (for example physician pharmacist)|3 - Yes; received from another health care provider (for example physician pharmacist)|59
623|4 - No; patient offered and declined |4 - No; patient offered and declined |59
624|5 - No; patient assessed and determined to have medical contraindication(s)|5 - No; patient assessed and determined to have medical contraindication(s)|59
625|6 - No; not indicated - patient does not meet age/condition guidelines for influenza vaccine|6 - No; not indicated - patient does not meet age/condition guidelines for influenza vaccine|59
626|7 - No; inability to obtain vaccine due to declared shortage |7 - No; inability to obtain vaccine due to declared shortage |59
627|8 - No; patient did not receive the vaccine due to reasons other than those listed in responses 4 v 7. |8 - No; patient did not receive the vaccine due to reasons other than those listed in responses 4v7.|59
628|1 - Offered and declined|1 - Offered and declined|59
629|2 - Assessed and determined to have medical contraindication(s) |2 - Assessed and determined to have medical contraindication(s) |59
630|3 - Not indicated; patient does not meet age/condition guidelines for Pneumococcal Vaccine|3 - Not indicated; patient does not meet age/condition guidelines for Pneumococcal Vaccine|59
631|4 - None of the above|4 - None of the above|59
632|0 - No assistance needed v patient is independent or does not have needs in this area|0 - No assistance needed v patient is independent or does not have needs in this area|59
633|1 - Non-agency caregiver(s) currently provide assistance |1 - Non-agency caregiver(s) currently provide assistance |59
634|2 - Non-agency caregiver(s) need training/ supportive services to provide assistance|2 - Non-agency caregiver(s) need training/ supportive services to provide assistance|59
635|3 - Non-agency caregiver(s) are not likely to provide assistance OR it is unclear if they will provide assistance|3 - Non-agency caregiver(s) are not likely to provide assistance OR unclear if will provide asst|59
636|4 - Assistance needed but no non-agency caregiver(s) available|4 - Assistance needed but no non-agency caregiver(s) available|59
2|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; OR (b) Is physically, cognitively, and mentally able to prepare light meals on a regular basis but has not routinely performed light meal preparation in the past (i.e., prior to this home care admission).|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; O|61
3|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and mentally able to perform all housekeeping tasks .|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and menta|61
4|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and mentally able to do laundry and access facilities.|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and menta|61
5|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying packages OR b) Physically, cognitively, and mentally able to take care of shopping, but has not done shopping in the past (i.e., prior to this home care admission).|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying|61
6|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|61
7|0 - Able to dial numbers and answer calls appropriately and as desired.|0 - Able to dial numbers and answer calls appropriately and as desired.|61
8|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body without assistance.|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body|61
9|0 - Able to get to and from the toilet and transfer independently with or without a device.|0 - Able to get to and from the toilet and transfer independently with or without a device.|61
10|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|61
11|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible public bus.|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible p|61
12|0 - Able to independently feed self.|0 - Able to independently feed self.|61
13|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|61
14|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct times.|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct ti|61
15|0 - Able to independently transfer.|0 - Able to independently transfer.|61
16|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without rail|61
17|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings|61
18|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|61
19|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions independently.|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions indep|61
20|0 - Asymptomatic, no treatment needed at this time|0 - Asymptomatic, no treatment needed at this time|61
21|0 - Caregiver manages all tasks related to equipment completely independently.|0 - Caregiver manages all tasks related to equipment completely independently.|61
503|1 - Caregiver(s) currently provide assistance|1 - Caregiver(s) currently provide assistance|61
504|2 - Caregiver(s) need training/ supportive services to provide assistance|2 - Caregiver(s) need training/ supportive services to provide assistance|61
505|3 - Caregiver(s) not likely to provide assistance|3 - Caregiver(s) not likely to provide assistance|61
506|4 - Unclear if Caregiver(s) will provide assistance|4 - Unclear if Caregiver(s) will provide assistance|61
507|5 - Assistance needed, but no Caregiver(s) available|5 - Assistance needed, but no Caregiver(s) available|61
508|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will use standardized clinical guidelines accessible for all care providers to reference|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will|61
509|NA - Patient is not diabetic or is bilateral amputee|NA - Patient is not diabetic or is bilateral amputee|61
510|NA - Patient is not assessed to be at risk for falls|NA - Patient is not assessed to be at risk for falls|61
511|NA - Patient has no diagnosis or symptoms of depression|NA - Patient has no diagnosis or symptoms of depression|61
512|NA - No pain identified|NA - No pain identified|61
513|NA - Patient is not assessed to be at risk for pressure ulcers|NA - Patient is not assessed to be at risk for pressure ulcers|61
514|NA - Patient has no pressure ulcers with need for moist wound healing|NA - Patient has no pressure ulcers with need for moist wound healing|61
515|1 - Long-term nursing facility (NF)|1 - Long-term nursing facility (NF)|61
516|2 - Skilled nursing facility (SNF / TCU)|2 - Skilled nursing facility (SNF / TCU)|61
517|3 - Short stay acute hospital (IPP S)|3 - Short stay acute hospital (IPP S)|61
518|4 - Long-term care hospital (LTCH)|4 - Long-term care hospital (LTCH)|61
519|5 - Inpatient rehabilitation hospital or unit (IRF)|5 - Inpatient rehabilitation hospital or unit (IRF)|61
520|6 - Psychiatric hospital or unit|6 - Psychiatric hospital or unit|61
521|7 - Other|7 - Other|61
522|NA - Patient was not discharged from an inpatient facility [Go to M1017]|NA - Patient was not discharged from an inpatient facility [Go to M1017]|61
523|6 - Unable to participate effectively in bathing and is bathed totally by another person|6 - Unable to participate effectively in bathing and is bathed totally by another person|61
524|4 - Chairfast, unable to ambulate but is able to wheel self independently.|4 - Chairfast, unable to ambulate but is able to wheel self independently.|61
525|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask patient: "Over the last two weeks, how often have you been bothered by any of the following problems")  *Copyright+ Pfizer Inc. All rights reserved. Reproduced with permission.|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask|61
526|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluation for depression.|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluat|61
527|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet criteria for further evaluation for depression.|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet|61
528|0 - Not at all  0 - 1 day|0 - Not at all  0 - 1 day|61
529|1 - Several days  2 - 6 days|1 - Several days  2 - 6 days|61
530|2 - More than half of the days  7 - 11 days|2 - More than half of the days  7 - 11 days|61
531|3 - Nearly every day  12 - 14 days|3 - Nearly every day  12 - 14 days|61
532|NA - N/A  Unable to respond|NA - N/A  Unable to respond|61
533|2 - Able to take medication(s) at the correct times if given reminders by another person based on the frequency of the injection|2 - Able to take medication(s) at the correct times if given reminders by another person based on th|61
534|3 - Unable to take injectable medication unless administered by another person.|3 - Unable to take injectable medication unless administered by another person.|61
535|11 - Patient lives in congregate situation (e.g., assisted living) around the clock|11 - Patient lives in congregate situation (e.g., assisted living) around the clock|61
536|12 - Patient lives in congregate situation (e.g., assisted living) regular daytime|12 - Patient lives in congregate situation (e.g., assisted living) regular daytime|61
537|13 - Patient lives in congregate situation (e.g., assisted living) regular nighttime|13 - Patient lives in congregate situation (e.g., assisted living) regular nighttime|61
538|14 - Patient lives in congregate situation (e.g., assisted living) occasional / short-term assistance|14 - Patient lives in congregate situation (e.g., assisted living) occasional / short-term assistanc|61
539|15 - Patient lives in congregate situation (e.g., assisted living) no assistance available|15 - Patient lives in congregate situation (e.g., assisted living) no assistance available|61
545|NA - No observable pressure ulcer or unhealed pressure ulcer|NA - No observable pressure ulcer or unhealed pressure ulcer|61
582|NA - No specific SOC date ordered by physician|NA - No specific SOC date ordered by physician|61
585|UK - Inpatient Discharge Date Unknown|UK - Inpatient Discharge Date Unknown|61
600|1 - History of falls (2 or more falls - or any fall with an injury - in the past 12 months) |1 - History of falls (2 or more falls - or any fall with an injury - in the past 12 months) |61
602|2 - Unintentional weight loss of a total of 10 pounds or more in the past 12 months |2 - Unintentional weight loss of a total of 10 pounds or more in the past 12 months |61
604|3 - Multiple hospitalizations (2 or more) in the past 6 months|3 - Multiple hospitalizations (2 or more) in the past 6 months|61
606|4 - Multiple emergency department visits (2 or more) in the past 6 months|4 - Multiple emergency department visits (2 or more) in the past 6 months|61
608|5 - Decline in mental emotional or behavioral status in the past 3 months |5 - Decline in mental emotional or behavioral status in the past 3 months |61
610|6 - Reported or observed history of difficulty complying with any medical instructions (for example |6 - Reported or observed history of difficulty complying with any medical instructions (for example |61
612|7 - Currently taking 5 or more medications|7 - Currently taking 5 or more medications|61
614|8 - Currently reports exhaustion|8 - Currently reports exhaustion|61
616|9 - Other risk(s) not listed in 1 - 8|9 - Other risk(s) not listed in 1 - 8|61
618|10 - None of the above |10 - None of the above |61
632|0 - No assistance needed v patient is independent or does not have needs in this area|0 - No assistance needed v patient is independent or does not have needs in this area|61
633|1 - Non-agency caregiver(s) currently provide assistance |1 - Non-agency caregiver(s) currently provide assistance |61
634|2 - Non-agency caregiver(s) need training/ supportive services to provide assistance|2 - Non-agency caregiver(s) need training/ supportive services to provide assistance|61
22|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations with no observable impairment.|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations w|61
23|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|61
24|0 - Life expectancy is greater than 6 months|0 - Life expectancy is greater than 6 months|61
25|0 - Never|0 - Never|61
26|0 - Patient is not short of breath|0 - Patient is not short of breath|61
27|0 - No|0 - No|61
28|0 - No emergent care services|0 - No emergent care services|61
29|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [ Go to M1620 ]|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [ Go to M1620 ]|61
30|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and extended or abstract conversation.|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and exte|61
31|0 - No one person|0 - No one person|61
32|0 - None of the time|0 - None of the time|61
33|0 - None, no charge for current services|0 - None, no charge for current services|61
34|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|61
35|0 - Patient does NOT have an ostomy for bowel elimination.|0 - Patient does NOT have an ostomy for bowel elimination.|61
36|0 - Patient has no pain|0 - Patient has no pain|61
37|0 - Patient manages all tasks related to equipment completely independently.|0 - Patient manages all tasks related to equipment completely independently.|61
38|0 - Poor:  little or no recovery is expected and/or further decline is imminent|0 - Poor:  little or no recovery is expected and/or further decline is imminent|61
39|0 - Timed-voiding defers incontinence|0 - Timed-voiding defers incontinence|61
40|0 - Very rarely or never has bowel incontinence|0 - Very rarely or never has bowel incontinence|61
41|0 - Zero|0 - Zero|61
42|00 - No|00 - No|61
43|01 - Yes|01 - Yes|61
44|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or mental limitations, needs assistance with heavy laundry.|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or|61
45|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the patient.|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the|61
46|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|61
47|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or supervision from another person OR c) a liquid, pureed or ground meat diet.|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or su|61
48|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|61
49|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|61
50|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independently.|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independe|61
51|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only when assisted or accompanied by another person.|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only w|61
52|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepa|61
53|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance by another person OR b) given daily reminders.|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance b|61
54|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advan|61
55|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advan|61
56|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for the deaf) and call essential numbers.|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for t|61
57|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|61
58|1 - American Indian or Alaska Native|1 - American Indian or Alaska Native|61
59|1 - Depressed mood (e.g., feeling sad, tearful)|1 - Depressed mood (e.g., feeling sad, tearful)|61
60|1 - During the night only|1 - During the night only|61
61|1 - Fully granulating|1 - Fully granulating|61
62|1 - Good/Fair:  partial to full recovery is expected|1 - Good/Fair:  partial to full recovery is expected|61
63|1 - Good:  marked improvement in functional status is expected|1 - Good:  marked improvement in functional status is expected|61
64|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|61
65|1 - Smoking|1 - Smoking|61
66|1 - Hospital|1 - Hospital|61
67|1 - Hospital emergency room (includes 23-hour holding)|1 - Hospital emergency room (includes 23-hour holding)|61
68|1 - Hospitalization for EMERGENT (unscheduled) care|1 - Hospitalization for EMERGENT (unscheduled) care|61
69|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepared solutions), patient is able to manage all other aspects of equipment.|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepar|61
70|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|61
71|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|61
72|1 - In new or complex situations only|1 - In new or complex situations only|61
73|1 - Intravenous or infusion therapy (excludes TPN)|1 - Intravenous or infusion therapy (excludes TPN)|61
74|1 - Less often than daily|1 - Less often than daily|61
75|1 - Less than once a month|1 - Less than once a month|61
76|1 - Less than once weekly|1 - Less than once weekly|61
77|1 - Life expectancy is 6 months or fewer|1 - Life expectancy is 6 months or fewer|61
78|1 - Lives alone|1 - Lives alone|61
79|1 - Male|1 - Male|61
80|1 - Medicare (traditional fee-for-service)|1 - Medicare (traditional fee-for-service)|61
81|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of past 24 hours, significant memory loss so that supervision is required|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of pas|61
82|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors in word choice, grammar or speech intelligibility, needs minimal prompting or assistance).|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors i|61
83|1 - No assistance or services received|1 - No assistance or services received|61
84|1 - One|1 - One|61
85|1 - Oxygen (intermittent or continuous)|1 - Oxygen (intermittent or continuous)|61
86|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, and the surrounding layout, can count fingers at arm's length.|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, a|61
87|1 - Patient is incontinent|1 - Patient is incontinent|61
88|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|61
89|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical or treatment regimen.|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical|61
90|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient/couple/significant other)|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient|61
91|1 - Relatives, friends, or neighbors living outside the home|1 - Relatives, friends, or neighbors living outside the home|61
92|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions.|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions|61
93|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independentl|61
94|1 - Several times during day and night|1 - Several times during day and night|61
95|1 - Spouse or significant other|1 - Spouse or significant other|61
96|1 - Stage 1|1 - Stage 1|61
97|1 - Start of care - further visits planned|1 - Start of care - further visits planned|61
98|1 - Symptoms well controlled with current therapy|1 - Symptoms well controlled with current therapy|61
99|1 - Therapy services|1 - Therapy services|61
100|1 - Able to transfer with minimal human assistance or with use of an assistive device.|1 - Able to transfer with minimal human assistance or with use of an assistive device.|61
101|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitations.|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitatio|61
102|1 - Urinary incontinence|1 - Urinary incontinence|61
103|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and transfer.|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and|61
104|1 - When walking more than 20 feet, climbing stairs|1 - When walking more than 20 feet, climbing stairs|61
105|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary conversation. May need occasional repetition, extra time, or louder voice.|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary c|61
106|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting in and out of tub/shower|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting|61
107|1 - Yes|1 - Yes|61
108|1-RN|1-RN|61
109|10 - Discharge from agency - no visits completed after start/resumption of care assessment|10 - Discharge from agency - no visits completed after start/resumption of care assessment|61
110|10 - Scheduled surgical procedure|10 - Scheduled surgical procedure|61
111|10 - Self-pay|10 - Self-pay|61
112|11 - Other|11 - Other|61
113|11 - Urinary tract infection|11 - Urinary tract infection|61
114|12 - IV catheter-related infection|12 - IV catheter-related infection|61
115|13 - Deep vein thrombosis, pulmonary embolus|13 - Deep vein thrombosis, pulmonary embolus|61
116|14 - Uncontrolled pain|14 - Uncontrolled pain|61
117|15 - Psychotic episode|15 - Psychotic episode|61
118|16 - Other than above reasons|16 - Other than above reasons|61
119|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing calls.|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing|61
120|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another person.|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another pers|61
121|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface a|61
122|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for intermittent supervision or encouragement or reminders, OR (b) to get in and out of the shower or tub, OR (c) for washing difficult to reach areas.|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for inter|61
123|2 - Asian|2 - Asian|61
124|2 - Caregiver requires considerable assistance from another person to manage equipment, but independently completes significant portions of task.|2 - Caregiver requires considerable assistance from another person to manage equipment, but independ|61
125|2 - Daily, but not constantly|2 - Daily, but not constantly|61
126|2 - Daughter or son|2 - Daughter or son|61
127|2 - Doctor's office emergency visit/house call|2 - Doctor's office emergency visit/house call|61
128|2 - During the day and night|2 - During the day and night|61
129|2 - Early/partial granulation|2 - Early/partial granulation|61
130|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors in word choice, organization or speech intelligibility). Speaks in phrases or short sentences.|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors|61
131|2 - Family member's residence|2 - Family member's residence|61
132|2 - Female|2 - Female|61
133|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conversation, needs frequent prompting or assistance.|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conver|61
134|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|61
135|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|61
136|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately stop activities, jeopardizes safety through actions|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately st|61
137|2 - Indwelling/suprapubic catheter|2 - Indwelling/suprapubic catheter|61
138|2 - Injury caused by fall or accident at home|2 - Injury caused by fall or accident at home|61
139|2 - Medicare (HMO/managed care/Advantage plan)|2 - Medicare (HMO/managed care/Advantage plan)|61
140|2 - Nausea, dehydration, malnutrition, constipation, impaction|2 - Nausea, dehydration, malnutrition, constipation, impaction|61
141|2 - Obesity|2 - Obesity|61
142|2 - On awakening or at night only|2 - On awakening or at night only|61
143|2 - Once a month|2 - Once a month|61
144|2 - One to three times weekly|2 - One to three times weekly|61
145|2 - Parenteral nutrition (TPN or lipids)|2 - Parenteral nutrition (TPN or lipids)|61
146|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic)  [ Go to M1620 ]|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic)  [ Go|61
147|2 - Patient requires considerable assistance from another person to manage equipment, but independently completes portions of the task.|2 - Patient requires considerable assistance from another person to manage equipment, but independen|61
148|2 - Patient transferred to a noninstitutional hospice|2 - Patient transferred to a noninstitutional hospice|61
149|2 - Person residing in the home (EXCLUDING paid help)|2 - Person residing in the home (EXCLUDING paid help)|61
150|2 - Rehabilitation facility|2 - Rehabilitation facility|61
151|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifting of attention) or consistently requires low stimulus environment due to distractibility.|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifti|61
152|2 - Respite care|2 - Respite care|61
153|2 - Sense of failure or self reproach|2 - Sense of failure or self reproach|61
154|2 - Several times during day|2 - Several times during day|61
155|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonresponsive.|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonrespons|61
156|2 - Someone must assist the patient to groom self.|2 - Someone must assist the patient to groom self.|61
157|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|61
158|2 - Someone must help the patient put on upper body clothing.|2 - Someone must help the patient put on upper body clothing.|61
159|2 - Stage 2|2 - Stage 2|61
160|2 - Start of care - no further visits planned|2 - Start of care - no further visits planned|61
161|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitoring|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitori|61
162|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment regimen.|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment re|61
163|2 - Two|2 - Two|61
164|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistance due to cognitive or mental limitation.|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistanc|61
165|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|61
166|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assistance).|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assis|61
167|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home delivery.|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home deli|61
168|2 - Unable to prepare any light meals or reheat any delivered meals.|2 - Unable to prepare any light meals or reheat any delivered meals.|61
169|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|61
170|2 - UNABLE to take injectable medications unless administered by someone else.|2 - UNABLE to take injectable medications unless administered by someone else.|61
171|2 - UNABLE to take medication unless administered by someone else.|2 - UNABLE to take medication unless administered by someone else.|61
172|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|61
173|2 - Ventilator (continually or at night)|2 - Ventilator (continually or at night)|61
174|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less than 20 feet)|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less th|61
175|2 - With spouse or significant other|2 - With spouse or significant other|61
176|2 - Yes, assistance or services provided by family or friends|2 - Yes, assistance or services provided by family or friends|61
177|2-PT|2-PT|61
178|3 - Able to answer the telephone only some of the time or is able to carry on only a limited conversation.|3 - Able to answer the telephone only some of the time or is able to carry on only a limited convers|61
179|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube or gastrostomy.|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube|61
180|3 - Alcohol dependency|3 - Alcohol dependency|61
181|3 - All of the time|3 - All of the time|61
182|3 - Black or African-American|3 - Black or African-American|61
183|3 - Boarding home or rented room|3 - Boarding home or rented room|61
184|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment, clean/store/dispose of equipment or supplies).|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment,|61
185|3 -Able to walk only with the supervision or assistance of another person at all times.|3 -Able to walk only with the supervision or assistance of another person at all times.|61
186|3 - Continuous / Bi-level positive airway pressure|3 - Continuous / Bi-level positive airway pressure|61
187|3 - During the day and evening, but not constantly|3 - During the day and evening, but not constantly|61
188|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the alimentary canal)|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the|61
189|3 - Environmental support (e.g., housing, home maintenance)|3 - Environmental support (e.g., housing, home maintenance)|61
190|3 - Four to six times weekly|3 - Four to six times weekly|61
191|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessing by listener.  Speech limited to single words or short phrases.|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessin|61
192|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires multiple repetitions, restatements, demonstrations, additional time.|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires m|61
193|3 - Hopelessness|3 - Hopelessness|61
194|3 - Hospice care|3 - Hospice care|61
195|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|61
196|3 - Injury caused by fall or accident at home|3 - Injury caused by fall or accident at home|61
197|3 - Intractable pain|3 - Intractable pain|61
198|3 - Medicaid (traditional fee-for-service)|3 - Medicaid (traditional fee-for-service)|61
199|3 - Needs someone to do all shopping and errands.|3 - Needs someone to do all shopping and errands.|61
200|3 - Not healing|3 - Not healing|61
201|3 - Nursing home|3 - Nursing home|61
202|3 - Once daily|3 - Once daily|61
203|3 - Other family member|3 - Other family member|61
204|3 - Outpatient department/clinic emergency (includes urgicenter sites)|3 - Outpatient department/clinic emergency (includes urgicenter sites)|61
205|3 - Paid help|3 - Paid help|61
206|3 - Able to participate in bathing self in shower or tub, but requires presence of another person throughout the bath for assistance or supervision.|3 - Able to participate in bathing self in shower or tub, but requires presence of another person th|61
207|3 - Patient depends entirely upon another person to dress lower body.|3 - Patient depends entirely upon another person to dress lower body.|61
208|3 - Patient depends entirely upon another person to dress the upper body.|3 - Patient depends entirely upon another person to dress the upper body.|61
209|3 - Patient depends entirely upon someone else for grooming needs.|3 - Patient depends entirely upon someone else for grooming needs.|61
210|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone else to manage the equipment.|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone|61
211|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable to shift attention and recall directions more than half the time.|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable|61
212|3 - Respiratory problems (SOB, infection, obstruction)|3 - Respiratory problems (SOB, infection, obstruction)|61
213|3 - Resumption of care (after inpatient stay)|3 - Resumption of care (after inpatient stay)|61
214|3 - Several times each month|3 - Several times each month|61
215|3 - Skilled Nursing Facility|3 - Skilled Nursing Facility|61
216|3 - Stage 3|3 - Stage 3|61
217|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|61
218|3 - Three|3 - Three|61
219|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person throughout the process.|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person through|61
220|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal independently.|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal indep|61
221|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person.|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person|61
222|3 - Unknown because patient moved to a geographic location not served by this agency|3 - Unknown because patient moved to a geographic location not served by this agency|61
223|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|61
224|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|61
225|3 - With other family member|3 - With other family member|61
226|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home health services, homemaker assistance, transportation assistance, assisted living, board and care)|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home h|61
227|3-SLP/ST|3-SLP/ST|61
228|4 - At rest (during day or night)|4 - At rest (during day or night)|61
229|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|61
230|4 - Board and care or assisted living facility|4 - Board and care or assisted living facility|61
231|4 - Caregiver is completely dependent on someone else to manage all equipment.|4 - Caregiver is completely dependent on someone else to manage all equipment.|61
232|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|61
233|4 - Constantly|4 - Constantly|61
234|4 - Drug dependency|4 - Drug dependency|61
235|4 - Four or more|4 - Four or more|61
236|4 - Friend or neighbor or community or church member|4 - Friend or neighbor or community or church member|61
237|4 - Hispanic or Latino|4 - Hispanic or Latino|61
238|4 - Hospice|4 - Hospice|61
239|4 - Impaired decision-making|4 - Impaired decision-making|61
240|4 - Is totally dependent in toileting.|4 - Is totally dependent in toileting.|61
241|4 - Medicaid (HMO/managed care)|4 - Medicaid (HMO/managed care)|61
242|4 - None of the above|4 - None of the above|61
243|4 - Nursing home|4 - Nursing home|61
244|4 - On a daily basis|4 - On a daily basis|61
245|4 - Patient is completely dependent on someone else to manage all equipment.|4 - Patient is completely dependent on someone else to manage all equipment.|61
246|4 - Permanent placement|4 - Permanent placement|61
247|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, punches, dangerous maneuvers w/ wheelchair or other objects)|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, pu|61
248|4 - Psychosocial support (e.g., socialization, companionship, recreation)|4 - Psychosocial support (e.g., socialization, companionship, recreation)|61
249|4 - Recertification (follow-up) reassessment|4 - Recertification (follow-up) reassessment|61
250|4 - Recurrent thoughts of death|4 - Recurrent thoughts of death|61
251|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruction)|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruc|61
252|4 - Several times a week|4 - Several times a week|61
253|4 - Stage 4|4 - Stage 4|61
254|4 - Symptoms poorly controlled, history of re-hospitalizations|4 - Symptoms poorly controlled, history of re-hospitalizations|61
255|4 - Three or more times per week|4 - Three or more times per week|61
256|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetative state, or delirium.|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetati|61
257|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|61
258|4 - Unable to effectively participate in any housekeeping tasks.|4 - Unable to effectively participate in any housekeeping tasks.|61
259|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or unresponsive (e.g., speech is nonsensical or unintelligible).|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or u|61
260|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonresponsive.|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonr|61
261|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostomy.|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostom|61
262|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of devices at the sink, in chair, or on commode|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of|61
263|4 - With a friend|4 - With a friend|61
264|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|61
265|4-OT|4-OT|61
266|5 - Advocates or facilitates patient's participation in appropriate medical care|5 - Advocates or facilitates patient's participation in appropriate medical care|61
267|5 - At least daily|5 - At least daily|61
268|6 - Bedfast, unable to ambulate or be up in a chair.|6 - Bedfast, unable to ambulate or be up in a chair.|61
269|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|61
270|5 - Disruptive or socially inappropriate behavior|5 - Disruptive or socially inappropriate behavior|61
271|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|61
272|5 - Hypo/Hyperglycemia, diabetes out of control|5 - Hypo/Hyperglycemia, diabetes out of control|61
273|5 - More often than once daily|5 - More often than once daily|61
274|5 - Native Hawaiian or Pacific Islander|5 - Native Hawaiian or Pacific Islander|61
275|5 - None of the above|5 - None of the above|61
276|5 - One to two times per week|5 - One to two times per week|61
277|5 - Other|5 - Other|61
278|5 - Other follow-up|5 - Other follow-up|61
279|5 - Paid help|5 - Paid help|61
280|5 - Patient nonresponsive or unable to speak.|5 - Patient nonresponsive or unable to speak.|61
281|5 - Thoughts of suicide|5 - Thoughts of suicide|61
282|5 - Totally unable to use the telephone.|5 - Totally unable to use the telephone.|61
283|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|61
284|5 - Unable to take in nutrients orally or by tube feeding.|5 - Unable to take in nutrients orally or by tube feeding.|61
285|5 - Unsafe for care at home|5 - Unsafe for care at home|61
286|5 - With paid help (other than home care agency staff)|5 - With paid help (other than home care agency staff)|61
287|5 - Workers' compensation|5 - Workers' compensation|61
288|5 - Wound infection, deteriorating wound status, new lesion/ulcer|5 - Wound infection, deteriorating wound status, new lesion/ulcer|61
289|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|61
290|6 - Delusional, hallucinatory, or paranoid behavior|6 - Delusional, hallucinatory, or paranoid behavior|61
291|6 - Financial agent, power of attorney, or conservator of finance|6 - Financial agent, power of attorney, or conservator of finance|61
292|6 - GI bleeding, obstruction|6 - GI bleeding, obstruction|61
293|6 - Less often than weekly|6 - Less often than weekly|61
294|6 - Memory loss to the extent that supervision required|6 - Memory loss to the extent that supervision required|61
295|6 - None of the above feelings observed or reported|6 - None of the above feelings observed or reported|61
296|6 - Other|6 - Other|61
297|6 - Title programs (e.g., Title III, V, or XX)|6 - Title programs (e.g., Title III, V, or XX)|61
298|6 - Transferred to an inpatient facility - patient not discharged from agency|6 - Transferred to an inpatient facility - patient not discharged from agency|61
299|6 - White|6 - White|61
300|6 - With other than above|6 - With other than above|61
301|7 - Exacerbation of CHF, fluid overload, heart failure|7 - Exacerbation of CHF, fluid overload, heart failure|61
302|7 - Health care agent, conservator of person, or medical power of attorney|7 - Health care agent, conservator of person, or medical power of attorney|61
303|7 - Hypo/Hyperglycemia, diabetes out of control|7 - Hypo/Hyperglycemia, diabetes out of control|61
304|7 - None of the above|7 - None of the above|61
305|7 - None of the above behaviors demonstrated|7 - None of the above behaviors demonstrated|61
306|7 - Other government (e.g., TriCare, VA, etc.)|7 - Other government (e.g., TriCare, VA, etc.)|61
307|7 - Transferred to an inpatient facility - patient discharged from agency|7 - Transferred to an inpatient facility - patient discharged from agency|61
308|8 - Death at home|8 - Death at home|61
309|8 - GI bleeding, obstruction|8 - GI bleeding, obstruction|61
310|8 - Myocardial infarction, stroke|8 - Myocardial infarction, stroke|61
311|8 - Private insurance|8 - Private insurance|61
312|9 - Chemotherapy|9 - Chemotherapy|61
313|9 - Discharge from agency|9 - Discharge from agency|61
314|9 - Other than above reasons|9 - Other than above reasons|61
315|9 - Private HMO/managed care|9 - Private HMO/managed care|61
316|NA - No caregiver|NA - No caregiver|61
317|NA - No equipment of this type used in care.|NA - No equipment of this type used in care.|61
318|NA - No inhalant/mist medications prescribed.|NA - No inhalant/mist medications prescribed.|61
319|NA - No injectable medications prescribed.|NA - No injectable medications prescribed.|61
320|NA - No inpatient facility admission|NA - No inpatient facility admission|61
321|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|61
322|NA - No Medicaid|NA - No Medicaid|61
323|NA - No Medicare|NA - No Medicare|61
324|NA - No observable pressure ulcer|NA - No observable pressure ulcer|61
325|NA - No observable stasis ulcer|NA - No observable stasis ulcer|61
326|NA - No observable surgical wound|NA - No observable surgical wound|61
327|NA - No oral medications prescribed.|NA - No oral medications prescribed.|61
328|NA - Not applicable|NA - Not applicable|61
329|NA - Patient does not have a telephone.|NA - Patient does not have a telephone.|61
330|NA - Patient has ostomy for bowel elimination|NA - Patient has ostomy for bowel elimination|61
331|NA - Patient nonresponsive|NA - Patient nonresponsive|61
332|NA - Patient on prophylactic treatment|NA - Patient on prophylactic treatment|61
333|NA - Patient was not discharged from an inpatient facility [Go to M1017]|NA - Patient was not discharged from an inpatient facility [Go to M1017]|61
334|UK - Other unknown|UK - Other unknown|61
335|UK - Reason unknown|UK - Reason unknown|61
336|UK - Unknown|UK - Unknown|61
337|UK - Unknown or Not Available|UK - Unknown or Not Available|61
341|01 - Early|01 - Early|61
342|02 - Late|02 - Late|61
343|NA - Not Applicable. No case mix group defined for this assessment.|NA - Not Applicable. No case mix group defined for this assessment.|61
344|NA - No case mix group defined by this assessment.|NA - No case mix group defined by this assessment.|61
345|1 - Recent decline in mental, emotional, or behavioral status|1 - Recent decline in mental, emotional, or behavioral status|61
346|2 - Multiple hospitalizations (2 or more) in the past 12 months|2 - Multiple hospitalizations (2 or more) in the past 12 months|61
347|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|61
348|4 - Taking five or more medications|4 - Taking five or more medications|61
349|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|61
350|6 - Other|6 - Other|61
351|7 - None of the above|7 - None of the above|61
352|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond tho|61
353|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable without heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable wi|61
354|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious complications and death.|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious compl|61
355|3 - The patient has serious progressive conditions that could lead to death within a year.|3 - The patient has serious progressive conditions that could lead to death within a year.|61
356|UK - The patient+s situation is unknown or unclear.|UK - The patient+s situation is unknown or unclear.|61
357|1 - Yes [ Go to M1050 ]|1 - Yes [ Go to M1050 ]|61
358|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this influenza season. [ Go to M1050 ]|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this i|61
359|1 - Received from another health care provider (e.g., physician)|1 - Received from another health care provider (e.g., physician)|61
360|2 - Received from your agency previously during this year+s flu season|2 - Received from your agency previously during this year+s flu season|61
361|3 - Offered and declined|3 - Offered and declined|61
362|4 - Assessed and determined to have medical contraindication(s)|4 - Assessed and determined to have medical contraindication(s)|61
363|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|61
364|6 - Inability to obtain vaccine due to declared shortage|6 - Inability to obtain vaccine due to declared shortage|61
365|1 - Yes [ Go to M1501 at TRN; Go to M1230 at DC ]|1 - Yes [ Go to M1501 at TRN; Go to M1230 at DC ]|61
366|1 - Patient has received PPV in the past|1 - Patient has received PPV in the past|61
367|2 - Offered and declined|2 - Offered and declined|61
368|3 - Assessed and determined to have medical contraindication(s)|3 - Assessed and determined to have medical contraindication(s)|61
369|4 - Not indicated; patient does not meet age/condition guidelines for PPV|4 - Not indicated; patient does not meet age/condition guidelines for PPV|61
370|5 - None of the above|5 - None of the above|61
371|0 - Adequate: hears normal conversation without difficulty.|0 - Adequate: hears normal conversation without difficulty.|61
372|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to increase volume or speak distinctly.|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to in|61
373|2 - Severely Impaired: absence of useful hearing.|2 - Severely Impaired: absence of useful hearing.|61
374|UK - Unable to assess hearing.|UK - Unable to assess hearing.|61
375|0 - Understands: clear comprehension without cues or repetitions.|0 - Understands: clear comprehension without cues or repetitions.|61
376|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Requires cues at times to understand.|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Req|61
377|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequently requires cues to understand.|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequentl|61
378|3 - Rarely/Never Understands|3 - Rarely/Never Understands|61
379|UK - Unable to assess understanding.|UK - Unable to assess understanding.|61
380|0 - No standardized assessment conducted|0 - No standardized assessment conducted|61
381|1 - Yes, and it does not indicate severe pain|1 - Yes, and it does not indicate severe pain|61
382|2 - Yes, and it indicates severe pain|2 - Yes, and it indicates severe pain|61
383|0 - Patient has no pain|0 - Patient has no pain|61
384|1 - Patient has pain that does not interfere with activity or movement|1 - Patient has pain that does not interfere with activity or movement|61
385|2 - Less often than daily|2 - Less often than daily|61
386|3 - Daily, but not constantly|3 - Daily, but not constantly|61
387|4 - All of the time|4 - All of the time|61
388|0 - No assessment conducted [ Go to M1306 ]|0 - No assessment conducted [ Go to M1306 ]|61
389|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc., without use of standardized tool|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc.,|61
390|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|61
391|0 - No [ Go to M1322]|0 - No [ Go to M1322]|61
392|0 v Newly epithelialized|0 - Newly epithelialized|61
393|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|61
394|2 - Yes, patient has observable stasis ulcers ONLY|2 - Yes, patient has observable stasis ulcers ONLY|61
395|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable dressing) [Go to M1340]|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable|61
396|0 - No [ Go to M1350 ]|0 - No [ Go to M1350 ]|61
397|1 - Yes, patient has at least one (observable) surgical wound|1 - Yes, patient has at least one (observable) surgical wound|61
398|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1350 ]|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1350 ]|61
399|0 - Patient is not short of breath|0 - Patient is not short of breath|61
400|3 - Continuous Bi-level positive airway pressure|3 - Continuous Bi-level positive airway pressure|61
401|0 - No [ Go to M1732 at TRN; Go to M1600 at DC ]|0 - No [ Go to M1732 at TRN; Go to M1600 at DC ]|61
402|2 - Not assessed [Go to M1732 at TRN; Go to M1600 at DC ]|2 - Not assessed [Go to M1732 at TRN; Go to M1600 at DC ]|61
403|NA - Patient does not have diagnosis of heart failure [Go to M2005 at TRN; Go to M1600 at DC]|NA - Patient does not have diagnosis of heart failure [Go to M2005 at TRN; Go to M1600 at DC]|61
404|0 - No action taken|0 - No action taken|61
405|1 - Patient+s physician (or other primary care practitioner) contacted the same day|1 - Patient+s physician (or other primary care practitioner) contacted the same day|61
406|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|61
407|3 - Implement physician-ordered patient-specific established parameters for treatment|3 - Implement physician-ordered patient-specific established parameters for treatment|61
408|4 - Patient education or other clinical interventions|4 - Patient education or other clinical interventions|61
409|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequency, telehealth, etc.)|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequ|61
410|1 - Occasional stress incontinence|1 - Occasional stress incontinence|61
411|2 - During the night only|2 - During the night only|61
412|3 - During the day only|3 - During the day only|61
413|4 - During the day and night|4 - During the day and night|61
414|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|61
415|0 - Able to manage toileting hygiene and clothing management without assistance.|0 - Able to manage toileting hygiene and clothing management without assistance.|61
416|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implements are laid out for the patient.|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implemen|61
417|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|61
418|3 - Patient depends entirely upon another person to maintain toileting hygiene.|3 - Patient depends entirely upon another person to maintain toileting hygiene.|61
419|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independent|61
420|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface|61
421|0 - No multi-factor falls risk assessment conducted.|0 - No multi-factor falls risk assessment conducted.|61
422|1 - Yes, and it does not indicate a risk for falls.|1 - Yes, and it does not indicate a risk for falls.|61
423|2 - Yes, and it indicates a risk for falls.|2 - Yes, and it indicates a risk for falls.|61
424|0 - Not assessed/reviewed [ Go to M2010 ]|0 - Not assessed/reviewed [ Go to M2010 ]|61
425|No - No issues found during review [ Go to M2010 ]|No - No issues found during review [ Go to M2010 ]|61
426|Yes - Issues found during review|Yes - Issues found during review|61
427|NA - Patient is not taking any medications [ Go to M2040 ]|NA - Patient is not taking any medications [ Go to M2040 ]|61
428|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special precautions associated with all high-risk medications|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special p|61
429|NA - Patient not taking any drugs|NA - Patient not taking any drugs|61
430|2 - Able to take medication(s) at the correct times if given reminders by another person at the appropriate times|2 - Able to take medication(s) at the correct times if given reminders by another person at the appr|61
431|3 - Unable to take medication unless administered by another person.|3 - Unable to take medication unless administered by another person.|61
432|1 - At least daily|1 - At least daily|61
433|2 - Three or more times per week|2 - Three or more times per week|61
434|3 - One to two times per week|3 - One to two times per week|61
435|4 - Received, but less often than weekly|4 - Received, but less often than weekly|61
436|5 - No assistance received|5 - No assistance received|61
437|0 - No [Go to M2401]|0 - No [Go to M2401]|61
438|1 - Yes, used hospital emergency department WITHOUT hospital admission|1 - Yes, used hospital emergency department WITHOUT hospital admission|61
439|2 - Yes, used hospital emergency department WITH hospital admission|2 - Yes, used hospital emergency department WITH hospital admission|61
440|UK - Unknown [Go to M2401]|UK - Unknown [Go to M2401]|61
441|2 - Injury caused by fall|2 - Injury caused by fall|61
442|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|61
443|4 - Other respiratory problem|4 - Other respiratory problem|61
444|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|61
445|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|61
446|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|61
447|8 - Other heart disease|8 - Other heart disease|61
448|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|61
449|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|61
450|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|61
451|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|61
452|13 - Urinary tract infection|13 - Urinary tract infection|61
453|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|61
454|15 - Wound infection or deterioration|15 - Wound infection or deterioration|61
455|16 - Uncontrolled pain|16 - Uncontrolled pain|61
456|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|61
457|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|61
458|19 - Other than above reasons|19 - Other than above reasons|61
459|2 - Patient remained in the community (with formal assistive services)|2 - Patient remained in the community (with formal assistive services)|61
460|3 - Patient transferred to a noninstitutional hospice|3 - Patient transferred to a noninstitutional hospice|61
461|4 - Unknown because patient moved to a geographic location not served by this agency|4 - Unknown because patient moved to a geographic location not served by this agency|61
462|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|61
463|4 - Other respiratory problem|4 - Other respiratory problem|61
464|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|61
465|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|61
466|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|61
467|8 - Other heart disease|8 - Other heart disease|61
468|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|61
469|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|61
470|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|61
471|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|61
472|13 - Urinary tract infection|13 - Urinary tract infection|61
473|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|61
474|15 - Wound infection or deterioration|15 - Wound infection or deterioration|61
475|16 - Uncontrolled pain|16 - Uncontrolled pain|61
476|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|61
477|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|61
478|19 - Scheduled treatment or procedure|19 - Scheduled treatment or procedure|61
479|20 - Other than above reasons|20 - Other than above reasons|61
480|UK - Reason unknown [Go to M0903]|UK - Reason unknown [Go to M0903]|61
482|01 - Patient lives alone around the clock|01 - Patient lives alone around the clock|61
483|02 - Patient lives alone regular daytime|02 - Patient lives alone regular daytime|61
484|03 - Patient lives alone regular nighttime|03 - Patient lives alone regular nighttime|61
485|04 - Patient lives alone occassional/short term assistance|04 - Patient lives alone occassional/short term assistance|61
486|05 - Patient lives alone no assisstance available|05 - Patient lives alone no assisstance available|61
487|06 - Patient lives with other person(s) in the home around the clock|06 - Patient lives with other person(s) in the home around the clock|61
488|07 - Patient lives with other person(s) in the home regular daytime|07 - Patient lives with other person(s) in the home regular daytime|61
489|08 - Patient lives with other person(s) in the home regular nighttime|08 - Patient lives with other person(s) in the home regular nighttime|61
490|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|61
491|10 - Patient lives with other person(s) in the home no assistance available|10 - Patient lives with other person(s) in the home no assistance available|61
492|1 - Was present at the most recent SOC/ROC assessment|1 - Was present at the most recent SOC/ROC assessment|61
493|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|61
494|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|61
495|0 - Newly epithelialized|0 - Newly epithelialized|61
496|0 - No [ Go to M1340 ]|0 - No [ Go to M1340 ]|61
498|0 - Independent|0 - Independent|61
499|1 - Needed Some Help|1 - Needed Some Help|61
500|2 - Dependent|2 - Dependent|61
502|0 - No assistance needed in this area|0 - No assistance needed in this area|61
635|3 - Non-agency caregiver(s) are not likely to provide assistance OR it is unclear if they will provide assistance|3 - Non-agency caregiver(s) are not likely to provide assistance OR unclear if will provide asst|61
636|4 - Assistance needed but no non-agency caregiver(s) available|4 - Assistance needed but no non-agency caregiver(s) available|61
637|1 - Peripheral Vascular Disease (PVD) or Peripheral Arterial Disease (PAD)|1 - Peripheral Vascular Disease (PVD) or Peripheral Arterial Disease (PAD)|61
638|2 - Diabetes Mellitus (DM)|2 - Diabetes Mellitus (DM)|61
639|06 - Independent - Patient completes the activity by him/herself with no assistance from a helper.|06 Independent - Patient completes the activity by him/herself with no assistance from a helper.|61
640|05 - Setup or clean-up assistance - Helper SETS UP or CLEANS UP; patient completes activity. Helper assists only prior to or following the activity.|05 Setup or clean-up assistance - Helper SETS UP or CLEANS UP; patient completes activity. He|61
641|04 - Supervision or touching assistance - Helper provides VERBAL CUES or TOUCHING/STEADYING assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently.|04 Supervision or touching assistance - Helper provides VERBAL CUES or TOUCHING/STEADYING|61
642|03 - Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort.|03 Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or |61
643|02 - Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.|02 Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds |61
644|01 - Dependent - Helper does ALL of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity.|01 Dependent - Helper does ALL of the effort. Patient does none of the effort to complete the act|61
645|07 - Activity not attempted - Patient refused|07 Activity not attempted - Patient refused|61
646|09 - Activity not attempted - Not applicable|09 Activity not attempted - Not applicable|61
647|88 - Not attempted due to medical condition or safety concerns|88 Not attempted due to medical condition or safety concerns|61
647|88 - Not attempted due to medical condition or safety concerns|88 Not attempted due to medical condition or safety concerns|63
646|09 - Activity not attempted - Not applicable|09 Activity not attempted - Not applicable|63
645|07 - Activity not attempted - Patient refused|07 Activity not attempted - Patient refused|63
644|01 - Dependent - Helper does ALL of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity.|01 Dependent - Helper does ALL of the effort. Patient does none of the effort to complete the act|63
643|02 - Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.|02 Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds |63
642|03 - Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort.|03 Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or |63
641|04 - Supervision or touching assistance - Helper provides VERBAL CUES or TOUCHING/STEADYING assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently.|04 Supervision or touching assistance - Helper provides VERBAL CUES or TOUCHING/STEADYING |63
640|05 - Setup or clean-up assistance -  Helper SETS UP or CLEANS UP; patient completes activity. Helper assists only prior to or following the activity.|05 Setup or clean-up assistance - Helper SETS UP or CLEANS UP; patient completes activity. Hel|63
639|06 - Independent - Patient completes the activity by him/herself with no assistance from a helper.|06 Independent - Patient completes the activity by him/herself with no assistance from a helper.|63
638|2 - Diabetes Mellitus (DM)|2 - Diabetes Mellitus (DM)|63
637|1 - Peripheral Vascular Disease (PVD) or Peripheral Arterial Disease (PAD)|1 - Peripheral Vascular Disease (PVD) or Peripheral Arterial Disease (PAD)|63
2|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; OR (b) Is physically, cognitively, and mentally able to prepare light meals on a regular basis but has not routinely performed light meal preparation in the past (i.e., prior to this home care admission).|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; O|63
3|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and mentally able to perform all housekeeping tasks .|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and menta|63
4|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and mentally able to do laundry and access facilities.|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and menta|63
5|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying packages OR b) Physically, cognitively, and mentally able to take care of shopping, but has not done shopping in the past (i.e., prior to this home care admission).|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying|63
6|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|63
7|0 - Able to dial numbers and answer calls appropriately and as desired.|0 - Able to dial numbers and answer calls appropriately and as desired.|63
8|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body without assistance.|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body|63
9|0 - Able to get to and from the toilet and transfer independently with or without a device.|0 - Able to get to and from the toilet and transfer independently with or without a device.|63
10|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|63
11|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible public bus.|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible p|63
12|0 - Able to independently feed self.|0 - Able to independently feed self.|63
13|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|63
14|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct times.|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct ti|63
15|0 - Able to independently transfer.|0 - Able to independently transfer.|63
16|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without rail|63
17|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings|63
18|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|63
19|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions independently.|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions indep|63
20|0 - Asymptomatic, no treatment needed at this time|0 - Asymptomatic, no treatment needed at this time|63
21|0 - Caregiver manages all tasks related to equipment completely independently.|0 - Caregiver manages all tasks related to equipment completely independently.|63
22|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations with no observable impairment.|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations w|63
23|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|63
24|0 - Life expectancy is greater than 6 months|0 - Life expectancy is greater than 6 months|63
25|0 - Never|0 - Never|63
26|0 - Patient is not short of breath|0 - Patient is not short of breath|63
27|0 - No|0 - No|63
28|0 - No emergent care services|0 - No emergent care services|63
29|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [ Go to M1620 ]|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [ Go to M1620 ]|63
30|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and extended or abstract conversation.|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and exte|63
31|0 - No one person|0 - No one person|63
32|0 - None of the time|0 - None of the time|63
33|0 - None, no charge for current services|0 - None, no charge for current services|63
34|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|63
35|0 - Patient does NOT have an ostomy for bowel elimination.|0 - Patient does NOT have an ostomy for bowel elimination.|63
36|0 - Patient has no pain|0 - Patient has no pain|63
37|0 - Patient manages all tasks related to equipment completely independently.|0 - Patient manages all tasks related to equipment completely independently.|63
38|0 - Poor:  little or no recovery is expected and/or further decline is imminent|0 - Poor:  little or no recovery is expected and/or further decline is imminent|63
39|0 - Timed-voiding defers incontinence|0 - Timed-voiding defers incontinence|63
40|0 - Very rarely or never has bowel incontinence|0 - Very rarely or never has bowel incontinence|63
41|0 - Zero|0 - Zero|63
42|00 - No|00 - No|63
43|01 - Yes|01 - Yes|63
44|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or mental limitations, needs assistance with heavy laundry.|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or|63
45|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the patient.|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the|63
46|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|63
47|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or supervision from another person OR c) a liquid, pureed or ground meat diet.|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or su|63
48|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|63
49|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|63
50|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independently.|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independe|63
51|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only when assisted or accompanied by another person.|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only w|63
52|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepa|63
53|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance by another person OR b) given daily reminders.|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance b|63
54|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advan|63
55|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advan|63
56|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for the deaf) and call essential numbers.|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for t|63
57|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|63
58|1 - American Indian or Alaska Native|1 - American Indian or Alaska Native|63
59|1 - Depressed mood (e.g., feeling sad, tearful)|1 - Depressed mood (e.g., feeling sad, tearful)|63
60|1 - During the night only|1 - During the night only|63
61|1 - Fully granulating|1 - Fully granulating|63
62|1 - Good/Fair:  partial to full recovery is expected|1 - Good/Fair:  partial to full recovery is expected|63
63|1 - Good:  marked improvement in functional status is expected|1 - Good:  marked improvement in functional status is expected|63
64|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|63
65|1 - Smoking|1 - Smoking|63
66|1 - Hospital|1 - Hospital|63
67|1 - Hospital emergency room (includes 23-hour holding)|1 - Hospital emergency room (includes 23-hour holding)|63
68|1 - Hospitalization for EMERGENT (unscheduled) care|1 - Hospitalization for EMERGENT (unscheduled) care|63
69|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepared solutions), patient is able to manage all other aspects of equipment.|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepar|63
70|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|63
71|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|63
72|1 - In new or complex situations only|1 - In new or complex situations only|63
73|1 - Intravenous or infusion therapy (excludes TPN)|1 - Intravenous or infusion therapy (excludes TPN)|63
74|1 - Less often than daily|1 - Less often than daily|63
75|1 - Less than once a month|1 - Less than once a month|63
76|1 - Less than once weekly|1 - Less than once weekly|63
77|1 - Life expectancy is 6 months or fewer|1 - Life expectancy is 6 months or fewer|63
78|1 - Lives alone|1 - Lives alone|63
79|1 - Male|1 - Male|63
80|1 - Medicare (traditional fee-for-service)|1 - Medicare (traditional fee-for-service)|63
81|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of past 24 hours, significant memory loss so that supervision is required|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of pas|63
82|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors in word choice, grammar or speech intelligibility, needs minimal prompting or assistance).|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors i|63
83|1 - No assistance or services received|1 - No assistance or services received|63
84|1 - One|1 - One|63
85|1 - Oxygen (intermittent or continuous)|1 - Oxygen (intermittent or continuous)|63
86|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, and the surrounding layout, can count fingers at arm's length.|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, a|63
87|1 - Patient is incontinent|1 - Patient is incontinent|63
88|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|63
89|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical or treatment regimen.|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical|63
90|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient/couple/significant other)|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient|63
91|1 - Relatives, friends, or neighbors living outside the home|1 - Relatives, friends, or neighbors living outside the home|63
92|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions.|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions|63
93|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independentl|63
94|1 - Several times during day and night|1 - Several times during day and night|63
95|1 - Spouse or significant other|1 - Spouse or significant other|63
96|1 - Stage 1|1 - Stage 1|63
97|1 - Start of care - further visits planned|1 - Start of care - further visits planned|63
98|1 - Symptoms well controlled with current therapy|1 - Symptoms well controlled with current therapy|63
99|1 - Therapy services|1 - Therapy services|63
100|1 - Able to transfer with minimal human assistance or with use of an assistive device.|1 - Able to transfer with minimal human assistance or with use of an assistive device.|63
101|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitations.|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitatio|63
102|1 - Urinary incontinence|1 - Urinary incontinence|63
103|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and transfer.|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and|63
104|1 - When walking more than 20 feet, climbing stairs|1 - When walking more than 20 feet, climbing stairs|63
105|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary conversation. May need occasional repetition, extra time, or louder voice.|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary c|63
106|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting in and out of tub/shower|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting|63
107|1 - Yes|1 - Yes|63
108|1-RN|1-RN|63
109|10 - Discharge from agency - no visits completed after start/resumption of care assessment|10 - Discharge from agency - no visits completed after start/resumption of care assessment|63
110|10 - Scheduled surgical procedure|10 - Scheduled surgical procedure|63
111|10 - Self-pay|10 - Self-pay|63
112|11 - Other|11 - Other|63
113|11 - Urinary tract infection|11 - Urinary tract infection|63
114|12 - IV catheter-related infection|12 - IV catheter-related infection|63
115|13 - Deep vein thrombosis, pulmonary embolus|13 - Deep vein thrombosis, pulmonary embolus|63
116|14 - Uncontrolled pain|14 - Uncontrolled pain|63
117|15 - Psychotic episode|15 - Psychotic episode|63
118|16 - Other than above reasons|16 - Other than above reasons|63
119|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing calls.|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing|63
120|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another person.|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another pers|63
121|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface a|63
122|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for intermittent supervision or encouragement or reminders, OR (b) to get in and out of the shower or tub, OR (c) for washing difficult to reach areas.|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for inter|63
123|2 - Asian|2 - Asian|63
124|2 - Caregiver requires considerable assistance from another person to manage equipment, but independently completes significant portions of task.|2 - Caregiver requires considerable assistance from another person to manage equipment, but independ|63
125|2 - Daily, but not constantly|2 - Daily, but not constantly|63
126|2 - Daughter or son|2 - Daughter or son|63
127|2 - Doctor's office emergency visit/house call|2 - Doctor's office emergency visit/house call|63
128|2 - During the day and night|2 - During the day and night|63
129|2 - Early/partial granulation|2 - Early/partial granulation|63
130|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors in word choice, organization or speech intelligibility). Speaks in phrases or short sentences.|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors|63
131|2 - Family member's residence|2 - Family member's residence|63
132|2 - Female|2 - Female|63
133|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conversation, needs frequent prompting or assistance.|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conver|63
134|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|63
135|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|63
136|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately stop activities, jeopardizes safety through actions|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately st|63
137|2 - Indwelling/suprapubic catheter|2 - Indwelling/suprapubic catheter|63
138|2 - Injury caused by fall or accident at home|2 - Injury caused by fall or accident at home|63
139|2 - Medicare (HMO/managed care/Advantage plan)|2 - Medicare (HMO/managed care/Advantage plan)|63
140|2 - Nausea, dehydration, malnutrition, constipation, impaction|2 - Nausea, dehydration, malnutrition, constipation, impaction|63
141|2 - Obesity|2 - Obesity|63
142|2 - On awakening or at night only|2 - On awakening or at night only|63
143|2 - Once a month|2 - Once a month|63
144|2 - One to three times weekly|2 - One to three times weekly|63
145|2 - Parenteral nutrition (TPN or lipids)|2 - Parenteral nutrition (TPN or lipids)|63
146|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic)  [ Go to M1620 ]|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic)  [ Go|63
147|2 - Patient requires considerable assistance from another person to manage equipment, but independently completes portions of the task.|2 - Patient requires considerable assistance from another person to manage equipment, but independen|63
148|2 - Patient transferred to a noninstitutional hospice|2 - Patient transferred to a noninstitutional hospice|63
149|2 - Person residing in the home (EXCLUDING paid help)|2 - Person residing in the home (EXCLUDING paid help)|63
150|2 - Rehabilitation facility|2 - Rehabilitation facility|63
151|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifting of attention) or consistently requires low stimulus environment due to distractibility.|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifti|63
152|2 - Respite care|2 - Respite care|63
153|2 - Sense of failure or self reproach|2 - Sense of failure or self reproach|63
154|2 - Several times during day|2 - Several times during day|63
155|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonresponsive.|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonrespons|63
156|2 - Someone must assist the patient to groom self.|2 - Someone must assist the patient to groom self.|63
157|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|63
158|2 - Someone must help the patient put on upper body clothing.|2 - Someone must help the patient put on upper body clothing.|63
159|2 - Stage 2|2 - Stage 2|63
160|2 - Start of care - no further visits planned|2 - Start of care - no further visits planned|63
161|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitoring|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitori|63
162|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment regimen.|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment re|63
163|2 - Two|2 - Two|63
164|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistance due to cognitive or mental limitation.|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistanc|63
165|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|63
166|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assistance).|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assis|63
167|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home delivery.|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home deli|63
168|2 - Unable to prepare any light meals or reheat any delivered meals.|2 - Unable to prepare any light meals or reheat any delivered meals.|63
169|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|63
170|2 - UNABLE to take injectable medications unless administered by someone else.|2 - UNABLE to take injectable medications unless administered by someone else.|63
171|2 - UNABLE to take medication unless administered by someone else.|2 - UNABLE to take medication unless administered by someone else.|63
172|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|63
173|2 - Ventilator (continually or at night)|2 - Ventilator (continually or at night)|63
174|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less than 20 feet)|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less th|63
175|2 - With spouse or significant other|2 - With spouse or significant other|63
176|2 - Yes, assistance or services provided by family or friends|2 - Yes, assistance or services provided by family or friends|63
177|2-PT|2-PT|63
178|3 - Able to answer the telephone only some of the time or is able to carry on only a limited conversation.|3 - Able to answer the telephone only some of the time or is able to carry on only a limited convers|63
179|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube or gastrostomy.|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube|63
180|3 - Alcohol dependency|3 - Alcohol dependency|63
181|3 - All of the time|3 - All of the time|63
182|3 - Black or African-American|3 - Black or African-American|63
183|3 - Boarding home or rented room|3 - Boarding home or rented room|63
184|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment, clean/store/dispose of equipment or supplies).|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment,|63
185|3 -Able to walk only with the supervision or assistance of another person at all times.|3 -Able to walk only with the supervision or assistance of another person at all times.|63
186|3 - Continuous / Bi-level positive airway pressure|3 - Continuous / Bi-level positive airway pressure|63
187|3 - During the day and evening, but not constantly|3 - During the day and evening, but not constantly|63
188|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the alimentary canal)|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the|63
189|3 - Environmental support (e.g., housing, home maintenance)|3 - Environmental support (e.g., housing, home maintenance)|63
190|3 - Four to six times weekly|3 - Four to six times weekly|63
191|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessing by listener.  Speech limited to single words or short phrases.|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessin|63
192|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires multiple repetitions, restatements, demonstrations, additional time.|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires m|63
193|3 - Hopelessness|3 - Hopelessness|63
194|3 - Hospice care|3 - Hospice care|63
195|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|63
196|3 - Injury caused by fall or accident at home|3 - Injury caused by fall or accident at home|63
197|3 - Intractable pain|3 - Intractable pain|63
198|3 - Medicaid (traditional fee-for-service)|3 - Medicaid (traditional fee-for-service)|63
199|3 - Needs someone to do all shopping and errands.|3 - Needs someone to do all shopping and errands.|63
200|3 - Not healing|3 - Not healing|63
201|3 - Nursing home|3 - Nursing home|63
202|3 - Once daily|3 - Once daily|63
203|3 - Other family member|3 - Other family member|63
204|3 - Outpatient department/clinic emergency (includes urgicenter sites)|3 - Outpatient department/clinic emergency (includes urgicenter sites)|63
205|3 - Paid help|3 - Paid help|63
206|3 - Able to participate in bathing self in shower or tub, but requires presence of another person throughout the bath for assistance or supervision.|3 - Able to participate in bathing self in shower or tub, but requires presence of another person th|63
207|3 - Patient depends entirely upon another person to dress lower body.|3 - Patient depends entirely upon another person to dress lower body.|63
208|3 - Patient depends entirely upon another person to dress the upper body.|3 - Patient depends entirely upon another person to dress the upper body.|63
209|3 - Patient depends entirely upon someone else for grooming needs.|3 - Patient depends entirely upon someone else for grooming needs.|63
210|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone else to manage the equipment.|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone|63
211|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable to shift attention and recall directions more than half the time.|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable|63
212|3 - Respiratory problems (SOB, infection, obstruction)|3 - Respiratory problems (SOB, infection, obstruction)|63
213|3 - Resumption of care (after inpatient stay)|3 - Resumption of care (after inpatient stay)|63
214|3 - Several times each month|3 - Several times each month|63
215|3 - Skilled Nursing Facility|3 - Skilled Nursing Facility|63
216|3 - Stage 3|3 - Stage 3|63
217|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|63
218|3 - Three|3 - Three|63
219|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person throughout the process.|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person through|63
220|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal independently.|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal indep|63
221|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person.|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person|63
222|3 - Unknown because patient moved to a geographic location not served by this agency|3 - Unknown because patient moved to a geographic location not served by this agency|63
223|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|63
224|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|63
225|3 - With other family member|3 - With other family member|63
226|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home health services, homemaker assistance, transportation assistance, assisted living, board and care)|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home h|63
227|3-SLP/ST|3-SLP/ST|63
228|4 - At rest (during day or night)|4 - At rest (during day or night)|63
229|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|63
230|4 - Board and care or assisted living facility|4 - Board and care or assisted living facility|63
231|4 - Caregiver is completely dependent on someone else to manage all equipment.|4 - Caregiver is completely dependent on someone else to manage all equipment.|63
232|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|63
233|4 - Constantly|4 - Constantly|63
234|4 - Drug dependency|4 - Drug dependency|63
235|4 - Four or more|4 - Four or more|63
236|4 - Friend or neighbor or community or church member|4 - Friend or neighbor or community or church member|63
237|4 - Hispanic or Latino|4 - Hispanic or Latino|63
238|4 - Hospice|4 - Hospice|63
239|4 - Impaired decision-making|4 - Impaired decision-making|63
240|4 - Is totally dependent in toileting.|4 - Is totally dependent in toileting.|63
241|4 - Medicaid (HMO/managed care)|4 - Medicaid (HMO/managed care)|63
242|4 - None of the above|4 - None of the above|63
243|4 - Nursing home|4 - Nursing home|63
244|4 - On a daily basis|4 - On a daily basis|63
245|4 - Patient is completely dependent on someone else to manage all equipment.|4 - Patient is completely dependent on someone else to manage all equipment.|63
246|4 - Permanent placement|4 - Permanent placement|63
247|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, punches, dangerous maneuvers w/ wheelchair or other objects)|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, pu|63
248|4 - Psychosocial support (e.g., socialization, companionship, recreation)|4 - Psychosocial support (e.g., socialization, companionship, recreation)|63
249|4 - Recertification (follow-up) reassessment|4 - Recertification (follow-up) reassessment|63
250|4 - Recurrent thoughts of death|4 - Recurrent thoughts of death|63
251|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruction)|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruc|63
252|4 - Several times a week|4 - Several times a week|63
253|4 - Stage 4|4 - Stage 4|63
254|4 - Symptoms poorly controlled, history of re-hospitalizations|4 - Symptoms poorly controlled, history of re-hospitalizations|63
255|4 - Three or more times per week|4 - Three or more times per week|63
256|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetative state, or delirium.|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetati|63
257|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|63
258|4 - Unable to effectively participate in any housekeeping tasks.|4 - Unable to effectively participate in any housekeeping tasks.|63
259|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or unresponsive (e.g., speech is nonsensical or unintelligible).|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or u|63
260|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonresponsive.|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonr|63
261|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostomy.|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostom|63
262|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of devices at the sink, in chair, or on commode|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of|63
263|4 - With a friend|4 - With a friend|63
264|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|63
265|4-OT|4-OT|63
266|5 - Advocates or facilitates patient's participation in appropriate medical care|5 - Advocates or facilitates patient's participation in appropriate medical care|63
267|5 - At least daily|5 - At least daily|63
268|6 - Bedfast, unable to ambulate or be up in a chair.|6 - Bedfast, unable to ambulate or be up in a chair.|63
269|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|63
270|5 - Disruptive or socially inappropriate behavior|5 - Disruptive or socially inappropriate behavior|63
271|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|63
272|5 - Hypo/Hyperglycemia, diabetes out of control|5 - Hypo/Hyperglycemia, diabetes out of control|63
273|5 - More often than once daily|5 - More often than once daily|63
274|5 - Native Hawaiian or Pacific Islander|5 - Native Hawaiian or Pacific Islander|63
275|5 - None of the above|5 - None of the above|63
276|5 - One to two times per week|5 - One to two times per week|63
277|5 - Other|5 - Other|63
278|5 - Other follow-up|5 - Other follow-up|63
279|5 - Paid help|5 - Paid help|63
280|5 - Patient nonresponsive or unable to speak.|5 - Patient nonresponsive or unable to speak.|63
281|5 - Thoughts of suicide|5 - Thoughts of suicide|63
282|5 - Totally unable to use the telephone.|5 - Totally unable to use the telephone.|63
283|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|63
284|5 - Unable to take in nutrients orally or by tube feeding.|5 - Unable to take in nutrients orally or by tube feeding.|63
285|5 - Unsafe for care at home|5 - Unsafe for care at home|63
286|5 - With paid help (other than home care agency staff)|5 - With paid help (other than home care agency staff)|63
287|5 - Workers' compensation|5 - Workers' compensation|63
288|5 - Wound infection, deteriorating wound status, new lesion/ulcer|5 - Wound infection, deteriorating wound status, new lesion/ulcer|63
289|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|63
290|6 - Delusional, hallucinatory, or paranoid behavior|6 - Delusional, hallucinatory, or paranoid behavior|63
291|6 - Financial agent, power of attorney, or conservator of finance|6 - Financial agent, power of attorney, or conservator of finance|63
292|6 - GI bleeding, obstruction|6 - GI bleeding, obstruction|63
293|6 - Less often than weekly|6 - Less often than weekly|63
294|6 - Memory loss to the extent that supervision required|6 - Memory loss to the extent that supervision required|63
295|6 - None of the above feelings observed or reported|6 - None of the above feelings observed or reported|63
296|6 - Other|6 - Other|63
297|6 - Title programs (e.g., Title III, V, or XX)|6 - Title programs (e.g., Title III, V, or XX)|63
298|6 - Transferred to an inpatient facility - patient not discharged from agency|6 - Transferred to an inpatient facility - patient not discharged from agency|63
299|6 - White|6 - White|63
300|6 - With other than above|6 - With other than above|63
301|7 - Exacerbation of CHF, fluid overload, heart failure|7 - Exacerbation of CHF, fluid overload, heart failure|63
302|7 - Health care agent, conservator of person, or medical power of attorney|7 - Health care agent, conservator of person, or medical power of attorney|63
303|7 - Hypo/Hyperglycemia, diabetes out of control|7 - Hypo/Hyperglycemia, diabetes out of control|63
304|7 - None of the above|7 - None of the above|63
305|7 - None of the above behaviors demonstrated|7 - None of the above behaviors demonstrated|63
306|7 - Other government (e.g., TriCare, VA, etc.)|7 - Other government (e.g., TriCare, VA, etc.)|63
307|7 - Transferred to an inpatient facility - patient discharged from agency|7 - Transferred to an inpatient facility - patient discharged from agency|63
308|8 - Death at home|8 - Death at home|63
309|8 - GI bleeding, obstruction|8 - GI bleeding, obstruction|63
310|8 - Myocardial infarction, stroke|8 - Myocardial infarction, stroke|63
311|8 - Private insurance|8 - Private insurance|63
312|9 - Chemotherapy|9 - Chemotherapy|63
313|9 - Discharge from agency|9 - Discharge from agency|63
314|9 - Other than above reasons|9 - Other than above reasons|63
315|9 - Private HMO/managed care|9 - Private HMO/managed care|63
316|NA - No caregiver|NA - No caregiver|63
317|NA - No equipment of this type used in care.|NA - No equipment of this type used in care.|63
318|NA - No inhalant/mist medications prescribed.|NA - No inhalant/mist medications prescribed.|63
319|NA - No injectable medications prescribed.|NA - No injectable medications prescribed.|63
320|NA - No inpatient facility admission|NA - No inpatient facility admission|63
321|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|63
322|NA - No Medicaid|NA - No Medicaid|63
323|NA - No Medicare|NA - No Medicare|63
324|NA - No observable pressure ulcer or unhealed pressure ulcer|NA - No observable pressure ulcer or unhealed pressure ulcer|63
325|NA - No observable stasis ulcer|NA - No observable stasis ulcer|63
326|NA - No observable surgical wound|NA - No observable surgical wound|63
327|NA - No oral medications prescribed.|NA - No oral medications prescribed.|63
328|NA - Not applicable|NA - Not applicable|63
329|NA - Patient does not have a telephone.|NA - Patient does not have a telephone.|63
330|NA - Patient has ostomy for bowel elimination|NA - Patient has ostomy for bowel elimination|63
331|NA - Patient nonresponsive|NA - Patient nonresponsive|63
332|NA - Patient on prophylactic treatment|NA - Patient on prophylactic treatment|63
333|NA - Patient was not discharged from an inpatient facility [Go to M1017]|NA - Patient was not discharged from an inpatient facility [Go to M1017]|63
334|UK - Other unknown|UK - Other unknown|63
335|UK - Reason unknown|UK - Reason unknown|63
336|UK - Unknown|UK - Unknown|63
337|UK - Unknown or Not Available|UK - Unknown or Not Available|63
341|01 - Early|01 - Early|63
342|02 - Late|02 - Late|63
343|NA - Not Applicable. No case mix group defined for this assessment.|NA - Not Applicable. No case mix group defined for this assessment.|63
344|NA - No case mix group defined by this assessment.|NA - No case mix group defined by this assessment.|63
345|1 - Recent decline in mental, emotional, or behavioral status|1 - Recent decline in mental, emotional, or behavioral status|63
346|2 - Multiple hospitalizations (2 or more) in the past 12 months|2 - Multiple hospitalizations (2 or more) in the past 12 months|63
347|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|63
348|4 - Taking five or more medications|4 - Taking five or more medications|63
349|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|63
350|6 - Other|6 - Other|63
351|7 - None of the above|7 - None of the above|63
352|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond tho|63
353|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable without heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable wi|63
354|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious complications and death.|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious compl|63
355|3 - The patient has serious progressive conditions that could lead to death within a year.|3 - The patient has serious progressive conditions that could lead to death within a year.|63
356|UK - The patient+s situation is unknown or unclear.|UK - The patient+s situation is unknown or unclear.|63
357|1 - Yes [ Go to M1050 ]|1 - Yes [ Go to M1050 ]|63
358|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this influenza season. [ Go to M1050 ]|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this i|63
359|1 - Received from another health care provider (e.g., physician)|1 - Received from another health care provider (e.g., physician)|63
360|2 - Received from your agency previously during this year+s flu season|2 - Received from your agency previously during this year+s flu season|63
361|3 - Offered and declined|3 - Offered and declined|63
362|4 - Assessed and determined to have medical contraindication(s)|4 - Assessed and determined to have medical contraindication(s)|63
363|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|63
364|6 - Inability to obtain vaccine due to declared shortage|6 - Inability to obtain vaccine due to declared shortage|63
365|1 - Yes [ Go to M1501 at TRN; Go to M1230 at DC ]|1 - Yes [ Go to M1501 at TRN; Go to M1230 at DC ]|63
366|1 - Patient has received PPV in the past|1 - Patient has received PPV in the past|63
367|2 - Offered and declined|2 - Offered and declined|63
368|3 - Assessed and determined to have medical contraindication(s)|3 - Assessed and determined to have medical contraindication(s)|63
369|4 - Not indicated; patient does not meet age/condition guidelines for PPV|4 - Not indicated; patient does not meet age/condition guidelines for PPV|63
370|5 - None of the above|5 - None of the above|63
371|0 - Adequate: hears normal conversation without difficulty.|0 - Adequate: hears normal conversation without difficulty.|63
372|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to increase volume or speak distinctly.|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to in|63
373|2 - Severely Impaired: absence of useful hearing.|2 - Severely Impaired: absence of useful hearing.|63
374|UK - Unable to assess hearing.|UK - Unable to assess hearing.|63
375|0 - Understands: clear comprehension without cues or repetitions.|0 - Understands: clear comprehension without cues or repetitions.|63
376|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Requires cues at times to understand.|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Req|63
377|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequently requires cues to understand.|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequentl|63
378|3 - Rarely/Never Understands|3 - Rarely/Never Understands|63
379|UK - Unable to assess understanding.|UK - Unable to assess understanding.|63
380|0 - No standardized assessment conducted|0 - No standardized assessment conducted|63
381|1 - Yes, and it does not indicate severe pain|1 - Yes, and it does not indicate severe pain|63
382|2 - Yes, and it indicates severe pain|2 - Yes, and it indicates severe pain|63
383|0 - Patient has no pain|0 - Patient has no pain|63
384|1 - Patient has pain that does not interfere with activity or movement|1 - Patient has pain that does not interfere with activity or movement|63
385|2 - Less often than daily|2 - Less often than daily|63
386|3 - Daily, but not constantly|3 - Daily, but not constantly|63
387|4 - All of the time|4 - All of the time|63
388|0 - No assessment conducted [ Go to M1306 ]|0 - No assessment conducted [ Go to M1306 ]|63
389|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc., without use of standardized tool|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc.,|63
390|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|63
391|0 - No [ Go to M1322]|0 - No [ Go to M1322]|63
392|0 v Newly epithelialized|0 v Newly epithelialized|63
393|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|63
394|2 - Yes, patient has observable stasis ulcers ONLY|2 - Yes, patient has observable stasis ulcers ONLY|63
395|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable dressing) [Go to M1340]|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable|63
396|0 - No [ Go to M1350 ]|0 - No [ Go to M1350 ]|63
397|1 - Yes, patient has at least one (observable) surgical wound|1 - Yes, patient has at least one (observable) surgical wound|63
398|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1350 ]|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1350 ]|63
399|0 - Patient is not short of breath|0 - Patient is not short of breath|63
400|3 - Continuous Bi-level positive airway pressure|3 - Continuous Bi-level positive airway pressure|63
401|0 - No [ Go to M1732 at TRN; Go to M1600 at DC ]|0 - No [ Go to M1732 at TRN; Go to M1600 at DC ]|63
402|2 - Not assessed [Go to M1732 at TRN; Go to M1600 at DC ]|2 - Not assessed [Go to M1732 at TRN; Go to M1600 at DC ]|63
403|NA - Patient does not have diagnosis of heart failure [Go to M2005 at TRN; Go to M1600 at DC]|NA - Patient does not have diagnosis of heart failure [Go to M2005 at TRN; Go to M1600 at DC]|63
404|0 - No action taken|0 - No action taken|63
405|1 - Patient+s physician (or other primary care practitioner) contacted the same day|1 - Patient+s physician (or other primary care practitioner) contacted the same day|63
406|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|63
407|3 - Implement physician-ordered patient-specific established parameters for treatment|3 - Implement physician-ordered patient-specific established parameters for treatment|63
408|4 - Patient education or other clinical interventions|4 - Patient education or other clinical interventions|63
409|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequency, telehealth, etc.)|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequ|63
410|1 - Occasional stress incontinence|1 - Occasional stress incontinence|63
411|2 - During the night only|2 - During the night only|63
412|3 - During the day only|3 - During the day only|63
413|4 - During the day and night|4 - During the day and night|63
414|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|63
415|0 - Able to manage toileting hygiene and clothing management without assistance.|0 - Able to manage toileting hygiene and clothing management without assistance.|63
416|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implements are laid out for the patient.|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implemen|63
417|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|63
418|3 - Patient depends entirely upon another person to maintain toileting hygiene.|3 - Patient depends entirely upon another person to maintain toileting hygiene.|63
419|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independent|63
420|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface|63
421|0 - No multi-factor falls risk assessment conducted.|0 - No multi-factor falls risk assessment conducted.|63
422|1 - Yes, and it does not indicate a risk for falls.|1 - Yes, and it does not indicate a risk for falls.|63
423|2 - Yes, and it indicates a risk for falls.|2 - Yes, and it indicates a risk for falls.|63
424|0 - Not assessed/reviewed [ Go to M2010 ]|0 - Not assessed/reviewed [ Go to M2010 ]|63
425|No - No issues found during review [ Go to M2010 ]|No - No issues found during review [ Go to M2010 ]|63
426|Yes - Issues found during review|Yes - Issues found during review|63
427|NA - Patient is not taking any medications [ Go to M2040 ]|NA - Patient is not taking any medications [ Go to M2040 ]|63
428|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special precautions associated with all high-risk medications|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special p|63
429|NA - Patient not taking any drugs|NA - Patient not taking any drugs|63
430|2 - Able to take medication(s) at the correct times if given reminders by another person at the appropriate times|2 - Able to take medication(s) at the correct times if given reminders by another person at the appr|63
431|3 - Unable to take medication unless administered by another person.|3 - Unable to take medication unless administered by another person.|63
432|1 - At least daily|1 - At least daily|63
433|2 - Three or more times per week|2 - Three or more times per week|63
434|3 - One to two times per week|3 - One to two times per week|63
435|4 - Received, but less often than weekly|4 - Received, but less often than weekly|63
436|5 - No assistance received|5 - No assistance received|63
437|0 - No [Go to M2401]|0 - No [Go to M2401]|63
438|1 - Yes, used hospital emergency department WITHOUT hospital admission|1 - Yes, used hospital emergency department WITHOUT hospital admission|63
439|2 - Yes, used hospital emergency department WITH hospital admission|2 - Yes, used hospital emergency department WITH hospital admission|63
440|UK - Unknown [Go to M2401]|UK - Unknown [Go to M2401]|63
441|2 - Injury caused by fall|2 - Injury caused by fall|63
442|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|63
443|4 - Other respiratory problem|4 - Other respiratory problem|63
444|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|63
445|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|63
446|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|63
447|8 - Other heart disease|8 - Other heart disease|63
448|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|63
449|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|63
450|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|63
451|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|63
452|13 - Urinary tract infection|13 - Urinary tract infection|63
453|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|63
454|15 - Wound infection or deterioration|15 - Wound infection or deterioration|63
455|16 - Uncontrolled pain|16 - Uncontrolled pain|63
456|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|63
457|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|63
458|19 - Other than above reasons|19 - Other than above reasons|63
459|2 - Patient remained in the community (with formal assistive services)|2 - Patient remained in the community (with formal assistive services)|63
460|3 - Patient transferred to a noninstitutional hospice|3 - Patient transferred to a noninstitutional hospice|63
461|4 - Unknown because patient moved to a geographic location not served by this agency|4 - Unknown because patient moved to a geographic location not served by this agency|63
462|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|63
463|4 - Other respiratory problem|4 - Other respiratory problem|63
464|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|63
465|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|63
466|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|63
467|8 - Other heart disease|8 - Other heart disease|63
468|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|63
469|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|63
470|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|63
471|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|63
472|13 - Urinary tract infection|13 - Urinary tract infection|63
473|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|63
474|15 - Wound infection or deterioration|15 - Wound infection or deterioration|63
475|16 - Uncontrolled pain|16 - Uncontrolled pain|63
476|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|63
477|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|63
478|19 - Scheduled treatment or procedure|19 - Scheduled treatment or procedure|63
479|20 - Other than above reasons|20 - Other than above reasons|63
480|UK - Reason unknown [Go to M0903]|UK - Reason unknown [Go to M0903]|63
482|01 - Patient lives alone around the clock|01 - Patient lives alone around the clock|63
483|02 - Patient lives alone regular daytime|02 - Patient lives alone regular daytime|63
484|03 - Patient lives alone regular nighttime|03 - Patient lives alone regular nighttime|63
485|04 - Patient lives alone occassional/short term assistance|04 - Patient lives alone occassional/short term assistance|63
486|05 - Patient lives alone no assisstance available|05 - Patient lives alone no assisstance available|63
487|06 - Patient lives with other person(s) in the home around the clock|06 - Patient lives with other person(s) in the home around the clock|63
488|07 - Patient lives with other person(s) in the home regular daytime|07 - Patient lives with other person(s) in the home regular daytime|63
489|08 - Patient lives with other person(s) in the home regular nighttime|08 - Patient lives with other person(s) in the home regular nighttime|63
490|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|63
491|10 - Patient lives with other person(s) in the home no assistance available|10 - Patient lives with other person(s) in the home no assistance available|63
492|1 - Was present at the most recent SOC/ROC assessment|1 - Was present at the most recent SOC/ROC assessment|63
493|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|63
494|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|63
495|0 - Newly epithelialized|0 - Newly epithelialized|63
496|0 - No [ Go to M1340 ]|0 - No [ Go to M1340 ]|63
498|0 - Independent|0 - Independent|63
499|1 - Needed Some Help|1 - Needed Some Help|63
500|2 - Dependent|2 - Dependent|63
502|0 - No assistance needed in this area|0 - No assistance needed in this area|63
503|1 - Caregiver(s) currently provide assistance|1 - Caregiver(s) currently provide assistance|63
504|2 - Caregiver(s) need training/ supportive services to provide assistance|2 - Caregiver(s) need training/ supportive services to provide assistance|63
505|3 - Caregiver(s) not likely to provide assistance|3 - Caregiver(s) not likely to provide assistance|63
506|4 - Unclear if Caregiver(s) will provide assistance|4 - Unclear if Caregiver(s) will provide assistance|63
507|5 - Assistance needed, but no Caregiver(s) available|5 - Assistance needed, but no Caregiver(s) available|63
508|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will use standardized clinical guidelines accessible for all care providers to reference|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will|63
509|NA - Patient is not diabetic or is bilateral amputee|NA - Patient is not diabetic or is bilateral amputee|63
510|NA - Patient is not assessed to be at risk for falls|NA - Patient is not assessed to be at risk for falls|63
511|NA - Patient has no diagnosis or symptoms of depression|NA - Patient has no diagnosis or symptoms of depression|63
512|NA - No pain identified|NA - No pain identified|63
513|NA - Patient is not assessed to be at risk for pressure ulcers|NA - Patient is not assessed to be at risk for pressure ulcers|63
514|NA - Patient has no pressure ulcers with need for moist wound healing|NA - Patient has no pressure ulcers with need for moist wound healing|63
515|1 - Long-term nursing facility (NF)|1 - Long-term nursing facility (NF)|63
516|2 - Skilled nursing facility (SNF / TCU)|2 - Skilled nursing facility (SNF / TCU)|63
517|3 - Short stay acute hospital (IPP S)|3 - Short stay acute hospital (IPP S)|63
518|4 - Long-term care hospital (LTCH)|4 - Long-term care hospital (LTCH)|63
519|5 - Inpatient rehabilitation hospital or unit (IRF)|5 - Inpatient rehabilitation hospital or unit (IRF)|63
520|6 - Psychiatric hospital or unit|6 - Psychiatric hospital or unit|63
521|7 - Other|7 - Other|63
522|NA - Patient was not discharged from an inpatient facility [Go to M1017]|NA - Patient was not discharged from an inpatient facility [Go to M1017]|63
523|6 - Unable to participate effectively in bathing and is bathed totally by another person|6 - Unable to participate effectively in bathing and is bathed totally by another person|63
524|4 - Chairfast, unable to ambulate but is able to wheel self independently.|4 - Chairfast, unable to ambulate but is able to wheel self independently.|63
525|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask patient: "Over the last two weeks, how often have you been bothered by any of the following problems")  *Copyright+ Pfizer Inc. All rights reserved. Reproduced with permission.|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask|63
526|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluation for depression.|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluat|63
527|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet criteria for further evaluation for depression.|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet|63
528|0 - Not at all  0 - 1 day|0 - Not at all  0 - 1 day|63
529|1 - Several days  2 - 6 days|1 - Several days  2 - 6 days|63
530|2 - More than half of the days  7 - 11 days|2 - More than half of the days  7 - 11 days|63
531|3 - Nearly every day  12 - 14 days|3 - Nearly every day  12 - 14 days|63
532|NA - N/A  Unable to respond|NA - N/A  Unable to respond|63
533|2 - Able to take medication(s) at the correct times if given reminders by another person based on the frequency of the injection|2 - Able to take medication(s) at the correct times if given reminders by another person based on th|63
534|3 - Unable to take injectable medication unless administered by another person.|3 - Unable to take injectable medication unless administered by another person.|63
540|11 - Patient lives in congregate situation (e.g., assisted living) around the clock|11 - Patient lives in congregate situation (e.g., assisted living) around the clock|63
541|12 - Patient lives in congregate situation (e.g., assisted living) regular daytime|12 - Patient lives in congregate situation (e.g., assisted living) regular daytime|63
542|13 - Patient lives in congregate situation (e.g., assisted living) regular nighttime|13 - Patient lives in congregate situation (e.g., assisted living) regular nighttime|63
543|14 - Patient lives in congregate situation (e.g., assisted living) occasional / short-term assistance|14 - Patient lives in congregate situation (e.g., assisted living) occasional / short-term assistanc|63
544|15 - Patient lives in congregate situation (e.g., assisted living) no available assistance|15 - Patient lives in congregate situation (e.g., assisted living) no available assistance|63
546|NA - No observable pressure ulcer|NA - No observable pressure ulcer|63
583|NA - No specific SOC date ordered by physician|NA - No specific SOC date ordered by physician|63
586|UK - Inpatient Discharge Date Unknown|UK - Inpatient Discharge Date Unknown|63
601|1 - History of falls (2 or more falls - or any fall with an injury - in the past 12 months) |1 - History of falls (2 or more falls - or any fall with an injury - in the past 12 months) |63
603|2 - Unintentional weight loss of a total of 10 pounds or more in the past 12 months |2 - Unintentional weight loss of a total of 10 pounds or more in the past 12 months |63
605|3 - Multiple hospitalizations (2 or more) in the past 6 months|3 - Multiple hospitalizations (2 or more) in the past 6 months|63
607|4 - Multiple emergency department visits (2 or more) in the past 6 months|4 - Multiple emergency department visits (2 or more) in the past 6 months|63
609|5 - Decline in mental emotional or behavioral status in the past 3 months |5 - Decline in mental emotional or behavioral status in the past 3 months |63
611|6 - Reported or observed history of difficulty complying with any medical instructions (for example |6 - Reported or observed history of difficulty complying with any medical instructions (for example |63
613|7 - Currently taking 5 or more medications|7 - Currently taking 5 or more medications|63
615|8 - Currently reports exhaustion|8 - Currently reports exhaustion|63
617|9 - Other risk(s) not listed in 1 - 8|9 - Other risk(s) not listed in 1 - 8|63
619|10 - None of the above |10 - None of the above |63
632|0 - No assistance needed v patient is independent or does not have needs in this area|0 - No assistance needed v patient is independent or does not have needs in this area|63
633|1 - Non-agency caregiver(s) currently provide assistance |1 - Non-agency caregiver(s) currently provide assistance |63
634|2 - Non-agency caregiver(s) need training/ supportive services to provide assistance|2 - Non-agency caregiver(s) need training/ supportive services to provide assistance|63
635|3 - Non-agency caregiver(s) are not likely to provide assistance OR it is unclear if they will provide assistance|3 - Non-agency caregiver(s) are not likely to provide assistance OR unclear if will provide asst|63
636|4 - Assistance needed but no non-agency caregiver(s) available|4 - Assistance needed but no non-agency caregiver(s) available|63
2|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; OR (b) Is physically, cognitively, and mentally able to prepare light meals on a regular basis but has not routinely performed light meal preparation in the past (i.e., prior to this home care admission).|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; O|64
3|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and mentally able to perform all housekeeping tasks .|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and menta|64
4|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and mentally able to do laundry and access facilities.|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and menta|64
5|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying packages OR b) Physically, cognitively, and mentally able to take care of shopping, but has not done shopping in the past (i.e., prior to this home care admission).|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying|64
6|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|64
7|0 - Able to dial numbers and answer calls appropriately and as desired.|0 - Able to dial numbers and answer calls appropriately and as desired.|64
8|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body without assistance.|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body|64
9|0 - Able to get to and from the toilet and transfer independently with or without a device.|0 - Able to get to and from the toilet and transfer independently with or without a device.|64
10|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|64
11|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible public bus.|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible p|64
12|0 - Able to independently feed self.|0 - Able to independently feed self.|64
13|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|64
14|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct times.|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct ti|64
15|0 - Able to independently transfer.|0 - Able to independently transfer.|64
16|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without rail|64
17|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings|64
18|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|64
19|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions independently.|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions indep|64
20|0 - Asymptomatic, no treatment needed at this time|0 - Asymptomatic, no treatment needed at this time|64
21|0 - Caregiver manages all tasks related to equipment completely independently.|0 - Caregiver manages all tasks related to equipment completely independently.|64
22|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations with no observable impairment.|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations w|64
23|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|64
24|0 - Life expectancy is greater than 6 months|0 - Life expectancy is greater than 6 months|64
25|0 - Never|0 - Never|64
26|0 - Patient is not short of breath|0 - Patient is not short of breath|64
27|0 - No|0 - No|64
28|0 - No emergent care services|0 - No emergent care services|64
29|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [Goto M1620]|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [Goto M1620]|64
30|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and extended or abstract conversation.|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and exte|64
31|0 - No one person|0 - No one person|64
32|0 - None of the time|0 - None of the time|64
33|0 - None, no charge for current services|0 - None, no charge for current services|64
34|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|64
35|0 - Patient does NOT have an ostomy for bowel elimination.|0 - Patient does NOT have an ostomy for bowel elimination.|64
36|0 - Patient has no pain|0 - Patient has no pain|64
37|0 - Patient manages all tasks related to equipment completely independently.|0 - Patient manages all tasks related to equipment completely independently.|64
38|0 - Poor:  little or no recovery is expected and/or further decline is imminent|0 - Poor:  little or no recovery is expected and/or further decline is imminent|64
39|0 - Timed-voiding defers incontinence|0 - Timed-voiding defers incontinence|64
40|0 - Very rarely or never has bowel incontinence|0 - Very rarely or never has bowel incontinence|64
41|0 - Zero|0 - Zero|64
42|00 - No|00 - No|64
43|01 - Yes|01 - Yes|64
44|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or mental limitations, needs assistance with heavy laundry.|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or|64
45|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the patient.|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the|64
46|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|64
47|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or supervision from another person OR c) a liquid, pureed or ground meat diet.|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or su|64
48|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|64
49|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|64
50|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independently.|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independe|64
51|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only when assisted or accompanied by another person.|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only w|64
52|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepa|64
53|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance by another person OR b) given daily reminders.|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance b|64
54|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advan|64
55|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advan|64
56|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for the deaf) and call essential numbers.|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for t|64
57|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|64
58|1 - American Indian or Alaska Native|1 - American Indian or Alaska Native|64
59|1 - Depressed mood (e.g., feeling sad, tearful)|1 - Depressed mood (e.g., feeling sad, tearful)|64
60|1 - During the night only|1 - During the night only|64
61|1 - Fully granulating|1 - Fully granulating|64
62|1 - Good/Fair:  partial to full recovery is expected|1 - Good/Fair:  partial to full recovery is expected|64
63|1 - Good:  marked improvement in functional status is expected|1 - Good:  marked improvement in functional status is expected|64
64|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|64
65|1 - Smoking|1 - Smoking|64
66|1 - Hospital|1 - Hospital|64
67|1 - Hospital emergency room (includes 23-hour holding)|1 - Hospital emergency room (includes 23-hour holding)|64
68|1 - Hospitalization for EMERGENT (unscheduled) care|1 - Hospitalization for EMERGENT (unscheduled) care|64
69|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepared solutions), patient is able to manage all other aspects of equipment.|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepar|64
70|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|64
71|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|64
72|1 - In new or complex situations only|1 - In new or complex situations only|64
73|1 - Intravenous or infusion therapy (excludes TPN)|1 - Intravenous or infusion therapy (excludes TPN)|64
74|1 - Less often than daily|1 - Less often than daily|64
75|1 - Less than once a month|1 - Less than once a month|64
76|1 - Less than once weekly|1 - Less than once weekly|64
77|1 - Life expectancy is 6 months or fewer|1 - Life expectancy is 6 months or fewer|64
78|1 - Lives alone|1 - Lives alone|64
79|1 - Male|1 - Male|64
80|1 - Medicare (traditional fee-for-service)|1 - Medicare (traditional fee-for-service)|64
81|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of past 24 hours, significant memory loss so that supervision is required|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of pas|64
82|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors in word choice, grammar or speech intelligibility, needs minimal prompting or assistance).|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors i|64
83|1 - No assistance or services received|1 - No assistance or services received|64
84|1 - One|1 - One|64
85|1 - Oxygen (intermittent or continuous)|1 - Oxygen (intermittent or continuous)|64
86|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, and the surrounding layout, can count fingers at arm's length.|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, a|64
87|1 - Patient is incontinent|1 - Patient is incontinent|64
88|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|64
89|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical or treatment regimen.|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical|64
90|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient/couple/significant other)|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient|64
91|1 - Relatives, friends, or neighbors living outside the home|1 - Relatives, friends, or neighbors living outside the home|64
92|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions.|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions|64
93|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independentl|64
94|1 - Several times during day and night|1 - Several times during day and night|64
95|1 - Spouse or significant other|1 - Spouse or significant other|64
96|1 - Stage 1|1 - Stage 1|64
97|1 - Start of care - further visits planned|1 - Start of care - further visits planned|64
98|1 - Symptoms well controlled with current therapy|1 - Symptoms well controlled with current therapy|64
99|1 - Therapy services|1 - Therapy services|64
100|1 - Able to transfer with minimal human assistance or with use of an assistive device.|1 - Able to transfer with minimal human assistance or with use of an assistive device.|64
101|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitations.|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitatio|64
102|1 - Urinary incontinence|1 - Urinary incontinence|64
103|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and transfer.|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and|64
104|1 - When walking more than 20 feet, climbing stairs|1 - When walking more than 20 feet, climbing stairs|64
105|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary conversation. May need occasional repetition, extra time, or louder voice.|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary c|64
106|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting in and out of tub/shower|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting|64
107|1 - Yes|1 - Yes|64
108|1-RN|1-RN|64
109|10 - Discharge from agency - no visits completed after start/resumption of care assessment|10 - Discharge from agency - no visits completed after start/resumption of care assessment|64
110|10 - Scheduled surgical procedure|10 - Scheduled surgical procedure|64
111|10 - Self-pay|10 - Self-pay|64
112|11 - Other|11 - Other|64
113|11 - Urinary tract infection|11 - Urinary tract infection|64
114|12 - IV catheter-related infection|12 - IV catheter-related infection|64
115|13 - Deep vein thrombosis, pulmonary embolus|13 - Deep vein thrombosis, pulmonary embolus|64
116|14 - Uncontrolled pain|14 - Uncontrolled pain|64
117|15 - Psychotic episode|15 - Psychotic episode|64
118|16 - Other than above reasons|16 - Other than above reasons|64
119|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing calls.|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing|64
120|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another person.|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another pers|64
121|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface a|64
122|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for intermittent supervision or encouragement or reminders, OR (b) to get in and out of the shower or tub, OR (c) for washing difficult to reach areas.|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for inter|64
123|2 - Asian|2 - Asian|64
124|2 - Caregiver requires considerable assistance from another person to manage equipment, but independently completes significant portions of task.|2 - Caregiver requires considerable assistance from another person to manage equipment, but independ|64
125|2 - Daily, but not constantly|2 - Daily, but not constantly|64
126|2 - Daughter or son|2 - Daughter or son|64
127|2 - Doctor's office emergency visit/house call|2 - Doctor's office emergency visit/house call|64
128|2 - During the day and night|2 - During the day and night|64
129|2 - Early/partial granulation|2 - Early/partial granulation|64
130|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors in word choice, organization or speech intelligibility). Speaks in phrases or short sentences.|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors|64
131|2 - Family member's residence|2 - Family member's residence|64
132|2 - Female|2 - Female|64
133|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conversation, needs frequent prompting or assistance.|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conver|64
134|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|64
135|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|64
136|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately stop activities, jeopardizes safety through actions|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately st|64
137|2 - Indwelling/suprapubic catheter|2 - Indwelling/suprapubic catheter|64
138|2 - Injury caused by fall or accident at home|2 - Injury caused by fall or accident at home|64
139|2 - Medicare (HMO/managed care/Advantage plan)|2 - Medicare (HMO/managed care/Advantage plan)|64
140|2 - Nausea, dehydration, malnutrition, constipation, impaction|2 - Nausea, dehydration, malnutrition, constipation, impaction|64
141|2 - Obesity|2 - Obesity|64
142|2 - On awakening or at night only|2 - On awakening or at night only|64
143|2 - Once a month|2 - Once a month|64
144|2 - One to three times weekly|2 - One to three times weekly|64
145|2 - Parenteral nutrition (TPN or lipids)|2 - Parenteral nutrition (TPN or lipids)|64
146|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic) [ Go to M1620 ]|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic) [ Go|64
147|2 - Patient requires considerable assistance from another person to manage equipment, but independently completes portions of the task.|2 - Patient requires considerable assistance from another person to manage equipment, but independen|64
148|2 - Patient transferred to a noninstitutional hospice|2 - Patient transferred to a noninstitutional hospice|64
149|2 - Person residing in the home (EXCLUDING paid help)|2 - Person residing in the home (EXCLUDING paid help)|64
150|2 - Rehabilitation facility|2 - Rehabilitation facility|64
151|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifting of attention) or consistently requires low stimulus environment due to distractibility.|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifti|64
152|2 - Respite care|2 - Respite care|64
153|2 - Sense of failure or self reproach|2 - Sense of failure or self reproach|64
154|2 - Several times during day|2 - Several times during day|64
155|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonresponsive.|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonrespons|64
156|2 - Someone must assist the patient to groom self.|2 - Someone must assist the patient to groom self.|64
157|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|64
158|2 - Someone must help the patient put on upper body clothing.|2 - Someone must help the patient put on upper body clothing.|64
159|2 - Stage 2|2 - Stage 2|64
160|2 - Start of care - no further visits planned|2 - Start of care - no further visits planned|64
161|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitoring|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitori|64
162|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment regimen.|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment re|64
163|2 - Two|2 - Two|64
164|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistance due to cognitive or mental limitation.|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistanc|64
165|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|64
166|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assistance).|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assis|64
167|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home delivery.|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home deli|64
168|2 - Unable to prepare any light meals or reheat any delivered meals.|2 - Unable to prepare any light meals or reheat any delivered meals.|64
169|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|64
170|2 - UNABLE to take injectable medications unless administered by someone else.|2 - UNABLE to take injectable medications unless administered by someone else.|64
171|2 - UNABLE to take medication unless administered by someone else.|2 - UNABLE to take medication unless administered by someone else.|64
172|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|64
173|2 - Ventilator (continually or at night)|2 - Ventilator (continually or at night)|64
174|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less than 20 feet)|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less th|64
175|2 - With spouse or significant other|2 - With spouse or significant other|64
176|2 - Yes, assistance or services provided by family or friends|2 - Yes, assistance or services provided by family or friends|64
177|2-PT|2-PT|64
178|3 - Able to answer the telephone only some of the time or is able to carry on only a limited conversation.|3 - Able to answer the telephone only some of the time or is able to carry on only a limited convers|64
179|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube or gastrostomy.|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube|64
180|3 - Alcohol dependency|3 - Alcohol dependency|64
181|3 - All of the time|3 - All of the time|64
182|3 - Black or African-American|3 - Black or African-American|64
183|3 - Boarding home or rented room|3 - Boarding home or rented room|64
184|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment, clean/store/dispose of equipment or supplies).|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment,|64
185|3 -Able to walk only with the supervision or assistance of another person at all times.|3 -Able to walk only with the supervision or assistance of another person at all times.|64
186|3 - Continuous / Bi-level positive airway pressure|3 - Continuous / Bi-level positive airway pressure|64
187|3 - During the day and evening, but not constantly|3 - During the day and evening, but not constantly|64
188|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the alimentary canal)|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the|64
189|3 - Environmental support (e.g., housing, home maintenance)|3 - Environmental support (e.g., housing, home maintenance)|64
190|3 - Four to six times weekly|3 - Four to six times weekly|64
191|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessing by listener.  Speech limited to single words or short phrases.|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessin|64
192|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires multiple repetitions, restatements, demonstrations, additional time.|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires m|64
193|3 - Hopelessness|3 - Hopelessness|64
194|3 - Hospice care|3 - Hospice care|64
195|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|64
196|3 - Injury caused by fall or accident at home|3 - Injury caused by fall or accident at home|64
197|3 - Intractable pain|3 - Intractable pain|64
198|3 - Medicaid (traditional fee-for-service)|3 - Medicaid (traditional fee-for-service)|64
199|3 - Needs someone to do all shopping and errands.|3 - Needs someone to do all shopping and errands.|64
200|3 - Not healing|3 - Not healing|64
201|3 - Nursing home|3 - Nursing home|64
202|3 - Once daily|3 - Once daily|64
203|3 - Other family member|3 - Other family member|64
204|3 - Outpatient department/clinic emergency (includes urgicenter sites)|3 - Outpatient department/clinic emergency (includes urgicenter sites)|64
205|3 - Paid help|3 - Paid help|64
206|3 - Able to participate in bathing self in shower or tub, but requires presence of another person throughout the bath for assistance or supervision.|3 - Able to participate in bathing self in shower or tub, but requires presence of another person th|64
207|3 - Patient depends entirely upon another person to dress lower body.|3 - Patient depends entirely upon another person to dress lower body.|64
208|3 - Patient depends entirely upon another person to dress the upper body.|3 - Patient depends entirely upon another person to dress the upper body.|64
209|3 - Patient depends entirely upon someone else for grooming needs.|3 - Patient depends entirely upon someone else for grooming needs.|64
210|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone else to manage the equipment.|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone|64
211|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable to shift attention and recall directions more than half the time.|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable|64
212|3 - Respiratory problems (SOB, infection, obstruction)|3 - Respiratory problems (SOB, infection, obstruction)|64
213|3 - Resumption of care (after inpatient stay)|3 - Resumption of care (after inpatient stay)|64
214|3 - Several times each month|3 - Several times each month|64
215|3 - Skilled Nursing Facility|3 - Skilled Nursing Facility|64
216|3 - Stage 3|3 - Stage 3|64
217|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|64
218|3 - Three|3 - Three|64
219|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person throughout the process.|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person through|64
220|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal independently.|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal indep|64
221|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person.|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person|64
222|3 - Unknown because patient moved to a geographic location not served by this agency|3 - Unknown because patient moved to a geographic location not served by this agency|64
223|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|64
224|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|64
225|3 - With other family member|3 - With other family member|64
226|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home health services, homemaker assistance, transportation assistance, assisted living, board and care)|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home h|64
227|3-SLP/ST|3-SLP/ST|64
228|4 - At rest (during day or night)|4 - At rest (during day or night)|64
229|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|64
230|4 - Board and care or assisted living facility|4 - Board and care or assisted living facility|64
231|4 - Caregiver is completely dependent on someone else to manage all equipment.|4 - Caregiver is completely dependent on someone else to manage all equipment.|64
232|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|64
233|4 - Constantly|4 - Constantly|64
234|4 - Drug dependency|4 - Drug dependency|64
235|4 - Four or more|4 - Four or more|64
236|4 - Friend or neighbor or community or church member|4 - Friend or neighbor or community or church member|64
237|4 - Hispanic or Latino|4 - Hispanic or Latino|64
238|4 - Hospice|4 - Hospice|64
239|4 - Impaired decision-making|4 - Impaired decision-making|64
240|4 - Is totally dependent in toileting.|4 - Is totally dependent in toileting.|64
241|4 - Medicaid (HMO/managed care)|4 - Medicaid (HMO/managed care)|64
242|4 - None of the above|4 - None of the above|64
243|4 - Nursing home|4 - Nursing home|64
244|4 - On a daily basis|4 - On a daily basis|64
245|4 - Patient is completely dependent on someone else to manage all equipment.|4 - Patient is completely dependent on someone else to manage all equipment.|64
246|4 - Permanent placement|4 - Permanent placement|64
247|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, punches, dangerous maneuvers w/ wheelchair or other objects)|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, pu|64
248|4 - Psychosocial support (e.g., socialization, companionship, recreation)|4 - Psychosocial support (e.g., socialization, companionship, recreation)|64
249|4 - Recertification (follow-up) reassessment|4 - Recertification (follow-up) reassessment|64
250|4 - Recurrent thoughts of death|4 - Recurrent thoughts of death|64
251|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruction)|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruc|64
252|4 - Several times a week|4 - Several times a week|64
253|4 - Stage 4|4 - Stage 4|64
254|4 - Symptoms poorly controlled, history of re-hospitalizations|4 - Symptoms poorly controlled, history of re-hospitalizations|64
255|4 - Three or more times per week|4 - Three or more times per week|64
256|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetative state, or delirium.|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetati|64
257|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|64
258|4 - Unable to effectively participate in any housekeeping tasks.|4 - Unable to effectively participate in any housekeeping tasks.|64
259|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or unresponsive (e.g., speech is nonsensical or unintelligible).|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or u|64
260|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonresponsive.|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonr|64
261|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostomy.|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostom|64
262|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of devices at the sink, in chair, or on commode|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of|64
263|4 - With a friend|4 - With a friend|64
264|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|64
265|4-OT|4-OT|64
266|5 - Advocates or facilitates patient's participation in appropriate medical care|5 - Advocates or facilitates patient's participation in appropriate medical care|64
267|5 - At least daily|5 - At least daily|64
268|6 - Bedfast, unable to ambulate or be up in a chair.|6 - Bedfast, unable to ambulate or be up in a chair.|64
269|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|64
270|5 - Disruptive or socially inappropriate behavior|5 - Disruptive or socially inappropriate behavior|64
271|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|64
272|5 - Hypo/Hyperglycemia, diabetes out of control|5 - Hypo/Hyperglycemia, diabetes out of control|64
273|5 - More often than once daily|5 - More often than once daily|64
274|5 - Native Hawaiian or Pacific Islander|5 - Native Hawaiian or Pacific Islander|64
275|5 - None of the above|5 - None of the above|64
276|5 - One to two times per week|5 - One to two times per week|64
277|5 - Other|5 - Other|64
278|5 - Other follow-up|5 - Other follow-up|64
279|5 - Paid help|5 - Paid help|64
280|5 - Patient nonresponsive or unable to speak.|5 - Patient nonresponsive or unable to speak.|64
281|5 - Thoughts of suicide|5 - Thoughts of suicide|64
282|5 - Totally unable to use the telephone.|5 - Totally unable to use the telephone.|64
283|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|64
284|5 - Unable to take in nutrients orally or by tube feeding.|5 - Unable to take in nutrients orally or by tube feeding.|64
285|5 - Unsafe for care at home|5 - Unsafe for care at home|64
286|5 - With paid help (other than home care agency staff)|5 - With paid help (other than home care agency staff)|64
287|5 - Workers' compensation|5 - Workers' compensation|64
288|5 - Wound infection, deteriorating wound status, new lesion/ulcer|5 - Wound infection, deteriorating wound status, new lesion/ulcer|64
289|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|64
290|6 - Delusional, hallucinatory, or paranoid behavior|6 - Delusional, hallucinatory, or paranoid behavior|64
291|6 - Financial agent, power of attorney, or conservator of finance|6 - Financial agent, power of attorney, or conservator of finance|64
292|6 - GI bleeding, obstruction|6 - GI bleeding, obstruction|64
293|6 - Less often than weekly|6 - Less often than weekly|64
294|6 - Memory loss to the extent that supervision required|6 - Memory loss to the extent that supervision required|64
295|6 - None of the above feelings observed or reported|6 - None of the above feelings observed or reported|64
296|6 - Other|6 - Other|64
297|6 - Title programs (e.g., Title III, V, or XX)|6 - Title programs (e.g., Title III, V, or XX)|64
298|6 - Transferred to an inpatient facility - patient not discharged from agency|6 - Transferred to an inpatient facility - patient not discharged from agency|64
299|6 - White|6 - White|64
300|6 - With other than above|6 - With other than above|64
301|7 - Exacerbation of CHF, fluid overload, heart failure|7 - Exacerbation of CHF, fluid overload, heart failure|64
302|7 - Health care agent, conservator of person, or medical power of attorney|7 - Health care agent, conservator of person, or medical power of attorney|64
303|7 - Hypo/Hyperglycemia, diabetes out of control|7 - Hypo/Hyperglycemia, diabetes out of control|64
304|7 - None of the above|7 - None of the above|64
305|7 - None of the above behaviors demonstrated|7 - None of the above behaviors demonstrated|64
306|7 - Other government (e.g., TriCare, VA, etc.)|7 - Other government (e.g., TriCare, VA, etc.)|64
307|7 - Transferred to an inpatient facility - patient discharged from agency|7 - Transferred to an inpatient facility - patient discharged from agency|64
308|8 - Death at home|8 - Death at home|64
309|8 - GI bleeding, obstruction|8 - GI bleeding, obstruction|64
310|8 - Myocardial infarction, stroke|8 - Myocardial infarction, stroke|64
311|8 - Private insurance|8 - Private insurance|64
312|9 - Chemotherapy|9 - Chemotherapy|64
313|9 - Discharge from agency|9 - Discharge from agency|64
314|9 - Other than above reasons|9 - Other than above reasons|64
315|9 - Private HMO/managed care|9 - Private HMO/managed care|64
316|NA - No caregiver|NA - No caregiver|64
317|NA - No equipment of this type used in care.|NA - No equipment of this type used in care.|64
318|NA - No inhalant/mist medications prescribed.|NA - No inhalant/mist medications prescribed.|64
319|NA - No injectable medications prescribed.|NA - No injectable medications prescribed.|64
320|NA - No inpatient facility admission|NA - No inpatient facility admission|64
321|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|64
322|NA - No Medicaid|NA - No Medicaid|64
323|NA - No Medicare|NA - No Medicare|64
324|NA - No observable pressure ulcer or unhealed pressure ulcer|NA - No observable pressure ulcer or unhealed pressure ulcer|64
325|NA - No observable stasis ulcer|NA - No observable stasis ulcer|64
326|NA - No observable surgical wound|NA - No observable surgical wound|64
327|NA - No oral medications prescribed.|NA - No oral medications prescribed.|64
328|NA - Not applicable|NA - Not applicable|64
329|NA - Patient does not have a telephone.|NA - Patient does not have a telephone.|64
330|NA - Patient has ostomy for bowel elimination|NA - Patient has ostomy for bowel elimination|64
331|NA - Patient nonresponsive|NA - Patient nonresponsive|64
332|NA - Patient on prophylactic treatment|NA - Patient on prophylactic treatment|64
333|NA - Patient was not discharged from an inpatient facility [Go to M1017]|NA - Patient was not discharged from an inpatient facility [Go to M1017]|64
334|UK - Other unknown|UK - Other unknown|64
335|UK - Reason unknown|UK - Reason unknown|64
336|UK - Unknown|UK - Unknown|64
337|UK - Unknown or Not Available|UK - Unknown or Not Available|64
341|01 - Early|01 - Early|64
342|02 - Late|02 - Late|64
343|NA - Not Applicable. No case mix group defined for this assessment.|NA - Not Applicable. No case mix group defined for this assessment.|64
344|NA - No case mix group defined by this assessment.|NA - No case mix group defined by this assessment.|64
345|1 - Recent decline in mental, emotional, or behavioral status|1 - Recent decline in mental, emotional, or behavioral status|64
346|2 - Multiple hospitalizations (2 or more) in the past 12 months|2 - Multiple hospitalizations (2 or more) in the past 12 months|64
347|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|64
348|4 - Taking five or more medications|4 - Taking five or more medications|64
349|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|64
350|6 - Other|6 - Other|64
351|7 - None of the above|7 - None of the above|64
352|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond tho|64
353|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable without heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable wi|64
354|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious complications and death.|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious compl|64
355|3 - The patient has serious progressive conditions that could lead to death within a year.|3 - The patient has serious progressive conditions that could lead to death within a year.|64
356|UK - The patient+s situation is unknown or unclear.|UK - The patient+s situation is unknown or unclear.|64
357|1 - Yes [ Go to M1050 ]|1 - Yes [ Go to M1050 ]|64
358|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this influenza season. [ Go to M1050 ]|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this i|64
359|1 - Received from another health care provider (e.g., physician)|1 - Received from another health care provider (e.g., physician)|64
360|2 - Received from your agency previously during this year+s flu season|2 - Received from your agency previously during this year+s flu season|64
361|3 - Offered and declined|3 - Offered and declined|64
362|4 - Assessed and determined to have medical contraindication(s)|4 - Assessed and determined to have medical contraindication(s)|64
363|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|64
364|6 - Inability to obtain vaccine due to declared shortage|6 - Inability to obtain vaccine due to declared shortage|64
365|1 - Yes [ Go to M1501 at TRN; Go to M1230 at DC ]|1 - Yes [ Go to M1501 at TRN; Go to M1230 at DC ]|64
366|1 - Patient has received PPV in the past|1 - Patient has received PPV in the past|64
367|2 - Offered and declined|2 - Offered and declined|64
368|3 - Assessed and determined to have medical contraindication(s)|3 - Assessed and determined to have medical contraindication(s)|64
369|4 - Not indicated; patient does not meet age/condition guidelines for PPV|4 - Not indicated; patient does not meet age/condition guidelines for PPV|64
370|5 - None of the above|5 - None of the above|64
371|0 - Adequate: hears normal conversation without difficulty.|0 - Adequate: hears normal conversation without difficulty.|64
372|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to increase volume or speak distinctly.|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to in|64
373|2 - Severely Impaired: absence of useful hearing.|2 - Severely Impaired: absence of useful hearing.|64
374|UK - Unable to assess hearing.|UK - Unable to assess hearing.|64
375|0 - Understands: clear comprehension without cues or repetitions.|0 - Understands: clear comprehension without cues or repetitions.|64
376|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Requires cues at times to understand.|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Req|64
377|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequently requires cues to understand.|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequentl|64
378|3 - Rarely/Never Understands|3 - Rarely/Never Understands|64
379|UK - Unable to assess understanding.|UK - Unable to assess understanding.|64
380|0 - No standardized assessment conducted|0 - No standardized assessment conducted|64
381|1 - Yes, and it does not indicate severe pain|1 - Yes, and it does not indicate severe pain|64
382|2 - Yes, and it indicates severe pain|2 - Yes, and it indicates severe pain|64
383|0 - Patient has no pain|0 - Patient has no pain|64
384|1 - Patient has pain that does not interfere with activity or movement|1 - Patient has pain that does not interfere with activity or movement|64
385|2 - Less often than daily|2 - Less often than daily|64
386|3 - Daily, but not constantly|3 - Daily, but not constantly|64
387|4 - All of the time|4 - All of the time|64
388|0 - No assessment conducted [ Go to M1306 ]|0 - No assessment conducted [ Go to M1306 ]|64
389|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc., without use of standardized tool|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc.,|64
390|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|64
391|0 - No [ Go to M1322]|0 - No [ Go to M1322]|64
392|0 v Newly epithelialized|0 v Newly epithelialized|64
393|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|64
394|2 - Yes, patient has observable stasis ulcers ONLY|2 - Yes, patient has observable stasis ulcers ONLY|64
395|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable dressing) [Go to M1340]|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable|64
396|0 - No [ Go to M1400 ]|0 - No [ Go to M1400 ]|64
397|1 - Yes, patient has at least one (observable) surgical wound|1 - Yes, patient has at least one (observable) surgical wound|64
398|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1400 ]|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1400 ]|64
399|0 - Patient is not short of breath|0 - Patient is not short of breath|64
400|3 - Continuous Bi-level positive airway pressure|3 - Continuous Bi-level positive airway pressure|64
401|0 - No [ Go to M1732 at TRN; Go to M1600 at DC ]|0 - No [ Go to M1732 at TRN; Go to M1600 at DC ]|64
402|2 - Not assessed [Go to M1732 at TRN; Go to M1600 at DC ]|2 - Not assessed [Go to M1732 at TRN; Go to M1600 at DC ]|64
403|NA - Patient does not have diagnosis of heart failure [Go to M2005 at TRN; Go to M1600 at DC]|NA - Patient does not have diagnosis of heart failure [Go to M2005 at TRN; Go to M1600 at DC]|64
404|0 - No action taken|0 - No action taken|64
405|1 - Patient+s physician (or other primary care practitioner) contacted the same day|1 - Patient+s physician (or other primary care practitioner) contacted the same day|64
406|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|64
407|3 - Implement physician-ordered patient-specific established parameters for treatment|3 - Implement physician-ordered patient-specific established parameters for treatment|64
408|4 - Patient education or other clinical interventions|4 - Patient education or other clinical interventions|64
409|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequency, telehealth, etc.)|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequ|64
410|1 - Occasional stress incontinence|1 - Occasional stress incontinence|64
411|2 - During the night only|2 - During the night only|64
412|3 - During the day only|3 - During the day only|64
413|4 - During the day and night|4 - During the day and night|64
414|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|64
415|0 - Able to manage toileting hygiene and clothing management without assistance.|0 - Able to manage toileting hygiene and clothing management without assistance.|64
416|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implements are laid out for the patient.|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implemen|64
417|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|64
418|3 - Patient depends entirely upon another person to maintain toileting hygiene.|3 - Patient depends entirely upon another person to maintain toileting hygiene.|64
419|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independent|64
420|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface|64
421|0 - No multi-factor falls risk assessment conducted.|0 - No multi-factor falls risk assessment conducted.|64
422|1 - Yes, and it does not indicate a risk for falls.|1 - Yes, and it does not indicate a risk for falls.|64
423|2 - Yes, and it indicates a risk for falls.|2 - Yes, and it indicates a risk for falls.|64
424|0 - Not assessed/reviewed [ Go to M2010 ]|0 - Not assessed/reviewed [ Go to M2010 ]|64
425|1 - No problems found during review [ Go to M2010 ]|1 - No problems found during review [ Go to M2010 ]|64
426|2 - Problems found during review|2 - Problems found during review|64
427|NA - Patient is not taking any medications [ Go to M2040 ]|NA - Patient is not taking any medications [ Go to M2040 ]|64
428|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special precautions associated with all high-risk medications|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special p|64
429|NA - Patient not taking any drugs|NA - Patient not taking any drugs|64
430|2 - Able to take medication(s) at the correct times if given reminders by another person at the appropriate times|2 - Able to take medication(s) at the correct times if given reminders by another person at the appr|64
431|3 - Unable to take medication unless administered by another person.|3 - Unable to take medication unless administered by another person.|64
432|1 - At least daily|1 - At least daily|64
433|2 - Three or more times per week|2 - Three or more times per week|64
434|3 - One to two times per week|3 - One to two times per week|64
435|4 - Received, but less often than weekly|4 - Received, but less often than weekly|64
436|5 - No assistance received|5 - No assistance received|64
437|0 - No [Go to M2401]|0 - No [Go to M2401]|64
438|1 - Yes, used hospital emergency department WITHOUT hospital admission|1 - Yes, used hospital emergency department WITHOUT hospital admission|64
439|2 - Yes, used hospital emergency department WITH hospital admission|2 - Yes, used hospital emergency department WITH hospital admission|64
440|UK - Unknown [Go to M2401]|UK - Unknown [Go to M2401]|64
441|2 - Injury caused by fall|2 - Injury caused by fall|64
442|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|64
443|4 - Other respiratory problem|4 - Other respiratory problem|64
444|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|64
445|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|64
446|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|64
447|8 - Other heart disease|8 - Other heart disease|64
448|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|64
449|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|64
450|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|64
451|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|64
452|13 - Urinary tract infection|13 - Urinary tract infection|64
453|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|64
454|15 - Wound infection or deterioration|15 - Wound infection or deterioration|64
455|16 - Uncontrolled pain|16 - Uncontrolled pain|64
456|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|64
457|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|64
458|19 - Other than above reasons|19 - Other than above reasons|64
459|2 - Patient remained in the community (with formal assistive services)|2 - Patient remained in the community (with formal assistive services)|64
460|3 - Patient transferred to a noninstitutional hospice|3 - Patient transferred to a noninstitutional hospice|64
461|4 - Unknown because patient moved to a geographic location not served by this agency|4 - Unknown because patient moved to a geographic location not served by this agency|64
462|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|64
463|4 - Other respiratory problem|4 - Other respiratory problem|64
464|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|64
465|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|64
466|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|64
467|8 - Other heart disease|8 - Other heart disease|64
468|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|64
469|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|64
470|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|64
471|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|64
472|13 - Urinary tract infection|13 - Urinary tract infection|64
473|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|64
474|15 - Wound infection or deterioration|15 - Wound infection or deterioration|64
475|16 - Uncontrolled pain|16 - Uncontrolled pain|64
476|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|64
477|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|64
478|19 - Scheduled treatment or procedure|19 - Scheduled treatment or procedure|64
479|20 - Other than above reasons|20 - Other than above reasons|64
480|UK - Reason unknown [Go to M0903]|UK - Reason unknown [Go to M0903]|64
482|01 - Patient lives alone around the clock|01 - Patient lives alone around the clock|64
483|02 - Patient lives alone regular daytime|02 - Patient lives alone regular daytime|64
484|03 - Patient lives alone regular nighttime|03 - Patient lives alone regular nighttime|64
485|04 - Patient lives alone occassional/short term assistance|04 - Patient lives alone occassional/short term assistance|64
486|05 - Patient lives alone no assisstance available|05 - Patient lives alone no assisstance available|64
487|06 - Patient lives with other person(s) in the home around the clock|06 - Patient lives with other person(s) in the home around the clock|64
488|07 - Patient lives with other person(s) in the home regular daytime|07 - Patient lives with other person(s) in the home regular daytime|64
489|08 - Patient lives with other person(s) in the home regular nighttime|08 - Patient lives with other person(s) in the home regular nighttime|64
490|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|64
491|10 - Patient lives with other person(s) in the home no assistance available|10 - Patient lives with other person(s) in the home no assistance available|64
492|1 - Was present at the most recent SOC/ROC assessment|1 - Was present at the most recent SOC/ROC assessment|64
493|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|64
494|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|64
495|0 - Newly epithelialized|0 - Newly epithelialized|64
496|0 - No [ Go to M1340 ]|0 - No [ Go to M1340 ]|64
498|0 - Independent|0 - Independent|64
499|1 - Needed Some Help|1 - Needed Some Help|64
500|2 - Dependent|2 - Dependent|64
502|0 - No assistance needed in this area|0 - No assistance needed in this area|64
503|1 - Caregiver(s) currently provide assistance|1 - Caregiver(s) currently provide assistance|64
504|2 - Caregiver(s) need training/ supportive services to provide assistance|2 - Caregiver(s) need training/ supportive services to provide assistance|64
505|3 - Caregiver(s) not likely to provide assistance|3 - Caregiver(s) not likely to provide assistance|64
506|4 - Unclear if Caregiver(s) will provide assistance|4 - Unclear if Caregiver(s) will provide assistance|64
507|5 - Assistance needed, but no Caregiver(s) available|5 - Assistance needed, but no Caregiver(s) available|64
508|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will use standardized clinical guidelines accessible for all care providers to reference|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will|64
510|NA - Patient is not assessed to be at risk for falls|NA - Patient is not assessed to be at risk for falls|64
511|NA - Patient has no diagnosis or symptoms of depression|NA - Patient has no diagnosis or symptoms of depression|64
512|NA - No pain identified|NA - No pain identified|64
513|NA - Patient is not assessed to be at risk for pressure ulcers|NA - Patient is not assessed to be at risk for pressure ulcers|64
514|NA - Patient has no pressure ulcers with need for moist wound healing|NA - Patient has no pressure ulcers with need for moist wound healing|64
515|1 - Long-term nursing facility (NF)|1 - Long-term nursing facility (NF)|64
516|2 - Skilled nursing facility (SNF / TCU)|2 - Skilled nursing facility (SNF / TCU)|64
517|3 - Short stay acute hospital (IPP S)|3 - Short stay acute hospital (IPP S)|64
518|4 - Long-term care hospital (LTCH)|4 - Long-term care hospital (LTCH)|64
519|5 - Inpatient rehabilitation hospital or unit (IRF)|5 - Inpatient rehabilitation hospital or unit (IRF)|64
520|6 - Psychiatric hospital or unit|6 - Psychiatric hospital or unit|64
521|7 - Other|7 - Other|64
522|NA - Patient was not discharged from an inpatient facility [Go to M1017]|NA - Patient was not discharged from an inpatient facility [Go to M1017]|64
523|6 - Unable to participate effectively in bathing and is bathed totally by another person|6 - Unable to participate effectively in bathing and is bathed totally by another person|64
524|4 - Chairfast, unable to ambulate but is able to wheel self independently.|4 - Chairfast, unable to ambulate but is able to wheel self independently.|64
525|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask patient: "Over the last two weeks, how often have you been bothered by any of the following problems")  *Copyright+ Pfizer Inc. All rights reserved. Reproduced with permission.|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask|64
526|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluation for depression.|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluat|64
527|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet criteria for further evaluation for depression.|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet|64
528|0 - Not at all  0 - 1 day|0 - Not at all  0 - 1 day|64
529|1 - Several days  2 - 6 days|1 - Several days  2 - 6 days|64
530|2 - More than half of the days  7 - 11 days|2 - More than half of the days  7 - 11 days|64
531|3 - Nearly every day  12 - 14 days|3 - Nearly every day  12 - 14 days|64
532|NA - N/A  Unable to respond|NA - N/A  Unable to respond|64
533|2 - Able to take medication(s) at the correct times if given reminders by another person based on the frequency of the injection|2 - Able to take medication(s) at the correct times if given reminders by another person based on th|64
534|3 - Unable to take injectable medication unless administered by another person.|3 - Unable to take injectable medication unless administered by another person.|64
535|UK - Inpatient Discharge Date Unknown|UK - Inpatient Discharge Date Unknown|64
538|NA - Inpatient stay within last 14 days Not Applicable|NA - Inpatient stay within last 14 days Not Applicable|64
2|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; OR (b) Is physically, cognitively, and mentally able to prepare light meals on a regular basis but has not routinely performed light meal preparation in the past (i.e., prior to this home care admission).|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; O|65
3|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and mentally able to perform all housekeeping tasks .|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and menta|65
4|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and mentally able to do laundry and access facilities.|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and menta|65
5|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying packages OR b) Physically, cognitively, and mentally able to take care of shopping, but has not done shopping in the past (i.e., prior to this home care admission).|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying|65
6|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|65
7|0 - Able to dial numbers and answer calls appropriately and as desired.|0 - Able to dial numbers and answer calls appropriately and as desired.|65
8|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body without assistance.|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body|65
9|0 - Able to get to and from the toilet and transfer independently with or without a device.|0 - Able to get to and from the toilet and transfer independently with or without a device.|65
10|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|65
11|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible public bus.|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible p|65
12|0 - Able to independently feed self.|0 - Able to independently feed self.|65
13|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|65
14|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct times.|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct ti|65
15|0 - Able to independently transfer.|0 - Able to independently transfer.|65
16|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without rail|65
17|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings|65
18|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|65
19|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions independently.|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions indep|65
20|0 - Asymptomatic, no treatment needed at this time|0 - Asymptomatic, no treatment needed at this time|65
21|0 - Caregiver manages all tasks related to equipment completely independently.|0 - Caregiver manages all tasks related to equipment completely independently.|65
22|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations with no observable impairment.|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations w|65
23|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|65
24|0 - Life expectancy is greater than 6 months|0 - Life expectancy is greater than 6 months|65
25|0 - Never|0 - Never|65
26|0 - Patient is not short of breath|0 - Patient is not short of breath|65
27|0 - No|0 - No|65
28|0 - No emergent care services|0 - No emergent care services|65
29|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [Goto M1620]|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [Goto M1620]|65
30|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and extended or abstract conversation.|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and exte|65
31|0 - No one person|0 - No one person|65
32|0 - None of the time|0 - None of the time|65
33|0 - None, no charge for current services|0 - None, no charge for current services|65
34|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|65
35|0 - Patient does NOT have an ostomy for bowel elimination.|0 - Patient does NOT have an ostomy for bowel elimination.|65
36|0 - Patient has no pain|0 - Patient has no pain|65
37|0 - Patient manages all tasks related to equipment completely independently.|0 - Patient manages all tasks related to equipment completely independently.|65
38|0 - Poor:  little or no recovery is expected and/or further decline is imminent|0 - Poor:  little or no recovery is expected and/or further decline is imminent|65
39|0 - Timed-voiding defers incontinence|0 - Timed-voiding defers incontinence|65
40|0 - Very rarely or never has bowel incontinence|0 - Very rarely or never has bowel incontinence|65
41|0 - Zero|0 - Zero|65
42|00 - No|00 - No|65
43|01 - Yes|01 - Yes|65
44|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or mental limitations, needs assistance with heavy laundry.|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or|65
45|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the patient.|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the|65
46|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|65
47|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or supervision from another person OR c) a liquid, pureed or ground meat diet.|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or su|65
48|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|65
49|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|65
50|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independently.|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independe|65
51|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only when assisted or accompanied by another person.|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only w|65
52|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepa|65
53|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance by another person OR b) given daily reminders.|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance b|65
54|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advan|65
55|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advan|65
56|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for the deaf) and call essential numbers.|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for t|65
57|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|65
58|1 - American Indian or Alaska Native|1 - American Indian or Alaska Native|65
59|1 - Depressed mood (e.g., feeling sad, tearful)|1 - Depressed mood (e.g., feeling sad, tearful)|65
60|1 - During the night only|1 - During the night only|65
61|1 - Fully granulating|1 - Fully granulating|65
62|1 - Good/Fair:  partial to full recovery is expected|1 - Good/Fair:  partial to full recovery is expected|65
63|1 - Good:  marked improvement in functional status is expected|1 - Good:  marked improvement in functional status is expected|65
64|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|65
65|1 - Smoking|1 - Smoking|65
66|1 - Hospital|1 - Hospital|65
67|1 - Hospital emergency room (includes 23-hour holding)|1 - Hospital emergency room (includes 23-hour holding)|65
68|1 - Hospitalization for EMERGENT (unscheduled) care|1 - Hospitalization for EMERGENT (unscheduled) care|65
69|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepared solutions), patient is able to manage all other aspects of equipment.|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepar|65
70|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|65
71|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|65
72|1 - In new or complex situations only|1 - In new or complex situations only|65
73|1 - Intravenous or infusion therapy (excludes TPN)|1 - Intravenous or infusion therapy (excludes TPN)|65
74|1 - Less often than daily|1 - Less often than daily|65
75|1 - Less than once a month|1 - Less than once a month|65
76|1 - Less than once weekly|1 - Less than once weekly|65
77|1 - Life expectancy is 6 months or fewer|1 - Life expectancy is 6 months or fewer|65
78|1 - Lives alone|1 - Lives alone|65
79|1 - Male|1 - Male|65
80|1 - Medicare (traditional fee-for-service)|1 - Medicare (traditional fee-for-service)|65
81|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of past 24 hours, significant memory loss so that supervision is required|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of pas|65
82|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors in word choice, grammar or speech intelligibility, needs minimal prompting or assistance).|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors i|65
83|1 - No assistance or services received|1 - No assistance or services received|65
84|1 - One|1 - One|65
85|1 - Oxygen (intermittent or continuous)|1 - Oxygen (intermittent or continuous)|65
86|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, and the surrounding layout, can count fingers at arm's length.|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, a|65
87|1 - Patient is incontinent|1 - Patient is incontinent|65
88|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|65
89|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical or treatment regimen.|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical|65
90|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient/couple/significant other)|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient|65
91|1 - Relatives, friends, or neighbors living outside the home|1 - Relatives, friends, or neighbors living outside the home|65
92|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions.|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions|65
93|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independentl|65
94|1 - Several times during day and night|1 - Several times during day and night|65
95|1 - Spouse or significant other|1 - Spouse or significant other|65
96|1 - Stage 1|1 - Stage 1|65
97|1 - Start of care - further visits planned|1 - Start of care - further visits planned|65
98|1 - Symptoms well controlled with current therapy|1 - Symptoms well controlled with current therapy|65
99|1 - Therapy services|1 - Therapy services|65
100|1 - Able to transfer with minimal human assistance or with use of an assistive device.|1 - Able to transfer with minimal human assistance or with use of an assistive device.|65
101|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitations.|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitatio|65
102|1 - Urinary incontinence|1 - Urinary incontinence|65
103|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and transfer.|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and|65
104|1 - When walking more than 20 feet, climbing stairs|1 - When walking more than 20 feet, climbing stairs|65
105|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary conversation. May need occasional repetition, extra time, or louder voice.|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary c|65
106|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting in and out of tub/shower|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting|65
107|1 - Yes|1 - Yes|65
108|1-RN|1-RN|65
109|10 - Discharge from agency - no visits completed after start/resumption of care assessment|10 - Discharge from agency - no visits completed after start/resumption of care assessment|65
110|10 - Scheduled surgical procedure|10 - Scheduled surgical procedure|65
111|10 - Self-pay|10 - Self-pay|65
112|11 - Other|11 - Other|65
113|11 - Urinary tract infection|11 - Urinary tract infection|65
114|12 - IV catheter-related infection|12 - IV catheter-related infection|65
115|13 - Deep vein thrombosis, pulmonary embolus|13 - Deep vein thrombosis, pulmonary embolus|65
116|14 - Uncontrolled pain|14 - Uncontrolled pain|65
117|15 - Psychotic episode|15 - Psychotic episode|65
118|16 - Other than above reasons|16 - Other than above reasons|65
119|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing calls.|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing|65
120|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another person.|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another pers|65
121|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface a|65
122|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for intermittent supervision or encouragement or reminders, OR (b) to get in and out of the shower or tub, OR (c) for washing difficult to reach areas.|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for inter|65
123|2 - Asian|2 - Asian|65
124|2 - Caregiver requires considerable assistance from another person to manage equipment, but independently completes significant portions of task.|2 - Caregiver requires considerable assistance from another person to manage equipment, but independ|65
125|2 - Daily, but not constantly|2 - Daily, but not constantly|65
126|2 - Daughter or son|2 - Daughter or son|65
127|2 - Doctor's office emergency visit/house call|2 - Doctor's office emergency visit/house call|65
128|2 - During the day and night|2 - During the day and night|65
129|2 - Early/partial granulation|2 - Early/partial granulation|65
130|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors in word choice, organization or speech intelligibility). Speaks in phrases or short sentences.|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors|65
131|2 - Family member's residence|2 - Family member's residence|65
132|2 - Female|2 - Female|65
133|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conversation, needs frequent prompting or assistance.|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conver|65
134|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|65
135|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|65
136|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately stop activities, jeopardizes safety through actions|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately st|65
137|2 - Indwelling/suprapubic catheter|2 - Indwelling/suprapubic catheter|65
138|2 - Injury caused by fall or accident at home|2 - Injury caused by fall or accident at home|65
139|2 - Medicare (HMO/managed care/Advantage plan)|2 - Medicare (HMO/managed care/Advantage plan)|65
140|2 - Nausea, dehydration, malnutrition, constipation, impaction|2 - Nausea, dehydration, malnutrition, constipation, impaction|65
141|2 - Obesity|2 - Obesity|65
142|2 - On awakening or at night only|2 - On awakening or at night only|65
143|2 - Once a month|2 - Once a month|65
144|2 - One to three times weekly|2 - One to three times weekly|65
145|2 - Parenteral nutrition (TPN or lipids)|2 - Parenteral nutrition (TPN or lipids)|65
146|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic) [ Go to M1620 ]|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic) [ Go|65
147|2 - Patient requires considerable assistance from another person to manage equipment, but independently completes portions of the task.|2 - Patient requires considerable assistance from another person to manage equipment, but independen|65
148|2 - Patient transferred to a noninstitutional hospice|2 - Patient transferred to a noninstitutional hospice|65
149|2 - Person residing in the home (EXCLUDING paid help)|2 - Person residing in the home (EXCLUDING paid help)|65
150|2 - Rehabilitation facility|2 - Rehabilitation facility|65
151|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifting of attention) or consistently requires low stimulus environment due to distractibility.|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifti|65
152|2 - Respite care|2 - Respite care|65
153|2 - Sense of failure or self reproach|2 - Sense of failure or self reproach|65
154|2 - Several times during day|2 - Several times during day|65
155|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonresponsive.|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonrespons|65
156|2 - Someone must assist the patient to groom self.|2 - Someone must assist the patient to groom self.|65
157|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|65
158|2 - Someone must help the patient put on upper body clothing.|2 - Someone must help the patient put on upper body clothing.|65
159|2 - Stage 2|2 - Stage 2|65
160|2 - Start of care - no further visits planned|2 - Start of care - no further visits planned|65
161|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitoring|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitori|65
162|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment regimen.|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment re|65
163|2 - Two|2 - Two|65
164|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistance due to cognitive or mental limitation.|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistanc|65
165|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|65
166|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assistance).|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assis|65
167|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home delivery.|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home deli|65
168|2 - Unable to prepare any light meals or reheat any delivered meals.|2 - Unable to prepare any light meals or reheat any delivered meals.|65
169|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|65
170|2 - UNABLE to take injectable medications unless administered by someone else.|2 - UNABLE to take injectable medications unless administered by someone else.|65
171|2 - UNABLE to take medication unless administered by someone else.|2 - UNABLE to take medication unless administered by someone else.|65
172|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|65
173|2 - Ventilator (continually or at night)|2 - Ventilator (continually or at night)|65
174|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less than 20 feet)|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less th|65
175|2 - With spouse or significant other|2 - With spouse or significant other|65
176|2 - Yes, assistance or services provided by family or friends|2 - Yes, assistance or services provided by family or friends|65
177|2-PT|2-PT|65
178|3 - Able to answer the telephone only some of the time or is able to carry on only a limited conversation.|3 - Able to answer the telephone only some of the time or is able to carry on only a limited convers|65
179|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube or gastrostomy.|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube|65
180|3 - Alcohol dependency|3 - Alcohol dependency|65
181|3 - All of the time|3 - All of the time|65
182|3 - Black or African-American|3 - Black or African-American|65
183|3 - Boarding home or rented room|3 - Boarding home or rented room|65
184|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment, clean/store/dispose of equipment or supplies).|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment,|65
185|3 -Able to walk only with the supervision or assistance of another person at all times.|3 -Able to walk only with the supervision or assistance of another person at all times.|65
186|3 - Continuous / Bi-level positive airway pressure|3 - Continuous / Bi-level positive airway pressure|65
187|3 - During the day and evening, but not constantly|3 - During the day and evening, but not constantly|65
188|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the alimentary canal)|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the|65
189|3 - Environmental support (e.g., housing, home maintenance)|3 - Environmental support (e.g., housing, home maintenance)|65
190|3 - Four to six times weekly|3 - Four to six times weekly|65
191|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessing by listener.  Speech limited to single words or short phrases.|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessin|65
192|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires multiple repetitions, restatements, demonstrations, additional time.|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires m|65
193|3 - Hopelessness|3 - Hopelessness|65
194|3 - Hospice care|3 - Hospice care|65
195|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|65
196|3 - Injury caused by fall or accident at home|3 - Injury caused by fall or accident at home|65
197|3 - Intractable pain|3 - Intractable pain|65
198|3 - Medicaid (traditional fee-for-service)|3 - Medicaid (traditional fee-for-service)|65
199|3 - Needs someone to do all shopping and errands.|3 - Needs someone to do all shopping and errands.|65
200|3 - Not healing|3 - Not healing|65
201|3 - Nursing home|3 - Nursing home|65
202|3 - Once daily|3 - Once daily|65
203|3 - Other family member|3 - Other family member|65
204|3 - Outpatient department/clinic emergency (includes urgicenter sites)|3 - Outpatient department/clinic emergency (includes urgicenter sites)|65
205|3 - Paid help|3 - Paid help|65
206|3 - Able to participate in bathing self in shower or tub, but requires presence of another person throughout the bath for assistance or supervision.|3 - Able to participate in bathing self in shower or tub, but requires presence of another person th|65
207|3 - Patient depends entirely upon another person to dress lower body.|3 - Patient depends entirely upon another person to dress lower body.|65
208|3 - Patient depends entirely upon another person to dress the upper body.|3 - Patient depends entirely upon another person to dress the upper body.|65
209|3 - Patient depends entirely upon someone else for grooming needs.|3 - Patient depends entirely upon someone else for grooming needs.|65
210|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone else to manage the equipment.|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone|65
211|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable to shift attention and recall directions more than half the time.|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable|65
212|3 - Respiratory problems (SOB, infection, obstruction)|3 - Respiratory problems (SOB, infection, obstruction)|65
213|3 - Resumption of care (after inpatient stay)|3 - Resumption of care (after inpatient stay)|65
214|3 - Several times each month|3 - Several times each month|65
215|3 - Skilled Nursing Facility|3 - Skilled Nursing Facility|65
216|3 - Stage 3|3 - Stage 3|65
217|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|65
218|3 - Three|3 - Three|65
219|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person throughout the process.|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person through|65
220|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal independently.|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal indep|65
221|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person.|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person|65
222|3 - Unknown because patient moved to a geographic location not served by this agency|3 - Unknown because patient moved to a geographic location not served by this agency|65
223|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|65
224|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|65
225|3 - With other family member|3 - With other family member|65
226|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home health services, homemaker assistance, transportation assistance, assisted living, board and care)|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home h|65
227|3-SLP/ST|3-SLP/ST|65
228|4 - At rest (during day or night)|4 - At rest (during day or night)|65
229|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|65
230|4 - Board and care or assisted living facility|4 - Board and care or assisted living facility|65
231|4 - Caregiver is completely dependent on someone else to manage all equipment.|4 - Caregiver is completely dependent on someone else to manage all equipment.|65
232|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|65
233|4 - Constantly|4 - Constantly|65
234|4 - Drug dependency|4 - Drug dependency|65
235|4 - Four or more|4 - Four or more|65
236|4 - Friend or neighbor or community or church member|4 - Friend or neighbor or community or church member|65
237|4 - Hispanic or Latino|4 - Hispanic or Latino|65
238|4 - Hospice|4 - Hospice|65
239|4 - Impaired decision-making|4 - Impaired decision-making|65
240|4 - Is totally dependent in toileting.|4 - Is totally dependent in toileting.|65
241|4 - Medicaid (HMO/managed care)|4 - Medicaid (HMO/managed care)|65
242|4 - None of the above|4 - None of the above|65
243|4 - Nursing home|4 - Nursing home|65
244|4 - On a daily basis|4 - On a daily basis|65
245|4 - Patient is completely dependent on someone else to manage all equipment.|4 - Patient is completely dependent on someone else to manage all equipment.|65
246|4 - Permanent placement|4 - Permanent placement|65
247|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, punches, dangerous maneuvers w/ wheelchair or other objects)|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, pu|65
248|4 - Psychosocial support (e.g., socialization, companionship, recreation)|4 - Psychosocial support (e.g., socialization, companionship, recreation)|65
249|4 - Recertification (follow-up) reassessment|4 - Recertification (follow-up) reassessment|65
250|4 - Recurrent thoughts of death|4 - Recurrent thoughts of death|65
251|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruction)|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruc|65
252|4 - Several times a week|4 - Several times a week|65
253|4 - Stage 4|4 - Stage 4|65
254|4 - Symptoms poorly controlled, history of re-hospitalizations|4 - Symptoms poorly controlled, history of re-hospitalizations|65
255|4 - Three or more times per week|4 - Three or more times per week|65
256|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetative state, or delirium.|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetati|65
257|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|65
258|4 - Unable to effectively participate in any housekeeping tasks.|4 - Unable to effectively participate in any housekeeping tasks.|65
259|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or unresponsive (e.g., speech is nonsensical or unintelligible).|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or u|65
260|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonresponsive.|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonr|65
261|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostomy.|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostom|65
262|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of devices at the sink, in chair, or on commode|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of|65
263|4 - With a friend|4 - With a friend|65
264|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|65
265|4-OT|4-OT|65
266|5 - Advocates or facilitates patient's participation in appropriate medical care|5 - Advocates or facilitates patient's participation in appropriate medical care|65
267|5 - At least daily|5 - At least daily|65
268|6 - Bedfast, unable to ambulate or be up in a chair.|6 - Bedfast, unable to ambulate or be up in a chair.|65
269|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|65
270|5 - Disruptive or socially inappropriate behavior|5 - Disruptive or socially inappropriate behavior|65
271|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|65
272|5 - Hypo/Hyperglycemia, diabetes out of control|5 - Hypo/Hyperglycemia, diabetes out of control|65
273|5 - More often than once daily|5 - More often than once daily|65
274|5 - Native Hawaiian or Pacific Islander|5 - Native Hawaiian or Pacific Islander|65
275|5 - None of the above|5 - None of the above|65
276|5 - One to two times per week|5 - One to two times per week|65
277|5 - Other|5 - Other|65
278|5 - Other follow-up|5 - Other follow-up|65
279|5 - Paid help|5 - Paid help|65
280|5 - Patient nonresponsive or unable to speak.|5 - Patient nonresponsive or unable to speak.|65
281|5 - Thoughts of suicide|5 - Thoughts of suicide|65
282|5 - Totally unable to use the telephone.|5 - Totally unable to use the telephone.|65
283|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|65
284|5 - Unable to take in nutrients orally or by tube feeding.|5 - Unable to take in nutrients orally or by tube feeding.|65
285|5 - Unsafe for care at home|5 - Unsafe for care at home|65
286|5 - With paid help (other than home care agency staff)|5 - With paid help (other than home care agency staff)|65
287|5 - Workers' compensation|5 - Workers' compensation|65
288|5 - Wound infection, deteriorating wound status, new lesion/ulcer|5 - Wound infection, deteriorating wound status, new lesion/ulcer|65
289|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|65
290|6 - Delusional, hallucinatory, or paranoid behavior|6 - Delusional, hallucinatory, or paranoid behavior|65
291|6 - Financial agent, power of attorney, or conservator of finance|6 - Financial agent, power of attorney, or conservator of finance|65
292|6 - GI bleeding, obstruction|6 - GI bleeding, obstruction|65
293|6 - Less often than weekly|6 - Less often than weekly|65
294|6 - Memory loss to the extent that supervision required|6 - Memory loss to the extent that supervision required|65
295|6 - None of the above feelings observed or reported|6 - None of the above feelings observed or reported|65
296|6 - Other|6 - Other|65
297|6 - Title programs (e.g., Title III, V, or XX)|6 - Title programs (e.g., Title III, V, or XX)|65
298|6 - Transferred to an inpatient facility - patient not discharged from agency|6 - Transferred to an inpatient facility - patient not discharged from agency|65
299|6 - White|6 - White|65
300|6 - With other than above|6 - With other than above|65
301|7 - Exacerbation of CHF, fluid overload, heart failure|7 - Exacerbation of CHF, fluid overload, heart failure|65
302|7 - Health care agent, conservator of person, or medical power of attorney|7 - Health care agent, conservator of person, or medical power of attorney|65
303|7 - Hypo/Hyperglycemia, diabetes out of control|7 - Hypo/Hyperglycemia, diabetes out of control|65
304|7 - None of the above|7 - None of the above|65
305|7 - None of the above behaviors demonstrated|7 - None of the above behaviors demonstrated|65
306|7 - Other government (e.g., TriCare, VA, etc.)|7 - Other government (e.g., TriCare, VA, etc.)|65
307|7 - Transferred to an inpatient facility - patient discharged from agency|7 - Transferred to an inpatient facility - patient discharged from agency|65
308|8 - Death at home|8 - Death at home|65
309|8 - GI bleeding, obstruction|8 - GI bleeding, obstruction|65
310|8 - Myocardial infarction, stroke|8 - Myocardial infarction, stroke|65
311|8 - Private insurance|8 - Private insurance|65
312|9 - Chemotherapy|9 - Chemotherapy|65
313|9 - Discharge from agency|9 - Discharge from agency|65
314|9 - Other than above reasons|9 - Other than above reasons|65
315|9 - Private HMO/managed care|9 - Private HMO/managed care|65
316|NA - No caregiver|NA - No caregiver|65
317|NA - No equipment of this type used in care.|NA - No equipment of this type used in care.|65
318|NA - No inhalant/mist medications prescribed.|NA - No inhalant/mist medications prescribed.|65
319|NA - No injectable medications prescribed.|NA - No injectable medications prescribed.|65
320|NA - No inpatient facility admission|NA - No inpatient facility admission|65
321|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|65
322|NA - No Medicaid|NA - No Medicaid|65
323|NA - No Medicare|NA - No Medicare|65
324|NA - No observable pressure ulcer or unhealed pressure ulcer|NA - No observable pressure ulcer or unhealed pressure ulcer|65
325|NA - No observable stasis ulcer|NA - No observable stasis ulcer|65
326|NA - No observable surgical wound|NA - No observable surgical wound|65
327|NA - No oral medications prescribed.|NA - No oral medications prescribed.|65
328|NA - Not applicable|NA - Not applicable|65
329|NA - Patient does not have a telephone.|NA - Patient does not have a telephone.|65
330|NA - Patient has ostomy for bowel elimination|NA - Patient has ostomy for bowel elimination|65
331|NA - Patient nonresponsive|NA - Patient nonresponsive|65
332|NA - Patient on prophylactic treatment|NA - Patient on prophylactic treatment|65
333|NA - Patient was not discharged from an inpatient facility [Go to M1017]|NA - Patient was not discharged from an inpatient facility [Go to M1017]|65
334|UK - Other unknown|UK - Other unknown|65
335|UK - Reason unknown|UK - Reason unknown|65
336|UK - Unknown|UK - Unknown|65
337|UK - Unknown or Not Available|UK - Unknown or Not Available|65
341|01 - Early|01 - Early|65
342|02 - Late|02 - Late|65
343|NA - Not Applicable. No case mix group defined for this assessment.|NA - Not Applicable. No case mix group defined for this assessment.|65
344|NA - No case mix group defined by this assessment.|NA - No case mix group defined by this assessment.|65
345|1 - Recent decline in mental, emotional, or behavioral status|1 - Recent decline in mental, emotional, or behavioral status|65
346|2 - Multiple hospitalizations (2 or more) in the past 12 months|2 - Multiple hospitalizations (2 or more) in the past 12 months|65
347|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|65
348|4 - Taking five or more medications|4 - Taking five or more medications|65
349|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|65
350|6 - Other|6 - Other|65
351|7 - None of the above|7 - None of the above|65
352|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond tho|65
353|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable without heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable wi|65
354|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious complications and death.|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious compl|65
355|3 - The patient has serious progressive conditions that could lead to death within a year.|3 - The patient has serious progressive conditions that could lead to death within a year.|65
356|UK - The patient+s situation is unknown or unclear.|UK - The patient+s situation is unknown or unclear.|65
357|1 - Yes [ Go to M1050 ]|1 - Yes [ Go to M1050 ]|65
358|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this influenza season. [ Go to M1050 ]|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this i|65
359|1 - Received from another health care provider (e.g., physician)|1 - Received from another health care provider (e.g., physician)|65
360|2 - Received from your agency previously during this year+s flu season|2 - Received from your agency previously during this year+s flu season|65
361|3 - Offered and declined|3 - Offered and declined|65
362|4 - Assessed and determined to have medical contraindication(s)|4 - Assessed and determined to have medical contraindication(s)|65
363|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|65
364|6 - Inability to obtain vaccine due to declared shortage|6 - Inability to obtain vaccine due to declared shortage|65
365|1 - Yes [ Go to M1501 at TRN; Go to M1230 at DC ]|1 - Yes [ Go to M1501 at TRN; Go to M1230 at DC ]|65
366|1 - Patient has received PPV in the past|1 - Patient has received PPV in the past|65
367|2 - Offered and declined|2 - Offered and declined|65
368|3 - Assessed and determined to have medical contraindication(s)|3 - Assessed and determined to have medical contraindication(s)|65
369|4 - Not indicated; patient does not meet age/condition guidelines for PPV|4 - Not indicated; patient does not meet age/condition guidelines for PPV|65
370|5 - None of the above|5 - None of the above|65
371|0 - Adequate: hears normal conversation without difficulty.|0 - Adequate: hears normal conversation without difficulty.|65
372|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to increase volume or speak distinctly.|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to in|65
373|2 - Severely Impaired: absence of useful hearing.|2 - Severely Impaired: absence of useful hearing.|65
374|UK - Unable to assess hearing.|UK - Unable to assess hearing.|65
375|0 - Understands: clear comprehension without cues or repetitions.|0 - Understands: clear comprehension without cues or repetitions.|65
376|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Requires cues at times to understand.|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Req|65
377|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequently requires cues to understand.|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequentl|65
378|3 - Rarely/Never Understands|3 - Rarely/Never Understands|65
379|UK - Unable to assess understanding.|UK - Unable to assess understanding.|65
380|0 - No standardized assessment conducted|0 - No standardized assessment conducted|65
381|1 - Yes, and it does not indicate severe pain|1 - Yes, and it does not indicate severe pain|65
382|2 - Yes, and it indicates severe pain|2 - Yes, and it indicates severe pain|65
383|0 - Patient has no pain|0 - Patient has no pain|65
384|1 - Patient has pain that does not interfere with activity or movement|1 - Patient has pain that does not interfere with activity or movement|65
385|2 - Less often than daily|2 - Less often than daily|65
386|3 - Daily, but not constantly|3 - Daily, but not constantly|65
387|4 - All of the time|4 - All of the time|65
388|0 - No assessment conducted [ Go to M1306 ]|0 - No assessment conducted [ Go to M1306 ]|65
389|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc., without use of standardized tool|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc.,|65
390|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|65
391|0 - No [ Go to M1322]|0 - No [ Go to M1322]|65
392|0 v Newly epithelialized|0 v Newly epithelialized|65
393|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|65
394|2 - Yes, patient has observable stasis ulcers ONLY|2 - Yes, patient has observable stasis ulcers ONLY|65
395|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable dressing) [Go to M1340]|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable|65
396|0 - No [ Go to M1400 ]|0 - No [ Go to M1400 ]|65
397|1 - Yes, patient has at least one (observable) surgical wound|1 - Yes, patient has at least one (observable) surgical wound|65
398|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1400 ]|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1400 ]|65
399|0 - Patient is not short of breath|0 - Patient is not short of breath|65
400|3 - Continuous Bi-level positive airway pressure|3 - Continuous Bi-level positive airway pressure|65
401|0 - No [ Go to M1732 at TRN; Go to M1600 at DC ]|0 - No [ Go to M1732 at TRN; Go to M1600 at DC ]|65
402|2 - Not assessed [Go to M1732 at TRN; Go to M1600 at DC ]|2 - Not assessed [Go to M1732 at TRN; Go to M1600 at DC ]|65
403|NA - Patient does not have diagnosis of heart failure [Go to M2005 at TRN; Go to M1600 at DC]|NA - Patient does not have diagnosis of heart failure [Go to M2005 at TRN; Go to M1600 at DC]|65
404|0 - No action taken|0 - No action taken|65
405|1 - Patient+s physician (or other primary care practitioner) contacted the same day|1 - Patient+s physician (or other primary care practitioner) contacted the same day|65
406|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|65
407|3 - Implement physician-ordered patient-specific established parameters for treatment|3 - Implement physician-ordered patient-specific established parameters for treatment|65
408|4 - Patient education or other clinical interventions|4 - Patient education or other clinical interventions|65
409|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequency, telehealth, etc.)|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequ|65
410|1 - Occasional stress incontinence|1 - Occasional stress incontinence|65
411|2 - During the night only|2 - During the night only|65
412|3 - During the day only|3 - During the day only|65
413|4 - During the day and night|4 - During the day and night|65
414|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|65
415|0 - Able to manage toileting hygiene and clothing management without assistance.|0 - Able to manage toileting hygiene and clothing management without assistance.|65
416|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implements are laid out for the patient.|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implemen|65
417|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|65
418|3 - Patient depends entirely upon another person to maintain toileting hygiene.|3 - Patient depends entirely upon another person to maintain toileting hygiene.|65
419|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independent|65
420|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface|65
421|0 - No multi-factor falls risk assessment conducted.|0 - No multi-factor falls risk assessment conducted.|65
422|1 - Yes, and it does not indicate a risk for falls.|1 - Yes, and it does not indicate a risk for falls.|65
423|2 - Yes, and it indicates a risk for falls.|2 - Yes, and it indicates a risk for falls.|65
424|0 - Not assessed/reviewed [ Go to M2010 ]|0 - Not assessed/reviewed [ Go to M2010 ]|65
425|1 - No problems found during review [ Go to M2010 ]|1 - No problems found during review [ Go to M2010 ]|65
426|2 - Problems found during review|2 - Problems found during review|65
427|NA - Patient is not taking any medications [ Go to M2040 ]|NA - Patient is not taking any medications [ Go to M2040 ]|65
428|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special precautions associated with all high-risk medications|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special p|65
429|NA - Patient not taking any drugs|NA - Patient not taking any drugs|65
430|2 - Able to take medication(s) at the correct times if given reminders by another person at the appropriate times|2 - Able to take medication(s) at the correct times if given reminders by another person at the appr|65
431|3 - Unable to take medication unless administered by another person.|3 - Unable to take medication unless administered by another person.|65
432|1 - At least daily|1 - At least daily|65
433|2 - Three or more times per week|2 - Three or more times per week|65
434|3 - One to two times per week|3 - One to two times per week|65
435|4 - Received, but less often than weekly|4 - Received, but less often than weekly|65
436|5 - No assistance received|5 - No assistance received|65
437|0 - No [Go to M2401]|0 - No [Go to M2401]|65
438|1 - Yes, used hospital emergency department WITHOUT hospital admission|1 - Yes, used hospital emergency department WITHOUT hospital admission|65
439|2 - Yes, used hospital emergency department WITH hospital admission|2 - Yes, used hospital emergency department WITH hospital admission|65
440|UK - Unknown [Go to M2401]|UK - Unknown [Go to M2401]|65
441|2 - Injury caused by fall|2 - Injury caused by fall|65
442|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|65
443|4 - Other respiratory problem|4 - Other respiratory problem|65
444|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|65
445|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|65
446|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|65
447|8 - Other heart disease|8 - Other heart disease|65
448|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|65
449|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|65
450|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|65
451|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|65
452|13 - Urinary tract infection|13 - Urinary tract infection|65
453|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|65
454|15 - Wound infection or deterioration|15 - Wound infection or deterioration|65
455|16 - Uncontrolled pain|16 - Uncontrolled pain|65
456|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|65
457|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|65
458|19 - Other than above reasons|19 - Other than above reasons|65
459|2 - Patient remained in the community (with formal assistive services)|2 - Patient remained in the community (with formal assistive services)|65
460|3 - Patient transferred to a noninstitutional hospice|3 - Patient transferred to a noninstitutional hospice|65
461|4 - Unknown because patient moved to a geographic location not served by this agency|4 - Unknown because patient moved to a geographic location not served by this agency|65
462|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|65
463|4 - Other respiratory problem|4 - Other respiratory problem|65
464|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|65
465|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|65
466|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|65
467|8 - Other heart disease|8 - Other heart disease|65
468|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|65
469|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|65
470|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|65
471|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|65
472|13 - Urinary tract infection|13 - Urinary tract infection|65
473|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|65
474|15 - Wound infection or deterioration|15 - Wound infection or deterioration|65
475|16 - Uncontrolled pain|16 - Uncontrolled pain|65
476|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|65
477|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|65
478|19 - Scheduled treatment or procedure|19 - Scheduled treatment or procedure|65
479|20 - Other than above reasons|20 - Other than above reasons|65
480|UK - Reason unknown [Go to M0903]|UK - Reason unknown [Go to M0903]|65
482|01 - Patient lives alone around the clock|01 - Patient lives alone around the clock|65
483|02 - Patient lives alone regular daytime|02 - Patient lives alone regular daytime|65
484|03 - Patient lives alone regular nighttime|03 - Patient lives alone regular nighttime|65
485|04 - Patient lives alone occassional/short term assistance|04 - Patient lives alone occassional/short term assistance|65
486|05 - Patient lives alone no assisstance available|05 - Patient lives alone no assisstance available|65
487|06 - Patient lives with other person(s) in the home around the clock|06 - Patient lives with other person(s) in the home around the clock|65
488|07 - Patient lives with other person(s) in the home regular daytime|07 - Patient lives with other person(s) in the home regular daytime|65
489|08 - Patient lives with other person(s) in the home regular nighttime|08 - Patient lives with other person(s) in the home regular nighttime|65
490|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|65
491|10 - Patient lives with other person(s) in the home no assistance available|10 - Patient lives with other person(s) in the home no assistance available|65
492|1 - Was present at the most recent SOC/ROC assessment|1 - Was present at the most recent SOC/ROC assessment|65
493|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|65
494|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|65
495|0 - Newly epithelialized|0 - Newly epithelialized|65
496|0 - No [ Go to M1340 ]|0 - No [ Go to M1340 ]|65
498|0 - Independent|0 - Independent|65
499|1 - Needed Some Help|1 - Needed Some Help|65
500|2 - Dependent|2 - Dependent|65
502|0 - No assistance needed in this area|0 - No assistance needed in this area|65
503|1 - Caregiver(s) currently provide assistance|1 - Caregiver(s) currently provide assistance|65
504|2 - Caregiver(s) need training/ supportive services to provide assistance|2 - Caregiver(s) need training/ supportive services to provide assistance|65
505|3 - Caregiver(s) not likely to provide assistance|3 - Caregiver(s) not likely to provide assistance|65
506|4 - Unclear if Caregiver(s) will provide assistance|4 - Unclear if Caregiver(s) will provide assistance|65
507|5 - Assistance needed, but no Caregiver(s) available|5 - Assistance needed, but no Caregiver(s) available|65
508|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will use standardized clinical guidelines accessible for all care providers to reference|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will|65
510|NA - Patient is not assessed to be at risk for falls|NA - Patient is not assessed to be at risk for falls|65
511|NA - Patient has no diagnosis or symptoms of depression|NA - Patient has no diagnosis or symptoms of depression|65
512|NA - No pain identified|NA - No pain identified|65
513|NA - Patient is not assessed to be at risk for pressure ulcers|NA - Patient is not assessed to be at risk for pressure ulcers|65
514|NA - Patient has no pressure ulcers with need for moist wound healing|NA - Patient has no pressure ulcers with need for moist wound healing|65
515|1 - Long-term nursing facility (NF)|1 - Long-term nursing facility (NF)|65
516|2 - Skilled nursing facility (SNF / TCU)|2 - Skilled nursing facility (SNF / TCU)|65
517|3 - Short stay acute hospital (IPP S)|3 - Short stay acute hospital (IPP S)|65
518|4 - Long-term care hospital (LTCH)|4 - Long-term care hospital (LTCH)|65
519|5 - Inpatient rehabilitation hospital or unit (IRF)|5 - Inpatient rehabilitation hospital or unit (IRF)|65
520|6 - Psychiatric hospital or unit|6 - Psychiatric hospital or unit|65
521|7 - Other|7 - Other|65
522|NA - Patient was not discharged from an inpatient facility [Go to M1017]|NA - Patient was not discharged from an inpatient facility [Go to M1017]|65
523|6 - Unable to participate effectively in bathing and is bathed totally by another person|6 - Unable to participate effectively in bathing and is bathed totally by another person|65
524|4 - Chairfast, unable to ambulate but is able to wheel self independently.|4 - Chairfast, unable to ambulate but is able to wheel self independently.|65
525|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask patient: "Over the last two weeks, how often have you been bothered by any of the following problems")   *Copyright+ Pfizer Inc. All rights reserved. Reproduced with permission.|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask|65
526|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluation for depression.|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluat|65
527|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet criteria for further evaluation for depression.|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet|65
528|0 - Not at all  0 - 1 day|0 - Not at all  0 - 1 day|65
529|1 - Several days  2 - 6 days|1 - Several days  2 - 6 days|65
530|2 - More than half of the days  7 - 11 days|2 - More than half of the days  7 - 11 days|65
531|3 - Nearly every day  12 - 14 days|3 - Nearly every day  12 - 14 days|65
532|NA - N/A  Unable to respond|NA - N/A  Unable to respond|65
533|2 - Able to take medication(s) at the correct times if given reminders by another person based on the frequency of the injection|2 - Able to take medication(s) at the correct times if given reminders by another person based on th|65
534|3 - Unable to take injectable medication unless administered by another person.|3 - Unable to take injectable medication unless administered by another person.|65
536|UK - Inpatient Discharge Date Unknown|UK - Inpatient Discharge Date Unknown|65
537|NA - Inpatient stay within last 14 days Not Applicable|NA - Inpatient stay within last 14 days Not Applicable|65
2|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; OR (b) Is physically, cognitively, and mentally able to prepare light meals on a regular basis but has not routinely performed light meal preparation in the past (i.e., prior to this home care admission).|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; O|66
3|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and mentally able to perform all housekeeping tasks .|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and menta|66
4|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and mentally able to do laundry and access facilities.|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and menta|66
5|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying packages OR b) Physically, cognitively, and mentally able to take care of shopping, but has not done shopping in the past (i.e., prior to this home care admission).|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying|66
6|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|66
7|0 - Able to dial numbers and answer calls appropriately and as desired.|0 - Able to dial numbers and answer calls appropriately and as desired.|66
8|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body without assistance.|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body|66
9|0 - Able to get to and from the toilet and transfer independently with or without a device.|0 - Able to get to and from the toilet and transfer independently with or without a device.|66
10|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|66
11|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible public bus.|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible p|66
12|0 - Able to independently feed self.|0 - Able to independently feed self.|66
13|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|66
14|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct times.|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct ti|66
15|0 - Able to independently transfer.|0 - Able to independently transfer.|66
16|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without rail|66
17|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings|66
18|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|66
19|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions independently.|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions indep|66
20|0 - Asymptomatic, no treatment needed at this time|0 - Asymptomatic, no treatment needed at this time|66
21|0 - Caregiver manages all tasks related to equipment completely independently.|0 - Caregiver manages all tasks related to equipment completely independently.|66
22|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations with no observable impairment.|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations w|66
23|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|66
24|0 - Life expectancy is greater than 6 months|0 - Life expectancy is greater than 6 months|66
25|0 - Never|0 - Never|66
26|0 - Patient is not short of breath|0 - Patient is not short of breath|66
27|0 - No|0 - No|66
28|0 - No emergent care services|0 - No emergent care services|66
29|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [Goto 1620]|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [Goto 1620]|66
30|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and extended or abstract conversation.|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and exte|66
31|0 - No one person|0 - No one person|66
32|0 - None of the time|0 - None of the time|66
33|0 - None, no charge for current services|0 - None, no charge for current services|66
34|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|66
35|0 - Patient does NOT have an ostomy for bowel elimination.|0 - Patient does NOT have an ostomy for bowel elimination.|66
36|0 - Patient has no pain|0 - Patient has no pain|66
37|0 - Patient manages all tasks related to equipment completely independently.|0 - Patient manages all tasks related to equipment completely independently.|66
38|0 - Poor:  little or no recovery is expected and/or further decline is imminent|0 - Poor:  little or no recovery is expected and/or further decline is imminent|66
39|0 - Timed-voiding defers incontinence|0 - Timed-voiding defers incontinence|66
40|0 - Very rarely or never has bowel incontinence|0 - Very rarely or never has bowel incontinence|66
41|0 - Zero|0 - Zero|66
42|00 - No|00 - No|66
43|01 - Yes|01 - Yes|66
44|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or mental limitations, needs assistance with heavy laundry.|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or|66
45|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the patient.|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the|66
46|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|66
47|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or supervision from another person OR c) a liquid, pureed or ground meat diet.|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or su|66
48|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|66
49|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|66
50|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independently.|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independe|66
51|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only when assisted or accompanied by another person.|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only w|66
52|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepa|66
53|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance by another person OR b) given daily reminders.|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance b|66
54|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advan|66
55|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advan|66
56|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for the deaf) and call essential numbers.|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for t|66
57|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|66
58|1 - American Indian or Alaska Native|1 - American Indian or Alaska Native|66
59|1 - Depressed mood (e.g., feeling sad, tearful)|1 - Depressed mood (e.g., feeling sad, tearful)|66
60|1 - During the night only|1 - During the night only|66
61|1 - Fully granulating|1 - Fully granulating|66
62|1 - Good/Fair:  partial to full recovery is expected|1 - Good/Fair:  partial to full recovery is expected|66
63|1 - Good:  marked improvement in functional status is expected|1 - Good:  marked improvement in functional status is expected|66
64|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|66
65|1 - Smoking|1 - Smoking|66
66|1 - Hospital|1 - Hospital|66
67|1 - Hospital emergency room (includes 23-hour holding)|1 - Hospital emergency room (includes 23-hour holding)|66
68|1 - Hospitalization for EMERGENT (unscheduled) care|1 - Hospitalization for EMERGENT (unscheduled) care|66
69|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepared solutions), patient is able to manage all other aspects of equipment.|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepar|66
70|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|66
71|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|66
72|1 - In new or complex situations only|1 - In new or complex situations only|66
73|1 - Intravenous or infusion therapy (excludes TPN)|1 - Intravenous or infusion therapy (excludes TPN)|66
74|1 - Less often than daily|1 - Less often than daily|66
75|1 - Less than once a month|1 - Less than once a month|66
76|1 - Less than once weekly|1 - Less than once weekly|66
77|1 - Life expectancy is 6 months or fewer|1 - Life expectancy is 6 months or fewer|66
78|1 - Lives alone|1 - Lives alone|66
79|1 - Male|1 - Male|66
80|1 - Medicare (traditional fee-for-service)|1 - Medicare (traditional fee-for-service)|66
81|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of past 24 hours, significant memory loss so that supervision is required|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of pas|66
82|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors in word choice, grammar or speech intelligibility, needs minimal prompting or assistance).|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors i|66
83|1 - No assistance or services received|1 - No assistance or services received|66
84|1 - One|1 - One|66
85|1 - Oxygen (intermittent or continuous)|1 - Oxygen (intermittent or continuous)|66
86|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, and the surrounding layout, can count fingers at arm's length.|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, a|66
87|1 - Patient is incontinent|1 - Patient is incontinent|66
88|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|66
89|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical or treatment regimen.|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical|66
90|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient/couple/significant other)|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient|66
91|1 - Relatives, friends, or neighbors living outside the home|1 - Relatives, friends, or neighbors living outside the home|66
92|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions.|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions|66
93|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independentl|66
94|1 - Several times during day and night|1 - Several times during day and night|66
95|1 - Spouse or significant other|1 - Spouse or significant other|66
96|1 - Stage 1|1 - Stage 1|66
97|1 - Start of care - further visits planned|1 - Start of care - further visits planned|66
98|1 - Symptoms well controlled with current therapy|1 - Symptoms well controlled with current therapy|66
99|1 - Therapy services|1 - Therapy services|66
100|1 - Able to transfer with minimal human assistance or with use of an assistive device.|1 - Able to transfer with minimal human assistance or with use of an assistive device.|66
101|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitations.|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitatio|66
102|1 - Urinary incontinence|1 - Urinary incontinence|66
103|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and transfer.|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and|66
104|1 - When walking more than 20 feet, climbing stairs|1 - When walking more than 20 feet, climbing stairs|66
105|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary conversation. May need occasional repetition, extra time, or louder voice.|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary c|66
106|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting in and out of tub/shower|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting|66
107|1 - Yes|1 - Yes|66
108|1-RN|1-RN|66
109|10 - Discharge from agency - no visits completed after start/resumption of care assessment|10 - Discharge from agency - no visits completed after start/resumption of care assessment|66
110|10 - Scheduled surgical procedure|10 - Scheduled surgical procedure|66
111|10 - Self-pay|10 - Self-pay|66
112|11 - Other|11 - Other|66
113|11 - Urinary tract infection|11 - Urinary tract infection|66
114|12 - IV catheter-related infection|12 - IV catheter-related infection|66
115|13 - Deep vein thrombosis, pulmonary embolus|13 - Deep vein thrombosis, pulmonary embolus|66
116|14 - Uncontrolled pain|14 - Uncontrolled pain|66
117|15 - Psychotic episode|15 - Psychotic episode|66
118|16 - Other than above reasons|16 - Other than above reasons|66
119|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing calls.|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing|66
120|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another person.|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another pers|66
121|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface a|66
122|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for intermittent supervision or encouragement or reminders, OR (b) to get in and out of the shower or tub, OR (c) for washing difficult to reach areas.|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for inter|66
123|2 - Asian|2 - Asian|66
124|2 - Caregiver requires considerable assistance from another person to manage equipment, but independently completes significant portions of task.|2 - Caregiver requires considerable assistance from another person to manage equipment, but independ|66
125|2 - Daily, but not constantly|2 - Daily, but not constantly|66
126|2 - Daughter or son|2 - Daughter or son|66
127|2 - Doctor's office emergency visit/house call|2 - Doctor's office emergency visit/house call|66
128|2 - During the day and night|2 - During the day and night|66
129|2 - Early/partial granulation|2 - Early/partial granulation|66
130|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors in word choice, organization or speech intelligibility). Speaks in phrases or short sentences.|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors|66
131|2 - Family member's residence|2 - Family member's residence|66
132|2 - Female|2 - Female|66
133|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conversation, needs frequent prompting or assistance.|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conver|66
134|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|66
135|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|66
136|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately stop activities, jeopardizes safety through actions|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately st|66
137|2 - Indwelling/suprapubic catheter|2 - Indwelling/suprapubic catheter|66
138|2 - Injury caused by fall|2 - Injury caused by fall|66
139|2 - Medicare (HMO/managed care/Advantage plan)|2 - Medicare (HMO/managed care/Advantage plan)|66
140|2 - Nausea, dehydration, malnutrition, constipation, impaction|2 - Nausea, dehydration, malnutrition, constipation, impaction|66
141|2 - Obesity|2 - Obesity|66
142|2 - On awakening or at night only|2 - On awakening or at night only|66
143|2 - Once a month|2 - Once a month|66
144|2 - One to three times weekly|2 - One to three times weekly|66
145|2 - Parenteral nutrition (TPN or lipids)|2 - Parenteral nutrition (TPN or lipids)|66
146|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic) [ Go to M1620]|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic) [ Go|66
147|2 - Patient requires considerable assistance from another person to manage equipment, but independently completes portions of the task.|2 - Patient requires considerable assistance from another person to manage equipment, but independen|66
148|2 - Patient transferred to a noninstitutional hospice|2 - Patient transferred to a noninstitutional hospice|66
149|2 - Person residing in the home (EXCLUDING paid help)|2 - Person residing in the home (EXCLUDING paid help)|66
150|2 - Rehabilitation facility|2 - Rehabilitation facility|66
151|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifting of attention) or consistently requires low stimulus environment due to distractibility.|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifti|66
152|2 - Respite care|2 - Respite care|66
153|2 - Sense of failure or self reproach|2 - Sense of failure or self reproach|66
154|2 - Several times during day|2 - Several times during day|66
155|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonresponsive.|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonrespons|66
156|2 - Someone must assist the patient to groom self.|2 - Someone must assist the patient to groom self.|66
157|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|66
158|2 - Someone must help the patient put on upper body clothing.|2 - Someone must help the patient put on upper body clothing.|66
159|2 - Stage 2|2 - Stage 2|66
160|2 - Start of care - no further visits planned|2 - Start of care - no further visits planned|66
161|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitoring|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitori|66
162|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment regimen.|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment re|66
163|2 - Two|2 - Two|66
164|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistance due to cognitive or mental limitation.|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistanc|66
165|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|66
166|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assistance).|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assis|66
167|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home delivery.|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home deli|66
168|2 - Unable to prepare any light meals or reheat any delivered meals.|2 - Unable to prepare any light meals or reheat any delivered meals.|66
169|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|66
170|2 - UNABLE to take injectable medications unless administered by someone else.|2 - UNABLE to take injectable medications unless administered by someone else.|66
171|2 - UNABLE to take medication unless administered by someone else.|2 - UNABLE to take medication unless administered by someone else.|66
172|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|66
173|2 - Ventilator (continually or at night)|2 - Ventilator (continually or at night)|66
174|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less than 20 feet)|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less th|66
175|2 - With spouse or significant other|2 - With spouse or significant other|66
176|2 - Yes, assistance or services provided by family or friends|2 - Yes, assistance or services provided by family or friends|66
177|2-PT|2-PT|66
178|3 - Able to answer the telephone only some of the time or is able to carry on only a limited conversation.|3 - Able to answer the telephone only some of the time or is able to carry on only a limited convers|66
179|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube or gastrostomy.|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube|66
180|3 - Alcohol dependency|3 - Alcohol dependency|66
181|3 - All of the time|3 - All of the time|66
182|3 - Black or African-American|3 - Black or African-American|66
183|3 - Boarding home or rented room|3 - Boarding home or rented room|66
184|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment, clean/store/dispose of equipment or supplies).|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment,|66
185|3 -Able to walk only with the supervision or assistance of another person at all times.|3 -Able to walk only with the supervision or assistance of another person at all times.|66
186|3 - Continuous / Bi-level positive airway pressure|3 - Continuous / Bi-level positive airway pressure|66
187|3 - During the day and evening, but not constantly|3 - During the day and evening, but not constantly|66
188|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the alimentary canal)|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the|66
189|3 - Environmental support (e.g., housing, home maintenance)|3 - Environmental support (e.g., housing, home maintenance)|66
190|3 - Four to six times weekly|3 - Four to six times weekly|66
191|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessing by listener.  Speech limited to single words or short phrases.|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessin|66
192|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires multiple repetitions, restatements, demonstrations, additional time.|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires m|66
193|3 - Hopelessness|3 - Hopelessness|66
194|3 - Hospice care|3 - Hospice care|66
195|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|66
196|3 - Injury caused by fall or accident at home|3 - Injury caused by fall or accident at home|66
197|3 - Intractable pain|3 - Intractable pain|66
198|3 - Medicaid (traditional fee-for-service)|3 - Medicaid (traditional fee-for-service)|66
199|3 - Needs someone to do all shopping and errands.|3 - Needs someone to do all shopping and errands.|66
200|3 - Not healing|3 - Not healing|66
201|3 - Nursing home|3 - Nursing home|66
202|3 - Once daily|3 - Once daily|66
203|3 - Other family member|3 - Other family member|66
204|3 - Outpatient department/clinic emergency (includes urgicenter sites)|3 - Outpatient department/clinic emergency (includes urgicenter sites)|66
205|3 - Paid help|3 - Paid help|66
206|3 - Able to participate in bathing self in shower or tub, but requires presence of another person throughout the bath for assistance or supervision.|3 - Able to participate in bathing self in shower or tub, but requires presence of another person th|66
207|3 - Patient depends entirely upon another person to dress lower body.|3 - Patient depends entirely upon another person to dress lower body.|66
208|3 - Patient depends entirely upon another person to dress the upper body.|3 - Patient depends entirely upon another person to dress the upper body.|66
209|3 - Patient depends entirely upon someone else for grooming needs.|3 - Patient depends entirely upon someone else for grooming needs.|66
210|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone else to manage the equipment.|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone|66
211|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable to shift attention and recall directions more than half the time.|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable|66
212|3 - Respiratory problems (SOB, infection, obstruction)|3 - Respiratory problems (SOB, infection, obstruction)|66
213|3 - Resumption of care (after inpatient stay)|3 - Resumption of care (after inpatient stay)|66
214|3 - Several times each month|3 - Several times each month|66
215|3 - Skilled Nursing Facility|3 - Skilled Nursing Facility|66
216|3 - Stage 3|3 - Stage 3|66
217|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|66
218|3 - Three|3 - Three|66
219|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person throughout the process.|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person through|66
220|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal independently.|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal indep|66
221|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person.|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person|66
222|3 - Unknown because patient moved to a geographic location not served by this agency|3 - Unknown because patient moved to a geographic location not served by this agency|66
223|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|66
224|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|66
225|3 - With other family member|3 - With other family member|66
226|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home health services, homemaker assistance, transportation assistance, assisted living, board and care)|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home h|66
227|3-SLP/ST|3-SLP/ST|66
228|4 - At rest (during day or night)|4 - At rest (during day or night)|66
229|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|66
230|4 - Board and care or assisted living facility|4 - Board and care or assisted living facility|66
231|4 - Caregiver is completely dependent on someone else to manage all equipment.|4 - Caregiver is completely dependent on someone else to manage all equipment.|66
232|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|66
233|4 - Constantly|4 - Constantly|66
234|4 - Drug dependency|4 - Drug dependency|66
235|4 - Four or more|4 - Four or more|66
236|4 - Friend or neighbor or community or church member|4 - Friend or neighbor or community or church member|66
237|4 - Hispanic or Latino|4 - Hispanic or Latino|66
238|4 - Hospice|4 - Hospice|66
239|4 - Impaired decision-making|4 - Impaired decision-making|66
240|4 - Is totally dependent in toileting.|4 - Is totally dependent in toileting.|66
241|4 - Medicaid (HMO/managed care)|4 - Medicaid (HMO/managed care)|66
242|4 - None of the above|4 - None of the above|66
243|4 - Nursing home|4 - Nursing home|66
244|4 - On a daily basis|4 - On a daily basis|66
245|4 - Patient is completely dependent on someone else to manage all equipment.|4 - Patient is completely dependent on someone else to manage all equipment.|66
246|4 - Permanent placement|4 - Permanent placement|66
247|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, punches, dangerous maneuvers w/ wheelchair or other objects)|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, pu|66
248|4 - Psychosocial support (e.g., socialization, companionship, recreation)|4 - Psychosocial support (e.g., socialization, companionship, recreation)|66
249|4 - Recertification (follow-up) reassessment|4 - Recertification (follow-up) reassessment|66
250|4 - Recurrent thoughts of death|4 - Recurrent thoughts of death|66
251|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruction)|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruc|66
252|4 - Several times a week|4 - Several times a week|66
253|4 - Stage 4|4 - Stage 4|66
254|4 - Symptoms poorly controlled, history of rehospitalizations|4 - Symptoms poorly controlled, history of rehospitalizations|66
255|4 - Three or more times per week|4 - Three or more times per week|66
256|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetative state, or delirium.|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetati|66
257|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|66
258|4 - Unable to effectively participate in any housekeeping tasks.|4 - Unable to effectively participate in any housekeeping tasks.|66
259|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or unresponsive (e.g., speech is nonsensical or unintelligible).|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or u|66
260|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonresponsive.|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonr|66
261|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostomy.|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostom|66
262|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of devices at the sink, in chair, or on commode|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of|66
263|4 - With a friend|4 - With a friend|66
264|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|66
265|4-OT|4-OT|66
266|5 - Advocates or facilitates patient's participation in appropriate medical care|5 - Advocates or facilitates patient's participation in appropriate medical care|66
267|5 - At least daily|5 - At least daily|66
268|6 - Bedfast, unable to ambulate or be up in a chair.|6 - Bedfast, unable to ambulate or be up in a chair.|66
269|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|66
270|5 - Disruptive or socially inappropriate behavior|5 - Disruptive or socially inappropriate behavior|66
271|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|66
272|5 - Hypo/Hyperglycemia, diabetes out of control|5 - Hypo/Hyperglycemia, diabetes out of control|66
273|5 - More often than once daily|5 - More often than once daily|66
274|5 - Native Hawaiian or Pacific Islander|5 - Native Hawaiian or Pacific Islander|66
275|5 - None of the above|5 - None of the above|66
276|5 - One to two times per week|5 - One to two times per week|66
277|5 - Other|5 - Other|66
278|5 - Other follow-up|5 - Other follow-up|66
279|5 - Paid help|5 - Paid help|66
280|5 - Patient nonresponsive or unable to speak.|5 - Patient nonresponsive or unable to speak.|66
281|5 - Thoughts of suicide|5 - Thoughts of suicide|66
282|5 - Totally unable to use the telephone.|5 - Totally unable to use the telephone.|66
283|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|66
284|5 - Unable to take in nutrients orally or by tube feeding.|5 - Unable to take in nutrients orally or by tube feeding.|66
285|5 - Unsafe for care at home|5 - Unsafe for care at home|66
286|5 - With paid help (other than home care agency staff)|5 - With paid help (other than home care agency staff)|66
287|5 - Workers' compensation|5 - Workers' compensation|66
288|5 - Wound infection, deteriorating wound status, new lesion/ulcer|5 - Wound infection, deteriorating wound status, new lesion/ulcer|66
289|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|66
290|6 - Delusional, hallucinatory, or paranoid behavior|6 - Delusional, hallucinatory, or paranoid behavior|66
291|6 - Financial agent, power of attorney, or conservator of finance|6 - Financial agent, power of attorney, or conservator of finance|66
292|6 - GI bleeding, obstruction|6 - GI bleeding, obstruction|66
293|6 - Less often than weekly|6 - Less often than weekly|66
294|6 - Memory loss to the extent that supervision required|6 - Memory loss to the extent that supervision required|66
295|6 - None of the above feelings observed or reported|6 - None of the above feelings observed or reported|66
296|6 - Other|6 - Other|66
297|6 - Title programs (e.g., Title III, V, or XX)|6 - Title programs (e.g., Title III, V, or XX)|66
298|6 - Transferred to an inpatient facility - patient not discharged from agency|6 - Transferred to an inpatient facility - patient not discharged from agency|66
299|6 - White|6 - White|66
300|6 - With other than above|6 - With other than above|66
301|7 - Exacerbation of CHF, fluid overload, heart failure|7 - Exacerbation of CHF, fluid overload, heart failure|66
302|7 - Health care agent, conservator of person, or medical power of attorney|7 - Health care agent, conservator of person, or medical power of attorney|66
303|7 - Hypo/Hyperglycemia, diabetes out of control|7 - Hypo/Hyperglycemia, diabetes out of control|66
304|7 - None of the above|7 - None of the above|66
305|7 - None of the above behaviors demonstrated|7 - None of the above behaviors demonstrated|66
306|7 - Other government (e.g., TriCare, VA, etc.)|7 - Other government (e.g., TriCare, VA, etc.)|66
307|7 - Transferred to an inpatient facility - patient discharged from agency|7 - Transferred to an inpatient facility - patient discharged from agency|66
308|8 - Death at home|8 - Death at home|66
309|8 - GI bleeding, obstruction|8 - GI bleeding, obstruction|66
310|8 - Myocardial infarction, stroke|8 - Myocardial infarction, stroke|66
311|8 - Private insurance|8 - Private insurance|66
312|9 - Chemotherapy|9 - Chemotherapy|66
313|9 - Discharge from agency|9 - Discharge from agency|66
314|9 - Other than above reasons|9 - Other than above reasons|66
315|9 - Private HMO/managed care|9 - Private HMO/managed care|66
316|NA - No caregiver|NA - No caregiver|66
317|NA - No equipment of this type used in care.|NA - No equipment of this type used in care.|66
318|NA - No inhalant/mist medications prescribed.|NA - No inhalant/mist medications prescribed.|66
319|NA - No injectable medications prescribed.|NA - No injectable medications prescribed.|66
320|NA - No inpatient facility admission|NA - No inpatient facility admission|66
321|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|66
322|NA - No Medicaid|NA - No Medicaid|66
323|NA - No Medicare|NA - No Medicare|66
324|NA - No observable pressure ulcer or unhealed pressure ulcer|NA - No observable pressure ulcer or unhealed pressure ulcer|66
325|NA - No observable stasis ulcer|NA - No observable stasis ulcer|66
326|NA - No observable surgical wound|NA - No observable surgical wound|66
327|NA - No oral medications prescribed.|NA - No oral medications prescribed.|66
328|NA - Not applicable|NA - Not applicable|66
329|NA - Patient does not have a telephone.|NA - Patient does not have a telephone.|66
330|NA - Patient has ostomy for bowel elimination|NA - Patient has ostomy for bowel elimination|66
331|NA - Patient nonresponsive|NA - Patient nonresponsive|66
332|NA - Patient on prophylactic treatment|NA - Patient on prophylactic treatment|66
333|NA - Patient was not discharged from an inpatient facility [Go to M1017]|NA - Patient was not discharged from an inpatient facility [Go to M1017]|66
334|UK - Other unknown|UK - Other unknown|66
335|UK - Reason unknown|UK - Reason unknown|66
336|UK - Unknown|UK - Unknown|66
337|UK - Unknown or Not Available|UK - Unknown or Not Available|66
341|01 - Early|01 - Early|66
342|02 - Late|02 - Late|66
343|NA - Not Applicable. No case mix group defined for this assessment.|NA - Not Applicable. No case mix group defined for this assessment.|66
344|NA - No case mix group defined by this assessment.|NA - No case mix group defined by this assessment.|66
345|1 - Recent decline in mental, emotional, or behavioral status|1 - Recent decline in mental, emotional, or behavioral status|66
346|2 - Multiple hospitalizations (2 or more) in the past 12 months|2 - Multiple hospitalizations (2 or more) in the past 12 months|66
347|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|66
348|4 - Taking five or more medications|4 - Taking five or more medications|66
349|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|66
350|6 - Other|6 - Other|66
351|7 - None of the above|7 - None of the above|66
352|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond tho|66
353|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable without heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable wi|66
354|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious complications and death.|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious compl|66
355|3 - The patient has serious progressive conditions that could lead to death within a year.|3 - The patient has serious progressive conditions that could lead to death within a year.|66
356|UK - The patient+s situation is unknown or unclear.|UK - The patient+s situation is unknown or unclear.|66
357|0 - No [ Go to M1051 ]|0 - No [ Go to M1051 ]|66
358|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this influenza season. [ Go to M1050 ]|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this i|66
359|1 - Received from another health care provider (e.g., physician)|1 - Received from another health care provider (e.g., physician)|66
360|2 - Received from your agency previously during this year+s flu season|2 - Received from your agency previously during this year+s flu season|66
361|3 - Offered and declined|3 - Offered and declined|66
362|4 - Assessed and determined to have medical contraindication(s)|4 - Assessed and determined to have medical contraindication(s)|66
363|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|66
364|6 - Inability to obtain vaccine due to declared shortage|6 - Inability to obtain vaccine due to declared shortage|66
365|1 - Yes [ Go to M1501 at TRN; Go to M1230 at DC ]|1 - Yes [ Go to M1501 at TRN; Go to M1230 at DC ]|66
366|1 - Patient has received PPV in the past|1 - Patient has received PPV in the past|66
367|2 - Offered and declined|2 - Offered and declined|66
368|3 - Assessed and determined to have medical contraindication(s)|3 - Assessed and determined to have medical contraindication(s)|66
369|4 - Not indicated; patient does not meet age/condition guidelines for PPV|4 - Not indicated; patient does not meet age/condition guidelines for PPV|66
370|5 - None of the above|5 - None of the above|66
371|0 - Adequate: hears normal conversation without difficulty.|0 - Adequate: hears normal conversation without difficulty.|66
372|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to increase volume or speak distinctly.|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to in|66
373|2 - Severely Impaired: absence of useful hearing.|2 - Severely Impaired: absence of useful hearing.|66
374|UK - Unable to assess hearing.|UK - Unable to assess hearing.|66
375|0 - Understands: clear comprehension without cues or repetitions.|0 - Understands: clear comprehension without cues or repetitions.|66
376|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Requires cues at times to understand.|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Req|66
377|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequently requires cues to understand.|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequentl|66
378|3 - Rarely/Never Understands|3 - Rarely/Never Understands|66
379|UK - Unable to assess understanding.|UK - Unable to assess understanding.|66
380|0 - No standardized assessment conducted|0 - No standardized assessment conducted|66
381|1 - Yes, and it does not indicate severe pain|1 - Yes, and it does not indicate severe pain|66
382|2 - Yes, and it indicates severe pain|2 - Yes, and it indicates severe pain|66
383|0 - Patient has no pain|0 - Patient has no pain|66
384|1 - Patient has pain that does not interfere with activity or movement|1 - Patient has pain that does not interfere with activity or movement|66
385|2 - Less often than daily|2 - Less often than daily|66
386|3 - Daily, but not constantly|3 - Daily, but not constantly|66
387|4 - All of the time|4 - All of the time|66
388|0 - No assessment conducted [ Go to M1306 ]|0 - No assessment conducted [ Go to M1306 ]|66
389|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc., without use of standardized tool|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc.,|66
390|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|66
391|0 - No [ Go to M1322]|0 - No [ Go to M1322]|66
392|0 v Newly epithelialized|0 v Newly epithelialized|66
393|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|66
394|2 - Yes, patient has observable stasis ulcers ONLY|2 - Yes, patient has observable stasis ulcers ONLY|66
395|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable dressing) [Go to M1340]|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable|66
396|0 - No [ Go to M1350 ]|0 - No [ Go to M1350 ]|66
397|1 - Yes, patient has at least one (observable) surgical wound|1 - Yes, patient has at least one (observable) surgical wound|66
398|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1350 ]|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1350 ]|66
399|0 - Patient is not short of breath|0 - Patient is not short of breath|66
400|3 - Continuous Bi-level positive airway pressure|3 - Continuous Bi-level positive airway pressure|66
401|0 - No [ Go to M2005 at TRN; Go to M1600 at DC ]|0 - No [ Go to M2005 at TRN; Go to M1600 at DC ]|66
402|2 - Not assessed [Go to M2005 at TRN; Go to M1600 at DC ]|2 - Not assessed [Go to M2005 at TRN; Go to M1600 at DC ]|66
403|NA - Patient does not have diagnosis of heart failure [Go to M2005 at TRN; Go to M1600 at DC]|NA - Patient does not have diagnosis of heart failure [Go to M2005 at TRN; Go to M1600 at DC]|66
404|0 - No action taken|0 - No action taken|66
405|1 - Patient+s physician (or other primary care practitioner) contacted the same day|1 - Patient+s physician (or other primary care practitioner) contacted the same day|66
406|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|66
407|3 - Implement physician-ordered patient-specific established parameters for treatment|3 - Implement physician-ordered patient-specific established parameters for treatment|66
408|4 - Patient education or other clinical interventions|4 - Patient education or other clinical interventions|66
409|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequency, telehealth, etc.)|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequ|66
410|1 - Occasional stress incontinence|1 - Occasional stress incontinence|66
411|2 - During the night only|2 - During the night only|66
412|3 - During the day only|3 - During the day only|66
413|4 - During the day and night|4 - During the day and night|66
414|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|66
415|0 - Able to manage toileting hygiene and clothing management without assistance.|0 - Able to manage toileting hygiene and clothing management without assistance.|66
416|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implements are laid out for the patient.|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implemen|66
417|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|66
418|3 - Patient depends entirely upon another person to maintain toileting hygiene.|3 - Patient depends entirely upon another person to maintain toileting hygiene.|66
419|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independent|66
420|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface|66
421|0 - No multi-factor falls risk assessment conducted.|0 - No multi-factor falls risk assessment conducted.|66
422|1 - Yes, and it does not indicate a risk for falls.|1 - Yes, and it does not indicate a risk for falls.|66
423|2 - Yes, and it indicates a risk for falls.|2 - Yes, and it indicates a risk for falls.|66
424|0 - Not assessed/reviewed [ Go to M2010 ]|0 - Not assessed/reviewed [ Go to M2010 ]|66
425|1 - No problems found during review [ Go to M2010 ]|1 - No problems found during review [ Go to M2010 ]|66
426|2 - Problems found during review|2 - Problems found during review|66
427|NA - Patient is not taking any medications [ Go to M2040 ]|NA - Patient is not taking any medications [ Go to M2040 ]|66
428|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special precautions associated with all high-risk medications|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special p|66
429|NA - Patient not taking any drugs|NA - Patient not taking any drugs|66
430|2 - Able to take medication(s) at the correct times if given reminders by another person at the appropriate times|2 - Able to take medication(s) at the correct times if given reminders by another person at the appr|66
431|3 - Unable to take medication unless administered by another person.|3 - Unable to take medication unless administered by another person.|66
432|1 - At least daily|1 - At least daily|66
433|2 - Three or more times per week|2 - Three or more times per week|66
434|3 - One to two times per week|3 - One to two times per week|66
435|4 - Received, but less often than weekly|4 - Received, but less often than weekly|66
436|5 - No assistance received|5 - No assistance received|66
437|0 - No [Go to M2401]|0 - No [Go to M2401]|66
438|1 - Yes, used hospital emergency department WITHOUT hospital admission|1 - Yes, used hospital emergency department WITHOUT hospital admission|66
439|2 - Yes, used hospital emergency department WITH hospital admission|2 - Yes, used hospital emergency department WITH hospital admission|66
440|UK - Unknown [Go to M2401]|UK - Unknown [Go to M2401]|66
441|2 - Injury caused by fall|2 - Injury caused by fall|66
442|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|66
443|4 - Other respiratory problem|4 - Other respiratory problem|66
444|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|66
445|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|66
446|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|66
447|8 - Other heart disease|8 - Other heart disease|66
448|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|66
449|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|66
450|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|66
451|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|66
452|13 - Urinary tract infection|13 - Urinary tract infection|66
453|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|66
454|15 - Wound infection or deterioration|15 - Wound infection or deterioration|66
455|16 - Uncontrolled pain|16 - Uncontrolled pain|66
456|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|66
457|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|66
458|19 - Other than above reasons|19 - Other than above reasons|66
459|2 - Patient remained in the community (with formal assistive services)|2 - Patient remained in the community (with formal assistive services)|66
460|3 - Patient transferred to a noninstitutional hospice|3 - Patient transferred to a noninstitutional hospice|66
461|4 - Unknown because patient moved to a geographic location not served by this agency|4 - Unknown because patient moved to a geographic location not served by this agency|66
462|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|66
463|4 - Other respiratory problem|4 - Other respiratory problem|66
464|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|66
465|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|66
466|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|66
467|8 - Other heart disease|8 - Other heart disease|66
468|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|66
469|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|66
470|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|66
471|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|66
472|13 - Urinary tract infection|13 - Urinary tract infection|66
473|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|66
474|15 - Wound infection or deterioration|15 - Wound infection or deterioration|66
475|16 - Uncontrolled pain|16 - Uncontrolled pain|66
476|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|66
477|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|66
478|19 - Scheduled treatment or procedure|19 - Scheduled treatment or procedure|66
479|20 - Other than above reasons|20 - Other than above reasons|66
480|UK - Reason unknown [Go to M0903]|UK - Reason unknown [Go to M0903]|66
482|01 - Patient lives alone around the clock|01 - Patient lives alone around the clock|66
483|02 - Patient lives alone regular daytime|02 - Patient lives alone regular daytime|66
484|03 - Patient lives alone regular nighttime|03 - Patient lives alone regular nighttime|66
485|04 - Patient lives alone occassional/short term assistance|04 - Patient lives alone occassional/short term assistance|66
486|05 - Patient lives alone no assisstance available|05 - Patient lives alone no assisstance available|66
487|06 - Patient lives with other person(s) in the home around the clock|06 - Patient lives with other person(s) in the home around the clock|66
488|07 - Patient lives with other person(s) in the home regular daytime|07 - Patient lives with other person(s) in the home regular daytime|66
489|08 - Patient lives with other person(s) in the home regular nighttime|08 - Patient lives with other person(s) in the home regular nighttime|66
490|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|66
491|10 - Patient lives with other person(s) in the home no assistance available|10 - Patient lives with other person(s) in the home no assistance available|66
492|1 - Was present at the most recent SOC/ROC assessment|1 - Was present at the most recent SOC/ROC assessment|66
493|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|66
494|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|66
495|0 - Newly epithelialized|0 - Newly epithelialized|66
496|0 - No [ Go to M1340 ]|0 - No [ Go to M1340 ]|66
498|0 - Independent|0 - Independent|66
499|1 - Needed Some Help|1 - Needed Some Help|66
500|2 - Dependent|2 - Dependent|66
502|0 - No assistance needed in this area|0 - No assistance needed in this area|66
503|1 - Caregiver(s) currently provide assistance|1 - Caregiver(s) currently provide assistance|66
504|2 - Caregiver(s) need training/ supportive services to provide assistance|2 - Caregiver(s) need training/ supportive services to provide assistance|66
505|3 - Caregiver(s) not likely to provide assistance|3 - Caregiver(s) not likely to provide assistance|66
506|4 - Unclear if Caregiver(s) will provide assistance|4 - Unclear if Caregiver(s) will provide assistance|66
507|5 - Assistance needed, but no Caregiver(s) available|5 - Assistance needed, but no Caregiver(s) available|66
508|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will use standardized clinical guidelines accessible for all care providers to reference|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will|66
510|NA - Patient is not assessed to be at risk for falls|NA - Patient is not assessed to be at risk for falls|66
511|NA - Patient has no diagnosis or symptoms of depression|NA - Patient has no diagnosis or symptoms of depression|66
512|NA - No pain identified|NA - No pain identified|66
513|NA - Patient is not assessed to be at risk for pressure ulcers|NA - Patient is not assessed to be at risk for pressure ulcers|66
514|NA - Patient has no pressure ulcers with need for moist wound healing|NA - Patient has no pressure ulcers with need for moist wound healing|66
515|1 - Long-term nursing facility (NF)|1 - Long-term nursing facility (NF)|66
516|2 - Skilled nursing facility (SNF / TCU)|2 - Skilled nursing facility (SNF / TCU)|66
517|3 - Short stay acute hospital (IPP S)|3 - Short stay acute hospital (IPP S)|66
518|4 - Long-term care hospital (LTCH)|4 - Long-term care hospital (LTCH)|66
519|5 - Inpatient rehabilitation hospital or unit (IRF)|5 - Inpatient rehabilitation hospital or unit (IRF)|66
520|6 - Psychiatric hospital or unit|6 - Psychiatric hospital or unit|66
521|7 - Other|7 - Other|66
522|NA - Patient was not discharged from an inpatient facility [Go to M1017]|NA - Patient was not discharged from an inpatient facility [Go to M1017]|66
523|6 - Unable to participate effectively in bathing and is bathed totally by another person|6 - Unable to participate effectively in bathing and is bathed totally by another person|66
524|4 - Chairfast, unable to ambulate but is able to wheel self independently.|4 - Chairfast, unable to ambulate but is able to wheel self independently.|66
525|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask patient: "Over the last two weeks, how often have you been bothered by any of the following problems")|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask|66
526|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluation for depression.|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluat|66
527|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet criteria for further evaluation for depression.|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet|66
528|0 - Not at all  0 - 1 day|0 - Not at all  0 - 1 day|66
529|1 - Several days  2 - 6 days|1 - Several days  2 - 6 days|66
530|2 - More than half of the days  7 - 11 days|2 - More than half of the days  7 - 11 days|66
531|3 - Nearly every day  12 - 14 days|3 - Nearly every day  12 - 14 days|66
532|NA - N/A  Unable to respond|NA - N/A  Unable to respond|66
533|2 - Able to take medication(s) at the correct times if given reminders by another person based on the frequency of the injection|2 - Able to take medication(s) at the correct times if given reminders by another person based on th|66
534|3 - Unable to take injectable medication unless administered by another person.|3 - Unable to take injectable medication unless administered by another person.|66
547|NA - There were no potential clinically significant medication issues identified since SOC/ROC or patient is not taking any medications|NA -  There were no potential clinically significant medication issues identified since SOC/ROC |66
552|1 - Hospital [ Go to M2430 ]|1 - Hospital [ Go to M2430 ]|66
553|2 - Rehabilitation facility [ Go to M0903 ]|2 - Rehabilitation facility [ Go to M0903 ]|66
554|3 - Nursing home [ Go to M2440 ]|3 - Nursing home [ Go to M2440 ]|66
555|4 - Hospice [ Go to M0903 ]|4 - Hospice [ Go to M0903 ]|66
557|NA - Patient is not diabetic or is bilateral amputee|NA - Patient is not diabetic or is bilateral amputee|66
558|NA - Every standardized,validated multifactor fall risk assessment conducted at or since the most recent SOC/ROC assessment indicates the patient has no risk for falls.|NA - Every standardized,validated multifactor fall risk assessment condition|66
559|NA - Patient has no diagnosis of depression AND every standardized, validated depression screening conducted at or since the most recent SOC/ROC assessment indicates the patient has: 1) no symptoms of depression; or 2) has some symptoms of depression but does not meet criteria for further evaluation of depression based on screening tool used.|NA - Patient has no diagnosis of depression AND every standardized, validated |66
560|NA - Every standardized, validated pain assessment conducted at or since the most recent SOC/ROC assessment indicates the patient has no pain.|NA - Every standardized, validated pain assessment conducted at or since the most|66
561|NA - Every standardized, validated pressure ulcer risk assessment conducted at or since the most recent SOC/ROC assessment indicates the patient is not at risk of developing pressure ulcers.|NA - Every standardized, validated pressure ulcer risk assessment conducted|66
562|NA - Dressings that support the principles of moist wound healing not indicated for this patient's pressure ulcers OR patient has no pressure ulcers with need for moist wound healing|NA - Dressings that support the principles of moist wound healing not indicated for this patient's p|66
620|1 - Yes; received from your agency during this episode of care (SOC/ROC to Transfer/Discharge)|1 - Yes; received from your agency during this episode of care (SOC/ROC to Transfer/Discharge)|66
621|2 - Yes; received from your agency during a prior episode of care (SOC/ROC to Transfer/Discharge)|2 - Yes; received from your agency during a prior episode of care (SOC/ROC to Transfer/Discharge)|66
622|3 - Yes; received from another health care provider (for example physician pharmacist)|3 - Yes; received from another health care provider (for example physician pharmacist)|66
623|4 - No; patient offered and declined |4 - No; patient offered and declined |66
624|5 - No; patient assessed and determined to have medical contraindication(s)|5 - No; patient assessed and determined to have medical contraindication(s)|66
625|6 - No; not indicated - patient does not meet age/condition guidelines for influenza vaccine|6 - No; not indicated - patient does not meet age/condition guidelines for influenza vaccine|66
626|7 - No; inability to obtain vaccine due to declared shortage |7 - No; inability to obtain vaccine due to declared shortage |66
627|8 - No; patient did not receive the vaccine due to reasons other than those listed in responses 4 v 7. |8 - No; patient did not receive the vaccine due to reasons other than those listed in responses 4v7.|66
628|1 - Offered and declined|1 - Offered and declined|66
629|2 - Assessed and determined to have medical contraindication(s) |2 - Assessed and determined to have medical contraindication(s) |66
630|3 - Not indicated; patient does not meet age/condition guidelines for Pneumococcal Vaccine|3 - Not indicated; patient does not meet age/condition guidelines for Pneumococcal Vaccine|66
631|4 - None of the above|4 - None of the above|66
2|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; OR (b) Is physically, cognitively, and mentally able to prepare light meals on a regular basis but has not routinely performed light meal preparation in the past (i.e., prior to this home care admission).|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; O|67
3|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and mentally able to perform all housekeeping tasks .|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and menta|67
4|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and mentally able to do laundry and access facilities.|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and menta|67
5|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying packages OR b) Physically, cognitively, and mentally able to take care of shopping, but has not done shopping in the past (i.e., prior to this home care admission).|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying|67
6|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|67
7|0 - Able to dial numbers and answer calls appropriately and as desired.|0 - Able to dial numbers and answer calls appropriately and as desired.|67
8|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body without assistance.|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body|67
9|0 - Able to get to and from the toilet and transfer independently with or without a device.|0 - Able to get to and from the toilet and transfer independently with or without a device.|67
10|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|67
11|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible public bus.|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible p|67
12|0 - Able to independently feed self.|0 - Able to independently feed self.|67
13|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|67
14|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct times.|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct ti|67
15|0 - Able to independently transfer.|0 - Able to independently transfer.|67
16|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without rail|67
17|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings|67
18|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|67
19|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions independently.|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions indep|67
20|0 - Asymptomatic, no treatment needed at this time|0 - Asymptomatic, no treatment needed at this time|67
21|0 - Caregiver manages all tasks related to equipment completely independently.|0 - Caregiver manages all tasks related to equipment completely independently.|67
22|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations with no observable impairment.|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations w|67
23|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|67
24|0 - Life expectancy is greater than 6 months|0 - Life expectancy is greater than 6 months|67
25|0 - Never|0 - Never|67
26|0 - Patient is not short of breath|0 - Patient is not short of breath|67
27|0 - No|0 - No|67
28|0 - No emergent care services|0 - No emergent care services|67
29|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [Goto 1620]|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [Goto 1620]|67
30|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and extended or abstract conversation.|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and exte|67
31|0 - No one person|0 - No one person|67
32|0 - None of the time|0 - None of the time|67
33|0 - None, no charge for current services|0 - None, no charge for current services|67
34|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|67
35|0 - Patient does NOT have an ostomy for bowel elimination.|0 - Patient does NOT have an ostomy for bowel elimination.|67
36|0 - Patient has no pain|0 - Patient has no pain|67
37|0 - Patient manages all tasks related to equipment completely independently.|0 - Patient manages all tasks related to equipment completely independently.|67
38|0 - Poor:  little or no recovery is expected and/or further decline is imminent|0 - Poor:  little or no recovery is expected and/or further decline is imminent|67
39|0 - Timed-voiding defers incontinence|0 - Timed-voiding defers incontinence|67
40|0 - Very rarely or never has bowel incontinence|0 - Very rarely or never has bowel incontinence|67
41|0 - Zero|0 - Zero|67
42|00 - No|00 - No|67
43|01 - Yes|01 - Yes|67
44|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or mental limitations, needs assistance with heavy laundry.|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or|67
45|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the patient.|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the|67
46|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|67
47|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or supervision from another person OR c) a liquid, pureed or ground meat diet.|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or su|67
48|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|67
49|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|67
50|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independently.|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independe|67
51|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only when assisted or accompanied by another person.|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only w|67
52|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepa|67
53|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance by another person OR b) given daily reminders.|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance b|67
54|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advan|67
55|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advan|67
56|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for the deaf) and call essential numbers.|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for t|67
57|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|67
58|1 - American Indian or Alaska Native|1 - American Indian or Alaska Native|67
59|1 - Depressed mood (e.g., feeling sad, tearful)|1 - Depressed mood (e.g., feeling sad, tearful)|67
60|1 - During the night only|1 - During the night only|67
61|1 - Fully granulating|1 - Fully granulating|67
62|1 - Good/Fair:  partial to full recovery is expected|1 - Good/Fair:  partial to full recovery is expected|67
63|1 - Good:  marked improvement in functional status is expected|1 - Good:  marked improvement in functional status is expected|67
64|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|67
65|1 - Smoking|1 - Smoking|67
66|1 - Hospital|1 - Hospital|67
67|1 - Hospital emergency room (includes 23-hour holding)|1 - Hospital emergency room (includes 23-hour holding)|67
68|1 - Hospitalization for EMERGENT (unscheduled) care|1 - Hospitalization for EMERGENT (unscheduled) care|67
69|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepared solutions), patient is able to manage all other aspects of equipment.|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepar|67
70|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|67
71|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|67
72|1 - In new or complex situations only|1 - In new or complex situations only|67
73|1 - Intravenous or infusion therapy (excludes TPN)|1 - Intravenous or infusion therapy (excludes TPN)|67
74|1 - Less often than daily|1 - Less often than daily|67
75|1 - Less than once a month|1 - Less than once a month|67
76|1 - Less than once weekly|1 - Less than once weekly|67
77|1 - Life expectancy is 6 months or fewer|1 - Life expectancy is 6 months or fewer|67
78|1 - Lives alone|1 - Lives alone|67
79|1 - Male|1 - Male|67
80|1 - Medicare (traditional fee-for-service)|1 - Medicare (traditional fee-for-service)|67
81|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of past 24 hours, significant memory loss so that supervision is required|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of pas|67
82|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors in word choice, grammar or speech intelligibility, needs minimal prompting or assistance).|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors i|67
83|1 - No assistance or services received|1 - No assistance or services received|67
84|1 - One|1 - One|67
85|1 - Oxygen (intermittent or continuous)|1 - Oxygen (intermittent or continuous)|67
86|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, and the surrounding layout, can count fingers at arm's length.|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, a|67
87|1 - Patient is incontinent|1 - Patient is incontinent|67
88|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|67
89|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical or treatment regimen.|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical|67
90|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient/couple/significant other)|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient|67
91|1 - Relatives, friends, or neighbors living outside the home|1 - Relatives, friends, or neighbors living outside the home|67
92|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions.|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions|67
93|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independentl|67
94|1 - Several times during day and night|1 - Several times during day and night|67
95|1 - Spouse or significant other|1 - Spouse or significant other|67
96|1 - Stage 1|1 - Stage 1|67
97|1 - Start of care - further visits planned|1 - Start of care - further visits planned|67
98|1 - Symptoms well controlled with current therapy|1 - Symptoms well controlled with current therapy|67
99|1 - Therapy services|1 - Therapy services|67
100|1 - Able to transfer with minimal human assistance or with use of an assistive device.|1 - Able to transfer with minimal human assistance or with use of an assistive device.|67
101|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitations.|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitatio|67
102|1 - Urinary incontinence|1 - Urinary incontinence|67
103|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and transfer.|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and|67
104|1 - When walking more than 20 feet, climbing stairs|1 - When walking more than 20 feet, climbing stairs|67
105|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary conversation. May need occasional repetition, extra time, or louder voice.|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary c|67
106|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting in and out of tub/shower|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting|67
107|1 - Yes|1 - Yes|67
108|1-RN|1-RN|67
109|10 - Discharge from agency - no visits completed after start/resumption of care assessment|10 - Discharge from agency - no visits completed after start/resumption of care assessment|67
110|10 - Scheduled surgical procedure|10 - Scheduled surgical procedure|67
111|10 - Self-pay|10 - Self-pay|67
112|11 - Other|11 - Other|67
113|11 - Urinary tract infection|11 - Urinary tract infection|67
114|12 - IV catheter-related infection|12 - IV catheter-related infection|67
115|13 - Deep vein thrombosis, pulmonary embolus|13 - Deep vein thrombosis, pulmonary embolus|67
116|14 - Uncontrolled pain|14 - Uncontrolled pain|67
117|15 - Psychotic episode|15 - Psychotic episode|67
118|16 - Other than above reasons|16 - Other than above reasons|67
119|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing calls.|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing|67
120|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another person.|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another pers|67
121|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface a|67
122|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for intermittent supervision or encouragement or reminders, OR (b) to get in and out of the shower or tub, OR (c) for washing difficult to reach areas.|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for inter|67
123|2 - Asian|2 - Asian|67
124|2 - Caregiver requires considerable assistance from another person to manage equipment, but independently completes significant portions of task.|2 - Caregiver requires considerable assistance from another person to manage equipment, but independ|67
125|2 - Daily, but not constantly|2 - Daily, but not constantly|67
126|2 - Daughter or son|2 - Daughter or son|67
127|2 - Doctor's office emergency visit/house call|2 - Doctor's office emergency visit/house call|67
128|2 - During the day and night|2 - During the day and night|67
129|2 - Early/partial granulation|2 - Early/partial granulation|67
130|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors in word choice, organization or speech intelligibility). Speaks in phrases or short sentences.|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors|67
131|2 - Family member's residence|2 - Family member's residence|67
132|2 - Female|2 - Female|67
133|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conversation, needs frequent prompting or assistance.|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conver|67
134|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|67
135|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|67
136|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately stop activities, jeopardizes safety through actions|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately st|67
137|2 - Indwelling/suprapubic catheter|2 - Indwelling/suprapubic catheter|67
138|2 - Injury caused by fall|2 - Injury caused by fall|67
139|2 - Medicare (HMO/managed care/Advantage plan)|2 - Medicare (HMO/managed care/Advantage plan)|67
140|2 - Nausea, dehydration, malnutrition, constipation, impaction|2 - Nausea, dehydration, malnutrition, constipation, impaction|67
141|2 - Obesity|2 - Obesity|67
142|2 - On awakening or at night only|2 - On awakening or at night only|67
143|2 - Once a month|2 - Once a month|67
144|2 - One to three times weekly|2 - One to three times weekly|67
145|2 - Parenteral nutrition (TPN or lipids)|2 - Parenteral nutrition (TPN or lipids)|67
146|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic) [ Go to M1620]|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic) [ Go|67
147|2 - Patient requires considerable assistance from another person to manage equipment, but independently completes portions of the task.|2 - Patient requires considerable assistance from another person to manage equipment, but independen|67
148|2 - Patient transferred to a noninstitutional hospice|2 - Patient transferred to a noninstitutional hospice|67
149|2 - Person residing in the home (EXCLUDING paid help)|2 - Person residing in the home (EXCLUDING paid help)|67
150|2 - Rehabilitation facility|2 - Rehabilitation facility|67
151|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifting of attention) or consistently requires low stimulus environment due to distractibility.|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifti|67
152|2 - Respite care|2 - Respite care|67
153|2 - Sense of failure or self reproach|2 - Sense of failure or self reproach|67
154|2 - Several times during day|2 - Several times during day|67
155|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonresponsive.|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonrespons|67
156|2 - Someone must assist the patient to groom self.|2 - Someone must assist the patient to groom self.|67
157|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|67
158|2 - Someone must help the patient put on upper body clothing.|2 - Someone must help the patient put on upper body clothing.|67
159|2 - Stage 2|2 - Stage 2|67
160|2 - Start of care - no further visits planned|2 - Start of care - no further visits planned|67
161|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitoring|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitori|67
162|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment regimen.|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment re|67
163|2 - Two|2 - Two|67
164|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistance due to cognitive or mental limitation.|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistanc|67
165|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|67
166|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assistance).|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assis|67
167|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home delivery.|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home deli|67
168|2 - Unable to prepare any light meals or reheat any delivered meals.|2 - Unable to prepare any light meals or reheat any delivered meals.|67
169|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|67
170|2 - UNABLE to take injectable medications unless administered by someone else.|2 - UNABLE to take injectable medications unless administered by someone else.|67
171|2 - UNABLE to take medication unless administered by someone else.|2 - UNABLE to take medication unless administered by someone else.|67
172|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|67
173|2 - Ventilator (continually or at night)|2 - Ventilator (continually or at night)|67
174|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less than 20 feet)|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less th|67
175|2 - With spouse or significant other|2 - With spouse or significant other|67
176|2 - Yes, assistance or services provided by family or friends|2 - Yes, assistance or services provided by family or friends|67
177|2-PT|2-PT|67
178|3 - Able to answer the telephone only some of the time or is able to carry on only a limited conversation.|3 - Able to answer the telephone only some of the time or is able to carry on only a limited convers|67
179|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube or gastrostomy.|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube|67
180|3 - Alcohol dependency|3 - Alcohol dependency|67
181|3 - All of the time|3 - All of the time|67
182|3 - Black or African-American|3 - Black or African-American|67
183|3 - Boarding home or rented room|3 - Boarding home or rented room|67
184|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment, clean/store/dispose of equipment or supplies).|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment,|67
185|3 -Able to walk only with the supervision or assistance of another person at all times.|3 -Able to walk only with the supervision or assistance of another person at all times.|67
186|3 - Continuous / Bi-level positive airway pressure|3 - Continuous / Bi-level positive airway pressure|67
187|3 - During the day and evening, but not constantly|3 - During the day and evening, but not constantly|67
188|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the alimentary canal)|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the|67
189|3 - Environmental support (e.g., housing, home maintenance)|3 - Environmental support (e.g., housing, home maintenance)|67
190|3 - Four to six times weekly|3 - Four to six times weekly|67
191|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessing by listener.  Speech limited to single words or short phrases.|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessin|67
192|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires multiple repetitions, restatements, demonstrations, additional time.|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires m|67
193|3 - Hopelessness|3 - Hopelessness|67
194|3 - Hospice care|3 - Hospice care|67
195|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|67
196|3 - Injury caused by fall or accident at home|3 - Injury caused by fall or accident at home|67
197|3 - Intractable pain|3 - Intractable pain|67
198|3 - Medicaid (traditional fee-for-service)|3 - Medicaid (traditional fee-for-service)|67
199|3 - Needs someone to do all shopping and errands.|3 - Needs someone to do all shopping and errands.|67
200|3 - Not healing|3 - Not healing|67
201|3 - Nursing home|3 - Nursing home|67
202|3 - Once daily|3 - Once daily|67
203|3 - Other family member|3 - Other family member|67
204|3 - Outpatient department/clinic emergency (includes urgicenter sites)|3 - Outpatient department/clinic emergency (includes urgicenter sites)|67
205|3 - Paid help|3 - Paid help|67
206|3 - Able to participate in bathing self in shower or tub, but requires presence of another person throughout the bath for assistance or supervision.|3 - Able to participate in bathing self in shower or tub, but requires presence of another person th|67
207|3 - Patient depends entirely upon another person to dress lower body.|3 - Patient depends entirely upon another person to dress lower body.|67
208|3 - Patient depends entirely upon another person to dress the upper body.|3 - Patient depends entirely upon another person to dress the upper body.|67
209|3 - Patient depends entirely upon someone else for grooming needs.|3 - Patient depends entirely upon someone else for grooming needs.|67
210|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone else to manage the equipment.|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone|67
211|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable to shift attention and recall directions more than half the time.|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable|67
212|3 - Respiratory problems (SOB, infection, obstruction)|3 - Respiratory problems (SOB, infection, obstruction)|67
213|3 - Resumption of care (after inpatient stay)|3 - Resumption of care (after inpatient stay)|67
214|3 - Several times each month|3 - Several times each month|67
215|3 - Skilled Nursing Facility|3 - Skilled Nursing Facility|67
216|3 - Stage 3|3 - Stage 3|67
217|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|67
218|3 - Three|3 - Three|67
219|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person throughout the process.|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person through|67
220|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal independently.|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal indep|67
221|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person.|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person|67
222|3 - Unknown because patient moved to a geographic location not served by this agency|3 - Unknown because patient moved to a geographic location not served by this agency|67
223|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|67
224|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|67
225|3 - With other family member|3 - With other family member|67
226|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home health services, homemaker assistance, transportation assistance, assisted living, board and care)|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home h|67
227|3-SLP/ST|3-SLP/ST|67
228|4 - At rest (during day or night)|4 - At rest (during day or night)|67
229|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|67
230|4 - Board and care or assisted living facility|4 - Board and care or assisted living facility|67
231|4 - Caregiver is completely dependent on someone else to manage all equipment.|4 - Caregiver is completely dependent on someone else to manage all equipment.|67
232|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|67
233|4 - Constantly|4 - Constantly|67
234|4 - Drug dependency|4 - Drug dependency|67
235|4 - Four or more|4 - Four or more|67
236|4 - Friend or neighbor or community or church member|4 - Friend or neighbor or community or church member|67
237|4 - Hispanic or Latino|4 - Hispanic or Latino|67
238|4 - Hospice|4 - Hospice|67
239|4 - Impaired decision-making|4 - Impaired decision-making|67
240|4 - Is totally dependent in toileting.|4 - Is totally dependent in toileting.|67
241|4 - Medicaid (HMO/managed care)|4 - Medicaid (HMO/managed care)|67
242|4 - None of the above|4 - None of the above|67
243|4 - Nursing home|4 - Nursing home|67
244|4 - On a daily basis|4 - On a daily basis|67
245|4 - Patient is completely dependent on someone else to manage all equipment.|4 - Patient is completely dependent on someone else to manage all equipment.|67
246|4 - Permanent placement|4 - Permanent placement|67
247|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, punches, dangerous maneuvers w/ wheelchair or other objects)|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, pu|67
248|4 - Psychosocial support (e.g., socialization, companionship, recreation)|4 - Psychosocial support (e.g., socialization, companionship, recreation)|67
249|4 - Recertification (follow-up) reassessment|4 - Recertification (follow-up) reassessment|67
250|4 - Recurrent thoughts of death|4 - Recurrent thoughts of death|67
251|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruction)|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruc|67
252|4 - Several times a week|4 - Several times a week|67
253|4 - Stage 4|4 - Stage 4|67
254|4 - Symptoms poorly controlled, history of rehospitalizations|4 - Symptoms poorly controlled, history of rehospitalizations|67
255|4 - Three or more times per week|4 - Three or more times per week|67
256|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetative state, or delirium.|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetati|67
257|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|67
258|4 - Unable to effectively participate in any housekeeping tasks.|4 - Unable to effectively participate in any housekeeping tasks.|67
259|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or unresponsive (e.g., speech is nonsensical or unintelligible).|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or u|67
260|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonresponsive.|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonr|67
261|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostomy.|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostom|67
262|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of devices at the sink, in chair, or on commode|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of|67
263|4 - With a friend|4 - With a friend|67
264|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|67
265|4-OT|4-OT|67
266|5 - Advocates or facilitates patient's participation in appropriate medical care|5 - Advocates or facilitates patient's participation in appropriate medical care|67
267|5 - At least daily|5 - At least daily|67
268|6 - Bedfast, unable to ambulate or be up in a chair.|6 - Bedfast, unable to ambulate or be up in a chair.|67
269|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|67
270|5 - Disruptive or socially inappropriate behavior|5 - Disruptive or socially inappropriate behavior|67
271|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|67
272|5 - Hypo/Hyperglycemia, diabetes out of control|5 - Hypo/Hyperglycemia, diabetes out of control|67
273|5 - More often than once daily|5 - More often than once daily|67
274|5 - Native Hawaiian or Pacific Islander|5 - Native Hawaiian or Pacific Islander|67
275|5 - None of the above|5 - None of the above|67
276|5 - One to two times per week|5 - One to two times per week|67
277|5 - Other|5 - Other|67
278|5 - Other follow-up|5 - Other follow-up|67
279|5 - Paid help|5 - Paid help|67
280|5 - Patient nonresponsive or unable to speak.|5 - Patient nonresponsive or unable to speak.|67
281|5 - Thoughts of suicide|5 - Thoughts of suicide|67
282|5 - Totally unable to use the telephone.|5 - Totally unable to use the telephone.|67
283|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|67
284|5 - Unable to take in nutrients orally or by tube feeding.|5 - Unable to take in nutrients orally or by tube feeding.|67
285|5 - Unsafe for care at home|5 - Unsafe for care at home|67
286|5 - With paid help (other than home care agency staff)|5 - With paid help (other than home care agency staff)|67
287|5 - Workers' compensation|5 - Workers' compensation|67
288|5 - Wound infection, deteriorating wound status, new lesion/ulcer|5 - Wound infection, deteriorating wound status, new lesion/ulcer|67
289|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|67
290|6 - Delusional, hallucinatory, or paranoid behavior|6 - Delusional, hallucinatory, or paranoid behavior|67
291|6 - Financial agent, power of attorney, or conservator of finance|6 - Financial agent, power of attorney, or conservator of finance|67
292|6 - GI bleeding, obstruction|6 - GI bleeding, obstruction|67
293|6 - Less often than weekly|6 - Less often than weekly|67
294|6 - Memory loss to the extent that supervision required|6 - Memory loss to the extent that supervision required|67
295|6 - None of the above feelings observed or reported|6 - None of the above feelings observed or reported|67
296|6 - Other|6 - Other|67
297|6 - Title programs (e.g., Title III, V, or XX)|6 - Title programs (e.g., Title III, V, or XX)|67
298|6 - Transferred to an inpatient facility - patient not discharged from agency|6 - Transferred to an inpatient facility - patient not discharged from agency|67
299|6 - White|6 - White|67
300|6 - With other than above|6 - With other than above|67
301|7 - Exacerbation of CHF, fluid overload, heart failure|7 - Exacerbation of CHF, fluid overload, heart failure|67
302|7 - Health care agent, conservator of person, or medical power of attorney|7 - Health care agent, conservator of person, or medical power of attorney|67
303|7 - Hypo/Hyperglycemia, diabetes out of control|7 - Hypo/Hyperglycemia, diabetes out of control|67
304|7 - None of the above|7 - None of the above|67
305|7 - None of the above behaviors demonstrated|7 - None of the above behaviors demonstrated|67
306|7 - Other government (e.g., TriCare, VA, etc.)|7 - Other government (e.g., TriCare, VA, etc.)|67
307|7 - Transferred to an inpatient facility - patient discharged from agency|7 - Transferred to an inpatient facility - patient discharged from agency|67
308|8 - Death at home|8 - Death at home|67
309|8 - GI bleeding, obstruction|8 - GI bleeding, obstruction|67
310|8 - Myocardial infarction, stroke|8 - Myocardial infarction, stroke|67
311|8 - Private insurance|8 - Private insurance|67
312|9 - Chemotherapy|9 - Chemotherapy|67
313|9 - Discharge from agency|9 - Discharge from agency|67
314|9 - Other than above reasons|9 - Other than above reasons|67
315|9 - Private HMO/managed care|9 - Private HMO/managed care|67
316|NA - No caregiver|NA - No caregiver|67
317|NA - No equipment of this type used in care.|NA - No equipment of this type used in care.|67
318|NA - No inhalant/mist medications prescribed.|NA - No inhalant/mist medications prescribed.|67
319|NA - No injectable medications prescribed.|NA - No injectable medications prescribed.|67
320|NA - No inpatient facility admission|NA - No inpatient facility admission|67
321|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|67
322|NA - No Medicaid|NA - No Medicaid|67
323|NA - No Medicare|NA - No Medicare|67
324|NA - No observable pressure ulcer or unhealed pressure ulcer|NA - No observable pressure ulcer or unhealed pressure ulcer|67
325|NA - No observable stasis ulcer|NA - No observable stasis ulcer|67
326|NA - No observable surgical wound|NA - No observable surgical wound|67
327|NA - No oral medications prescribed.|NA - No oral medications prescribed.|67
328|NA - Not applicable|NA - Not applicable|67
329|NA - Patient does not have a telephone.|NA - Patient does not have a telephone.|67
330|NA - Patient has ostomy for bowel elimination|NA - Patient has ostomy for bowel elimination|67
331|NA - Patient nonresponsive|NA - Patient nonresponsive|67
332|NA - Patient on prophylactic treatment|NA - Patient on prophylactic treatment|67
333|NA - Patient was not discharged from an inpatient facility [Go to M1017]|NA - Patient was not discharged from an inpatient facility [Go to M1017]|67
334|UK - Other unknown|UK - Other unknown|67
335|UK - Reason unknown|UK - Reason unknown|67
336|UK - Unknown|UK - Unknown|67
337|UK - Unknown or Not Available|UK - Unknown or Not Available|67
341|01 - Early|01 - Early|67
342|02 - Late|02 - Late|67
343|NA - Not Applicable. No case mix group defined for this assessment.|NA - Not Applicable. No case mix group defined for this assessment.|67
344|NA - No case mix group defined by this assessment.|NA - No case mix group defined by this assessment.|67
345|1 - Recent decline in mental, emotional, or behavioral status|1 - Recent decline in mental, emotional, or behavioral status|67
346|2 - Multiple hospitalizations (2 or more) in the past 12 months|2 - Multiple hospitalizations (2 or more) in the past 12 months|67
347|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|67
348|4 - Taking five or more medications|4 - Taking five or more medications|67
349|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|67
350|6 - Other|6 - Other|67
351|7 - None of the above|7 - None of the above|67
352|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond tho|67
353|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable without heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable wi|67
354|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious complications and death.|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious compl|67
355|3 - The patient has serious progressive conditions that could lead to death within a year.|3 - The patient has serious progressive conditions that could lead to death within a year.|67
356|UK - The patient+s situation is unknown or unclear.|UK - The patient+s situation is unknown or unclear.|67
357|0 - No [ Go to M1051 ]|0 - No [ Go to M1051 ]|67
358|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this influenza season. [ Go to M1050 ]|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this i|67
359|1 - Received from another health care provider (e.g., physician)|1 - Received from another health care provider (e.g., physician)|67
360|2 - Received from your agency previously during this year+s flu season|2 - Received from your agency previously during this year+s flu season|67
361|3 - Offered and declined|3 - Offered and declined|67
362|4 - Assessed and determined to have medical contraindication(s)|4 - Assessed and determined to have medical contraindication(s)|67
363|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|67
364|6 - Inability to obtain vaccine due to declared shortage|6 - Inability to obtain vaccine due to declared shortage|67
365|1 - Yes [ Go to M1501 at TRN; Go to M1230 at DC ]|1 - Yes [ Go to M1501 at TRN; Go to M1230 at DC ]|67
366|1 - Patient has received PPV in the past|1 - Patient has received PPV in the past|67
367|2 - Offered and declined|2 - Offered and declined|67
368|3 - Assessed and determined to have medical contraindication(s)|3 - Assessed and determined to have medical contraindication(s)|67
369|4 - Not indicated; patient does not meet age/condition guidelines for PPV|4 - Not indicated; patient does not meet age/condition guidelines for PPV|67
370|5 - None of the above|5 - None of the above|67
371|0 - Adequate: hears normal conversation without difficulty.|0 - Adequate: hears normal conversation without difficulty.|67
372|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to increase volume or speak distinctly.|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to in|67
373|2 - Severely Impaired: absence of useful hearing.|2 - Severely Impaired: absence of useful hearing.|67
374|UK - Unable to assess hearing.|UK - Unable to assess hearing.|67
375|0 - Understands: clear comprehension without cues or repetitions.|0 - Understands: clear comprehension without cues or repetitions.|67
376|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Requires cues at times to understand.|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Req|67
377|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequently requires cues to understand.|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequentl|67
378|3 - Rarely/Never Understands|3 - Rarely/Never Understands|67
379|UK - Unable to assess understanding.|UK - Unable to assess understanding.|67
380|0 - No standardized assessment conducted|0 - No standardized assessment conducted|67
381|1 - Yes, and it does not indicate severe pain|1 - Yes, and it does not indicate severe pain|67
382|2 - Yes, and it indicates severe pain|2 - Yes, and it indicates severe pain|67
383|0 - Patient has no pain|0 - Patient has no pain|67
384|1 - Patient has pain that does not interfere with activity or movement|1 - Patient has pain that does not interfere with activity or movement|67
385|2 - Less often than daily|2 - Less often than daily|67
386|3 - Daily, but not constantly|3 - Daily, but not constantly|67
387|4 - All of the time|4 - All of the time|67
388|0 - No assessment conducted [ Go to M1306 ]|0 - No assessment conducted [ Go to M1306 ]|67
389|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc., without use of standardized tool|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc.,|67
390|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|67
391|0 - No [ Go to M1322]|0 - No [ Go to M1322]|67
392|0 v Newly epithelialized|0 v Newly epithelialized|67
393|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|67
394|2 - Yes, patient has observable stasis ulcers ONLY|2 - Yes, patient has observable stasis ulcers ONLY|67
395|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable dressing) [Go to M1340]|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable|67
396|0 - No [ Go to M1350 ]|0 - No [ Go to M1350 ]|67
397|1 - Yes, patient has at least one (observable) surgical wound|1 - Yes, patient has at least one (observable) surgical wound|67
398|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1350 ]|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1350 ]|67
399|0 - Patient is not short of breath|0 - Patient is not short of breath|67
400|3 - Continuous Bi-level positive airway pressure|3 - Continuous Bi-level positive airway pressure|67
401|0 - No [ Go to M2005 at TRN; Go to M1600 at DC ]|0 - No [ Go to M2005 at TRN; Go to M1600 at DC ]|67
402|2 - Not assessed [Go to M2005 at TRN; Go to M1600 at DC ]|2 - Not assessed [Go to M2005 at TRN; Go to M1600 at DC ]|67
403|NA - Patient does not have diagnosis of heart failure [Go to M2005 at TRN; Go to M1600 at DC]|NA - Patient does not have diagnosis of heart failure [Go to M2005 at TRN; Go to M1600 at DC]|67
404|0 - No action taken|0 - No action taken|67
405|1 - Patient+s physician (or other primary care practitioner) contacted the same day|1 - Patient+s physician (or other primary care practitioner) contacted the same day|67
406|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|67
407|3 - Implement physician-ordered patient-specific established parameters for treatment|3 - Implement physician-ordered patient-specific established parameters for treatment|67
408|4 - Patient education or other clinical interventions|4 - Patient education or other clinical interventions|67
409|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequency, telehealth, etc.)|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequ|67
410|1 - Occasional stress incontinence|1 - Occasional stress incontinence|67
411|2 - During the night only|2 - During the night only|67
412|3 - During the day only|3 - During the day only|67
413|4 - During the day and night|4 - During the day and night|67
414|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|67
415|0 - Able to manage toileting hygiene and clothing management without assistance.|0 - Able to manage toileting hygiene and clothing management without assistance.|67
416|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implements are laid out for the patient.|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implemen|67
417|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|67
418|3 - Patient depends entirely upon another person to maintain toileting hygiene.|3 - Patient depends entirely upon another person to maintain toileting hygiene.|67
419|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independent|67
420|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface|67
421|0 - No multi-factor falls risk assessment conducted.|0 - No multi-factor falls risk assessment conducted.|67
422|1 - Yes, and it does not indicate a risk for falls.|1 - Yes, and it does not indicate a risk for falls.|67
423|2 - Yes, and it indicates a risk for falls.|2 - Yes, and it indicates a risk for falls.|67
424|0 - Not assessed/reviewed [ Go to M2010 ]|0 - Not assessed/reviewed [ Go to M2010 ]|67
425|1 - No problems found during review [ Go to M2010 ]|1 - No problems found during review [ Go to M2010 ]|67
426|2 - Problems found during review|2 - Problems found during review|67
427|NA - Patient is not taking any medications [ Go to M2040 ]|NA - Patient is not taking any medications [ Go to M2040 ]|67
428|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special precautions associated with all high-risk medications|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special p|67
429|NA - Patient not taking any drugs|NA - Patient not taking any drugs|67
430|2 - Able to take medication(s) at the correct times if given reminders by another person at the appropriate times|2 - Able to take medication(s) at the correct times if given reminders by another person at the appr|67
431|3 - Unable to take medication unless administered by another person.|3 - Unable to take medication unless administered by another person.|67
432|1 - At least daily|1 - At least daily|67
433|2 - Three or more times per week|2 - Three or more times per week|67
434|3 - One to two times per week|3 - One to two times per week|67
435|4 - Received, but less often than weekly|4 - Received, but less often than weekly|67
436|5 - No assistance received|5 - No assistance received|67
437|0 - No [Go to M2401]|0 - No [Go to M2401]|67
438|1 - Yes, used hospital emergency department WITHOUT hospital admission|1 - Yes, used hospital emergency department WITHOUT hospital admission|67
439|2 - Yes, used hospital emergency department WITH hospital admission|2 - Yes, used hospital emergency department WITH hospital admission|67
440|UK - Unknown [Go to M2401]|UK - Unknown [Go to M2401]|67
441|2 - Injury caused by fall|2 - Injury caused by fall|67
442|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|67
443|4 - Other respiratory problem|4 - Other respiratory problem|67
444|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|67
445|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|67
446|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|67
447|8 - Other heart disease|8 - Other heart disease|67
448|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|67
449|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|67
450|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|67
451|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|67
452|13 - Urinary tract infection|13 - Urinary tract infection|67
453|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|67
454|15 - Wound infection or deterioration|15 - Wound infection or deterioration|67
455|16 - Uncontrolled pain|16 - Uncontrolled pain|67
456|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|67
457|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|67
458|19 - Other than above reasons|19 - Other than above reasons|67
459|2 - Patient remained in the community (with formal assistive services)|2 - Patient remained in the community (with formal assistive services)|67
460|3 - Patient transferred to a noninstitutional hospice|3 - Patient transferred to a noninstitutional hospice|67
461|4 - Unknown because patient moved to a geographic location not served by this agency|4 - Unknown because patient moved to a geographic location not served by this agency|67
462|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|67
463|4 - Other respiratory problem|4 - Other respiratory problem|67
464|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|67
465|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|67
466|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|67
467|8 - Other heart disease|8 - Other heart disease|67
468|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|67
469|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|67
470|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|67
471|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|67
472|13 - Urinary tract infection|13 - Urinary tract infection|67
473|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|67
474|15 - Wound infection or deterioration|15 - Wound infection or deterioration|67
475|16 - Uncontrolled pain|16 - Uncontrolled pain|67
476|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|67
477|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|67
478|19 - Scheduled treatment or procedure|19 - Scheduled treatment or procedure|67
479|20 - Other than above reasons|20 - Other than above reasons|67
480|UK - Reason unknown [Go to M0903]|UK - Reason unknown [Go to M0903]|67
482|01 - Patient lives alone around the clock|01 - Patient lives alone around the clock|67
483|02 - Patient lives alone regular daytime|02 - Patient lives alone regular daytime|67
484|03 - Patient lives alone regular nighttime|03 - Patient lives alone regular nighttime|67
485|04 - Patient lives alone occassional/short term assistance|04 - Patient lives alone occassional/short term assistance|67
486|05 - Patient lives alone no assisstance available|05 - Patient lives alone no assisstance available|67
487|06 - Patient lives with other person(s) in the home around the clock|06 - Patient lives with other person(s) in the home around the clock|67
488|07 - Patient lives with other person(s) in the home regular daytime|07 - Patient lives with other person(s) in the home regular daytime|67
489|08 - Patient lives with other person(s) in the home regular nighttime|08 - Patient lives with other person(s) in the home regular nighttime|67
490|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|67
491|10 - Patient lives with other person(s) in the home no assistance available|10 - Patient lives with other person(s) in the home no assistance available|67
492|1 - Was present at the most recent SOC/ROC assessment|1 - Was present at the most recent SOC/ROC assessment|67
493|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|67
494|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|67
495|0 - Newly epithelialized|0 - Newly epithelialized|67
496|0 - No [ Go to M1340 ]|0 - No [ Go to M1340 ]|67
498|0 - Independent|0 - Independent|67
499|1 - Needed Some Help|1 - Needed Some Help|67
500|2 - Dependent|2 - Dependent|67
502|0 - No assistance needed in this area|0 - No assistance needed in this area|67
503|1 - Caregiver(s) currently provide assistance|1 - Caregiver(s) currently provide assistance|67
504|2 - Caregiver(s) need training/ supportive services to provide assistance|2 - Caregiver(s) need training/ supportive services to provide assistance|67
505|3 - Caregiver(s) not likely to provide assistance|3 - Caregiver(s) not likely to provide assistance|67
506|4 - Unclear if Caregiver(s) will provide assistance|4 - Unclear if Caregiver(s) will provide assistance|67
507|5 - Assistance needed, but no Caregiver(s) available|5 - Assistance needed, but no Caregiver(s) available|67
508|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will use standardized clinical guidelines accessible for all care providers to reference|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will|67
510|NA - Patient is not assessed to be at risk for falls|NA - Patient is not assessed to be at risk for falls|67
511|NA - Patient has no diagnosis or symptoms of depression|NA - Patient has no diagnosis or symptoms of depression|67
512|NA - No pain identified|NA - No pain identified|67
513|NA - Patient is not assessed to be at risk for pressure ulcers|NA - Patient is not assessed to be at risk for pressure ulcers|67
514|NA - Patient has no pressure ulcers with need for moist wound healing|NA - Patient has no pressure ulcers with need for moist wound healing|67
515|1 - Long-term nursing facility (NF)|1 - Long-term nursing facility (NF)|67
516|2 - Skilled nursing facility (SNF / TCU)|2 - Skilled nursing facility (SNF / TCU)|67
517|3 - Short stay acute hospital (IPP S)|3 - Short stay acute hospital (IPP S)|67
518|4 - Long-term care hospital (LTCH)|4 - Long-term care hospital (LTCH)|67
519|5 - Inpatient rehabilitation hospital or unit (IRF)|5 - Inpatient rehabilitation hospital or unit (IRF)|67
520|6 - Psychiatric hospital or unit|6 - Psychiatric hospital or unit|67
521|7 - Other|7 - Other|67
522|NA - Patient was not discharged from an inpatient facility [Go to M1017]|NA - Patient was not discharged from an inpatient facility [Go to M1017]|67
523|6 - Unable to participate effectively in bathing and is bathed totally by another person|6 - Unable to participate effectively in bathing and is bathed totally by another person|67
524|4 - Chairfast, unable to ambulate but is able to wheel self independently.|4 - Chairfast, unable to ambulate but is able to wheel self independently.|67
525|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask patient: "Over the last two weeks, how often have you been bothered by any of the following problems")|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask|67
526|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluation for depression.|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluat|67
527|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet criteria for further evaluation for depression.|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet|67
528|0 - Not at all  0 - 1 day|0 - Not at all  0 - 1 day|67
529|1 - Several days  2 - 6 days|1 - Several days  2 - 6 days|67
530|2 - More than half of the days  7 - 11 days|2 - More than half of the days  7 - 11 days|67
531|3 - Nearly every day  12 - 14 days|3 - Nearly every day  12 - 14 days|67
532|NA - N/A  Unable to respond|NA - N/A  Unable to respond|67
533|2 - Able to take medication(s) at the correct times if given reminders by another person based on the frequency of the injection|2 - Able to take medication(s) at the correct times if given reminders by another person based on th|67
534|3 - Unable to take injectable medication unless administered by another person.|3 - Unable to take injectable medication unless administered by another person.|67
547|NA - There were no potential clinically significant medication issues identified since SOC/ROC or patient is not taking any medications|NA v There were no potential clinically significant medication issues identified since SOC/ROC |67
552|1 - Hospital [ Go to M2430 ]|1 - Hospital [ Go to M2430 ]|67
553|2 - Rehabilitation facility [ Go to M0903 ]|2 - Rehabilitation facility [ Go to M0903 ]|67
554|3 - Nursing home [ Go to M2440 ]|3 - Nursing home [ Go to M2440 ]|67
555|4 - Hospice [ Go to M0903 ]|4 - Hospice [ Go to M0903 ]|67
564|NA - Patient is not diabetic or is bilateral amputee|NA - Patient is not diabetic or is bilateral amputee|67
565|NA - Every standardized,validated multifactor fall risk assessment conducted at or since the most recent SOC/ROC assessment indicates the patient has no risk for falls.|NA - Every standardized,validated multifactor fall risk assessment condition|67
566|NA - Patient has no diagnosis of depression AND every standardized, validated depression screening conducted at or since the most recent SOC/ROC assessment indicates the patient has: 1) no symptoms of depression; or 2) has some symptoms of depression but does not meet criteria for further evaluation of depression based on screening tool used.|NA - Patient has no diagnosis of depression AND every standardized, validated |67
567|NA - Every standardized, validated pain assessment conducted at or since the most recent SOC/ROC assessment indicates the patient has no pain.|NA - Every standardized, validated pain assessment conducted at or since the most|67
568|NA - Every standardized, validated pressure ulcer risk assessment conducted at or since the most recent SOC/ROC assessment indicates the patient is not at risk of developing pressure ulcers.|NA - Every standardized, validated pressure ulcer risk assessment conducted|67
569|NA - Dressings that support the principles of moist wound healing not indicated for this patient's pressure ulcers OR patient has no pressure ulcers with need for moist wound healing|NA - Dressings that support the principles of moist wound healing not indicated for this patient's p|67
620|1 - Yes; received from your agency during this episode of care (SOC/ROC to Transfer/Discharge)|1 - Yes; received from your agency during this episode of care (SOC/ROC to Transfer/Discharge)|67
621|2 - Yes; received from your agency during a prior episode of care (SOC/ROC to Transfer/Discharge)|2 - Yes; received from your agency during a prior episode of care (SOC/ROC to Transfer/Discharge)|67
622|3 - Yes; received from another health care provider (for example physician pharmacist)|3 - Yes; received from another health care provider (for example physician pharmacist)|67
623|4 - No; patient offered and declined |4 - No; patient offered and declined |67
624|5 - No; patient assessed and determined to have medical contraindication(s)|5 - No; patient assessed and determined to have medical contraindication(s)|67
625|6 - No; not indicated - patient does not meet age/condition guidelines for influenza vaccine|6 - No; not indicated - patient does not meet age/condition guidelines for influenza vaccine|67
626|7 - No; inability to obtain vaccine due to declared shortage |7 - No; inability to obtain vaccine due to declared shortage |67
627|8 - No; patient did not receive the vaccine due to reasons other than those listed in responses 4 v 7. |8 - No; patient did not receive the vaccine due to reasons other than those listed in responses 4v7.|67
628|1 - Offered and declined|1 - Offered and declined|67
629|2 - Assessed and determined to have medical contraindication(s) |2 - Assessed and determined to have medical contraindication(s) |67
630|3 - Not indicated; patient does not meet age/condition guidelines for Pneumococcal Vaccine|3 - Not indicated; patient does not meet age/condition guidelines for Pneumococcal Vaccine|67
631|4 - None of the above|4 - None of the above|67
2|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; OR (b) Is physically, cognitively, and mentally able to prepare light meals on a regular basis but has not routinely performed light meal preparation in the past (i.e., prior to this home care admission).|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; O|68
3|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and mentally able to perform all housekeeping tasks .|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and menta|68
4|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and mentally able to do laundry and access facilities.|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and menta|68
5|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying packages OR b) Physically, cognitively, and mentally able to take care of shopping, but has not done shopping in the past (i.e., prior to this home care admission).|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying|68
6|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|68
7|0 - Able to dial numbers and answer calls appropriately and as desired.|0 - Able to dial numbers and answer calls appropriately and as desired.|68
8|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body without assistance.|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body|68
9|0 - Able to get to and from the toilet and transfer independently with or without a device.|0 - Able to get to and from the toilet and transfer independently with or without a device.|68
10|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|68
11|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible public bus.|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible p|68
12|0 - Able to independently feed self.|0 - Able to independently feed self.|68
13|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|68
14|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct times.|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct ti|68
15|0 - Able to independently transfer.|0 - Able to independently transfer.|68
16|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without rail|68
17|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings|68
18|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|68
19|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions independently.|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions indep|68
20|0 - Asymptomatic, no treatment needed at this time|0 - Asymptomatic, no treatment needed at this time|68
21|0 - Caregiver manages all tasks related to equipment completely independently.|0 - Caregiver manages all tasks related to equipment completely independently.|68
22|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations with no observable impairment.|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations w|68
23|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|68
24|0 - Life expectancy is greater than 6 months|0 - Life expectancy is greater than 6 months|68
25|0 - Never|0 - Never|68
26|0 - Patient is not short of breath|0 - Patient is not short of breath|68
27|0 - No|0 - No|68
28|0 - No emergent care services|0 - No emergent care services|68
29|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [Goto 1620]|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [Goto 1620]|68
30|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and extended or abstract conversation.|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and exte|68
31|0 - No one person|0 - No one person|68
32|0 - None of the time|0 - None of the time|68
33|0 - None, no charge for current services|0 - None, no charge for current services|68
34|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|68
35|0 - Patient does NOT have an ostomy for bowel elimination.|0 - Patient does NOT have an ostomy for bowel elimination.|68
36|0 - Patient has no pain|0 - Patient has no pain|68
37|0 - Patient manages all tasks related to equipment completely independently.|0 - Patient manages all tasks related to equipment completely independently.|68
38|0 - Poor:  little or no recovery is expected and/or further decline is imminent|0 - Poor:  little or no recovery is expected and/or further decline is imminent|68
39|0 - Timed-voiding defers incontinence|0 - Timed-voiding defers incontinence|68
40|0 - Very rarely or never has bowel incontinence|0 - Very rarely or never has bowel incontinence|68
41|0 - Zero|0 - Zero|68
42|00 - No|00 - No|68
43|01 - Yes|01 - Yes|68
44|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or mental limitations, needs assistance with heavy laundry.|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or|68
45|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the patient.|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the|68
46|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|68
47|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or supervision from another person OR c) a liquid, pureed or ground meat diet.|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or su|68
48|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|68
49|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|68
50|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independently.|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independe|68
51|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only when assisted or accompanied by another person.|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only w|68
52|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepa|68
53|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance by another person OR b) given daily reminders.|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance b|68
54|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advan|68
55|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advan|68
56|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for the deaf) and call essential numbers.|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for t|68
57|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|68
58|1 - American Indian or Alaska Native|1 - American Indian or Alaska Native|68
59|1 - Depressed mood (e.g., feeling sad, tearful)|1 - Depressed mood (e.g., feeling sad, tearful)|68
60|1 - During the night only|1 - During the night only|68
61|1 - Fully granulating|1 - Fully granulating|68
62|1 - Good/Fair:  partial to full recovery is expected|1 - Good/Fair:  partial to full recovery is expected|68
63|1 - Good:  marked improvement in functional status is expected|1 - Good:  marked improvement in functional status is expected|68
64|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|68
65|1 - Smoking|1 - Smoking|68
66|1 - Hospital|1 - Hospital|68
67|1 - Hospital emergency room (includes 23-hour holding)|1 - Hospital emergency room (includes 23-hour holding)|68
68|1 - Hospitalization for EMERGENT (unscheduled) care|1 - Hospitalization for EMERGENT (unscheduled) care|68
69|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepared solutions), patient is able to manage all other aspects of equipment.|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepar|68
70|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|68
71|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|68
72|1 - In new or complex situations only|1 - In new or complex situations only|68
73|1 - Intravenous or infusion therapy (excludes TPN)|1 - Intravenous or infusion therapy (excludes TPN)|68
74|1 - Less often than daily|1 - Less often than daily|68
75|1 - Less than once a month|1 - Less than once a month|68
76|1 - Less than once weekly|1 - Less than once weekly|68
77|1 - Life expectancy is 6 months or fewer|1 - Life expectancy is 6 months or fewer|68
78|1 - Lives alone|1 - Lives alone|68
79|1 - Male|1 - Male|68
80|1 - Medicare (traditional fee-for-service)|1 - Medicare (traditional fee-for-service)|68
81|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of past 24 hours, significant memory loss so that supervision is required|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of pas|68
82|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors in word choice, grammar or speech intelligibility, needs minimal prompting or assistance).|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors i|68
83|1 - No assistance or services received|1 - No assistance or services received|68
84|1 - One|1 - One|68
85|1 - Oxygen (intermittent or continuous)|1 - Oxygen (intermittent or continuous)|68
86|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, and the surrounding layout, can count fingers at arm's length.|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, a|68
87|1 - Patient is incontinent|1 - Patient is incontinent|68
88|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|68
89|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical or treatment regimen.|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical|68
90|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient/couple/significant other)|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient|68
91|1 - Relatives, friends, or neighbors living outside the home|1 - Relatives, friends, or neighbors living outside the home|68
92|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions.|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions|68
93|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independentl|68
94|1 - Several times during day and night|1 - Several times during day and night|68
95|1 - Spouse or significant other|1 - Spouse or significant other|68
96|1 - Stage 1|1 - Stage 1|68
97|1 - Start of care - further visits planned|1 - Start of care - further visits planned|68
98|1 - Symptoms well controlled with current therapy|1 - Symptoms well controlled with current therapy|68
99|1 - Therapy services|1 - Therapy services|68
100|1 - Able to transfer with minimal human assistance or with use of an assistive device.|1 - Able to transfer with minimal human assistance or with use of an assistive device.|68
101|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitations.|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitatio|68
102|1 - Urinary incontinence|1 - Urinary incontinence|68
103|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and transfer.|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and|68
104|1 - When walking more than 20 feet, climbing stairs|1 - When walking more than 20 feet, climbing stairs|68
105|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary conversation. May need occasional repetition, extra time, or louder voice.|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary c|68
106|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting in and out of tub/shower|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting|68
107|1 - Yes|1 - Yes|68
108|1-RN|1-RN|68
109|10 - Discharge from agency - no visits completed after start/resumption of care assessment|10 - Discharge from agency - no visits completed after start/resumption of care assessment|68
110|10 - Scheduled surgical procedure|10 - Scheduled surgical procedure|68
111|10 - Self-pay|10 - Self-pay|68
112|11 - Other|11 - Other|68
113|11 - Urinary tract infection|11 - Urinary tract infection|68
114|12 - IV catheter-related infection|12 - IV catheter-related infection|68
115|13 - Deep vein thrombosis, pulmonary embolus|13 - Deep vein thrombosis, pulmonary embolus|68
116|14 - Uncontrolled pain|14 - Uncontrolled pain|68
117|15 - Psychotic episode|15 - Psychotic episode|68
118|16 - Other than above reasons|16 - Other than above reasons|68
119|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing calls.|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing|68
120|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another person.|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another pers|68
121|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface a|68
122|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for intermittent supervision or encouragement or reminders, OR (b) to get in and out of the shower or tub, OR (c) for washing difficult to reach areas.|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for inter|68
123|2 - Asian|2 - Asian|68
124|2 - Caregiver requires considerable assistance from another person to manage equipment, but independently completes significant portions of task.|2 - Caregiver requires considerable assistance from another person to manage equipment, but independ|68
125|2 - Daily, but not constantly|2 - Daily, but not constantly|68
126|2 - Daughter or son|2 - Daughter or son|68
127|2 - Doctor's office emergency visit/house call|2 - Doctor's office emergency visit/house call|68
128|2 - During the day and night|2 - During the day and night|68
129|2 - Early/partial granulation|2 - Early/partial granulation|68
130|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors in word choice, organization or speech intelligibility). Speaks in phrases or short sentences.|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors|68
131|2 - Family member's residence|2 - Family member's residence|68
132|2 - Female|2 - Female|68
133|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conversation, needs frequent prompting or assistance.|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conver|68
134|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|68
135|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|68
136|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately stop activities, jeopardizes safety through actions|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately st|68
137|2 - Indwelling/suprapubic catheter|2 - Indwelling/suprapubic catheter|68
138|2 - Injury caused by fall or accident at home|2 - Injury caused by fall or accident at home|68
139|2 - Medicare (HMO/managed care/Advantage plan)|2 - Medicare (HMO/managed care/Advantage plan)|68
140|2 - Nausea, dehydration, malnutrition, constipation, impaction|2 - Nausea, dehydration, malnutrition, constipation, impaction|68
141|2 - Obesity|2 - Obesity|68
142|2 - On awakening or at night only|2 - On awakening or at night only|68
143|2 - Once a month|2 - Once a month|68
144|2 - One to three times weekly|2 - One to three times weekly|68
145|2 - Parenteral nutrition (TPN or lipids)|2 - Parenteral nutrition (TPN or lipids)|68
146|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic) [ Go to M1620]|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic) [ Go|68
147|2 - Patient requires considerable assistance from another person to manage equipment, but independently completes portions of the task.|2 - Patient requires considerable assistance from another person to manage equipment, but independen|68
148|2 - Patient transferred to a noninstitutional hospice|2 - Patient transferred to a noninstitutional hospice|68
149|2 - Person residing in the home (EXCLUDING paid help)|2 - Person residing in the home (EXCLUDING paid help)|68
150|2 - Rehabilitation facility|2 - Rehabilitation facility|68
151|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifting of attention) or consistently requires low stimulus environment due to distractibility.|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifti|68
152|2 - Respite care|2 - Respite care|68
153|2 - Sense of failure or self reproach|2 - Sense of failure or self reproach|68
154|2 - Several times during day|2 - Several times during day|68
155|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonresponsive.|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonrespons|68
156|2 - Someone must assist the patient to groom self.|2 - Someone must assist the patient to groom self.|68
157|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|68
158|2 - Someone must help the patient put on upper body clothing.|2 - Someone must help the patient put on upper body clothing.|68
159|2 - Stage 2|2 - Stage 2|68
160|2 - Start of care - no further visits planned|2 - Start of care - no further visits planned|68
161|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitoring|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitori|68
162|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment regimen.|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment re|68
163|2 - Two|2 - Two|68
164|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistance due to cognitive or mental limitation.|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistanc|68
165|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|68
166|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assistance).|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assis|68
167|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home delivery.|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home deli|68
168|2 - Unable to prepare any light meals or reheat any delivered meals.|2 - Unable to prepare any light meals or reheat any delivered meals.|68
169|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|68
170|2 - UNABLE to take injectable medications unless administered by someone else.|2 - UNABLE to take injectable medications unless administered by someone else.|68
171|2 - UNABLE to take medication unless administered by someone else.|2 - UNABLE to take medication unless administered by someone else.|68
172|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|68
173|2 - Ventilator (continually or at night)|2 - Ventilator (continually or at night)|68
174|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less than 20 feet)|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less th|68
175|2 - With spouse or significant other|2 - With spouse or significant other|68
176|2 - Yes, assistance or services provided by family or friends|2 - Yes, assistance or services provided by family or friends|68
177|2-PT|2-PT|68
178|3 - Able to answer the telephone only some of the time or is able to carry on only a limited conversation.|3 - Able to answer the telephone only some of the time or is able to carry on only a limited convers|68
179|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube or gastrostomy.|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube|68
180|3 - Alcohol dependency|3 - Alcohol dependency|68
181|3 - All of the time|3 - All of the time|68
182|3 - Black or African-American|3 - Black or African-American|68
183|3 - Boarding home or rented room|3 - Boarding home or rented room|68
184|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment, clean/store/dispose of equipment or supplies).|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment,|68
185|3 -Able to walk only with the supervision or assistance of another person at all times.|3 -Able to walk only with the supervision or assistance of another person at all times.|68
186|3 - Continuous / Bi-level positive airway pressure|3 - Continuous / Bi-level positive airway pressure|68
187|3 - During the day and evening, but not constantly|3 - During the day and evening, but not constantly|68
188|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the alimentary canal)|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the|68
189|3 - Environmental support (e.g., housing, home maintenance)|3 - Environmental support (e.g., housing, home maintenance)|68
190|3 - Four to six times weekly|3 - Four to six times weekly|68
191|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessing by listener.  Speech limited to single words or short phrases.|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessin|68
192|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires multiple repetitions, restatements, demonstrations, additional time.|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires m|68
193|3 - Hopelessness|3 - Hopelessness|68
194|3 - Hospice care|3 - Hospice care|68
195|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|68
196|3 - Injury caused by fall or accident at home|3 - Injury caused by fall or accident at home|68
197|3 - Intractable pain|3 - Intractable pain|68
198|3 - Medicaid (traditional fee-for-service)|3 - Medicaid (traditional fee-for-service)|68
199|3 - Needs someone to do all shopping and errands.|3 - Needs someone to do all shopping and errands.|68
200|3 - Not healing|3 - Not healing|68
201|3 - Nursing home|3 - Nursing home|68
202|3 - Once daily|3 - Once daily|68
203|3 - Other family member|3 - Other family member|68
204|3 - Outpatient department/clinic emergency (includes urgicenter sites)|3 - Outpatient department/clinic emergency (includes urgicenter sites)|68
205|3 - Paid help|3 - Paid help|68
206|3 - Able to participate in bathing self in shower or tub, but requires presence of another person throughout the bath for assistance or supervision.|3 - Able to participate in bathing self in shower or tub, but requires presence of another person th|68
207|3 - Patient depends entirely upon another person to dress lower body.|3 - Patient depends entirely upon another person to dress lower body.|68
208|3 - Patient depends entirely upon another person to dress the upper body.|3 - Patient depends entirely upon another person to dress the upper body.|68
209|3 - Patient depends entirely upon someone else for grooming needs.|3 - Patient depends entirely upon someone else for grooming needs.|68
210|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone else to manage the equipment.|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone|68
211|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable to shift attention and recall directions more than half the time.|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable|68
212|3 - Respiratory problems (SOB, infection, obstruction)|3 - Respiratory problems (SOB, infection, obstruction)|68
213|3 - Resumption of care (after inpatient stay)|3 - Resumption of care (after inpatient stay)|68
214|3 - Several times each month|3 - Several times each month|68
215|3 - Skilled Nursing Facility|3 - Skilled Nursing Facility|68
216|3 - Stage 3|3 - Stage 3|68
217|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|68
218|3 - Three|3 - Three|68
219|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person throughout the process.|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person through|68
220|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal independently.|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal indep|68
221|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person.|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person|68
222|3 - Unknown because patient moved to a geographic location not served by this agency|3 - Unknown because patient moved to a geographic location not served by this agency|68
223|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|68
224|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|68
225|3 - With other family member|3 - With other family member|68
226|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home health services, homemaker assistance, transportation assistance, assisted living, board and care)|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home h|68
227|3-SLP/ST|3-SLP/ST|68
228|4 - At rest (during day or night)|4 - At rest (during day or night)|68
229|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|68
230|4 - Board and care or assisted living facility|4 - Board and care or assisted living facility|68
231|4 - Caregiver is completely dependent on someone else to manage all equipment.|4 - Caregiver is completely dependent on someone else to manage all equipment.|68
232|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|68
233|4 - Constantly|4 - Constantly|68
234|4 - Drug dependency|4 - Drug dependency|68
235|4 - Four or more|4 - Four or more|68
236|4 - Friend or neighbor or community or church member|4 - Friend or neighbor or community or church member|68
237|4 - Hispanic or Latino|4 - Hispanic or Latino|68
238|4 - Hospice|4 - Hospice|68
239|4 - Impaired decision-making|4 - Impaired decision-making|68
240|4 - Is totally dependent in toileting.|4 - Is totally dependent in toileting.|68
241|4 - Medicaid (HMO/managed care)|4 - Medicaid (HMO/managed care)|68
242|4 - None of the above|4 - None of the above|68
243|4 - Nursing home|4 - Nursing home|68
244|4 - On a daily basis|4 - On a daily basis|68
245|4 - Patient is completely dependent on someone else to manage all equipment.|4 - Patient is completely dependent on someone else to manage all equipment.|68
246|4 - Permanent placement|4 - Permanent placement|68
247|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, punches, dangerous maneuvers w/ wheelchair or other objects)|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, pu|68
248|4 - Psychosocial support (e.g., socialization, companionship, recreation)|4 - Psychosocial support (e.g., socialization, companionship, recreation)|68
249|4 - Recertification (follow-up) reassessment|4 - Recertification (follow-up) reassessment|68
250|4 - Recurrent thoughts of death|4 - Recurrent thoughts of death|68
251|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruction)|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruc|68
252|4 - Several times a week|4 - Several times a week|68
253|4 - Stage 4|4 - Stage 4|68
254|4 - Symptoms poorly controlled, history of rehospitalizations|4 - Symptoms poorly controlled, history of rehospitalizations|68
255|4 - Three or more times per week|4 - Three or more times per week|68
256|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetative state, or delirium.|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetati|68
257|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|68
258|4 - Unable to effectively participate in any housekeeping tasks.|4 - Unable to effectively participate in any housekeeping tasks.|68
259|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or unresponsive (e.g., speech is nonsensical or unintelligible).|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or u|68
260|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonresponsive.|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonr|68
261|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostomy.|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostom|68
262|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of devices at the sink, in chair, or on commode|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of|68
263|4 - With a friend|4 - With a friend|68
264|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|68
265|4-OT|4-OT|68
266|5 - Advocates or facilitates patient's participation in appropriate medical care|5 - Advocates or facilitates patient's participation in appropriate medical care|68
267|5 - At least daily|5 - At least daily|68
268|6 - Bedfast, unable to ambulate or be up in a chair.|6 - Bedfast, unable to ambulate or be up in a chair.|68
269|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|68
270|5 - Disruptive or socially inappropriate behavior|5 - Disruptive or socially inappropriate behavior|68
271|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|68
272|5 - Hypo/Hyperglycemia, diabetes out of control|5 - Hypo/Hyperglycemia, diabetes out of control|68
273|5 - More often than once daily|5 - More often than once daily|68
274|5 - Native Hawaiian or Pacific Islander|5 - Native Hawaiian or Pacific Islander|68
275|5 - None of the above|5 - None of the above|68
276|5 - One to two times per week|5 - One to two times per week|68
277|5 - Other|5 - Other|68
278|5 - Other follow-up|5 - Other follow-up|68
279|5 - Paid help|5 - Paid help|68
280|5 - Patient nonresponsive or unable to speak.|5 - Patient nonresponsive or unable to speak.|68
281|5 - Thoughts of suicide|5 - Thoughts of suicide|68
282|5 - Totally unable to use the telephone.|5 - Totally unable to use the telephone.|68
283|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|68
284|5 - Unable to take in nutrients orally or by tube feeding.|5 - Unable to take in nutrients orally or by tube feeding.|68
285|5 - Unsafe for care at home|5 - Unsafe for care at home|68
286|5 - With paid help (other than home care agency staff)|5 - With paid help (other than home care agency staff)|68
287|5 - Workers' compensation|5 - Workers' compensation|68
288|5 - Wound infection, deteriorating wound status, new lesion/ulcer|5 - Wound infection, deteriorating wound status, new lesion/ulcer|68
289|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|68
290|6 - Delusional, hallucinatory, or paranoid behavior|6 - Delusional, hallucinatory, or paranoid behavior|68
291|6 - Financial agent, power of attorney, or conservator of finance|6 - Financial agent, power of attorney, or conservator of finance|68
292|6 - GI bleeding, obstruction|6 - GI bleeding, obstruction|68
293|6 - Less often than weekly|6 - Less often than weekly|68
294|6 - Memory loss to the extent that supervision required|6 - Memory loss to the extent that supervision required|68
295|6 - None of the above feelings observed or reported|6 - None of the above feelings observed or reported|68
296|6 - Other|6 - Other|68
297|6 - Title programs (e.g., Title III, V, or XX)|6 - Title programs (e.g., Title III, V, or XX)|68
298|6 - Transferred to an inpatient facility - patient not discharged from agency|6 - Transferred to an inpatient facility - patient not discharged from agency|68
299|6 - White|6 - White|68
300|6 - With other than above|6 - With other than above|68
301|7 - Exacerbation of CHF, fluid overload, heart failure|7 - Exacerbation of CHF, fluid overload, heart failure|68
302|7 - Health care agent, conservator of person, or medical power of attorney|7 - Health care agent, conservator of person, or medical power of attorney|68
303|7 - Hypo/Hyperglycemia, diabetes out of control|7 - Hypo/Hyperglycemia, diabetes out of control|68
304|7 - None of the above|7 - None of the above|68
305|7 - None of the above behaviors demonstrated|7 - None of the above behaviors demonstrated|68
306|7 - Other government (e.g., TriCare, VA, etc.)|7 - Other government (e.g., TriCare, VA, etc.)|68
307|7 - Transferred to an inpatient facility - patient discharged from agency|7 - Transferred to an inpatient facility - patient discharged from agency|68
308|8 - Death at home|8 - Death at home|68
309|8 - GI bleeding, obstruction|8 - GI bleeding, obstruction|68
310|8 - Myocardial infarction, stroke|8 - Myocardial infarction, stroke|68
311|8 - Private insurance|8 - Private insurance|68
312|9 - Chemotherapy|9 - Chemotherapy|68
313|9 - Discharge from agency|9 - Discharge from agency|68
314|9 - Other than above reasons|9 - Other than above reasons|68
315|9 - Private HMO/managed care|9 - Private HMO/managed care|68
316|NA - No caregiver|NA - No caregiver|68
317|NA - No equipment of this type used in care.|NA - No equipment of this type used in care.|68
318|NA - No inhalant/mist medications prescribed.|NA - No inhalant/mist medications prescribed.|68
319|NA - No injectable medications prescribed.|NA - No injectable medications prescribed.|68
320|NA - No inpatient facility admission|NA - No inpatient facility admission|68
321|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|68
322|NA - No Medicaid|NA - No Medicaid|68
323|NA - No Medicare|NA - No Medicare|68
324|NA - No observable pressure ulcer or unhealed pressure ulcer|NA - No observable pressure ulcer or unhealed pressure ulcer|68
325|NA - No observable stasis ulcer|NA - No observable stasis ulcer|68
326|NA - No observable surgical wound|NA - No observable surgical wound|68
327|NA - No oral medications prescribed.|NA - No oral medications prescribed.|68
328|NA - Not applicable|NA - Not applicable|68
329|NA - Patient does not have a telephone.|NA - Patient does not have a telephone.|68
330|NA - Patient has ostomy for bowel elimination|NA - Patient has ostomy for bowel elimination|68
331|NA - Patient nonresponsive|NA - Patient nonresponsive|68
332|NA - Patient on prophylactic treatment|NA - Patient on prophylactic treatment|68
333|NA - Patient was not discharged from an inpatient facility [Go to M1017]|NA - Patient was not discharged from an inpatient facility [Go to M1017]|68
334|UK - Other unknown|UK - Other unknown|68
335|UK - Reason unknown|UK - Reason unknown|68
336|UK - Unknown|UK - Unknown|68
337|UK - Unknown or Not Available|UK - Unknown or Not Available|68
341|01 - Early|01 - Early|68
342|02 - Late|02 - Late|68
343|NA - Not Applicable. No case mix group defined for this assessment.|NA - Not Applicable. No case mix group defined for this assessment.|68
344|NA - No case mix group defined by this assessment.|NA - No case mix group defined by this assessment.|68
345|1 - Recent decline in mental, emotional, or behavioral status|1 - Recent decline in mental, emotional, or behavioral status|68
346|2 - Multiple hospitalizations (2 or more) in the past 12 months|2 - Multiple hospitalizations (2 or more) in the past 12 months|68
347|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|68
348|4 - Taking five or more medications|4 - Taking five or more medications|68
349|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|68
350|6 - Other|6 - Other|68
351|7 - None of the above|7 - None of the above|68
352|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond tho|68
353|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable without heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable wi|68
354|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious complications and death.|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious compl|68
355|3 - The patient has serious progressive conditions that could lead to death within a year.|3 - The patient has serious progressive conditions that could lead to death within a year.|68
356|UK - The patient+s situation is unknown or unclear.|UK - The patient+s situation is unknown or unclear.|68
357|1 - Yes [ Go to M1050 ]|1 - Yes [ Go to M1050 ]|68
358|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this influenza season. [ Go to M1050 ]|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this i|68
359|1 - Received from another health care provider (e.g., physician)|1 - Received from another health care provider (e.g., physician)|68
360|2 - Received from your agency previously during this year+s flu season|2 - Received from your agency previously during this year+s flu season|68
361|3 - Offered and declined|3 - Offered and declined|68
362|4 - Assessed and determined to have medical contraindication(s)|4 - Assessed and determined to have medical contraindication(s)|68
363|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|68
364|6 - Inability to obtain vaccine due to declared shortage|6 - Inability to obtain vaccine due to declared shortage|68
365|1 - Yes [ Go to M1501 at TRN; Go to M1230 at DC ]|1 - Yes [ Go to M1501 at TRN; Go to M1230 at DC ]|68
366|1 - Patient has received PPV in the past|1 - Patient has received PPV in the past|68
367|2 - Offered and declined|2 - Offered and declined|68
368|3 - Assessed and determined to have medical contraindication(s)|3 - Assessed and determined to have medical contraindication(s)|68
369|4 - Not indicated; patient does not meet age/condition guidelines for PPV|4 - Not indicated; patient does not meet age/condition guidelines for PPV|68
370|5 - None of the above|5 - None of the above|68
371|0 - Adequate: hears normal conversation without difficulty.|0 - Adequate: hears normal conversation without difficulty.|68
372|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to increase volume or speak distinctly.|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to in|68
373|2 - Severely Impaired: absence of useful hearing.|2 - Severely Impaired: absence of useful hearing.|68
374|UK - Unable to assess hearing.|UK - Unable to assess hearing.|68
375|0 - Understands: clear comprehension without cues or repetitions.|0 - Understands: clear comprehension without cues or repetitions.|68
376|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Requires cues at times to understand.|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Req|68
377|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequently requires cues to understand.|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequentl|68
378|3 - Rarely/Never Understands|3 - Rarely/Never Understands|68
379|UK - Unable to assess understanding.|UK - Unable to assess understanding.|68
380|0 - No standardized assessment conducted|0 - No standardized assessment conducted|68
381|1 - Yes, and it does not indicate severe pain|1 - Yes, and it does not indicate severe pain|68
382|2 - Yes, and it indicates severe pain|2 - Yes, and it indicates severe pain|68
383|0 - Patient has no pain|0 - Patient has no pain|68
384|1 - Patient has pain that does not interfere with activity or movement|1 - Patient has pain that does not interfere with activity or movement|68
385|2 - Less often than daily|2 - Less often than daily|68
386|3 - Daily, but not constantly|3 - Daily, but not constantly|68
387|4 - All of the time|4 - All of the time|68
388|0 - No assessment conducted [ Go to M1306 ]|0 - No assessment conducted [ Go to M1306 ]|68
389|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc., without use of standardized tool|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc.,|68
390|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|68
391|0 - No [ Go to M1322]|0 - No [ Go to M1322]|68
392|0 v Newly epithelialized|0 v Newly epithelialized|68
393|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|68
394|2 - Yes, patient has observable stasis ulcers ONLY|2 - Yes, patient has observable stasis ulcers ONLY|68
395|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable dressing) [Go to M1340]|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable|68
396|0 - No [ Go to M1350 ]|0 - No [ Go to M1350 ]|68
397|1 - Yes, patient has at least one (observable) surgical wound|1 - Yes, patient has at least one (observable) surgical wound|68
398|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1350 ]|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1350 ]|68
399|0 - Patient is not short of breath|0 - Patient is not short of breath|68
400|3 - Continuous Bi-level positive airway pressure|3 - Continuous Bi-level positive airway pressure|68
401|0 - No [ Go to M2005 at TRN; Go to M1600 at DC ]|0 - No [ Go to M2005 at TRN; Go to M1600 at DC ]|68
402|2 - Not assessed [Go to M2005 at TRN; Go to M1600 at DC ]|2 - Not assessed [Go to M2005 at TRN; Go to M1600 at DC ]|68
403|NA - Patient does not have diagnosis of heart failure [Go to M2005 at TRN; Go to M1600 at DC]|NA - Patient does not have diagnosis of heart failure [Go to M2005 at TRN; Go to M1600 at DC]|68
404|0 - No action taken|0 - No action taken|68
405|1 - Patient+s physician (or other primary care practitioner) contacted the same day|1 - Patient+s physician (or other primary care practitioner) contacted the same day|68
406|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|68
407|3 - Implement physician-ordered patient-specific established parameters for treatment|3 - Implement physician-ordered patient-specific established parameters for treatment|68
408|4 - Patient education or other clinical interventions|4 - Patient education or other clinical interventions|68
409|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequency, telehealth, etc.)|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequ|68
410|1 - Occasional stress incontinence|1 - Occasional stress incontinence|68
411|2 - During the night only|2 - During the night only|68
412|3 - During the day only|3 - During the day only|68
413|4 - During the day and night|4 - During the day and night|68
414|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|68
415|0 - Able to manage toileting hygiene and clothing management without assistance.|0 - Able to manage toileting hygiene and clothing management without assistance.|68
416|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implements are laid out for the patient.|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implemen|68
417|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|68
418|3 - Patient depends entirely upon another person to maintain toileting hygiene.|3 - Patient depends entirely upon another person to maintain toileting hygiene.|68
419|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independent|68
420|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface|68
421|0 - No multi-factor falls risk assessment conducted.|0 - No multi-factor falls risk assessment conducted.|68
422|1 - Yes, and it does not indicate a risk for falls.|1 - Yes, and it does not indicate a risk for falls.|68
423|2 - Yes, and it indicates a risk for falls.|2 - Yes, and it indicates a risk for falls.|68
424|0 - Not assessed/reviewed [ Go to M2010 ]|0 - Not assessed/reviewed [ Go to M2010 ]|68
425|1 - No problems found during review [ Go to M2010 ]|1 - No problems found during review [ Go to M2010 ]|68
426|2 - Problems found during review|2 - Problems found during review|68
427|NA - Patient is not taking any medications [ Go to M2040 ]|NA - Patient is not taking any medications [ Go to M2040 ]|68
428|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special precautions associated with all high-risk medications|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special p|68
429|NA - Patient not taking any drugs|NA - Patient not taking any drugs|68
430|2 - Able to take medication(s) at the correct times if given reminders by another person at the appropriate times|2 - Able to take medication(s) at the correct times if given reminders by another person at the appr|68
431|3 - Unable to take medication unless administered by another person.|3 - Unable to take medication unless administered by another person.|68
432|1 - At least daily|1 - At least daily|68
433|2 - Three or more times per week|2 - Three or more times per week|68
434|3 - One to two times per week|3 - One to two times per week|68
435|4 - Received, but less often than weekly|4 - Received, but less often than weekly|68
436|5 - No assistance received|5 - No assistance received|68
437|0 - No [Go to M2401]|0 - No [Go to M2401]|68
438|1 - Yes, used hospital emergency department WITHOUT hospital admission|1 - Yes, used hospital emergency department WITHOUT hospital admission|68
439|2 - Yes, used hospital emergency department WITH hospital admission|2 - Yes, used hospital emergency department WITH hospital admission|68
440|UK - Unknown [Go to M2401]|UK - Unknown [Go to M2401]|68
441|2 - Injury caused by fall|2 - Injury caused by fall|68
442|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|68
443|4 - Other respiratory problem|4 - Other respiratory problem|68
444|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|68
445|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|68
446|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|68
447|8 - Other heart disease|8 - Other heart disease|68
448|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|68
449|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|68
450|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|68
451|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|68
452|13 - Urinary tract infection|13 - Urinary tract infection|68
453|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|68
454|15 - Wound infection or deterioration|15 - Wound infection or deterioration|68
455|16 - Uncontrolled pain|16 - Uncontrolled pain|68
456|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|68
457|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|68
458|19 - Other than above reasons|19 - Other than above reasons|68
459|2 - Patient remained in the community (with formal assistive services)|2 - Patient remained in the community (with formal assistive services)|68
460|3 - Patient transferred to a noninstitutional hospice|3 - Patient transferred to a noninstitutional hospice|68
461|4 - Unknown because patient moved to a geographic location not served by this agency|4 - Unknown because patient moved to a geographic location not served by this agency|68
462|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|68
463|4 - Other respiratory problem|4 - Other respiratory problem|68
464|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|68
465|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|68
466|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|68
467|8 - Other heart disease|8 - Other heart disease|68
468|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|68
469|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|68
470|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|68
471|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|68
472|13 - Urinary tract infection|13 - Urinary tract infection|68
473|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|68
474|15 - Wound infection or deterioration|15 - Wound infection or deterioration|68
475|16 - Uncontrolled pain|16 - Uncontrolled pain|68
476|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|68
477|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|68
478|19 - Scheduled treatment or procedure|19 - Scheduled treatment or procedure|68
479|20 - Other than above reasons|20 - Other than above reasons|68
480|UK - Reason unknown [Go to M0903]|UK - Reason unknown [Go to M0903]|68
482|01 - Patient lives alone around the clock|01 - Patient lives alone around the clock|68
483|02 - Patient lives alone regular daytime|02 - Patient lives alone regular daytime|68
484|03 - Patient lives alone regular nighttime|03 - Patient lives alone regular nighttime|68
485|04 - Patient lives alone occassional/short term assistance|04 - Patient lives alone occassional/short term assistance|68
486|05 - Patient lives alone no assisstance available|05 - Patient lives alone no assisstance available|68
487|06 - Patient lives with other person(s) in the home around the clock|06 - Patient lives with other person(s) in the home around the clock|68
488|07 - Patient lives with other person(s) in the home regular daytime|07 - Patient lives with other person(s) in the home regular daytime|68
489|08 - Patient lives with other person(s) in the home regular nighttime|08 - Patient lives with other person(s) in the home regular nighttime|68
490|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|68
491|10 - Patient lives with other person(s) in the home no assistance available|10 - Patient lives with other person(s) in the home no assistance available|68
492|1 - Was present at the most recent SOC/ROC assessment|1 - Was present at the most recent SOC/ROC assessment|68
493|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|68
494|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|68
495|0 - Newly epithelialized|0 - Newly epithelialized|68
496|0 - No [ Go to M1340 ]|0 - No [ Go to M1340 ]|68
498|0 - Independent|0 - Independent|68
499|1 - Needed Some Help|1 - Needed Some Help|68
500|2 - Dependent|2 - Dependent|68
502|0 - No assistance needed in this area|0 - No assistance needed in this area|68
503|1 - Caregiver(s) currently provide assistance|1 - Caregiver(s) currently provide assistance|68
504|2 - Caregiver(s) need training/ supportive services to provide assistance|2 - Caregiver(s) need training/ supportive services to provide assistance|68
505|3 - Caregiver(s) not likely to provide assistance|3 - Caregiver(s) not likely to provide assistance|68
506|4 - Unclear if Caregiver(s) will provide assistance|4 - Unclear if Caregiver(s) will provide assistance|68
507|5 - Assistance needed, but no Caregiver(s) available|5 - Assistance needed, but no Caregiver(s) available|68
508|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will use standardized clinical guidelines accessible for all care providers to reference|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will|68
510|NA - Patient is not assessed to be at risk for falls|NA - Patient is not assessed to be at risk for falls|68
511|NA - Patient has no diagnosis or symptoms of depression|NA - Patient has no diagnosis or symptoms of depression|68
512|NA - No pain identified|NA - No pain identified|68
513|NA - Patient is not assessed to be at risk for pressure ulcers|NA - Patient is not assessed to be at risk for pressure ulcers|68
514|NA - Patient has no pressure ulcers with need for moist wound healing|NA - Patient has no pressure ulcers with need for moist wound healing|68
515|1 - Long-term nursing facility (NF)|1 - Long-term nursing facility (NF)|68
516|2 - Skilled nursing facility (SNF / TCU)|2 - Skilled nursing facility (SNF / TCU)|68
517|3 - Short stay acute hospital (IPP S)|3 - Short stay acute hospital (IPP S)|68
518|4 - Long-term care hospital (LTCH)|4 - Long-term care hospital (LTCH)|68
519|5 - Inpatient rehabilitation hospital or unit (IRF)|5 - Inpatient rehabilitation hospital or unit (IRF)|68
520|6 - Psychiatric hospital or unit|6 - Psychiatric hospital or unit|68
521|7 - Other|7 - Other|68
522|NA - Patient was not discharged from an inpatient facility [Go to M1017]|NA - Patient was not discharged from an inpatient facility [Go to M1017]|68
523|6 - Unable to participate effectively in bathing and is bathed totally by another person|6 - Unable to participate effectively in bathing and is bathed totally by another person|68
524|4 - Chairfast, unable to ambulate but is able to wheel self independently.|4 - Chairfast, unable to ambulate but is able to wheel self independently.|68
525|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask patient: "Over the last two weeks, how often have you been bothered by any of the following problems")|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask|68
526|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluation for depression.|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluat|68
527|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet criteria for further evaluation for depression.|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet|68
528|0 - Not at all  0 - 1 day|0 - Not at all  0 - 1 day|68
529|1 - Several days  2 - 6 days|1 - Several days  2 - 6 days|68
530|2 - More than half of the days  7 - 11 days|2 - More than half of the days  7 - 11 days|68
531|3 - Nearly every day  12 - 14 days|3 - Nearly every day  12 - 14 days|68
532|NA - N/A  Unable to respond|NA - N/A  Unable to respond|68
533|2 - Able to take medication(s) at the correct times if given reminders by another person based on the frequency of the injection|2 - Able to take medication(s) at the correct times if given reminders by another person based on th|68
534|3 - Unable to take injectable medication unless administered by another person.|3 - Unable to take injectable medication unless administered by another person.|68
547|NA - There were no potential clinically significant medication issues identified since SOC/ROC or patient is not taking any medications|NA v There were no potential clinically significant medication issues identified since SOC/ROC |68
552|1 - Hospital [ Go to M2430 ]|1 - Hospital [ Go to M2430 ]|68
553|2 - Rehabilitation facility [ Go to M0903 ]|2 - Rehabilitation facility [ Go to M0903 ]|68
554|3 - Nursing home [ Go to M2440 ]|3 - Nursing home [ Go to M2440 ]|68
555|4 - Hospice [ Go to M0903 ]|4 - Hospice [ Go to M0903 ]|68
47|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or supervision from another person OR c) a liquid, pureed or ground meat diet.|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or su|69
2|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; OR (b) Is physically, cognitively, and mentally able to prepare light meals on a regular basis but has not routinely performed light meal preparation in the past (i.e., prior to this home care admission).|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; O|69
3|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and mentally able to perform all housekeeping tasks .|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and menta|69
4|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and mentally able to do laundry and access facilities.|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and menta|69
5|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying packages OR b) Physically, cognitively, and mentally able to take care of shopping, but has not done shopping in the past (i.e., prior to this home care admission).|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying|69
6|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|69
7|0 - Able to dial numbers and answer calls appropriately and as desired.|0 - Able to dial numbers and answer calls appropriately and as desired.|69
8|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body without assistance.|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body|69
9|0 - Able to get to and from the toilet and transfer independently with or without a device.|0 - Able to get to and from the toilet and transfer independently with or without a device.|69
10|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|69
11|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible public bus.|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible p|69
12|0 - Able to independently feed self.|0 - Able to independently feed self.|69
13|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|69
14|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct times.|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct ti|69
15|0 - Able to independently transfer.|0 - Able to independently transfer.|69
16|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without rail|69
17|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings|69
18|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|69
19|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions independently.|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions indep|69
20|0 - Asymptomatic, no treatment needed at this time|0 - Asymptomatic, no treatment needed at this time|69
21|0 - Caregiver manages all tasks related to equipment completely independently.|0 - Caregiver manages all tasks related to equipment completely independently.|69
22|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations with no observable impairment.|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations w|69
23|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|69
24|0 - Life expectancy is greater than 6 months|0 - Life expectancy is greater than 6 months|69
25|0 - Never|0 - Never|69
26|0 - Patient is not short of breath|0 - Patient is not short of breath|69
27|0 - No|0 - No|69
28|0 - No emergent care services|0 - No emergent care services|69
29|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [Goto M1620]|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [Goto M1620]|69
30|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and extended or abstract conversation.|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and exte|69
31|0 - No one person|0 - No one person|69
32|0 - None of the time|0 - None of the time|69
33|0 - None, no charge for current services|0 - None, no charge for current services|69
34|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|69
35|0 - Patient does NOT have an ostomy for bowel elimination.|0 - Patient does NOT have an ostomy for bowel elimination.|69
36|0 - Patient has no pain|0 - Patient has no pain|69
37|0 - Patient manages all tasks related to equipment completely independently.|0 - Patient manages all tasks related to equipment completely independently.|69
38|0 - Poor:  little or no recovery is expected and/or further decline is imminent|0 - Poor:  little or no recovery is expected and/or further decline is imminent|69
39|0 - Timed-voiding defers incontinence|0 - Timed-voiding defers incontinence|69
40|0 - Very rarely or never has bowel incontinence|0 - Very rarely or never has bowel incontinence|69
41|0 - Zero|0 - Zero|69
42|00 - No|00 - No|69
43|01 - Yes|01 - Yes|69
44|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or mental limitations, needs assistance with heavy laundry.|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or|69
45|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the patient.|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the|69
46|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|69
48|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|69
49|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|69
50|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independently.|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independe|69
51|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only when assisted or accompanied by another person.|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only w|69
52|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepa|69
53|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance by another person OR b) given daily reminders.|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance b|69
54|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advan|69
55|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advan|69
56|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for the deaf) and call essential numbers.|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for t|69
57|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|69
58|1 - American Indian or Alaska Native|1 - American Indian or Alaska Native|69
59|1 - Depressed mood (e.g., feeling sad, tearful)|1 - Depressed mood (e.g., feeling sad, tearful)|69
60|1 - During the night only|1 - During the night only|69
61|1 - Fully granulating|1 - Fully granulating|69
62|1 - Good/Fair:  partial to full recovery is expected|1 - Good/Fair:  partial to full recovery is expected|69
63|1 - Good:  marked improvement in functional status is expected|1 - Good:  marked improvement in functional status is expected|69
64|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|69
65|1 - Smoking|1 - Smoking|69
66|1 - Hospital [ Go to M2430 ]|1 - Hospital [ Go to M2430 ]|69
67|1 - Hospital emergency room (includes 23-hour holding)|1 - Hospital emergency room (includes 23-hour holding)|69
68|1 - Hospitalization for EMERGENT (unscheduled) care|1 - Hospitalization for EMERGENT (unscheduled) care|69
69|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepared solutions), patient is able to manage all other aspects of equipment.|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepar|69
70|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|69
71|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|69
72|1 - In new or complex situations only|1 - In new or complex situations only|69
73|1 - Intravenous or infusion therapy (excludes TPN)|1 - Intravenous or infusion therapy (excludes TPN)|69
74|1 - Less often than daily|1 - Less often than daily|69
75|1 - Less than once a month|1 - Less than once a month|69
76|1 - Less than once weekly|1 - Less than once weekly|69
77|1 - Life expectancy is 6 months or fewer|1 - Life expectancy is 6 months or fewer|69
78|1 - Lives alone|1 - Lives alone|69
79|1 - Male|1 - Male|69
80|1 - Medicare (traditional fee-for-service)|1 - Medicare (traditional fee-for-service)|69
81|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of past 24 hours, significant memory loss so that supervision is required|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of pas|69
82|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors in word choice, grammar or speech intelligibility, needs minimal prompting or assistance).|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors i|69
83|1 - No assistance or services received|1 - No assistance or services received|69
84|1 - One|1 - One|69
85|1 - Oxygen (intermittent or continuous)|1 - Oxygen (intermittent or continuous)|69
86|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, and the surrounding layout, can count fingers at arm's length.|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, a|69
87|1 - Patient is incontinent|1 - Patient is incontinent|69
88|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|69
89|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical or treatment regimen.|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical|69
90|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient/couple/significant other)|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient|69
91|1 - Relatives, friends, or neighbors living outside the home|1 - Relatives, friends, or neighbors living outside the home|69
92|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions.|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions|69
93|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independentl|69
94|1 - Several times during day and night|1 - Several times during day and night|69
95|1 - Spouse or significant other|1 - Spouse or significant other|69
96|1 - Stage 1|1 - Stage 1|69
97|1 - Start of care - further visits planned|1 - Start of care - further visits planned|69
98|1 - Symptoms well controlled with current therapy|1 - Symptoms well controlled with current therapy|69
99|1 - Therapy services|1 - Therapy services|69
100|1 - Able to transfer with minimal human assistance or with use of an assistive device.|1 - Able to transfer with minimal human assistance or with use of an assistive device.|69
101|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitations.|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitatio|69
102|1 - Urinary incontinence|1 - Urinary incontinence|69
103|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and transfer.|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and|69
104|1 - When walking more than 20 feet, climbing stairs|1 - When walking more than 20 feet, climbing stairs|69
105|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary conversation. May need occasional repetition, extra time, or louder voice.|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary c|69
106|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting in and out of tub/shower|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting|69
107|1 - Yes|1 - Yes|69
108|1-RN|1-RN|69
109|10 - Discharge from agency - no visits completed after start/resumption of care assessment|10 - Discharge from agency - no visits completed after start/resumption of care assessment|69
110|10 - Scheduled surgical procedure|10 - Scheduled surgical procedure|69
111|10 - Self-pay|10 - Self-pay|69
112|11 - Other|11 - Other|69
113|11 - Urinary tract infection|11 - Urinary tract infection|69
114|12 - IV catheter-related infection|12 - IV catheter-related infection|69
115|13 - Deep vein thrombosis, pulmonary embolus|13 - Deep vein thrombosis, pulmonary embolus|69
116|14 - Uncontrolled pain|14 - Uncontrolled pain|69
117|15 - Psychotic episode|15 - Psychotic episode|69
118|16 - Other than above reasons|16 - Other than above reasons|69
119|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing calls.|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing|69
120|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another person.|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another pers|69
121|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface a|69
122|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for intermittent supervision or encouragement or reminders, OR (b) to get in and out of the shower or tub, OR (c) for washing difficult to reach areas.|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for inter|69
123|2 - Asian|2 - Asian|69
124|2 - Caregiver requires considerable assistance from another person to manage equipment, but independently completes significant portions of task.|2 - Caregiver requires considerable assistance from another person to manage equipment, but independ|69
125|2 - Daily, but not constantly|2 - Daily, but not constantly|69
126|2 - Daughter or son|2 - Daughter or son|69
127|2 - Doctor's office emergency visit/house call|2 - Doctor's office emergency visit/house call|69
128|2 - During the day and night|2 - During the day and night|69
129|2 - Early/partial granulation|2 - Early/partial granulation|69
130|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors in word choice, organization or speech intelligibility). Speaks in phrases or short sentences.|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors|69
131|2 - Family member's residence|2 - Family member's residence|69
132|2 - Female|2 - Female|69
133|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conversation, needs frequent prompting or assistance.|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conver|69
134|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|69
135|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|69
136|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately stop activities, jeopardizes safety through actions|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately st|69
137|2 - Indwelling/suprapubic catheter|2 - Indwelling/suprapubic catheter|69
138|2 - Injury caused by fall or accident at home|2 - Injury caused by fall or accident at home|69
139|2 - Medicare (HMO/managed care/Advantage plan)|2 - Medicare (HMO/managed care/Advantage plan)|69
140|2 - Nausea, dehydration, malnutrition, constipation, impaction|2 - Nausea, dehydration, malnutrition, constipation, impaction|69
141|2 - Obesity|2 - Obesity|69
142|2 - On awakening or at night only|2 - On awakening or at night only|69
143|2 - Once a month|2 - Once a month|69
144|2 - One to three times weekly|2 - One to three times weekly|69
145|2 - Parenteral nutrition (TPN or lipids)|2 - Parenteral nutrition (TPN or lipids)|69
146|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic) [ Go to M1620 ]|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic) [ Go|69
147|2 - Patient requires considerable assistance from another person to manage equipment, but independently completes portions of the task.|2 - Patient requires considerable assistance from another person to manage equipment, but independen|69
148|2 - Patient transferred to a noninstitutional hospice|2 - Patient transferred to a noninstitutional hospice|69
149|2 - Person residing in the home (EXCLUDING paid help)|2 - Person residing in the home (EXCLUDING paid help)|69
150|2 - Rehabilitation facility [ Go to M0903 ]|2 - Rehabilitation facility [ Go to M0903 ]|69
151|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifting of attention) or consistently requires low stimulus environment due to distractibility.|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifti|69
152|2 - Respite care|2 - Respite care|69
153|2 - Sense of failure or self reproach|2 - Sense of failure or self reproach|69
154|2 - Several times during day|2 - Several times during day|69
155|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonresponsive.|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonrespons|69
156|2 - Someone must assist the patient to groom self.|2 - Someone must assist the patient to groom self.|69
157|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|69
158|2 - Someone must help the patient put on upper body clothing.|2 - Someone must help the patient put on upper body clothing.|69
159|2 - Stage 2|2 - Stage 2|69
160|2 - Start of care - no further visits planned|2 - Start of care - no further visits planned|69
161|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitoring|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitori|69
162|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment regimen.|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment re|69
163|2 - Two|2 - Two|69
164|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistance due to cognitive or mental limitation.|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistanc|69
165|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|69
166|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assistance).|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assis|69
167|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home delivery.|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home deli|69
168|2 - Unable to prepare any light meals or reheat any delivered meals.|2 - Unable to prepare any light meals or reheat any delivered meals.|69
169|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|69
170|2 - UNABLE to take injectable medications unless administered by someone else.|2 - UNABLE to take injectable medications unless administered by someone else.|69
171|2 - UNABLE to take medication unless administered by someone else.|2 - UNABLE to take medication unless administered by someone else.|69
172|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|69
173|2 - Ventilator (continually or at night)|2 - Ventilator (continually or at night)|69
174|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less than 20 feet)|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less th|69
175|2 - With spouse or significant other|2 - With spouse or significant other|69
176|2 - Yes, assistance or services provided by family or friends|2 - Yes, assistance or services provided by family or friends|69
177|2-PT|2-PT|69
178|3 - Able to answer the telephone only some of the time or is able to carry on only a limited conversation.|3 - Able to answer the telephone only some of the time or is able to carry on only a limited convers|69
179|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube or gastrostomy.|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube|69
180|3 - Alcohol dependency|3 - Alcohol dependency|69
181|3 - All of the time|3 - All of the time|69
182|3 - Black or African-American|3 - Black or African-American|69
183|3 - Boarding home or rented room|3 - Boarding home or rented room|69
184|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment, clean/store/dispose of equipment or supplies).|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment,|69
185|3 -Able to walk only with the supervision or assistance of another person at all times.|3 -Able to walk only with the supervision or assistance of another person at all times.|69
186|3 - Continuous / Bi-level positive airway pressure|3 - Continuous / Bi-level positive airway pressure|69
187|3 - During the day and evening, but not constantly|3 - During the day and evening, but not constantly|69
188|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the alimentary canal)|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the|69
189|3 - Environmental support (e.g., housing, home maintenance)|3 - Environmental support (e.g., housing, home maintenance)|69
190|3 - Four to six times weekly|3 - Four to six times weekly|69
191|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessing by listener.  Speech limited to single words or short phrases.|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessin|69
192|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires multiple repetitions, restatements, demonstrations, additional time.|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires m|69
193|3 - Hopelessness|3 - Hopelessness|69
194|3 - Hospice care|3 - Hospice care|69
195|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|69
196|3 - Injury caused by fall or accident at home|3 - Injury caused by fall or accident at home|69
197|3 - Intractable pain|3 - Intractable pain|69
198|3 - Medicaid (traditional fee-for-service)|3 - Medicaid (traditional fee-for-service)|69
199|3 - Needs someone to do all shopping and errands.|3 - Needs someone to do all shopping and errands.|69
200|3 - Not healing|3 - Not healing|69
201|3 - Nursing home [ Go to M2440 ]|3 - Nursing home [ Go to M2440 ]|69
202|3 - Once daily|3 - Once daily|69
203|3 - Other family member|3 - Other family member|69
204|3 - Outpatient department/clinic emergency (includes urgicenter sites)|3 - Outpatient department/clinic emergency (includes urgicenter sites)|69
205|3 - Paid help|3 - Paid help|69
206|3 - Able to participate in bathing self in shower or tub, but requires presence of another person throughout the bath for assistance or supervision.|3 - Able to participate in bathing self in shower or tub, but requires presence of another person th|69
207|3 - Patient depends entirely upon another person to dress lower body.|3 - Patient depends entirely upon another person to dress lower body.|69
208|3 - Patient depends entirely upon another person to dress the upper body.|3 - Patient depends entirely upon another person to dress the upper body.|69
209|3 - Patient depends entirely upon someone else for grooming needs.|3 - Patient depends entirely upon someone else for grooming needs.|69
210|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone else to manage the equipment.|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone|69
211|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable to shift attention and recall directions more than half the time.|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable|69
212|3 - Respiratory problems (SOB, infection, obstruction)|3 - Respiratory problems (SOB, infection, obstruction)|69
213|3 - Resumption of care (after inpatient stay)|3 - Resumption of care (after inpatient stay)|69
214|3 - Several times each month|3 - Several times each month|69
215|3 - Skilled Nursing Facility|3 - Skilled Nursing Facility|69
216|3 - Stage 3|3 - Stage 3|69
217|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|69
218|3 - Three|3 - Three|69
219|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person throughout the process.|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person through|69
220|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal independently.|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal indep|69
221|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person.|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person|69
222|3 - Unknown because patient moved to a geographic location not served by this agency|3 - Unknown because patient moved to a geographic location not served by this agency|69
223|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|69
224|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|69
225|3 - With other family member|3 - With other family member|69
226|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home health services, homemaker assistance, transportation assistance, assisted living, board and care)|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home h|69
227|3-SLP/ST|3-SLP/ST|69
228|4 - At rest (during day or night)|4 - At rest (during day or night)|69
229|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|69
230|4 - Board and care or assisted living facility|4 - Board and care or assisted living facility|69
231|4 - Caregiver is completely dependent on someone else to manage all equipment.|4 - Caregiver is completely dependent on someone else to manage all equipment.|69
232|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|69
233|4 - Constantly|4 - Constantly|69
234|4 - Drug dependency|4 - Drug dependency|69
235|4 - Four or more|4 - Four or more|69
236|4 - Friend or neighbor or community or church member|4 - Friend or neighbor or community or church member|69
237|4 - Hispanic or Latino|4 - Hispanic or Latino|69
238|4 - Hospice [ Go to M0903 ]|4 - Hospice [ Go to M0903 ]|69
239|4 - Impaired decision-making|4 - Impaired decision-making|69
240|4 - Is totally dependent in toileting.|4 - Is totally dependent in toileting.|69
241|4 - Medicaid (HMO/managed care)|4 - Medicaid (HMO/managed care)|69
242|4 - None of the above|4 - None of the above|69
243|4 - Nursing home|4 - Nursing home|69
244|4 - On a daily basis|4 - On a daily basis|69
245|4 - Patient is completely dependent on someone else to manage all equipment.|4 - Patient is completely dependent on someone else to manage all equipment.|69
246|4 - Permanent placement|4 - Permanent placement|69
247|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, punches, dangerous maneuvers w/ wheelchair or other objects)|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, pu|69
248|4 - Psychosocial support (e.g., socialization, companionship, recreation)|4 - Psychosocial support (e.g., socialization, companionship, recreation)|69
249|4 - Recertification (follow-up) reassessment|4 - Recertification (follow-up) reassessment|69
250|4 - Recurrent thoughts of death|4 - Recurrent thoughts of death|69
251|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruction)|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruc|69
252|4 - Several times a week|4 - Several times a week|69
253|4 - Stage 4|4 - Stage 4|69
254|4 - Symptoms poorly controlled, history of re-hospitalizations|4 - Symptoms poorly controlled, history of re-hospitalizations|69
255|4 - Three or more times per week|4 - Three or more times per week|69
256|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetative state, or delirium.|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetati|69
257|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|69
258|4 - Unable to effectively participate in any housekeeping tasks.|4 - Unable to effectively participate in any housekeeping tasks.|69
259|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or unresponsive (e.g., speech is nonsensical or unintelligible).|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or u|69
260|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonresponsive.|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonr|69
261|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostomy.|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostom|69
262|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of devices at the sink, in chair, or on commode|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of|69
263|4 - With a friend|4 - With a friend|69
264|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|69
265|4-OT|4-OT|69
266|5 - Advocates or facilitates patient's participation in appropriate medical care|5 - Advocates or facilitates patient's participation in appropriate medical care|69
267|5 - At least daily|5 - At least daily|69
268|6 - Bedfast, unable to ambulate or be up in a chair.|6 - Bedfast, unable to ambulate or be up in a chair.|69
269|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|69
270|5 - Disruptive or socially inappropriate behavior|5 - Disruptive or socially inappropriate behavior|69
271|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|69
272|5 - Hypo/Hyperglycemia, diabetes out of control|5 - Hypo/Hyperglycemia, diabetes out of control|69
273|5 - More often than once daily|5 - More often than once daily|69
274|5 - Native Hawaiian or Pacific Islander|5 - Native Hawaiian or Pacific Islander|69
275|5 - None of the above|5 - None of the above|69
276|5 - One to two times per week|5 - One to two times per week|69
277|5 - Other|5 - Other|69
278|5 - Other follow-up|5 - Other follow-up|69
279|5 - Paid help|5 - Paid help|69
280|5 - Patient nonresponsive or unable to speak.|5 - Patient nonresponsive or unable to speak.|69
281|5 - Thoughts of suicide|5 - Thoughts of suicide|69
282|5 - Totally unable to use the telephone.|5 - Totally unable to use the telephone.|69
283|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|69
284|5 - Unable to take in nutrients orally or by tube feeding.|5 - Unable to take in nutrients orally or by tube feeding.|69
285|5 - Unsafe for care at home|5 - Unsafe for care at home|69
286|5 - With paid help (other than home care agency staff)|5 - With paid help (other than home care agency staff)|69
287|5 - Workers' compensation|5 - Workers' compensation|69
288|5 - Wound infection, deteriorating wound status, new lesion/ulcer|5 - Wound infection, deteriorating wound status, new lesion/ulcer|69
289|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|69
290|6 - Delusional, hallucinatory, or paranoid behavior|6 - Delusional, hallucinatory, or paranoid behavior|69
291|6 - Financial agent, power of attorney, or conservator of finance|6 - Financial agent, power of attorney, or conservator of finance|69
292|6 - GI bleeding, obstruction|6 - GI bleeding, obstruction|69
293|6 - Less often than weekly|6 - Less often than weekly|69
294|6 - Memory loss to the extent that supervision required|6 - Memory loss to the extent that supervision required|69
295|6 - None of the above feelings observed or reported|6 - None of the above feelings observed or reported|69
296|6 - Other|6 - Other|69
297|6 - Title programs (e.g., Title III, V, or XX)|6 - Title programs (e.g., Title III, V, or XX)|69
298|6 - Transferred to an inpatient facility - patient not discharged from agency|6 - Transferred to an inpatient facility - patient not discharged from agency|69
299|6 - White|6 - White|69
300|6 - With other than above|6 - With other than above|69
301|7 - Exacerbation of CHF, fluid overload, heart failure|7 - Exacerbation of CHF, fluid overload, heart failure|69
302|7 - Health care agent, conservator of person, or medical power of attorney|7 - Health care agent, conservator of person, or medical power of attorney|69
303|7 - Hypo/Hyperglycemia, diabetes out of control|7 - Hypo/Hyperglycemia, diabetes out of control|69
304|7 - None of the above|7 - None of the above|69
305|7 - None of the above behaviors demonstrated|7 - None of the above behaviors demonstrated|69
306|7 - Other government (e.g., TriCare, VA, etc.)|7 - Other government (e.g., TriCare, VA, etc.)|69
307|7 - Transferred to an inpatient facility - patient discharged from agency|7 - Transferred to an inpatient facility - patient discharged from agency|69
308|8 - Death at home|8 - Death at home|69
309|8 - GI bleeding, obstruction|8 - GI bleeding, obstruction|69
310|8 - Myocardial infarction, stroke|8 - Myocardial infarction, stroke|69
311|8 - Private insurance|8 - Private insurance|69
312|9 - Chemotherapy|9 - Chemotherapy|69
313|9 - Discharge from agency|9 - Discharge from agency|69
314|9 - Other than above reasons|9 - Other than above reasons|69
315|9 - Private HMO/managed care|9 - Private HMO/managed care|69
316|NA - No caregiver|NA - No caregiver|69
317|NA - No equipment of this type used in care.|NA - No equipment of this type used in care.|69
318|NA - No inhalant/mist medications prescribed.|NA - No inhalant/mist medications prescribed.|69
319|NA - No injectable medications prescribed.|NA - No injectable medications prescribed.|69
320|NA - No inpatient facility admission|NA - No inpatient facility admission|69
321|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|69
322|NA - No Medicaid|NA - No Medicaid|69
323|NA - No Medicare|NA - No Medicare|69
324|NA - No observable pressure ulcer|NA - No observable pressure ulcer|69
325|NA - No observable stasis ulcer|NA - No observable stasis ulcer|69
326|NA - No observable surgical wound|NA - No observable surgical wound|69
327|NA - No oral medications prescribed.|NA - No oral medications prescribed.|69
328|NA - Not applicable|NA - Not applicable|69
329|NA - Patient does not have a telephone.|NA - Patient does not have a telephone.|69
330|NA - Patient has ostomy for bowel elimination|NA - Patient has ostomy for bowel elimination|69
331|NA - Patient nonresponsive|NA - Patient nonresponsive|69
332|NA - Patient on prophylactic treatment|NA - Patient on prophylactic treatment|69
333|NA - Patient was not discharged from an inpatient facility [Go to M1017]|NA - Patient was not discharged from an inpatient facility [Go to M1017]|69
334|UK - Other unknown|UK - Other unknown|69
335|UK - Reason unknown|UK - Reason unknown|69
336|UK - Unknown|UK - Unknown|69
337|UK - Unknown or Not Available|UK - Unknown or Not Available|69
341|01 - Early|01 - Early|69
342|02 - Late|02 - Late|69
343|NA - Not Applicable. No case mix group defined for this assessment.|NA - Not Applicable. No case mix group defined for this assessment.|69
344|NA - No case mix group defined by this assessment.|NA - No case mix group defined by this assessment.|69
345|1 - Recent decline in mental, emotional, or behavioral status|1 - Recent decline in mental, emotional, or behavioral status|69
346|2 - Multiple hospitalizations (2 or more) in the past 12 months|2 - Multiple hospitalizations (2 or more) in the past 12 months|69
347|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|69
348|4 - Taking five or more medications|4 - Taking five or more medications|69
349|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|69
350|6 - Other|6 - Other|69
351|7 - None of the above|7 - None of the above|69
352|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond tho|69
353|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable without heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable wi|69
354|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious complications and death.|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious compl|69
355|3 - The patient has serious progressive conditions that could lead to death within a year.|3 - The patient has serious progressive conditions that could lead to death within a year.|69
356|UK - The patient+s situation is unknown or unclear.|UK - The patient+s situation is unknown or unclear.|69
357|0 - No [ Go to M1051 ]|0 - No [ Go to M1051 ]|69
358|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this influenza season. [ Go to M1050 ]|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this i|69
359|1 - Received from another health care provider (e.g., physician)|1 - Received from another health care provider (e.g., physician)|69
360|2 - Received from your agency previously during this year+s flu season|2 - Received from your agency previously during this year+s flu season|69
361|3 - Offered and declined|3 - Offered and declined|69
362|4 - Assessed and determined to have medical contraindication(s)|4 - Assessed and determined to have medical contraindication(s)|69
363|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|69
364|6 - Inability to obtain vaccine due to declared shortage|6 - Inability to obtain vaccine due to declared shortage|69
365|1 - Yes [ Go to M1501 at TRN; Go to M1230 at DC ]|1 - Yes [ Go to M1501 at TRN; Go to M1230 at DC ]|69
366|1 - Patient has received PPV in the past|1 - Patient has received PPV in the past|69
367|2 - Offered and declined|2 - Offered and declined|69
368|3 - Assessed and determined to have medical contraindication(s)|3 - Assessed and determined to have medical contraindication(s)|69
369|4 - Not indicated; patient does not meet age/condition guidelines for PPV|4 - Not indicated; patient does not meet age/condition guidelines for PPV|69
370|5 - None of the above|5 - None of the above|69
371|0 - Adequate: hears normal conversation without difficulty.|0 - Adequate: hears normal conversation without difficulty.|69
372|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to increase volume or speak distinctly.|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to in|69
373|2 - Severely Impaired: absence of useful hearing.|2 - Severely Impaired: absence of useful hearing.|69
374|UK - Unable to assess hearing.|UK - Unable to assess hearing.|69
375|0 - Understands: clear comprehension without cues or repetitions.|0 - Understands: clear comprehension without cues or repetitions.|69
376|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Requires cues at times to understand.|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Req|69
377|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequently requires cues to understand.|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequentl|69
378|3 - Rarely/Never Understands|3 - Rarely/Never Understands|69
379|UK - Unable to assess understanding.|UK - Unable to assess understanding.|69
380|0 - No standardized assessment conducted|0 - No standardized assessment conducted|69
381|1 - Yes, and it does not indicate severe pain|1 - Yes, and it does not indicate severe pain|69
382|2 - Yes, and it indicates severe pain|2 - Yes, and it indicates severe pain|69
383|0 - Patient has no pain|0 - Patient has no pain|69
384|1 - Patient has pain that does not interfere with activity or movement|1 - Patient has pain that does not interfere with activity or movement|69
385|2 - Less often than daily|2 - Less often than daily|69
386|3 - Daily, but not constantly|3 - Daily, but not constantly|69
387|4 - All of the time|4 - All of the time|69
388|0 - No assessment conducted [ Go to M1306 ]|0 - No assessment conducted [ Go to M1306 ]|69
389|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc., without use of standardized tool|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc.,|69
390|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|69
391|0 - No [ Go to M1322]|0 - No [ Go to M1322]|69
392|0 v Newly epithelialized|0 v Newly epithelialized|69
393|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|69
394|2 - Yes, patient has observable stasis ulcers ONLY|2 - Yes, patient has observable stasis ulcers ONLY|69
395|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable dressing) [Go to M1340]|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable|69
396|0 - No [ Go to M1400 ]|0 - No [ Go to M1400 ]|69
397|1 - Yes, patient has at least one (observable) surgical wound|1 - Yes, patient has at least one (observable) surgical wound|69
398|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1400 ]|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1400 ]|69
399|0 - Patient is not short of breath|0 - Patient is not short of breath|69
400|3 - Continuous Bi-level positive airway pressure|3 - Continuous Bi-level positive airway pressure|69
401|0 - No [ Go to M2005 at TRN; Go to M1600 at DC ]|0 - No [ Go to M2005 at TRN; Go to M1600 at DC ]|69
402|2 - Not assessed [Go to M2005 at TRN; Go to M1600 at DC ]|2 - Not assessed [Go to M1732 at TRN; Go to M1600 at DC ]|69
403|NA - Patient does not have diagnosis of heart failure [Go to M2005 at TRN; Go to M1600 at DC]|NA - Patient does not have diagnosis of heart failure [Go to M2005 at TRN; Go to M1600 at DC]|69
404|0 - No action taken|0 - No action taken|69
405|1 - Patient+s physician (or other primary care practitioner) contacted the same day|1 - Patient+s physician (or other primary care practitioner) contacted the same day|69
406|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|69
407|3 - Implement physician-ordered patient-specific established parameters for treatment|3 - Implement physician-ordered patient-specific established parameters for treatment|69
408|4 - Patient education or other clinical interventions|4 - Patient education or other clinical interventions|69
409|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequency, telehealth, etc.)|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequ|69
410|1 - Occasional stress incontinence|1 - Occasional stress incontinence|69
411|2 - During the night only|2 - During the night only|69
412|3 - During the day only|3 - During the day only|69
413|4 - During the day and night|4 - During the day and night|69
414|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|69
415|0 - Able to manage toileting hygiene and clothing management without assistance.|0 - Able to manage toileting hygiene and clothing management without assistance.|69
416|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implements are laid out for the patient.|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implemen|69
417|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|69
418|3 - Patient depends entirely upon another person to maintain toileting hygiene.|3 - Patient depends entirely upon another person to maintain toileting hygiene.|69
419|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independent|69
420|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface|69
421|0 - No multi-factor falls risk assessment conducted.|0 - No multi-factor falls risk assessment conducted.|69
422|1 - Yes, and it does not indicate a risk for falls.|1 - Yes, and it does not indicate a risk for falls.|69
423|2 - Yes, and it indicates a risk for falls.|2 - Yes, and it indicates a risk for falls.|69
424|0 - Not assessed/reviewed [ Go to M2010 ]|0 - Not assessed/reviewed [ Go to M2010 ]|69
425|1 - No problems found during review [ Go to M2010 ]|1 - No problems found during review [ Go to M2010 ]|69
426|2 - Problems found during review|2 - Problems found during review|69
427|NA - Patient is not taking any medications [ Go to M2040 ]|NA - Patient is not taking any medications [ Go to M2040 ]|69
428|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special precautions associated with all high-risk medications|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special p|69
429|NA - Patient not taking any drugs|NA - Patient not taking any drugs|69
430|2 - Able to take medication(s) at the correct times if given reminders by another person at the appropriate times|2 - Able to take medication(s) at the correct times if given reminders by another person at the appr|69
431|3 - Unable to take medication unless administered by another person.|3 - Unable to take medication unless administered by another person.|69
432|1 - At least daily|1 - At least daily|69
433|2 - Three or more times per week|2 - Three or more times per week|69
434|3 - One to two times per week|3 - One to two times per week|69
435|4 - Received, but less often than weekly|4 - Received, but less often than weekly|69
436|5 - No assistance received|5 - No assistance received|69
437|0 - No [Go to M2401]|0 - No [Go to M2401]|69
438|1 - Yes, used hospital emergency department WITHOUT hospital admission|1 - Yes, used hospital emergency department WITHOUT hospital admission|69
439|2 - Yes, used hospital emergency department WITH hospital admission|2 - Yes, used hospital emergency department WITH hospital admission|69
440|UK - Unknown [Go to M2401]|UK - Unknown [Go to M2401]|69
441|2 - Injury caused by fall|2 - Injury caused by fall|69
442|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|69
443|4 - Other respiratory problem|4 - Other respiratory problem|69
444|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|69
445|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|69
446|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|69
447|8 - Other heart disease|8 - Other heart disease|69
448|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|69
449|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|69
450|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|69
451|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|69
452|13 - Urinary tract infection|13 - Urinary tract infection|69
453|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|69
454|15 - Wound infection or deterioration|15 - Wound infection or deterioration|69
455|16 - Uncontrolled pain|16 - Uncontrolled pain|69
456|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|69
457|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|69
458|19 - Other than above reasons|19 - Other than above reasons|69
459|2 - Patient remained in the community (with formal assistive services)|2 - Patient remained in the community (with formal assistive services)|69
460|3 - Patient transferred to a noninstitutional hospice|3 - Patient transferred to a noninstitutional hospice|69
461|4 - Unknown because patient moved to a geographic location not served by this agency|4 - Unknown because patient moved to a geographic location not served by this agency|69
462|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|69
463|4 - Other respiratory problem|4 - Other respiratory problem|69
464|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|69
465|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|69
466|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|69
467|8 - Other heart disease|8 - Other heart disease|69
468|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|69
469|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|69
470|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|69
471|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|69
472|13 - Urinary tract infection|13 - Urinary tract infection|69
473|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|69
474|15 - Wound infection or deterioration|15 - Wound infection or deterioration|69
475|16 - Uncontrolled pain|16 - Uncontrolled pain|69
476|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|69
477|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|69
478|19 - Scheduled treatment or procedure|19 - Scheduled treatment or procedure|69
479|20 - Other than above reasons|20 - Other than above reasons|69
480|UK - Reason unknown [Go to M0903]|UK - Reason unknown [Go to M0903]|69
482|01 - Patient lives alone around the clock|01 - Patient lives alone around the clock|69
483|02 - Patient lives alone regular daytime|02 - Patient lives alone regular daytime|69
484|03 - Patient lives alone regular nighttime|03 - Patient lives alone regular nighttime|69
485|04 - Patient lives alone occassional/short term assistance|04 - Patient lives alone occassional/short term assistance|69
486|05 - Patient lives alone no assisstance available|05 - Patient lives alone no assisstance available|69
487|06 - Patient lives with other person(s) in the home around the clock|06 - Patient lives with other person(s) in the home around the clock|69
488|07 - Patient lives with other person(s) in the home regular daytime|07 - Patient lives with other person(s) in the home regular daytime|69
489|08 - Patient lives with other person(s) in the home regular nighttime|08 - Patient lives with other person(s) in the home regular nighttime|69
490|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|69
491|10 - Patient lives with other person(s) in the home no assistance available|10 - Patient lives with other person(s) in the home no assistance available|69
492|1 - Was present at the most recent SOC/ROC assessment [Goto M1311A1]|1 - Was present at the most recent SOC/ROC assessment [Goto M1311A1]|69
493|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|69
494|NA - No non-epithelialized Stage II pressure ulcers are present at discharge [Goto M1311A1]|NA - No non-epithelialized Stage II pressure ulcers are present at discharge [Goto M1311A1]|69
495|0 - Newly epithelialized|0 - Newly epithelialized|69
496|0 - No [ Go to M1340 ]|0 - No [ Go to M1340 ]|69
498|0 - Independent|0 - Independent|69
499|1 - Needed Some Help|1 - Needed Some Help|69
500|2 - Dependent|2 - Dependent|69
502|0 - No assistance needed in this area|0 - No assistance needed in this area|69
503|1 - Caregiver(s) currently provide assistance|1 - Caregiver(s) currently provide assistance|69
504|2 - Caregiver(s) need training/ supportive services to provide assistance|2 - Caregiver(s) need training/ supportive services to provide assistance|69
505|3 - Caregiver(s) not likely to provide assistance|3 - Caregiver(s) not likely to provide assistance|69
506|4 - Unclear if Caregiver(s) will provide assistance|4 - Unclear if Caregiver(s) will provide assistance|69
507|5 - Assistance needed, but no Caregiver(s) available|5 - Assistance needed, but no Caregiver(s) available|69
508|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will use standardized clinical guidelines accessible for all care providers to reference|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will|69
510|NA - Patient is not assessed to be at risk for falls|NA - Patient is not assessed to be at risk for falls|69
511|NA - Patient has no diagnosis or symptoms of depression|NA - Patient has no diagnosis or symptoms of depression|69
512|NA - No pain identified|NA - No pain identified|69
513|NA - Patient is not assessed to be at risk for pressure ulcers|NA - Patient is not assessed to be at risk for pressure ulcers|69
514|NA - Patient has no pressure ulcers with need for moist wound healing|NA - Patient has no pressure ulcers with need for moist wound healing|69
515|1 - Long-term nursing facility (NF)|1 - Long-term nursing facility (NF)|69
516|2 - Skilled nursing facility (SNF / TCU)|2 - Skilled nursing facility (SNF / TCU)|69
517|3 - Short stay acute hospital (IPP S)|3 - Short stay acute hospital (IPP S)|69
518|4 - Long-term care hospital (LTCH)|4 - Long-term care hospital (LTCH)|69
519|5 - Inpatient rehabilitation hospital or unit (IRF)|5 - Inpatient rehabilitation hospital or unit (IRF)|69
520|6 - Psychiatric hospital or unit|6 - Psychiatric hospital or unit|69
521|7 - Other|7 - Other|69
522|NA - Patient was not discharged from an inpatient facility [Go to M1017]|NA - Patient was not discharged from an inpatient facility [Go to M1017]|69
523|6 - Unable to participate effectively in bathing and is bathed totally by another person|6 - Unable to participate effectively in bathing and is bathed totally by another person|69
524|4 - Chairfast, unable to ambulate but is able to wheel self independently.|4 - Chairfast, unable to ambulate but is able to wheel self independently.|69
525|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask patient: "Over the last two weeks, how often have you been bothered by any of the following problems")  *Copyright+ Pfizer Inc. All rights reserved. Reproduced with permission.|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask|69
526|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluation for depression.|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluat|69
527|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet criteria for further evaluation for depression.|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet|69
528|0 - Not at all  0 - 1 day|0 - Not at all  0 - 1 day|69
529|1 - Several days  2 - 6 days|1 - Several days  2 - 6 days|69
530|2 - More than half of the days  7 - 11 days|2 - More than half of the days  7 - 11 days|69
531|3 - Nearly every day  12 - 14 days|3 - Nearly every day  12 - 14 days|69
532|NA - N/A  Unable to respond|NA - N/A  Unable to respond|69
533|2 - Able to take medication(s) at the correct times if given reminders by another person based on the frequency of the injection|2 - Able to take medication(s) at the correct times if given reminders by another person based on th|69
534|3 - Unable to take injectable medication unless administered by another person.|3 - Unable to take injectable medication unless administered by another person.|69
570|NA - No observable pressure ulcer or unhealed pressure ulcer|NA - No observable pressure ulcer or unhealed pressure ulcer|69
571|NA v There were no potential clinically significant medication issues identified since SOC/ROC or patient is not taking any medications|NA - There were no potential clinically significant medication issues identified sinc|69
572|NA - Patient is not diabetic or is bilateral amputee|NA - Patient is not diabetic or is bilateral amputee|69
573|NA - Every standardized,validated multifactor fall risk assessment conducted at or since the most recent SOC/ROC assessment indicates the patient has no risk for falls.|NA - Every standardized,validated multifactor fall risk assessment condition|69
574|NA - Patient has no diagnosis of depression AND every standardized, validated depression screening conducted at or since the most recent SOC/ROC assessment indicates the patient has: 1) no symptoms of depression; or 2) has some symptoms of depression but does not meet criteria for further evaluation of depression based on screening tool used.|NA - Patient has no diagnosis of depression AND every standardized, validated |69
575|NA - Every standardized, validated pain assessment conducted at or since the most recent SOC/ROC assessment indicates the patient has no pain.|NA - Every standardized, validated pain assessment conducted at or since the most|69
576|NA - Every standardized, validated pressure ulcer risk assessment conducted at or since the most recent SOC/ROC assessment indicates the patient is not at risk of developing pressure ulcers.|NA - Every standardized, validated pressure ulcer risk assessment conducted|69
577|NA - Dressings that support the principles of moist wound healing not indicated for this patient's pressure ulcers OR patient has no pressure ulcers with need for moist wound healing|NA - Dressings that support the principles of moist wound healing not indicated for this patient's p|69
578|1 - Patient remained in the community (without formal assistive services)|1 - Patient remained in the community (without formal assistive services)|69
579|2 - Patient remained in the community (with formal assistive services)|2 - Patient remained in the community (with formal assistive services)|69
580|3 - Patient transferred to a non-institutional hospice|3 - Patient transferred to a non-institutional hospice|69
581|4 - Unknown because patient moved to a geographic location not served by this agency|4 - Unknown because patient moved to a geographic location not served by this agency|69
620|1 - Yes; received from your agency during this episode of care (SOC/ROC to Transfer/Discharge)|1 - Yes; received from your agency during this episode of care (SOC/ROC to Transfer/Discharge)|69
621|2 - Yes; received from your agency during a prior episode of care (SOC/ROC to Transfer/Discharge)|2 - Yes; received from your agency during a prior episode of care (SOC/ROC to Transfer/Discharge)|69
622|3 - Yes; received from another health care provider (for example physician pharmacist)|3 - Yes; received from another health care provider (for example physician pharmacist)|69
623|4 - No; patient offered and declined |4 - No; patient offered and declined |69
624|5 - No; patient assessed and determined to have medical contraindication(s)|5 - No; patient assessed and determined to have medical contraindication(s)|69
625|6 - No; not indicated - patient does not meet age/condition guidelines for influenza vaccine|6 - No; not indicated - patient does not meet age/condition guidelines for influenza vaccine|69
626|7 - No; inability to obtain vaccine due to declared shortage |7 - No; inability to obtain vaccine due to declared shortage |69
627|8 - No; patient did not receive the vaccine due to reasons other than those listed in responses 4 v 7. |8 - No; patient did not receive the vaccine due to reasons other than those listed in responses 4v7.|69
628|1 - Offered and declined|1 - Offered and declined|69
629|2 - Assessed and determined to have medical contraindication(s) |2 - Assessed and determined to have medical contraindication(s) |69
630|3 - Not indicated; patient does not meet age/condition guidelines for Pneumococcal Vaccine|3 - Not indicated; patient does not meet age/condition guidelines for Pneumococcal Vaccine|69
631|4 - None of the above|4 - None of the above|69
632|0 - No assistance needed v patient is independent or does not have needs in this area|0 - No assistance needed v patient is independent or does not have needs in this area|69
633|1 - Non-agency caregiver(s) currently provide assistance |1 - Non-agency caregiver(s) currently provide assistance |69
634|2 - Non-agency caregiver(s) need training/ supportive services to provide assistance|2 - Non-agency caregiver(s) need training/ supportive services to provide assistance|69
635|3 - Non-agency caregiver(s) are not likely to provide assistance OR it is unclear if they will provide assistance|3 - Non-agency caregiver(s) are not likely to provide assistance OR unclear if will provide asst|69
636|4 - Assistance needed but no non-agency caregiver(s) available|4 - Assistance needed but no non-agency caregiver(s) available|69
157|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|71
158|2 - Someone must help the patient put on upper body clothing.|2 - Someone must help the patient put on upper body clothing.|71
159|2 - Stage 2|2 - Stage 2|71
160|2 - Start of care - no further visits planned|2 - Start of care - no further visits planned|71
161|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitoring|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitori|71
162|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment regimen.|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment re|71
163|2 - Two|2 - Two|71
164|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistance due to cognitive or mental limitation.|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistanc|71
165|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|71
166|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assistance).|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assis|71
167|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home delivery.|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home deli|71
168|2 - Unable to prepare any light meals or reheat any delivered meals.|2 - Unable to prepare any light meals or reheat any delivered meals.|71
169|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|71
170|2 - UNABLE to take injectable medications unless administered by someone else.|2 - UNABLE to take injectable medications unless administered by someone else.|71
171|2 - UNABLE to take medication unless administered by someone else.|2 - UNABLE to take medication unless administered by someone else.|71
172|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|71
173|2 - Ventilator (continually or at night)|2 - Ventilator (continually or at night)|71
174|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less than 20 feet)|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less th|71
175|2 - With spouse or significant other|2 - With spouse or significant other|71
176|2 - Yes, assistance or services provided by family or friends|2 - Yes, assistance or services provided by family or friends|71
177|2-PT|2-PT|71
178|3 - Able to answer the telephone only some of the time or is able to carry on only a limited conversation.|3 - Able to answer the telephone only some of the time or is able to carry on only a limited convers|71
179|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube or gastrostomy.|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube|71
180|3 - Alcohol dependency|3 - Alcohol dependency|71
181|3 - All of the time|3 - All of the time|71
182|3 - Black or African-American|3 - Black or African-American|71
183|3 - Boarding home or rented room|3 - Boarding home or rented room|71
184|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment, clean/store/dispose of equipment or supplies).|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment,|71
185|3 -Able to walk only with the supervision or assistance of another person at all times.|3 -Able to walk only with the supervision or assistance of another person at all times.|71
186|3 - Continuous / Bi-level positive airway pressure|3 - Continuous / Bi-level positive airway pressure|71
187|3 - During the day and evening, but not constantly|3 - During the day and evening, but not constantly|71
188|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the alimentary canal)|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the|71
189|3 - Environmental support (e.g., housing, home maintenance)|3 - Environmental support (e.g., housing, home maintenance)|71
190|3 - Four to six times weekly|3 - Four to six times weekly|71
191|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessing by listener.  Speech limited to single words or short phrases.|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessin|71
192|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires multiple repetitions, restatements, demonstrations, additional time.|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires m|71
193|3 - Hopelessness|3 - Hopelessness|71
194|3 - Hospice care|3 - Hospice care|71
195|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|71
196|3 - Injury caused by fall or accident at home|3 - Injury caused by fall or accident at home|71
197|3 - Intractable pain|3 - Intractable pain|71
198|3 - Medicaid (traditional fee-for-service)|3 - Medicaid (traditional fee-for-service)|71
199|3 - Needs someone to do all shopping and errands.|3 - Needs someone to do all shopping and errands.|71
200|3 - Not healing|3 - Not healing|71
201|3 - Nursing home|3 - Nursing home|71
202|3 - Once daily|3 - Once daily|71
203|3 - Other family member|3 - Other family member|71
204|3 - Outpatient department/clinic emergency (includes urgicenter sites)|3 - Outpatient department/clinic emergency (includes urgicenter sites)|71
205|3 - Paid help|3 - Paid help|71
206|3 - Able to participate in bathing self in shower or tub, but requires presence of another person throughout the bath for assistance or supervision.|3 - Able to participate in bathing self in shower or tub, but requires presence of another person th|71
207|3 - Patient depends entirely upon another person to dress lower body.|3 - Patient depends entirely upon another person to dress lower body.|71
208|3 - Patient depends entirely upon another person to dress the upper body.|3 - Patient depends entirely upon another person to dress the upper body.|71
209|3 - Patient depends entirely upon someone else for grooming needs.|3 - Patient depends entirely upon someone else for grooming needs.|71
210|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone else to manage the equipment.|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone|71
211|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable to shift attention and recall directions more than half the time.|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable|71
212|3 - Respiratory problems (SOB, infection, obstruction)|3 - Respiratory problems (SOB, infection, obstruction)|71
213|3 - Resumption of care (after inpatient stay)|3 - Resumption of care (after inpatient stay)|71
214|3 - Several times each month|3 - Several times each month|71
215|3 - Skilled Nursing Facility|3 - Skilled Nursing Facility|71
216|3 - Stage 3|3 - Stage 3|71
217|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|71
218|3 - Three|3 - Three|71
219|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person throughout the process.|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person through|71
220|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal independently.|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal indep|71
221|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person.|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person|71
222|3 - Unknown because patient moved to a geographic location not served by this agency|3 - Unknown because patient moved to a geographic location not served by this agency|71
223|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|71
224|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|71
225|3 - With other family member|3 - With other family member|71
226|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home health services, homemaker assistance, transportation assistance, assisted living, board and care)|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home h|71
227|3-SLP/ST|3-SLP/ST|71
228|4 - At rest (during day or night)|4 - At rest (during day or night)|71
229|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|71
230|4 - Board and care or assisted living facility|4 - Board and care or assisted living facility|71
231|4 - Caregiver is completely dependent on someone else to manage all equipment.|4 - Caregiver is completely dependent on someone else to manage all equipment.|71
232|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|71
233|4 - Constantly|4 - Constantly|71
234|4 - Drug dependency|4 - Drug dependency|71
235|4 - Four or more|4 - Four or more|71
236|4 - Friend or neighbor or community or church member|4 - Friend or neighbor or community or church member|71
237|4 - Hispanic or Latino|4 - Hispanic or Latino|71
238|4 - Hospice|4 - Hospice|71
239|4 - Impaired decision-making|4 - Impaired decision-making|71
240|4 - Is totally dependent in toileting.|4 - Is totally dependent in toileting.|71
241|4 - Medicaid (HMO/managed care)|4 - Medicaid (HMO/managed care)|71
242|4 - None of the above|4 - None of the above|71
243|4 - Nursing home|4 - Nursing home|71
244|4 - On a daily basis|4 - On a daily basis|71
245|4 - Patient is completely dependent on someone else to manage all equipment.|4 - Patient is completely dependent on someone else to manage all equipment.|71
246|4 - Permanent placement|4 - Permanent placement|71
247|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, punches, dangerous maneuvers w/ wheelchair or other objects)|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, pu|71
248|4 - Psychosocial support (e.g., socialization, companionship, recreation)|4 - Psychosocial support (e.g., socialization, companionship, recreation)|71
249|4 - Recertification (follow-up) reassessment|4 - Recertification (follow-up) reassessment|71
250|4 - Recurrent thoughts of death|4 - Recurrent thoughts of death|71
251|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruction)|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruc|71
252|4 - Several times a week|4 - Several times a week|71
253|4 - Stage 4|4 - Stage 4|71
254|4 - Symptoms poorly controlled, history of re-hospitalizations|4 - Symptoms poorly controlled, history of re-hospitalizations|71
255|4 - Three or more times per week|4 - Three or more times per week|71
256|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetative state, or delirium.|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetati|71
257|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|71
258|4 - Unable to effectively participate in any housekeeping tasks.|4 - Unable to effectively participate in any housekeeping tasks.|71
259|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or unresponsive (e.g., speech is nonsensical or unintelligible).|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or u|71
260|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonresponsive.|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonr|71
261|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostomy.|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostom|71
262|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of devices at the sink, in chair, or on commode|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of|71
263|4 - With a friend|4 - With a friend|71
264|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|71
265|4-OT|4-OT|71
266|5 - Advocates or facilitates patient's participation in appropriate medical care|5 - Advocates or facilitates patient's participation in appropriate medical care|71
267|5 - At least daily|5 - At least daily|71
268|6 - Bedfast, unable to ambulate or be up in a chair.|6 - Bedfast, unable to ambulate or be up in a chair.|71
269|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|71
270|5 - Disruptive or socially inappropriate behavior|5 - Disruptive or socially inappropriate behavior|71
271|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|71
272|5 - Hypo/Hyperglycemia, diabetes out of control|5 - Hypo/Hyperglycemia, diabetes out of control|71
273|5 - More often than once daily|5 - More often than once daily|71
274|5 - Native Hawaiian or Pacific Islander|5 - Native Hawaiian or Pacific Islander|71
275|5 - None of the above|5 - None of the above|71
276|5 - One to two times per week|5 - One to two times per week|71
277|5 - Other|5 - Other|71
278|5 - Other follow-up|5 - Other follow-up|71
279|5 - Paid help|5 - Paid help|71
280|5 - Patient nonresponsive or unable to speak.|5 - Patient nonresponsive or unable to speak.|71
281|5 - Thoughts of suicide|5 - Thoughts of suicide|71
282|5 - Totally unable to use the telephone.|5 - Totally unable to use the telephone.|71
283|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|71
284|5 - Unable to take in nutrients orally or by tube feeding.|5 - Unable to take in nutrients orally or by tube feeding.|71
285|5 - Unsafe for care at home|5 - Unsafe for care at home|71
286|5 - With paid help (other than home care agency staff)|5 - With paid help (other than home care agency staff)|71
287|5 - Workers' compensation|5 - Workers' compensation|71
288|5 - Wound infection, deteriorating wound status, new lesion/ulcer|5 - Wound infection, deteriorating wound status, new lesion/ulcer|71
289|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|71
290|6 - Delusional, hallucinatory, or paranoid behavior|6 - Delusional, hallucinatory, or paranoid behavior|71
291|6 - Financial agent, power of attorney, or conservator of finance|6 - Financial agent, power of attorney, or conservator of finance|71
292|6 - GI bleeding, obstruction|6 - GI bleeding, obstruction|71
293|6 - Less often than weekly|6 - Less often than weekly|71
294|6 - Memory loss to the extent that supervision required|6 - Memory loss to the extent that supervision required|71
295|6 - None of the above feelings observed or reported|6 - None of the above feelings observed or reported|71
296|6 - Other|6 - Other|71
297|6 - Title programs (e.g., Title III, V, or XX)|6 - Title programs (e.g., Title III, V, or XX)|71
298|6 - Transferred to an inpatient facility - patient not discharged from agency|6 - Transferred to an inpatient facility - patient not discharged from agency|71
299|6 - White|6 - White|71
300|6 - With other than above|6 - With other than above|71
301|7 - Exacerbation of CHF, fluid overload, heart failure|7 - Exacerbation of CHF, fluid overload, heart failure|71
302|7 - Health care agent, conservator of person, or medical power of attorney|7 - Health care agent, conservator of person, or medical power of attorney|71
303|7 - Hypo/Hyperglycemia, diabetes out of control|7 - Hypo/Hyperglycemia, diabetes out of control|71
304|7 - None of the above|7 - None of the above|71
305|7 - None of the above behaviors demonstrated|7 - None of the above behaviors demonstrated|71
306|7 - Other government (e.g., TriCare, VA, etc.)|7 - Other government (e.g., TriCare, VA, etc.)|71
307|7 - Transferred to an inpatient facility - patient discharged from agency|7 - Transferred to an inpatient facility - patient discharged from agency|71
308|8 - Death at home|8 - Death at home|71
309|8 - GI bleeding, obstruction|8 - GI bleeding, obstruction|71
310|8 - Myocardial infarction, stroke|8 - Myocardial infarction, stroke|71
311|8 - Private insurance|8 - Private insurance|71
312|9 - Chemotherapy|9 - Chemotherapy|71
313|9 - Discharge from agency|9 - Discharge from agency|71
314|9 - Other than above reasons|9 - Other than above reasons|71
315|9 - Private HMO/managed care|9 - Private HMO/managed care|71
316|NA - No caregiver|NA - No caregiver|71
317|NA - No equipment of this type used in care.|NA - No equipment of this type used in care.|71
318|NA - No inhalant/mist medications prescribed.|NA - No inhalant/mist medications prescribed.|71
319|NA - No injectable medications prescribed.|NA - No injectable medications prescribed.|71
320|NA - No inpatient facility admission|NA - No inpatient facility admission|71
321|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|71
322|NA - No Medicaid|NA - No Medicaid|71
323|NA - No Medicare|NA - No Medicare|71
324|NA - No observable pressure ulcer|NA - No observable pressure ulcer|71
325|NA - No observable stasis ulcer|NA - No observable stasis ulcer|71
326|NA - No observable surgical wound|NA - No observable surgical wound|71
327|NA - No oral medications prescribed.|NA - No oral medications prescribed.|71
328|NA - Not applicable|NA - Not applicable|71
329|NA - Patient does not have a telephone.|NA - Patient does not have a telephone.|71
330|NA - Patient has ostomy for bowel elimination|NA - Patient has ostomy for bowel elimination|71
331|NA - Patient nonresponsive|NA - Patient nonresponsive|71
332|NA - Patient on prophylactic treatment|NA - Patient on prophylactic treatment|71
333|NA - Patient was not discharged from an inpatient facility [Go to M1021]|NA - Patient was not discharged from an inpatient facility [Go to M1017]|71
334|UK - Other unknown|UK - Other unknown|71
335|UK - Reason unknown|UK - Reason unknown|71
336|UK - Unknown|UK - Unknown|71
337|UK - Unknown or Not Available|UK - Unknown or Not Available|71
341|01 - Early|01 - Early|71
342|02 - Late|02 - Late|71
343|NA - Not Applicable. No case mix group defined for this assessment.|NA - Not Applicable. No case mix group defined for this assessment.|71
344|NA - No case mix group defined by this assessment.|NA - No case mix group defined by this assessment.|71
345|1 - Recent decline in mental, emotional, or behavioral status|1 - Recent decline in mental, emotional, or behavioral status|71
346|2 - Multiple hospitalizations (2 or more) in the past 12 months|2 - Multiple hospitalizations (2 or more) in the past 12 months|71
347|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|71
348|4 - Taking five or more medications|4 - Taking five or more medications|71
349|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|71
350|6 - Other|6 - Other|71
351|7 - None of the above|7 - None of the above|71
352|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond tho|71
353|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable without heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable wi|71
354|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious complications and death.|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious compl|71
355|3 - The patient has serious progressive conditions that could lead to death within a year.|3 - The patient has serious progressive conditions that could lead to death within a year.|71
356|UK - The patient+s situation is unknown or unclear.|UK - The patient+s situation is unknown or unclear.|71
357|1 - Yes [ Go to M1050 ]|1 - Yes [ Go to M1050 ]|71
358|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this influenza season. [ Go to M1050 ]|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this i|71
359|1 - Received from another health care provider (e.g., physician)|1 - Received from another health care provider (e.g., physician)|71
360|2 - Received from your agency previously during this year+s flu season|2 - Received from your agency previously during this year+s flu season|71
361|3 - Offered and declined|3 - Offered and declined|71
362|4 - Assessed and determined to have medical contraindication(s)|4 - Assessed and determined to have medical contraindication(s)|71
363|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|71
364|6 - Inability to obtain vaccine due to declared shortage|6 - Inability to obtain vaccine due to declared shortage|71
365|1 - Yes [ Go to M2005 at TRN; Go to M1230 at DC ]|1 - Yes [ Go to M2005 at TRN; Go to M1230 at DC ]|71
366|1 - Patient has received PPV in the past|1 - Patient has received PPV in the past|71
367|2 - Offered and declined|2 - Offered and declined|71
368|3 - Assessed and determined to have medical contraindication(s)|3 - Assessed and determined to have medical contraindication(s)|71
369|4 - Not indicated; patient does not meet age/condition guidelines for PPV|4 - Not indicated; patient does not meet age/condition guidelines for PPV|71
370|5 - None of the above|5 - None of the above|71
371|0 - Adequate: hears normal conversation without difficulty.|0 - Adequate: hears normal conversation without difficulty.|71
372|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to increase volume or speak distinctly.|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to in|71
373|2 - Severely Impaired: absence of useful hearing.|2 - Severely Impaired: absence of useful hearing.|71
374|UK - Unable to assess hearing.|UK - Unable to assess hearing.|71
375|0 - Understands: clear comprehension without cues or repetitions.|0 - Understands: clear comprehension without cues or repetitions.|71
376|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Requires cues at times to understand.|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Req|71
377|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequently requires cues to understand.|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequentl|71
378|3 - Rarely/Never Understands|3 - Rarely/Never Understands|71
379|UK - Unable to assess understanding.|UK - Unable to assess understanding.|71
380|0 - No standardized assessment conducted|0 - No standardized assessment conducted|71
381|1 - Yes, and it does not indicate severe pain|1 - Yes, and it does not indicate severe pain|71
382|2 - Yes, and it indicates severe pain|2 - Yes, and it indicates severe pain|71
383|0 - Patient has no pain|0 - Patient has no pain|71
384|1 - Patient has pain that does not interfere with activity or movement|1 - Patient has pain that does not interfere with activity or movement|71
385|2 - Less often than daily|2 - Less often than daily|71
386|3 - Daily, but not constantly|3 - Daily, but not constantly|71
387|4 - All of the time|4 - All of the time|71
388|0 - No assessment conducted [ Go to M1306 ]|0 - No assessment conducted [ Go to M1306 ]|71
389|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc., without use of standardized tool|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc.,|71
390|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|71
391|0 - No [ Go to M1322]|0 - No [ Go to M1322]|71
392|0 v Newly epithelialized|0 - Newly epithelialized|71
393|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|71
394|2 - Yes, patient has observable stasis ulcers ONLY|2 - Yes, patient has observable stasis ulcers ONLY|71
395|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable dressing) [Go to M1340]|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable|71
396|0 - No [ Go to M1400 ]|0 - No [ Go to M1400 ]|71
397|1 - Yes, patient has at least one (observable) surgical wound|1 - Yes, patient has at least one (observable) surgical wound|71
398|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1350 ]|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1350 ]|71
399|0 - Patient is not short of breath|0 - Patient is not short of breath|71
400|3 - Continuous Bi-level positive airway pressure|3 - Continuous Bi-level positive airway pressure|71
401|0 - No [ Go to M1732 at TRN; Go to M1600 at DC ]|0 - No [ Go to M1732 at TRN; Go to M1600 at DC ]|71
402|2 - Not assessed [Go to M1732 at TRN; Go to M1600 at DC ]|2 - Not assessed [Go to M1732 at TRN; Go to M1600 at DC ]|71
403|NA - Patient does not have diagnosis of heart failure [Go to M2005 at TRN; Go to M1600 at DC]|NA - Patient does not have diagnosis of heart failure [Go to M2005 at TRN; Go to M1600 at DC]|71
404|0 - No action taken|0 - No action taken|71
405|1 - Patient+s physician (or other primary care practitioner) contacted the same day|1 - Patient+s physician (or other primary care practitioner) contacted the same day|71
406|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|71
407|3 - Implement physician-ordered patient-specific established parameters for treatment|3 - Implement physician-ordered patient-specific established parameters for treatment|71
408|4 - Patient education or other clinical interventions|4 - Patient education or other clinical interventions|71
409|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequency, telehealth, etc.)|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequ|71
410|1 - Occasional stress incontinence|1 - Occasional stress incontinence|71
411|2 - During the night only|2 - During the night only|71
412|3 - During the day only|3 - During the day only|71
413|4 - During the day and night|4 - During the day and night|71
414|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|71
415|0 - Able to manage toileting hygiene and clothing management without assistance.|0 - Able to manage toileting hygiene and clothing management without assistance.|71
416|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implements are laid out for the patient.|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implemen|71
417|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|71
418|3 - Patient depends entirely upon another person to maintain toileting hygiene.|3 - Patient depends entirely upon another person to maintain toileting hygiene.|71
419|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independent|71
420|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface|71
421|0 - No multi-factor falls risk assessment conducted.|0 - No multi-factor falls risk assessment conducted.|71
422|1 - Yes, and it does not indicate a risk for falls.|1 - Yes, and it does not indicate a risk for falls.|71
423|2 - Yes, and it indicates a risk for falls.|2 - Yes, and it indicates a risk for falls.|71
424|0 - Not assessed/reviewed [ Go to M2010 ]|0 - Not assessed/reviewed [ Go to M2010 ]|71
425|No - No issues found during review [ Go to M2010 ]|No - No issues found during review [ Go to M2010 ]|71
426|Yes - Issues found during review|Yes - Issues found during review|71
427|NA - Patient is not taking any medications [ Go to M2102 ]|NA - Patient is not taking any medications [ Go to M2102 ]|71
428|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special precautions associated with all high-risk medications|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special p|71
429|NA - Patient not taking any drugs|NA - Patient not taking any drugs|71
430|2 - Able to take medication(s) at the correct times if given reminders by another person at the appropriate times|2 - Able to take medication(s) at the correct times if given reminders by another person at the appr|71
431|3 - Unable to take medication unless administered by another person.|3 - Unable to take medication unless administered by another person.|71
432|1 - At least daily|1 - At least daily|71
433|2 - Three or more times per week|2 - Three or more times per week|71
434|3 - One to two times per week|3 - One to two times per week|71
435|4 - Received, but less often than weekly|4 - Received, but less often than weekly|71
436|5 - No assistance received|5 - No assistance received|71
437|0 - No [Go to M2401]|0 - No [Go to M2401]|71
438|1 - Yes, used hospital emergency department WITHOUT hospital admission|1 - Yes, used hospital emergency department WITHOUT hospital admission|71
439|2 - Yes, used hospital emergency department WITH hospital admission|2 - Yes, used hospital emergency department WITH hospital admission|71
440|UK - Unknown [Go to M2401]|UK - Unknown [Go to M2401]|71
441|2 - Injury caused by fall|2 - Injury caused by fall|71
442|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|71
443|4 - Other respiratory problem|4 - Other respiratory problem|71
444|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|71
445|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|71
446|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|71
447|8 - Other heart disease|8 - Other heart disease|71
448|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|71
449|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|71
450|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|71
451|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|71
452|13 - Urinary tract infection|13 - Urinary tract infection|71
453|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|71
454|15 - Wound infection or deterioration|15 - Wound infection or deterioration|71
455|16 - Uncontrolled pain|16 - Uncontrolled pain|71
456|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|71
457|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|71
458|19 - Other than above reasons|19 - Other than above reasons|71
459|2 - Patient remained in the community (with formal assistive services)|2 - Patient remained in the community (with formal assistive services)|71
460|3 - Patient transferred to a noninstitutional hospice|3 - Patient transferred to a noninstitutional hospice|71
461|4 - Unknown because patient moved to a geographic location not served by this agency|4 - Unknown because patient moved to a geographic location not served by this agency|71
462|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|71
463|4 - Other respiratory problem|4 - Other respiratory problem|71
464|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|71
465|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|71
466|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|71
467|8 - Other heart disease|8 - Other heart disease|71
468|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|71
469|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|71
470|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|71
471|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|71
472|13 - Urinary tract infection|13 - Urinary tract infection|71
473|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|71
474|15 - Wound infection or deterioration|15 - Wound infection or deterioration|71
475|16 - Uncontrolled pain|16 - Uncontrolled pain|71
476|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|71
477|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|71
478|19 - Scheduled treatment or procedure|19 - Scheduled treatment or procedure|71
479|20 - Other than above reasons|20 - Other than above reasons|71
480|UK - Reason unknown [Go to M0903]|UK - Reason unknown [Go to M0903]|71
482|01 - Patient lives alone around the clock|01 - Patient lives alone around the clock|71
483|02 - Patient lives alone regular daytime|02 - Patient lives alone regular daytime|71
484|03 - Patient lives alone regular nighttime|03 - Patient lives alone regular nighttime|71
485|04 - Patient lives alone occassional/short term assistance|04 - Patient lives alone occassional/short term assistance|71
486|05 - Patient lives alone no assisstance available|05 - Patient lives alone no assisstance available|71
487|06 - Patient lives with other person(s) in the home around the clock|06 - Patient lives with other person(s) in the home around the clock|71
488|07 - Patient lives with other person(s) in the home regular daytime|07 - Patient lives with other person(s) in the home regular daytime|71
489|08 - Patient lives with other person(s) in the home regular nighttime|08 - Patient lives with other person(s) in the home regular nighttime|71
490|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|71
491|10 - Patient lives with other person(s) in the home no assistance available|10 - Patient lives with other person(s) in the home no assistance available|71
492|1 - Was present at the most recent SOC/ROC assessment|1 - Was present at the most recent SOC/ROC assessment|71
493|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|71
494|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|71
495|0 - Newly epithelialized|0 - Newly epithelialized|71
496|0 - No [ Go to M1340 ]|0 - No [ Go to M1340 ]|71
498|0 - Independent|0 - Independent|71
499|1 - Needed Some Help|1 - Needed Some Help|71
500|2 - Dependent|2 - Dependent|71
502|0 - No assistance needed in this area|0 - No assistance needed in this area|71
635|3 - Non-agency caregiver(s) are not likely to provide assistance OR it is unclear if they will provide assistance|3 - Non-agency caregiver(s) are not likely to provide assistance OR unclear if will provide asst|71
636|4 - Assistance needed but no non-agency caregiver(s) available|4 - Assistance needed but no non-agency caregiver(s) available|71
637|1 - Peripheral Vascular Disease (PVD) or Peripheral Arterial Disease (PAD)|1 - Peripheral Vascular Disease (PVD) or Peripheral Arterial Disease (PAD)|71
638|2 - Diabetes Mellitus (DM)|2 - Diabetes Mellitus (DM)|71
639|06 - Independent - Patient completes the activity by him/herself with no assistance from a helper.|06 Independent - Patient completes the activity by him/herself with no assistance from a helper.|71
640|05 - Setup or clean-up assistance - Helper SETS UP or CLEANS UP; patient completes activity. Helper assists only prior to or following the activity.|05 Setup or clean-up assistance - Helper SETS UP or CLEANS UP; patient completes activity. He|71
641|04 - Supervision or touching assistance - Helper provides VERBAL CUES or TOUCHING/STEADYING assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently.|04 Supervision or touching assistance - Helper provides VERBAL CUES or TOUCHING/STEADYING|71
642|03 - Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort.|03 Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or |71
643|02 - Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.|02 Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds |71
644|01 - Dependent - Helper does ALL of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity.|01 Dependent - Helper does ALL of the effort. Patient does none of the effort to complete the act|71
645|07 - Activity not attempted - Patient refused|07 Activity not attempted - Patient refused|71
646|09 - Activity not attempted - Not applicable|09 Activity not attempted - Not applicable|71
647|88 - Not attempted due to medical condition or safety concerns|88 Not attempted due to medical condition or safety concerns|71
527|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet criteria for further evaluation for depression.|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet|71
528|0 - Not at all  0 - 1 day|0 - Not at all  0 - 1 day|71
529|1 - Several days  2 - 6 days|1 - Several days  2 - 6 days|71
530|2 - More than half of the days  7 - 11 days|2 - More than half of the days  7 - 11 days|71
531|3 - Nearly every day  12 - 14 days|3 - Nearly every day  12 - 14 days|71
532|NA - N/A  Unable to respond|NA - N/A  Unable to respond|71
533|2 - Able to take medication(s) at the correct times if given reminders by another person based on the frequency of the injection|2 - Able to take medication(s) at the correct times if given reminders by another person based on th|71
2|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; OR (b) Is physically, cognitively, and mentally able to prepare light meals on a regular basis but has not routinely performed light meal preparation in the past (i.e., prior to this home care admission).|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; O|71
3|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and mentally able to perform all housekeeping tasks .|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and menta|71
4|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and mentally able to do laundry and access facilities.|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and menta|71
5|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying packages OR b) Physically, cognitively, and mentally able to take care of shopping, but has not done shopping in the past (i.e., prior to this home care admission).|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying|71
6|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|71
7|0 - Able to dial numbers and answer calls appropriately and as desired.|0 - Able to dial numbers and answer calls appropriately and as desired.|71
8|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body without assistance.|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body|71
9|0 - Able to get to and from the toilet and transfer independently with or without a device.|0 - Able to get to and from the toilet and transfer independently with or without a device.|71
10|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|71
11|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible public bus.|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible p|71
12|0 - Able to independently feed self.|0 - Able to independently feed self.|71
13|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|71
14|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct times.|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct ti|71
15|0 - Able to independently transfer.|0 - Able to independently transfer.|71
16|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without rail|71
17|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings|71
18|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|71
19|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions independently.|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions indep|71
20|0 - Asymptomatic, no treatment needed at this time|0 - Asymptomatic, no treatment needed at this time|71
21|0 - Caregiver manages all tasks related to equipment completely independently.|0 - Caregiver manages all tasks related to equipment completely independently.|71
503|1 - Caregiver(s) currently provide assistance|1 - Caregiver(s) currently provide assistance|71
504|2 - Caregiver(s) need training/ supportive services to provide assistance|2 - Caregiver(s) need training/ supportive services to provide assistance|71
505|3 - Caregiver(s) not likely to provide assistance|3 - Caregiver(s) not likely to provide assistance|71
506|4 - Unclear if Caregiver(s) will provide assistance|4 - Unclear if Caregiver(s) will provide assistance|71
507|5 - Assistance needed, but no Caregiver(s) available|5 - Assistance needed, but no Caregiver(s) available|71
508|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will use standardized clinical guidelines accessible for all care providers to reference|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will|71
509|NA - Patient is not diabetic or is bilateral amputee|NA - Patient is not diabetic or is bilateral amputee|71
510|NA - Patient is not assessed to be at risk for falls|NA - Patient is not assessed to be at risk for falls|71
511|NA - Patient has no diagnosis or symptoms of depression|NA - Patient has no diagnosis or symptoms of depression|71
512|NA - No pain identified|NA - No pain identified|71
513|NA - Patient is not assessed to be at risk for pressure ulcers|NA - Patient is not assessed to be at risk for pressure ulcers|71
514|NA - Patient has no pressure ulcers with need for moist wound healing|NA - Patient has no pressure ulcers with need for moist wound healing|71
515|1 - Long-term nursing facility (NF)|1 - Long-term nursing facility (NF)|71
516|2 - Skilled nursing facility (SNF / TCU)|2 - Skilled nursing facility (SNF / TCU)|71
517|3 - Short stay acute hospital (IPP S)|3 - Short stay acute hospital (IPP S)|71
518|4 - Long-term care hospital (LTCH)|4 - Long-term care hospital (LTCH)|71
519|5 - Inpatient rehabilitation hospital or unit (IRF)|5 - Inpatient rehabilitation hospital or unit (IRF)|71
520|6 - Psychiatric hospital or unit|6 - Psychiatric hospital or unit|71
521|7 - Other|7 - Other|71
522|NA - Patient was not discharged from an inpatient facility [Go to M1017]|NA - Patient was not discharged from an inpatient facility [Go to M1017]|71
523|6 - Unable to participate effectively in bathing and is bathed totally by another person|6 - Unable to participate effectively in bathing and is bathed totally by another person|71
524|4 - Chairfast, unable to ambulate but is able to wheel self independently.|4 - Chairfast, unable to ambulate but is able to wheel self independently.|71
525|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask patient: "Over the last two weeks, how often have you been bothered by any of the following problems")  *Copyright+ Pfizer Inc. All rights reserved. Reproduced with permission.|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask|71
526|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluation for depression.|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluat|71
534|3 - Unable to take injectable medication unless administered by another person.|3 - Unable to take injectable medication unless administered by another person.|71
535|11 - Patient lives in congregate situation (e.g., assisted living) around the clock|11 - Patient lives in congregate situation (e.g., assisted living) around the clock|71
536|12 - Patient lives in congregate situation (e.g., assisted living) regular daytime|12 - Patient lives in congregate situation (e.g., assisted living) regular daytime|71
537|13 - Patient lives in congregate situation (e.g., assisted living) regular nighttime|13 - Patient lives in congregate situation (e.g., assisted living) regular nighttime|71
538|14 - Patient lives in congregate situation (e.g., assisted living) occasional / short-term assistance|14 - Patient lives in congregate situation (e.g., assisted living) occasional / short-term assistanc|71
539|15 - Patient lives in congregate situation (e.g., assisted living) no assistance available|15 - Patient lives in congregate situation (e.g., assisted living) no assistance available|71
545|NA - No observable pressure ulcer or unhealed pressure ulcer|NA - No observable pressure ulcer or unhealed pressure ulcer|71
582|NA - No specific SOC date ordered by physician|NA - No specific SOC date ordered by physician|71
585|UK - Inpatient Discharge Date Unknown|UK - Inpatient Discharge Date Unknown|71
600|1 - History of falls (2 or more falls - or any fall with an injury - in the past 12 months) |1 - History of falls (2 or more falls - or any fall with an injury - in the past 12 months) |71
602|2 - Unintentional weight loss of a total of 10 pounds or more in the past 12 months |2 - Unintentional weight loss of a total of 10 pounds or more in the past 12 months |71
604|3 - Multiple hospitalizations (2 or more) in the past 6 months|3 - Multiple hospitalizations (2 or more) in the past 6 months|71
606|4 - Multiple emergency department visits (2 or more) in the past 6 months|4 - Multiple emergency department visits (2 or more) in the past 6 months|71
608|5 - Decline in mental emotional or behavioral status in the past 3 months |5 - Decline in mental emotional or behavioral status in the past 3 months |71
610|6 - Reported or observed history of difficulty complying with any medical instructions (for example,medications, diet, exercise) in the past 3 months|6 - Reported or observed history of difficulty complying with any medical instructions (for example |71
612|7 - Currently taking 5 or more medications|7 - Currently taking 5 or more medications|71
614|8 - Currently reports exhaustion|8 - Currently reports exhaustion|71
616|9 - Other risk(s) not listed in 1 - 8|9 - Other risk(s) not listed in 1 - 8|71
618|10 - None of the above |10 - None of the above |71
632|0 - No assistance needed v patient is independent or does not have needs in this area|0 - No assistance needed v patient is independent or does not have needs in this area|71
633|1 - Non-agency caregiver(s) currently provide assistance |1 - Non-agency caregiver(s) currently provide assistance |71
634|2 - Non-agency caregiver(s) need training/ supportive services to provide assistance|2 - Non-agency caregiver(s) need training/ supportive services to provide assistance|71
22|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations with no observable impairment.|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations w|71
23|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|71
24|0 - Life expectancy is greater than 6 months|0 - Life expectancy is greater than 6 months|71
25|0 - Never|0 - Never|71
26|0 - Patient is not short of breath|0 - Patient is not short of breath|71
27|0 - No|0 - No|71
28|0 - No emergent care services|0 - No emergent care services|71
29|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) |0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage)|71
30|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and extended or abstract conversation.|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and exte|71
31|0 - No one person|0 - No one person|71
32|0 - None of the time|0 - None of the time|71
33|0 - None, no charge for current services|0 - None, no charge for current services|71
34|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|71
35|0 - Patient does NOT have an ostomy for bowel elimination.|0 - Patient does NOT have an ostomy for bowel elimination.|71
36|0 - Patient has no pain|0 - Patient has no pain|71
37|0 - Patient manages all tasks related to equipment completely independently.|0 - Patient manages all tasks related to equipment completely independently.|71
38|0 - Poor:  little or no recovery is expected and/or further decline is imminent|0 - Poor:  little or no recovery is expected and/or further decline is imminent|71
39|0 - Timed-voiding defers incontinence|0 - Timed-voiding defers incontinence|71
40|0 - Very rarely or never has bowel incontinence|0 - Very rarely or never has bowel incontinence|71
41|0 - Zero|0 - Zero|71
42|00 - No|00 - No|71
43|01 - Yes|01 - Yes|71
44|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or mental limitations, needs assistance with heavy laundry.|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or|71
45|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the patient.|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the|71
46|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|71
47|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or supervision from another person OR c) a liquid, pureed or ground meat diet.|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or su|71
48|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|71
49|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|71
50|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independently.|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independe|71
51|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only when assisted or accompanied by another person.|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only w|71
52|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepa|71
53|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance by another person OR b) given daily reminders.|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance b|71
54|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advan|71
55|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advan|71
56|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for the deaf) and call essential numbers.|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for t|71
57|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|71
58|1 - American Indian or Alaska Native|1 - American Indian or Alaska Native|71
59|1 - Depressed mood (e.g., feeling sad, tearful)|1 - Depressed mood (e.g., feeling sad, tearful)|71
60|1 - During the night only|1 - During the night only|71
61|1 - Fully granulating|1 - Fully granulating|71
62|1 - Good/Fair:  partial to full recovery is expected|1 - Good/Fair:  partial to full recovery is expected|71
63|1 - Good:  marked improvement in functional status is expected|1 - Good:  marked improvement in functional status is expected|71
64|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|71
65|1 - Smoking|1 - Smoking|71
66|1 - Hospital|1 - Hospital|71
67|1 - Hospital emergency room (includes 23-hour holding)|1 - Hospital emergency room (includes 23-hour holding)|71
68|1 - Hospitalization for EMERGENT (unscheduled) care|1 - Hospitalization for EMERGENT (unscheduled) care|71
69|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepared solutions), patient is able to manage all other aspects of equipment.|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepar|71
70|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|71
71|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|71
72|1 - In new or complex situations only|1 - In new or complex situations only|71
73|1 - Intravenous or infusion therapy (excludes TPN)|1 - Intravenous or infusion therapy (excludes TPN)|71
74|1 - Less often than daily|1 - Less often than daily|71
75|1 - Less than once a month|1 - Less than once a month|71
76|1 - Less than once weekly|1 - Less than once weekly|71
77|1 - Life expectancy is 6 months or fewer|1 - Life expectancy is 6 months or fewer|71
78|1 - Lives alone|1 - Lives alone|71
79|1 - Male|1 - Male|71
80|1 - Medicare (traditional fee-for-service)|1 - Medicare (traditional fee-for-service)|71
81|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of past 24 hours, significant memory loss so that supervision is required|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of pas|71
82|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors in word choice, grammar or speech intelligibility, needs minimal prompting or assistance).|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors i|71
83|1 - No assistance or services received|1 - No assistance or services received|71
84|1 - One|1 - One|71
85|1 - Oxygen (intermittent or continuous)|1 - Oxygen (intermittent or continuous)|71
86|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, and the surrounding layout, can count fingers at arm's length.|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, a|71
87|1 - Patient is incontinent|1 - Patient is incontinent|71
88|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|71
89|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical or treatment regimen.|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical|71
90|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient/couple/significant other)|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient|71
91|1 - Relatives, friends, or neighbors living outside the home|1 - Relatives, friends, or neighbors living outside the home|71
92|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions.|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions|71
93|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independentl|71
94|1 - Several times during day and night|1 - Several times during day and night|71
95|1 - Spouse or significant other|1 - Spouse or significant other|71
96|1 - Stage 1|1 - Stage 1|71
97|1 - Start of care - further visits planned|1 - Start of care - further visits planned|71
98|1 - Symptoms well controlled with current therapy|1 - Symptoms well controlled with current therapy|71
99|1 - Therapy services|1 - Therapy services|71
100|1 - Able to transfer with minimal human assistance or with use of an assistive device.|1 - Able to transfer with minimal human assistance or with use of an assistive device.|71
101|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitations.|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitatio|71
102|1 - Urinary incontinence|1 - Urinary incontinence|71
103|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and transfer.|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and|71
104|1 - When walking more than 20 feet, climbing stairs|1 - When walking more than 20 feet, climbing stairs|71
105|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary conversation. May need occasional repetition, extra time, or louder voice.|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary c|71
106|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting in and out of tub/shower|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting|71
107|1 - Yes|1 - Yes|71
108|1-RN|1-RN|71
109|10 - Discharge from agency - no visits completed after start/resumption of care assessment|10 - Discharge from agency - no visits completed after start/resumption of care assessment|71
110|10 - Scheduled surgical procedure|10 - Scheduled surgical procedure|71
111|10 - Self-pay|10 - Self-pay|71
112|11 - Other|11 - Other|71
113|11 - Urinary tract infection|11 - Urinary tract infection|71
114|12 - IV catheter-related infection|12 - IV catheter-related infection|71
115|13 - Deep vein thrombosis, pulmonary embolus|13 - Deep vein thrombosis, pulmonary embolus|71
116|14 - Uncontrolled pain|14 - Uncontrolled pain|71
117|15 - Psychotic episode|15 - Psychotic episode|71
118|16 - Other than above reasons|16 - Other than above reasons|71
119|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing calls.|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing|71
120|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another person.|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another pers|71
121|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface a|71
122|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for intermittent supervision or encouragement or reminders, OR (b) to get in and out of the shower or tub, OR (c) for washing difficult to reach areas.|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for inter|71
123|2 - Asian|2 - Asian|71
124|2 - Caregiver requires considerable assistance from another person to manage equipment, but independently completes significant portions of task.|2 - Caregiver requires considerable assistance from another person to manage equipment, but independ|71
125|2 - Daily, but not constantly|2 - Daily, but not constantly|71
126|2 - Daughter or son|2 - Daughter or son|71
127|2 - Doctor's office emergency visit/house call|2 - Doctor's office emergency visit/house call|71
128|2 - During the day and night|2 - During the day and night|71
129|2 - Early/partial granulation|2 - Early/partial granulation|71
130|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors in word choice, organization or speech intelligibility). Speaks in phrases or short sentences.|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors|71
131|2 - Family member's residence|2 - Family member's residence|71
132|2 - Female|2 - Female|71
133|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conversation, needs frequent prompting or assistance.|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conver|71
134|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|71
135|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|71
136|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately stop activities, jeopardizes safety through actions|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately st|71
137|2 - Indwelling/suprapubic catheter|2 - Indwelling/suprapubic catheter|71
138|2 - Injury caused by fall or accident at home|2 - Injury caused by fall or accident at home|71
139|2 - Medicare (HMO/managed care/Advantage plan)|2 - Medicare (HMO/managed care/Advantage plan)|71
140|2 - Nausea, dehydration, malnutrition, constipation, impaction|2 - Nausea, dehydration, malnutrition, constipation, impaction|71
141|2 - Obesity|2 - Obesity|71
142|2 - On awakening or at night only|2 - On awakening or at night only|71
143|2 - Once a month|2 - Once a month|71
144|2 - One to three times weekly|2 - One to three times weekly|71
145|2 - Parenteral nutrition (TPN or lipids)|2 - Parenteral nutrition (TPN or lipids)|71
146|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic)  [ Go to M1620 ]|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic)  [ Go|71
147|2 - Patient requires considerable assistance from another person to manage equipment, but independently completes portions of the task.|2 - Patient requires considerable assistance from another person to manage equipment, but independen|71
148|2 - Patient transferred to a noninstitutional hospice|2 - Patient transferred to a noninstitutional hospice|71
149|2 - Person residing in the home (EXCLUDING paid help)|2 - Person residing in the home (EXCLUDING paid help)|71
150|2 - Rehabilitation facility|2 - Rehabilitation facility|71
151|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifting of attention) or consistently requires low stimulus environment due to distractibility.|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifti|71
152|2 - Respite care|2 - Respite care|71
153|2 - Sense of failure or self reproach|2 - Sense of failure or self reproach|71
154|2 - Several times during day|2 - Several times during day|71
155|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonresponsive.|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonrespons|71
156|2 - Someone must assist the patient to groom self.|2 - Someone must assist the patient to groom self.|71
648|06 - Independent - Patient completes the activity by him/herself with no assistance from a helper.|06 - Independent - Patient completes the activity by him/herself with no assistance from a helper.|71
649|05 - Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity.|05 - Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper|71
650|04 - Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently.|04 - Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/|71
651|03 - Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort.|03 - Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or sup|71
652|02 - Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.|02 - Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds t|71
653|01 - Dependent - Helper does ALL of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity.|01 - Dependent - Helper does ALL of the effort. Patient does none of the effort to complete the acti|71
654|07 - Patient refused|07 - Patient refused|71
655|09 - Not applicable - Not attempted and the patient did not perform this activity prior to the current illness,exacerbation or injury.|09 - Not applicable - Not attempted and the patient did not perform this activity prior to the curre|71
656|10 - Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)|10 - Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)|71
657|88 - Not attempted due to medical conditions or safety concerns|88 - Not attempted due to medical conditions or safety concerns|71
658|0 - No [STOP]|0 - No [STOP]|71
659|0 - No [Skip GG0170R]|0 - No [Skip GG0170R]|71
660|1 - Yes [Continue to GG0170R, Wheel 50 feet with two turns.]|1 - Yes [Continue to GG0170R, Wheel 50 feet with two turns.]|71
661|1 - Manual|1 - Manual|71
662|2 - Motorized|2 - Motorized|71
663|0 - No [Skip to J1800 Any falls since SOC/ROC, whichever is more recent.]|0 - No [Skip to J1800 Any falls since SOC/ROC, whichever is more recent.]|71
664|0 - No [STOP]|0 - No [STOP]|71
665|1 - Yes [Continue to J1900, Number of Falls Since SOC/ROC, whichever is more recent]|1 - Yes [Continue to J1900, Number of Falls Since SOC/ROC, whichever is more recent]|71
666|0 - None|0 - None|71
667|1 - One|1 - One|71
668|2 - Two or More|2 - Two or More|71
669|3 - Independent - Patient completed the activities by him/herself, with or without an assistive device, with no assistance from a helper.|3 - Independent - Patient completed the activities by him/herself, with or without an assistive devi|71
670|2 - Needed Some Help - Patient needed partial assistance from another person to complete activities.|2 - Needed Some Help - Patient needed partial assistance from another person to complete activities.|71
671|1 - Dependent - A helper completed the activities for the patient.|1 - Dependent - A helper completed the activities for the patient.|71
672|8 - Unknown|8 - Unknown|71
673|9 - Not Applicable|9 - Not Applicable|71
674|A - Manual wheelchair|A - Manual wheelchair|71
675|B - Motorized wheelchair and/or scooter|B - Motorized wheelchair and/or scooter|71
676|C - Mechanical lift|C - Mechanical lift|71
677|D - Walker|D - Walker|71
678|E - Orthotics/Prosthetics|E - Orthotics/Prosthetics|71
679|Z - None of the above|Z - None of the above|71
680|3 - None of the above|3 - None of the above|71
680|3 - None of the above|3 - None of the above|73
679|Z - None of the above|Z - None of the above|73
678|E - Orthotics/Prosthetics|E - Orthotics/Prosthetics|73
677|D - Walker|D - Walker|73
676|C - Mechanical lift|C - Mechanical lift|73
675|B - Motorized wheelchair and/or scooter|B - Motorized wheelchair and/or scooter|73
674|A - Manual wheelchair|A - Manual wheelchair|73
673|9 - Not Applicable|9 - Not Applicable|73
672|8 - Unknown|8 - Unknown|73
671|1 - Dependent - A helper completed the activities for the patient.|1 - Dependent - A helper completed the activities for the patient.|73
670|2 - Needed Some Help - Patient needed partial assistance from another person to complete activities.|2 - Needed Some Help - Patient needed partial assistance from another person to complete activities.|73
669|3 - Independent - Patient completed the activities by him/herself, with or without an assistive device, with no assistance from a helper.|3 - Independent - Patient completed the activities by him/herself, with or without an assistive devi|73
668|2 - Two or More|2 - Two or More|73
667|1 - One|1 - One|73
666|0 - None|0 - None|73
665|1 - Yes [Continue to J1900, Number of Falls Since SOC/ROC, whichever is more recent]|1 - Yes [Continue to J1900, Number of Falls Since SOC/ROC, whichever is more recent]|73
664|0 - No [STOP]|0 - No [STOP]|73
663|0 - No [Skip to J1800 Any falls since SOC/ROC, whichever is more recent.]|0 - No [Skip to J1800 Any falls since SOC/ROC, whichever is more recent.]|73
662|2 - Motorized|2 - Motorized|73
661|1 - Manual|1 - Manual|73
660|1 - Yes [Continue to GG0170R, Wheel 50 feet with two turns.]|1 - Yes [Continue to GG0170R, Wheel 50 feet with two turns.]|73
659|0 - No [Skip GG0170R]|0 - No [Skip GG0170R]|73
658|0 - No [STOP]|0 - No [STOP]|73
657|88 - Not attempted due to medical conditions or safety concerns|88 - Not attempted due to medical conditions or safety concerns|73
656|10 - Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)|10 - Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)|73
655|09 - Not applicable - Not attempted and the patient did not perform this activity prior to the current illness,exacerbation or injury.|09 - Not applicable - Not attempted and the patient did not perform this activity prior to the curre|73
654|07 - Patient refused|07 - Patient refused|73
653|01 - Dependent - Helper does ALL of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity.|01 - Dependent - Helper does ALL of the effort. Patient does none of the effort to complete the acti|73
652|02 - Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.|02 - Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds t|73
651|03 - Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort.|03 - Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or sup|73
650|04 - Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently.|04 - Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/|73
649|05 - Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity.|05 - Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper|73
648|06 - Independent - Patient completes the activity by him/herself with no assistance from a helper.|06 - Independent - Patient completes the activity by him/herself with no assistance from a helper.|73
647|88 - Not attempted due to medical condition or safety concerns|88 Not attempted due to medical condition or safety concerns|73
646|09 - Activity not attempted - Not applicable|09 Activity not attempted - Not applicable|73
645|07 - Activity not attempted - Patient refused|07 Activity not attempted - Patient refused|73
644|01 - Dependent - Helper does ALL of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity.|01 Dependent - Helper does ALL of the effort. Patient does none of the effort to complete the act|73
643|02 - Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.|02 Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds |73
642|03 - Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort.|03 Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or |73
641|04 - Supervision or touching assistance - Helper provides VERBAL CUES or TOUCHING/STEADYING assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently.|04 Supervision or touching assistance - Helper provides VERBAL CUES or TOUCHING/STEADYING |73
640|05 - Setup or clean-up assistance -  Helper SETS UP or CLEANS UP; patient completes activity. Helper assists only prior to or following the activity.|05 Setup or clean-up assistance - Helper SETS UP or CLEANS UP; patient completes activity. Hel|73
639|06 - Independent - Patient completes the activity by him/herself with no assistance from a helper.|06 Independent - Patient completes the activity by him/herself with no assistance from a helper.|73
638|2 - Diabetes Mellitus (DM)|2 - Diabetes Mellitus (DM)|73
637|1 - Peripheral Vascular Disease (PVD) or Peripheral Arterial Disease (PAD)|1 - Peripheral Vascular Disease (PVD) or Peripheral Arterial Disease (PAD)|73
2|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; OR (b) Is physically, cognitively, and mentally able to prepare light meals on a regular basis but has not routinely performed light meal preparation in the past (i.e., prior to this home care admission).|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; O|73
3|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and mentally able to perform all housekeeping tasks .|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and menta|73
4|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and mentally able to do laundry and access facilities.|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and menta|73
5|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying packages OR b) Physically, cognitively, and mentally able to take care of shopping, but has not done shopping in the past (i.e., prior to this home care admission).|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying|73
6|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|73
7|0 - Able to dial numbers and answer calls appropriately and as desired.|0 - Able to dial numbers and answer calls appropriately and as desired.|73
8|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body without assistance.|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body|73
9|0 - Able to get to and from the toilet and transfer independently with or without a device.|0 - Able to get to and from the toilet and transfer independently with or without a device.|73
10|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|73
11|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible public bus.|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible p|73
12|0 - Able to independently feed self.|0 - Able to independently feed self.|73
13|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|73
14|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct times.|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct ti|73
15|0 - Able to independently transfer.|0 - Able to independently transfer.|73
16|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without rail|73
17|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings|73
18|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|73
19|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions independently.|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions indep|73
20|0 - Asymptomatic, no treatment needed at this time|0 - Asymptomatic, no treatment needed at this time|73
21|0 - Caregiver manages all tasks related to equipment completely independently.|0 - Caregiver manages all tasks related to equipment completely independently.|73
22|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations with no observable impairment.|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations w|73
23|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|73
24|0 - Life expectancy is greater than 6 months|0 - Life expectancy is greater than 6 months|73
25|0 - Never|0 - Never|73
26|0 - Patient is not short of breath|0 - Patient is not short of breath|73
27|0 - No|0 - No|73
28|0 - No emergent care services|0 - No emergent care services|73
29|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) |0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) |73
30|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and extended or abstract conversation.|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and exte|73
31|0 - No one person|0 - No one person|73
32|0 - None of the time|0 - None of the time|73
33|0 - None, no charge for current services|0 - None, no charge for current services|73
34|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|73
35|0 - Patient does NOT have an ostomy for bowel elimination.|0 - Patient does NOT have an ostomy for bowel elimination.|73
36|0 - Patient has no pain|0 - Patient has no pain|73
37|0 - Patient manages all tasks related to equipment completely independently.|0 - Patient manages all tasks related to equipment completely independently.|73
38|0 - Poor:  little or no recovery is expected and/or further decline is imminent|0 - Poor:  little or no recovery is expected and/or further decline is imminent|73
39|0 - Timed-voiding defers incontinence|0 - Timed-voiding defers incontinence|73
40|0 - Very rarely or never has bowel incontinence|0 - Very rarely or never has bowel incontinence|73
41|0 - Zero|0 - Zero|73
42|00 - No|00 - No|73
43|01 - Yes|01 - Yes|73
44|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or mental limitations, needs assistance with heavy laundry.|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or|73
45|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the patient.|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the|73
46|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|73
47|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or supervision from another person OR c) a liquid, pureed or ground meat diet.|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or su|73
48|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|73
49|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|73
50|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independently.|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independe|73
51|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only when assisted or accompanied by another person.|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only w|73
52|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepa|73
53|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance by another person OR b) given daily reminders.|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance b|73
54|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advan|73
55|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advan|73
56|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for the deaf) and call essential numbers.|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for t|73
57|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|73
58|1 - American Indian or Alaska Native|1 - American Indian or Alaska Native|73
59|1 - Depressed mood (e.g., feeling sad, tearful)|1 - Depressed mood (e.g., feeling sad, tearful)|73
60|1 - During the night only|1 - During the night only|73
61|1 - Fully granulating|1 - Fully granulating|73
62|1 - Good/Fair:  partial to full recovery is expected|1 - Good/Fair:  partial to full recovery is expected|73
63|1 - Good:  marked improvement in functional status is expected|1 - Good:  marked improvement in functional status is expected|73
64|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|73
65|1 - Smoking|1 - Smoking|73
66|1 - Hospital|1 - Hospital|73
67|1 - Hospital emergency room (includes 23-hour holding)|1 - Hospital emergency room (includes 23-hour holding)|73
68|1 - Hospitalization for EMERGENT (unscheduled) care|1 - Hospitalization for EMERGENT (unscheduled) care|73
69|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepared solutions), patient is able to manage all other aspects of equipment.|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepar|73
70|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|73
71|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|73
72|1 - In new or complex situations only|1 - In new or complex situations only|73
73|1 - Intravenous or infusion therapy (excludes TPN)|1 - Intravenous or infusion therapy (excludes TPN)|73
74|1 - Less often than daily|1 - Less often than daily|73
75|1 - Less than once a month|1 - Less than once a month|73
76|1 - Less than once weekly|1 - Less than once weekly|73
77|1 - Life expectancy is 6 months or fewer|1 - Life expectancy is 6 months or fewer|73
78|1 - Lives alone|1 - Lives alone|73
79|1 - Male|1 - Male|73
80|1 - Medicare (traditional fee-for-service)|1 - Medicare (traditional fee-for-service)|73
81|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of past 24 hours, significant memory loss so that supervision is required|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of pas|73
82|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors in word choice, grammar or speech intelligibility, needs minimal prompting or assistance).|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors i|73
83|1 - No assistance or services received|1 - No assistance or services received|73
84|1 - One|1 - One|73
85|1 - Oxygen (intermittent or continuous)|1 - Oxygen (intermittent or continuous)|73
86|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, and the surrounding layout, can count fingers at arm's length.|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, a|73
87|1 - Patient is incontinent|1 - Patient is incontinent|73
88|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|73
89|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical or treatment regimen.|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical|73
90|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient/couple/significant other)|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient|73
91|1 - Relatives, friends, or neighbors living outside the home|1 - Relatives, friends, or neighbors living outside the home|73
92|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions.|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions|73
93|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independentl|73
94|1 - Several times during day and night|1 - Several times during day and night|73
95|1 - Spouse or significant other|1 - Spouse or significant other|73
96|1 - Stage 1|1 - Stage 1|73
97|1 - Start of care - further visits planned|1 - Start of care - further visits planned|73
98|1 - Symptoms well controlled with current therapy|1 - Symptoms well controlled with current therapy|73
99|1 - Therapy services|1 - Therapy services|73
100|1 - Able to transfer with minimal human assistance or with use of an assistive device.|1 - Able to transfer with minimal human assistance or with use of an assistive device.|73
101|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitations.|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitatio|73
102|1 - Urinary incontinence|1 - Urinary incontinence|73
103|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and transfer.|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and|73
104|1 - When walking more than 20 feet, climbing stairs|1 - When walking more than 20 feet, climbing stairs|73
105|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary conversation. May need occasional repetition, extra time, or louder voice.|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary c|73
106|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting in and out of tub/shower|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting|73
107|1 - Yes|1 - Yes|73
108|1-RN|1-RN|73
109|10 - Discharge from agency - no visits completed after start/resumption of care assessment|10 - Discharge from agency - no visits completed after start/resumption of care assessment|73
110|10 - Scheduled surgical procedure|10 - Scheduled surgical procedure|73
111|10 - Self-pay|10 - Self-pay|73
112|11 - Other|11 - Other|73
113|11 - Urinary tract infection|11 - Urinary tract infection|73
114|12 - IV catheter-related infection|12 - IV catheter-related infection|73
115|13 - Deep vein thrombosis, pulmonary embolus|13 - Deep vein thrombosis, pulmonary embolus|73
116|14 - Uncontrolled pain|14 - Uncontrolled pain|73
117|15 - Psychotic episode|15 - Psychotic episode|73
118|16 - Other than above reasons|16 - Other than above reasons|73
119|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing calls.|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing|73
120|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another person.|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another pers|73
121|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface a|73
122|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for intermittent supervision or encouragement or reminders, OR (b) to get in and out of the shower or tub, OR (c) for washing difficult to reach areas.|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for inter|73
123|2 - Asian|2 - Asian|73
124|2 - Caregiver requires considerable assistance from another person to manage equipment, but independently completes significant portions of task.|2 - Caregiver requires considerable assistance from another person to manage equipment, but independ|73
125|2 - Daily, but not constantly|2 - Daily, but not constantly|73
126|2 - Daughter or son|2 - Daughter or son|73
127|2 - Doctor's office emergency visit/house call|2 - Doctor's office emergency visit/house call|73
128|2 - During the day and night|2 - During the day and night|73
129|2 - Early/partial granulation|2 - Early/partial granulation|73
130|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors in word choice, organization or speech intelligibility). Speaks in phrases or short sentences.|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors|73
131|2 - Family member's residence|2 - Family member's residence|73
132|2 - Female|2 - Female|73
133|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conversation, needs frequent prompting or assistance.|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conver|73
134|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|73
135|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|73
136|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately stop activities, jeopardizes safety through actions|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately st|73
137|2 - Indwelling/suprapubic catheter|2 - Indwelling/suprapubic catheter|73
138|2 - Injury caused by fall or accident at home|2 - Injury caused by fall or accident at home|73
139|2 - Medicare (HMO/managed care/Advantage plan)|2 - Medicare (HMO/managed care/Advantage plan)|73
140|2 - Nausea, dehydration, malnutrition, constipation, impaction|2 - Nausea, dehydration, malnutrition, constipation, impaction|73
141|2 - Obesity|2 - Obesity|73
142|2 - On awakening or at night only|2 - On awakening or at night only|73
143|2 - Once a month|2 - Once a month|73
144|2 - One to three times weekly|2 - One to three times weekly|73
145|2 - Parenteral nutrition (TPN or lipids)|2 - Parenteral nutrition (TPN or lipids)|73
146|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic)  [ Go to M1620 ]|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic)  [ Go|73
147|2 - Patient requires considerable assistance from another person to manage equipment, but independently completes portions of the task.|2 - Patient requires considerable assistance from another person to manage equipment, but independen|73
148|2 - Patient transferred to a noninstitutional hospice|2 - Patient transferred to a noninstitutional hospice|73
149|2 - Person residing in the home (EXCLUDING paid help)|2 - Person residing in the home (EXCLUDING paid help)|73
150|2 - Rehabilitation facility|2 - Rehabilitation facility|73
151|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifting of attention) or consistently requires low stimulus environment due to distractibility.|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifti|73
152|2 - Respite care|2 - Respite care|73
153|2 - Sense of failure or self reproach|2 - Sense of failure or self reproach|73
154|2 - Several times during day|2 - Several times during day|73
155|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonresponsive.|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonrespons|73
156|2 - Someone must assist the patient to groom self.|2 - Someone must assist the patient to groom self.|73
157|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|73
158|2 - Someone must help the patient put on upper body clothing.|2 - Someone must help the patient put on upper body clothing.|73
159|2 - Stage 2|2 - Stage 2|73
160|2 - Start of care - no further visits planned|2 - Start of care - no further visits planned|73
161|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitoring|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitori|73
162|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment regimen.|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment re|73
163|2 - Two|2 - Two|73
164|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistance due to cognitive or mental limitation.|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistanc|73
165|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|73
166|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assistance).|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assis|73
167|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home delivery.|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home deli|73
168|2 - Unable to prepare any light meals or reheat any delivered meals.|2 - Unable to prepare any light meals or reheat any delivered meals.|73
169|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|73
170|2 - UNABLE to take injectable medications unless administered by someone else.|2 - UNABLE to take injectable medications unless administered by someone else.|73
171|2 - UNABLE to take medication unless administered by someone else.|2 - UNABLE to take medication unless administered by someone else.|73
172|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|73
173|2 - Ventilator (continually or at night)|2 - Ventilator (continually or at night)|73
174|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less than 20 feet)|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less th|73
175|2 - With spouse or significant other|2 - With spouse or significant other|73
176|2 - Yes, assistance or services provided by family or friends|2 - Yes, assistance or services provided by family or friends|73
177|2-PT|2-PT|73
178|3 - Able to answer the telephone only some of the time or is able to carry on only a limited conversation.|3 - Able to answer the telephone only some of the time or is able to carry on only a limited convers|73
179|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube or gastrostomy.|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube|73
180|3 - Alcohol dependency|3 - Alcohol dependency|73
181|3 - All of the time|3 - All of the time|73
182|3 - Black or African-American|3 - Black or African-American|73
183|3 - Boarding home or rented room|3 - Boarding home or rented room|73
184|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment, clean/store/dispose of equipment or supplies).|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment,|73
185|3 -Able to walk only with the supervision or assistance of another person at all times.|3 -Able to walk only with the supervision or assistance of another person at all times.|73
186|3 - Continuous / Bi-level positive airway pressure|3 - Continuous / Bi-level positive airway pressure|73
187|3 - During the day and evening, but not constantly|3 - During the day and evening, but not constantly|73
188|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the alimentary canal)|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the|73
189|3 - Environmental support (e.g., housing, home maintenance)|3 - Environmental support (e.g., housing, home maintenance)|73
190|3 - Four to six times weekly|3 - Four to six times weekly|73
191|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessing by listener.  Speech limited to single words or short phrases.|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessin|73
192|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires multiple repetitions, restatements, demonstrations, additional time.|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires m|73
193|3 - Hopelessness|3 - Hopelessness|73
194|3 - Hospice care|3 - Hospice care|73
195|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|73
196|3 - Injury caused by fall or accident at home|3 - Injury caused by fall or accident at home|73
197|3 - Intractable pain|3 - Intractable pain|73
198|3 - Medicaid (traditional fee-for-service)|3 - Medicaid (traditional fee-for-service)|73
199|3 - Needs someone to do all shopping and errands.|3 - Needs someone to do all shopping and errands.|73
200|3 - Not healing|3 - Not healing|73
201|3 - Nursing home|3 - Nursing home|73
202|3 - Once daily|3 - Once daily|73
203|3 - Other family member|3 - Other family member|73
204|3 - Outpatient department/clinic emergency (includes urgicenter sites)|3 - Outpatient department/clinic emergency (includes urgicenter sites)|73
205|3 - Paid help|3 - Paid help|73
206|3 - Able to participate in bathing self in shower or tub, but requires presence of another person throughout the bath for assistance or supervision.|3 - Able to participate in bathing self in shower or tub, but requires presence of another person th|73
207|3 - Patient depends entirely upon another person to dress lower body.|3 - Patient depends entirely upon another person to dress lower body.|73
208|3 - Patient depends entirely upon another person to dress the upper body.|3 - Patient depends entirely upon another person to dress the upper body.|73
209|3 - Patient depends entirely upon someone else for grooming needs.|3 - Patient depends entirely upon someone else for grooming needs.|73
210|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone else to manage the equipment.|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone|73
211|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable to shift attention and recall directions more than half the time.|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable|73
212|3 - Respiratory problems (SOB, infection, obstruction)|3 - Respiratory problems (SOB, infection, obstruction)|73
213|3 - Resumption of care (after inpatient stay)|3 - Resumption of care (after inpatient stay)|73
214|3 - Several times each month|3 - Several times each month|73
215|3 - Skilled Nursing Facility|3 - Skilled Nursing Facility|73
216|3 - Stage 3|3 - Stage 3|73
217|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|73
218|3 - Three|3 - Three|73
219|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person throughout the process.|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person through|73
220|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal independently.|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal indep|73
221|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person.|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person|73
222|3 - Unknown because patient moved to a geographic location not served by this agency|3 - Unknown because patient moved to a geographic location not served by this agency|73
223|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|73
224|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|73
225|3 - With other family member|3 - With other family member|73
226|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home health services, homemaker assistance, transportation assistance, assisted living, board and care)|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home h|73
227|3-SLP/ST|3-SLP/ST|73
228|4 - At rest (during day or night)|4 - At rest (during day or night)|73
229|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|73
230|4 - Board and care or assisted living facility|4 - Board and care or assisted living facility|73
231|4 - Caregiver is completely dependent on someone else to manage all equipment.|4 - Caregiver is completely dependent on someone else to manage all equipment.|73
232|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|73
233|4 - Constantly|4 - Constantly|73
234|4 - Drug dependency|4 - Drug dependency|73
235|4 - Four or more|4 - Four or more|73
236|4 - Friend or neighbor or community or church member|4 - Friend or neighbor or community or church member|73
237|4 - Hispanic or Latino|4 - Hispanic or Latino|73
238|4 - Hospice|4 - Hospice|73
239|4 - Impaired decision-making|4 - Impaired decision-making|73
240|4 - Is totally dependent in toileting.|4 - Is totally dependent in toileting.|73
241|4 - Medicaid (HMO/managed care)|4 - Medicaid (HMO/managed care)|73
242|4 - None of the above|4 - None of the above|73
243|4 - Nursing home|4 - Nursing home|73
244|4 - On a daily basis|4 - On a daily basis|73
245|4 - Patient is completely dependent on someone else to manage all equipment.|4 - Patient is completely dependent on someone else to manage all equipment.|73
246|4 - Permanent placement|4 - Permanent placement|73
247|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, punches, dangerous maneuvers w/ wheelchair or other objects)|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, pu|73
248|4 - Psychosocial support (e.g., socialization, companionship, recreation)|4 - Psychosocial support (e.g., socialization, companionship, recreation)|73
249|4 - Recertification (follow-up) reassessment|4 - Recertification (follow-up) reassessment|73
250|4 - Recurrent thoughts of death|4 - Recurrent thoughts of death|73
251|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruction)|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruc|73
252|4 - Several times a week|4 - Several times a week|73
253|4 - Stage 4|4 - Stage 4|73
254|4 - Symptoms poorly controlled, history of re-hospitalizations|4 - Symptoms poorly controlled, history of re-hospitalizations|73
255|4 - Three or more times per week|4 - Three or more times per week|73
256|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetative state, or delirium.|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetati|73
257|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|73
258|4 - Unable to effectively participate in any housekeeping tasks.|4 - Unable to effectively participate in any housekeeping tasks.|73
259|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or unresponsive (e.g., speech is nonsensical or unintelligible).|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or u|73
260|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonresponsive.|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonr|73
261|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostomy.|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostom|73
262|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of devices at the sink, in chair, or on commode|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of|73
263|4 - With a friend|4 - With a friend|73
264|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|73
265|4-OT|4-OT|73
266|5 - Advocates or facilitates patient's participation in appropriate medical care|5 - Advocates or facilitates patient's participation in appropriate medical care|73
267|5 - At least daily|5 - At least daily|73
268|6 - Bedfast, unable to ambulate or be up in a chair.|6 - Bedfast, unable to ambulate or be up in a chair.|73
269|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|73
270|5 - Disruptive or socially inappropriate behavior|5 - Disruptive or socially inappropriate behavior|73
271|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|73
272|5 - Hypo/Hyperglycemia, diabetes out of control|5 - Hypo/Hyperglycemia, diabetes out of control|73
273|5 - More often than once daily|5 - More often than once daily|73
274|5 - Native Hawaiian or Pacific Islander|5 - Native Hawaiian or Pacific Islander|73
275|5 - None of the above|5 - None of the above|73
276|5 - One to two times per week|5 - One to two times per week|73
277|5 - Other|5 - Other|73
278|5 - Other follow-up|5 - Other follow-up|73
279|5 - Paid help|5 - Paid help|73
280|5 - Patient nonresponsive or unable to speak.|5 - Patient nonresponsive or unable to speak.|73
281|5 - Thoughts of suicide|5 - Thoughts of suicide|73
282|5 - Totally unable to use the telephone.|5 - Totally unable to use the telephone.|73
283|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|73
284|5 - Unable to take in nutrients orally or by tube feeding.|5 - Unable to take in nutrients orally or by tube feeding.|73
285|5 - Unsafe for care at home|5 - Unsafe for care at home|73
286|5 - With paid help (other than home care agency staff)|5 - With paid help (other than home care agency staff)|73
287|5 - Workers' compensation|5 - Workers' compensation|73
288|5 - Wound infection, deteriorating wound status, new lesion/ulcer|5 - Wound infection, deteriorating wound status, new lesion/ulcer|73
289|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|73
290|6 - Delusional, hallucinatory, or paranoid behavior|6 - Delusional, hallucinatory, or paranoid behavior|73
291|6 - Financial agent, power of attorney, or conservator of finance|6 - Financial agent, power of attorney, or conservator of finance|73
292|6 - GI bleeding, obstruction|6 - GI bleeding, obstruction|73
293|6 - Less often than weekly|6 - Less often than weekly|73
294|6 - Memory loss to the extent that supervision required|6 - Memory loss to the extent that supervision required|73
295|6 - None of the above feelings observed or reported|6 - None of the above feelings observed or reported|73
296|6 - Other|6 - Other|73
297|6 - Title programs (e.g., Title III, V, or XX)|6 - Title programs (e.g., Title III, V, or XX)|73
298|6 - Transferred to an inpatient facility - patient not discharged from agency|6 - Transferred to an inpatient facility - patient not discharged from agency|73
299|6 - White|6 - White|73
300|6 - With other than above|6 - With other than above|73
301|7 - Exacerbation of CHF, fluid overload, heart failure|7 - Exacerbation of CHF, fluid overload, heart failure|73
302|7 - Health care agent, conservator of person, or medical power of attorney|7 - Health care agent, conservator of person, or medical power of attorney|73
303|7 - Hypo/Hyperglycemia, diabetes out of control|7 - Hypo/Hyperglycemia, diabetes out of control|73
304|7 - None of the above|7 - None of the above|73
305|7 - None of the above behaviors demonstrated|7 - None of the above behaviors demonstrated|73
306|7 - Other government (e.g., TriCare, VA, etc.)|7 - Other government (e.g., TriCare, VA, etc.)|73
307|7 - Transferred to an inpatient facility - patient discharged from agency|7 - Transferred to an inpatient facility - patient discharged from agency|73
308|8 - Death at home|8 - Death at home|73
309|8 - GI bleeding, obstruction|8 - GI bleeding, obstruction|73
310|8 - Myocardial infarction, stroke|8 - Myocardial infarction, stroke|73
311|8 - Private insurance|8 - Private insurance|73
312|9 - Chemotherapy|9 - Chemotherapy|73
313|9 - Discharge from agency|9 - Discharge from agency|73
314|9 - Other than above reasons|9 - Other than above reasons|73
315|9 - Private HMO/managed care|9 - Private HMO/managed care|73
316|NA - No caregiver|NA - No caregiver|73
317|NA - No equipment of this type used in care.|NA - No equipment of this type used in care.|73
318|NA - No inhalant/mist medications prescribed.|NA - No inhalant/mist medications prescribed.|73
319|NA - No injectable medications prescribed.|NA - No injectable medications prescribed.|73
320|NA - No inpatient facility admission|NA - No inpatient facility admission|73
321|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|73
322|NA - No Medicaid|NA - No Medicaid|73
323|NA - No Medicare|NA - No Medicare|73
324|NA - No observable pressure ulcer or unhealed pressure ulcer|NA - No observable pressure ulcer or unhealed pressure ulcer|73
325|NA - No observable stasis ulcer|NA - No observable stasis ulcer|73
326|NA - No observable surgical wound|NA - No observable surgical wound|73
327|NA - No oral medications prescribed.|NA - No oral medications prescribed.|73
328|NA - Not applicable|NA - Not applicable|73
329|NA - Patient does not have a telephone.|NA - Patient does not have a telephone.|73
330|NA - Patient has ostomy for bowel elimination|NA - Patient has ostomy for bowel elimination|73
331|NA - Patient nonresponsive|NA - Patient nonresponsive|73
332|NA - Patient on prophylactic treatment|NA - Patient on prophylactic treatment|73
333|NA - Patient was not discharged from an inpatient facility [Go to M1021]|NA - Patient was not discharged from an inpatient facility [Go to M1017]|73
334|UK - Other unknown|UK - Other unknown|73
335|UK - Reason unknown|UK - Reason unknown|73
336|UK - Unknown|UK - Unknown|73
337|UK - Unknown or Not Available|UK - Unknown or Not Available|73
341|01 - Early|01 - Early|73
342|02 - Late|02 - Late|73
343|NA - Not Applicable. No case mix group defined for this assessment.|NA - Not Applicable. No case mix group defined for this assessment.|73
344|NA - No case mix group defined by this assessment.|NA - No case mix group defined by this assessment.|73
345|1 - Recent decline in mental, emotional, or behavioral status|1 - Recent decline in mental, emotional, or behavioral status|73
346|2 - Multiple hospitalizations (2 or more) in the past 12 months|2 - Multiple hospitalizations (2 or more) in the past 12 months|73
347|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|73
348|4 - Taking five or more medications|4 - Taking five or more medications|73
349|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|73
350|6 - Other|6 - Other|73
351|7 - None of the above|7 - None of the above|73
352|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond tho|73
353|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable without heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable wi|73
354|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious complications and death.|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious compl|73
355|3 - The patient has serious progressive conditions that could lead to death within a year.|3 - The patient has serious progressive conditions that could lead to death within a year.|73
356|UK - The patient+s situation is unknown or unclear.|UK - The patient+s situation is unknown or unclear.|73
357|1 - Yes [ Go to M1050 ]|1 - Yes [ Go to M1050 ]|73
358|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this influenza season. [ Go to M1050 ]|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this i|73
359|1 - Received from another health care provider (e.g., physician)|1 - Received from another health care provider (e.g., physician)|73
360|2 - Received from your agency previously during this year+s flu season|2 - Received from your agency previously during this year+s flu season|73
361|3 - Offered and declined|3 - Offered and declined|73
362|4 - Assessed and determined to have medical contraindication(s)|4 - Assessed and determined to have medical contraindication(s)|73
363|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|73
364|6 - Inability to obtain vaccine due to declared shortage|6 - Inability to obtain vaccine due to declared shortage|73
365|1 - Yes [ Go to M2005 at TRN; Go to M1230 at DC ]|1 - Yes [ Go to M2005 at TRN; Go to M1230 at DC ]|73
366|1 - Patient has received PPV in the past|1 - Patient has received PPV in the past|73
367|2 - Offered and declined|2 - Offered and declined|73
368|3 - Assessed and determined to have medical contraindication(s)|3 - Assessed and determined to have medical contraindication(s)|73
369|4 - Not indicated; patient does not meet age/condition guidelines for PPV|4 - Not indicated; patient does not meet age/condition guidelines for PPV|73
370|5 - None of the above|5 - None of the above|73
371|0 - Adequate: hears normal conversation without difficulty.|0 - Adequate: hears normal conversation without difficulty.|73
372|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to increase volume or speak distinctly.|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to in|73
373|2 - Severely Impaired: absence of useful hearing.|2 - Severely Impaired: absence of useful hearing.|73
374|UK - Unable to assess hearing.|UK - Unable to assess hearing.|73
375|0 - Understands: clear comprehension without cues or repetitions.|0 - Understands: clear comprehension without cues or repetitions.|73
376|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Requires cues at times to understand.|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Req|73
377|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequently requires cues to understand.|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequentl|73
378|3 - Rarely/Never Understands|3 - Rarely/Never Understands|73
379|UK - Unable to assess understanding.|UK - Unable to assess understanding.|73
380|0 - No standardized assessment conducted|0 - No standardized assessment conducted|73
381|1 - Yes, and it does not indicate severe pain|1 - Yes, and it does not indicate severe pain|73
382|2 - Yes, and it indicates severe pain|2 - Yes, and it indicates severe pain|73
383|0 - Patient has no pain|0 - Patient has no pain|73
384|1 - Patient has pain that does not interfere with activity or movement|1 - Patient has pain that does not interfere with activity or movement|73
385|2 - Less often than daily|2 - Less often than daily|73
386|3 - Daily, but not constantly|3 - Daily, but not constantly|73
387|4 - All of the time|4 - All of the time|73
388|0 - No assessment conducted [ Go to M1306 ]|0 - No assessment conducted [ Go to M1306 ]|73
389|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc., without use of standardized tool|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc.,|73
390|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|73
391|0 - No [ Go to M1322]|0 - No [ Go to M1322]|73
392|0 v Newly epithelialized|0 v Newly epithelialized|73
393|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|73
394|2 - Yes, patient has observable stasis ulcers ONLY|2 - Yes, patient has observable stasis ulcers ONLY|73
395|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable dressing) [Go to M1340]|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable|73
396|0 - No [ Go to M1400 ]|0 - No [ Go to M1400 ]|73
397|1 - Yes, patient has at least one (observable) surgical wound|1 - Yes, patient has at least one (observable) surgical wound|73
398|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1350 ]|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1350 ]|73
399|0 - Patient is not short of breath|0 - Patient is not short of breath|73
400|3 - Continuous Bi-level positive airway pressure|3 - Continuous Bi-level positive airway pressure|73
401|0 - No [ Go to M1732 at TRN; Go to M1600 at DC ]|0 - No [ Go to M1732 at TRN; Go to M1600 at DC ]|73
402|2 - Not assessed [Go to M1732 at TRN; Go to M1600 at DC ]|2 - Not assessed [Go to M1732 at TRN; Go to M1600 at DC ]|73
403|NA - Patient does not have diagnosis of heart failure [Go to M2005 at TRN; Go to M1600 at DC]|NA - Patient does not have diagnosis of heart failure [Go to M2005 at TRN; Go to M1600 at DC]|73
404|0 - No action taken|0 - No action taken|73
405|1 - Patient+s physician (or other primary care practitioner) contacted the same day|1 - Patient+s physician (or other primary care practitioner) contacted the same day|73
406|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|73
407|3 - Implement physician-ordered patient-specific established parameters for treatment|3 - Implement physician-ordered patient-specific established parameters for treatment|73
408|4 - Patient education or other clinical interventions|4 - Patient education or other clinical interventions|73
409|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequency, telehealth, etc.)|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequ|73
410|1 - Occasional stress incontinence|1 - Occasional stress incontinence|73
411|2 - During the night only|2 - During the night only|73
412|3 - During the day only|3 - During the day only|73
413|4 - During the day and night|4 - During the day and night|73
414|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|73
415|0 - Able to manage toileting hygiene and clothing management without assistance.|0 - Able to manage toileting hygiene and clothing management without assistance.|73
416|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implements are laid out for the patient.|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implemen|73
417|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|73
418|3 - Patient depends entirely upon another person to maintain toileting hygiene.|3 - Patient depends entirely upon another person to maintain toileting hygiene.|73
419|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independent|73
420|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface|73
421|0 - No multi-factor falls risk assessment conducted.|0 - No multi-factor falls risk assessment conducted.|73
422|1 - Yes, and it does not indicate a risk for falls.|1 - Yes, and it does not indicate a risk for falls.|73
423|2 - Yes, and it indicates a risk for falls.|2 - Yes, and it indicates a risk for falls.|73
424|0 - Not assessed/reviewed [ Go to M2010 ]|0 - Not assessed/reviewed [ Go to M2010 ]|73
425|No - No issues found during review [ Go to M2010 ]|No - No issues found during review [ Go to M2010 ]|73
426|Yes - Issues found during review|Yes - Issues found during review|73
427|NA - Patient is not taking any medications [ Go to M2102 ]|NA - Patient is not taking any medications [ Go to M2102 ]|73
428|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special precautions associated with all high-risk medications|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special p|73
429|NA - Patient not taking any drugs|NA - Patient not taking any drugs|73
430|2 - Able to take medication(s) at the correct times if given reminders by another person at the appropriate times|2 - Able to take medication(s) at the correct times if given reminders by another person at the appr|73
431|3 - Unable to take medication unless administered by another person.|3 - Unable to take medication unless administered by another person.|73
432|1 - At least daily|1 - At least daily|73
433|2 - Three or more times per week|2 - Three or more times per week|73
434|3 - One to two times per week|3 - One to two times per week|73
435|4 - Received, but less often than weekly|4 - Received, but less often than weekly|73
436|5 - No assistance received|5 - No assistance received|73
437|0 - No [Go to M2401]|0 - No [Go to M2401]|73
438|1 - Yes, used hospital emergency department WITHOUT hospital admission|1 - Yes, used hospital emergency department WITHOUT hospital admission|73
439|2 - Yes, used hospital emergency department WITH hospital admission|2 - Yes, used hospital emergency department WITH hospital admission|73
440|UK - Unknown [Go to M2401]|UK - Unknown [Go to M2401]|73
441|2 - Injury caused by fall|2 - Injury caused by fall|73
442|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|73
443|4 - Other respiratory problem|4 - Other respiratory problem|73
444|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|73
445|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|73
446|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|73
447|8 - Other heart disease|8 - Other heart disease|73
448|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|73
449|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|73
450|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|73
451|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|73
452|13 - Urinary tract infection|13 - Urinary tract infection|73
453|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|73
454|15 - Wound infection or deterioration|15 - Wound infection or deterioration|73
455|16 - Uncontrolled pain|16 - Uncontrolled pain|73
456|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|73
457|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|73
458|19 - Other than above reasons|19 - Other than above reasons|73
459|2 - Patient remained in the community (with formal assistive services)|2 - Patient remained in the community (with formal assistive services)|73
460|3 - Patient transferred to a noninstitutional hospice|3 - Patient transferred to a noninstitutional hospice|73
461|4 - Unknown because patient moved to a geographic location not served by this agency|4 - Unknown because patient moved to a geographic location not served by this agency|73
462|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|73
463|4 - Other respiratory problem|4 - Other respiratory problem|73
464|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|73
465|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|73
466|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|73
467|8 - Other heart disease|8 - Other heart disease|73
468|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|73
469|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|73
470|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|73
471|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|73
472|13 - Urinary tract infection|13 - Urinary tract infection|73
473|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|73
474|15 - Wound infection or deterioration|15 - Wound infection or deterioration|73
475|16 - Uncontrolled pain|16 - Uncontrolled pain|73
476|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|73
477|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|73
478|19 - Scheduled treatment or procedure|19 - Scheduled treatment or procedure|73
479|20 - Other than above reasons|20 - Other than above reasons|73
480|UK - Reason unknown [Go to M0903]|UK - Reason unknown [Go to M0903]|73
482|01 - Patient lives alone around the clock|01 - Patient lives alone around the clock|73
483|02 - Patient lives alone regular daytime|02 - Patient lives alone regular daytime|73
484|03 - Patient lives alone regular nighttime|03 - Patient lives alone regular nighttime|73
485|04 - Patient lives alone occassional/short term assistance|04 - Patient lives alone occassional/short term assistance|73
486|05 - Patient lives alone no assisstance available|05 - Patient lives alone no assisstance available|73
487|06 - Patient lives with other person(s) in the home around the clock|06 - Patient lives with other person(s) in the home around the clock|73
488|07 - Patient lives with other person(s) in the home regular daytime|07 - Patient lives with other person(s) in the home regular daytime|73
489|08 - Patient lives with other person(s) in the home regular nighttime|08 - Patient lives with other person(s) in the home regular nighttime|73
490|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|73
491|10 - Patient lives with other person(s) in the home no assistance available|10 - Patient lives with other person(s) in the home no assistance available|73
492|1 - Was present at the most recent SOC/ROC assessment|1 - Was present at the most recent SOC/ROC assessment|73
493|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|73
494|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|73
495|0 - Newly epithelialized|0 - Newly epithelialized|73
496|0 - No [ Go to M1340 ]|0 - No [ Go to M1340 ]|73
498|0 - Independent|0 - Independent|73
499|1 - Needed Some Help|1 - Needed Some Help|73
500|2 - Dependent|2 - Dependent|73
502|0 - No assistance needed in this area|0 - No assistance needed in this area|73
503|1 - Caregiver(s) currently provide assistance|1 - Caregiver(s) currently provide assistance|73
504|2 - Caregiver(s) need training/ supportive services to provide assistance|2 - Caregiver(s) need training/ supportive services to provide assistance|73
505|3 - Caregiver(s) not likely to provide assistance|3 - Caregiver(s) not likely to provide assistance|73
506|4 - Unclear if Caregiver(s) will provide assistance|4 - Unclear if Caregiver(s) will provide assistance|73
507|5 - Assistance needed, but no Caregiver(s) available|5 - Assistance needed, but no Caregiver(s) available|73
508|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will use standardized clinical guidelines accessible for all care providers to reference|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will|73
509|NA - Patient is not diabetic or is bilateral amputee|NA - Patient is not diabetic or is bilateral amputee|73
510|NA - Patient is not assessed to be at risk for falls|NA - Patient is not assessed to be at risk for falls|73
511|NA - Patient has no diagnosis or symptoms of depression|NA - Patient has no diagnosis or symptoms of depression|73
512|NA - No pain identified|NA - No pain identified|73
513|NA - Patient is not assessed to be at risk for pressure ulcers|NA - Patient is not assessed to be at risk for pressure ulcers|73
514|NA - Patient has no pressure ulcers with need for moist wound healing|NA - Patient has no pressure ulcers with need for moist wound healing|73
515|1 - Long-term nursing facility (NF)|1 - Long-term nursing facility (NF)|73
516|2 - Skilled nursing facility (SNF / TCU)|2 - Skilled nursing facility (SNF / TCU)|73
517|3 - Short stay acute hospital (IPP S)|3 - Short stay acute hospital (IPP S)|73
518|4 - Long-term care hospital (LTCH)|4 - Long-term care hospital (LTCH)|73
519|5 - Inpatient rehabilitation hospital or unit (IRF)|5 - Inpatient rehabilitation hospital or unit (IRF)|73
520|6 - Psychiatric hospital or unit|6 - Psychiatric hospital or unit|73
521|7 - Other|7 - Other|73
522|NA - Patient was not discharged from an inpatient facility [Go to M1017]|NA - Patient was not discharged from an inpatient facility [Go to M1017]|73
523|6 - Unable to participate effectively in bathing and is bathed totally by another person|6 - Unable to participate effectively in bathing and is bathed totally by another person|73
524|4 - Chairfast, unable to ambulate but is able to wheel self independently.|4 - Chairfast, unable to ambulate but is able to wheel self independently.|73
525|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask patient: "Over the last two weeks, how often have you been bothered by any of the following problems")  *Copyright+ Pfizer Inc. All rights reserved. Reproduced with permission.|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask|73
526|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluation for depression.|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluat|73
527|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet criteria for further evaluation for depression.|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet|73
528|0 - Not at all  0 - 1 day|0 - Not at all  0 - 1 day|73
529|1 - Several days  2 - 6 days|1 - Several days  2 - 6 days|73
530|2 - More than half of the days  7 - 11 days|2 - More than half of the days  7 - 11 days|73
531|3 - Nearly every day  12 - 14 days|3 - Nearly every day  12 - 14 days|73
532|NA - N/A  Unable to respond|NA - N/A  Unable to respond|73
533|2 - Able to take medication(s) at the correct times if given reminders by another person based on the frequency of the injection|2 - Able to take medication(s) at the correct times if given reminders by another person based on th|73
534|3 - Unable to take injectable medication unless administered by another person.|3 - Unable to take injectable medication unless administered by another person.|73
540|11 - Patient lives in congregate situation (e.g., assisted living) around the clock|11 - Patient lives in congregate situation (e.g., assisted living) around the clock|73
541|12 - Patient lives in congregate situation (e.g., assisted living) regular daytime|12 - Patient lives in congregate situation (e.g., assisted living) regular daytime|73
542|13 - Patient lives in congregate situation (e.g., assisted living) regular nighttime|13 - Patient lives in congregate situation (e.g., assisted living) regular nighttime|73
543|14 - Patient lives in congregate situation (e.g., assisted living) occasional / short-term assistance|14 - Patient lives in congregate situation (e.g., assisted living) occasional / short-term assistanc|73
544|15 - Patient lives in congregate situation (e.g., assisted living) no available assistance|15 - Patient lives in congregate situation (e.g., assisted living) no available assistance|73
546|NA - No observable pressure ulcer|NA - No observable pressure ulcer|73
583|NA - No specific SOC date ordered by physician|NA - No specific SOC date ordered by physician|73
586|UK - Inpatient Discharge Date Unknown|UK - Inpatient Discharge Date Unknown|73
601|1 - History of falls (2 or more falls - or any fall with an injury - in the past 12 months) |1 - History of falls (2 or more falls - or any fall with an injury - in the past 12 months) |73
603|2 - Unintentional weight loss of a total of 10 pounds or more in the past 12 months |2 - Unintentional weight loss of a total of 10 pounds or more in the past 12 months |73
605|3 - Multiple hospitalizations (2 or more) in the past 6 months|3 - Multiple hospitalizations (2 or more) in the past 6 months|73
607|4 - Multiple emergency department visits (2 or more) in the past 6 months|4 - Multiple emergency department visits (2 or more) in the past 6 months|73
609|5 - Decline in mental emotional or behavioral status in the past 3 months |5 - Decline in mental emotional or behavioral status in the past 3 months |73
611|6 - Reported or observed history of difficulty complying with any medical instructions (for example,medications, diet, exercise) in the past 3 months|6 - Reported or observed history of difficulty complying with any medical instructions (for example |73
613|7 - Currently taking 5 or more medications|7 - Currently taking 5 or more medications|73
615|8 - Currently reports exhaustion|8 - Currently reports exhaustion|73
617|9 - Other risk(s) not listed in 1 - 8|9 - Other risk(s) not listed in 1 - 8|73
619|10 - None of the above |10 - None of the above |73
632|0 - No assistance needed v patient is independent or does not have needs in this area|0 - No assistance needed v patient is independent or does not have needs in this area|73
633|1 - Non-agency caregiver(s) currently provide assistance |1 - Non-agency caregiver(s) currently provide assistance |73
634|2 - Non-agency caregiver(s) need training/ supportive services to provide assistance|2 - Non-agency caregiver(s) need training/ supportive services to provide assistance|73
635|3 - Non-agency caregiver(s) are not likely to provide assistance OR it is unclear if they will provide assistance|3 - Non-agency caregiver(s) are not likely to provide assistance OR unclear if will provide asst|73
636|4 - Assistance needed but no non-agency caregiver(s) available|4 - Assistance needed but no non-agency caregiver(s) available|73
2|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; OR (b) Is physically, cognitively, and mentally able to prepare light meals on a regular basis but has not routinely performed light meal preparation in the past (i.e., prior to this home care admission).|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; O|74
3|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and mentally able to perform all housekeeping tasks .|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and menta|74
4|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and mentally able to do laundry and access facilities.|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and menta|74
5|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying packages OR b) Physically, cognitively, and mentally able to take care of shopping, but has not done shopping in the past (i.e., prior to this home care admission).|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying|74
6|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|74
7|0 - Able to dial numbers and answer calls appropriately and as desired.|0 - Able to dial numbers and answer calls appropriately and as desired.|74
8|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body without assistance.|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body|74
9|0 - Able to get to and from the toilet and transfer independently with or without a device.|0 - Able to get to and from the toilet and transfer independently with or without a device.|74
10|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|74
539|06 - Independent - Patient completes the activity by him/herself with no assistance from a helper.|06 - Independent - Patient completes the activity by him/herself with no assistance from a helper.|74
540|05 - Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity.|05 - Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper|74
541|04 - Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently.|04 - Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/|74
542|03 - Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort.|03 - Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or sup|74
543|02 - Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.|02 - Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds t|74
544|01 - Dependent - Helper does ALL of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity.|01 - Dependent - Helper does ALL of the effort. Patient does none of the effort to complete the acti|74
545|07 - Patient refused|07 - Patient refused|74
546|09 - Not applicable - Not attempted and the patient did not perform this activity prior to the current illness,exacerbation or injury.|09 - Not applicable - Not attempted and the patient did not perform this activity prior to the curre|74
547|10 - Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)|10 - Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)|74
548|88 - Not attempted due to medical conditions or safety concerns|88 - Not attempted due to medical conditions or safety concerns|74
549|0 - No [STOP]|0 - No [STOP]|74
550|0 - No [STOP]|0 - No [Skip GG0170R]|74
551|1 - Yes [Continue to GG0170R, Wheel 50 feet with two turns.]|1 - Yes [Continue to GG0170R, Wheel 50 feet with two turns.]|74
552|1 - Manual|1 - Manual|74
553|2 - Motorized|2 - Motorized|74
554|0 - No [Skip to J1800 Any falls since SOC/ROC, whichever is more recent.]|0 - No [Skip to J1800 Any falls since SOC/ROC, whichever is more recent.]|74
555|0 - No [STOP]|0 - No [STOP]|74
556|1 - Yes [Continue to J1900, Number of Falls Since SOC/ROC, whichever is more recent]|1 - Yes [Continue to J1900, Number of Falls Since SOC/ROC, whichever is more recent]|74
557|0 - None|0 - None|74
558|1 - One|1 - One|74
559|2 - Two or More|2 - Two or More|74
560|3 - Independent - Patient completed the activities by him/herself, with or without an assistive device, with no assistance from a helper.|3 - Independent - Patient completed the activities by him/herself, with or without an assistive devi|74
561|2 - Needed Some Help - Patient needed partial assistance from another person to complete activities.|2 - Needed Some Help - Patient needed partial assistance from another person to complete activities.|74
562|1 - Dependent - A helper completed the activities for the patient.|1 - Dependent - A helper completed the activities for the patient.|74
563|8 - Unknown|8 - Unknown|74
564|9 - Not Applicable|9 - Not Applicable|74
565|A - Manual wheelchair|A - Manual wheelchair|74
566|B - Motorized wheelchair and/or scooter|B - Motorized wheelchair and/or scooter|74
567|C - Mechanical lift|C - Mechanical lift|74
568|D - Walker|D - Walker|74
569|E - Orthotics/Prosthetics|E - Orthotics/Prosthetics|74
570|Z - None of the above|Z - None of the above|74
11|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible public bus.|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible p|74
12|0 - Able to independently feed self.|0 - Able to independently feed self.|74
13|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|74
14|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct times.|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct ti|74
15|0 - Able to independently transfer.|0 - Able to independently transfer.|74
16|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without rail|74
17|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings|74
18|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|74
19|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions independently.|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions indep|74
20|0 - Asymptomatic, no treatment needed at this time|0 - Asymptomatic, no treatment needed at this time|74
21|0 - Caregiver manages all tasks related to equipment completely independently.|0 - Caregiver manages all tasks related to equipment completely independently.|74
22|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations with no observable impairment.|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations w|74
23|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|74
24|0 - Life expectancy is greater than 6 months|0 - Life expectancy is greater than 6 months|74
25|0 - Never|0 - Never|74
26|0 - Patient is not short of breath|0 - Patient is not short of breath|74
27|0 - No|0 - No|74
28|0 - No emergent care services|0 - No emergent care services|74
29|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [Goto M1620]|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [Goto M1620]|74
30|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and extended or abstract conversation.|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and exte|74
31|0 - No one person|0 - No one person|74
32|0 - None of the time|0 - None of the time|74
33|0 - None, no charge for current services|0 - None, no charge for current services|74
34|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|74
35|0 - Patient does NOT have an ostomy for bowel elimination.|0 - Patient does NOT have an ostomy for bowel elimination.|74
36|0 - Patient has no pain|0 - Patient has no pain|74
37|0 - Patient manages all tasks related to equipment completely independently.|0 - Patient manages all tasks related to equipment completely independently.|74
38|0 - Poor:  little or no recovery is expected and/or further decline is imminent|0 - Poor:  little or no recovery is expected and/or further decline is imminent|74
39|0 - Timed-voiding defers incontinence|0 - Timed-voiding defers incontinence|74
40|0 - Very rarely or never has bowel incontinence|0 - Very rarely or never has bowel incontinence|74
41|0 - Zero|0 - Zero|74
42|00 - No|00 - No|74
43|01 - Yes|01 - Yes|74
44|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or mental limitations, needs assistance with heavy laundry.|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or|74
45|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the patient.|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the|74
46|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|74
47|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or supervision from another person OR c) a liquid, pureed or ground meat diet.|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or su|74
48|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|74
49|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|74
50|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independently.|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independe|74
51|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only when assisted or accompanied by another person.|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only w|74
52|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepa|74
53|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance by another person OR b) given daily reminders.|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance b|74
54|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advan|74
55|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advan|74
56|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for the deaf) and call essential numbers.|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for t|74
57|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|74
58|1 - American Indian or Alaska Native|1 - American Indian or Alaska Native|74
59|1 - Depressed mood (e.g., feeling sad, tearful)|1 - Depressed mood (e.g., feeling sad, tearful)|74
60|1 - During the night only|1 - During the night only|74
61|1 - Fully granulating|1 - Fully granulating|74
62|1 - Good/Fair:  partial to full recovery is expected|1 - Good/Fair:  partial to full recovery is expected|74
63|1 - Good:  marked improvement in functional status is expected|1 - Good:  marked improvement in functional status is expected|74
64|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|74
65|1 - Smoking|1 - Smoking|74
66|1 - Hospital|1 - Hospital|74
67|1 - Hospital emergency room (includes 23-hour holding)|1 - Hospital emergency room (includes 23-hour holding)|74
68|1 - Hospitalization for EMERGENT (unscheduled) care|1 - Hospitalization for EMERGENT (unscheduled) care|74
69|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepared solutions), patient is able to manage all other aspects of equipment.|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepar|74
70|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|74
71|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|74
72|1 - In new or complex situations only|1 - In new or complex situations only|74
73|1 - Intravenous or infusion therapy (excludes TPN)|1 - Intravenous or infusion therapy (excludes TPN)|74
74|1 - Less often than daily|1 - Less often than daily|74
75|1 - Less than once a month|1 - Less than once a month|74
76|1 - Less than once weekly|1 - Less than once weekly|74
77|1 - Life expectancy is 6 months or fewer|1 - Life expectancy is 6 months or fewer|74
78|1 - Lives alone|1 - Lives alone|74
79|1 - Male|1 - Male|74
80|1 - Medicare (traditional fee-for-service)|1 - Medicare (traditional fee-for-service)|74
81|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of past 24 hours, significant memory loss so that supervision is required|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of pas|74
82|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors in word choice, grammar or speech intelligibility, needs minimal prompting or assistance).|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors i|74
83|1 - No assistance or services received|1 - No assistance or services received|74
84|1 - One|1 - One|74
85|1 - Oxygen (intermittent or continuous)|1 - Oxygen (intermittent or continuous)|74
86|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, and the surrounding layout, can count fingers at arm's length.|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, a|74
87|1 - Patient is incontinent|1 - Patient is incontinent|74
88|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|74
89|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical or treatment regimen.|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical|74
90|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient/couple/significant other)|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient|74
91|1 - Relatives, friends, or neighbors living outside the home|1 - Relatives, friends, or neighbors living outside the home|74
92|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions.|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions|74
93|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independentl|74
94|1 - Several times during day and night|1 - Several times during day and night|74
95|1 - Spouse or significant other|1 - Spouse or significant other|74
96|1 - Stage 1|1 - Stage 1|74
97|1 - Start of care - further visits planned|1 - Start of care - further visits planned|74
98|1 - Symptoms well controlled with current therapy|1 - Symptoms well controlled with current therapy|74
99|1 - Therapy services|1 - Therapy services|74
100|1 - Able to transfer with minimal human assistance or with use of an assistive device.|1 - Able to transfer with minimal human assistance or with use of an assistive device.|74
101|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitations.|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitatio|74
102|1 - Urinary incontinence|1 - Urinary incontinence|74
103|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and transfer.|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and|74
104|1 - When walking more than 20 feet, climbing stairs|1 - When walking more than 20 feet, climbing stairs|74
105|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary conversation. May need occasional repetition, extra time, or louder voice.|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary c|74
106|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting in and out of tub/shower|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting|74
107|1 - Yes|1 - Yes|74
108|1-RN|1-RN|74
109|10 - Discharge from agency - no visits completed after start/resumption of care assessment|10 - Discharge from agency - no visits completed after start/resumption of care assessment|74
110|10 - Scheduled surgical procedure|10 - Scheduled surgical procedure|74
111|10 - Self-pay|10 - Self-pay|74
112|11 - Other|11 - Other|74
113|11 - Urinary tract infection|11 - Urinary tract infection|74
114|12 - IV catheter-related infection|12 - IV catheter-related infection|74
115|13 - Deep vein thrombosis, pulmonary embolus|13 - Deep vein thrombosis, pulmonary embolus|74
116|14 - Uncontrolled pain|14 - Uncontrolled pain|74
117|15 - Psychotic episode|15 - Psychotic episode|74
118|16 - Other than above reasons|16 - Other than above reasons|74
119|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing calls.|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing|74
120|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another person.|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another pers|74
121|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface a|74
122|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for intermittent supervision or encouragement or reminders, OR (b) to get in and out of the shower or tub, OR (c) for washing difficult to reach areas.|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for inter|74
123|2 - Asian|2 - Asian|74
124|2 - Caregiver requires considerable assistance from another person to manage equipment, but independently completes significant portions of task.|2 - Caregiver requires considerable assistance from another person to manage equipment, but independ|74
125|2 - Daily, but not constantly|2 - Daily, but not constantly|74
126|2 - Daughter or son|2 - Daughter or son|74
127|2 - Doctor's office emergency visit/house call|2 - Doctor's office emergency visit/house call|74
128|2 - During the day and night|2 - During the day and night|74
129|2 - Early/partial granulation|2 - Early/partial granulation|74
130|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors in word choice, organization or speech intelligibility). Speaks in phrases or short sentences.|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors|74
131|2 - Family member's residence|2 - Family member's residence|74
132|2 - Female|2 - Female|74
133|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conversation, needs frequent prompting or assistance.|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conver|74
134|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|74
135|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|74
136|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately stop activities, jeopardizes safety through actions|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately st|74
137|2 - Indwelling/suprapubic catheter|2 - Indwelling/suprapubic catheter|74
138|2 - Injury caused by fall or accident at home|2 - Injury caused by fall or accident at home|74
139|2 - Medicare (HMO/managed care/Advantage plan)|2 - Medicare (HMO/managed care/Advantage plan)|74
140|2 - Nausea, dehydration, malnutrition, constipation, impaction|2 - Nausea, dehydration, malnutrition, constipation, impaction|74
141|2 - Obesity|2 - Obesity|74
142|2 - On awakening or at night only|2 - On awakening or at night only|74
143|2 - Once a month|2 - Once a month|74
144|2 - One to three times weekly|2 - One to three times weekly|74
145|2 - Parenteral nutrition (TPN or lipids)|2 - Parenteral nutrition (TPN or lipids)|74
146|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic) [ Go to M1620 ]|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic) [ Go|74
147|2 - Patient requires considerable assistance from another person to manage equipment, but independently completes portions of the task.|2 - Patient requires considerable assistance from another person to manage equipment, but independen|74
148|2 - Patient transferred to a noninstitutional hospice|2 - Patient transferred to a noninstitutional hospice|74
149|2 - Person residing in the home (EXCLUDING paid help)|2 - Person residing in the home (EXCLUDING paid help)|74
150|2 - Rehabilitation facility|2 - Rehabilitation facility|74
151|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifting of attention) or consistently requires low stimulus environment due to distractibility.|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifti|74
152|2 - Respite care|2 - Respite care|74
153|2 - Sense of failure or self reproach|2 - Sense of failure or self reproach|74
154|2 - Several times during day|2 - Several times during day|74
155|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonresponsive.|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonrespons|74
156|2 - Someone must assist the patient to groom self.|2 - Someone must assist the patient to groom self.|74
157|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|74
158|2 - Someone must help the patient put on upper body clothing.|2 - Someone must help the patient put on upper body clothing.|74
159|2 - Stage 2|2 - Stage 2|74
160|2 - Start of care - no further visits planned|2 - Start of care - no further visits planned|74
161|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitoring|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitori|74
162|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment regimen.|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment re|74
163|2 - Two|2 - Two|74
164|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistance due to cognitive or mental limitation.|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistanc|74
165|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|74
166|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assistance).|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assis|74
167|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home delivery.|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home deli|74
168|2 - Unable to prepare any light meals or reheat any delivered meals.|2 - Unable to prepare any light meals or reheat any delivered meals.|74
169|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|74
170|2 - UNABLE to take injectable medications unless administered by someone else.|2 - UNABLE to take injectable medications unless administered by someone else.|74
171|2 - UNABLE to take medication unless administered by someone else.|2 - UNABLE to take medication unless administered by someone else.|74
172|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|74
173|2 - Ventilator (continually or at night)|2 - Ventilator (continually or at night)|74
174|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less than 20 feet)|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less th|74
175|2 - With spouse or significant other|2 - With spouse or significant other|74
176|2 - Yes, assistance or services provided by family or friends|2 - Yes, assistance or services provided by family or friends|74
177|2-PT|2-PT|74
178|3 - Able to answer the telephone only some of the time or is able to carry on only a limited conversation.|3 - Able to answer the telephone only some of the time or is able to carry on only a limited convers|74
179|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube or gastrostomy.|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube|74
180|3 - Alcohol dependency|3 - Alcohol dependency|74
181|3 - All of the time|3 - All of the time|74
182|3 - Black or African-American|3 - Black or African-American|74
183|3 - Boarding home or rented room|3 - Boarding home or rented room|74
184|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment, clean/store/dispose of equipment or supplies).|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment,|74
185|3 -Able to walk only with the supervision or assistance of another person at all times.|3 -Able to walk only with the supervision or assistance of another person at all times.|74
186|3 - Continuous / Bi-level positive airway pressure|3 - Continuous / Bi-level positive airway pressure|74
187|3 - During the day and evening, but not constantly|3 - During the day and evening, but not constantly|74
188|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the alimentary canal)|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the|74
189|3 - Environmental support (e.g., housing, home maintenance)|3 - Environmental support (e.g., housing, home maintenance)|74
190|3 - Four to six times weekly|3 - Four to six times weekly|74
191|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessing by listener.  Speech limited to single words or short phrases.|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessin|74
192|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires multiple repetitions, restatements, demonstrations, additional time.|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires m|74
193|3 - Hopelessness|3 - Hopelessness|74
194|3 - Hospice care|3 - Hospice care|74
195|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|74
196|3 - Injury caused by fall or accident at home|3 - Injury caused by fall or accident at home|74
197|3 - Intractable pain|3 - Intractable pain|74
198|3 - Medicaid (traditional fee-for-service)|3 - Medicaid (traditional fee-for-service)|74
199|3 - Needs someone to do all shopping and errands.|3 - Needs someone to do all shopping and errands.|74
200|3 - Not healing|3 - Not healing|74
201|3 - Nursing home|3 - Nursing home|74
202|3 - Once daily|3 - Once daily|74
203|3 - Other family member|3 - Other family member|74
204|3 - Outpatient department/clinic emergency (includes urgicenter sites)|3 - Outpatient department/clinic emergency (includes urgicenter sites)|74
205|3 - Paid help|3 - Paid help|74
206|3 - Able to participate in bathing self in shower or tub, but requires presence of another person throughout the bath for assistance or supervision.|3 - Able to participate in bathing self in shower or tub, but requires presence of another person th|74
207|3 - Patient depends entirely upon another person to dress lower body.|3 - Patient depends entirely upon another person to dress lower body.|74
208|3 - Patient depends entirely upon another person to dress the upper body.|3 - Patient depends entirely upon another person to dress the upper body.|74
209|3 - Patient depends entirely upon someone else for grooming needs.|3 - Patient depends entirely upon someone else for grooming needs.|74
210|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone else to manage the equipment.|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone|74
211|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable to shift attention and recall directions more than half the time.|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable|74
212|3 - Respiratory problems (SOB, infection, obstruction)|3 - Respiratory problems (SOB, infection, obstruction)|74
213|3 - Resumption of care (after inpatient stay)|3 - Resumption of care (after inpatient stay)|74
214|3 - Several times each month|3 - Several times each month|74
215|3 - Skilled Nursing Facility|3 - Skilled Nursing Facility|74
216|3 - Stage 3|3 - Stage 3|74
217|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|74
218|3 - Three|3 - Three|74
219|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person throughout the process.|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person through|74
220|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal independently.|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal indep|74
221|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person.|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person|74
222|3 - Unknown because patient moved to a geographic location not served by this agency|3 - Unknown because patient moved to a geographic location not served by this agency|74
223|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|74
224|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|74
225|3 - With other family member|3 - With other family member|74
226|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home health services, homemaker assistance, transportation assistance, assisted living, board and care)|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home h|74
227|3-SLP/ST|3-SLP/ST|74
228|4 - At rest (during day or night)|4 - At rest (during day or night)|74
229|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|74
230|4 - Board and care or assisted living facility|4 - Board and care or assisted living facility|74
231|4 - Caregiver is completely dependent on someone else to manage all equipment.|4 - Caregiver is completely dependent on someone else to manage all equipment.|74
232|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|74
233|4 - Constantly|4 - Constantly|74
234|4 - Drug dependency|4 - Drug dependency|74
235|4 - Four or more|4 - Four or more|74
236|4 - Friend or neighbor or community or church member|4 - Friend or neighbor or community or church member|74
237|4 - Hispanic or Latino|4 - Hispanic or Latino|74
238|4 - Hospice|4 - Hospice|74
239|4 - Impaired decision-making|4 - Impaired decision-making|74
240|4 - Is totally dependent in toileting.|4 - Is totally dependent in toileting.|74
241|4 - Medicaid (HMO/managed care)|4 - Medicaid (HMO/managed care)|74
242|4 - None of the above|4 - None of the above|74
243|4 - Nursing home|4 - Nursing home|74
244|4 - On a daily basis|4 - On a daily basis|74
245|4 - Patient is completely dependent on someone else to manage all equipment.|4 - Patient is completely dependent on someone else to manage all equipment.|74
246|4 - Permanent placement|4 - Permanent placement|74
247|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, punches, dangerous maneuvers w/ wheelchair or other objects)|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, pu|74
248|4 - Psychosocial support (e.g., socialization, companionship, recreation)|4 - Psychosocial support (e.g., socialization, companionship, recreation)|74
249|4 - Recertification (follow-up) reassessment|4 - Recertification (follow-up) reassessment|74
250|4 - Recurrent thoughts of death|4 - Recurrent thoughts of death|74
251|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruction)|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruc|74
252|4 - Several times a week|4 - Several times a week|74
253|4 - Stage 4|4 - Stage 4|74
254|4 - Symptoms poorly controlled, history of re-hospitalizations|4 - Symptoms poorly controlled, history of re-hospitalizations|74
255|4 - Three or more times per week|4 - Three or more times per week|74
256|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetative state, or delirium.|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetati|74
257|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|74
258|4 - Unable to effectively participate in any housekeeping tasks.|4 - Unable to effectively participate in any housekeeping tasks.|74
259|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or unresponsive (e.g., speech is nonsensical or unintelligible).|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or u|74
260|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonresponsive.|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonr|74
261|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostomy.|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostom|74
262|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of devices at the sink, in chair, or on commode|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of|74
263|4 - With a friend|4 - With a friend|74
264|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|74
265|4-OT|4-OT|74
266|5 - Advocates or facilitates patient's participation in appropriate medical care|5 - Advocates or facilitates patient's participation in appropriate medical care|74
267|5 - At least daily|5 - At least daily|74
268|6 - Bedfast, unable to ambulate or be up in a chair.|6 - Bedfast, unable to ambulate or be up in a chair.|74
269|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|74
270|5 - Disruptive or socially inappropriate behavior|5 - Disruptive or socially inappropriate behavior|74
271|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|74
272|5 - Hypo/Hyperglycemia, diabetes out of control|5 - Hypo/Hyperglycemia, diabetes out of control|74
273|5 - More often than once daily|5 - More often than once daily|74
274|5 - Native Hawaiian or Pacific Islander|5 - Native Hawaiian or Pacific Islander|74
275|5 - None of the above|5 - None of the above|74
276|5 - One to two times per week|5 - One to two times per week|74
277|5 - Other|5 - Other|74
278|5 - Other follow-up|5 - Other follow-up|74
279|5 - Paid help|5 - Paid help|74
280|5 - Patient nonresponsive or unable to speak.|5 - Patient nonresponsive or unable to speak.|74
281|5 - Thoughts of suicide|5 - Thoughts of suicide|74
282|5 - Totally unable to use the telephone.|5 - Totally unable to use the telephone.|74
283|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|74
284|5 - Unable to take in nutrients orally or by tube feeding.|5 - Unable to take in nutrients orally or by tube feeding.|74
285|5 - Unsafe for care at home|5 - Unsafe for care at home|74
286|5 - With paid help (other than home care agency staff)|5 - With paid help (other than home care agency staff)|74
287|5 - Workers' compensation|5 - Workers' compensation|74
288|5 - Wound infection, deteriorating wound status, new lesion/ulcer|5 - Wound infection, deteriorating wound status, new lesion/ulcer|74
289|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|74
290|6 - Delusional, hallucinatory, or paranoid behavior|6 - Delusional, hallucinatory, or paranoid behavior|74
291|6 - Financial agent, power of attorney, or conservator of finance|6 - Financial agent, power of attorney, or conservator of finance|74
292|6 - GI bleeding, obstruction|6 - GI bleeding, obstruction|74
293|6 - Less often than weekly|6 - Less often than weekly|74
294|6 - Memory loss to the extent that supervision required|6 - Memory loss to the extent that supervision required|74
295|6 - None of the above feelings observed or reported|6 - None of the above feelings observed or reported|74
296|6 - Other|6 - Other|74
297|6 - Title programs (e.g., Title III, V, or XX)|6 - Title programs (e.g., Title III, V, or XX)|74
298|6 - Transferred to an inpatient facility - patient not discharged from agency|6 - Transferred to an inpatient facility - patient not discharged from agency|74
299|6 - White|6 - White|74
300|6 - With other than above|6 - With other than above|74
301|7 - Exacerbation of CHF, fluid overload, heart failure|7 - Exacerbation of CHF, fluid overload, heart failure|74
302|7 - Health care agent, conservator of person, or medical power of attorney|7 - Health care agent, conservator of person, or medical power of attorney|74
303|7 - Hypo/Hyperglycemia, diabetes out of control|7 - Hypo/Hyperglycemia, diabetes out of control|74
304|7 - None of the above|7 - None of the above|74
305|7 - None of the above behaviors demonstrated|7 - None of the above behaviors demonstrated|74
306|7 - Other government (e.g., TriCare, VA, etc.)|7 - Other government (e.g., TriCare, VA, etc.)|74
307|7 - Transferred to an inpatient facility - patient discharged from agency|7 - Transferred to an inpatient facility - patient discharged from agency|74
308|8 - Death at home|8 - Death at home|74
309|8 - GI bleeding, obstruction|8 - GI bleeding, obstruction|74
310|8 - Myocardial infarction, stroke|8 - Myocardial infarction, stroke|74
311|8 - Private insurance|8 - Private insurance|74
312|9 - Chemotherapy|9 - Chemotherapy|74
313|9 - Discharge from agency|9 - Discharge from agency|74
314|9 - Other than above reasons|9 - Other than above reasons|74
315|9 - Private HMO/managed care|9 - Private HMO/managed care|74
316|NA - No caregiver|NA - No caregiver|74
317|NA - No equipment of this type used in care.|NA - No equipment of this type used in care.|74
318|NA - No inhalant/mist medications prescribed.|NA - No inhalant/mist medications prescribed.|74
319|NA - No injectable medications prescribed.|NA - No injectable medications prescribed.|74
320|NA - No inpatient facility admission|NA - No inpatient facility admission|74
321|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|74
322|NA - No Medicaid|NA - No Medicaid|74
323|NA - No Medicare|NA - No Medicare|74
324|NA - No observable pressure ulcer or unhealed pressure ulcer|NA - No observable pressure ulcer or unhealed pressure ulcer|74
325|NA - No observable stasis ulcer|NA - No observable stasis ulcer|74
326|NA - No observable surgical wound|NA - No observable surgical wound|74
327|NA - No oral medications prescribed.|NA - No oral medications prescribed.|74
328|NA - Not applicable|NA - Not applicable|74
329|NA - Patient does not have a telephone.|NA - Patient does not have a telephone.|74
330|NA - Patient has ostomy for bowel elimination|NA - Patient has ostomy for bowel elimination|74
331|NA - Patient nonresponsive|NA - Patient nonresponsive|74
332|NA - Patient on prophylactic treatment|NA - Patient on prophylactic treatment|74
333|NA - Patient was not discharged from an inpatient facility [Go to M1017]|NA - Patient was not discharged from an inpatient facility [Go to M1017]|74
334|UK - Other unknown|UK - Other unknown|74
335|UK - Reason unknown|UK - Reason unknown|74
336|UK - Unknown|UK - Unknown|74
337|UK - Unknown or Not Available|UK - Unknown or Not Available|74
341|01 - Early|01 - Early|74
342|02 - Late|02 - Late|74
343|NA - Not Applicable. No case mix group defined for this assessment.|NA - Not Applicable. No case mix group defined for this assessment.|74
344|NA - No case mix group defined by this assessment.|NA - No case mix group defined by this assessment.|74
345|1 - Recent decline in mental, emotional, or behavioral status|1 - Recent decline in mental, emotional, or behavioral status|74
346|2 - Multiple hospitalizations (2 or more) in the past 12 months|2 - Multiple hospitalizations (2 or more) in the past 12 months|74
347|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|74
348|4 - Taking five or more medications|4 - Taking five or more medications|74
349|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|74
350|6 - Other|6 - Other|74
351|7 - None of the above|7 - None of the above|74
352|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond tho|74
353|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable without heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable wi|74
354|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious complications and death.|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious compl|74
355|3 - The patient has serious progressive conditions that could lead to death within a year.|3 - The patient has serious progressive conditions that could lead to death within a year.|74
356|UK - The patient+s situation is unknown or unclear.|UK - The patient+s situation is unknown or unclear.|74
357|1 - Yes [ Go to M1050 ]|1 - Yes [ Go to M1050 ]|74
358|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this influenza season. [ Go to M1050 ]|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this i|74
359|1 - Received from another health care provider (e.g., physician)|1 - Received from another health care provider (e.g., physician)|74
360|2 - Received from your agency previously during this year+s flu season|2 - Received from your agency previously during this year+s flu season|74
361|3 - Offered and declined|3 - Offered and declined|74
362|4 - Assessed and determined to have medical contraindication(s)|4 - Assessed and determined to have medical contraindication(s)|74
363|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|74
364|6 - Inability to obtain vaccine due to declared shortage|6 - Inability to obtain vaccine due to declared shortage|74
365|1 - Yes [ Go to M2005 at TRN; Go to M1230 at DC ]|1 - Yes [ Go to M2005 at TRN; Go to M1230 at DC ]|74
366|1 - Patient has received PPV in the past|1 - Patient has received PPV in the past|74
367|2 - Offered and declined|2 - Offered and declined|74
368|3 - Assessed and determined to have medical contraindication(s)|3 - Assessed and determined to have medical contraindication(s)|74
369|4 - Not indicated; patient does not meet age/condition guidelines for PPV|4 - Not indicated; patient does not meet age/condition guidelines for PPV|74
370|5 - None of the above|5 - None of the above|74
371|0 - Adequate: hears normal conversation without difficulty.|0 - Adequate: hears normal conversation without difficulty.|74
372|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to increase volume or speak distinctly.|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to in|74
373|2 - Severely Impaired: absence of useful hearing.|2 - Severely Impaired: absence of useful hearing.|74
374|UK - Unable to assess hearing.|UK - Unable to assess hearing.|74
375|0 - Understands: clear comprehension without cues or repetitions.|0 - Understands: clear comprehension without cues or repetitions.|74
376|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Requires cues at times to understand.|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Req|74
377|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequently requires cues to understand.|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequentl|74
378|3 - Rarely/Never Understands|3 - Rarely/Never Understands|74
379|UK - Unable to assess understanding.|UK - Unable to assess understanding.|74
380|0 - No standardized assessment conducted|0 - No standardized assessment conducted|74
381|1 - Yes, and it does not indicate severe pain|1 - Yes, and it does not indicate severe pain|74
382|2 - Yes, and it indicates severe pain|2 - Yes, and it indicates severe pain|74
383|0 - Patient has no pain|0 - Patient has no pain|74
384|1 - Patient has pain that does not interfere with activity or movement|1 - Patient has pain that does not interfere with activity or movement|74
385|2 - Less often than daily|2 - Less often than daily|74
386|3 - Daily, but not constantly|3 - Daily, but not constantly|74
387|4 - All of the time|4 - All of the time|74
388|0 - No assessment conducted [ Go to M1306 ]|0 - No assessment conducted [ Go to M1306 ]|74
389|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc., without use of standardized tool|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc.,|74
390|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|74
391|0 - No [ Go to M1322]|0 - No [ Go to M1322]|74
392|0 v Newly epithelialized|0 v Newly epithelialized|74
393|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|74
394|2 - Yes, patient has observable stasis ulcers ONLY|2 - Yes, patient has observable stasis ulcers ONLY|74
395|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable dressing) [Go to M1340]|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable|74
396|0 - No [ Go to M1400 ]|0 - No [ Go to M1400 ]|74
397|1 - Yes, patient has at least one (observable) surgical wound|1 - Yes, patient has at least one (observable) surgical wound|74
398|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1400 ]|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1400 ]|74
399|0 - Patient is not short of breath|0 - Patient is not short of breath|74
400|3 - Continuous Bi-level positive airway pressure|3 - Continuous Bi-level positive airway pressure|74
401|0 - No [ Go to M1732 at TRN; Go to M1600 at DC ]|0 - No [ Go to M1732 at TRN; Go to M1600 at DC ]|74
402|2 - Not assessed [Go to M1732 at TRN; Go to M1600 at DC ]|2 - Not assessed [Go to M1732 at TRN; Go to M1600 at DC ]|74
403|NA - Patient does not have diagnosis of heart failure [Go to M2005 at TRN; Go to M1600 at DC]|NA - Patient does not have diagnosis of heart failure [Go to M2005 at TRN; Go to M1600 at DC]|74
404|0 - No action taken|0 - No action taken|74
405|1 - Patient+s physician (or other primary care practitioner) contacted the same day|1 - Patient+s physician (or other primary care practitioner) contacted the same day|74
406|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|74
407|3 - Implement physician-ordered patient-specific established parameters for treatment|3 - Implement physician-ordered patient-specific established parameters for treatment|74
408|4 - Patient education or other clinical interventions|4 - Patient education or other clinical interventions|74
409|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequency, telehealth, etc.)|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequ|74
410|1 - Occasional stress incontinence|1 - Occasional stress incontinence|74
411|2 - During the night only|2 - During the night only|74
412|3 - During the day only|3 - During the day only|74
413|4 - During the day and night|4 - During the day and night|74
414|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|74
415|0 - Able to manage toileting hygiene and clothing management without assistance.|0 - Able to manage toileting hygiene and clothing management without assistance.|74
416|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implements are laid out for the patient.|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implemen|74
417|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|74
418|3 - Patient depends entirely upon another person to maintain toileting hygiene.|3 - Patient depends entirely upon another person to maintain toileting hygiene.|74
419|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independent|74
420|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface|74
421|0 - No multi-factor falls risk assessment conducted.|0 - No multi-factor falls risk assessment conducted.|74
422|1 - Yes, and it does not indicate a risk for falls.|1 - Yes, and it does not indicate a risk for falls.|74
423|2 - Yes, and it indicates a risk for falls.|2 - Yes, and it indicates a risk for falls.|74
424|0 - Not assessed/reviewed [ Go to M2010 ]|0 - Not assessed/reviewed [ Go to M2010 ]|74
425|1 - No problems found during review [ Go to M2010 ]|1 - No problems found during review [ Go to M2010 ]|74
426|2 - Problems found during review|2 - Problems found during review|74
427|NA - Patient is not taking any medications [ Go to M2040 ]|NA - Patient is not taking any medications [ Go to M2040 ]|74
428|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special precautions associated with all high-risk medications|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special p|74
429|NA - Patient not taking any drugs|NA - Patient not taking any drugs|74
430|2 - Able to take medication(s) at the correct times if given reminders by another person at the appropriate times|2 - Able to take medication(s) at the correct times if given reminders by another person at the appr|74
431|3 - Unable to take medication unless administered by another person.|3 - Unable to take medication unless administered by another person.|74
432|1 - At least daily|1 - At least daily|74
433|2 - Three or more times per week|2 - Three or more times per week|74
434|3 - One to two times per week|3 - One to two times per week|74
435|4 - Received, but less often than weekly|4 - Received, but less often than weekly|74
436|5 - No assistance received|5 - No assistance received|74
437|0 - No [Go to M2401]|0 - No [Go to M2401]|74
438|1 - Yes, used hospital emergency department WITHOUT hospital admission|1 - Yes, used hospital emergency department WITHOUT hospital admission|74
439|2 - Yes, used hospital emergency department WITH hospital admission|2 - Yes, used hospital emergency department WITH hospital admission|74
440|UK - Unknown [Go to M2401]|UK - Unknown [Go to M2401]|74
441|2 - Injury caused by fall|2 - Injury caused by fall|74
442|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|74
443|4 - Other respiratory problem|4 - Other respiratory problem|74
444|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|74
445|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|74
446|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|74
447|8 - Other heart disease|8 - Other heart disease|74
448|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|74
449|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|74
450|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|74
451|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|74
452|13 - Urinary tract infection|13 - Urinary tract infection|74
453|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|74
454|15 - Wound infection or deterioration|15 - Wound infection or deterioration|74
455|16 - Uncontrolled pain|16 - Uncontrolled pain|74
456|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|74
457|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|74
458|19 - Other than above reasons|19 - Other than above reasons|74
459|2 - Patient remained in the community (with formal assistive services)|2 - Patient remained in the community (with formal assistive services)|74
460|3 - Patient transferred to a noninstitutional hospice|3 - Patient transferred to a noninstitutional hospice|74
461|4 - Unknown because patient moved to a geographic location not served by this agency|4 - Unknown because patient moved to a geographic location not served by this agency|74
462|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|74
463|4 - Other respiratory problem|4 - Other respiratory problem|74
464|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|74
465|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|74
466|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|74
467|8 - Other heart disease|8 - Other heart disease|74
468|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|74
469|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|74
470|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|74
471|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|74
472|13 - Urinary tract infection|13 - Urinary tract infection|74
473|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|74
474|15 - Wound infection or deterioration|15 - Wound infection or deterioration|74
475|16 - Uncontrolled pain|16 - Uncontrolled pain|74
476|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|74
477|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|74
478|19 - Scheduled treatment or procedure|19 - Scheduled treatment or procedure|74
479|20 - Other than above reasons|20 - Other than above reasons|74
480|UK - Reason unknown [Go to M0903]|UK - Reason unknown [Go to M0903]|74
482|01 - Patient lives alone around the clock|01 - Patient lives alone around the clock|74
483|02 - Patient lives alone regular daytime|02 - Patient lives alone regular daytime|74
484|03 - Patient lives alone regular nighttime|03 - Patient lives alone regular nighttime|74
485|04 - Patient lives alone occassional/short term assistance|04 - Patient lives alone occassional/short term assistance|74
486|05 - Patient lives alone no assisstance available|05 - Patient lives alone no assisstance available|74
487|06 - Patient lives with other person(s) in the home around the clock|06 - Patient lives with other person(s) in the home around the clock|74
488|07 - Patient lives with other person(s) in the home regular daytime|07 - Patient lives with other person(s) in the home regular daytime|74
489|08 - Patient lives with other person(s) in the home regular nighttime|08 - Patient lives with other person(s) in the home regular nighttime|74
490|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|74
491|10 - Patient lives with other person(s) in the home no assistance available|10 - Patient lives with other person(s) in the home no assistance available|74
492|1 - Was present at the most recent SOC/ROC assessment|1 - Was present at the most recent SOC/ROC assessment|74
493|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|74
494|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|74
495|0 - Newly epithelialized|0 - Newly epithelialized|74
496|0 - No [ Go to M1340 ]|0 - No [ Go to M1340 ]|74
498|0 - Independent|0 - Independent|74
499|1 - Needed Some Help|1 - Needed Some Help|74
500|2 - Dependent|2 - Dependent|74
502|0 - No assistance needed in this area|0 - No assistance needed in this area|74
503|1 - Caregiver(s) currently provide assistance|1 - Caregiver(s) currently provide assistance|74
504|2 - Caregiver(s) need training/ supportive services to provide assistance|2 - Caregiver(s) need training/ supportive services to provide assistance|74
505|3 - Caregiver(s) not likely to provide assistance|3 - Caregiver(s) not likely to provide assistance|74
506|4 - Unclear if Caregiver(s) will provide assistance|4 - Unclear if Caregiver(s) will provide assistance|74
507|5 - Assistance needed, but no Caregiver(s) available|5 - Assistance needed, but no Caregiver(s) available|74
508|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will use standardized clinical guidelines accessible for all care providers to reference|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will|74
510|NA - Patient is not assessed to be at risk for falls|NA - Patient is not assessed to be at risk for falls|74
511|NA - Patient has no diagnosis or symptoms of depression|NA - Patient has no diagnosis or symptoms of depression|74
512|NA - No pain identified|NA - No pain identified|74
513|NA - Patient is not assessed to be at risk for pressure ulcers|NA - Patient is not assessed to be at risk for pressure ulcers|74
514|NA - Patient has no pressure ulcers with need for moist wound healing|NA - Patient has no pressure ulcers with need for moist wound healing|74
515|1 - Long-term nursing facility (NF)|1 - Long-term nursing facility (NF)|74
516|2 - Skilled nursing facility (SNF / TCU)|2 - Skilled nursing facility (SNF / TCU)|74
517|3 - Short stay acute hospital (IPP S)|3 - Short stay acute hospital (IPP S)|74
518|4 - Long-term care hospital (LTCH)|4 - Long-term care hospital (LTCH)|74
519|5 - Inpatient rehabilitation hospital or unit (IRF)|5 - Inpatient rehabilitation hospital or unit (IRF)|74
520|6 - Psychiatric hospital or unit|6 - Psychiatric hospital or unit|74
521|7 - Other|7 - Other|74
522|NA - Patient was not discharged from an inpatient facility [Go to M1017]|NA - Patient was not discharged from an inpatient facility [Go to M1017]|74
523|6 - Unable to participate effectively in bathing and is bathed totally by another person|6 - Unable to participate effectively in bathing and is bathed totally by another person|74
524|4 - Chairfast, unable to ambulate but is able to wheel self independently.|4 - Chairfast, unable to ambulate but is able to wheel self independently.|74
525|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask patient: "Over the last two weeks, how often have you been bothered by any of the following problems")  *Copyright+ Pfizer Inc. All rights reserved. Reproduced with permission.|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask|74
526|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluation for depression.|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluat|74
527|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet criteria for further evaluation for depression.|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet|74
528|0 - Not at all  0 - 1 day|0 - Not at all  0 - 1 day|74
529|1 - Several days  2 - 6 days|1 - Several days  2 - 6 days|74
530|2 - More than half of the days  7 - 11 days|2 - More than half of the days  7 - 11 days|74
531|3 - Nearly every day  12 - 14 days|3 - Nearly every day  12 - 14 days|74
532|NA - N/A  Unable to respond|NA - N/A  Unable to respond|74
533|2 - Able to take medication(s) at the correct times if given reminders by another person based on the frequency of the injection|2 - Able to take medication(s) at the correct times if given reminders by another person based on th|74
534|3 - Unable to take injectable medication unless administered by another person.|3 - Unable to take injectable medication unless administered by another person.|74
535|UK - Inpatient Discharge Date Unknown|UK - Inpatient Discharge Date Unknown|74
538|NA - Inpatient stay within last 14 days Not Applicable|NA - Inpatient stay within last 14 days Not Applicable|74
47|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or supervision from another person OR c) a liquid, pureed or ground meat diet.|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or su|75
48|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|75
2|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; OR (b) Is physically, cognitively, and mentally able to prepare light meals on a regular basis but has not routinely performed light meal preparation in the past (i.e., prior to this home care admission).|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; O|75
3|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and mentally able to perform all housekeeping tasks .|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and menta|75
4|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and mentally able to do laundry and access facilities.|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and menta|75
5|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying packages OR b) Physically, cognitively, and mentally able to take care of shopping, but has not done shopping in the past (i.e., prior to this home care admission).|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying|75
6|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|75
7|0 - Able to dial numbers and answer calls appropriately and as desired.|0 - Able to dial numbers and answer calls appropriately and as desired.|75
8|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body without assistance.|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body|75
9|0 - Able to get to and from the toilet and transfer independently with or without a device.|0 - Able to get to and from the toilet and transfer independently with or without a device.|75
10|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|75
11|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible public bus.|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible p|75
12|0 - Able to independently feed self.|0 - Able to independently feed self.|75
13|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|75
14|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct times.|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct ti|75
15|0 - Able to independently transfer.|0 - Able to independently transfer.|75
16|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without rail|75
17|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings|75
18|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|75
19|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions independently.|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions indep|75
20|0 - Asymptomatic, no treatment needed at this time|0 - Asymptomatic, no treatment needed at this time|75
21|0 - Caregiver manages all tasks related to equipment completely independently.|0 - Caregiver manages all tasks related to equipment completely independently.|75
22|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations with no observable impairment.|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations w|75
23|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|75
24|0 - Life expectancy is greater than 6 months|0 - Life expectancy is greater than 6 months|75
25|0 - Never|0 - Never|75
26|0 - Patient is not short of breath|0 - Patient is not short of breath|75
27|0 - No|0 - No|75
28|0 - No emergent care services|0 - No emergent care services|75
29|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [Goto M1620]|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [Goto M1620]|75
30|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and extended or abstract conversation.|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and exte|75
31|0 - No one person|0 - No one person|75
32|0 - None of the time|0 - None of the time|75
33|0 - None, no charge for current services|0 - None, no charge for current services|75
34|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|75
35|0 - Patient does NOT have an ostomy for bowel elimination.|0 - Patient does NOT have an ostomy for bowel elimination.|75
36|0 - Patient has no pain|0 - Patient has no pain|75
37|0 - Patient manages all tasks related to equipment completely independently.|0 - Patient manages all tasks related to equipment completely independently.|75
38|0 - Poor:  little or no recovery is expected and/or further decline is imminent|0 - Poor:  little or no recovery is expected and/or further decline is imminent|75
39|0 - Timed-voiding defers incontinence|0 - Timed-voiding defers incontinence|75
40|0 - Very rarely or never has bowel incontinence|0 - Very rarely or never has bowel incontinence|75
41|0 - Zero|0 - Zero|75
42|00 - No|00 - No|75
43|01 - Yes|01 - Yes|75
44|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or mental limitations, needs assistance with heavy laundry.|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or|75
45|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the patient.|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the|75
46|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|75
49|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|75
50|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independently.|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independe|75
51|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only when assisted or accompanied by another person.|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only w|75
52|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepa|75
53|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance by another person OR b) given daily reminders.|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance b|75
54|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advan|75
55|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advan|75
56|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for the deaf) and call essential numbers.|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for t|75
57|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|75
58|1 - American Indian or Alaska Native|1 - American Indian or Alaska Native|75
59|1 - Depressed mood (e.g., feeling sad, tearful)|1 - Depressed mood (e.g., feeling sad, tearful)|75
60|1 - During the night only|1 - During the night only|75
61|1 - Fully granulating|1 - Fully granulating|75
62|1 - Good/Fair:  partial to full recovery is expected|1 - Good/Fair:  partial to full recovery is expected|75
63|1 - Good:  marked improvement in functional status is expected|1 - Good:  marked improvement in functional status is expected|75
64|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|75
65|1 - Smoking|1 - Smoking|75
66|1 - Hospital|1 - Hospital|75
67|1 - Hospital emergency room (includes 23-hour holding)|1 - Hospital emergency room (includes 23-hour holding)|75
68|1 - Hospitalization for EMERGENT (unscheduled) care|1 - Hospitalization for EMERGENT (unscheduled) care|75
69|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepared solutions), patient is able to manage all other aspects of equipment.|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepar|75
70|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|75
71|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|75
72|1 - In new or complex situations only|1 - In new or complex situations only|75
73|1 - Intravenous or infusion therapy (excludes TPN)|1 - Intravenous or infusion therapy (excludes TPN)|75
74|1 - Less often than daily|1 - Less often than daily|75
75|1 - Less than once a month|1 - Less than once a month|75
76|1 - Less than once weekly|1 - Less than once weekly|75
77|1 - Life expectancy is 6 months or fewer|1 - Life expectancy is 6 months or fewer|75
78|1 - Lives alone|1 - Lives alone|75
79|1 - Male|1 - Male|75
80|1 - Medicare (traditional fee-for-service)|1 - Medicare (traditional fee-for-service)|75
81|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of past 24 hours, significant memory loss so that supervision is required|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of pas|75
82|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors in word choice, grammar or speech intelligibility, needs minimal prompting or assistance).|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors i|75
83|1 - No assistance or services received|1 - No assistance or services received|75
84|1 - One|1 - One|75
85|1 - Oxygen (intermittent or continuous)|1 - Oxygen (intermittent or continuous)|75
86|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, and the surrounding layout, can count fingers at arm's length.|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, a|75
87|1 - Patient is incontinent|1 - Patient is incontinent|75
88|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|75
89|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical or treatment regimen.|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical|75
90|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient/couple/significant other)|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient|75
91|1 - Relatives, friends, or neighbors living outside the home|1 - Relatives, friends, or neighbors living outside the home|75
92|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions.|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions|75
93|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independentl|75
94|1 - Several times during day and night|1 - Several times during day and night|75
95|1 - Spouse or significant other|1 - Spouse or significant other|75
96|1 - Stage 1|1 - Stage 1|75
97|1 - Start of care - further visits planned|1 - Start of care - further visits planned|75
98|1 - Symptoms well controlled with current therapy|1 - Symptoms well controlled with current therapy|75
99|1 - Therapy services|1 - Therapy services|75
100|1 - Able to transfer with minimal human assistance or with use of an assistive device.|1 - Able to transfer with minimal human assistance or with use of an assistive device.|75
101|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitations.|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitatio|75
102|1 - Urinary incontinence|1 - Urinary incontinence|75
103|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and transfer.|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and|75
104|1 - When walking more than 20 feet, climbing stairs|1 - When walking more than 20 feet, climbing stairs|75
105|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary conversation. May need occasional repetition, extra time, or louder voice.|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary c|75
106|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting in and out of tub/shower|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting|75
107|1 - Yes|1 - Yes|75
108|1-RN|1-RN|75
109|10 - Discharge from agency - no visits completed after start/resumption of care assessment|10 - Discharge from agency - no visits completed after start/resumption of care assessment|75
110|10 - Scheduled surgical procedure|10 - Scheduled surgical procedure|75
111|10 - Self-pay|10 - Self-pay|75
112|11 - Other|11 - Other|75
113|11 - Urinary tract infection|11 - Urinary tract infection|75
114|12 - IV catheter-related infection|12 - IV catheter-related infection|75
115|13 - Deep vein thrombosis, pulmonary embolus|13 - Deep vein thrombosis, pulmonary embolus|75
116|14 - Uncontrolled pain|14 - Uncontrolled pain|75
117|15 - Psychotic episode|15 - Psychotic episode|75
118|16 - Other than above reasons|16 - Other than above reasons|75
119|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing calls.|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing|75
120|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another person.|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another pers|75
121|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface a|75
122|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for intermittent supervision or encouragement or reminders, OR (b) to get in and out of the shower or tub, OR (c) for washing difficult to reach areas.|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for inter|75
123|2 - Asian|2 - Asian|75
124|2 - Caregiver requires considerable assistance from another person to manage equipment, but independently completes significant portions of task.|2 - Caregiver requires considerable assistance from another person to manage equipment, but independ|75
125|2 - Daily, but not constantly|2 - Daily, but not constantly|75
126|2 - Daughter or son|2 - Daughter or son|75
127|2 - Doctor's office emergency visit/house call|2 - Doctor's office emergency visit/house call|75
128|2 - During the day and night|2 - During the day and night|75
129|2 - Early/partial granulation|2 - Early/partial granulation|75
130|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors in word choice, organization or speech intelligibility). Speaks in phrases or short sentences.|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors|75
131|2 - Family member's residence|2 - Family member's residence|75
132|2 - Female|2 - Female|75
133|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conversation, needs frequent prompting or assistance.|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conver|75
134|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|75
135|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|75
136|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately stop activities, jeopardizes safety through actions|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately st|75
137|2 - Indwelling/suprapubic catheter|2 - Indwelling/suprapubic catheter|75
138|2 - Injury caused by fall or accident at home|2 - Injury caused by fall or accident at home|75
139|2 - Medicare (HMO/managed care/Advantage plan)|2 - Medicare (HMO/managed care/Advantage plan)|75
140|2 - Nausea, dehydration, malnutrition, constipation, impaction|2 - Nausea, dehydration, malnutrition, constipation, impaction|75
141|2 - Obesity|2 - Obesity|75
142|2 - On awakening or at night only|2 - On awakening or at night only|75
143|2 - Once a month|2 - Once a month|75
144|2 - One to three times weekly|2 - One to three times weekly|75
145|2 - Parenteral nutrition (TPN or lipids)|2 - Parenteral nutrition (TPN or lipids)|75
146|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic) [ Go to M1620 ]|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic) [ Go|75
147|2 - Patient requires considerable assistance from another person to manage equipment, but independently completes portions of the task.|2 - Patient requires considerable assistance from another person to manage equipment, but independen|75
148|2 - Patient transferred to a noninstitutional hospice|2 - Patient transferred to a noninstitutional hospice|75
149|2 - Person residing in the home (EXCLUDING paid help)|2 - Person residing in the home (EXCLUDING paid help)|75
150|2 - Rehabilitation facility|2 - Rehabilitation facility|75
151|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifting of attention) or consistently requires low stimulus environment due to distractibility.|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifti|75
152|2 - Respite care|2 - Respite care|75
153|2 - Sense of failure or self reproach|2 - Sense of failure or self reproach|75
154|2 - Several times during day|2 - Several times during day|75
155|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonresponsive.|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonrespons|75
156|2 - Someone must assist the patient to groom self.|2 - Someone must assist the patient to groom self.|75
157|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|75
158|2 - Someone must help the patient put on upper body clothing.|2 - Someone must help the patient put on upper body clothing.|75
159|2 - Stage 2|2 - Stage 2|75
160|2 - Start of care - no further visits planned|2 - Start of care - no further visits planned|75
161|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitoring|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitori|75
162|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment regimen.|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment re|75
163|2 - Two|2 - Two|75
164|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistance due to cognitive or mental limitation.|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistanc|75
165|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|75
166|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assistance).|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assis|75
167|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home delivery.|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home deli|75
168|2 - Unable to prepare any light meals or reheat any delivered meals.|2 - Unable to prepare any light meals or reheat any delivered meals.|75
169|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|75
170|2 - UNABLE to take injectable medications unless administered by someone else.|2 - UNABLE to take injectable medications unless administered by someone else.|75
171|2 - UNABLE to take medication unless administered by someone else.|2 - UNABLE to take medication unless administered by someone else.|75
172|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|75
173|2 - Ventilator (continually or at night)|2 - Ventilator (continually or at night)|75
174|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less than 20 feet)|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less th|75
175|2 - With spouse or significant other|2 - With spouse or significant other|75
176|2 - Yes, assistance or services provided by family or friends|2 - Yes, assistance or services provided by family or friends|75
177|2-PT|2-PT|75
178|3 - Able to answer the telephone only some of the time or is able to carry on only a limited conversation.|3 - Able to answer the telephone only some of the time or is able to carry on only a limited convers|75
179|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube or gastrostomy.|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube|75
180|3 - Alcohol dependency|3 - Alcohol dependency|75
181|3 - All of the time|3 - All of the time|75
182|3 - Black or African-American|3 - Black or African-American|75
183|3 - Boarding home or rented room|3 - Boarding home or rented room|75
184|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment, clean/store/dispose of equipment or supplies).|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment,|75
185|3 -Able to walk only with the supervision or assistance of another person at all times.|3 -Able to walk only with the supervision or assistance of another person at all times.|75
186|3 - Continuous / Bi-level positive airway pressure|3 - Continuous / Bi-level positive airway pressure|75
187|3 - During the day and evening, but not constantly|3 - During the day and evening, but not constantly|75
188|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the alimentary canal)|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the|75
189|3 - Environmental support (e.g., housing, home maintenance)|3 - Environmental support (e.g., housing, home maintenance)|75
190|3 - Four to six times weekly|3 - Four to six times weekly|75
191|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessing by listener.  Speech limited to single words or short phrases.|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessin|75
192|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires multiple repetitions, restatements, demonstrations, additional time.|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires m|75
193|3 - Hopelessness|3 - Hopelessness|75
194|3 - Hospice care|3 - Hospice care|75
195|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|75
196|3 - Injury caused by fall or accident at home|3 - Injury caused by fall or accident at home|75
197|3 - Intractable pain|3 - Intractable pain|75
198|3 - Medicaid (traditional fee-for-service)|3 - Medicaid (traditional fee-for-service)|75
199|3 - Needs someone to do all shopping and errands.|3 - Needs someone to do all shopping and errands.|75
200|3 - Not healing|3 - Not healing|75
201|3 - Nursing home|3 - Nursing home|75
202|3 - Once daily|3 - Once daily|75
203|3 - Other family member|3 - Other family member|75
204|3 - Outpatient department/clinic emergency (includes urgicenter sites)|3 - Outpatient department/clinic emergency (includes urgicenter sites)|75
205|3 - Paid help|3 - Paid help|75
206|3 - Able to participate in bathing self in shower or tub, but requires presence of another person throughout the bath for assistance or supervision.|3 - Able to participate in bathing self in shower or tub, but requires presence of another person th|75
207|3 - Patient depends entirely upon another person to dress lower body.|3 - Patient depends entirely upon another person to dress lower body.|75
208|3 - Patient depends entirely upon another person to dress the upper body.|3 - Patient depends entirely upon another person to dress the upper body.|75
209|3 - Patient depends entirely upon someone else for grooming needs.|3 - Patient depends entirely upon someone else for grooming needs.|75
210|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone else to manage the equipment.|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone|75
211|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable to shift attention and recall directions more than half the time.|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable|75
212|3 - Respiratory problems (SOB, infection, obstruction)|3 - Respiratory problems (SOB, infection, obstruction)|75
213|3 - Resumption of care (after inpatient stay)|3 - Resumption of care (after inpatient stay)|75
214|3 - Several times each month|3 - Several times each month|75
215|3 - Skilled Nursing Facility|3 - Skilled Nursing Facility|75
216|3 - Stage 3|3 - Stage 3|75
217|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|75
218|3 - Three|3 - Three|75
219|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person throughout the process.|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person through|75
220|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal independently.|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal indep|75
221|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person.|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person|75
222|3 - Unknown because patient moved to a geographic location not served by this agency|3 - Unknown because patient moved to a geographic location not served by this agency|75
223|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|75
224|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|75
225|3 - With other family member|3 - With other family member|75
226|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home health services, homemaker assistance, transportation assistance, assisted living, board and care)|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home h|75
227|3-SLP/ST|3-SLP/ST|75
228|4 - At rest (during day or night)|4 - At rest (during day or night)|75
229|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|75
230|4 - Board and care or assisted living facility|4 - Board and care or assisted living facility|75
231|4 - Caregiver is completely dependent on someone else to manage all equipment.|4 - Caregiver is completely dependent on someone else to manage all equipment.|75
232|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|75
233|4 - Constantly|4 - Constantly|75
234|4 - Drug dependency|4 - Drug dependency|75
235|4 - Four or more|4 - Four or more|75
236|4 - Friend or neighbor or community or church member|4 - Friend or neighbor or community or church member|75
237|4 - Hispanic or Latino|4 - Hispanic or Latino|75
238|4 - Hospice|4 - Hospice|75
239|4 - Impaired decision-making|4 - Impaired decision-making|75
240|4 - Is totally dependent in toileting.|4 - Is totally dependent in toileting.|75
241|4 - Medicaid (HMO/managed care)|4 - Medicaid (HMO/managed care)|75
242|4 - None of the above|4 - None of the above|75
243|4 - Nursing home|4 - Nursing home|75
244|4 - On a daily basis|4 - On a daily basis|75
245|4 - Patient is completely dependent on someone else to manage all equipment.|4 - Patient is completely dependent on someone else to manage all equipment.|75
246|4 - Permanent placement|4 - Permanent placement|75
247|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, punches, dangerous maneuvers w/ wheelchair or other objects)|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, pu|75
248|4 - Psychosocial support (e.g., socialization, companionship, recreation)|4 - Psychosocial support (e.g., socialization, companionship, recreation)|75
249|4 - Recertification (follow-up) reassessment|4 - Recertification (follow-up) reassessment|75
250|4 - Recurrent thoughts of death|4 - Recurrent thoughts of death|75
251|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruction)|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruc|75
252|4 - Several times a week|4 - Several times a week|75
253|4 - Stage 4|4 - Stage 4|75
254|4 - Symptoms poorly controlled, history of re-hospitalizations|4 - Symptoms poorly controlled, history of re-hospitalizations|75
255|4 - Three or more times per week|4 - Three or more times per week|75
256|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetative state, or delirium.|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetati|75
257|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|75
258|4 - Unable to effectively participate in any housekeeping tasks.|4 - Unable to effectively participate in any housekeeping tasks.|75
259|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or unresponsive (e.g., speech is nonsensical or unintelligible).|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or u|75
260|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonresponsive.|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonr|75
261|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostomy.|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostom|75
262|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of devices at the sink, in chair, or on commode|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of|75
263|4 - With a friend|4 - With a friend|75
264|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|75
265|4-OT|4-OT|75
266|5 - Advocates or facilitates patient's participation in appropriate medical care|5 - Advocates or facilitates patient's participation in appropriate medical care|75
267|5 - At least daily|5 - At least daily|75
268|6 - Bedfast, unable to ambulate or be up in a chair.|6 - Bedfast, unable to ambulate or be up in a chair.|75
269|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|75
270|5 - Disruptive or socially inappropriate behavior|5 - Disruptive or socially inappropriate behavior|75
271|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|75
272|5 - Hypo/Hyperglycemia, diabetes out of control|5 - Hypo/Hyperglycemia, diabetes out of control|75
273|5 - More often than once daily|5 - More often than once daily|75
274|5 - Native Hawaiian or Pacific Islander|5 - Native Hawaiian or Pacific Islander|75
275|5 - None of the above|5 - None of the above|75
276|5 - One to two times per week|5 - One to two times per week|75
277|5 - Other|5 - Other|75
278|5 - Other follow-up|5 - Other follow-up|75
279|5 - Paid help|5 - Paid help|75
280|5 - Patient nonresponsive or unable to speak.|5 - Patient nonresponsive or unable to speak.|75
281|5 - Thoughts of suicide|5 - Thoughts of suicide|75
282|5 - Totally unable to use the telephone.|5 - Totally unable to use the telephone.|75
283|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|75
284|5 - Unable to take in nutrients orally or by tube feeding.|5 - Unable to take in nutrients orally or by tube feeding.|75
285|5 - Unsafe for care at home|5 - Unsafe for care at home|75
286|5 - With paid help (other than home care agency staff)|5 - With paid help (other than home care agency staff)|75
287|5 - Workers' compensation|5 - Workers' compensation|75
288|5 - Wound infection, deteriorating wound status, new lesion/ulcer|5 - Wound infection, deteriorating wound status, new lesion/ulcer|75
289|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|75
290|6 - Delusional, hallucinatory, or paranoid behavior|6 - Delusional, hallucinatory, or paranoid behavior|75
291|6 - Financial agent, power of attorney, or conservator of finance|6 - Financial agent, power of attorney, or conservator of finance|75
292|6 - GI bleeding, obstruction|6 - GI bleeding, obstruction|75
293|6 - Less often than weekly|6 - Less often than weekly|75
294|6 - Memory loss to the extent that supervision required|6 - Memory loss to the extent that supervision required|75
295|6 - None of the above feelings observed or reported|6 - None of the above feelings observed or reported|75
296|6 - Other|6 - Other|75
297|6 - Title programs (e.g., Title III, V, or XX)|6 - Title programs (e.g., Title III, V, or XX)|75
298|6 - Transferred to an inpatient facility - patient not discharged from agency|6 - Transferred to an inpatient facility - patient not discharged from agency|75
299|6 - White|6 - White|75
300|6 - With other than above|6 - With other than above|75
301|7 - Exacerbation of CHF, fluid overload, heart failure|7 - Exacerbation of CHF, fluid overload, heart failure|75
302|7 - Health care agent, conservator of person, or medical power of attorney|7 - Health care agent, conservator of person, or medical power of attorney|75
303|7 - Hypo/Hyperglycemia, diabetes out of control|7 - Hypo/Hyperglycemia, diabetes out of control|75
304|7 - None of the above|7 - None of the above|75
305|7 - None of the above behaviors demonstrated|7 - None of the above behaviors demonstrated|75
306|7 - Other government (e.g., TriCare, VA, etc.)|7 - Other government (e.g., TriCare, VA, etc.)|75
307|7 - Transferred to an inpatient facility - patient discharged from agency|7 - Transferred to an inpatient facility - patient discharged from agency|75
308|8 - Death at home|8 - Death at home|75
309|8 - GI bleeding, obstruction|8 - GI bleeding, obstruction|75
310|8 - Myocardial infarction, stroke|8 - Myocardial infarction, stroke|75
311|8 - Private insurance|8 - Private insurance|75
312|9 - Chemotherapy|9 - Chemotherapy|75
313|9 - Discharge from agency|9 - Discharge from agency|75
314|9 - Other than above reasons|9 - Other than above reasons|75
315|9 - Private HMO/managed care|9 - Private HMO/managed care|75
316|NA - No caregiver|NA - No caregiver|75
317|NA - No equipment of this type used in care.|NA - No equipment of this type used in care.|75
318|NA - No inhalant/mist medications prescribed.|NA - No inhalant/mist medications prescribed.|75
319|NA - No injectable medications prescribed.|NA - No injectable medications prescribed.|75
320|NA - No inpatient facility admission|NA - No inpatient facility admission|75
321|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|75
322|NA - No Medicaid|NA - No Medicaid|75
323|NA - No Medicare|NA - No Medicare|75
324|NA - No observable pressure ulcer or unhealed pressure ulcer|NA - No observable pressure ulcer or unhealed pressure ulcer|75
325|NA - No observable stasis ulcer|NA - No observable stasis ulcer|75
326|NA - No observable surgical wound|NA - No observable surgical wound|75
327|NA - No oral medications prescribed.|NA - No oral medications prescribed.|75
328|NA - Not applicable|NA - Not applicable|75
329|NA - Patient does not have a telephone.|NA - Patient does not have a telephone.|75
330|NA - Patient has ostomy for bowel elimination|NA - Patient has ostomy for bowel elimination|75
331|NA - Patient nonresponsive|NA - Patient nonresponsive|75
332|NA - Patient on prophylactic treatment|NA - Patient on prophylactic treatment|75
333|NA - Patient was not discharged from an inpatient facility [Go to M1017]|NA - Patient was not discharged from an inpatient facility [Go to M1017]|75
334|UK - Other unknown|UK - Other unknown|75
335|UK - Reason unknown|UK - Reason unknown|75
336|UK - Unknown|UK - Unknown|75
337|UK - Unknown or Not Available|UK - Unknown or Not Available|75
341|01 - Early|01 - Early|75
342|02 - Late|02 - Late|75
343|NA - Not Applicable. No case mix group defined for this assessment.|NA - Not Applicable. No case mix group defined for this assessment.|75
344|NA - No case mix group defined by this assessment.|NA - No case mix group defined by this assessment.|75
345|1 - Recent decline in mental, emotional, or behavioral status|1 - Recent decline in mental, emotional, or behavioral status|75
346|2 - Multiple hospitalizations (2 or more) in the past 12 months|2 - Multiple hospitalizations (2 or more) in the past 12 months|75
347|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|75
348|4 - Taking five or more medications|4 - Taking five or more medications|75
349|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|75
350|6 - Other|6 - Other|75
351|7 - None of the above|7 - None of the above|75
352|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond tho|75
353|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable without heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable wi|75
354|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious complications and death.|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious compl|75
355|3 - The patient has serious progressive conditions that could lead to death within a year.|3 - The patient has serious progressive conditions that could lead to death within a year.|75
356|UK - The patient+s situation is unknown or unclear.|UK - The patient+s situation is unknown or unclear.|75
357|1 - Yes [ Go to M1050 ]|1 - Yes [ Go to M1050 ]|75
358|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this influenza season. [ Go to M1050 ]|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this i|75
359|1 - Received from another health care provider (e.g., physician)|1 - Received from another health care provider (e.g., physician)|75
360|2 - Received from your agency previously during this year+s flu season|2 - Received from your agency previously during this year+s flu season|75
361|3 - Offered and declined|3 - Offered and declined|75
362|4 - Assessed and determined to have medical contraindication(s)|4 - Assessed and determined to have medical contraindication(s)|75
363|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|75
364|6 - Inability to obtain vaccine due to declared shortage|6 - Inability to obtain vaccine due to declared shortage|75
365|1 - Yes [ Go to M2005 at TRN; Go to M1230 at DC ]|1 - Yes [ Go to M2005 at TRN; Go to M1230 at DC ]|75
366|1 - Patient has received PPV in the past|1 - Patient has received PPV in the past|75
367|2 - Offered and declined|2 - Offered and declined|75
368|3 - Assessed and determined to have medical contraindication(s)|3 - Assessed and determined to have medical contraindication(s)|75
369|4 - Not indicated; patient does not meet age/condition guidelines for PPV|4 - Not indicated; patient does not meet age/condition guidelines for PPV|75
370|5 - None of the above|5 - None of the above|75
371|0 - Adequate: hears normal conversation without difficulty.|0 - Adequate: hears normal conversation without difficulty.|75
372|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to increase volume or speak distinctly.|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to in|75
373|2 - Severely Impaired: absence of useful hearing.|2 - Severely Impaired: absence of useful hearing.|75
374|UK - Unable to assess hearing.|UK - Unable to assess hearing.|75
375|0 - Understands: clear comprehension without cues or repetitions.|0 - Understands: clear comprehension without cues or repetitions.|75
376|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Requires cues at times to understand.|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Req|75
377|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequently requires cues to understand.|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequentl|75
378|3 - Rarely/Never Understands|3 - Rarely/Never Understands|75
379|UK - Unable to assess understanding.|UK - Unable to assess understanding.|75
380|0 - No standardized assessment conducted|0 - No standardized assessment conducted|75
381|1 - Yes, and it does not indicate severe pain|1 - Yes, and it does not indicate severe pain|75
382|2 - Yes, and it indicates severe pain|2 - Yes, and it indicates severe pain|75
383|0 - Patient has no pain|0 - Patient has no pain|75
384|1 - Patient has pain that does not interfere with activity or movement|1 - Patient has pain that does not interfere with activity or movement|75
385|2 - Less often than daily|2 - Less often than daily|75
386|3 - Daily, but not constantly|3 - Daily, but not constantly|75
387|4 - All of the time|4 - All of the time|75
388|0 - No assessment conducted [ Go to M1306 ]|0 - No assessment conducted [ Go to M1306 ]|75
389|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc., without use of standardized tool|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc.,|75
390|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|75
391|0 - No [ Go to M1322]|0 - No [ Go to M1322]|75
392|0 v Newly epithelialized|0 v Newly epithelialized|75
393|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|75
394|2 - Yes, patient has observable stasis ulcers ONLY|2 - Yes, patient has observable stasis ulcers ONLY|75
395|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable dressing) [Go to M1340]|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable|75
396|0 - No [ Go to M1400 ]|0 - No [ Go to M1400 ]|75
397|1 - Yes, patient has at least one (observable) surgical wound|1 - Yes, patient has at least one (observable) surgical wound|75
398|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1400 ]|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1400 ]|75
399|0 - Patient is not short of breath|0 - Patient is not short of breath|75
400|3 - Continuous Bi-level positive airway pressure|3 - Continuous Bi-level positive airway pressure|75
401|0 - No [ Go to M1732 at TRN; Go to M1600 at DC ]|0 - No [ Go to M1732 at TRN; Go to M1600 at DC ]|75
402|2 - Not assessed [Go to M1732 at TRN; Go to M1600 at DC ]|2 - Not assessed [Go to M1732 at TRN; Go to M1600 at DC ]|75
570|Z - None of the above|Z - None of the above|75
569|E - Orthotics/Prosthetics|E - Orthotics/Prosthetics|75
568|D - Walker|D - Walker|75
567|C - Mechanical lift|C - Mechanical lift|75
566|B - Motorized wheelchair and/or scooter|B - Motorized wheelchair and/or scooter|75
565|A - Manual wheelchair|A - Manual wheelchair|75
564|9 - Not Applicable|9 - Not Applicable|75
563|8 - Unknown|8 - Unknown|75
562|1 - Dependent - A helper completed the activities for the patient.|1 - Dependent - A helper completed the activities for the patient.|75
561|2 - Needed Some Help - Patient needed partial assistance from another person to complete activities.|2 - Needed Some Help - Patient needed partial assistance from another person to complete activities.|75
560|3 - Independent - Patient completed the activities by him/herself, with or without an assistive device, with no assistance from a helper.|3 - Independent - Patient completed the activities by him/herself, with or without an assistive devi|75
559|2 - Two or More|2 - Two or More|75
558|1 - One|1 - One|75
557|0 - None|0 - None|75
556|1 - Yes [Continue to J1900, Number of Falls Since SOC/ROC, whichever is more recent]|1 - Yes [Continue to J1900, Number of Falls Since SOC/ROC, whichever is more recent]|75
555|0 - No [STOP]|0 - No [STOP]|75
554|0 - No [Skip to J1800 Any falls since SOC/ROC, whichever is more recent.]|0 - No [Skip to J1800 Any falls since SOC/ROC, whichever is more recent.]|75
553|2 - Motorized|2 - Motorized|75
552|1 - Manual|1 - Manual|75
551|1 - Yes [Continue to GG0170R, Wheel 50 feet with two turns.]|1 - Yes [Continue to GG0170R, Wheel 50 feet with two turns.]|75
550|0 - No [STOP]|0 - No [Skip GG0170R]|75
549|0 - No [STOP]|0 - No [STOP]|75
548|88 - Not attempted due to medical conditions or safety concerns|88 - Not attempted due to medical conditions or safety concerns|75
547|10 - Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)|10 - Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)|75
546|09 - Not applicable - Not attempted and the patient did not perform this activity prior to the current illness,exacerbation or injury.|09 - Not applicable - Not attempted and the patient did not perform this activity prior to the curre|75
545|07 - Patient refused|07 - Patient refused|75
544|01 - Dependent - Helper does ALL of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity.|01 - Dependent - Helper does ALL of the effort. Patient does none of the effort to complete the acti|75
543|02 - Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.|02 - Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds t|75
542|03 - Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort.|03 - Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or sup|75
541|04 - Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently.|04 - Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/|75
540|05 - Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity.|05 - Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper|75
539|06 - Independent - Patient completes the activity by him/herself with no assistance from a helper.|06 - Independent - Patient completes the activity by him/herself with no assistance from a helper.|75
403|NA - Patient does not have diagnosis of heart failure [Go to M2005 at TRN; Go to M1600 at DC]|NA - Patient does not have diagnosis of heart failure [Go to M2005 at TRN; Go to M1600 at DC]|75
404|0 - No action taken|0 - No action taken|75
405|1 - Patient+s physician (or other primary care practitioner) contacted the same day|1 - Patient+s physician (or other primary care practitioner) contacted the same day|75
406|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|75
407|3 - Implement physician-ordered patient-specific established parameters for treatment|3 - Implement physician-ordered patient-specific established parameters for treatment|75
408|4 - Patient education or other clinical interventions|4 - Patient education or other clinical interventions|75
409|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequency, telehealth, etc.)|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequ|75
410|1 - Occasional stress incontinence|1 - Occasional stress incontinence|75
411|2 - During the night only|2 - During the night only|75
412|3 - During the day only|3 - During the day only|75
413|4 - During the day and night|4 - During the day and night|75
414|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|75
415|0 - Able to manage toileting hygiene and clothing management without assistance.|0 - Able to manage toileting hygiene and clothing management without assistance.|75
416|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implements are laid out for the patient.|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implemen|75
417|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|75
418|3 - Patient depends entirely upon another person to maintain toileting hygiene.|3 - Patient depends entirely upon another person to maintain toileting hygiene.|75
419|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independent|75
420|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface|75
421|0 - No multi-factor falls risk assessment conducted.|0 - No multi-factor falls risk assessment conducted.|75
422|1 - Yes, and it does not indicate a risk for falls.|1 - Yes, and it does not indicate a risk for falls.|75
423|2 - Yes, and it indicates a risk for falls.|2 - Yes, and it indicates a risk for falls.|75
424|0 - Not assessed/reviewed [ Go to M2010 ]|0 - Not assessed/reviewed [ Go to M2010 ]|75
425|1 - No problems found during review [ Go to M2010 ]|1 - No problems found during review [ Go to M2010 ]|75
426|2 - Problems found during review|2 - Problems found during review|75
427|NA - Patient is not taking any medications [ Go to M2040 ]|NA - Patient is not taking any medications [ Go to M2040 ]|75
428|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special precautions associated with all high-risk medications|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special p|75
429|NA - Patient not taking any drugs|NA - Patient not taking any drugs|75
430|2 - Able to take medication(s) at the correct times if given reminders by another person at the appropriate times|2 - Able to take medication(s) at the correct times if given reminders by another person at the appr|75
431|3 - Unable to take medication unless administered by another person.|3 - Unable to take medication unless administered by another person.|75
432|1 - At least daily|1 - At least daily|75
433|2 - Three or more times per week|2 - Three or more times per week|75
434|3 - One to two times per week|3 - One to two times per week|75
435|4 - Received, but less often than weekly|4 - Received, but less often than weekly|75
436|5 - No assistance received|5 - No assistance received|75
437|0 - No [Go to M2401]|0 - No [Go to M2401]|75
438|1 - Yes, used hospital emergency department WITHOUT hospital admission|1 - Yes, used hospital emergency department WITHOUT hospital admission|75
439|2 - Yes, used hospital emergency department WITH hospital admission|2 - Yes, used hospital emergency department WITH hospital admission|75
440|UK - Unknown [Go to M2401]|UK - Unknown [Go to M2401]|75
441|2 - Injury caused by fall|2 - Injury caused by fall|75
442|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|75
443|4 - Other respiratory problem|4 - Other respiratory problem|75
444|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|75
445|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|75
446|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|75
447|8 - Other heart disease|8 - Other heart disease|75
448|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|75
449|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|75
450|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|75
451|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|75
452|13 - Urinary tract infection|13 - Urinary tract infection|75
453|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|75
454|15 - Wound infection or deterioration|15 - Wound infection or deterioration|75
455|16 - Uncontrolled pain|16 - Uncontrolled pain|75
456|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|75
457|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|75
458|19 - Other than above reasons|19 - Other than above reasons|75
459|2 - Patient remained in the community (with formal assistive services)|2 - Patient remained in the community (with formal assistive services)|75
460|3 - Patient transferred to a noninstitutional hospice|3 - Patient transferred to a noninstitutional hospice|75
461|4 - Unknown because patient moved to a geographic location not served by this agency|4 - Unknown because patient moved to a geographic location not served by this agency|75
462|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|75
463|4 - Other respiratory problem|4 - Other respiratory problem|75
464|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|75
465|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|75
466|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|75
467|8 - Other heart disease|8 - Other heart disease|75
468|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|75
469|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|75
470|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|75
471|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|75
472|13 - Urinary tract infection|13 - Urinary tract infection|75
473|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|75
474|15 - Wound infection or deterioration|15 - Wound infection or deterioration|75
475|16 - Uncontrolled pain|16 - Uncontrolled pain|75
476|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|75
477|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|75
478|19 - Scheduled treatment or procedure|19 - Scheduled treatment or procedure|75
479|20 - Other than above reasons|20 - Other than above reasons|75
480|UK - Reason unknown [Go to M0903]|UK - Reason unknown [Go to M0903]|75
482|01 - Patient lives alone around the clock|01 - Patient lives alone around the clock|75
483|02 - Patient lives alone regular daytime|02 - Patient lives alone regular daytime|75
484|03 - Patient lives alone regular nighttime|03 - Patient lives alone regular nighttime|75
485|04 - Patient lives alone occassional/short term assistance|04 - Patient lives alone occassional/short term assistance|75
486|05 - Patient lives alone no assisstance available|05 - Patient lives alone no assisstance available|75
487|06 - Patient lives with other person(s) in the home around the clock|06 - Patient lives with other person(s) in the home around the clock|75
488|07 - Patient lives with other person(s) in the home regular daytime|07 - Patient lives with other person(s) in the home regular daytime|75
489|08 - Patient lives with other person(s) in the home regular nighttime|08 - Patient lives with other person(s) in the home regular nighttime|75
490|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|75
491|10 - Patient lives with other person(s) in the home no assistance available|10 - Patient lives with other person(s) in the home no assistance available|75
492|1 - Was present at the most recent SOC/ROC assessment|1 - Was present at the most recent SOC/ROC assessment|75
493|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|75
494|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|75
495|0 - Newly epithelialized|0 - Newly epithelialized|75
496|0 - No [ Go to M1340 ]|0 - No [ Go to M1340 ]|75
498|0 - Independent|0 - Independent|75
499|1 - Needed Some Help|1 - Needed Some Help|75
500|2 - Dependent|2 - Dependent|75
502|0 - No assistance needed in this area|0 - No assistance needed in this area|75
503|1 - Caregiver(s) currently provide assistance|1 - Caregiver(s) currently provide assistance|75
504|2 - Caregiver(s) need training/ supportive services to provide assistance|2 - Caregiver(s) need training/ supportive services to provide assistance|75
505|3 - Caregiver(s) not likely to provide assistance|3 - Caregiver(s) not likely to provide assistance|75
506|4 - Unclear if Caregiver(s) will provide assistance|4 - Unclear if Caregiver(s) will provide assistance|75
507|5 - Assistance needed, but no Caregiver(s) available|5 - Assistance needed, but no Caregiver(s) available|75
508|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will use standardized clinical guidelines accessible for all care providers to reference|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will|75
510|NA - Patient is not assessed to be at risk for falls|NA - Patient is not assessed to be at risk for falls|75
511|NA - Patient has no diagnosis or symptoms of depression|NA - Patient has no diagnosis or symptoms of depression|75
512|NA - No pain identified|NA - No pain identified|75
513|NA - Patient is not assessed to be at risk for pressure ulcers|NA - Patient is not assessed to be at risk for pressure ulcers|75
514|NA - Patient has no pressure ulcers with need for moist wound healing|NA - Patient has no pressure ulcers with need for moist wound healing|75
515|1 - Long-term nursing facility (NF)|1 - Long-term nursing facility (NF)|75
516|2 - Skilled nursing facility (SNF / TCU)|2 - Skilled nursing facility (SNF / TCU)|75
517|3 - Short stay acute hospital (IPP S)|3 - Short stay acute hospital (IPP S)|75
518|4 - Long-term care hospital (LTCH)|4 - Long-term care hospital (LTCH)|75
519|5 - Inpatient rehabilitation hospital or unit (IRF)|5 - Inpatient rehabilitation hospital or unit (IRF)|75
520|6 - Psychiatric hospital or unit|6 - Psychiatric hospital or unit|75
521|7 - Other|7 - Other|75
522|NA - Patient was not discharged from an inpatient facility [Go to M1017]|NA - Patient was not discharged from an inpatient facility [Go to M1017]|75
523|6 - Unable to participate effectively in bathing and is bathed totally by another person|6 - Unable to participate effectively in bathing and is bathed totally by another person|75
524|4 - Chairfast, unable to ambulate but is able to wheel self independently.|4 - Chairfast, unable to ambulate but is able to wheel self independently.|75
525|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask patient: "Over the last two weeks, how often have you been bothered by any of the following problems")   *Copyright+ Pfizer Inc. All rights reserved. Reproduced with permission.|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask|75
526|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluation for depression.|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluat|75
527|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet criteria for further evaluation for depression.|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet|75
528|0 - Not at all  0 - 1 day|0 - Not at all  0 - 1 day|75
529|1 - Several days  2 - 6 days|1 - Several days  2 - 6 days|75
530|2 - More than half of the days  7 - 11 days|2 - More than half of the days  7 - 11 days|75
531|3 - Nearly every day  12 - 14 days|3 - Nearly every day  12 - 14 days|75
532|NA - N/A  Unable to respond|NA - N/A  Unable to respond|75
533|2 - Able to take medication(s) at the correct times if given reminders by another person based on the frequency of the injection|2 - Able to take medication(s) at the correct times if given reminders by another person based on th|75
534|3 - Unable to take injectable medication unless administered by another person.|3 - Unable to take injectable medication unless administered by another person.|75
536|UK - Inpatient Discharge Date Unknown|UK - Inpatient Discharge Date Unknown|75
537|NA - Inpatient stay within last 14 days Not Applicable|NA - Inpatient stay within last 14 days Not Applicable|75
2|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; OR (b) Is physically, cognitively, and mentally able to prepare light meals on a regular basis but has not routinely performed light meal preparation in the past (i.e., prior to this home care admission).|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; O|76
3|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and mentally able to perform all housekeeping tasks .|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and menta|76
4|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and mentally able to do laundry and access facilities.|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and menta|76
5|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying packages OR b) Physically, cognitively, and mentally able to take care of shopping, but has not done shopping in the past (i.e., prior to this home care admission).|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying|76
6|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|76
7|0 - Able to dial numbers and answer calls appropriately and as desired.|0 - Able to dial numbers and answer calls appropriately and as desired.|76
8|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body without assistance.|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body|76
9|0 - Able to get to and from the toilet and transfer independently with or without a device.|0 - Able to get to and from the toilet and transfer independently with or without a device.|76
10|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|76
11|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible public bus.|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible p|76
12|0 - Able to independently feed self.|0 - Able to independently feed self.|76
13|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|76
14|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct times.|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct ti|76
15|0 - Able to independently transfer.|0 - Able to independently transfer.|76
16|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without rail|76
17|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings|76
18|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|76
19|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions independently.|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions indep|76
20|0 - Asymptomatic, no treatment needed at this time|0 - Asymptomatic, no treatment needed at this time|76
21|0 - Caregiver manages all tasks related to equipment completely independently.|0 - Caregiver manages all tasks related to equipment completely independently.|76
22|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations with no observable impairment.|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations w|76
23|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|76
24|0 - Life expectancy is greater than 6 months|0 - Life expectancy is greater than 6 months|76
25|0 - Never|0 - Never|76
26|0 - Patient is not short of breath|0 - Patient is not short of breath|76
27|0 - No|0 - No|76
28|0 - No emergent care services|0 - No emergent care services|76
29|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [Goto 1620]|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [Goto 1620]|76
30|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and extended or abstract conversation.|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and exte|76
31|0 - No one person|0 - No one person|76
32|0 - None of the time|0 - None of the time|76
33|0 - None, no charge for current services|0 - None, no charge for current services|76
34|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|76
35|0 - Patient does NOT have an ostomy for bowel elimination.|0 - Patient does NOT have an ostomy for bowel elimination.|76
36|0 - Patient has no pain|0 - Patient has no pain|76
37|0 - Patient manages all tasks related to equipment completely independently.|0 - Patient manages all tasks related to equipment completely independently.|76
38|0 - Poor:  little or no recovery is expected and/or further decline is imminent|0 - Poor:  little or no recovery is expected and/or further decline is imminent|76
39|0 - Timed-voiding defers incontinence|0 - Timed-voiding defers incontinence|76
40|0 - Very rarely or never has bowel incontinence|0 - Very rarely or never has bowel incontinence|76
41|0 - Zero|0 - Zero|76
42|00 - No|00 - No|76
43|01 - Yes|01 - Yes|76
44|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or mental limitations, needs assistance with heavy laundry.|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or|76
45|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the patient.|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the|76
46|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|76
47|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or supervision from another person OR c) a liquid, pureed or ground meat diet.|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or su|76
48|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|76
49|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|76
50|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independently.|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independe|76
51|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only when assisted or accompanied by another person.|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only w|76
52|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepa|76
53|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance by another person OR b) given daily reminders.|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance b|76
54|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advan|76
55|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advan|76
56|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for the deaf) and call essential numbers.|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for t|76
57|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|76
58|1 - American Indian or Alaska Native|1 - American Indian or Alaska Native|76
59|1 - Depressed mood (e.g., feeling sad, tearful)|1 - Depressed mood (e.g., feeling sad, tearful)|76
60|1 - During the night only|1 - During the night only|76
61|1 - Fully granulating|1 - Fully granulating|76
62|1 - Good/Fair:  partial to full recovery is expected|1 - Good/Fair:  partial to full recovery is expected|76
63|1 - Good:  marked improvement in functional status is expected|1 - Good:  marked improvement in functional status is expected|76
64|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|76
65|1 - Smoking|1 - Smoking|76
66|1 - Hospital|1 - Hospital|76
67|1 - Hospital emergency room (includes 23-hour holding)|1 - Hospital emergency room (includes 23-hour holding)|76
68|1 - Hospitalization for EMERGENT (unscheduled) care|1 - Hospitalization for EMERGENT (unscheduled) care|76
69|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepared solutions), patient is able to manage all other aspects of equipment.|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepar|76
70|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|76
71|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|76
72|1 - In new or complex situations only|1 - In new or complex situations only|76
73|1 - Intravenous or infusion therapy (excludes TPN)|1 - Intravenous or infusion therapy (excludes TPN)|76
74|1 - Less often than daily|1 - Less often than daily|76
75|1 - Less than once a month|1 - Less than once a month|76
76|1 - Less than once weekly|1 - Less than once weekly|76
77|1 - Life expectancy is 6 months or fewer|1 - Life expectancy is 6 months or fewer|76
78|1 - Lives alone|1 - Lives alone|76
79|1 - Male|1 - Male|76
80|1 - Medicare (traditional fee-for-service)|1 - Medicare (traditional fee-for-service)|76
81|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of past 24 hours, significant memory loss so that supervision is required|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of pas|76
82|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors in word choice, grammar or speech intelligibility, needs minimal prompting or assistance).|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors i|76
83|1 - No assistance or services received|1 - No assistance or services received|76
84|1 - One|1 - One|76
85|1 - Oxygen (intermittent or continuous)|1 - Oxygen (intermittent or continuous)|76
86|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, and the surrounding layout, can count fingers at arm's length.|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, a|76
87|1 - Patient is incontinent|1 - Patient is incontinent|76
88|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|76
89|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical or treatment regimen.|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical|76
90|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient/couple/significant other)|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient|76
91|1 - Relatives, friends, or neighbors living outside the home|1 - Relatives, friends, or neighbors living outside the home|76
92|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions.|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions|76
93|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independentl|76
94|1 - Several times during day and night|1 - Several times during day and night|76
95|1 - Spouse or significant other|1 - Spouse or significant other|76
96|1 - Stage 1|1 - Stage 1|76
97|1 - Start of care - further visits planned|1 - Start of care - further visits planned|76
98|1 - Symptoms well controlled with current therapy|1 - Symptoms well controlled with current therapy|76
99|1 - Therapy services|1 - Therapy services|76
100|1 - Able to transfer with minimal human assistance or with use of an assistive device.|1 - Able to transfer with minimal human assistance or with use of an assistive device.|76
101|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitations.|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitatio|76
102|1 - Urinary incontinence|1 - Urinary incontinence|76
103|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and transfer.|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and|76
104|1 - When walking more than 20 feet, climbing stairs|1 - When walking more than 20 feet, climbing stairs|76
105|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary conversation. May need occasional repetition, extra time, or louder voice.|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary c|76
106|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting in and out of tub/shower|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting|76
107|1 - Yes|1 - Yes|76
108|1-RN|1-RN|76
109|10 - Discharge from agency - no visits completed after start/resumption of care assessment|10 - Discharge from agency - no visits completed after start/resumption of care assessment|76
110|10 - Scheduled surgical procedure|10 - Scheduled surgical procedure|76
111|10 - Self-pay|10 - Self-pay|76
112|11 - Other|11 - Other|76
113|11 - Urinary tract infection|11 - Urinary tract infection|76
114|12 - IV catheter-related infection|12 - IV catheter-related infection|76
115|13 - Deep vein thrombosis, pulmonary embolus|13 - Deep vein thrombosis, pulmonary embolus|76
116|14 - Uncontrolled pain|14 - Uncontrolled pain|76
117|15 - Psychotic episode|15 - Psychotic episode|76
118|16 - Other than above reasons|16 - Other than above reasons|76
119|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing calls.|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing|76
120|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another person.|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another pers|76
121|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface a|76
122|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for intermittent supervision or encouragement or reminders, OR (b) to get in and out of the shower or tub, OR (c) for washing difficult to reach areas.|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for inter|76
123|2 - Asian|2 - Asian|76
124|2 - Caregiver requires considerable assistance from another person to manage equipment, but independently completes significant portions of task.|2 - Caregiver requires considerable assistance from another person to manage equipment, but independ|76
125|2 - Daily, but not constantly|2 - Daily, but not constantly|76
126|2 - Daughter or son|2 - Daughter or son|76
127|2 - Doctor's office emergency visit/house call|2 - Doctor's office emergency visit/house call|76
128|2 - During the day and night|2 - During the day and night|76
129|2 - Early/partial granulation|2 - Early/partial granulation|76
130|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors in word choice, organization or speech intelligibility). Speaks in phrases or short sentences.|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors|76
131|2 - Family member's residence|2 - Family member's residence|76
132|2 - Female|2 - Female|76
133|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conversation, needs frequent prompting or assistance.|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conver|76
134|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|76
135|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|76
136|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately stop activities, jeopardizes safety through actions|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately st|76
137|2 - Indwelling/suprapubic catheter|2 - Indwelling/suprapubic catheter|76
138|2 - Injury caused by fall|2 - Injury caused by fall|76
139|2 - Medicare (HMO/managed care/Advantage plan)|2 - Medicare (HMO/managed care/Advantage plan)|76
140|2 - Nausea, dehydration, malnutrition, constipation, impaction|2 - Nausea, dehydration, malnutrition, constipation, impaction|76
141|2 - Obesity|2 - Obesity|76
142|2 - On awakening or at night only|2 - On awakening or at night only|76
143|2 - Once a month|2 - Once a month|76
144|2 - One to three times weekly|2 - One to three times weekly|76
145|2 - Parenteral nutrition (TPN or lipids)|2 - Parenteral nutrition (TPN or lipids)|76
146|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic) [ Go to M1620]|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic) [ Go|76
147|2 - Patient requires considerable assistance from another person to manage equipment, but independently completes portions of the task.|2 - Patient requires considerable assistance from another person to manage equipment, but independen|76
148|2 - Patient transferred to a noninstitutional hospice|2 - Patient transferred to a noninstitutional hospice|76
149|2 - Person residing in the home (EXCLUDING paid help)|2 - Person residing in the home (EXCLUDING paid help)|76
150|2 - Rehabilitation facility|2 - Rehabilitation facility|76
151|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifting of attention) or consistently requires low stimulus environment due to distractibility.|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifti|76
152|2 - Respite care|2 - Respite care|76
153|2 - Sense of failure or self reproach|2 - Sense of failure or self reproach|76
154|2 - Several times during day|2 - Several times during day|76
155|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonresponsive.|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonrespons|76
156|2 - Someone must assist the patient to groom self.|2 - Someone must assist the patient to groom self.|76
157|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|76
158|2 - Someone must help the patient put on upper body clothing.|2 - Someone must help the patient put on upper body clothing.|76
159|2 - Stage 2|2 - Stage 2|76
160|2 - Start of care - no further visits planned|2 - Start of care - no further visits planned|76
161|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitoring|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitori|76
162|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment regimen.|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment re|76
163|2 - Two|2 - Two|76
164|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistance due to cognitive or mental limitation.|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistanc|76
165|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|76
166|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assistance).|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assis|76
167|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home delivery.|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home deli|76
168|2 - Unable to prepare any light meals or reheat any delivered meals.|2 - Unable to prepare any light meals or reheat any delivered meals.|76
169|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|76
170|2 - UNABLE to take injectable medications unless administered by someone else.|2 - UNABLE to take injectable medications unless administered by someone else.|76
171|2 - UNABLE to take medication unless administered by someone else.|2 - UNABLE to take medication unless administered by someone else.|76
172|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|76
173|2 - Ventilator (continually or at night)|2 - Ventilator (continually or at night)|76
174|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less than 20 feet)|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less th|76
175|2 - With spouse or significant other|2 - With spouse or significant other|76
176|2 - Yes, assistance or services provided by family or friends|2 - Yes, assistance or services provided by family or friends|76
177|2-PT|2-PT|76
178|3 - Able to answer the telephone only some of the time or is able to carry on only a limited conversation.|3 - Able to answer the telephone only some of the time or is able to carry on only a limited convers|76
179|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube or gastrostomy.|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube|76
180|3 - Alcohol dependency|3 - Alcohol dependency|76
181|3 - All of the time|3 - All of the time|76
182|3 - Black or African-American|3 - Black or African-American|76
183|3 - Boarding home or rented room|3 - Boarding home or rented room|76
184|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment, clean/store/dispose of equipment or supplies).|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment,|76
185|3 -Able to walk only with the supervision or assistance of another person at all times.|3 -Able to walk only with the supervision or assistance of another person at all times.|76
186|3 - Continuous / Bi-level positive airway pressure|3 - Continuous / Bi-level positive airway pressure|76
187|3 - During the day and evening, but not constantly|3 - During the day and evening, but not constantly|76
188|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the alimentary canal)|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the|76
189|3 - Environmental support (e.g., housing, home maintenance)|3 - Environmental support (e.g., housing, home maintenance)|76
190|3 - Four to six times weekly|3 - Four to six times weekly|76
191|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessing by listener.  Speech limited to single words or short phrases.|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessin|76
192|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires multiple repetitions, restatements, demonstrations, additional time.|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires m|76
193|3 - Hopelessness|3 - Hopelessness|76
194|3 - Hospice care|3 - Hospice care|76
195|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|76
196|3 - Injury caused by fall or accident at home|3 - Injury caused by fall or accident at home|76
197|3 - Intractable pain|3 - Intractable pain|76
198|3 - Medicaid (traditional fee-for-service)|3 - Medicaid (traditional fee-for-service)|76
199|3 - Needs someone to do all shopping and errands.|3 - Needs someone to do all shopping and errands.|76
200|3 - Not healing|3 - Not healing|76
201|3 - Nursing home|3 - Nursing home|76
202|3 - Once daily|3 - Once daily|76
203|3 - Other family member|3 - Other family member|76
204|3 - Outpatient department/clinic emergency (includes urgicenter sites)|3 - Outpatient department/clinic emergency (includes urgicenter sites)|76
205|3 - Paid help|3 - Paid help|76
206|3 - Able to participate in bathing self in shower or tub, but requires presence of another person throughout the bath for assistance or supervision.|3 - Able to participate in bathing self in shower or tub, but requires presence of another person th|76
207|3 - Patient depends entirely upon another person to dress lower body.|3 - Patient depends entirely upon another person to dress lower body.|76
208|3 - Patient depends entirely upon another person to dress the upper body.|3 - Patient depends entirely upon another person to dress the upper body.|76
209|3 - Patient depends entirely upon someone else for grooming needs.|3 - Patient depends entirely upon someone else for grooming needs.|76
210|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone else to manage the equipment.|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone|76
211|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable to shift attention and recall directions more than half the time.|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable|76
212|3 - Respiratory problems (SOB, infection, obstruction)|3 - Respiratory problems (SOB, infection, obstruction)|76
213|3 - Resumption of care (after inpatient stay)|3 - Resumption of care (after inpatient stay)|76
214|3 - Several times each month|3 - Several times each month|76
215|3 - Skilled Nursing Facility|3 - Skilled Nursing Facility|76
216|3 - Stage 3|3 - Stage 3|76
217|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|76
218|3 - Three|3 - Three|76
219|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person throughout the process.|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person through|76
220|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal independently.|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal indep|76
221|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person.|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person|76
222|3 - Unknown because patient moved to a geographic location not served by this agency|3 - Unknown because patient moved to a geographic location not served by this agency|76
223|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|76
224|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|76
225|3 - With other family member|3 - With other family member|76
226|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home health services, homemaker assistance, transportation assistance, assisted living, board and care)|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home h|76
227|3-SLP/ST|3-SLP/ST|76
228|4 - At rest (during day or night)|4 - At rest (during day or night)|76
229|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|76
230|4 - Board and care or assisted living facility|4 - Board and care or assisted living facility|76
231|4 - Caregiver is completely dependent on someone else to manage all equipment.|4 - Caregiver is completely dependent on someone else to manage all equipment.|76
232|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|76
233|4 - Constantly|4 - Constantly|76
234|4 - Drug dependency|4 - Drug dependency|76
235|4 - Four or more|4 - Four or more|76
236|4 - Friend or neighbor or community or church member|4 - Friend or neighbor or community or church member|76
237|4 - Hispanic or Latino|4 - Hispanic or Latino|76
238|4 - Hospice|4 - Hospice|76
239|4 - Impaired decision-making|4 - Impaired decision-making|76
240|4 - Is totally dependent in toileting.|4 - Is totally dependent in toileting.|76
241|4 - Medicaid (HMO/managed care)|4 - Medicaid (HMO/managed care)|76
242|4 - None of the above|4 - None of the above|76
243|4 - Nursing home|4 - Nursing home|76
244|4 - On a daily basis|4 - On a daily basis|76
245|4 - Patient is completely dependent on someone else to manage all equipment.|4 - Patient is completely dependent on someone else to manage all equipment.|76
246|4 - Permanent placement|4 - Permanent placement|76
247|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, punches, dangerous maneuvers w/ wheelchair or other objects)|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, pu|76
248|4 - Psychosocial support (e.g., socialization, companionship, recreation)|4 - Psychosocial support (e.g., socialization, companionship, recreation)|76
249|4 - Recertification (follow-up) reassessment|4 - Recertification (follow-up) reassessment|76
250|4 - Recurrent thoughts of death|4 - Recurrent thoughts of death|76
251|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruction)|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruc|76
252|4 - Several times a week|4 - Several times a week|76
253|4 - Stage 4|4 - Stage 4|76
254|4 - Symptoms poorly controlled, history of rehospitalizations|4 - Symptoms poorly controlled, history of rehospitalizations|76
255|4 - Three or more times per week|4 - Three or more times per week|76
256|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetative state, or delirium.|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetati|76
257|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|76
258|4 - Unable to effectively participate in any housekeeping tasks.|4 - Unable to effectively participate in any housekeeping tasks.|76
259|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or unresponsive (e.g., speech is nonsensical or unintelligible).|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or u|76
260|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonresponsive.|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonr|76
261|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostomy.|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostom|76
262|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of devices at the sink, in chair, or on commode|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of|76
263|4 - With a friend|4 - With a friend|76
264|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|76
265|4-OT|4-OT|76
266|5 - Advocates or facilitates patient's participation in appropriate medical care|5 - Advocates or facilitates patient's participation in appropriate medical care|76
267|5 - At least daily|5 - At least daily|76
268|6 - Bedfast, unable to ambulate or be up in a chair.|6 - Bedfast, unable to ambulate or be up in a chair.|76
269|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|76
270|5 - Disruptive or socially inappropriate behavior|5 - Disruptive or socially inappropriate behavior|76
271|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|76
272|5 - Hypo/Hyperglycemia, diabetes out of control|5 - Hypo/Hyperglycemia, diabetes out of control|76
273|5 - More often than once daily|5 - More often than once daily|76
274|5 - Native Hawaiian or Pacific Islander|5 - Native Hawaiian or Pacific Islander|76
275|5 - None of the above|5 - None of the above|76
276|5 - One to two times per week|5 - One to two times per week|76
277|5 - Other|5 - Other|76
278|5 - Other follow-up|5 - Other follow-up|76
279|5 - Paid help|5 - Paid help|76
280|5 - Patient nonresponsive or unable to speak.|5 - Patient nonresponsive or unable to speak.|76
281|5 - Thoughts of suicide|5 - Thoughts of suicide|76
282|5 - Totally unable to use the telephone.|5 - Totally unable to use the telephone.|76
283|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|76
284|5 - Unable to take in nutrients orally or by tube feeding.|5 - Unable to take in nutrients orally or by tube feeding.|76
285|5 - Unsafe for care at home|5 - Unsafe for care at home|76
286|5 - With paid help (other than home care agency staff)|5 - With paid help (other than home care agency staff)|76
287|5 - Workers' compensation|5 - Workers' compensation|76
288|5 - Wound infection, deteriorating wound status, new lesion/ulcer|5 - Wound infection, deteriorating wound status, new lesion/ulcer|76
289|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|76
290|6 - Delusional, hallucinatory, or paranoid behavior|6 - Delusional, hallucinatory, or paranoid behavior|76
291|6 - Financial agent, power of attorney, or conservator of finance|6 - Financial agent, power of attorney, or conservator of finance|76
292|6 - GI bleeding, obstruction|6 - GI bleeding, obstruction|76
293|6 - Less often than weekly|6 - Less often than weekly|76
294|6 - Memory loss to the extent that supervision required|6 - Memory loss to the extent that supervision required|76
295|6 - None of the above feelings observed or reported|6 - None of the above feelings observed or reported|76
296|6 - Other|6 - Other|76
297|6 - Title programs (e.g., Title III, V, or XX)|6 - Title programs (e.g., Title III, V, or XX)|76
298|6 - Transferred to an inpatient facility - patient not discharged from agency|6 - Transferred to an inpatient facility - patient not discharged from agency|76
299|6 - White|6 - White|76
300|6 - With other than above|6 - With other than above|76
301|7 - Exacerbation of CHF, fluid overload, heart failure|7 - Exacerbation of CHF, fluid overload, heart failure|76
302|7 - Health care agent, conservator of person, or medical power of attorney|7 - Health care agent, conservator of person, or medical power of attorney|76
303|7 - Hypo/Hyperglycemia, diabetes out of control|7 - Hypo/Hyperglycemia, diabetes out of control|76
304|7 - None of the above|7 - None of the above|76
305|7 - None of the above behaviors demonstrated|7 - None of the above behaviors demonstrated|76
306|7 - Other government (e.g., TriCare, VA, etc.)|7 - Other government (e.g., TriCare, VA, etc.)|76
307|7 - Transferred to an inpatient facility - patient discharged from agency|7 - Transferred to an inpatient facility - patient discharged from agency|76
308|8 - Death at home|8 - Death at home|76
309|8 - GI bleeding, obstruction|8 - GI bleeding, obstruction|76
310|8 - Myocardial infarction, stroke|8 - Myocardial infarction, stroke|76
311|8 - Private insurance|8 - Private insurance|76
312|9 - Chemotherapy|9 - Chemotherapy|76
313|9 - Discharge from agency|9 - Discharge from agency|76
314|9 - Other than above reasons|9 - Other than above reasons|76
315|9 - Private HMO/managed care|9 - Private HMO/managed care|76
316|NA - No caregiver|NA - No caregiver|76
317|NA - No equipment of this type used in care.|NA - No equipment of this type used in care.|76
318|NA - No inhalant/mist medications prescribed.|NA - No inhalant/mist medications prescribed.|76
319|NA - No injectable medications prescribed.|NA - No injectable medications prescribed.|76
320|NA - No inpatient facility admission|NA - No inpatient facility admission|76
321|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|76
322|NA - No Medicaid|NA - No Medicaid|76
323|NA - No Medicare|NA - No Medicare|76
324|NA - No observable pressure ulcer or unhealed pressure ulcer|NA - No observable pressure ulcer or unhealed pressure ulcer|76
325|NA - No observable stasis ulcer|NA - No observable stasis ulcer|76
326|NA - No observable surgical wound|NA - No observable surgical wound|76
327|NA - No oral medications prescribed.|NA - No oral medications prescribed.|76
328|NA - Not applicable|NA - Not applicable|76
329|NA - Patient does not have a telephone.|NA - Patient does not have a telephone.|76
330|NA - Patient has ostomy for bowel elimination|NA - Patient has ostomy for bowel elimination|76
331|NA - Patient nonresponsive|NA - Patient nonresponsive|76
332|NA - Patient on prophylactic treatment|NA - Patient on prophylactic treatment|76
333|NA - Patient was not discharged from an inpatient facility [Go to M1017]|NA - Patient was not discharged from an inpatient facility [Go to M1017]|76
334|UK - Other unknown|UK - Other unknown|76
335|UK - Reason unknown|UK - Reason unknown|76
336|UK - Unknown|UK - Unknown|76
337|UK - Unknown or Not Available|UK - Unknown or Not Available|76
341|01 - Early|01 - Early|76
342|02 - Late|02 - Late|76
343|NA - Not Applicable. No case mix group defined for this assessment.|NA - Not Applicable. No case mix group defined for this assessment.|76
344|NA - No case mix group defined by this assessment.|NA - No case mix group defined by this assessment.|76
345|1 - Recent decline in mental, emotional, or behavioral status|1 - Recent decline in mental, emotional, or behavioral status|76
346|2 - Multiple hospitalizations (2 or more) in the past 12 months|2 - Multiple hospitalizations (2 or more) in the past 12 months|76
347|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|76
348|4 - Taking five or more medications|4 - Taking five or more medications|76
349|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|76
350|6 - Other|6 - Other|76
351|7 - None of the above|7 - None of the above|76
352|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond tho|76
353|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable without heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable wi|76
354|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious complications and death.|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious compl|76
355|3 - The patient has serious progressive conditions that could lead to death within a year.|3 - The patient has serious progressive conditions that could lead to death within a year.|76
356|UK - The patient+s situation is unknown or unclear.|UK - The patient+s situation is unknown or unclear.|76
357|0 - No [ Go to M1051 ]|0 - No [ Go to M1051 ]|76
358|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this influenza season. [ Go to M1050 ]|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this i|76
359|1 - Received from another health care provider (e.g., physician)|1 - Received from another health care provider (e.g., physician)|76
360|2 - Received from your agency previously during this year+s flu season|2 - Received from your agency previously during this year+s flu season|76
361|3 - Offered and declined|3 - Offered and declined|76
362|4 - Assessed and determined to have medical contraindication(s)|4 - Assessed and determined to have medical contraindication(s)|76
363|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|76
364|6 - Inability to obtain vaccine due to declared shortage|6 - Inability to obtain vaccine due to declared shortage|76
365|1 - Yes [ Go to M2005 at TRN; Go to M1230 at DC ]|1 - Yes [ Go to M2005 at TRN; Go to M1230 at DC ]|76
366|1 - Patient has received PPV in the past|1 - Patient has received PPV in the past|76
367|2 - Offered and declined|2 - Offered and declined|76
368|3 - Assessed and determined to have medical contraindication(s)|3 - Assessed and determined to have medical contraindication(s)|76
369|4 - Not indicated; patient does not meet age/condition guidelines for PPV|4 - Not indicated; patient does not meet age/condition guidelines for PPV|76
370|5 - None of the above|5 - None of the above|76
371|0 - Adequate: hears normal conversation without difficulty.|0 - Adequate: hears normal conversation without difficulty.|76
372|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to increase volume or speak distinctly.|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to in|76
373|2 - Severely Impaired: absence of useful hearing.|2 - Severely Impaired: absence of useful hearing.|76
374|UK - Unable to assess hearing.|UK - Unable to assess hearing.|76
375|0 - Understands: clear comprehension without cues or repetitions.|0 - Understands: clear comprehension without cues or repetitions.|76
376|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Requires cues at times to understand.|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Req|76
377|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequently requires cues to understand.|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequentl|76
378|3 - Rarely/Never Understands|3 - Rarely/Never Understands|76
379|UK - Unable to assess understanding.|UK - Unable to assess understanding.|76
380|0 - No standardized assessment conducted|0 - No standardized assessment conducted|76
381|1 - Yes, and it does not indicate severe pain|1 - Yes, and it does not indicate severe pain|76
382|2 - Yes, and it indicates severe pain|2 - Yes, and it indicates severe pain|76
383|0 - Patient has no pain|0 - Patient has no pain|76
384|1 - Patient has pain that does not interfere with activity or movement|1 - Patient has pain that does not interfere with activity or movement|76
385|2 - Less often than daily|2 - Less often than daily|76
386|3 - Daily, but not constantly|3 - Daily, but not constantly|76
387|4 - All of the time|4 - All of the time|76
388|0 - No assessment conducted [ Go to M1306 ]|0 - No assessment conducted [ Go to M1306 ]|76
389|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc., without use of standardized tool|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc.,|76
390|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|76
391|0 - No [ Go to M1322]|0 - No [ Go to M1322]|76
392|0 v Newly epithelialized|0 v Newly epithelialized|76
393|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|76
394|2 - Yes, patient has observable stasis ulcers ONLY|2 - Yes, patient has observable stasis ulcers ONLY|76
395|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable dressing) [Go to M1340]|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable|76
396|0 - No [ Go to M1350 ]|0 - No [ Go to M1350 ]|76
397|1 - Yes, patient has at least one (observable) surgical wound|1 - Yes, patient has at least one (observable) surgical wound|76
398|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1350 ]|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1350 ]|76
399|0 - Patient is not short of breath|0 - Patient is not short of breath|76
400|3 - Continuous Bi-level positive airway pressure|3 - Continuous Bi-level positive airway pressure|76
401|0 - No [ Go to M2005 at TRN; Go to M1600 at DC ]|0 - No [ Go to M2005 at TRN; Go to M1600 at DC ]|76
402|2 - Not assessed [Go to M2005 at TRN; Go to M1600 at DC ]|2 - Not assessed [Go to M2005 at TRN; Go to M1600 at DC ]|76
403|NA - Patient does not have diagnosis of heart failure [Go to M2005 at TRN; Go to M1600 at DC]|NA - Patient does not have diagnosis of heart failure [Go to M2005 at TRN; Go to M1600 at DC]|76
404|0 - No action taken|0 - No action taken|76
405|1 - Patient+s physician (or other primary care practitioner) contacted the same day|1 - Patient+s physician (or other primary care practitioner) contacted the same day|76
406|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|76
407|3 - Implement physician-ordered patient-specific established parameters for treatment|3 - Implement physician-ordered patient-specific established parameters for treatment|76
408|4 - Patient education or other clinical interventions|4 - Patient education or other clinical interventions|76
409|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequency, telehealth, etc.)|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequ|76
410|1 - Occasional stress incontinence|1 - Occasional stress incontinence|76
411|2 - During the night only|2 - During the night only|76
412|3 - During the day only|3 - During the day only|76
413|4 - During the day and night|4 - During the day and night|76
414|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|76
415|0 - Able to manage toileting hygiene and clothing management without assistance.|0 - Able to manage toileting hygiene and clothing management without assistance.|76
416|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implements are laid out for the patient.|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implemen|76
417|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|76
418|3 - Patient depends entirely upon another person to maintain toileting hygiene.|3 - Patient depends entirely upon another person to maintain toileting hygiene.|76
419|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independent|76
420|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface|76
421|0 - No multi-factor falls risk assessment conducted.|0 - No multi-factor falls risk assessment conducted.|76
422|1 - Yes, and it does not indicate a risk for falls.|1 - Yes, and it does not indicate a risk for falls.|76
423|2 - Yes, and it indicates a risk for falls.|2 - Yes, and it indicates a risk for falls.|76
424|0 - Not assessed/reviewed [ Go to M2010 ]|0 - Not assessed/reviewed [ Go to M2010 ]|76
425|1 - No problems found during review [ Go to M2010 ]|1 - No problems found during review [ Go to M2010 ]|76
426|2 - Problems found during review|2 - Problems found during review|76
427|NA - Patient is not taking any medications [ Go to M2040 ]|NA - Patient is not taking any medications [ Go to M2040 ]|76
428|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special precautions associated with all high-risk medications|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special p|76
429|NA - Patient not taking any drugs|NA - Patient not taking any drugs|76
430|2 - Able to take medication(s) at the correct times if given reminders by another person at the appropriate times|2 - Able to take medication(s) at the correct times if given reminders by another person at the appr|76
431|3 - Unable to take medication unless administered by another person.|3 - Unable to take medication unless administered by another person.|76
432|1 - At least daily|1 - At least daily|76
433|2 - Three or more times per week|2 - Three or more times per week|76
434|3 - One to two times per week|3 - One to two times per week|76
435|4 - Received, but less often than weekly|4 - Received, but less often than weekly|76
436|5 - No assistance received|5 - No assistance received|76
437|0 - No [Go to M2401]|0 - No [Go to M2401]|76
438|1 - Yes, used hospital emergency department WITHOUT hospital admission|1 - Yes, used hospital emergency department WITHOUT hospital admission|76
439|2 - Yes, used hospital emergency department WITH hospital admission|2 - Yes, used hospital emergency department WITH hospital admission|76
440|UK - Unknown [Go to M2401]|UK - Unknown [Go to M2401]|76
441|2 - Injury caused by fall|2 - Injury caused by fall|76
442|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|76
443|4 - Other respiratory problem|4 - Other respiratory problem|76
444|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|76
445|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|76
446|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|76
447|8 - Other heart disease|8 - Other heart disease|76
448|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|76
449|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|76
450|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|76
451|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|76
452|13 - Urinary tract infection|13 - Urinary tract infection|76
453|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|76
454|15 - Wound infection or deterioration|15 - Wound infection or deterioration|76
455|16 - Uncontrolled pain|16 - Uncontrolled pain|76
456|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|76
457|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|76
458|19 - Other than above reasons|19 - Other than above reasons|76
459|2 - Patient remained in the community (with formal assistive services)|2 - Patient remained in the community (with formal assistive services)|76
460|3 - Patient transferred to a noninstitutional hospice|3 - Patient transferred to a noninstitutional hospice|76
461|4 - Unknown because patient moved to a geographic location not served by this agency|4 - Unknown because patient moved to a geographic location not served by this agency|76
462|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|76
463|4 - Other respiratory problem|4 - Other respiratory problem|76
464|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|76
465|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|76
466|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|76
467|8 - Other heart disease|8 - Other heart disease|76
468|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|76
469|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|76
470|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|76
471|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|76
472|13 - Urinary tract infection|13 - Urinary tract infection|76
473|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|76
474|15 - Wound infection or deterioration|15 - Wound infection or deterioration|76
475|16 - Uncontrolled pain|16 - Uncontrolled pain|76
476|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|76
477|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|76
478|19 - Scheduled treatment or procedure|19 - Scheduled treatment or procedure|76
479|20 - Other than above reasons|20 - Other than above reasons|76
480|UK - Reason unknown [Go to M0903]|UK - Reason unknown [Go to M0903]|76
482|01 - Patient lives alone around the clock|01 - Patient lives alone around the clock|76
483|02 - Patient lives alone regular daytime|02 - Patient lives alone regular daytime|76
484|03 - Patient lives alone regular nighttime|03 - Patient lives alone regular nighttime|76
485|04 - Patient lives alone occassional/short term assistance|04 - Patient lives alone occassional/short term assistance|76
486|05 - Patient lives alone no assisstance available|05 - Patient lives alone no assisstance available|76
487|06 - Patient lives with other person(s) in the home around the clock|06 - Patient lives with other person(s) in the home around the clock|76
488|07 - Patient lives with other person(s) in the home regular daytime|07 - Patient lives with other person(s) in the home regular daytime|76
489|08 - Patient lives with other person(s) in the home regular nighttime|08 - Patient lives with other person(s) in the home regular nighttime|76
490|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|76
491|10 - Patient lives with other person(s) in the home no assistance available|10 - Patient lives with other person(s) in the home no assistance available|76
492|1 - Was present at the most recent SOC/ROC assessment|1 - Was present at the most recent SOC/ROC assessment|76
493|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|76
494|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|76
495|0 - Newly epithelialized|0 - Newly epithelialized|76
496|0 - No [ Go to M1340 ]|0 - No [ Go to M1340 ]|76
498|0 - Independent|0 - Independent|76
499|1 - Needed Some Help|1 - Needed Some Help|76
500|2 - Dependent|2 - Dependent|76
502|0 - No assistance needed in this area|0 - No assistance needed in this area|76
503|1 - Caregiver(s) currently provide assistance|1 - Caregiver(s) currently provide assistance|76
504|2 - Caregiver(s) need training/ supportive services to provide assistance|2 - Caregiver(s) need training/ supportive services to provide assistance|76
505|3 - Caregiver(s) not likely to provide assistance|3 - Caregiver(s) not likely to provide assistance|76
506|4 - Unclear if Caregiver(s) will provide assistance|4 - Unclear if Caregiver(s) will provide assistance|76
507|5 - Assistance needed, but no Caregiver(s) available|5 - Assistance needed, but no Caregiver(s) available|76
508|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will use standardized clinical guidelines accessible for all care providers to reference|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will|76
510|NA - Patient is not assessed to be at risk for falls|NA - Patient is not assessed to be at risk for falls|76
511|NA - Patient has no diagnosis or symptoms of depression|NA - Patient has no diagnosis or symptoms of depression|76
512|NA - No pain identified|NA - No pain identified|76
513|NA - Patient is not assessed to be at risk for pressure ulcers|NA - Patient is not assessed to be at risk for pressure ulcers|76
514|NA - Patient has no pressure ulcers with need for moist wound healing|NA - Patient has no pressure ulcers with need for moist wound healing|76
515|1 - Long-term nursing facility (NF)|1 - Long-term nursing facility (NF)|76
516|2 - Skilled nursing facility (SNF / TCU)|2 - Skilled nursing facility (SNF / TCU)|76
517|3 - Short stay acute hospital (IPP S)|3 - Short stay acute hospital (IPP S)|76
518|4 - Long-term care hospital (LTCH)|4 - Long-term care hospital (LTCH)|76
519|5 - Inpatient rehabilitation hospital or unit (IRF)|5 - Inpatient rehabilitation hospital or unit (IRF)|76
520|6 - Psychiatric hospital or unit|6 - Psychiatric hospital or unit|76
521|7 - Other|7 - Other|76
522|NA - Patient was not discharged from an inpatient facility [Go to M1017]|NA - Patient was not discharged from an inpatient facility [Go to M1017]|76
523|6 - Unable to participate effectively in bathing and is bathed totally by another person|6 - Unable to participate effectively in bathing and is bathed totally by another person|76
524|4 - Chairfast, unable to ambulate but is able to wheel self independently.|4 - Chairfast, unable to ambulate but is able to wheel self independently.|76
525|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask patient: "Over the last two weeks, how often have you been bothered by any of the following problems")|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask|76
526|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluation for depression.|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluat|76
527|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet criteria for further evaluation for depression.|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet|76
528|0 - Not at all  0 - 1 day|0 - Not at all  0 - 1 day|76
529|1 - Several days  2 - 6 days|1 - Several days  2 - 6 days|76
530|2 - More than half of the days  7 - 11 days|2 - More than half of the days  7 - 11 days|76
531|3 - Nearly every day  12 - 14 days|3 - Nearly every day  12 - 14 days|76
532|NA - N/A  Unable to respond|NA - N/A  Unable to respond|76
533|2 - Able to take medication(s) at the correct times if given reminders by another person based on the frequency of the injection|2 - Able to take medication(s) at the correct times if given reminders by another person based on th|76
534|3 - Unable to take injectable medication unless administered by another person.|3 - Unable to take injectable medication unless administered by another person.|76
547|NA - There were no potential clinically significant medication issues identified since SOC/ROC or patient is not taking any medications|NA -  There were no potential clinically significant medication issues identified since SOC/ROC |76
552|1 - Hospital|1 - Hospital [ Go to M2430 ]|76
553|2 - Rehabilitation facility |2 - Rehabilitation facility [ Go to M0903 ]|76
554|3 - Nursing home|3 - Nursing home [ Go to M2440 ]|76
555|4 - Hospice|4 - Hospice [ Go to M0903 ]|76
557|NA - Patient is not diabetic or is bilateral amputee|NA - Patient is not diabetic or is bilateral amputee|76
558|NA - Every standardized,validated multifactor fall risk assessment conducted at or since the most recent SOC/ROC assessment indicates the patient has no risk for falls.|NA - Every standardized,validated multifactor fall risk assessment condition|76
559|NA - Patient has no diagnosis of depression AND every standardized, validated depression screening conducted at or since the most recent SOC/ROC assessment indicates the patient has: 1) no symptoms of depression; or 2) has some symptoms of depression but does not meet criteria for further evaluation of depression based on screening tool used.|NA - Patient has no diagnosis of depression AND every standardized, validated |76
560|NA - Every standardized, validated pain assessment conducted at or since the most recent SOC/ROC assessment indicates the patient has no pain.|NA - Every standardized, validated pain assessment conducted at or since the most|76
561|NA - Every standardized, validated pressure ulcer risk assessment conducted at or since the most recent SOC/ROC assessment indicates the patient is not at risk of developing pressure ulcers.|NA - Every standardized, validated pressure ulcer risk assessment conducted|76
562|NA - Dressings that support the principles of moist wound healing not indicated for this patient's pressure ulcers OR patient has no pressure ulcers with need for moist wound healing|NA - Dressings that support the principles of moist wound healing not indicated for this patient's p|76
620|1 - Yes; received from your agency during this episode of care (SOC/ROC to Transfer/Discharge)|1 - Yes; received from your agency during this episode of care (SOC/ROC to Transfer/Discharge)|76
621|2 - Yes; received from your agency during a prior episode of care (SOC/ROC to Transfer/Discharge)|2 - Yes; received from your agency during a prior episode of care (SOC/ROC to Transfer/Discharge)|76
622|3 - Yes; received from another health care provider (for example physician pharmacist)|3 - Yes; received from another health care provider (for example physician pharmacist)|76
623|4 - No; patient offered and declined |4 - No; patient offered and declined |76
624|5 - No; patient assessed and determined to have medical contraindication(s)|5 - No; patient assessed and determined to have medical contraindication(s)|76
625|6 - No; not indicated - patient does not meet age/condition guidelines for influenza vaccine|6 - No; not indicated - patient does not meet age/condition guidelines for influenza vaccine|76
626|7 - No; inability to obtain vaccine due to declared shortage |7 - No; inability to obtain vaccine due to declared shortage |76
627|8 - No; patient did not receive the vaccine due to reasons other than those listed in responses 4 v 7. |8 - No; patient did not receive the vaccine due to reasons other than those listed in responses 4v7.|76
628|1 - Offered and declined|1 - Offered and declined|76
629|2 - Assessed and determined to have medical contraindication(s) |2 - Assessed and determined to have medical contraindication(s) |76
630|3 - Not indicated; patient does not meet age/condition guidelines for Pneumococcal Vaccine|3 - Not indicated; patient does not meet age/condition guidelines for Pneumococcal Vaccine|76
631|4 - None of the above|4 - None of the above|76
653|0 - No [STOP]|0 - No [STOP]|76
654|1 - Yes |1 - Yes|76
655|0 - None|0 - None|76
656|1 - One|1 - One|76
657|2 - Two or More|2 - Two or More|76
653|0 - No [STOP]|0 - No [STOP]|77
654|1 - Yes |1 - Yes|77
655|0 - None|0 - None|77
656|1 - One|1 - One|77
657|2 - Two or More|2 - Two or More|77
2|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; OR (b) Is physically, cognitively, and mentally able to prepare light meals on a regular basis but has not routinely performed light meal preparation in the past (i.e., prior to this home care admission).|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; O|77
3|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and mentally able to perform all housekeeping tasks .|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and menta|77
4|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and mentally able to do laundry and access facilities.|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and menta|77
5|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying packages OR b) Physically, cognitively, and mentally able to take care of shopping, but has not done shopping in the past (i.e., prior to this home care admission).|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying|77
6|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|77
7|0 - Able to dial numbers and answer calls appropriately and as desired.|0 - Able to dial numbers and answer calls appropriately and as desired.|77
8|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body without assistance.|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body|77
9|0 - Able to get to and from the toilet and transfer independently with or without a device.|0 - Able to get to and from the toilet and transfer independently with or without a device.|77
10|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|77
11|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible public bus.|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible p|77
12|0 - Able to independently feed self.|0 - Able to independently feed self.|77
13|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|77
14|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct times.|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct ti|77
15|0 - Able to independently transfer.|0 - Able to independently transfer.|77
16|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without rail|77
17|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings|77
18|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|77
19|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions independently.|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions indep|77
20|0 - Asymptomatic, no treatment needed at this time|0 - Asymptomatic, no treatment needed at this time|77
21|0 - Caregiver manages all tasks related to equipment completely independently.|0 - Caregiver manages all tasks related to equipment completely independently.|77
22|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations with no observable impairment.|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations w|77
23|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|77
24|0 - Life expectancy is greater than 6 months|0 - Life expectancy is greater than 6 months|77
25|0 - Never|0 - Never|77
26|0 - Patient is not short of breath|0 - Patient is not short of breath|77
27|0 - No|0 - No|77
28|0 - No emergent care services|0 - No emergent care services|77
29|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [Goto 1620]|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [Goto 1620]|77
30|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and extended or abstract conversation.|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and exte|77
31|0 - No one person|0 - No one person|77
32|0 - None of the time|0 - None of the time|77
33|0 - None, no charge for current services|0 - None, no charge for current services|77
34|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|77
35|0 - Patient does NOT have an ostomy for bowel elimination.|0 - Patient does NOT have an ostomy for bowel elimination.|77
36|0 - Patient has no pain|0 - Patient has no pain|77
37|0 - Patient manages all tasks related to equipment completely independently.|0 - Patient manages all tasks related to equipment completely independently.|77
38|0 - Poor:  little or no recovery is expected and/or further decline is imminent|0 - Poor:  little or no recovery is expected and/or further decline is imminent|77
39|0 - Timed-voiding defers incontinence|0 - Timed-voiding defers incontinence|77
40|0 - Very rarely or never has bowel incontinence|0 - Very rarely or never has bowel incontinence|77
41|0 - Zero|0 - Zero|77
42|00 - No|00 - No|77
43|01 - Yes|01 - Yes|77
44|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or mental limitations, needs assistance with heavy laundry.|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or|77
45|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the patient.|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the|77
46|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|77
47|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or supervision from another person OR c) a liquid, pureed or ground meat diet.|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or su|77
48|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|77
49|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|77
50|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independently.|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independe|77
51|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only when assisted or accompanied by another person.|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only w|77
52|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepa|77
53|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance by another person OR b) given daily reminders.|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance b|77
54|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advan|77
55|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advan|77
56|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for the deaf) and call essential numbers.|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for t|77
57|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|77
58|1 - American Indian or Alaska Native|1 - American Indian or Alaska Native|77
59|1 - Depressed mood (e.g., feeling sad, tearful)|1 - Depressed mood (e.g., feeling sad, tearful)|77
60|1 - During the night only|1 - During the night only|77
61|1 - Fully granulating|1 - Fully granulating|77
62|1 - Good/Fair:  partial to full recovery is expected|1 - Good/Fair:  partial to full recovery is expected|77
63|1 - Good:  marked improvement in functional status is expected|1 - Good:  marked improvement in functional status is expected|77
64|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|77
65|1 - Smoking|1 - Smoking|77
66|1 - Hospital|1 - Hospital|77
67|1 - Hospital emergency room (includes 23-hour holding)|1 - Hospital emergency room (includes 23-hour holding)|77
68|1 - Hospitalization for EMERGENT (unscheduled) care|1 - Hospitalization for EMERGENT (unscheduled) care|77
69|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepared solutions), patient is able to manage all other aspects of equipment.|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepar|77
70|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|77
71|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|77
72|1 - In new or complex situations only|1 - In new or complex situations only|77
73|1 - Intravenous or infusion therapy (excludes TPN)|1 - Intravenous or infusion therapy (excludes TPN)|77
74|1 - Less often than daily|1 - Less often than daily|77
75|1 - Less than once a month|1 - Less than once a month|77
76|1 - Less than once weekly|1 - Less than once weekly|77
77|1 - Life expectancy is 6 months or fewer|1 - Life expectancy is 6 months or fewer|77
78|1 - Lives alone|1 - Lives alone|77
79|1 - Male|1 - Male|77
80|1 - Medicare (traditional fee-for-service)|1 - Medicare (traditional fee-for-service)|77
81|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of past 24 hours, significant memory loss so that supervision is required|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of pas|77
82|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors in word choice, grammar or speech intelligibility, needs minimal prompting or assistance).|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors i|77
83|1 - No assistance or services received|1 - No assistance or services received|77
84|1 - One|1 - One|77
85|1 - Oxygen (intermittent or continuous)|1 - Oxygen (intermittent or continuous)|77
86|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, and the surrounding layout, can count fingers at arm's length.|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, a|77
87|1 - Patient is incontinent|1 - Patient is incontinent|77
88|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|77
89|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical or treatment regimen.|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical|77
90|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient/couple/significant other)|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient|77
91|1 - Relatives, friends, or neighbors living outside the home|1 - Relatives, friends, or neighbors living outside the home|77
92|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions.|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions|77
93|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independentl|77
94|1 - Several times during day and night|1 - Several times during day and night|77
95|1 - Spouse or significant other|1 - Spouse or significant other|77
96|1 - Stage 1|1 - Stage 1|77
97|1 - Start of care - further visits planned|1 - Start of care - further visits planned|77
98|1 - Symptoms well controlled with current therapy|1 - Symptoms well controlled with current therapy|77
99|1 - Therapy services|1 - Therapy services|77
100|1 - Able to transfer with minimal human assistance or with use of an assistive device.|1 - Able to transfer with minimal human assistance or with use of an assistive device.|77
101|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitations.|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitatio|77
102|1 - Urinary incontinence|1 - Urinary incontinence|77
103|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and transfer.|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and|77
104|1 - When walking more than 20 feet, climbing stairs|1 - When walking more than 20 feet, climbing stairs|77
105|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary conversation. May need occasional repetition, extra time, or louder voice.|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary c|77
106|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting in and out of tub/shower|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting|77
107|1 - Yes|1 - Yes|77
108|1-RN|1-RN|77
109|10 - Discharge from agency - no visits completed after start/resumption of care assessment|10 - Discharge from agency - no visits completed after start/resumption of care assessment|77
110|10 - Scheduled surgical procedure|10 - Scheduled surgical procedure|77
111|10 - Self-pay|10 - Self-pay|77
112|11 - Other|11 - Other|77
113|11 - Urinary tract infection|11 - Urinary tract infection|77
114|12 - IV catheter-related infection|12 - IV catheter-related infection|77
115|13 - Deep vein thrombosis, pulmonary embolus|13 - Deep vein thrombosis, pulmonary embolus|77
116|14 - Uncontrolled pain|14 - Uncontrolled pain|77
117|15 - Psychotic episode|15 - Psychotic episode|77
118|16 - Other than above reasons|16 - Other than above reasons|77
119|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing calls.|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing|77
120|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another person.|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another pers|77
121|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface a|77
122|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for intermittent supervision or encouragement or reminders, OR (b) to get in and out of the shower or tub, OR (c) for washing difficult to reach areas.|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for inter|77
123|2 - Asian|2 - Asian|77
124|2 - Caregiver requires considerable assistance from another person to manage equipment, but independently completes significant portions of task.|2 - Caregiver requires considerable assistance from another person to manage equipment, but independ|77
125|2 - Daily, but not constantly|2 - Daily, but not constantly|77
126|2 - Daughter or son|2 - Daughter or son|77
127|2 - Doctor's office emergency visit/house call|2 - Doctor's office emergency visit/house call|77
128|2 - During the day and night|2 - During the day and night|77
129|2 - Early/partial granulation|2 - Early/partial granulation|77
130|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors in word choice, organization or speech intelligibility). Speaks in phrases or short sentences.|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors|77
131|2 - Family member's residence|2 - Family member's residence|77
132|2 - Female|2 - Female|77
133|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conversation, needs frequent prompting or assistance.|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conver|77
134|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|77
135|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|77
136|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately stop activities, jeopardizes safety through actions|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately st|77
137|2 - Indwelling/suprapubic catheter|2 - Indwelling/suprapubic catheter|77
138|2 - Injury caused by fall|2 - Injury caused by fall|77
139|2 - Medicare (HMO/managed care/Advantage plan)|2 - Medicare (HMO/managed care/Advantage plan)|77
140|2 - Nausea, dehydration, malnutrition, constipation, impaction|2 - Nausea, dehydration, malnutrition, constipation, impaction|77
141|2 - Obesity|2 - Obesity|77
142|2 - On awakening or at night only|2 - On awakening or at night only|77
143|2 - Once a month|2 - Once a month|77
144|2 - One to three times weekly|2 - One to three times weekly|77
145|2 - Parenteral nutrition (TPN or lipids)|2 - Parenteral nutrition (TPN or lipids)|77
146|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic) [ Go to M1620]|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic) [ Go|77
147|2 - Patient requires considerable assistance from another person to manage equipment, but independently completes portions of the task.|2 - Patient requires considerable assistance from another person to manage equipment, but independen|77
148|2 - Patient transferred to a noninstitutional hospice|2 - Patient transferred to a noninstitutional hospice|77
149|2 - Person residing in the home (EXCLUDING paid help)|2 - Person residing in the home (EXCLUDING paid help)|77
150|2 - Rehabilitation facility|2 - Rehabilitation facility|77
151|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifting of attention) or consistently requires low stimulus environment due to distractibility.|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifti|77
152|2 - Respite care|2 - Respite care|77
153|2 - Sense of failure or self reproach|2 - Sense of failure or self reproach|77
154|2 - Several times during day|2 - Several times during day|77
155|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonresponsive.|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonrespons|77
156|2 - Someone must assist the patient to groom self.|2 - Someone must assist the patient to groom self.|77
157|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|77
158|2 - Someone must help the patient put on upper body clothing.|2 - Someone must help the patient put on upper body clothing.|77
159|2 - Stage 2|2 - Stage 2|77
160|2 - Start of care - no further visits planned|2 - Start of care - no further visits planned|77
161|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitoring|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitori|77
162|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment regimen.|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment re|77
163|2 - Two|2 - Two|77
164|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistance due to cognitive or mental limitation.|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistanc|77
165|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|77
166|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assistance).|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assis|77
167|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home delivery.|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home deli|77
168|2 - Unable to prepare any light meals or reheat any delivered meals.|2 - Unable to prepare any light meals or reheat any delivered meals.|77
169|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|77
170|2 - UNABLE to take injectable medications unless administered by someone else.|2 - UNABLE to take injectable medications unless administered by someone else.|77
171|2 - UNABLE to take medication unless administered by someone else.|2 - UNABLE to take medication unless administered by someone else.|77
172|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|77
173|2 - Ventilator (continually or at night)|2 - Ventilator (continually or at night)|77
174|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less than 20 feet)|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less th|77
175|2 - With spouse or significant other|2 - With spouse or significant other|77
176|2 - Yes, assistance or services provided by family or friends|2 - Yes, assistance or services provided by family or friends|77
177|2-PT|2-PT|77
178|3 - Able to answer the telephone only some of the time or is able to carry on only a limited conversation.|3 - Able to answer the telephone only some of the time or is able to carry on only a limited convers|77
179|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube or gastrostomy.|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube|77
180|3 - Alcohol dependency|3 - Alcohol dependency|77
181|3 - All of the time|3 - All of the time|77
182|3 - Black or African-American|3 - Black or African-American|77
183|3 - Boarding home or rented room|3 - Boarding home or rented room|77
184|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment, clean/store/dispose of equipment or supplies).|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment,|77
185|3 -Able to walk only with the supervision or assistance of another person at all times.|3 -Able to walk only with the supervision or assistance of another person at all times.|77
186|3 - Continuous / Bi-level positive airway pressure|3 - Continuous / Bi-level positive airway pressure|77
187|3 - During the day and evening, but not constantly|3 - During the day and evening, but not constantly|77
188|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the alimentary canal)|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the|77
189|3 - Environmental support (e.g., housing, home maintenance)|3 - Environmental support (e.g., housing, home maintenance)|77
190|3 - Four to six times weekly|3 - Four to six times weekly|77
191|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessing by listener.  Speech limited to single words or short phrases.|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessin|77
192|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires multiple repetitions, restatements, demonstrations, additional time.|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires m|77
193|3 - Hopelessness|3 - Hopelessness|77
194|3 - Hospice care|3 - Hospice care|77
195|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|77
196|3 - Injury caused by fall or accident at home|3 - Injury caused by fall or accident at home|77
197|3 - Intractable pain|3 - Intractable pain|77
198|3 - Medicaid (traditional fee-for-service)|3 - Medicaid (traditional fee-for-service)|77
199|3 - Needs someone to do all shopping and errands.|3 - Needs someone to do all shopping and errands.|77
200|3 - Not healing|3 - Not healing|77
201|3 - Nursing home|3 - Nursing home|77
202|3 - Once daily|3 - Once daily|77
203|3 - Other family member|3 - Other family member|77
204|3 - Outpatient department/clinic emergency (includes urgicenter sites)|3 - Outpatient department/clinic emergency (includes urgicenter sites)|77
205|3 - Paid help|3 - Paid help|77
206|3 - Able to participate in bathing self in shower or tub, but requires presence of another person throughout the bath for assistance or supervision.|3 - Able to participate in bathing self in shower or tub, but requires presence of another person th|77
207|3 - Patient depends entirely upon another person to dress lower body.|3 - Patient depends entirely upon another person to dress lower body.|77
208|3 - Patient depends entirely upon another person to dress the upper body.|3 - Patient depends entirely upon another person to dress the upper body.|77
209|3 - Patient depends entirely upon someone else for grooming needs.|3 - Patient depends entirely upon someone else for grooming needs.|77
210|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone else to manage the equipment.|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone|77
211|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable to shift attention and recall directions more than half the time.|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable|77
212|3 - Respiratory problems (SOB, infection, obstruction)|3 - Respiratory problems (SOB, infection, obstruction)|77
213|3 - Resumption of care (after inpatient stay)|3 - Resumption of care (after inpatient stay)|77
214|3 - Several times each month|3 - Several times each month|77
215|3 - Skilled Nursing Facility|3 - Skilled Nursing Facility|77
216|3 - Stage 3|3 - Stage 3|77
217|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|77
218|3 - Three|3 - Three|77
219|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person throughout the process.|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person through|77
220|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal independently.|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal indep|77
221|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person.|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person|77
222|3 - Unknown because patient moved to a geographic location not served by this agency|3 - Unknown because patient moved to a geographic location not served by this agency|77
223|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|77
224|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|77
225|3 - With other family member|3 - With other family member|77
226|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home health services, homemaker assistance, transportation assistance, assisted living, board and care)|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home h|77
227|3-SLP/ST|3-SLP/ST|77
228|4 - At rest (during day or night)|4 - At rest (during day or night)|77
229|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|77
230|4 - Board and care or assisted living facility|4 - Board and care or assisted living facility|77
231|4 - Caregiver is completely dependent on someone else to manage all equipment.|4 - Caregiver is completely dependent on someone else to manage all equipment.|77
232|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|77
233|4 - Constantly|4 - Constantly|77
234|4 - Drug dependency|4 - Drug dependency|77
235|4 - Four or more|4 - Four or more|77
236|4 - Friend or neighbor or community or church member|4 - Friend or neighbor or community or church member|77
237|4 - Hispanic or Latino|4 - Hispanic or Latino|77
238|4 - Hospice|4 - Hospice|77
239|4 - Impaired decision-making|4 - Impaired decision-making|77
240|4 - Is totally dependent in toileting.|4 - Is totally dependent in toileting.|77
241|4 - Medicaid (HMO/managed care)|4 - Medicaid (HMO/managed care)|77
242|4 - None of the above|4 - None of the above|77
243|4 - Nursing home|4 - Nursing home|77
244|4 - On a daily basis|4 - On a daily basis|77
245|4 - Patient is completely dependent on someone else to manage all equipment.|4 - Patient is completely dependent on someone else to manage all equipment.|77
246|4 - Permanent placement|4 - Permanent placement|77
247|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, punches, dangerous maneuvers w/ wheelchair or other objects)|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, pu|77
248|4 - Psychosocial support (e.g., socialization, companionship, recreation)|4 - Psychosocial support (e.g., socialization, companionship, recreation)|77
249|4 - Recertification (follow-up) reassessment|4 - Recertification (follow-up) reassessment|77
250|4 - Recurrent thoughts of death|4 - Recurrent thoughts of death|77
251|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruction)|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruc|77
252|4 - Several times a week|4 - Several times a week|77
253|4 - Stage 4|4 - Stage 4|77
254|4 - Symptoms poorly controlled, history of rehospitalizations|4 - Symptoms poorly controlled, history of rehospitalizations|77
255|4 - Three or more times per week|4 - Three or more times per week|77
256|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetative state, or delirium.|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetati|77
257|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|77
258|4 - Unable to effectively participate in any housekeeping tasks.|4 - Unable to effectively participate in any housekeeping tasks.|77
259|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or unresponsive (e.g., speech is nonsensical or unintelligible).|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or u|77
260|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonresponsive.|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonr|77
261|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostomy.|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostom|77
262|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of devices at the sink, in chair, or on commode|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of|77
263|4 - With a friend|4 - With a friend|77
264|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|77
265|4-OT|4-OT|77
266|5 - Advocates or facilitates patient's participation in appropriate medical care|5 - Advocates or facilitates patient's participation in appropriate medical care|77
267|5 - At least daily|5 - At least daily|77
268|6 - Bedfast, unable to ambulate or be up in a chair.|6 - Bedfast, unable to ambulate or be up in a chair.|77
269|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|77
270|5 - Disruptive or socially inappropriate behavior|5 - Disruptive or socially inappropriate behavior|77
271|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|77
272|5 - Hypo/Hyperglycemia, diabetes out of control|5 - Hypo/Hyperglycemia, diabetes out of control|77
273|5 - More often than once daily|5 - More often than once daily|77
274|5 - Native Hawaiian or Pacific Islander|5 - Native Hawaiian or Pacific Islander|77
275|5 - None of the above|5 - None of the above|77
276|5 - One to two times per week|5 - One to two times per week|77
277|5 - Other|5 - Other|77
278|5 - Other follow-up|5 - Other follow-up|77
279|5 - Paid help|5 - Paid help|77
280|5 - Patient nonresponsive or unable to speak.|5 - Patient nonresponsive or unable to speak.|77
281|5 - Thoughts of suicide|5 - Thoughts of suicide|77
282|5 - Totally unable to use the telephone.|5 - Totally unable to use the telephone.|77
283|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|77
284|5 - Unable to take in nutrients orally or by tube feeding.|5 - Unable to take in nutrients orally or by tube feeding.|77
285|5 - Unsafe for care at home|5 - Unsafe for care at home|77
286|5 - With paid help (other than home care agency staff)|5 - With paid help (other than home care agency staff)|77
287|5 - Workers' compensation|5 - Workers' compensation|77
288|5 - Wound infection, deteriorating wound status, new lesion/ulcer|5 - Wound infection, deteriorating wound status, new lesion/ulcer|77
289|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|77
290|6 - Delusional, hallucinatory, or paranoid behavior|6 - Delusional, hallucinatory, or paranoid behavior|77
291|6 - Financial agent, power of attorney, or conservator of finance|6 - Financial agent, power of attorney, or conservator of finance|77
292|6 - GI bleeding, obstruction|6 - GI bleeding, obstruction|77
293|6 - Less often than weekly|6 - Less often than weekly|77
294|6 - Memory loss to the extent that supervision required|6 - Memory loss to the extent that supervision required|77
295|6 - None of the above feelings observed or reported|6 - None of the above feelings observed or reported|77
296|6 - Other|6 - Other|77
297|6 - Title programs (e.g., Title III, V, or XX)|6 - Title programs (e.g., Title III, V, or XX)|77
298|6 - Transferred to an inpatient facility - patient not discharged from agency|6 - Transferred to an inpatient facility - patient not discharged from agency|77
299|6 - White|6 - White|77
300|6 - With other than above|6 - With other than above|77
301|7 - Exacerbation of CHF, fluid overload, heart failure|7 - Exacerbation of CHF, fluid overload, heart failure|77
302|7 - Health care agent, conservator of person, or medical power of attorney|7 - Health care agent, conservator of person, or medical power of attorney|77
303|7 - Hypo/Hyperglycemia, diabetes out of control|7 - Hypo/Hyperglycemia, diabetes out of control|77
304|7 - None of the above|7 - None of the above|77
305|7 - None of the above behaviors demonstrated|7 - None of the above behaviors demonstrated|77
306|7 - Other government (e.g., TriCare, VA, etc.)|7 - Other government (e.g., TriCare, VA, etc.)|77
307|7 - Transferred to an inpatient facility - patient discharged from agency|7 - Transferred to an inpatient facility - patient discharged from agency|77
308|8 - Death at home|8 - Death at home|77
309|8 - GI bleeding, obstruction|8 - GI bleeding, obstruction|77
310|8 - Myocardial infarction, stroke|8 - Myocardial infarction, stroke|77
311|8 - Private insurance|8 - Private insurance|77
312|9 - Chemotherapy|9 - Chemotherapy|77
313|9 - Discharge from agency|9 - Discharge from agency|77
314|9 - Other than above reasons|9 - Other than above reasons|77
315|9 - Private HMO/managed care|9 - Private HMO/managed care|77
316|NA - No caregiver|NA - No caregiver|77
317|NA - No equipment of this type used in care.|NA - No equipment of this type used in care.|77
318|NA - No inhalant/mist medications prescribed.|NA - No inhalant/mist medications prescribed.|77
319|NA - No injectable medications prescribed.|NA - No injectable medications prescribed.|77
320|NA - No inpatient facility admission|NA - No inpatient facility admission|77
321|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|77
322|NA - No Medicaid|NA - No Medicaid|77
323|NA - No Medicare|NA - No Medicare|77
324|NA - No observable pressure ulcer or unhealed pressure ulcer|NA - No observable pressure ulcer or unhealed pressure ulcer|77
325|NA - No observable stasis ulcer|NA - No observable stasis ulcer|77
326|NA - No observable surgical wound|NA - No observable surgical wound|77
327|NA - No oral medications prescribed.|NA - No oral medications prescribed.|77
328|NA - Not applicable|NA - Not applicable|77
329|NA - Patient does not have a telephone.|NA - Patient does not have a telephone.|77
330|NA - Patient has ostomy for bowel elimination|NA - Patient has ostomy for bowel elimination|77
331|NA - Patient nonresponsive|NA - Patient nonresponsive|77
332|NA - Patient on prophylactic treatment|NA - Patient on prophylactic treatment|77
333|NA - Patient was not discharged from an inpatient facility [Go to M1017]|NA - Patient was not discharged from an inpatient facility [Go to M1017]|77
334|UK - Other unknown|UK - Other unknown|77
335|UK - Reason unknown|UK - Reason unknown|77
336|UK - Unknown|UK - Unknown|77
337|UK - Unknown or Not Available|UK - Unknown or Not Available|77
341|01 - Early|01 - Early|77
342|02 - Late|02 - Late|77
343|NA - Not Applicable. No case mix group defined for this assessment.|NA - Not Applicable. No case mix group defined for this assessment.|77
344|NA - No case mix group defined by this assessment.|NA - No case mix group defined by this assessment.|77
345|1 - Recent decline in mental, emotional, or behavioral status|1 - Recent decline in mental, emotional, or behavioral status|77
346|2 - Multiple hospitalizations (2 or more) in the past 12 months|2 - Multiple hospitalizations (2 or more) in the past 12 months|77
347|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|77
348|4 - Taking five or more medications|4 - Taking five or more medications|77
349|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|77
350|6 - Other|6 - Other|77
351|7 - None of the above|7 - None of the above|77
352|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond tho|77
353|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable without heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable wi|77
354|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious complications and death.|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious compl|77
355|3 - The patient has serious progressive conditions that could lead to death within a year.|3 - The patient has serious progressive conditions that could lead to death within a year.|77
356|UK - The patient+s situation is unknown or unclear.|UK - The patient+s situation is unknown or unclear.|77
357|0 - No [ Go to M1051 ]|0 - No [ Go to M1051 ]|77
358|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this influenza season. [ Go to M1050 ]|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this i|77
359|1 - Received from another health care provider (e.g., physician)|1 - Received from another health care provider (e.g., physician)|77
360|2 - Received from your agency previously during this year+s flu season|2 - Received from your agency previously during this year+s flu season|77
361|3 - Offered and declined|3 - Offered and declined|77
362|4 - Assessed and determined to have medical contraindication(s)|4 - Assessed and determined to have medical contraindication(s)|77
363|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|77
364|6 - Inability to obtain vaccine due to declared shortage|6 - Inability to obtain vaccine due to declared shortage|77
365|1 - Yes [ Go to M2005 at TRN; Go to M1230 at DC ]|1 - Yes [ Go to M2005 at TRN; Go to M1230 at DC ]|77
366|1 - Patient has received PPV in the past|1 - Patient has received PPV in the past|77
367|2 - Offered and declined|2 - Offered and declined|77
368|3 - Assessed and determined to have medical contraindication(s)|3 - Assessed and determined to have medical contraindication(s)|77
369|4 - Not indicated; patient does not meet age/condition guidelines for PPV|4 - Not indicated; patient does not meet age/condition guidelines for PPV|77
370|5 - None of the above|5 - None of the above|77
371|0 - Adequate: hears normal conversation without difficulty.|0 - Adequate: hears normal conversation without difficulty.|77
372|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to increase volume or speak distinctly.|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to in|77
373|2 - Severely Impaired: absence of useful hearing.|2 - Severely Impaired: absence of useful hearing.|77
374|UK - Unable to assess hearing.|UK - Unable to assess hearing.|77
375|0 - Understands: clear comprehension without cues or repetitions.|0 - Understands: clear comprehension without cues or repetitions.|77
376|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Requires cues at times to understand.|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Req|77
377|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequently requires cues to understand.|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequentl|77
378|3 - Rarely/Never Understands|3 - Rarely/Never Understands|77
379|UK - Unable to assess understanding.|UK - Unable to assess understanding.|77
380|0 - No standardized assessment conducted|0 - No standardized assessment conducted|77
381|1 - Yes, and it does not indicate severe pain|1 - Yes, and it does not indicate severe pain|77
382|2 - Yes, and it indicates severe pain|2 - Yes, and it indicates severe pain|77
383|0 - Patient has no pain|0 - Patient has no pain|77
384|1 - Patient has pain that does not interfere with activity or movement|1 - Patient has pain that does not interfere with activity or movement|77
385|2 - Less often than daily|2 - Less often than daily|77
386|3 - Daily, but not constantly|3 - Daily, but not constantly|77
387|4 - All of the time|4 - All of the time|77
388|0 - No assessment conducted [ Go to M1306 ]|0 - No assessment conducted [ Go to M1306 ]|77
389|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc., without use of standardized tool|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc.,|77
390|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|77
391|0 - No [ Go to M1322]|0 - No [ Go to M1322]|77
392|0 v Newly epithelialized|0 v Newly epithelialized|77
393|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|77
394|2 - Yes, patient has observable stasis ulcers ONLY|2 - Yes, patient has observable stasis ulcers ONLY|77
395|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable dressing) [Go to M1340]|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable|77
396|0 - No [ Go to M1350 ]|0 - No [ Go to M1350 ]|77
397|1 - Yes, patient has at least one (observable) surgical wound|1 - Yes, patient has at least one (observable) surgical wound|77
398|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1350 ]|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1350 ]|77
399|0 - Patient is not short of breath|0 - Patient is not short of breath|77
400|3 - Continuous Bi-level positive airway pressure|3 - Continuous Bi-level positive airway pressure|77
401|0 - No [ Go to M2005 at TRN; Go to M1600 at DC ]|0 - No [ Go to M2005 at TRN; Go to M1600 at DC ]|77
402|2 - Not assessed [Go to M2005 at TRN; Go to M1600 at DC ]|2 - Not assessed [Go to M2005 at TRN; Go to M1600 at DC ]|77
403|NA - Patient does not have diagnosis of heart failure [Go to M2005 at TRN; Go to M1600 at DC]|NA - Patient does not have diagnosis of heart failure [Go to M2005 at TRN; Go to M1600 at DC]|77
404|0 - No action taken|0 - No action taken|77
405|1 - Patient+s physician (or other primary care practitioner) contacted the same day|1 - Patient+s physician (or other primary care practitioner) contacted the same day|77
406|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|77
407|3 - Implement physician-ordered patient-specific established parameters for treatment|3 - Implement physician-ordered patient-specific established parameters for treatment|77
408|4 - Patient education or other clinical interventions|4 - Patient education or other clinical interventions|77
409|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequency, telehealth, etc.)|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequ|77
410|1 - Occasional stress incontinence|1 - Occasional stress incontinence|77
411|2 - During the night only|2 - During the night only|77
412|3 - During the day only|3 - During the day only|77
413|4 - During the day and night|4 - During the day and night|77
414|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|77
415|0 - Able to manage toileting hygiene and clothing management without assistance.|0 - Able to manage toileting hygiene and clothing management without assistance.|77
416|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implements are laid out for the patient.|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implemen|77
417|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|77
418|3 - Patient depends entirely upon another person to maintain toileting hygiene.|3 - Patient depends entirely upon another person to maintain toileting hygiene.|77
419|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independent|77
420|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface|77
421|0 - No multi-factor falls risk assessment conducted.|0 - No multi-factor falls risk assessment conducted.|77
422|1 - Yes, and it does not indicate a risk for falls.|1 - Yes, and it does not indicate a risk for falls.|77
423|2 - Yes, and it indicates a risk for falls.|2 - Yes, and it indicates a risk for falls.|77
424|0 - Not assessed/reviewed [ Go to M2010 ]|0 - Not assessed/reviewed [ Go to M2010 ]|77
425|1 - No problems found during review [ Go to M2010 ]|1 - No problems found during review [ Go to M2010 ]|77
426|2 - Problems found during review|2 - Problems found during review|77
427|NA - Patient is not taking any medications [ Go to M2040 ]|NA - Patient is not taking any medications [ Go to M2040 ]|77
428|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special precautions associated with all high-risk medications|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special p|77
429|NA - Patient not taking any drugs|NA - Patient not taking any drugs|77
430|2 - Able to take medication(s) at the correct times if given reminders by another person at the appropriate times|2 - Able to take medication(s) at the correct times if given reminders by another person at the appr|77
431|3 - Unable to take medication unless administered by another person.|3 - Unable to take medication unless administered by another person.|77
432|1 - At least daily|1 - At least daily|77
433|2 - Three or more times per week|2 - Three or more times per week|77
434|3 - One to two times per week|3 - One to two times per week|77
435|4 - Received, but less often than weekly|4 - Received, but less often than weekly|77
436|5 - No assistance received|5 - No assistance received|77
437|0 - No [Go to M2401]|0 - No [Go to M2401]|77
438|1 - Yes, used hospital emergency department WITHOUT hospital admission|1 - Yes, used hospital emergency department WITHOUT hospital admission|77
439|2 - Yes, used hospital emergency department WITH hospital admission|2 - Yes, used hospital emergency department WITH hospital admission|77
440|UK - Unknown [Go to M2401]|UK - Unknown [Go to M2401]|77
441|2 - Injury caused by fall|2 - Injury caused by fall|77
442|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|77
443|4 - Other respiratory problem|4 - Other respiratory problem|77
444|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|77
445|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|77
446|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|77
447|8 - Other heart disease|8 - Other heart disease|77
448|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|77
449|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|77
450|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|77
451|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|77
452|13 - Urinary tract infection|13 - Urinary tract infection|77
453|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|77
454|15 - Wound infection or deterioration|15 - Wound infection or deterioration|77
455|16 - Uncontrolled pain|16 - Uncontrolled pain|77
456|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|77
457|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|77
458|19 - Other than above reasons|19 - Other than above reasons|77
459|2 - Patient remained in the community (with formal assistive services)|2 - Patient remained in the community (with formal assistive services)|77
460|3 - Patient transferred to a noninstitutional hospice|3 - Patient transferred to a noninstitutional hospice|77
461|4 - Unknown because patient moved to a geographic location not served by this agency|4 - Unknown because patient moved to a geographic location not served by this agency|77
462|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|77
463|4 - Other respiratory problem|4 - Other respiratory problem|77
464|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|77
465|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|77
466|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|77
467|8 - Other heart disease|8 - Other heart disease|77
468|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|77
469|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|77
470|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|77
471|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|77
472|13 - Urinary tract infection|13 - Urinary tract infection|77
473|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|77
474|15 - Wound infection or deterioration|15 - Wound infection or deterioration|77
475|16 - Uncontrolled pain|16 - Uncontrolled pain|77
476|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|77
477|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|77
478|19 - Scheduled treatment or procedure|19 - Scheduled treatment or procedure|77
479|20 - Other than above reasons|20 - Other than above reasons|77
480|UK - Reason unknown [Go to M0903]|UK - Reason unknown [Go to M0903]|77
482|01 - Patient lives alone around the clock|01 - Patient lives alone around the clock|77
483|02 - Patient lives alone regular daytime|02 - Patient lives alone regular daytime|77
484|03 - Patient lives alone regular nighttime|03 - Patient lives alone regular nighttime|77
485|04 - Patient lives alone occassional/short term assistance|04 - Patient lives alone occassional/short term assistance|77
486|05 - Patient lives alone no assisstance available|05 - Patient lives alone no assisstance available|77
487|06 - Patient lives with other person(s) in the home around the clock|06 - Patient lives with other person(s) in the home around the clock|77
488|07 - Patient lives with other person(s) in the home regular daytime|07 - Patient lives with other person(s) in the home regular daytime|77
489|08 - Patient lives with other person(s) in the home regular nighttime|08 - Patient lives with other person(s) in the home regular nighttime|77
490|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|77
491|10 - Patient lives with other person(s) in the home no assistance available|10 - Patient lives with other person(s) in the home no assistance available|77
492|1 - Was present at the most recent SOC/ROC assessment|1 - Was present at the most recent SOC/ROC assessment|77
493|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|77
494|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|77
495|0 - Newly epithelialized|0 - Newly epithelialized|77
496|0 - No [ Go to M1340 ]|0 - No [ Go to M1340 ]|77
498|0 - Independent|0 - Independent|77
499|1 - Needed Some Help|1 - Needed Some Help|77
500|2 - Dependent|2 - Dependent|77
502|0 - No assistance needed in this area|0 - No assistance needed in this area|77
503|1 - Caregiver(s) currently provide assistance|1 - Caregiver(s) currently provide assistance|77
504|2 - Caregiver(s) need training/ supportive services to provide assistance|2 - Caregiver(s) need training/ supportive services to provide assistance|77
505|3 - Caregiver(s) not likely to provide assistance|3 - Caregiver(s) not likely to provide assistance|77
506|4 - Unclear if Caregiver(s) will provide assistance|4 - Unclear if Caregiver(s) will provide assistance|77
507|5 - Assistance needed, but no Caregiver(s) available|5 - Assistance needed, but no Caregiver(s) available|77
508|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will use standardized clinical guidelines accessible for all care providers to reference|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will|77
510|NA - Patient is not assessed to be at risk for falls|NA - Patient is not assessed to be at risk for falls|77
511|NA - Patient has no diagnosis or symptoms of depression|NA - Patient has no diagnosis or symptoms of depression|77
512|NA - No pain identified|NA - No pain identified|77
513|NA - Patient is not assessed to be at risk for pressure ulcers|NA - Patient is not assessed to be at risk for pressure ulcers|77
514|NA - Patient has no pressure ulcers with need for moist wound healing|NA - Patient has no pressure ulcers with need for moist wound healing|77
515|1 - Long-term nursing facility (NF)|1 - Long-term nursing facility (NF)|77
516|2 - Skilled nursing facility (SNF / TCU)|2 - Skilled nursing facility (SNF / TCU)|77
517|3 - Short stay acute hospital (IPP S)|3 - Short stay acute hospital (IPP S)|77
518|4 - Long-term care hospital (LTCH)|4 - Long-term care hospital (LTCH)|77
519|5 - Inpatient rehabilitation hospital or unit (IRF)|5 - Inpatient rehabilitation hospital or unit (IRF)|77
520|6 - Psychiatric hospital or unit|6 - Psychiatric hospital or unit|77
521|7 - Other|7 - Other|77
522|NA - Patient was not discharged from an inpatient facility [Go to M1017]|NA - Patient was not discharged from an inpatient facility [Go to M1017]|77
523|6 - Unable to participate effectively in bathing and is bathed totally by another person|6 - Unable to participate effectively in bathing and is bathed totally by another person|77
524|4 - Chairfast, unable to ambulate but is able to wheel self independently.|4 - Chairfast, unable to ambulate but is able to wheel self independently.|77
525|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask patient: "Over the last two weeks, how often have you been bothered by any of the following problems")|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask|77
526|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluation for depression.|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluat|77
527|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet criteria for further evaluation for depression.|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet|77
528|0 - Not at all  0 - 1 day|0 - Not at all  0 - 1 day|77
529|1 - Several days  2 - 6 days|1 - Several days  2 - 6 days|77
530|2 - More than half of the days  7 - 11 days|2 - More than half of the days  7 - 11 days|77
531|3 - Nearly every day  12 - 14 days|3 - Nearly every day  12 - 14 days|77
532|NA - N/A  Unable to respond|NA - N/A  Unable to respond|77
533|2 - Able to take medication(s) at the correct times if given reminders by another person based on the frequency of the injection|2 - Able to take medication(s) at the correct times if given reminders by another person based on th|77
534|3 - Unable to take injectable medication unless administered by another person.|3 - Unable to take injectable medication unless administered by another person.|77
547|NA - There were no potential clinically significant medication issues identified since SOC/ROC or patient is not taking any medications|NA v There were no potential clinically significant medication issues identified since SOC/ROC |77
552|1 - Hospital|1 - Hospital [ Go to M2430 ]|77
553|2 - Rehabilitation facility |2 - Rehabilitation facility [ Go to M0903 ]|77
554|3 - Nursing home|3 - Nursing home [ Go to M2440 ]|77
555|4 - Hospice|4 - Hospice [ Go to M0903 ]|77
564|NA - Patient is not diabetic or is bilateral amputee|NA - Patient is not diabetic or is bilateral amputee|77
565|NA - Every standardized,validated multifactor fall risk assessment conducted at or since the most recent SOC/ROC assessment indicates the patient has no risk for falls.|NA - Every standardized,validated multifactor fall risk assessment condition|77
566|NA - Patient has no diagnosis of depression AND every standardized, validated depression screening conducted at or since the most recent SOC/ROC assessment indicates the patient has: 1) no symptoms of depression; or 2) has some symptoms of depression but does not meet criteria for further evaluation of depression based on screening tool used.|NA - Patient has no diagnosis of depression AND every standardized, validated |77
567|NA - Every standardized, validated pain assessment conducted at or since the most recent SOC/ROC assessment indicates the patient has no pain.|NA - Every standardized, validated pain assessment conducted at or since the most|77
568|NA - Every standardized, validated pressure ulcer risk assessment conducted at or since the most recent SOC/ROC assessment indicates the patient is not at risk of developing pressure ulcers.|NA - Every standardized, validated pressure ulcer risk assessment conducted|77
569|NA - Dressings that support the principles of moist wound healing not indicated for this patient's pressure ulcers OR patient has no pressure ulcers with need for moist wound healing|NA - Dressings that support the principles of moist wound healing not indicated for this patient's p|77
620|1 - Yes; received from your agency during this episode of care (SOC/ROC to Transfer/Discharge)|1 - Yes; received from your agency during this episode of care (SOC/ROC to Transfer/Discharge)|77
621|2 - Yes; received from your agency during a prior episode of care (SOC/ROC to Transfer/Discharge)|2 - Yes; received from your agency during a prior episode of care (SOC/ROC to Transfer/Discharge)|77
622|3 - Yes; received from another health care provider (for example physician pharmacist)|3 - Yes; received from another health care provider (for example physician pharmacist)|77
623|4 - No; patient offered and declined |4 - No; patient offered and declined |77
624|5 - No; patient assessed and determined to have medical contraindication(s)|5 - No; patient assessed and determined to have medical contraindication(s)|77
625|6 - No; not indicated - patient does not meet age/condition guidelines for influenza vaccine|6 - No; not indicated - patient does not meet age/condition guidelines for influenza vaccine|77
626|7 - No; inability to obtain vaccine due to declared shortage |7 - No; inability to obtain vaccine due to declared shortage |77
627|8 - No; patient did not receive the vaccine due to reasons other than those listed in responses 4 v 7. |8 - No; patient did not receive the vaccine due to reasons other than those listed in responses 4v7.|77
628|1 - Offered and declined|1 - Offered and declined|77
629|2 - Assessed and determined to have medical contraindication(s) |2 - Assessed and determined to have medical contraindication(s) |77
630|3 - Not indicated; patient does not meet age/condition guidelines for Pneumococcal Vaccine|3 - Not indicated; patient does not meet age/condition guidelines for Pneumococcal Vaccine|77
631|4 - None of the above|4 - None of the above|77
2|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; OR (b) Is physically, cognitively, and mentally able to prepare light meals on a regular basis but has not routinely performed light meal preparation in the past (i.e., prior to this home care admission).|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; O|78
3|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and mentally able to perform all housekeeping tasks .|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and menta|78
4|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and mentally able to do laundry and access facilities.|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and menta|78
5|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying packages OR b) Physically, cognitively, and mentally able to take care of shopping, but has not done shopping in the past (i.e., prior to this home care admission).|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying|78
6|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|78
7|0 - Able to dial numbers and answer calls appropriately and as desired.|0 - Able to dial numbers and answer calls appropriately and as desired.|78
8|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body without assistance.|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body|78
9|0 - Able to get to and from the toilet and transfer independently with or without a device.|0 - Able to get to and from the toilet and transfer independently with or without a device.|78
10|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|78
11|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible public bus.|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible p|78
12|0 - Able to independently feed self.|0 - Able to independently feed self.|78
13|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|78
14|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct times.|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct ti|78
15|0 - Able to independently transfer.|0 - Able to independently transfer.|78
16|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without rail|78
17|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings|78
18|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|78
19|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions independently.|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions indep|78
20|0 - Asymptomatic, no treatment needed at this time|0 - Asymptomatic, no treatment needed at this time|78
21|0 - Caregiver manages all tasks related to equipment completely independently.|0 - Caregiver manages all tasks related to equipment completely independently.|78
22|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations with no observable impairment.|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations w|78
23|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|78
24|0 - Life expectancy is greater than 6 months|0 - Life expectancy is greater than 6 months|78
25|0 - Never|0 - Never|78
26|0 - Patient is not short of breath|0 - Patient is not short of breath|78
27|0 - No|0 - No|78
28|0 - No emergent care services|0 - No emergent care services|78
29|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [Goto 1620]|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [Goto 1620]|78
30|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and extended or abstract conversation.|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and exte|78
31|0 - No one person|0 - No one person|78
32|0 - None of the time|0 - None of the time|78
33|0 - None, no charge for current services|0 - None, no charge for current services|78
34|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|78
35|0 - Patient does NOT have an ostomy for bowel elimination.|0 - Patient does NOT have an ostomy for bowel elimination.|78
36|0 - Patient has no pain|0 - Patient has no pain|78
37|0 - Patient manages all tasks related to equipment completely independently.|0 - Patient manages all tasks related to equipment completely independently.|78
38|0 - Poor:  little or no recovery is expected and/or further decline is imminent|0 - Poor:  little or no recovery is expected and/or further decline is imminent|78
39|0 - Timed-voiding defers incontinence|0 - Timed-voiding defers incontinence|78
40|0 - Very rarely or never has bowel incontinence|0 - Very rarely or never has bowel incontinence|78
41|0 - Zero|0 - Zero|78
42|00 - No|00 - No|78
43|01 - Yes|01 - Yes|78
44|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or mental limitations, needs assistance with heavy laundry.|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or|78
45|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the patient.|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the|78
46|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|78
47|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or supervision from another person OR c) a liquid, pureed or ground meat diet.|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or su|78
48|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|78
49|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|78
50|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independently.|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independe|78
51|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only when assisted or accompanied by another person.|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only w|78
52|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepa|78
53|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance by another person OR b) given daily reminders.|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance b|78
54|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advan|78
55|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advan|78
56|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for the deaf) and call essential numbers.|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for t|78
57|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|78
58|1 - American Indian or Alaska Native|1 - American Indian or Alaska Native|78
59|1 - Depressed mood (e.g., feeling sad, tearful)|1 - Depressed mood (e.g., feeling sad, tearful)|78
60|1 - During the night only|1 - During the night only|78
61|1 - Fully granulating|1 - Fully granulating|78
62|1 - Good/Fair:  partial to full recovery is expected|1 - Good/Fair:  partial to full recovery is expected|78
63|1 - Good:  marked improvement in functional status is expected|1 - Good:  marked improvement in functional status is expected|78
64|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|78
65|1 - Smoking|1 - Smoking|78
66|1 - Hospital|1 - Hospital|78
67|1 - Hospital emergency room (includes 23-hour holding)|1 - Hospital emergency room (includes 23-hour holding)|78
68|1 - Hospitalization for EMERGENT (unscheduled) care|1 - Hospitalization for EMERGENT (unscheduled) care|78
69|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepared solutions), patient is able to manage all other aspects of equipment.|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepar|78
70|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|78
71|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|78
72|1 - In new or complex situations only|1 - In new or complex situations only|78
73|1 - Intravenous or infusion therapy (excludes TPN)|1 - Intravenous or infusion therapy (excludes TPN)|78
74|1 - Less often than daily|1 - Less often than daily|78
75|1 - Less than once a month|1 - Less than once a month|78
76|1 - Less than once weekly|1 - Less than once weekly|78
77|1 - Life expectancy is 6 months or fewer|1 - Life expectancy is 6 months or fewer|78
78|1 - Lives alone|1 - Lives alone|78
79|1 - Male|1 - Male|78
80|1 - Medicare (traditional fee-for-service)|1 - Medicare (traditional fee-for-service)|78
81|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of past 24 hours, significant memory loss so that supervision is required|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of pas|78
82|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors in word choice, grammar or speech intelligibility, needs minimal prompting or assistance).|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors i|78
83|1 - No assistance or services received|1 - No assistance or services received|78
84|1 - One|1 - One|78
85|1 - Oxygen (intermittent or continuous)|1 - Oxygen (intermittent or continuous)|78
86|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, and the surrounding layout, can count fingers at arm's length.|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, a|78
87|1 - Patient is incontinent|1 - Patient is incontinent|78
88|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|78
89|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical or treatment regimen.|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical|78
90|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient/couple/significant other)|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient|78
91|1 - Relatives, friends, or neighbors living outside the home|1 - Relatives, friends, or neighbors living outside the home|78
92|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions.|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions|78
93|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independentl|78
94|1 - Several times during day and night|1 - Several times during day and night|78
95|1 - Spouse or significant other|1 - Spouse or significant other|78
96|1 - Stage 1|1 - Stage 1|78
97|1 - Start of care - further visits planned|1 - Start of care - further visits planned|78
98|1 - Symptoms well controlled with current therapy|1 - Symptoms well controlled with current therapy|78
99|1 - Therapy services|1 - Therapy services|78
100|1 - Able to transfer with minimal human assistance or with use of an assistive device.|1 - Able to transfer with minimal human assistance or with use of an assistive device.|78
101|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitations.|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitatio|78
102|1 - Urinary incontinence|1 - Urinary incontinence|78
103|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and transfer.|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and|78
104|1 - When walking more than 20 feet, climbing stairs|1 - When walking more than 20 feet, climbing stairs|78
105|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary conversation. May need occasional repetition, extra time, or louder voice.|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary c|78
106|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting in and out of tub/shower|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting|78
107|1 - Yes|1 - Yes|78
108|1-RN|1-RN|78
109|10 - Discharge from agency - no visits completed after start/resumption of care assessment|10 - Discharge from agency - no visits completed after start/resumption of care assessment|78
110|10 - Scheduled surgical procedure|10 - Scheduled surgical procedure|78
111|10 - Self-pay|10 - Self-pay|78
112|11 - Other|11 - Other|78
113|11 - Urinary tract infection|11 - Urinary tract infection|78
114|12 - IV catheter-related infection|12 - IV catheter-related infection|78
115|13 - Deep vein thrombosis, pulmonary embolus|13 - Deep vein thrombosis, pulmonary embolus|78
116|14 - Uncontrolled pain|14 - Uncontrolled pain|78
117|15 - Psychotic episode|15 - Psychotic episode|78
118|16 - Other than above reasons|16 - Other than above reasons|78
119|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing calls.|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing|78
120|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another person.|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another pers|78
121|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface a|78
122|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for intermittent supervision or encouragement or reminders, OR (b) to get in and out of the shower or tub, OR (c) for washing difficult to reach areas.|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for inter|78
123|2 - Asian|2 - Asian|78
124|2 - Caregiver requires considerable assistance from another person to manage equipment, but independently completes significant portions of task.|2 - Caregiver requires considerable assistance from another person to manage equipment, but independ|78
125|2 - Daily, but not constantly|2 - Daily, but not constantly|78
126|2 - Daughter or son|2 - Daughter or son|78
127|2 - Doctor's office emergency visit/house call|2 - Doctor's office emergency visit/house call|78
128|2 - During the day and night|2 - During the day and night|78
129|2 - Early/partial granulation|2 - Early/partial granulation|78
130|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors in word choice, organization or speech intelligibility). Speaks in phrases or short sentences.|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors|78
131|2 - Family member's residence|2 - Family member's residence|78
132|2 - Female|2 - Female|78
133|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conversation, needs frequent prompting or assistance.|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conver|78
134|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|78
135|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|78
136|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately stop activities, jeopardizes safety through actions|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately st|78
137|2 - Indwelling/suprapubic catheter|2 - Indwelling/suprapubic catheter|78
138|2 - Injury caused by fall or accident at home|2 - Injury caused by fall or accident at home|78
139|2 - Medicare (HMO/managed care/Advantage plan)|2 - Medicare (HMO/managed care/Advantage plan)|78
140|2 - Nausea, dehydration, malnutrition, constipation, impaction|2 - Nausea, dehydration, malnutrition, constipation, impaction|78
141|2 - Obesity|2 - Obesity|78
142|2 - On awakening or at night only|2 - On awakening or at night only|78
143|2 - Once a month|2 - Once a month|78
144|2 - One to three times weekly|2 - One to three times weekly|78
145|2 - Parenteral nutrition (TPN or lipids)|2 - Parenteral nutrition (TPN or lipids)|78
146|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic) [ Go to M1620]|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic) [ Go|78
147|2 - Patient requires considerable assistance from another person to manage equipment, but independently completes portions of the task.|2 - Patient requires considerable assistance from another person to manage equipment, but independen|78
148|2 - Patient transferred to a noninstitutional hospice|2 - Patient transferred to a noninstitutional hospice|78
149|2 - Person residing in the home (EXCLUDING paid help)|2 - Person residing in the home (EXCLUDING paid help)|78
150|2 - Rehabilitation facility|2 - Rehabilitation facility|78
151|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifting of attention) or consistently requires low stimulus environment due to distractibility.|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifti|78
152|2 - Respite care|2 - Respite care|78
153|2 - Sense of failure or self reproach|2 - Sense of failure or self reproach|78
154|2 - Several times during day|2 - Several times during day|78
155|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonresponsive.|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonrespons|78
156|2 - Someone must assist the patient to groom self.|2 - Someone must assist the patient to groom self.|78
157|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|78
158|2 - Someone must help the patient put on upper body clothing.|2 - Someone must help the patient put on upper body clothing.|78
159|2 - Stage 2|2 - Stage 2|78
160|2 - Start of care - no further visits planned|2 - Start of care - no further visits planned|78
161|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitoring|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitori|78
162|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment regimen.|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment re|78
163|2 - Two|2 - Two|78
164|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistance due to cognitive or mental limitation.|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistanc|78
165|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|78
166|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assistance).|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assis|78
167|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home delivery.|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home deli|78
168|2 - Unable to prepare any light meals or reheat any delivered meals.|2 - Unable to prepare any light meals or reheat any delivered meals.|78
169|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|78
170|2 - UNABLE to take injectable medications unless administered by someone else.|2 - UNABLE to take injectable medications unless administered by someone else.|78
171|2 - UNABLE to take medication unless administered by someone else.|2 - UNABLE to take medication unless administered by someone else.|78
172|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|78
173|2 - Ventilator (continually or at night)|2 - Ventilator (continually or at night)|78
174|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less than 20 feet)|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less th|78
175|2 - With spouse or significant other|2 - With spouse or significant other|78
176|2 - Yes, assistance or services provided by family or friends|2 - Yes, assistance or services provided by family or friends|78
177|2-PT|2-PT|78
178|3 - Able to answer the telephone only some of the time or is able to carry on only a limited conversation.|3 - Able to answer the telephone only some of the time or is able to carry on only a limited convers|78
179|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube or gastrostomy.|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube|78
180|3 - Alcohol dependency|3 - Alcohol dependency|78
181|3 - All of the time|3 - All of the time|78
182|3 - Black or African-American|3 - Black or African-American|78
183|3 - Boarding home or rented room|3 - Boarding home or rented room|78
184|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment, clean/store/dispose of equipment or supplies).|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment,|78
185|3 -Able to walk only with the supervision or assistance of another person at all times.|3 -Able to walk only with the supervision or assistance of another person at all times.|78
186|3 - Continuous / Bi-level positive airway pressure|3 - Continuous / Bi-level positive airway pressure|78
187|3 - During the day and evening, but not constantly|3 - During the day and evening, but not constantly|78
188|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the alimentary canal)|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the|78
189|3 - Environmental support (e.g., housing, home maintenance)|3 - Environmental support (e.g., housing, home maintenance)|78
190|3 - Four to six times weekly|3 - Four to six times weekly|78
191|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessing by listener.  Speech limited to single words or short phrases.|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessin|78
192|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires multiple repetitions, restatements, demonstrations, additional time.|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires m|78
193|3 - Hopelessness|3 - Hopelessness|78
194|3 - Hospice care|3 - Hospice care|78
195|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|78
196|3 - Injury caused by fall or accident at home|3 - Injury caused by fall or accident at home|78
197|3 - Intractable pain|3 - Intractable pain|78
198|3 - Medicaid (traditional fee-for-service)|3 - Medicaid (traditional fee-for-service)|78
199|3 - Needs someone to do all shopping and errands.|3 - Needs someone to do all shopping and errands.|78
200|3 - Not healing|3 - Not healing|78
201|3 - Nursing home|3 - Nursing home|78
202|3 - Once daily|3 - Once daily|78
203|3 - Other family member|3 - Other family member|78
204|3 - Outpatient department/clinic emergency (includes urgicenter sites)|3 - Outpatient department/clinic emergency (includes urgicenter sites)|78
205|3 - Paid help|3 - Paid help|78
206|3 - Able to participate in bathing self in shower or tub, but requires presence of another person throughout the bath for assistance or supervision.|3 - Able to participate in bathing self in shower or tub, but requires presence of another person th|78
207|3 - Patient depends entirely upon another person to dress lower body.|3 - Patient depends entirely upon another person to dress lower body.|78
208|3 - Patient depends entirely upon another person to dress the upper body.|3 - Patient depends entirely upon another person to dress the upper body.|78
209|3 - Patient depends entirely upon someone else for grooming needs.|3 - Patient depends entirely upon someone else for grooming needs.|78
210|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone else to manage the equipment.|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone|78
211|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable to shift attention and recall directions more than half the time.|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable|78
212|3 - Respiratory problems (SOB, infection, obstruction)|3 - Respiratory problems (SOB, infection, obstruction)|78
213|3 - Resumption of care (after inpatient stay)|3 - Resumption of care (after inpatient stay)|78
214|3 - Several times each month|3 - Several times each month|78
215|3 - Skilled Nursing Facility|3 - Skilled Nursing Facility|78
216|3 - Stage 3|3 - Stage 3|78
217|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|78
218|3 - Three|3 - Three|78
219|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person throughout the process.|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person through|78
220|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal independently.|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal indep|78
221|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person.|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person|78
222|3 - Unknown because patient moved to a geographic location not served by this agency|3 - Unknown because patient moved to a geographic location not served by this agency|78
223|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|78
224|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|78
225|3 - With other family member|3 - With other family member|78
226|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home health services, homemaker assistance, transportation assistance, assisted living, board and care)|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home h|78
227|3-SLP/ST|3-SLP/ST|78
228|4 - At rest (during day or night)|4 - At rest (during day or night)|78
229|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|78
230|4 - Board and care or assisted living facility|4 - Board and care or assisted living facility|78
231|4 - Caregiver is completely dependent on someone else to manage all equipment.|4 - Caregiver is completely dependent on someone else to manage all equipment.|78
232|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|78
233|4 - Constantly|4 - Constantly|78
234|4 - Drug dependency|4 - Drug dependency|78
235|4 - Four or more|4 - Four or more|78
236|4 - Friend or neighbor or community or church member|4 - Friend or neighbor or community or church member|78
237|4 - Hispanic or Latino|4 - Hispanic or Latino|78
238|4 - Hospice|4 - Hospice|78
239|4 - Impaired decision-making|4 - Impaired decision-making|78
240|4 - Is totally dependent in toileting.|4 - Is totally dependent in toileting.|78
241|4 - Medicaid (HMO/managed care)|4 - Medicaid (HMO/managed care)|78
242|4 - None of the above|4 - None of the above|78
243|4 - Nursing home|4 - Nursing home|78
244|4 - On a daily basis|4 - On a daily basis|78
245|4 - Patient is completely dependent on someone else to manage all equipment.|4 - Patient is completely dependent on someone else to manage all equipment.|78
246|4 - Permanent placement|4 - Permanent placement|78
247|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, punches, dangerous maneuvers w/ wheelchair or other objects)|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, pu|78
248|4 - Psychosocial support (e.g., socialization, companionship, recreation)|4 - Psychosocial support (e.g., socialization, companionship, recreation)|78
249|4 - Recertification (follow-up) reassessment|4 - Recertification (follow-up) reassessment|78
250|4 - Recurrent thoughts of death|4 - Recurrent thoughts of death|78
251|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruction)|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruc|78
252|4 - Several times a week|4 - Several times a week|78
253|4 - Stage 4|4 - Stage 4|78
254|4 - Symptoms poorly controlled, history of rehospitalizations|4 - Symptoms poorly controlled, history of rehospitalizations|78
255|4 - Three or more times per week|4 - Three or more times per week|78
256|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetative state, or delirium.|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetati|78
257|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|78
258|4 - Unable to effectively participate in any housekeeping tasks.|4 - Unable to effectively participate in any housekeeping tasks.|78
259|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or unresponsive (e.g., speech is nonsensical or unintelligible).|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or u|78
260|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonresponsive.|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonr|78
261|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostomy.|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostom|78
262|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of devices at the sink, in chair, or on commode|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of|78
263|4 - With a friend|4 - With a friend|78
264|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|78
265|4-OT|4-OT|78
266|5 - Advocates or facilitates patient's participation in appropriate medical care|5 - Advocates or facilitates patient's participation in appropriate medical care|78
267|5 - At least daily|5 - At least daily|78
268|6 - Bedfast, unable to ambulate or be up in a chair.|6 - Bedfast, unable to ambulate or be up in a chair.|78
269|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|78
270|5 - Disruptive or socially inappropriate behavior|5 - Disruptive or socially inappropriate behavior|78
271|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|78
272|5 - Hypo/Hyperglycemia, diabetes out of control|5 - Hypo/Hyperglycemia, diabetes out of control|78
273|5 - More often than once daily|5 - More often than once daily|78
274|5 - Native Hawaiian or Pacific Islander|5 - Native Hawaiian or Pacific Islander|78
275|5 - None of the above|5 - None of the above|78
276|5 - One to two times per week|5 - One to two times per week|78
277|5 - Other|5 - Other|78
278|5 - Other follow-up|5 - Other follow-up|78
279|5 - Paid help|5 - Paid help|78
280|5 - Patient nonresponsive or unable to speak.|5 - Patient nonresponsive or unable to speak.|78
281|5 - Thoughts of suicide|5 - Thoughts of suicide|78
282|5 - Totally unable to use the telephone.|5 - Totally unable to use the telephone.|78
283|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|78
284|5 - Unable to take in nutrients orally or by tube feeding.|5 - Unable to take in nutrients orally or by tube feeding.|78
285|5 - Unsafe for care at home|5 - Unsafe for care at home|78
286|5 - With paid help (other than home care agency staff)|5 - With paid help (other than home care agency staff)|78
287|5 - Workers' compensation|5 - Workers' compensation|78
288|5 - Wound infection, deteriorating wound status, new lesion/ulcer|5 - Wound infection, deteriorating wound status, new lesion/ulcer|78
289|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|78
290|6 - Delusional, hallucinatory, or paranoid behavior|6 - Delusional, hallucinatory, or paranoid behavior|78
291|6 - Financial agent, power of attorney, or conservator of finance|6 - Financial agent, power of attorney, or conservator of finance|78
292|6 - GI bleeding, obstruction|6 - GI bleeding, obstruction|78
293|6 - Less often than weekly|6 - Less often than weekly|78
294|6 - Memory loss to the extent that supervision required|6 - Memory loss to the extent that supervision required|78
295|6 - None of the above feelings observed or reported|6 - None of the above feelings observed or reported|78
296|6 - Other|6 - Other|78
297|6 - Title programs (e.g., Title III, V, or XX)|6 - Title programs (e.g., Title III, V, or XX)|78
298|6 - Transferred to an inpatient facility - patient not discharged from agency|6 - Transferred to an inpatient facility - patient not discharged from agency|78
299|6 - White|6 - White|78
300|6 - With other than above|6 - With other than above|78
301|7 - Exacerbation of CHF, fluid overload, heart failure|7 - Exacerbation of CHF, fluid overload, heart failure|78
302|7 - Health care agent, conservator of person, or medical power of attorney|7 - Health care agent, conservator of person, or medical power of attorney|78
303|7 - Hypo/Hyperglycemia, diabetes out of control|7 - Hypo/Hyperglycemia, diabetes out of control|78
304|7 - None of the above|7 - None of the above|78
305|7 - None of the above behaviors demonstrated|7 - None of the above behaviors demonstrated|78
306|7 - Other government (e.g., TriCare, VA, etc.)|7 - Other government (e.g., TriCare, VA, etc.)|78
307|7 - Transferred to an inpatient facility - patient discharged from agency|7 - Transferred to an inpatient facility - patient discharged from agency|78
308|8 - Death at home|8 - Death at home|78
309|8 - GI bleeding, obstruction|8 - GI bleeding, obstruction|78
310|8 - Myocardial infarction, stroke|8 - Myocardial infarction, stroke|78
311|8 - Private insurance|8 - Private insurance|78
312|9 - Chemotherapy|9 - Chemotherapy|78
313|9 - Discharge from agency|9 - Discharge from agency|78
314|9 - Other than above reasons|9 - Other than above reasons|78
315|9 - Private HMO/managed care|9 - Private HMO/managed care|78
316|NA - No caregiver|NA - No caregiver|78
317|NA - No equipment of this type used in care.|NA - No equipment of this type used in care.|78
318|NA - No inhalant/mist medications prescribed.|NA - No inhalant/mist medications prescribed.|78
319|NA - No injectable medications prescribed.|NA - No injectable medications prescribed.|78
320|NA - No inpatient facility admission|NA - No inpatient facility admission|78
321|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|78
322|NA - No Medicaid|NA - No Medicaid|78
323|NA - No Medicare|NA - No Medicare|78
324|NA - No observable pressure ulcer or unhealed pressure ulcer|NA - No observable pressure ulcer or unhealed pressure ulcer|78
325|NA - No observable stasis ulcer|NA - No observable stasis ulcer|78
326|NA - No observable surgical wound|NA - No observable surgical wound|78
327|NA - No oral medications prescribed.|NA - No oral medications prescribed.|78
328|NA - Not applicable|NA - Not applicable|78
329|NA - Patient does not have a telephone.|NA - Patient does not have a telephone.|78
330|NA - Patient has ostomy for bowel elimination|NA - Patient has ostomy for bowel elimination|78
331|NA - Patient nonresponsive|NA - Patient nonresponsive|78
332|NA - Patient on prophylactic treatment|NA - Patient on prophylactic treatment|78
333|NA - Patient was not discharged from an inpatient facility [Go to M1017]|NA - Patient was not discharged from an inpatient facility [Go to M1017]|78
334|UK - Other unknown|UK - Other unknown|78
335|UK - Reason unknown|UK - Reason unknown|78
336|UK - Unknown|UK - Unknown|78
337|UK - Unknown or Not Available|UK - Unknown or Not Available|78
341|01 - Early|01 - Early|78
342|02 - Late|02 - Late|78
343|NA - Not Applicable. No case mix group defined for this assessment.|NA - Not Applicable. No case mix group defined for this assessment.|78
344|NA - No case mix group defined by this assessment.|NA - No case mix group defined by this assessment.|78
345|1 - Recent decline in mental, emotional, or behavioral status|1 - Recent decline in mental, emotional, or behavioral status|78
346|2 - Multiple hospitalizations (2 or more) in the past 12 months|2 - Multiple hospitalizations (2 or more) in the past 12 months|78
347|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|78
348|4 - Taking five or more medications|4 - Taking five or more medications|78
349|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|78
350|6 - Other|6 - Other|78
351|7 - None of the above|7 - None of the above|78
352|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond tho|78
353|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable without heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable wi|78
354|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious complications and death.|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious compl|78
355|3 - The patient has serious progressive conditions that could lead to death within a year.|3 - The patient has serious progressive conditions that could lead to death within a year.|78
356|UK - The patient+s situation is unknown or unclear.|UK - The patient+s situation is unknown or unclear.|78
357|1 - Yes [ Go to M1050 ]|1 - Yes [ Go to M1050 ]|78
358|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this influenza season. [ Go to M1050 ]|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this i|78
359|1 - Received from another health care provider (e.g., physician)|1 - Received from another health care provider (e.g., physician)|78
360|2 - Received from your agency previously during this year+s flu season|2 - Received from your agency previously during this year+s flu season|78
361|3 - Offered and declined|3 - Offered and declined|78
362|4 - Assessed and determined to have medical contraindication(s)|4 - Assessed and determined to have medical contraindication(s)|78
363|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|78
364|6 - Inability to obtain vaccine due to declared shortage|6 - Inability to obtain vaccine due to declared shortage|78
365|1 - Yes [ Go to M2005 at TRN; Go to M1230 at DC ]|1 - Yes [ Go to M2005 at TRN; Go to M1230 at DC ]|78
366|1 - Patient has received PPV in the past|1 - Patient has received PPV in the past|78
367|2 - Offered and declined|2 - Offered and declined|78
368|3 - Assessed and determined to have medical contraindication(s)|3 - Assessed and determined to have medical contraindication(s)|78
369|4 - Not indicated; patient does not meet age/condition guidelines for PPV|4 - Not indicated; patient does not meet age/condition guidelines for PPV|78
370|5 - None of the above|5 - None of the above|78
371|0 - Adequate: hears normal conversation without difficulty.|0 - Adequate: hears normal conversation without difficulty.|78
372|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to increase volume or speak distinctly.|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to in|78
373|2 - Severely Impaired: absence of useful hearing.|2 - Severely Impaired: absence of useful hearing.|78
374|UK - Unable to assess hearing.|UK - Unable to assess hearing.|78
375|0 - Understands: clear comprehension without cues or repetitions.|0 - Understands: clear comprehension without cues or repetitions.|78
376|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Requires cues at times to understand.|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Req|78
377|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequently requires cues to understand.|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequentl|78
378|3 - Rarely/Never Understands|3 - Rarely/Never Understands|78
379|UK - Unable to assess understanding.|UK - Unable to assess understanding.|78
380|0 - No standardized assessment conducted|0 - No standardized assessment conducted|78
381|1 - Yes, and it does not indicate severe pain|1 - Yes, and it does not indicate severe pain|78
382|2 - Yes, and it indicates severe pain|2 - Yes, and it indicates severe pain|78
383|0 - Patient has no pain|0 - Patient has no pain|78
384|1 - Patient has pain that does not interfere with activity or movement|1 - Patient has pain that does not interfere with activity or movement|78
385|2 - Less often than daily|2 - Less often than daily|78
386|3 - Daily, but not constantly|3 - Daily, but not constantly|78
387|4 - All of the time|4 - All of the time|78
388|0 - No assessment conducted [ Go to M1306 ]|0 - No assessment conducted [ Go to M1306 ]|78
389|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc., without use of standardized tool|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc.,|78
390|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|78
391|0 - No [ Go to M1322]|0 - No [ Go to M1322]|78
392|0 v Newly epithelialized|0 v Newly epithelialized|78
393|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|78
394|2 - Yes, patient has observable stasis ulcers ONLY|2 - Yes, patient has observable stasis ulcers ONLY|78
395|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable dressing) [Go to M1340]|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable|78
396|0 - No [ Go to M1350 ]|0 - No [ Go to M1350 ]|78
397|1 - Yes, patient has at least one (observable) surgical wound|1 - Yes, patient has at least one (observable) surgical wound|78
398|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1350 ]|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1350 ]|78
399|0 - Patient is not short of breath|0 - Patient is not short of breath|78
400|3 - Continuous Bi-level positive airway pressure|3 - Continuous Bi-level positive airway pressure|78
401|0 - No [ Go to M2005 at TRN; Go to M1600 at DC ]|0 - No [ Go to M2005 at TRN; Go to M1600 at DC ]|78
402|2 - Not assessed [Go to M2005 at TRN; Go to M1600 at DC ]|2 - Not assessed [Go to M2005 at TRN; Go to M1600 at DC ]|78
403|NA - Patient does not have diagnosis of heart failure [Go to M2005 at TRN; Go to M1600 at DC]|NA - Patient does not have diagnosis of heart failure [Go to M2005 at TRN; Go to M1600 at DC]|78
404|0 - No action taken|0 - No action taken|78
405|1 - Patient+s physician (or other primary care practitioner) contacted the same day|1 - Patient+s physician (or other primary care practitioner) contacted the same day|78
406|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|78
407|3 - Implement physician-ordered patient-specific established parameters for treatment|3 - Implement physician-ordered patient-specific established parameters for treatment|78
408|4 - Patient education or other clinical interventions|4 - Patient education or other clinical interventions|78
409|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequency, telehealth, etc.)|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequ|78
410|1 - Occasional stress incontinence|1 - Occasional stress incontinence|78
411|2 - During the night only|2 - During the night only|78
412|3 - During the day only|3 - During the day only|78
413|4 - During the day and night|4 - During the day and night|78
414|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|78
415|0 - Able to manage toileting hygiene and clothing management without assistance.|0 - Able to manage toileting hygiene and clothing management without assistance.|78
416|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implements are laid out for the patient.|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implemen|78
417|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|78
418|3 - Patient depends entirely upon another person to maintain toileting hygiene.|3 - Patient depends entirely upon another person to maintain toileting hygiene.|78
419|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independent|78
420|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface|78
421|0 - No multi-factor falls risk assessment conducted.|0 - No multi-factor falls risk assessment conducted.|78
422|1 - Yes, and it does not indicate a risk for falls.|1 - Yes, and it does not indicate a risk for falls.|78
423|2 - Yes, and it indicates a risk for falls.|2 - Yes, and it indicates a risk for falls.|78
424|0 - Not assessed/reviewed [ Go to M2010 ]|0 - Not assessed/reviewed [ Go to M2010 ]|78
425|1 - No problems found during review [ Go to M2010 ]|1 - No problems found during review [ Go to M2010 ]|78
426|2 - Problems found during review|2 - Problems found during review|78
427|NA - Patient is not taking any medications [ Go to M2040 ]|NA - Patient is not taking any medications [ Go to M2040 ]|78
428|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special precautions associated with all high-risk medications|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special p|78
429|NA - Patient not taking any drugs|NA - Patient not taking any drugs|78
430|2 - Able to take medication(s) at the correct times if given reminders by another person at the appropriate times|2 - Able to take medication(s) at the correct times if given reminders by another person at the appr|78
431|3 - Unable to take medication unless administered by another person.|3 - Unable to take medication unless administered by another person.|78
432|1 - At least daily|1 - At least daily|78
433|2 - Three or more times per week|2 - Three or more times per week|78
434|3 - One to two times per week|3 - One to two times per week|78
435|4 - Received, but less often than weekly|4 - Received, but less often than weekly|78
436|5 - No assistance received|5 - No assistance received|78
437|0 - No [Go to M2401]|0 - No [Go to M2401]|78
438|1 - Yes, used hospital emergency department WITHOUT hospital admission|1 - Yes, used hospital emergency department WITHOUT hospital admission|78
439|2 - Yes, used hospital emergency department WITH hospital admission|2 - Yes, used hospital emergency department WITH hospital admission|78
440|UK - Unknown [Go to M2401]|UK - Unknown [Go to M2401]|78
441|2 - Injury caused by fall|2 - Injury caused by fall|78
442|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|78
443|4 - Other respiratory problem|4 - Other respiratory problem|78
444|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|78
445|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|78
446|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|78
447|8 - Other heart disease|8 - Other heart disease|78
448|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|78
449|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|78
450|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|78
451|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|78
452|13 - Urinary tract infection|13 - Urinary tract infection|78
453|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|78
454|15 - Wound infection or deterioration|15 - Wound infection or deterioration|78
455|16 - Uncontrolled pain|16 - Uncontrolled pain|78
456|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|78
457|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|78
458|19 - Other than above reasons|19 - Other than above reasons|78
459|2 - Patient remained in the community (with formal assistive services)|2 - Patient remained in the community (with formal assistive services)|78
460|3 - Patient transferred to a noninstitutional hospice|3 - Patient transferred to a noninstitutional hospice|78
461|4 - Unknown because patient moved to a geographic location not served by this agency|4 - Unknown because patient moved to a geographic location not served by this agency|78
462|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|78
463|4 - Other respiratory problem|4 - Other respiratory problem|78
464|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|78
465|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|78
466|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|78
467|8 - Other heart disease|8 - Other heart disease|78
468|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|78
469|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|78
470|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|78
471|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|78
472|13 - Urinary tract infection|13 - Urinary tract infection|78
473|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|78
474|15 - Wound infection or deterioration|15 - Wound infection or deterioration|78
475|16 - Uncontrolled pain|16 - Uncontrolled pain|78
476|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|78
477|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|78
478|19 - Scheduled treatment or procedure|19 - Scheduled treatment or procedure|78
479|20 - Other than above reasons|20 - Other than above reasons|78
480|UK - Reason unknown [Go to M0903]|UK - Reason unknown [Go to M0903]|78
482|01 - Patient lives alone around the clock|01 - Patient lives alone around the clock|78
483|02 - Patient lives alone regular daytime|02 - Patient lives alone regular daytime|78
484|03 - Patient lives alone regular nighttime|03 - Patient lives alone regular nighttime|78
485|04 - Patient lives alone occassional/short term assistance|04 - Patient lives alone occassional/short term assistance|78
486|05 - Patient lives alone no assisstance available|05 - Patient lives alone no assisstance available|78
487|06 - Patient lives with other person(s) in the home around the clock|06 - Patient lives with other person(s) in the home around the clock|78
488|07 - Patient lives with other person(s) in the home regular daytime|07 - Patient lives with other person(s) in the home regular daytime|78
489|08 - Patient lives with other person(s) in the home regular nighttime|08 - Patient lives with other person(s) in the home regular nighttime|78
490|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|78
491|10 - Patient lives with other person(s) in the home no assistance available|10 - Patient lives with other person(s) in the home no assistance available|78
492|1 - Was present at the most recent SOC/ROC assessment|1 - Was present at the most recent SOC/ROC assessment|78
493|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|78
494|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|78
495|0 - Newly epithelialized|0 - Newly epithelialized|78
496|0 - No [ Go to M1340 ]|0 - No [ Go to M1340 ]|78
498|0 - Independent|0 - Independent|78
499|1 - Needed Some Help|1 - Needed Some Help|78
500|2 - Dependent|2 - Dependent|78
502|0 - No assistance needed in this area|0 - No assistance needed in this area|78
503|1 - Caregiver(s) currently provide assistance|1 - Caregiver(s) currently provide assistance|78
504|2 - Caregiver(s) need training/ supportive services to provide assistance|2 - Caregiver(s) need training/ supportive services to provide assistance|78
505|3 - Caregiver(s) not likely to provide assistance|3 - Caregiver(s) not likely to provide assistance|78
506|4 - Unclear if Caregiver(s) will provide assistance|4 - Unclear if Caregiver(s) will provide assistance|78
507|5 - Assistance needed, but no Caregiver(s) available|5 - Assistance needed, but no Caregiver(s) available|78
508|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will use standardized clinical guidelines accessible for all care providers to reference|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will|78
510|NA - Patient is not assessed to be at risk for falls|NA - Patient is not assessed to be at risk for falls|78
511|NA - Patient has no diagnosis or symptoms of depression|NA - Patient has no diagnosis or symptoms of depression|78
512|NA - No pain identified|NA - No pain identified|78
513|NA - Patient is not assessed to be at risk for pressure ulcers|NA - Patient is not assessed to be at risk for pressure ulcers|78
514|NA - Patient has no pressure ulcers with need for moist wound healing|NA - Patient has no pressure ulcers with need for moist wound healing|78
515|1 - Long-term nursing facility (NF)|1 - Long-term nursing facility (NF)|78
516|2 - Skilled nursing facility (SNF / TCU)|2 - Skilled nursing facility (SNF / TCU)|78
517|3 - Short stay acute hospital (IPP S)|3 - Short stay acute hospital (IPP S)|78
518|4 - Long-term care hospital (LTCH)|4 - Long-term care hospital (LTCH)|78
519|5 - Inpatient rehabilitation hospital or unit (IRF)|5 - Inpatient rehabilitation hospital or unit (IRF)|78
520|6 - Psychiatric hospital or unit|6 - Psychiatric hospital or unit|78
521|7 - Other|7 - Other|78
522|NA - Patient was not discharged from an inpatient facility [Go to M1017]|NA - Patient was not discharged from an inpatient facility [Go to M1017]|78
523|6 - Unable to participate effectively in bathing and is bathed totally by another person|6 - Unable to participate effectively in bathing and is bathed totally by another person|78
524|4 - Chairfast, unable to ambulate but is able to wheel self independently.|4 - Chairfast, unable to ambulate but is able to wheel self independently.|78
525|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask patient: "Over the last two weeks, how often have you been bothered by any of the following problems")|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask|78
526|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluation for depression.|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluat|78
527|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet criteria for further evaluation for depression.|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet|78
528|0 - Not at all  0 - 1 day|0 - Not at all  0 - 1 day|78
529|1 - Several days  2 - 6 days|1 - Several days  2 - 6 days|78
530|2 - More than half of the days  7 - 11 days|2 - More than half of the days  7 - 11 days|78
531|3 - Nearly every day  12 - 14 days|3 - Nearly every day  12 - 14 days|78
532|NA - N/A  Unable to respond|NA - N/A  Unable to respond|78
533|2 - Able to take medication(s) at the correct times if given reminders by another person based on the frequency of the injection|2 - Able to take medication(s) at the correct times if given reminders by another person based on th|78
534|3 - Unable to take injectable medication unless administered by another person.|3 - Unable to take injectable medication unless administered by another person.|78
547|NA - There were no potential clinically significant medication issues identified since SOC/ROC or patient is not taking any medications|NA v There were no potential clinically significant medication issues identified since SOC/ROC |78
552|1 - Hospital|1 - Hospital [ Go to M2430 ]|78
553|2 - Rehabilitation facility|2 - Rehabilitation facility [ Go to M0903 ]|78
554|3 - Nursing home|3 - Nursing home [ Go to M2440 ]|78
555|4 - Hospice|4 - Hospice [ Go to M0903 ]|78
653|0 - No [STOP]|0 - No [STOP]|78
654|1 - Yes |1 - Yes|78
655|0 - None|0 - None|78
656|1 - One|1 - One|78
657|2 - Two or More|2 - Two or More|78
660|1 - Dependent - A helper completed the activities for the patient.|1 - Dependent - A helper completed the activities for the patient.|79
659|2 - Needed Some Help - Patient needed partial assistance from another person to complete activities.|2 - Needed Some Help - Patient needed partial assistance from another person to complete activities.|79
657|2 - Two or More|2 - Two or More|79
658|3 - Independent - Patient completed the activities by him/herself, with or without an assistive device, with no assistance from a helper.|3 - Independent - Patient completed the activities by him/herself, with or without an assistive devi|79
653|0 - No [STOP]|0 - No [STOP]|79
654|1 - Yes |1 - Yes|79
655|0 - None|0 - None|79
656|1 - One|1 - One|79
661|8 - Unknown|8 - Unknown|79
662|9 - Not Applicable|9 - Not Applicable|79
663|A - Manual wheelchair|A - Manual wheelchair|79
664|B - Motorized wheelchair and/or scooter|B - Motorized wheelchair and/or scooter|79
665|C - Mechanical lift|C - Mechanical lift|79
666|D - Walker|D - Walker|79
667|E - Orthotics/Prosthetics|E - Orthotics/Prosthetics|79
668|Z - None of the above|Z - None of the above|79
637|06 - Independent - Patient completes the activity by him/herself with no assistance from a helper.|06 - Independent - Patient completes the activity by him/herself with no assistance from a helper.|79
638|05 - Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity.|05 - Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper|79
639|04 - Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently.|04 - Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/|79
640|03 - Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort.|03 - Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or sup|79
641|02 - Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.|02 - Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds t|79
642|01 - Dependent - Helper does ALL of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity.|01 - Dependent - Helper does ALL of the effort. Patient does none of the effort to complete the acti|79
643|07 - Patient refused|07 - Patient refused|79
644|09 - Not applicable - Not attempted and the patient did not perform this activity prior to the current illness,exacerbation or injury.|09 - Not applicable - Not attempted and the patient did not perform this activity prior to the curre|79
645|10 - Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)|10 - Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)|79
646|88 - Not attempted due to medical conditions or safety concerns|88 - Not attempted due to medical conditions or safety concerns|79
647|0 - No [Skip GG0170R, GG0170RR, GG0170S, and GG0170SS]|0 - No [Skip GG0170R, GG0170RR1, GG0170S, and GG0170SS1.]|79
648|0 - No [Skip GG0170R]|0 - No [Skip GG0170R]|79
649|1 - Yes |1 - Yes [Continue to GG0170R, Wheel 50 feet with two turns.]|79
650|1 - Manual|1 - Manual|79
651|2 - Motorized|2 - Motorized|79
652|0 - No [Skip to J1800 Any falls since SOC/ROC, whichever is more recent.]|0 - No [Skip to J1800 Any falls since SOC/ROC, whichever is more recent.]|79
47|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or supervision from another person OR c) a liquid, pureed or ground meat diet.|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or su|79
2|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; OR (b) Is physically, cognitively, and mentally able to prepare light meals on a regular basis but has not routinely performed light meal preparation in the past (i.e., prior to this home care admission).|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; O|79
3|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and mentally able to perform all housekeeping tasks .|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and menta|79
4|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and mentally able to do laundry and access facilities.|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and menta|79
5|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying packages OR b) Physically, cognitively, and mentally able to take care of shopping, but has not done shopping in the past (i.e., prior to this home care admission).|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying|79
6|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|79
7|0 - Able to dial numbers and answer calls appropriately and as desired.|0 - Able to dial numbers and answer calls appropriately and as desired.|79
8|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body without assistance.|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body|79
9|0 - Able to get to and from the toilet and transfer independently with or without a device.|0 - Able to get to and from the toilet and transfer independently with or without a device.|79
10|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|79
11|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible public bus.|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible p|79
12|0 - Able to independently feed self.|0 - Able to independently feed self.|79
13|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|79
14|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct times.|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct ti|79
15|0 - Able to independently transfer.|0 - Able to independently transfer.|79
16|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without rail|79
17|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings|79
18|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|79
19|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions independently.|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions indep|79
20|0 - Asymptomatic, no treatment needed at this time|0 - Asymptomatic, no treatment needed at this time|79
21|0 - Caregiver manages all tasks related to equipment completely independently.|0 - Caregiver manages all tasks related to equipment completely independently.|79
22|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations with no observable impairment.|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations w|79
23|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|79
24|0 - Life expectancy is greater than 6 months|0 - Life expectancy is greater than 6 months|79
25|0 - Never|0 - Never|79
26|0 - Patient is not short of breath|0 - Patient is not short of breath|79
27|0 - No|0 - No|79
28|0 - No emergent care services|0 - No emergent care services|79
29|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [Goto M1620]|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [Goto M1620]|79
30|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and extended or abstract conversation.|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and exte|79
31|0 - No one person|0 - No one person|79
32|0 - None of the time|0 - None of the time|79
33|0 - None, no charge for current services|0 - None, no charge for current services|79
34|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|79
35|0 - Patient does NOT have an ostomy for bowel elimination.|0 - Patient does NOT have an ostomy for bowel elimination.|79
36|0 - Patient has no pain|0 - Patient has no pain|79
37|0 - Patient manages all tasks related to equipment completely independently.|0 - Patient manages all tasks related to equipment completely independently.|79
38|0 - Poor:  little or no recovery is expected and/or further decline is imminent|0 - Poor:  little or no recovery is expected and/or further decline is imminent|79
39|0 - Timed-voiding defers incontinence|0 - Timed-voiding defers incontinence|79
40|0 - Very rarely or never has bowel incontinence|0 - Very rarely or never has bowel incontinence|79
41|0 - Zero|0 - Zero|79
42|00 - No|00 - No|79
43|01 - Yes|01 - Yes|79
44|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or mental limitations, needs assistance with heavy laundry.|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or|79
45|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the patient.|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the|79
46|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|79
48|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|79
49|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|79
50|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independently.|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independe|79
51|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only when assisted or accompanied by another person.|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only w|79
52|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepa|79
53|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance by another person OR b) given daily reminders.|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance b|79
54|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advan|79
55|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advan|79
56|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for the deaf) and call essential numbers.|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for t|79
57|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|79
58|1 - American Indian or Alaska Native|1 - American Indian or Alaska Native|79
59|1 - Depressed mood (e.g., feeling sad, tearful)|1 - Depressed mood (e.g., feeling sad, tearful)|79
60|1 - During the night only|1 - During the night only|79
61|1 - Fully granulating|1 - Fully granulating|79
62|1 - Good/Fair:  partial to full recovery is expected|1 - Good/Fair:  partial to full recovery is expected|79
63|1 - Good:  marked improvement in functional status is expected|1 - Good:  marked improvement in functional status is expected|79
64|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|79
65|1 - Smoking|1 - Smoking|79
66|1 - Hospital|1 - Hospital [ Go to M2430 ]|79
67|1 - Hospital emergency room (includes 23-hour holding)|1 - Hospital emergency room (includes 23-hour holding)|79
68|1 - Hospitalization for EMERGENT (unscheduled) care|1 - Hospitalization for EMERGENT (unscheduled) care|79
69|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepared solutions), patient is able to manage all other aspects of equipment.|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepar|79
70|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|79
71|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|79
72|1 - In new or complex situations only|1 - In new or complex situations only|79
73|1 - Intravenous or infusion therapy (excludes TPN)|1 - Intravenous or infusion therapy (excludes TPN)|79
74|1 - Less often than daily|1 - Less often than daily|79
75|1 - Less than once a month|1 - Less than once a month|79
76|1 - Less than once weekly|1 - Less than once weekly|79
77|1 - Life expectancy is 6 months or fewer|1 - Life expectancy is 6 months or fewer|79
78|1 - Lives alone|1 - Lives alone|79
79|1 - Male|1 - Male|79
80|1 - Medicare (traditional fee-for-service)|1 - Medicare (traditional fee-for-service)|79
81|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of past 24 hours, significant memory loss so that supervision is required|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of pas|79
82|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors in word choice, grammar or speech intelligibility, needs minimal prompting or assistance).|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors i|79
83|1 - No assistance or services received|1 - No assistance or services received|79
84|1 - One|1 - One|79
85|1 - Oxygen (intermittent or continuous)|1 - Oxygen (intermittent or continuous)|79
86|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, and the surrounding layout, can count fingers at arm's length.|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, a|79
87|1 - Patient is incontinent|1 - Patient is incontinent|79
88|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|79
89|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical or treatment regimen.|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical|79
90|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient/couple/significant other)|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient|79
91|1 - Relatives, friends, or neighbors living outside the home|1 - Relatives, friends, or neighbors living outside the home|79
92|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions.|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions|79
93|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independentl|79
94|1 - Several times during day and night|1 - Several times during day and night|79
95|1 - Spouse or significant other|1 - Spouse or significant other|79
96|1 - Stage 1|1 - Stage 1|79
97|1 - Start of care - further visits planned|1 - Start of care - further visits planned|79
98|1 - Symptoms well controlled with current therapy|1 - Symptoms well controlled with current therapy|79
99|1 - Therapy services|1 - Therapy services|79
100|1 - Able to transfer with minimal human assistance or with use of an assistive device.|1 - Able to transfer with minimal human assistance or with use of an assistive device.|79
101|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitations.|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitatio|79
102|1 - Urinary incontinence|1 - Urinary incontinence|79
103|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and transfer.|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and|79
104|1 - When walking more than 20 feet, climbing stairs|1 - When walking more than 20 feet, climbing stairs|79
105|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary conversation. May need occasional repetition, extra time, or louder voice.|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary c|79
106|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting in and out of tub/shower|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting|79
107|1 - Yes|1 - Yes|79
108|1-RN|1-RN|79
109|10 - Discharge from agency - no visits completed after start/resumption of care assessment|10 - Discharge from agency - no visits completed after start/resumption of care assessment|79
110|10 - Scheduled surgical procedure|10 - Scheduled surgical procedure|79
111|10 - Self-pay|10 - Self-pay|79
112|11 - Other|11 - Other|79
113|11 - Urinary tract infection|11 - Urinary tract infection|79
114|12 - IV catheter-related infection|12 - IV catheter-related infection|79
115|13 - Deep vein thrombosis, pulmonary embolus|13 - Deep vein thrombosis, pulmonary embolus|79
116|14 - Uncontrolled pain|14 - Uncontrolled pain|79
117|15 - Psychotic episode|15 - Psychotic episode|79
118|16 - Other than above reasons|16 - Other than above reasons|79
119|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing calls.|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing|79
120|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another person.|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another pers|79
121|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface a|79
122|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for intermittent supervision or encouragement or reminders, OR (b) to get in and out of the shower or tub, OR (c) for washing difficult to reach areas.|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for inter|79
123|2 - Asian|2 - Asian|79
124|2 - Caregiver requires considerable assistance from another person to manage equipment, but independently completes significant portions of task.|2 - Caregiver requires considerable assistance from another person to manage equipment, but independ|79
125|2 - Daily, but not constantly|2 - Daily, but not constantly|79
126|2 - Daughter or son|2 - Daughter or son|79
127|2 - Doctor's office emergency visit/house call|2 - Doctor's office emergency visit/house call|79
128|2 - During the day and night|2 - During the day and night|79
129|2 - Early/partial granulation|2 - Early/partial granulation|79
130|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors in word choice, organization or speech intelligibility). Speaks in phrases or short sentences.|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors|79
131|2 - Family member's residence|2 - Family member's residence|79
132|2 - Female|2 - Female|79
133|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conversation, needs frequent prompting or assistance.|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conver|79
134|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|79
135|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|79
136|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately stop activities, jeopardizes safety through actions|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately st|79
137|2 - Indwelling/suprapubic catheter|2 - Indwelling/suprapubic catheter|79
138|2 - Injury caused by fall or accident at home|2 - Injury caused by fall or accident at home|79
139|2 - Medicare (HMO/managed care/Advantage plan)|2 - Medicare (HMO/managed care/Advantage plan)|79
140|2 - Nausea, dehydration, malnutrition, constipation, impaction|2 - Nausea, dehydration, malnutrition, constipation, impaction|79
141|2 - Obesity|2 - Obesity|79
142|2 - On awakening or at night only|2 - On awakening or at night only|79
143|2 - Once a month|2 - Once a month|79
144|2 - One to three times weekly|2 - One to three times weekly|79
145|2 - Parenteral nutrition (TPN or lipids)|2 - Parenteral nutrition (TPN or lipids)|79
146|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic) [ Go to M1620 ]|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic) [ Go|79
147|2 - Patient requires considerable assistance from another person to manage equipment, but independently completes portions of the task.|2 - Patient requires considerable assistance from another person to manage equipment, but independen|79
148|2 - Patient transferred to a noninstitutional hospice|2 - Patient transferred to a noninstitutional hospice|79
149|2 - Person residing in the home (EXCLUDING paid help)|2 - Person residing in the home (EXCLUDING paid help)|79
150|2 - Rehabilitation facility|2 - Rehabilitation facility [ Go to M0906 ]|79
151|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifting of attention) or consistently requires low stimulus environment due to distractibility.|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifti|79
152|2 - Respite care|2 - Respite care|79
153|2 - Sense of failure or self reproach|2 - Sense of failure or self reproach|79
154|2 - Several times during day|2 - Several times during day|79
155|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonresponsive.|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonrespons|79
156|2 - Someone must assist the patient to groom self.|2 - Someone must assist the patient to groom self.|79
157|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|79
158|2 - Someone must help the patient put on upper body clothing.|2 - Someone must help the patient put on upper body clothing.|79
159|2 - Stage 2|2 - Stage 2|79
160|2 - Start of care - no further visits planned|2 - Start of care - no further visits planned|79
161|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitoring|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitori|79
162|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment regimen.|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment re|79
163|2 - Two|2 - Two|79
164|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistance due to cognitive or mental limitation.|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistanc|79
165|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|79
166|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assistance).|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assis|79
167|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home delivery.|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home deli|79
168|2 - Unable to prepare any light meals or reheat any delivered meals.|2 - Unable to prepare any light meals or reheat any delivered meals.|79
169|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|79
170|2 - UNABLE to take injectable medications unless administered by someone else.|2 - UNABLE to take injectable medications unless administered by someone else.|79
171|2 - UNABLE to take medication unless administered by someone else.|2 - UNABLE to take medication unless administered by someone else.|79
172|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|79
173|2 - Ventilator (continually or at night)|2 - Ventilator (continually or at night)|79
174|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less than 20 feet)|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less th|79
175|2 - With spouse or significant other|2 - With spouse or significant other|79
176|2 - Yes, assistance or services provided by family or friends|2 - Yes, assistance or services provided by family or friends|79
177|2-PT|2-PT|79
178|3 - Able to answer the telephone only some of the time or is able to carry on only a limited conversation.|3 - Able to answer the telephone only some of the time or is able to carry on only a limited convers|79
179|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube or gastrostomy.|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube|79
180|3 - Alcohol dependency|3 - Alcohol dependency|79
181|3 - All of the time|3 - All of the time|79
182|3 - Black or African-American|3 - Black or African-American|79
183|3 - Boarding home or rented room|3 - Boarding home or rented room|79
184|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment, clean/store/dispose of equipment or supplies).|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment,|79
185|3 -Able to walk only with the supervision or assistance of another person at all times.|3 -Able to walk only with the supervision or assistance of another person at all times.|79
186|3 - Continuous / Bi-level positive airway pressure|3 - Continuous / Bi-level positive airway pressure|79
187|3 - During the day and evening, but not constantly|3 - During the day and evening, but not constantly|79
188|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the alimentary canal)|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the|79
189|3 - Environmental support (e.g., housing, home maintenance)|3 - Environmental support (e.g., housing, home maintenance)|79
190|3 - Four to six times weekly|3 - Four to six times weekly|79
191|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessing by listener.  Speech limited to single words or short phrases.|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessin|79
192|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires multiple repetitions, restatements, demonstrations, additional time.|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires m|79
193|3 - Hopelessness|3 - Hopelessness|79
194|3 - Hospice care|3 - Hospice care|79
195|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|79
196|3 - Injury caused by fall or accident at home|3 - Injury caused by fall or accident at home|79
197|3 - Intractable pain|3 - Intractable pain|79
198|3 - Medicaid (traditional fee-for-service)|3 - Medicaid (traditional fee-for-service)|79
199|3 - Needs someone to do all shopping and errands.|3 - Needs someone to do all shopping and errands.|79
200|3 - Not healing|3 - Not healing|79
201|3 - Nursing home|3 - Nursing home [ Go to M2440 ]|79
202|3 - Once daily|3 - Once daily|79
203|3 - Other family member|3 - Other family member|79
204|3 - Outpatient department/clinic emergency (includes urgicenter sites)|3 - Outpatient department/clinic emergency (includes urgicenter sites)|79
205|3 - Paid help|3 - Paid help|79
206|3 - Able to participate in bathing self in shower or tub, but requires presence of another person throughout the bath for assistance or supervision.|3 - Able to participate in bathing self in shower or tub, but requires presence of another person th|79
207|3 - Patient depends entirely upon another person to dress lower body.|3 - Patient depends entirely upon another person to dress lower body.|79
208|3 - Patient depends entirely upon another person to dress the upper body.|3 - Patient depends entirely upon another person to dress the upper body.|79
209|3 - Patient depends entirely upon someone else for grooming needs.|3 - Patient depends entirely upon someone else for grooming needs.|79
210|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone else to manage the equipment.|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone|79
211|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable to shift attention and recall directions more than half the time.|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable|79
212|3 - Respiratory problems (SOB, infection, obstruction)|3 - Respiratory problems (SOB, infection, obstruction)|79
213|3 - Resumption of care (after inpatient stay)|3 - Resumption of care (after inpatient stay)|79
214|3 - Several times each month|3 - Several times each month|79
215|3 - Skilled Nursing Facility|3 - Skilled Nursing Facility|79
216|3 - Stage 3|3 - Stage 3|79
217|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|79
218|3 - Three|3 - Three|79
219|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person throughout the process.|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person through|79
220|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal independently.|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal indep|79
221|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person.|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person|79
222|3 - Unknown because patient moved to a geographic location not served by this agency|3 - Unknown because patient moved to a geographic location not served by this agency|79
223|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|79
224|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|79
225|3 - With other family member|3 - With other family member|79
226|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home health services, homemaker assistance, transportation assistance, assisted living, board and care)|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home h|79
227|3-SLP/ST|3-SLP/ST|79
228|4 - At rest (during day or night)|4 - At rest (during day or night)|79
229|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|79
230|4 - Board and care or assisted living facility|4 - Board and care or assisted living facility|79
231|4 - Caregiver is completely dependent on someone else to manage all equipment.|4 - Caregiver is completely dependent on someone else to manage all equipment.|79
232|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|79
233|4 - Constantly|4 - Constantly|79
234|4 - Drug dependency|4 - Drug dependency|79
235|4 - Four or more|4 - Four or more|79
236|4 - Friend or neighbor or community or church member|4 - Friend or neighbor or community or church member|79
237|4 - Hispanic or Latino|4 - Hispanic or Latino|79
238|4 - Hospice|4 - Hospice [ Go to M0906 ]|79
239|4 - Impaired decision-making|4 - Impaired decision-making|79
240|4 - Is totally dependent in toileting.|4 - Is totally dependent in toileting.|79
241|4 - Medicaid (HMO/managed care)|4 - Medicaid (HMO/managed care)|79
242|4 - None of the above|4 - None of the above|79
243|4 - Nursing home|4 - Nursing home|79
244|4 - On a daily basis|4 - On a daily basis|79
245|4 - Patient is completely dependent on someone else to manage all equipment.|4 - Patient is completely dependent on someone else to manage all equipment.|79
246|4 - Permanent placement|4 - Permanent placement|79
247|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, punches, dangerous maneuvers w/ wheelchair or other objects)|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, pu|79
248|4 - Psychosocial support (e.g., socialization, companionship, recreation)|4 - Psychosocial support (e.g., socialization, companionship, recreation)|79
249|4 - Recertification (follow-up) reassessment|4 - Recertification (follow-up) reassessment|79
250|4 - Recurrent thoughts of death|4 - Recurrent thoughts of death|79
251|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruction)|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruc|79
252|4 - Several times a week|4 - Several times a week|79
253|4 - Stage 4|4 - Stage 4|79
254|4 - Symptoms poorly controlled, history of re-hospitalizations|4 - Symptoms poorly controlled, history of re-hospitalizations|79
255|4 - Three or more times per week|4 - Three or more times per week|79
256|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetative state, or delirium.|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetati|79
257|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|79
258|4 - Unable to effectively participate in any housekeeping tasks.|4 - Unable to effectively participate in any housekeeping tasks.|79
259|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or unresponsive (e.g., speech is nonsensical or unintelligible).|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or u|79
260|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonresponsive.|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonr|79
261|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostomy.|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostom|79
262|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of devices at the sink, in chair, or on commode|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of|79
263|4 - With a friend|4 - With a friend|79
264|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|79
265|4-OT|4-OT|79
266|5 - Advocates or facilitates patient's participation in appropriate medical care|5 - Advocates or facilitates patient's participation in appropriate medical care|79
267|5 - At least daily|5 - At least daily|79
268|6 - Bedfast, unable to ambulate or be up in a chair.|6 - Bedfast, unable to ambulate or be up in a chair.|79
269|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|79
270|5 - Disruptive or socially inappropriate behavior|5 - Disruptive or socially inappropriate behavior|79
271|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|79
272|5 - Hypo/Hyperglycemia, diabetes out of control|5 - Hypo/Hyperglycemia, diabetes out of control|79
273|5 - More often than once daily|5 - More often than once daily|79
274|5 - Native Hawaiian or Pacific Islander|5 - Native Hawaiian or Pacific Islander|79
275|5 - None of the above|5 - None of the above|79
276|5 - One to two times per week|5 - One to two times per week|79
277|5 - Other|5 - Other|79
278|5 - Other follow-up|5 - Other follow-up|79
279|5 - Paid help|5 - Paid help|79
280|5 - Patient nonresponsive or unable to speak.|5 - Patient nonresponsive or unable to speak.|79
281|5 - Thoughts of suicide|5 - Thoughts of suicide|79
282|5 - Totally unable to use the telephone.|5 - Totally unable to use the telephone.|79
283|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|79
284|5 - Unable to take in nutrients orally or by tube feeding.|5 - Unable to take in nutrients orally or by tube feeding.|79
285|5 - Unsafe for care at home|5 - Unsafe for care at home|79
286|5 - With paid help (other than home care agency staff)|5 - With paid help (other than home care agency staff)|79
287|5 - Workers' compensation|5 - Workers' compensation|79
288|5 - Wound infection, deteriorating wound status, new lesion/ulcer|5 - Wound infection, deteriorating wound status, new lesion/ulcer|79
289|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|79
290|6 - Delusional, hallucinatory, or paranoid behavior|6 - Delusional, hallucinatory, or paranoid behavior|79
291|6 - Financial agent, power of attorney, or conservator of finance|6 - Financial agent, power of attorney, or conservator of finance|79
292|6 - GI bleeding, obstruction|6 - GI bleeding, obstruction|79
293|6 - Less often than weekly|6 - Less often than weekly|79
294|6 - Memory loss to the extent that supervision required|6 - Memory loss to the extent that supervision required|79
295|6 - None of the above feelings observed or reported|6 - None of the above feelings observed or reported|79
296|6 - Other|6 - Other|79
297|6 - Title programs (e.g., Title III, V, or XX)|6 - Title programs (e.g., Title III, V, or XX)|79
298|6 - Transferred to an inpatient facility - patient not discharged from agency|6 - Transferred to an inpatient facility - patient not discharged from agency|79
299|6 - White|6 - White|79
300|6 - With other than above|6 - With other than above|79
301|7 - Exacerbation of CHF, fluid overload, heart failure|7 - Exacerbation of CHF, fluid overload, heart failure|79
302|7 - Health care agent, conservator of person, or medical power of attorney|7 - Health care agent, conservator of person, or medical power of attorney|79
303|7 - Hypo/Hyperglycemia, diabetes out of control|7 - Hypo/Hyperglycemia, diabetes out of control|79
304|7 - None of the above|7 - None of the above|79
305|7 - None of the above behaviors demonstrated|7 - None of the above behaviors demonstrated|79
306|7 - Other government (e.g., TriCare, VA, etc.)|7 - Other government (e.g., TriCare, VA, etc.)|79
307|7 - Transferred to an inpatient facility - patient discharged from agency|7 - Transferred to an inpatient facility - patient discharged from agency|79
308|8 - Death at home|8 - Death at home|79
309|8 - GI bleeding, obstruction|8 - GI bleeding, obstruction|79
310|8 - Myocardial infarction, stroke|8 - Myocardial infarction, stroke|79
311|8 - Private insurance|8 - Private insurance|79
312|9 - Chemotherapy|9 - Chemotherapy|79
313|9 - Discharge from agency|9 - Discharge from agency|79
314|9 - Other than above reasons|9 - Other than above reasons|79
315|9 - Private HMO/managed care|9 - Private HMO/managed care|79
316|NA - No caregiver|NA - No caregiver|79
317|NA - No equipment of this type used in care.|NA - No equipment of this type used in care.|79
318|NA - No inhalant/mist medications prescribed.|NA - No inhalant/mist medications prescribed.|79
319|NA - No injectable medications prescribed.|NA - No injectable medications prescribed.|79
320|NA - No inpatient facility admission|NA - No inpatient facility admission|79
321|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|79
322|NA - No Medicaid|NA - No Medicaid|79
323|NA - No Medicare|NA - No Medicare|79
324|NA - No observable pressure ulcer|NA - No observable pressure ulcer|79
325|NA - No observable stasis ulcer|NA - No observable stasis ulcer|79
326|NA - No observable surgical wound|NA - No observable surgical wound|79
327|NA - No oral medications prescribed.|NA - No oral medications prescribed.|79
328|NA - Not applicable|NA - Not applicable|79
329|NA - Patient does not have a telephone.|NA - Patient does not have a telephone.|79
330|NA - Patient has ostomy for bowel elimination|NA - Patient has ostomy for bowel elimination|79
331|NA - Patient nonresponsive|NA - Patient nonresponsive|79
332|NA - Patient on prophylactic treatment|NA - Patient on prophylactic treatment|79
333|NA - Patient was not discharged from an inpatient facility [Go to M1017]|NA - Patient was not discharged from an inpatient facility [Go to M1017]|79
334|UK - Other unknown|UK - Other unknown|79
335|UK - Reason unknown|UK - Reason unknown|79
336|UK - Unknown|UK - Unknown|79
337|UK - Unknown or Not Available|UK - Unknown or Not Available|79
341|01 - Early|01 - Early|79
342|02 - Late|02 - Late|79
343|NA - Not Applicable. No case mix group defined for this assessment.|NA - Not Applicable. No case mix group defined for this assessment.|79
344|NA - No case mix group defined by this assessment.|NA - No case mix group defined by this assessment.|79
345|1 - Recent decline in mental, emotional, or behavioral status|1 - Recent decline in mental, emotional, or behavioral status|79
346|2 - Multiple hospitalizations (2 or more) in the past 12 months|2 - Multiple hospitalizations (2 or more) in the past 12 months|79
347|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|79
348|4 - Taking five or more medications|4 - Taking five or more medications|79
349|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|79
350|6 - Other|6 - Other|79
351|7 - None of the above|7 - None of the above|79
352|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond tho|79
353|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable without heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable wi|79
354|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious complications and death.|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious compl|79
355|3 - The patient has serious progressive conditions that could lead to death within a year.|3 - The patient has serious progressive conditions that could lead to death within a year.|79
356|UK - The patient+s situation is unknown or unclear.|UK - The patient+s situation is unknown or unclear.|79
357|0 - No [ Go to M1051 ]|0 - No [ Go to M1051 ]|79
358|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this influenza season. [ Go to M1050 ]|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this i|79
359|1 - Received from another health care provider (e.g., physician)|1 - Received from another health care provider (e.g., physician)|79
360|2 - Received from your agency previously during this year+s flu season|2 - Received from your agency previously during this year+s flu season|79
361|3 - Offered and declined|3 - Offered and declined|79
362|4 - Assessed and determined to have medical contraindication(s)|4 - Assessed and determined to have medical contraindication(s)|79
363|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|79
364|6 - Inability to obtain vaccine due to declared shortage|6 - Inability to obtain vaccine due to declared shortage|79
365|1 - Yes [ Go to M2005 at TRN; Go to M1230 at DC ]|1 - Yes [ Go to M2005 at TRN; Go to M1230 at DC ]|79
366|1 - Patient has received PPV in the past|1 - Patient has received PPV in the past|79
367|2 - Offered and declined|2 - Offered and declined|79
368|3 - Assessed and determined to have medical contraindication(s)|3 - Assessed and determined to have medical contraindication(s)|79
369|4 - Not indicated; patient does not meet age/condition guidelines for PPV|4 - Not indicated; patient does not meet age/condition guidelines for PPV|79
370|5 - None of the above|5 - None of the above|79
371|0 - Adequate: hears normal conversation without difficulty.|0 - Adequate: hears normal conversation without difficulty.|79
372|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to increase volume or speak distinctly.|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to in|79
373|2 - Severely Impaired: absence of useful hearing.|2 - Severely Impaired: absence of useful hearing.|79
374|UK - Unable to assess hearing.|UK - Unable to assess hearing.|79
375|0 - Understands: clear comprehension without cues or repetitions.|0 - Understands: clear comprehension without cues or repetitions.|79
376|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Requires cues at times to understand.|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Req|79
377|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequently requires cues to understand.|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequentl|79
378|3 - Rarely/Never Understands|3 - Rarely/Never Understands|79
379|UK - Unable to assess understanding.|UK - Unable to assess understanding.|79
380|0 - No standardized assessment conducted|0 - No standardized assessment conducted|79
381|1 - Yes, and it does not indicate severe pain|1 - Yes, and it does not indicate severe pain|79
382|2 - Yes, and it indicates severe pain|2 - Yes, and it indicates severe pain|79
383|0 - Patient has no pain|0 - Patient has no pain|79
384|1 - Patient has pain that does not interfere with activity or movement|1 - Patient has pain that does not interfere with activity or movement|79
385|2 - Less often than daily|2 - Less often than daily|79
386|3 - Daily, but not constantly|3 - Daily, but not constantly|79
387|4 - All of the time|4 - All of the time|79
388|0 - No assessment conducted [ Go to M1306 ]|0 - No assessment conducted [ Go to M1306 ]|79
389|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc., without use of standardized tool|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc.,|79
390|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|79
391|0 - No [ Go to M1322]|0 - No [ Go to M1322]|79
392|0 v Newly epithelialized|0 v Newly epithelialized|79
393|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|79
394|2 - Yes, patient has observable stasis ulcers ONLY|2 - Yes, patient has observable stasis ulcers ONLY|79
395|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable dressing) [Go to M1340]|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable|79
396|0 - No [ Go to M1400 ]|0 - No [ Go to M1400 ]|79
397|1 - Yes, patient has at least one (observable) surgical wound|1 - Yes, patient has at least one (observable) surgical wound|79
398|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1400 ]|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1400 ]|79
399|0 - Patient is not short of breath|0 - Patient is not short of breath|79
400|3 - Continuous Bi-level positive airway pressure|3 - Continuous Bi-level positive airway pressure|79
401|0 - No [ Go to M2005 at TRN; Go to M1600 at DC ]|0 - No [ Go to M2005 at TRN; Go to M1600 at DC ]|79
402|2 - Not assessed [Go to M2005 at TRN; Go to M1600 at DC ]|2 - Not assessed [Go to M1732 at TRN; Go to M1600 at DC ]|79
403|NA - Patient does not have diagnosis of heart failure [Go to M2005 at TRN; Go to M1600 at DC]|NA - Patient does not have diagnosis of heart failure [Go to M2005 at TRN; Go to M1600 at DC]|79
404|0 - No action taken|0 - No action taken|79
405|1 - Patient+s physician (or other primary care practitioner) contacted the same day|1 - Patient+s physician (or other primary care practitioner) contacted the same day|79
406|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|79
407|3 - Implement physician-ordered patient-specific established parameters for treatment|3 - Implement physician-ordered patient-specific established parameters for treatment|79
408|4 - Patient education or other clinical interventions|4 - Patient education or other clinical interventions|79
409|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequency, telehealth, etc.)|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequ|79
410|1 - Occasional stress incontinence|1 - Occasional stress incontinence|79
411|2 - During the night only|2 - During the night only|79
412|3 - During the day only|3 - During the day only|79
413|4 - During the day and night|4 - During the day and night|79
414|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|79
415|0 - Able to manage toileting hygiene and clothing management without assistance.|0 - Able to manage toileting hygiene and clothing management without assistance.|79
416|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implements are laid out for the patient.|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implemen|79
417|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|79
418|3 - Patient depends entirely upon another person to maintain toileting hygiene.|3 - Patient depends entirely upon another person to maintain toileting hygiene.|79
419|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independent|79
420|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface|79
421|0 - No multi-factor falls risk assessment conducted.|0 - No multi-factor falls risk assessment conducted.|79
422|1 - Yes, and it does not indicate a risk for falls.|1 - Yes, and it does not indicate a risk for falls.|79
423|2 - Yes, and it indicates a risk for falls.|2 - Yes, and it indicates a risk for falls.|79
424|0 - Not assessed/reviewed [ Go to M2010 ]|0 - Not assessed/reviewed [ Go to M2010 ]|79
425|1 - No problems found during review [ Go to M2010 ]|1 - No problems found during review [ Go to M2010 ]|79
426|2 - Problems found during review|2 - Problems found during review|79
427|NA - Patient is not taking any medications [ Go to M2040 ]|NA - Patient is not taking any medications [ Go to M2040 ]|79
428|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special precautions associated with all high-risk medications|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special p|79
429|NA - Patient not taking any drugs|NA - Patient not taking any drugs|79
430|2 - Able to take medication(s) at the correct times if given reminders by another person at the appropriate times|2 - Able to take medication(s) at the correct times if given reminders by another person at the appr|79
431|3 - Unable to take medication unless administered by another person.|3 - Unable to take medication unless administered by another person.|79
432|1 - At least daily|1 - At least daily|79
433|2 - Three or more times per week|2 - Three or more times per week|79
434|3 - One to two times per week|3 - One to two times per week|79
435|4 - Received, but less often than weekly|4 - Received, but less often than weekly|79
436|5 - No assistance received|5 - No assistance received|79
437|0 - No [Go to M2401]|0 - No [Go to M2401]|79
438|1 - Yes, used hospital emergency department WITHOUT hospital admission|1 - Yes, used hospital emergency department WITHOUT hospital admission|79
439|2 - Yes, used hospital emergency department WITH hospital admission|2 - Yes, used hospital emergency department WITH hospital admission|79
440|UK - Unknown [Go to M2401]|UK - Unknown [Go to M2401]|79
441|2 - Injury caused by fall|2 - Injury caused by fall|79
442|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|79
443|4 - Other respiratory problem|4 - Other respiratory problem|79
444|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|79
445|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|79
446|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|79
447|8 - Other heart disease|8 - Other heart disease|79
448|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|79
449|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|79
450|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|79
451|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|79
452|13 - Urinary tract infection|13 - Urinary tract infection|79
453|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|79
454|15 - Wound infection or deterioration|15 - Wound infection or deterioration|79
455|16 - Uncontrolled pain|16 - Uncontrolled pain|79
456|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|79
457|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|79
458|19 - Other than above reasons|19 - Other than above reasons|79
459|2 - Patient remained in the community (with formal assistive services)|2 - Patient remained in the community (with formal assistive services)|79
460|3 - Patient transferred to a noninstitutional hospice|3 - Patient transferred to a noninstitutional hospice|79
461|4 - Unknown because patient moved to a geographic location not served by this agency|4 - Unknown because patient moved to a geographic location not served by this agency|79
462|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|79
463|4 - Other respiratory problem|4 - Other respiratory problem|79
464|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|79
465|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|79
466|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|79
467|8 - Other heart disease|8 - Other heart disease|79
468|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|79
469|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|79
470|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|79
471|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|79
472|13 - Urinary tract infection|13 - Urinary tract infection|79
473|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|79
474|15 - Wound infection or deterioration|15 - Wound infection or deterioration|79
475|16 - Uncontrolled pain|16 - Uncontrolled pain|79
476|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|79
477|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|79
478|19 - Scheduled treatment or procedure|19 - Scheduled treatment or procedure|79
479|20 - Other than above reasons|20 - Other than above reasons|79
480|UK - Reason unknown [Go to M0903]|UK - Reason unknown [Go to M0903]|79
482|01 - Patient lives alone around the clock|01 - Patient lives alone around the clock|79
483|02 - Patient lives alone regular daytime|02 - Patient lives alone regular daytime|79
484|03 - Patient lives alone regular nighttime|03 - Patient lives alone regular nighttime|79
485|04 - Patient lives alone occassional/short term assistance|04 - Patient lives alone occassional/short term assistance|79
486|05 - Patient lives alone no assisstance available|05 - Patient lives alone no assisstance available|79
487|06 - Patient lives with other person(s) in the home around the clock|06 - Patient lives with other person(s) in the home around the clock|79
488|07 - Patient lives with other person(s) in the home regular daytime|07 - Patient lives with other person(s) in the home regular daytime|79
489|08 - Patient lives with other person(s) in the home regular nighttime|08 - Patient lives with other person(s) in the home regular nighttime|79
490|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|79
491|10 - Patient lives with other person(s) in the home no assistance available|10 - Patient lives with other person(s) in the home no assistance available|79
492|1 - Was present at the most recent SOC/ROC assessment [Goto M1311A1]|1 - Was present at the most recent SOC/ROC assessment [Goto M1311A1]|79
493|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|79
494|NA - No non-epithelialized Stage II pressure ulcers are present at discharge [Goto M1311A1]|NA - No non-epithelialized Stage II pressure ulcers are present at discharge [Goto M1311A1]|79
495|0 - Newly epithelialized|0 - Newly epithelialized|79
496|0 - No [ Go to M1340 ]|0 - No [ Go to M1340 ]|79
498|0 - Independent|0 - Independent|79
499|1 - Needed Some Help|1 - Needed Some Help|79
500|2 - Dependent|2 - Dependent|79
502|0 - No assistance needed in this area|0 - No assistance needed in this area|79
503|1 - Caregiver(s) currently provide assistance|1 - Caregiver(s) currently provide assistance|79
504|2 - Caregiver(s) need training/ supportive services to provide assistance|2 - Caregiver(s) need training/ supportive services to provide assistance|79
505|3 - Caregiver(s) not likely to provide assistance|3 - Caregiver(s) not likely to provide assistance|79
506|4 - Unclear if Caregiver(s) will provide assistance|4 - Unclear if Caregiver(s) will provide assistance|79
507|5 - Assistance needed, but no Caregiver(s) available|5 - Assistance needed, but no Caregiver(s) available|79
508|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will use standardized clinical guidelines accessible for all care providers to reference|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will|79
510|NA - Patient is not assessed to be at risk for falls|NA - Patient is not assessed to be at risk for falls|79
511|NA - Patient has no diagnosis or symptoms of depression|NA - Patient has no diagnosis or symptoms of depression|79
512|NA - No pain identified|NA - No pain identified|79
513|NA - Patient is not assessed to be at risk for pressure ulcers|NA - Patient is not assessed to be at risk for pressure ulcers|79
514|NA - Patient has no pressure ulcers with need for moist wound healing|NA - Patient has no pressure ulcers with need for moist wound healing|79
515|1 - Long-term nursing facility (NF)|1 - Long-term nursing facility (NF)|79
516|2 - Skilled nursing facility (SNF / TCU)|2 - Skilled nursing facility (SNF / TCU)|79
517|3 - Short stay acute hospital (IPP S)|3 - Short stay acute hospital (IPP S)|79
518|4 - Long-term care hospital (LTCH)|4 - Long-term care hospital (LTCH)|79
519|5 - Inpatient rehabilitation hospital or unit (IRF)|5 - Inpatient rehabilitation hospital or unit (IRF)|79
520|6 - Psychiatric hospital or unit|6 - Psychiatric hospital or unit|79
521|7 - Other|7 - Other|79
522|NA - Patient was not discharged from an inpatient facility [Go to M1017]|NA - Patient was not discharged from an inpatient facility [Go to M1017]|79
523|6 - Unable to participate effectively in bathing and is bathed totally by another person|6 - Unable to participate effectively in bathing and is bathed totally by another person|79
524|4 - Chairfast, unable to ambulate but is able to wheel self independently.|4 - Chairfast, unable to ambulate but is able to wheel self independently.|79
525|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask patient: "Over the last two weeks, how often have you been bothered by any of the following problems")  *Copyright+ Pfizer Inc. All rights reserved. Reproduced with permission.|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask|79
526|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluation for depression.|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluat|79
527|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet criteria for further evaluation for depression.|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet|79
528|0 - Not at all  0 - 1 day|0 - Not at all  0 - 1 day|79
529|1 - Several days  2 - 6 days|1 - Several days  2 - 6 days|79
530|2 - More than half of the days  7 - 11 days|2 - More than half of the days  7 - 11 days|79
531|3 - Nearly every day  12 - 14 days|3 - Nearly every day  12 - 14 days|79
532|NA - N/A  Unable to respond|NA - N/A  Unable to respond|79
533|2 - Able to take medication(s) at the correct times if given reminders by another person based on the frequency of the injection|2 - Able to take medication(s) at the correct times if given reminders by another person based on th|79
534|3 - Unable to take injectable medication unless administered by another person.|3 - Unable to take injectable medication unless administered by another person.|79
570|NA - No observable pressure ulcer or unhealed pressure ulcer|NA - No observable pressure ulcer or unhealed pressure ulcer|79
571|NA - There were no potential clinically significant medication issues identified since SOC/ROC or patient is not taking any medications|NA - There were no potential clinically significant medication issues identified sinc|79
572|NA - Patient is not diabetic or is bilateral amputee|NA - Patient is not diabetic or is bilateral amputee|79
573|NA - Every standardized,validated multifactor fall risk assessment conducted at or since the most recent SOC/ROC assessment indicates the patient has no risk for falls.|NA - Every standardized,validated multifactor fall risk assessment condition|79
574|NA - Patient has no diagnosis of depression AND every standardized, validated depression screening conducted at or since the most recent SOC/ROC assessment indicates the patient has: 1) no symptoms of depression; or 2) has some symptoms of depression but does not meet criteria for further evaluation of depression based on screening tool used.|NA - Patient has no diagnosis of depression AND every standardized, validated |79
575|NA - Every standardized, validated pain assessment conducted at or since the most recent SOC/ROC assessment indicates the patient has no pain.|NA - Every standardized, validated pain assessment conducted at or since the most|79
576|NA - Every standardized, validated pressure ulcer risk assessment conducted at or since the most recent SOC/ROC assessment indicates the patient is not at risk of developing pressure ulcers.|NA - Every standardized, validated pressure ulcer risk assessment conducted|79
577|NA - Dressings that support the principles of moist wound healing not indicated for this patient's pressure ulcers OR patient has no pressure ulcers with need for moist wound healing|NA - Dressings that support the principles of moist wound healing not indicated for this patient's p|79
578|1 - Patient remained in the community (without formal assistive services)|1 - Patient remained in the community (without formal assistive services)|79
579|2 - Patient remained in the community (with formal assistive services)|2 - Patient remained in the community (with formal assistive services)|79
580|3 - Patient transferred to a non-institutional hospice|3 - Patient transferred to a non-institutional hospice|79
581|4 - Unknown because patient moved to a geographic location not served by this agency|4 - Unknown because patient moved to a geographic location not served by this agency|79
620|1 - Yes; received from your agency during this episode of care (SOC/ROC to Transfer/Discharge)|1 - Yes; received from your agency during this episode of care (SOC/ROC to Transfer/Discharge)|79
621|2 - Yes; received from your agency during a prior episode of care (SOC/ROC to Transfer/Discharge)|2 - Yes; received from your agency during a prior episode of care (SOC/ROC to Transfer/Discharge)|79
622|3 - Yes; received from another health care provider (for example physician pharmacist)|3 - Yes; received from another health care provider (for example physician pharmacist)|79
623|4 - No; patient offered and declined |4 - No; patient offered and declined |79
624|5 - No; patient assessed and determined to have medical contraindication(s)|5 - No; patient assessed and determined to have medical contraindication(s)|79
625|6 - No; not indicated - patient does not meet age/condition guidelines for influenza vaccine|6 - No; not indicated - patient does not meet age/condition guidelines for influenza vaccine|79
626|7 - No; inability to obtain vaccine due to declared shortage |7 - No; inability to obtain vaccine due to declared shortage |79
627|8 - No; patient did not receive the vaccine due to reasons other than those listed in responses 4 v 7. |8 - No; patient did not receive the vaccine due to reasons other than those listed in responses 4v7.|79
628|1 - Offered and declined|1 - Offered and declined|79
629|2 - Assessed and determined to have medical contraindication(s) |2 - Assessed and determined to have medical contraindication(s) |79
630|3 - Not indicated; patient does not meet age/condition guidelines for Pneumococcal Vaccine|3 - Not indicated; patient does not meet age/condition guidelines for Pneumococcal Vaccine|79
631|4 - None of the above|4 - None of the above|79
632|0 - No assistance needed v patient is independent or does not have needs in this area|0 - No assistance needed v patient is independent or does not have needs in this area|79
633|1 - Non-agency caregiver(s) currently provide assistance |1 - Non-agency caregiver(s) currently provide assistance |79
634|2 - Non-agency caregiver(s) need training/ supportive services to provide assistance|2 - Non-agency caregiver(s) need training/ supportive services to provide assistance|79
635|3 - Non-agency caregiver(s) are not likely to provide assistance OR it is unclear if they will provide assistance|3 - Non-agency caregiver(s) are not likely to provide assistance OR unclear if will provide asst|79
636|4 - Assistance needed but no non-agency caregiver(s) available|4 - Assistance needed but no non-agency caregiver(s) available|79
157|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|81
158|2 - Someone must help the patient put on upper body clothing.|2 - Someone must help the patient put on upper body clothing.|81
159|2 - Stage 2|2 - Stage 2|81
160|2 - Start of care - no further visits planned|2 - Start of care - no further visits planned|81
161|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitoring|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitori|81
162|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment regimen.|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment re|81
163|2 - Two|2 - Two|81
164|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistance due to cognitive or mental limitation.|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistanc|81
165|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|81
166|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assistance).|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assis|81
167|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home delivery.|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home deli|81
168|2 - Unable to prepare any light meals or reheat any delivered meals.|2 - Unable to prepare any light meals or reheat any delivered meals.|81
169|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|81
170|2 - UNABLE to take injectable medications unless administered by someone else.|2 - UNABLE to take injectable medications unless administered by someone else.|81
171|2 - UNABLE to take medication unless administered by someone else.|2 - UNABLE to take medication unless administered by someone else.|81
172|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|81
173|2 - Ventilator (continually or at night)|2 - Ventilator (continually or at night)|81
174|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less than 20 feet)|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less th|81
175|2 - With spouse or significant other|2 - With spouse or significant other|81
176|2 - Yes, assistance or services provided by family or friends|2 - Yes, assistance or services provided by family or friends|81
177|2-PT|2-PT|81
178|3 - Able to answer the telephone only some of the time or is able to carry on only a limited conversation.|3 - Able to answer the telephone only some of the time or is able to carry on only a limited convers|81
179|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube or gastrostomy.|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube|81
180|3 - Alcohol dependency|3 - Alcohol dependency|81
181|3 - All of the time|3 - All of the time|81
182|3 - Black or African-American|3 - Black or African-American|81
183|3 - Boarding home or rented room|3 - Boarding home or rented room|81
184|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment, clean/store/dispose of equipment or supplies).|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment,|81
185|3 -Able to walk only with the supervision or assistance of another person at all times.|3 -Able to walk only with the supervision or assistance of another person at all times.|81
186|3 - Continuous / Bi-level positive airway pressure|3 - Continuous / Bi-level positive airway pressure|81
187|3 - During the day and evening, but not constantly|3 - During the day and evening, but not constantly|81
188|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the alimentary canal)|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the|81
189|3 - Environmental support (e.g., housing, home maintenance)|3 - Environmental support (e.g., housing, home maintenance)|81
190|3 - Four to six times weekly|3 - Four to six times weekly|81
191|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessing by listener.  Speech limited to single words or short phrases.|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessin|81
192|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires multiple repetitions, restatements, demonstrations, additional time.|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires m|81
193|3 - Hopelessness|3 - Hopelessness|81
194|3 - Hospice care|3 - Hospice care|81
195|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|81
196|3 - Injury caused by fall or accident at home|3 - Injury caused by fall or accident at home|81
197|3 - Intractable pain|3 - Intractable pain|81
198|3 - Medicaid (traditional fee-for-service)|3 - Medicaid (traditional fee-for-service)|81
199|3 - Needs someone to do all shopping and errands.|3 - Needs someone to do all shopping and errands.|81
200|3 - Not healing|3 - Not healing|81
201|3 - Nursing home|3 - Nursing home|81
202|3 - Once daily|3 - Once daily|81
203|3 - Other family member|3 - Other family member|81
204|3 - Outpatient department/clinic emergency (includes urgicenter sites)|3 - Outpatient department/clinic emergency (includes urgicenter sites)|81
205|3 - Paid help|3 - Paid help|81
206|3 - Able to participate in bathing self in shower or tub, but requires presence of another person throughout the bath for assistance or supervision.|3 - Able to participate in bathing self in shower or tub, but requires presence of another person th|81
207|3 - Patient depends entirely upon another person to dress lower body.|3 - Patient depends entirely upon another person to dress lower body.|81
208|3 - Patient depends entirely upon another person to dress the upper body.|3 - Patient depends entirely upon another person to dress the upper body.|81
209|3 - Patient depends entirely upon someone else for grooming needs.|3 - Patient depends entirely upon someone else for grooming needs.|81
210|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone else to manage the equipment.|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone|81
211|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable to shift attention and recall directions more than half the time.|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable|81
212|3 - Respiratory problems (SOB, infection, obstruction)|3 - Respiratory problems (SOB, infection, obstruction)|81
213|3 - Resumption of care (after inpatient stay)|3 - Resumption of care (after inpatient stay)|81
214|3 - Several times each month|3 - Several times each month|81
215|3 - Skilled Nursing Facility|3 - Skilled Nursing Facility|81
216|3 - Stage 3|3 - Stage 3|81
217|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|81
218|3 - Three|3 - Three|81
219|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person throughout the process.|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person through|81
220|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal independently.|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal indep|81
221|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person.|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person|81
222|3 - Unknown because patient moved to a geographic location not served by this agency|3 - Unknown because patient moved to a geographic location not served by this agency|81
223|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|81
224|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|81
225|3 - With other family member|3 - With other family member|81
226|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home health services, homemaker assistance, transportation assistance, assisted living, board and care)|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home h|81
227|3-SLP/ST|3-SLP/ST|81
228|4 - At rest (during day or night)|4 - At rest (during day or night)|81
229|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|81
230|4 - Board and care or assisted living facility|4 - Board and care or assisted living facility|81
231|4 - Caregiver is completely dependent on someone else to manage all equipment.|4 - Caregiver is completely dependent on someone else to manage all equipment.|81
232|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|81
233|4 - Constantly|4 - Constantly|81
234|4 - Drug dependency|4 - Drug dependency|81
235|4 - Four or more|4 - Four or more|81
236|4 - Friend or neighbor or community or church member|4 - Friend or neighbor or community or church member|81
237|4 - Hispanic or Latino|4 - Hispanic or Latino|81
238|4 - Hospice|4 - Hospice|81
239|4 - Impaired decision-making|4 - Impaired decision-making|81
240|4 - Is totally dependent in toileting.|4 - Is totally dependent in toileting.|81
241|4 - Medicaid (HMO/managed care)|4 - Medicaid (HMO/managed care)|81
242|4 - None of the above|4 - None of the above|81
243|4 - Nursing home|4 - Nursing home|81
244|4 - On a daily basis|4 - On a daily basis|81
245|4 - Patient is completely dependent on someone else to manage all equipment.|4 - Patient is completely dependent on someone else to manage all equipment.|81
246|4 - Permanent placement|4 - Permanent placement|81
247|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, punches, dangerous maneuvers w/ wheelchair or other objects)|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, pu|81
248|4 - Psychosocial support (e.g., socialization, companionship, recreation)|4 - Psychosocial support (e.g., socialization, companionship, recreation)|81
249|4 - Recertification (follow-up) reassessment|4 - Recertification (follow-up) reassessment|81
250|4 - Recurrent thoughts of death|4 - Recurrent thoughts of death|81
251|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruction)|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruc|81
252|4 - Several times a week|4 - Several times a week|81
253|4 - Stage 4|4 - Stage 4|81
254|4 - Symptoms poorly controlled, history of re-hospitalizations|4 - Symptoms poorly controlled, history of re-hospitalizations|81
255|4 - Three or more times per week|4 - Three or more times per week|81
256|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetative state, or delirium.|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetati|81
257|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|81
258|4 - Unable to effectively participate in any housekeeping tasks.|4 - Unable to effectively participate in any housekeeping tasks.|81
259|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or unresponsive (e.g., speech is nonsensical or unintelligible).|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or u|81
260|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonresponsive.|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonr|81
261|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostomy.|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostom|81
262|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of devices at the sink, in chair, or on commode|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of|81
263|4 - With a friend|4 - With a friend|81
264|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|81
265|4-OT|4-OT|81
266|5 - Advocates or facilitates patient's participation in appropriate medical care|5 - Advocates or facilitates patient's participation in appropriate medical care|81
267|5 - At least daily|5 - At least daily|81
268|6 - Bedfast, unable to ambulate or be up in a chair.|6 - Bedfast, unable to ambulate or be up in a chair.|81
269|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|81
270|5 - Disruptive or socially inappropriate behavior|5 - Disruptive or socially inappropriate behavior|81
271|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|81
272|5 - Hypo/Hyperglycemia, diabetes out of control|5 - Hypo/Hyperglycemia, diabetes out of control|81
273|5 - More often than once daily|5 - More often than once daily|81
274|5 - Native Hawaiian or Pacific Islander|5 - Native Hawaiian or Pacific Islander|81
275|5 - None of the above|5 - None of the above|81
276|5 - One to two times per week|5 - One to two times per week|81
277|5 - Other|5 - Other|81
278|5 - Other follow-up|5 - Other follow-up|81
279|5 - Paid help|5 - Paid help|81
280|5 - Patient nonresponsive or unable to speak.|5 - Patient nonresponsive or unable to speak.|81
281|5 - Thoughts of suicide|5 - Thoughts of suicide|81
282|5 - Totally unable to use the telephone.|5 - Totally unable to use the telephone.|81
283|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|81
284|5 - Unable to take in nutrients orally or by tube feeding.|5 - Unable to take in nutrients orally or by tube feeding.|81
285|5 - Unsafe for care at home|5 - Unsafe for care at home|81
286|5 - With paid help (other than home care agency staff)|5 - With paid help (other than home care agency staff)|81
287|5 - Workers' compensation|5 - Workers' compensation|81
288|5 - Wound infection, deteriorating wound status, new lesion/ulcer|5 - Wound infection, deteriorating wound status, new lesion/ulcer|81
289|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|81
290|6 - Delusional, hallucinatory, or paranoid behavior|6 - Delusional, hallucinatory, or paranoid behavior|81
291|6 - Financial agent, power of attorney, or conservator of finance|6 - Financial agent, power of attorney, or conservator of finance|81
292|6 - GI bleeding, obstruction|6 - GI bleeding, obstruction|81
293|6 - Less often than weekly|6 - Less often than weekly|81
294|6 - Memory loss to the extent that supervision required|6 - Memory loss to the extent that supervision required|81
295|6 - None of the above feelings observed or reported|6 - None of the above feelings observed or reported|81
296|6 - Other|6 - Other|81
297|6 - Title programs (e.g., Title III, V, or XX)|6 - Title programs (e.g., Title III, V, or XX)|81
298|6 - Transferred to an inpatient facility - patient not discharged from agency|6 - Transferred to an inpatient facility - patient not discharged from agency|81
299|6 - White|6 - White|81
300|6 - With other than above|6 - With other than above|81
301|7 - Exacerbation of CHF, fluid overload, heart failure|7 - Exacerbation of CHF, fluid overload, heart failure|81
302|7 - Health care agent, conservator of person, or medical power of attorney|7 - Health care agent, conservator of person, or medical power of attorney|81
303|7 - Hypo/Hyperglycemia, diabetes out of control|7 - Hypo/Hyperglycemia, diabetes out of control|81
304|7 - None of the above|7 - None of the above|81
305|7 - None of the above behaviors demonstrated|7 - None of the above behaviors demonstrated|81
306|7 - Other government (e.g., TriCare, VA, etc.)|7 - Other government (e.g., TriCare, VA, etc.)|81
307|7 - Transferred to an inpatient facility - patient discharged from agency|7 - Transferred to an inpatient facility - patient discharged from agency|81
308|8 - Death at home|8 - Death at home|81
309|8 - GI bleeding, obstruction|8 - GI bleeding, obstruction|81
310|8 - Myocardial infarction, stroke|8 - Myocardial infarction, stroke|81
311|8 - Private insurance|8 - Private insurance|81
312|9 - Chemotherapy|9 - Chemotherapy|81
313|9 - Discharge from agency|9 - Discharge from agency|81
314|9 - Other than above reasons|9 - Other than above reasons|81
315|9 - Private HMO/managed care|9 - Private HMO/managed care|81
316|NA - No caregiver|NA - No caregiver|81
317|NA - No equipment of this type used in care.|NA - No equipment of this type used in care.|81
318|NA - No inhalant/mist medications prescribed.|NA - No inhalant/mist medications prescribed.|81
319|NA - No injectable medications prescribed.|NA - No injectable medications prescribed.|81
320|NA - No inpatient facility admission|NA - No inpatient facility admission|81
321|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|81
322|NA - No Medicaid|NA - No Medicaid|81
323|NA - No Medicare|NA - No Medicare|81
324|NA - No observable pressure ulcer|NA - No observable pressure ulcer|81
325|NA - No observable stasis ulcer|NA - No observable stasis ulcer|81
326|NA - No observable surgical wound|NA - No observable surgical wound|81
327|NA - No oral medications prescribed.|NA - No oral medications prescribed.|81
328|NA - Not applicable|NA - Not applicable|81
329|NA - Patient does not have a telephone.|NA - Patient does not have a telephone.|81
330|NA - Patient has ostomy for bowel elimination|NA - Patient has ostomy for bowel elimination|81
331|NA - Patient nonresponsive|NA - Patient nonresponsive|81
332|NA - Patient on prophylactic treatment|NA - Patient on prophylactic treatment|81
333|NA - Patient was not discharged from an inpatient facility [Go to M1021]|NA - Patient was not discharged from an inpatient facility [Go to M1017]|81
334|UK - Other unknown|UK - Other unknown|81
335|UK - Reason unknown|UK - Reason unknown|81
336|UK - Unknown|UK - Unknown|81
337|UK - Unknown or Not Available|UK - Unknown or Not Available|81
341|01 - Early|01 - Early|81
342|02 - Late|02 - Late|81
343|NA - Not Applicable. No case mix group defined for this assessment.|NA - Not Applicable. No case mix group defined for this assessment.|81
344|NA - No case mix group defined by this assessment.|NA - No case mix group defined by this assessment.|81
345|1 - Recent decline in mental, emotional, or behavioral status|1 - Recent decline in mental, emotional, or behavioral status|81
346|2 - Multiple hospitalizations (2 or more) in the past 12 months|2 - Multiple hospitalizations (2 or more) in the past 12 months|81
347|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|81
348|4 - Taking five or more medications|4 - Taking five or more medications|81
349|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|81
350|6 - Other|6 - Other|81
351|7 - None of the above|7 - None of the above|81
352|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond tho|81
353|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable without heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable wi|81
354|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious complications and death.|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious compl|81
355|3 - The patient has serious progressive conditions that could lead to death within a year.|3 - The patient has serious progressive conditions that could lead to death within a year.|81
356|UK - The patient+s situation is unknown or unclear.|UK - The patient+s situation is unknown or unclear.|81
357|1 - Yes [ Go to M1050 ]|1 - Yes [ Go to M1050 ]|81
358|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this influenza season. [ Go to M1050 ]|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this i|81
359|1 - Received from another health care provider (e.g., physician)|1 - Received from another health care provider (e.g., physician)|81
360|2 - Received from your agency previously during this year+s flu season|2 - Received from your agency previously during this year+s flu season|81
361|3 - Offered and declined|3 - Offered and declined|81
362|4 - Assessed and determined to have medical contraindication(s)|4 - Assessed and determined to have medical contraindication(s)|81
363|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|81
364|6 - Inability to obtain vaccine due to declared shortage|6 - Inability to obtain vaccine due to declared shortage|81
365|1 - Yes [ Go to M2005 at TRN; Go to M1230 at DC ]|1 - Yes [ Go to M2005 at TRN; Go to M1230 at DC ]|81
366|1 - Patient has received PPV in the past|1 - Patient has received PPV in the past|81
367|2 - Offered and declined|2 - Offered and declined|81
368|3 - Assessed and determined to have medical contraindication(s)|3 - Assessed and determined to have medical contraindication(s)|81
369|4 - Not indicated; patient does not meet age/condition guidelines for PPV|4 - Not indicated; patient does not meet age/condition guidelines for PPV|81
370|5 - None of the above|5 - None of the above|81
371|0 - Adequate: hears normal conversation without difficulty.|0 - Adequate: hears normal conversation without difficulty.|81
372|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to increase volume or speak distinctly.|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to in|81
373|2 - Severely Impaired: absence of useful hearing.|2 - Severely Impaired: absence of useful hearing.|81
374|UK - Unable to assess hearing.|UK - Unable to assess hearing.|81
375|0 - Understands: clear comprehension without cues or repetitions.|0 - Understands: clear comprehension without cues or repetitions.|81
376|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Requires cues at times to understand.|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Req|81
377|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequently requires cues to understand.|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequentl|81
378|3 - Rarely/Never Understands|3 - Rarely/Never Understands|81
379|UK - Unable to assess understanding.|UK - Unable to assess understanding.|81
380|0 - No standardized assessment conducted|0 - No standardized assessment conducted|81
381|1 - Yes, and it does not indicate severe pain|1 - Yes, and it does not indicate severe pain|81
382|2 - Yes, and it indicates severe pain|2 - Yes, and it indicates severe pain|81
383|0 - Patient has no pain|0 - Patient has no pain|81
384|1 - Patient has pain that does not interfere with activity or movement|1 - Patient has pain that does not interfere with activity or movement|81
385|2 - Less often than daily|2 - Less often than daily|81
386|3 - Daily, but not constantly|3 - Daily, but not constantly|81
387|4 - All of the time|4 - All of the time|81
388|0 - No assessment conducted [ Go to M1306 ]|0 - No assessment conducted [ Go to M1306 ]|81
389|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc., without use of standardized tool|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc.,|81
390|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|81
391|0 - No [ Go to M1322]|0 - No [ Go to M1322]|81
392|0 v Newly epithelialized|0 - Newly epithelialized|81
393|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|81
394|2 - Yes, patient has observable stasis ulcers ONLY|2 - Yes, patient has observable stasis ulcers ONLY|81
395|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable dressing) [Go to M1340]|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable|81
396|0 - No [ Go to M1400 ]|0 - No [ Go to M1400 ]|81
397|1 - Yes, patient has at least one (observable) surgical wound|1 - Yes, patient has at least one (observable) surgical wound|81
398|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1350 ]|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1350 ]|81
399|0 - Patient is not short of breath|0 - Patient is not short of breath|81
400|3 - Continuous Bi-level positive airway pressure|3 - Continuous Bi-level positive airway pressure|81
401|0 - No [ Go to M1732 at TRN; Go to M1600 at DC ]|0 - No [ Go to M1732 at TRN; Go to M1600 at DC ]|81
402|2 - Not assessed [Go to M1732 at TRN; Go to M1600 at DC ]|2 - Not assessed [Go to M1732 at TRN; Go to M1600 at DC ]|81
403|NA - Patient does not have diagnosis of heart failure [Go to M2005 at TRN; Go to M1600 at DC]|NA - Patient does not have diagnosis of heart failure [Go to M2005 at TRN; Go to M1600 at DC]|81
404|0 - No action taken|0 - No action taken|81
405|1 - Patient+s physician (or other primary care practitioner) contacted the same day|1 - Patient+s physician (or other primary care practitioner) contacted the same day|81
406|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|81
407|3 - Implement physician-ordered patient-specific established parameters for treatment|3 - Implement physician-ordered patient-specific established parameters for treatment|81
408|4 - Patient education or other clinical interventions|4 - Patient education or other clinical interventions|81
409|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequency, telehealth, etc.)|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequ|81
410|1 - Occasional stress incontinence|1 - Occasional stress incontinence|81
411|2 - During the night only|2 - During the night only|81
412|3 - During the day only|3 - During the day only|81
413|4 - During the day and night|4 - During the day and night|81
414|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|81
415|0 - Able to manage toileting hygiene and clothing management without assistance.|0 - Able to manage toileting hygiene and clothing management without assistance.|81
416|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implements are laid out for the patient.|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implemen|81
417|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|81
418|3 - Patient depends entirely upon another person to maintain toileting hygiene.|3 - Patient depends entirely upon another person to maintain toileting hygiene.|81
419|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independent|81
420|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface|81
421|0 - No multi-factor falls risk assessment conducted.|0 - No multi-factor falls risk assessment conducted.|81
422|1 - Yes, and it does not indicate a risk for falls.|1 - Yes, and it does not indicate a risk for falls.|81
423|2 - Yes, and it indicates a risk for falls.|2 - Yes, and it indicates a risk for falls.|81
424|0 - Not assessed/reviewed [ Go to M2010 ]|0 - Not assessed/reviewed [ Go to M2010 ]|81
425|No - No issues found during review [ Go to M2010 ]|No - No issues found during review [ Go to M2010 ]|81
426|Yes - Issues found during review|Yes - Issues found during review|81
427|NA - Patient is not taking any medications [ Go to M2102 ]|NA - Patient is not taking any medications [ Go to M2102 ]|81
428|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special precautions associated with all high-risk medications|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special p|81
429|NA - Patient not taking any drugs|NA - Patient not taking any drugs|81
430|2 - Able to take medication(s) at the correct times if given reminders by another person at the appropriate times|2 - Able to take medication(s) at the correct times if given reminders by another person at the appr|81
431|3 - Unable to take medication unless administered by another person.|3 - Unable to take medication unless administered by another person.|81
432|1 - At least daily|1 - At least daily|81
433|2 - Three or more times per week|2 - Three or more times per week|81
434|3 - One to two times per week|3 - One to two times per week|81
435|4 - Received, but less often than weekly|4 - Received, but less often than weekly|81
436|5 - No assistance received|5 - No assistance received|81
437|0 - No [Go to M2401]|0 - No [Go to M2401]|81
438|1 - Yes, used hospital emergency department WITHOUT hospital admission|1 - Yes, used hospital emergency department WITHOUT hospital admission|81
439|2 - Yes, used hospital emergency department WITH hospital admission|2 - Yes, used hospital emergency department WITH hospital admission|81
440|UK - Unknown [Go to M2401]|UK - Unknown [Go to M2401]|81
441|2 - Injury caused by fall|2 - Injury caused by fall|81
442|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|81
443|4 - Other respiratory problem|4 - Other respiratory problem|81
444|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|81
445|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|81
446|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|81
447|8 - Other heart disease|8 - Other heart disease|81
448|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|81
449|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|81
450|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|81
451|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|81
452|13 - Urinary tract infection|13 - Urinary tract infection|81
453|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|81
454|15 - Wound infection or deterioration|15 - Wound infection or deterioration|81
455|16 - Uncontrolled pain|16 - Uncontrolled pain|81
456|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|81
457|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|81
458|19 - Other than above reasons|19 - Other than above reasons|81
459|2 - Patient remained in the community (with formal assistive services)|2 - Patient remained in the community (with formal assistive services)|81
460|3 - Patient transferred to a noninstitutional hospice|3 - Patient transferred to a noninstitutional hospice|81
461|4 - Unknown because patient moved to a geographic location not served by this agency|4 - Unknown because patient moved to a geographic location not served by this agency|81
462|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|81
463|4 - Other respiratory problem|4 - Other respiratory problem|81
464|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|81
465|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|81
466|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|81
467|8 - Other heart disease|8 - Other heart disease|81
468|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|81
469|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|81
470|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|81
471|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|81
472|13 - Urinary tract infection|13 - Urinary tract infection|81
473|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|81
474|15 - Wound infection or deterioration|15 - Wound infection or deterioration|81
475|16 - Uncontrolled pain|16 - Uncontrolled pain|81
476|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|81
477|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|81
478|19 - Scheduled treatment or procedure|19 - Scheduled treatment or procedure|81
479|20 - Other than above reasons|20 - Other than above reasons|81
480|UK - Reason unknown [Go to M0903]|UK - Reason unknown [Go to M0903]|81
482|01 - Patient lives alone around the clock|01 - Patient lives alone around the clock|81
483|02 - Patient lives alone regular daytime|02 - Patient lives alone regular daytime|81
484|03 - Patient lives alone regular nighttime|03 - Patient lives alone regular nighttime|81
485|04 - Patient lives alone occassional/short term assistance|04 - Patient lives alone occassional/short term assistance|81
486|05 - Patient lives alone no assisstance available|05 - Patient lives alone no assisstance available|81
487|06 - Patient lives with other person(s) in the home around the clock|06 - Patient lives with other person(s) in the home around the clock|81
488|07 - Patient lives with other person(s) in the home regular daytime|07 - Patient lives with other person(s) in the home regular daytime|81
489|08 - Patient lives with other person(s) in the home regular nighttime|08 - Patient lives with other person(s) in the home regular nighttime|81
490|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|81
491|10 - Patient lives with other person(s) in the home no assistance available|10 - Patient lives with other person(s) in the home no assistance available|81
492|1 - Was present at the most recent SOC/ROC assessment|1 - Was present at the most recent SOC/ROC assessment|81
493|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|81
494|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|81
495|0 - Newly epithelialized|0 - Newly epithelialized|81
496|0 - No [ Go to M1340 ]|0 - No [ Go to M1340 ]|81
498|0 - Independent|0 - Independent|81
499|1 - Needed Some Help|1 - Needed Some Help|81
500|2 - Dependent|2 - Dependent|81
502|0 - No assistance needed in this area|0 - No assistance needed in this area|81
635|3 - Non-agency caregiver(s) are not likely to provide assistance OR it is unclear if they will provide assistance|3 - Non-agency caregiver(s) are not likely to provide assistance OR unclear if will provide asst|81
636|4 - Assistance needed but no non-agency caregiver(s) available|4 - Assistance needed but no non-agency caregiver(s) available|81
637|1 - Peripheral Vascular Disease (PVD) or Peripheral Arterial Disease (PAD)|1 - Peripheral Vascular Disease (PVD) or Peripheral Arterial Disease (PAD)|81
638|2 - Diabetes Mellitus (DM)|2 - Diabetes Mellitus (DM)|81
639|06 - Independent - Patient completes the activity by him/herself with no assistance from a helper.|06 Independent - Patient completes the activity by him/herself with no assistance from a helper.|81
640|05 - Setup or clean-up assistance - Helper SETS UP or CLEANS UP; patient completes activity. Helper assists only prior to or following the activity.|05 Setup or clean-up assistance - Helper SETS UP or CLEANS UP; patient completes activity. He|81
641|04 - Supervision or touching assistance - Helper provides VERBAL CUES or TOUCHING/STEADYING assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently.|04 Supervision or touching assistance - Helper provides VERBAL CUES or TOUCHING/STEADYING|81
642|03 - Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort.|03 Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or |81
643|02 - Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.|02 Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds |81
644|01 - Dependent - Helper does ALL of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity.|01 Dependent - Helper does ALL of the effort. Patient does none of the effort to complete the act|81
645|07 - Activity not attempted - Patient refused|07 Activity not attempted - Patient refused|81
646|09 - Activity not attempted - Not applicable|09 Activity not attempted - Not applicable|81
647|88 - Not attempted due to medical condition or safety concerns|88 Not attempted due to medical condition or safety concerns|81
527|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet criteria for further evaluation for depression.|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet|81
528|0 - Not at all  0 - 1 day|0 - Not at all  0 - 1 day|81
529|1 - Several days  2 - 6 days|1 - Several days  2 - 6 days|81
530|2 - More than half of the days  7 - 11 days|2 - More than half of the days  7 - 11 days|81
531|3 - Nearly every day  12 - 14 days|3 - Nearly every day  12 - 14 days|81
532|NA - N/A  Unable to respond|NA - N/A  Unable to respond|81
533|2 - Able to take medication(s) at the correct times if given reminders by another person based on the frequency of the injection|2 - Able to take medication(s) at the correct times if given reminders by another person based on th|81
2|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; OR (b) Is physically, cognitively, and mentally able to prepare light meals on a regular basis but has not routinely performed light meal preparation in the past (i.e., prior to this home care admission).|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; O|81
3|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and mentally able to perform all housekeeping tasks .|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and menta|81
4|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and mentally able to do laundry and access facilities.|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and menta|81
5|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying packages OR b) Physically, cognitively, and mentally able to take care of shopping, but has not done shopping in the past (i.e., prior to this home care admission).|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying|81
6|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|81
7|0 - Able to dial numbers and answer calls appropriately and as desired.|0 - Able to dial numbers and answer calls appropriately and as desired.|81
8|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body without assistance.|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body|81
9|0 - Able to get to and from the toilet and transfer independently with or without a device.|0 - Able to get to and from the toilet and transfer independently with or without a device.|81
10|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|81
11|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible public bus.|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible p|81
12|0 - Able to independently feed self.|0 - Able to independently feed self.|81
13|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|81
14|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct times.|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct ti|81
15|0 - Able to independently transfer.|0 - Able to independently transfer.|81
16|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without rail|81
17|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings|81
18|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|81
19|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions independently.|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions indep|81
20|0 - Asymptomatic, no treatment needed at this time|0 - Asymptomatic, no treatment needed at this time|81
21|0 - Caregiver manages all tasks related to equipment completely independently.|0 - Caregiver manages all tasks related to equipment completely independently.|81
503|1 - Caregiver(s) currently provide assistance|1 - Caregiver(s) currently provide assistance|81
504|2 - Caregiver(s) need training/ supportive services to provide assistance|2 - Caregiver(s) need training/ supportive services to provide assistance|81
505|3 - Caregiver(s) not likely to provide assistance|3 - Caregiver(s) not likely to provide assistance|81
506|4 - Unclear if Caregiver(s) will provide assistance|4 - Unclear if Caregiver(s) will provide assistance|81
507|5 - Assistance needed, but no Caregiver(s) available|5 - Assistance needed, but no Caregiver(s) available|81
508|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will use standardized clinical guidelines accessible for all care providers to reference|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will|81
509|NA - Patient is not diabetic or is bilateral amputee|NA - Patient is not diabetic or is bilateral amputee|81
510|NA - Patient is not assessed to be at risk for falls|NA - Patient is not assessed to be at risk for falls|81
511|NA - Patient has no diagnosis or symptoms of depression|NA - Patient has no diagnosis or symptoms of depression|81
512|NA - No pain identified|NA - No pain identified|81
513|NA - Patient is not assessed to be at risk for pressure ulcers|NA - Patient is not assessed to be at risk for pressure ulcers|81
514|NA - Patient has no pressure ulcers with need for moist wound healing|NA - Patient has no pressure ulcers with need for moist wound healing|81
515|1 - Long-term nursing facility (NF)|1 - Long-term nursing facility (NF)|81
516|2 - Skilled nursing facility (SNF / TCU)|2 - Skilled nursing facility (SNF / TCU)|81
517|3 - Short stay acute hospital (IPP S)|3 - Short stay acute hospital (IPP S)|81
518|4 - Long-term care hospital (LTCH)|4 - Long-term care hospital (LTCH)|81
519|5 - Inpatient rehabilitation hospital or unit (IRF)|5 - Inpatient rehabilitation hospital or unit (IRF)|81
520|6 - Psychiatric hospital or unit|6 - Psychiatric hospital or unit|81
521|7 - Other|7 - Other|81
522|NA - Patient was not discharged from an inpatient facility [Go to M1017]|NA - Patient was not discharged from an inpatient facility [Go to M1017]|81
523|6 - Unable to participate effectively in bathing and is bathed totally by another person|6 - Unable to participate effectively in bathing and is bathed totally by another person|81
524|4 - Chairfast, unable to ambulate but is able to wheel self independently.|4 - Chairfast, unable to ambulate but is able to wheel self independently.|81
525|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask patient: "Over the last two weeks, how often have you been bothered by any of the following problems")  *Copyright+ Pfizer Inc. All rights reserved. Reproduced with permission.|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask|81
526|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluation for depression.|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluat|81
534|3 - Unable to take injectable medication unless administered by another person.|3 - Unable to take injectable medication unless administered by another person.|81
535|11 - Patient lives in congregate situation (e.g., assisted living) around the clock|11 - Patient lives in congregate situation (e.g., assisted living) around the clock|81
536|12 - Patient lives in congregate situation (e.g., assisted living) regular daytime|12 - Patient lives in congregate situation (e.g., assisted living) regular daytime|81
537|13 - Patient lives in congregate situation (e.g., assisted living) regular nighttime|13 - Patient lives in congregate situation (e.g., assisted living) regular nighttime|81
538|14 - Patient lives in congregate situation (e.g., assisted living) occasional / short-term assistance|14 - Patient lives in congregate situation (e.g., assisted living) occasional / short-term assistanc|81
539|15 - Patient lives in congregate situation (e.g., assisted living) no assistance available|15 - Patient lives in congregate situation (e.g., assisted living) no assistance available|81
545|NA - No observable pressure ulcer or unhealed pressure ulcer|NA - No observable pressure ulcer or unhealed pressure ulcer|81
582|NA - No specific SOC date ordered by physician|NA - No specific SOC date ordered by physician|81
585|UK - Inpatient Discharge Date Unknown|UK - Inpatient Discharge Date Unknown|81
600|1 - History of falls (2 or more falls - or any fall with an injury - in the past 12 months) |1 - History of falls (2 or more falls - or any fall with an injury - in the past 12 months) |81
602|2 - Unintentional weight loss of a total of 10 pounds or more in the past 12 months |2 - Unintentional weight loss of a total of 10 pounds or more in the past 12 months |81
604|3 - Multiple hospitalizations (2 or more) in the past 6 months|3 - Multiple hospitalizations (2 or more) in the past 6 months|81
606|4 - Multiple emergency department visits (2 or more) in the past 6 months|4 - Multiple emergency department visits (2 or more) in the past 6 months|81
608|5 - Decline in mental emotional or behavioral status in the past 3 months |5 - Decline in mental emotional or behavioral status in the past 3 months |81
610|6 - Reported or observed history of difficulty complying with any medical instructions (for example,medications, diet, exercise) in the past 3 months|6 - Reported or observed history of difficulty complying with any medical instructions (for example |81
612|7 - Currently taking 5 or more medications|7 - Currently taking 5 or more medications|81
614|8 - Currently reports exhaustion|8 - Currently reports exhaustion|81
616|9 - Other risk(s) not listed in 1 - 8|9 - Other risk(s) not listed in 1 - 8|81
618|10 - None of the above |10 - None of the above |81
632|0 - No assistance needed v patient is independent or does not have needs in this area|0 - No assistance needed v patient is independent or does not have needs in this area|81
633|1 - Non-agency caregiver(s) currently provide assistance |1 - Non-agency caregiver(s) currently provide assistance |81
634|2 - Non-agency caregiver(s) need training/ supportive services to provide assistance|2 - Non-agency caregiver(s) need training/ supportive services to provide assistance|81
22|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations with no observable impairment.|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations w|81
23|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|81
24|0 - Life expectancy is greater than 6 months|0 - Life expectancy is greater than 6 months|81
25|0 - Never|0 - Never|81
26|0 - Patient is not short of breath|0 - Patient is not short of breath|81
27|0 - No|0 - No|81
28|0 - No emergent care services|0 - No emergent care services|81
29|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) |0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage)|81
30|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and extended or abstract conversation.|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and exte|81
31|0 - No one person|0 - No one person|81
32|0 - None of the time|0 - None of the time|81
33|0 - None, no charge for current services|0 - None, no charge for current services|81
34|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|81
35|0 - Patient does NOT have an ostomy for bowel elimination.|0 - Patient does NOT have an ostomy for bowel elimination.|81
36|0 - Patient has no pain|0 - Patient has no pain|81
37|0 - Patient manages all tasks related to equipment completely independently.|0 - Patient manages all tasks related to equipment completely independently.|81
38|0 - Poor:  little or no recovery is expected and/or further decline is imminent|0 - Poor:  little or no recovery is expected and/or further decline is imminent|81
39|0 - Timed-voiding defers incontinence|0 - Timed-voiding defers incontinence|81
40|0 - Very rarely or never has bowel incontinence|0 - Very rarely or never has bowel incontinence|81
41|0 - Zero|0 - Zero|81
42|00 - No|00 - No|81
43|01 - Yes|01 - Yes|81
44|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or mental limitations, needs assistance with heavy laundry.|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or|81
45|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the patient.|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the|81
46|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|81
47|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or supervision from another person OR c) a liquid, pureed or ground meat diet.|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or su|81
48|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|81
49|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|81
50|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independently.|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independe|81
51|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only when assisted or accompanied by another person.|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only w|81
52|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepa|81
53|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance by another person OR b) given daily reminders.|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance b|81
54|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advan|81
55|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advan|81
56|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for the deaf) and call essential numbers.|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for t|81
57|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|81
58|1 - American Indian or Alaska Native|1 - American Indian or Alaska Native|81
59|1 - Depressed mood (e.g., feeling sad, tearful)|1 - Depressed mood (e.g., feeling sad, tearful)|81
60|1 - During the night only|1 - During the night only|81
61|1 - Fully granulating|1 - Fully granulating|81
62|1 - Good/Fair:  partial to full recovery is expected|1 - Good/Fair:  partial to full recovery is expected|81
63|1 - Good:  marked improvement in functional status is expected|1 - Good:  marked improvement in functional status is expected|81
64|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|81
65|1 - Smoking|1 - Smoking|81
66|1 - Hospital|1 - Hospital|81
67|1 - Hospital emergency room (includes 23-hour holding)|1 - Hospital emergency room (includes 23-hour holding)|81
68|1 - Hospitalization for EMERGENT (unscheduled) care|1 - Hospitalization for EMERGENT (unscheduled) care|81
69|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepared solutions), patient is able to manage all other aspects of equipment.|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepar|81
70|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|81
71|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|81
72|1 - In new or complex situations only|1 - In new or complex situations only|81
73|1 - Intravenous or infusion therapy (excludes TPN)|1 - Intravenous or infusion therapy (excludes TPN)|81
74|1 - Less often than daily|1 - Less often than daily|81
75|1 - Less than once a month|1 - Less than once a month|81
76|1 - Less than once weekly|1 - Less than once weekly|81
77|1 - Life expectancy is 6 months or fewer|1 - Life expectancy is 6 months or fewer|81
78|1 - Lives alone|1 - Lives alone|81
79|1 - Male|1 - Male|81
80|1 - Medicare (traditional fee-for-service)|1 - Medicare (traditional fee-for-service)|81
81|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of past 24 hours, significant memory loss so that supervision is required|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of pas|81
82|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors in word choice, grammar or speech intelligibility, needs minimal prompting or assistance).|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors i|81
83|1 - No assistance or services received|1 - No assistance or services received|81
84|1 - One|1 - One|81
85|1 - Oxygen (intermittent or continuous)|1 - Oxygen (intermittent or continuous)|81
86|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, and the surrounding layout, can count fingers at arm's length.|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, a|81
87|1 - Patient is incontinent|1 - Patient is incontinent|81
88|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|81
89|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical or treatment regimen.|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical|81
90|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient/couple/significant other)|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient|81
91|1 - Relatives, friends, or neighbors living outside the home|1 - Relatives, friends, or neighbors living outside the home|81
92|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions.|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions|81
93|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independentl|81
94|1 - Several times during day and night|1 - Several times during day and night|81
95|1 - Spouse or significant other|1 - Spouse or significant other|81
96|1 - Stage 1|1 - Stage 1|81
97|1 - Start of care - further visits planned|1 - Start of care - further visits planned|81
98|1 - Symptoms well controlled with current therapy|1 - Symptoms well controlled with current therapy|81
99|1 - Therapy services|1 - Therapy services|81
100|1 - Able to transfer with minimal human assistance or with use of an assistive device.|1 - Able to transfer with minimal human assistance or with use of an assistive device.|81
101|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitations.|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitatio|81
102|1 - Urinary incontinence|1 - Urinary incontinence|81
103|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and transfer.|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and|81
104|1 - When walking more than 20 feet, climbing stairs|1 - When walking more than 20 feet, climbing stairs|81
105|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary conversation. May need occasional repetition, extra time, or louder voice.|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary c|81
106|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting in and out of tub/shower|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting|81
107|1 - Yes|1 - Yes|81
108|1-RN|1-RN|81
109|10 - Discharge from agency - no visits completed after start/resumption of care assessment|10 - Discharge from agency - no visits completed after start/resumption of care assessment|81
110|10 - Scheduled surgical procedure|10 - Scheduled surgical procedure|81
111|10 - Self-pay|10 - Self-pay|81
112|11 - Other|11 - Other|81
113|11 - Urinary tract infection|11 - Urinary tract infection|81
114|12 - IV catheter-related infection|12 - IV catheter-related infection|81
115|13 - Deep vein thrombosis, pulmonary embolus|13 - Deep vein thrombosis, pulmonary embolus|81
116|14 - Uncontrolled pain|14 - Uncontrolled pain|81
117|15 - Psychotic episode|15 - Psychotic episode|81
118|16 - Other than above reasons|16 - Other than above reasons|81
119|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing calls.|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing|81
120|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another person.|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another pers|81
121|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface a|81
122|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for intermittent supervision or encouragement or reminders, OR (b) to get in and out of the shower or tub, OR (c) for washing difficult to reach areas.|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for inter|81
123|2 - Asian|2 - Asian|81
124|2 - Caregiver requires considerable assistance from another person to manage equipment, but independently completes significant portions of task.|2 - Caregiver requires considerable assistance from another person to manage equipment, but independ|81
125|2 - Daily, but not constantly|2 - Daily, but not constantly|81
126|2 - Daughter or son|2 - Daughter or son|81
127|2 - Doctor's office emergency visit/house call|2 - Doctor's office emergency visit/house call|81
128|2 - During the day and night|2 - During the day and night|81
129|2 - Early/partial granulation|2 - Early/partial granulation|81
130|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors in word choice, organization or speech intelligibility). Speaks in phrases or short sentences.|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors|81
131|2 - Family member's residence|2 - Family member's residence|81
132|2 - Female|2 - Female|81
133|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conversation, needs frequent prompting or assistance.|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conver|81
134|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|81
135|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|81
136|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately stop activities, jeopardizes safety through actions|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately st|81
137|2 - Indwelling/suprapubic catheter|2 - Indwelling/suprapubic catheter|81
138|2 - Injury caused by fall or accident at home|2 - Injury caused by fall or accident at home|81
139|2 - Medicare (HMO/managed care/Advantage plan)|2 - Medicare (HMO/managed care/Advantage plan)|81
140|2 - Nausea, dehydration, malnutrition, constipation, impaction|2 - Nausea, dehydration, malnutrition, constipation, impaction|81
141|2 - Obesity|2 - Obesity|81
142|2 - On awakening or at night only|2 - On awakening or at night only|81
143|2 - Once a month|2 - Once a month|81
144|2 - One to three times weekly|2 - One to three times weekly|81
145|2 - Parenteral nutrition (TPN or lipids)|2 - Parenteral nutrition (TPN or lipids)|81
146|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic)  [ Go to M1620 ]|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic)  [ Go|81
147|2 - Patient requires considerable assistance from another person to manage equipment, but independently completes portions of the task.|2 - Patient requires considerable assistance from another person to manage equipment, but independen|81
148|2 - Patient transferred to a noninstitutional hospice|2 - Patient transferred to a noninstitutional hospice|81
149|2 - Person residing in the home (EXCLUDING paid help)|2 - Person residing in the home (EXCLUDING paid help)|81
150|2 - Rehabilitation facility|2 - Rehabilitation facility|81
151|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifting of attention) or consistently requires low stimulus environment due to distractibility.|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifti|81
152|2 - Respite care|2 - Respite care|81
153|2 - Sense of failure or self reproach|2 - Sense of failure or self reproach|81
154|2 - Several times during day|2 - Several times during day|81
155|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonresponsive.|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonrespons|81
156|2 - Someone must assist the patient to groom self.|2 - Someone must assist the patient to groom self.|81
648|06 - Independent - Patient completes the activity by him/herself with no assistance from a helper.|06 - Independent - Patient completes the activity by him/herself with no assistance from a helper.|81
649|05 - Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity.|05 - Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper|81
650|04 - Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently.|04 - Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/|81
651|03 - Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort.|03 - Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or sup|81
652|02 - Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.|02 - Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds t|81
653|01 - Dependent - Helper does ALL of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity.|01 - Dependent - Helper does ALL of the effort. Patient does none of the effort to complete the acti|81
654|07 - Patient refused|07 - Patient refused|81
655|09 - Not applicable - Not attempted and the patient did not perform this activity prior to the current illness,exacerbation or injury.|09 - Not applicable - Not attempted and the patient did not perform this activity prior to the curre|81
656|10 - Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)|10 - Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)|81
657|88 - Not attempted due to medical conditions or safety concerns|88 - Not attempted due to medical conditions or safety concerns|81
658|0 - No [STOP]|0 - No [STOP]|81
659|0 - No [Skip GG0170R]|0 - No [Skip GG0170R]|81
660|1 - Yes [Continue to GG0170R, Wheel 50 feet with two turns.]|1 - Yes [Continue to GG0170R, Wheel 50 feet with two turns.]|81
661|1 - Manual|1 - Manual|81
662|2 - Motorized|2 - Motorized|81
663|0 - No [Skip to J1800 Any falls since SOC/ROC, whichever is more recent.]|0 - No [Skip to J1800 Any falls since SOC/ROC, whichever is more recent.]|81
664|0 - No [STOP]|0 - No [STOP]|81
665|1 - Yes [Continue to J1900, Number of Falls Since SOC/ROC, whichever is more recent]|1 - Yes [Continue to J1900, Number of Falls Since SOC/ROC, whichever is more recent]|81
666|0 - None|0 - None|81
667|1 - One|1 - One|81
668|2 - Two or More|2 - Two or More|81
669|3 - Independent - Patient completed the activities by him/herself, with or without an assistive device, with no assistance from a helper.|3 - Independent - Patient completed the activities by him/herself, with or without an assistive devi|81
670|2 - Needed Some Help - Patient needed partial assistance from another person to complete activities.|2 - Needed Some Help - Patient needed partial assistance from another person to complete activities.|81
671|1 - Dependent - A helper completed the activities for the patient.|1 - Dependent - A helper completed the activities for the patient.|81
672|8 - Unknown|8 - Unknown|81
673|9 - Not Applicable|9 - Not Applicable|81
674|A - Manual wheelchair|A - Manual wheelchair|81
675|B - Motorized wheelchair and/or scooter|B - Motorized wheelchair and/or scooter|81
676|C - Mechanical lift|C - Mechanical lift|81
677|D - Walker|D - Walker|81
678|E - Orthotics/Prosthetics|E - Orthotics/Prosthetics|81
679|Z - None of the above|Z - None of the above|81
680|3 - None of the above|3 - None of the above|81
680|3 - None of the above|3 - None of the above|83
679|Z - None of the above|Z - None of the above|83
678|E - Orthotics/Prosthetics|E - Orthotics/Prosthetics|83
677|D - Walker|D - Walker|83
676|C - Mechanical lift|C - Mechanical lift|83
675|B - Motorized wheelchair and/or scooter|B - Motorized wheelchair and/or scooter|83
674|A - Manual wheelchair|A - Manual wheelchair|83
673|9 - Not Applicable|9 - Not Applicable|83
672|8 - Unknown|8 - Unknown|83
671|1 - Dependent - A helper completed the activities for the patient.|1 - Dependent - A helper completed the activities for the patient.|83
670|2 - Needed Some Help - Patient needed partial assistance from another person to complete activities.|2 - Needed Some Help - Patient needed partial assistance from another person to complete activities.|83
669|3 - Independent - Patient completed the activities by him/herself, with or without an assistive device, with no assistance from a helper.|3 - Independent - Patient completed the activities by him/herself, with or without an assistive devi|83
668|2 - Two or More|2 - Two or More|83
667|1 - One|1 - One|83
666|0 - None|0 - None|83
665|1 - Yes [Continue to J1900, Number of Falls Since SOC/ROC, whichever is more recent]|1 - Yes [Continue to J1900, Number of Falls Since SOC/ROC, whichever is more recent]|83
664|0 - No [STOP]|0 - No [STOP]|83
663|0 - No [Skip to J1800 Any falls since SOC/ROC, whichever is more recent.]|0 - No [Skip to J1800 Any falls since SOC/ROC, whichever is more recent.]|83
662|2 - Motorized|2 - Motorized|83
661|1 - Manual|1 - Manual|83
660|1 - Yes [Continue to GG0170R, Wheel 50 feet with two turns.]|1 - Yes [Continue to GG0170R, Wheel 50 feet with two turns.]|83
659|0 - No [Skip GG0170R]|0 - No [Skip GG0170R]|83
658|0 - No [STOP]|0 - No [STOP]|83
657|88 - Not attempted due to medical conditions or safety concerns|88 - Not attempted due to medical conditions or safety concerns|83
656|10 - Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)|10 - Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)|83
655|09 - Not applicable - Not attempted and the patient did not perform this activity prior to the current illness,exacerbation or injury.|09 - Not applicable - Not attempted and the patient did not perform this activity prior to the curre|83
654|07 - Patient refused|07 - Patient refused|83
653|01 - Dependent - Helper does ALL of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity.|01 - Dependent - Helper does ALL of the effort. Patient does none of the effort to complete the acti|83
652|02 - Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.|02 - Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds t|83
651|03 - Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort.|03 - Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or sup|83
650|04 - Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently.|04 - Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/|83
649|05 - Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity.|05 - Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper|83
648|06 - Independent - Patient completes the activity by him/herself with no assistance from a helper.|06 - Independent - Patient completes the activity by him/herself with no assistance from a helper.|83
647|88 - Not attempted due to medical condition or safety concerns|88 Not attempted due to medical condition or safety concerns|83
646|09 - Activity not attempted - Not applicable|09 Activity not attempted - Not applicable|83
645|07 - Activity not attempted - Patient refused|07 Activity not attempted - Patient refused|83
644|01 - Dependent - Helper does ALL of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity.|01 Dependent - Helper does ALL of the effort. Patient does none of the effort to complete the act|83
643|02 - Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.|02 Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds |83
642|03 - Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort.|03 Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or |83
641|04 - Supervision or touching assistance - Helper provides VERBAL CUES or TOUCHING/STEADYING assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently.|04 Supervision or touching assistance - Helper provides VERBAL CUES or TOUCHING/STEADYING |83
640|05 - Setup or clean-up assistance -  Helper SETS UP or CLEANS UP; patient completes activity. Helper assists only prior to or following the activity.|05 Setup or clean-up assistance - Helper SETS UP or CLEANS UP; patient completes activity. Hel|83
639|06 - Independent - Patient completes the activity by him/herself with no assistance from a helper.|06 Independent - Patient completes the activity by him/herself with no assistance from a helper.|83
638|2 - Diabetes Mellitus (DM)|2 - Diabetes Mellitus (DM)|83
637|1 - Peripheral Vascular Disease (PVD) or Peripheral Arterial Disease (PAD)|1 - Peripheral Vascular Disease (PVD) or Peripheral Arterial Disease (PAD)|83
2|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; OR (b) Is physically, cognitively, and mentally able to prepare light meals on a regular basis but has not routinely performed light meal preparation in the past (i.e., prior to this home care admission).|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; O|83
3|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and mentally able to perform all housekeeping tasks .|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and menta|83
4|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and mentally able to do laundry and access facilities.|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and menta|83
5|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying packages OR b) Physically, cognitively, and mentally able to take care of shopping, but has not done shopping in the past (i.e., prior to this home care admission).|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying|83
6|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|83
7|0 - Able to dial numbers and answer calls appropriately and as desired.|0 - Able to dial numbers and answer calls appropriately and as desired.|83
8|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body without assistance.|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body|83
9|0 - Able to get to and from the toilet and transfer independently with or without a device.|0 - Able to get to and from the toilet and transfer independently with or without a device.|83
10|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|83
11|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible public bus.|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible p|83
12|0 - Able to independently feed self.|0 - Able to independently feed self.|83
13|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|83
14|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct times.|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct ti|83
15|0 - Able to independently transfer.|0 - Able to independently transfer.|83
16|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without rail|83
17|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings|83
18|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|83
19|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions independently.|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions indep|83
20|0 - Asymptomatic, no treatment needed at this time|0 - Asymptomatic, no treatment needed at this time|83
21|0 - Caregiver manages all tasks related to equipment completely independently.|0 - Caregiver manages all tasks related to equipment completely independently.|83
22|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations with no observable impairment.|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations w|83
23|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|83
24|0 - Life expectancy is greater than 6 months|0 - Life expectancy is greater than 6 months|83
25|0 - Never|0 - Never|83
26|0 - Patient is not short of breath|0 - Patient is not short of breath|83
27|0 - No|0 - No|83
28|0 - No emergent care services|0 - No emergent care services|83
29|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) |0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) |83
30|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and extended or abstract conversation.|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and exte|83
31|0 - No one person|0 - No one person|83
32|0 - None of the time|0 - None of the time|83
33|0 - None, no charge for current services|0 - None, no charge for current services|83
34|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|83
35|0 - Patient does NOT have an ostomy for bowel elimination.|0 - Patient does NOT have an ostomy for bowel elimination.|83
36|0 - Patient has no pain|0 - Patient has no pain|83
37|0 - Patient manages all tasks related to equipment completely independently.|0 - Patient manages all tasks related to equipment completely independently.|83
38|0 - Poor:  little or no recovery is expected and/or further decline is imminent|0 - Poor:  little or no recovery is expected and/or further decline is imminent|83
39|0 - Timed-voiding defers incontinence|0 - Timed-voiding defers incontinence|83
40|0 - Very rarely or never has bowel incontinence|0 - Very rarely or never has bowel incontinence|83
41|0 - Zero|0 - Zero|83
42|00 - No|00 - No|83
43|01 - Yes|01 - Yes|83
44|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or mental limitations, needs assistance with heavy laundry.|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or|83
45|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the patient.|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the|83
46|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|83
47|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or supervision from another person OR c) a liquid, pureed or ground meat diet.|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or su|83
48|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|83
49|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|83
50|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independently.|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independe|83
51|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only when assisted or accompanied by another person.|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only w|83
52|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepa|83
53|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance by another person OR b) given daily reminders.|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance b|83
54|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advan|83
55|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advan|83
56|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for the deaf) and call essential numbers.|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for t|83
57|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|83
58|1 - American Indian or Alaska Native|1 - American Indian or Alaska Native|83
59|1 - Depressed mood (e.g., feeling sad, tearful)|1 - Depressed mood (e.g., feeling sad, tearful)|83
60|1 - During the night only|1 - During the night only|83
61|1 - Fully granulating|1 - Fully granulating|83
62|1 - Good/Fair:  partial to full recovery is expected|1 - Good/Fair:  partial to full recovery is expected|83
63|1 - Good:  marked improvement in functional status is expected|1 - Good:  marked improvement in functional status is expected|83
64|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|83
65|1 - Smoking|1 - Smoking|83
66|1 - Hospital|1 - Hospital|83
67|1 - Hospital emergency room (includes 23-hour holding)|1 - Hospital emergency room (includes 23-hour holding)|83
68|1 - Hospitalization for EMERGENT (unscheduled) care|1 - Hospitalization for EMERGENT (unscheduled) care|83
69|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepared solutions), patient is able to manage all other aspects of equipment.|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepar|83
70|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|83
71|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|83
72|1 - In new or complex situations only|1 - In new or complex situations only|83
73|1 - Intravenous or infusion therapy (excludes TPN)|1 - Intravenous or infusion therapy (excludes TPN)|83
74|1 - Less often than daily|1 - Less often than daily|83
75|1 - Less than once a month|1 - Less than once a month|83
76|1 - Less than once weekly|1 - Less than once weekly|83
77|1 - Life expectancy is 6 months or fewer|1 - Life expectancy is 6 months or fewer|83
78|1 - Lives alone|1 - Lives alone|83
79|1 - Male|1 - Male|83
80|1 - Medicare (traditional fee-for-service)|1 - Medicare (traditional fee-for-service)|83
81|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of past 24 hours, significant memory loss so that supervision is required|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of pas|83
82|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors in word choice, grammar or speech intelligibility, needs minimal prompting or assistance).|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors i|83
83|1 - No assistance or services received|1 - No assistance or services received|83
84|1 - One|1 - One|83
85|1 - Oxygen (intermittent or continuous)|1 - Oxygen (intermittent or continuous)|83
86|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, and the surrounding layout, can count fingers at arm's length.|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, a|83
87|1 - Patient is incontinent|1 - Patient is incontinent|83
88|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|83
89|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical or treatment regimen.|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical|83
90|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient/couple/significant other)|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient|83
91|1 - Relatives, friends, or neighbors living outside the home|1 - Relatives, friends, or neighbors living outside the home|83
92|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions.|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions|83
93|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independentl|83
94|1 - Several times during day and night|1 - Several times during day and night|83
95|1 - Spouse or significant other|1 - Spouse or significant other|83
96|1 - Stage 1|1 - Stage 1|83
97|1 - Start of care - further visits planned|1 - Start of care - further visits planned|83
98|1 - Symptoms well controlled with current therapy|1 - Symptoms well controlled with current therapy|83
99|1 - Therapy services|1 - Therapy services|83
100|1 - Able to transfer with minimal human assistance or with use of an assistive device.|1 - Able to transfer with minimal human assistance or with use of an assistive device.|83
101|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitations.|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitatio|83
102|1 - Urinary incontinence|1 - Urinary incontinence|83
103|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and transfer.|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and|83
104|1 - When walking more than 20 feet, climbing stairs|1 - When walking more than 20 feet, climbing stairs|83
105|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary conversation. May need occasional repetition, extra time, or louder voice.|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary c|83
106|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting in and out of tub/shower|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting|83
107|1 - Yes|1 - Yes|83
108|1-RN|1-RN|83
109|10 - Discharge from agency - no visits completed after start/resumption of care assessment|10 - Discharge from agency - no visits completed after start/resumption of care assessment|83
110|10 - Scheduled surgical procedure|10 - Scheduled surgical procedure|83
111|10 - Self-pay|10 - Self-pay|83
112|11 - Other|11 - Other|83
113|11 - Urinary tract infection|11 - Urinary tract infection|83
114|12 - IV catheter-related infection|12 - IV catheter-related infection|83
115|13 - Deep vein thrombosis, pulmonary embolus|13 - Deep vein thrombosis, pulmonary embolus|83
116|14 - Uncontrolled pain|14 - Uncontrolled pain|83
117|15 - Psychotic episode|15 - Psychotic episode|83
118|16 - Other than above reasons|16 - Other than above reasons|83
119|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing calls.|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing|83
120|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another person.|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another pers|83
121|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface a|83
122|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for intermittent supervision or encouragement or reminders, OR (b) to get in and out of the shower or tub, OR (c) for washing difficult to reach areas.|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for inter|83
123|2 - Asian|2 - Asian|83
124|2 - Caregiver requires considerable assistance from another person to manage equipment, but independently completes significant portions of task.|2 - Caregiver requires considerable assistance from another person to manage equipment, but independ|83
125|2 - Daily, but not constantly|2 - Daily, but not constantly|83
126|2 - Daughter or son|2 - Daughter or son|83
127|2 - Doctor's office emergency visit/house call|2 - Doctor's office emergency visit/house call|83
128|2 - During the day and night|2 - During the day and night|83
129|2 - Early/partial granulation|2 - Early/partial granulation|83
130|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors in word choice, organization or speech intelligibility). Speaks in phrases or short sentences.|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors|83
131|2 - Family member's residence|2 - Family member's residence|83
132|2 - Female|2 - Female|83
133|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conversation, needs frequent prompting or assistance.|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conver|83
134|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|83
135|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|83
136|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately stop activities, jeopardizes safety through actions|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately st|83
137|2 - Indwelling/suprapubic catheter|2 - Indwelling/suprapubic catheter|83
138|2 - Injury caused by fall or accident at home|2 - Injury caused by fall or accident at home|83
139|2 - Medicare (HMO/managed care/Advantage plan)|2 - Medicare (HMO/managed care/Advantage plan)|83
140|2 - Nausea, dehydration, malnutrition, constipation, impaction|2 - Nausea, dehydration, malnutrition, constipation, impaction|83
141|2 - Obesity|2 - Obesity|83
142|2 - On awakening or at night only|2 - On awakening or at night only|83
143|2 - Once a month|2 - Once a month|83
144|2 - One to three times weekly|2 - One to three times weekly|83
145|2 - Parenteral nutrition (TPN or lipids)|2 - Parenteral nutrition (TPN or lipids)|83
146|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic)  [ Go to M1620 ]|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic)  [ Go|83
147|2 - Patient requires considerable assistance from another person to manage equipment, but independently completes portions of the task.|2 - Patient requires considerable assistance from another person to manage equipment, but independen|83
148|2 - Patient transferred to a noninstitutional hospice|2 - Patient transferred to a noninstitutional hospice|83
149|2 - Person residing in the home (EXCLUDING paid help)|2 - Person residing in the home (EXCLUDING paid help)|83
150|2 - Rehabilitation facility|2 - Rehabilitation facility|83
151|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifting of attention) or consistently requires low stimulus environment due to distractibility.|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifti|83
152|2 - Respite care|2 - Respite care|83
153|2 - Sense of failure or self reproach|2 - Sense of failure or self reproach|83
154|2 - Several times during day|2 - Several times during day|83
155|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonresponsive.|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonrespons|83
156|2 - Someone must assist the patient to groom self.|2 - Someone must assist the patient to groom self.|83
157|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|83
158|2 - Someone must help the patient put on upper body clothing.|2 - Someone must help the patient put on upper body clothing.|83
159|2 - Stage 2|2 - Stage 2|83
160|2 - Start of care - no further visits planned|2 - Start of care - no further visits planned|83
161|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitoring|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitori|83
162|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment regimen.|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment re|83
163|2 - Two|2 - Two|83
164|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistance due to cognitive or mental limitation.|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistanc|83
165|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|83
166|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assistance).|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assis|83
167|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home delivery.|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home deli|83
168|2 - Unable to prepare any light meals or reheat any delivered meals.|2 - Unable to prepare any light meals or reheat any delivered meals.|83
169|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|83
170|2 - UNABLE to take injectable medications unless administered by someone else.|2 - UNABLE to take injectable medications unless administered by someone else.|83
171|2 - UNABLE to take medication unless administered by someone else.|2 - UNABLE to take medication unless administered by someone else.|83
172|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|83
173|2 - Ventilator (continually or at night)|2 - Ventilator (continually or at night)|83
174|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less than 20 feet)|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less th|83
175|2 - With spouse or significant other|2 - With spouse or significant other|83
176|2 - Yes, assistance or services provided by family or friends|2 - Yes, assistance or services provided by family or friends|83
177|2-PT|2-PT|83
178|3 - Able to answer the telephone only some of the time or is able to carry on only a limited conversation.|3 - Able to answer the telephone only some of the time or is able to carry on only a limited convers|83
179|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube or gastrostomy.|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube|83
180|3 - Alcohol dependency|3 - Alcohol dependency|83
181|3 - All of the time|3 - All of the time|83
182|3 - Black or African-American|3 - Black or African-American|83
183|3 - Boarding home or rented room|3 - Boarding home or rented room|83
184|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment, clean/store/dispose of equipment or supplies).|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment,|83
185|3 -Able to walk only with the supervision or assistance of another person at all times.|3 -Able to walk only with the supervision or assistance of another person at all times.|83
186|3 - Continuous / Bi-level positive airway pressure|3 - Continuous / Bi-level positive airway pressure|83
187|3 - During the day and evening, but not constantly|3 - During the day and evening, but not constantly|83
188|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the alimentary canal)|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the|83
189|3 - Environmental support (e.g., housing, home maintenance)|3 - Environmental support (e.g., housing, home maintenance)|83
190|3 - Four to six times weekly|3 - Four to six times weekly|83
191|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessing by listener.  Speech limited to single words or short phrases.|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessin|83
192|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires multiple repetitions, restatements, demonstrations, additional time.|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires m|83
193|3 - Hopelessness|3 - Hopelessness|83
194|3 - Hospice care|3 - Hospice care|83
195|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|83
196|3 - Injury caused by fall or accident at home|3 - Injury caused by fall or accident at home|83
197|3 - Intractable pain|3 - Intractable pain|83
198|3 - Medicaid (traditional fee-for-service)|3 - Medicaid (traditional fee-for-service)|83
199|3 - Needs someone to do all shopping and errands.|3 - Needs someone to do all shopping and errands.|83
200|3 - Not healing|3 - Not healing|83
201|3 - Nursing home|3 - Nursing home|83
202|3 - Once daily|3 - Once daily|83
203|3 - Other family member|3 - Other family member|83
204|3 - Outpatient department/clinic emergency (includes urgicenter sites)|3 - Outpatient department/clinic emergency (includes urgicenter sites)|83
205|3 - Paid help|3 - Paid help|83
206|3 - Able to participate in bathing self in shower or tub, but requires presence of another person throughout the bath for assistance or supervision.|3 - Able to participate in bathing self in shower or tub, but requires presence of another person th|83
207|3 - Patient depends entirely upon another person to dress lower body.|3 - Patient depends entirely upon another person to dress lower body.|83
208|3 - Patient depends entirely upon another person to dress the upper body.|3 - Patient depends entirely upon another person to dress the upper body.|83
209|3 - Patient depends entirely upon someone else for grooming needs.|3 - Patient depends entirely upon someone else for grooming needs.|83
210|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone else to manage the equipment.|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone|83
211|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable to shift attention and recall directions more than half the time.|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable|83
212|3 - Respiratory problems (SOB, infection, obstruction)|3 - Respiratory problems (SOB, infection, obstruction)|83
213|3 - Resumption of care (after inpatient stay)|3 - Resumption of care (after inpatient stay)|83
214|3 - Several times each month|3 - Several times each month|83
215|3 - Skilled Nursing Facility|3 - Skilled Nursing Facility|83
216|3 - Stage 3|3 - Stage 3|83
217|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|83
218|3 - Three|3 - Three|83
219|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person throughout the process.|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person through|83
220|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal independently.|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal indep|83
221|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person.|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person|83
222|3 - Unknown because patient moved to a geographic location not served by this agency|3 - Unknown because patient moved to a geographic location not served by this agency|83
223|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|83
224|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|83
225|3 - With other family member|3 - With other family member|83
226|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home health services, homemaker assistance, transportation assistance, assisted living, board and care)|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home h|83
227|3-SLP/ST|3-SLP/ST|83
228|4 - At rest (during day or night)|4 - At rest (during day or night)|83
229|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|83
230|4 - Board and care or assisted living facility|4 - Board and care or assisted living facility|83
231|4 - Caregiver is completely dependent on someone else to manage all equipment.|4 - Caregiver is completely dependent on someone else to manage all equipment.|83
232|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|83
233|4 - Constantly|4 - Constantly|83
234|4 - Drug dependency|4 - Drug dependency|83
235|4 - Four or more|4 - Four or more|83
236|4 - Friend or neighbor or community or church member|4 - Friend or neighbor or community or church member|83
237|4 - Hispanic or Latino|4 - Hispanic or Latino|83
238|4 - Hospice|4 - Hospice|83
239|4 - Impaired decision-making|4 - Impaired decision-making|83
240|4 - Is totally dependent in toileting.|4 - Is totally dependent in toileting.|83
241|4 - Medicaid (HMO/managed care)|4 - Medicaid (HMO/managed care)|83
242|4 - None of the above|4 - None of the above|83
243|4 - Nursing home|4 - Nursing home|83
244|4 - On a daily basis|4 - On a daily basis|83
245|4 - Patient is completely dependent on someone else to manage all equipment.|4 - Patient is completely dependent on someone else to manage all equipment.|83
246|4 - Permanent placement|4 - Permanent placement|83
247|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, punches, dangerous maneuvers w/ wheelchair or other objects)|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, pu|83
248|4 - Psychosocial support (e.g., socialization, companionship, recreation)|4 - Psychosocial support (e.g., socialization, companionship, recreation)|83
249|4 - Recertification (follow-up) reassessment|4 - Recertification (follow-up) reassessment|83
250|4 - Recurrent thoughts of death|4 - Recurrent thoughts of death|83
251|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruction)|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruc|83
252|4 - Several times a week|4 - Several times a week|83
253|4 - Stage 4|4 - Stage 4|83
254|4 - Symptoms poorly controlled, history of re-hospitalizations|4 - Symptoms poorly controlled, history of re-hospitalizations|83
255|4 - Three or more times per week|4 - Three or more times per week|83
256|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetative state, or delirium.|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetati|83
257|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|83
258|4 - Unable to effectively participate in any housekeeping tasks.|4 - Unable to effectively participate in any housekeeping tasks.|83
259|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or unresponsive (e.g., speech is nonsensical or unintelligible).|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or u|83
260|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonresponsive.|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonr|83
261|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostomy.|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostom|83
262|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of devices at the sink, in chair, or on commode|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of|83
263|4 - With a friend|4 - With a friend|83
264|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|83
265|4-OT|4-OT|83
266|5 - Advocates or facilitates patient's participation in appropriate medical care|5 - Advocates or facilitates patient's participation in appropriate medical care|83
267|5 - At least daily|5 - At least daily|83
268|6 - Bedfast, unable to ambulate or be up in a chair.|6 - Bedfast, unable to ambulate or be up in a chair.|83
269|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|83
270|5 - Disruptive or socially inappropriate behavior|5 - Disruptive or socially inappropriate behavior|83
271|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|83
272|5 - Hypo/Hyperglycemia, diabetes out of control|5 - Hypo/Hyperglycemia, diabetes out of control|83
273|5 - More often than once daily|5 - More often than once daily|83
274|5 - Native Hawaiian or Pacific Islander|5 - Native Hawaiian or Pacific Islander|83
275|5 - None of the above|5 - None of the above|83
276|5 - One to two times per week|5 - One to two times per week|83
277|5 - Other|5 - Other|83
278|5 - Other follow-up|5 - Other follow-up|83
279|5 - Paid help|5 - Paid help|83
280|5 - Patient nonresponsive or unable to speak.|5 - Patient nonresponsive or unable to speak.|83
281|5 - Thoughts of suicide|5 - Thoughts of suicide|83
282|5 - Totally unable to use the telephone.|5 - Totally unable to use the telephone.|83
283|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|83
284|5 - Unable to take in nutrients orally or by tube feeding.|5 - Unable to take in nutrients orally or by tube feeding.|83
285|5 - Unsafe for care at home|5 - Unsafe for care at home|83
286|5 - With paid help (other than home care agency staff)|5 - With paid help (other than home care agency staff)|83
287|5 - Workers' compensation|5 - Workers' compensation|83
288|5 - Wound infection, deteriorating wound status, new lesion/ulcer|5 - Wound infection, deteriorating wound status, new lesion/ulcer|83
289|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|83
290|6 - Delusional, hallucinatory, or paranoid behavior|6 - Delusional, hallucinatory, or paranoid behavior|83
291|6 - Financial agent, power of attorney, or conservator of finance|6 - Financial agent, power of attorney, or conservator of finance|83
292|6 - GI bleeding, obstruction|6 - GI bleeding, obstruction|83
293|6 - Less often than weekly|6 - Less often than weekly|83
294|6 - Memory loss to the extent that supervision required|6 - Memory loss to the extent that supervision required|83
295|6 - None of the above feelings observed or reported|6 - None of the above feelings observed or reported|83
296|6 - Other|6 - Other|83
297|6 - Title programs (e.g., Title III, V, or XX)|6 - Title programs (e.g., Title III, V, or XX)|83
298|6 - Transferred to an inpatient facility - patient not discharged from agency|6 - Transferred to an inpatient facility - patient not discharged from agency|83
299|6 - White|6 - White|83
300|6 - With other than above|6 - With other than above|83
301|7 - Exacerbation of CHF, fluid overload, heart failure|7 - Exacerbation of CHF, fluid overload, heart failure|83
302|7 - Health care agent, conservator of person, or medical power of attorney|7 - Health care agent, conservator of person, or medical power of attorney|83
303|7 - Hypo/Hyperglycemia, diabetes out of control|7 - Hypo/Hyperglycemia, diabetes out of control|83
304|7 - None of the above|7 - None of the above|83
305|7 - None of the above behaviors demonstrated|7 - None of the above behaviors demonstrated|83
306|7 - Other government (e.g., TriCare, VA, etc.)|7 - Other government (e.g., TriCare, VA, etc.)|83
307|7 - Transferred to an inpatient facility - patient discharged from agency|7 - Transferred to an inpatient facility - patient discharged from agency|83
308|8 - Death at home|8 - Death at home|83
309|8 - GI bleeding, obstruction|8 - GI bleeding, obstruction|83
310|8 - Myocardial infarction, stroke|8 - Myocardial infarction, stroke|83
311|8 - Private insurance|8 - Private insurance|83
312|9 - Chemotherapy|9 - Chemotherapy|83
313|9 - Discharge from agency|9 - Discharge from agency|83
314|9 - Other than above reasons|9 - Other than above reasons|83
315|9 - Private HMO/managed care|9 - Private HMO/managed care|83
316|NA - No caregiver|NA - No caregiver|83
317|NA - No equipment of this type used in care.|NA - No equipment of this type used in care.|83
318|NA - No inhalant/mist medications prescribed.|NA - No inhalant/mist medications prescribed.|83
319|NA - No injectable medications prescribed.|NA - No injectable medications prescribed.|83
320|NA - No inpatient facility admission|NA - No inpatient facility admission|83
321|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|83
322|NA - No Medicaid|NA - No Medicaid|83
323|NA - No Medicare|NA - No Medicare|83
324|NA - No observable pressure ulcer or unhealed pressure ulcer|NA - No observable pressure ulcer or unhealed pressure ulcer|83
325|NA - No observable stasis ulcer|NA - No observable stasis ulcer|83
326|NA - No observable surgical wound|NA - No observable surgical wound|83
327|NA - No oral medications prescribed.|NA - No oral medications prescribed.|83
328|NA - Not applicable|NA - Not applicable|83
329|NA - Patient does not have a telephone.|NA - Patient does not have a telephone.|83
330|NA - Patient has ostomy for bowel elimination|NA - Patient has ostomy for bowel elimination|83
331|NA - Patient nonresponsive|NA - Patient nonresponsive|83
332|NA - Patient on prophylactic treatment|NA - Patient on prophylactic treatment|83
333|NA - Patient was not discharged from an inpatient facility [Go to M1021]|NA - Patient was not discharged from an inpatient facility [Go to M1017]|83
334|UK - Other unknown|UK - Other unknown|83
335|UK - Reason unknown|UK - Reason unknown|83
336|UK - Unknown|UK - Unknown|83
337|UK - Unknown or Not Available|UK - Unknown or Not Available|83
341|01 - Early|01 - Early|83
342|02 - Late|02 - Late|83
343|NA - Not Applicable. No case mix group defined for this assessment.|NA - Not Applicable. No case mix group defined for this assessment.|83
344|NA - No case mix group defined by this assessment.|NA - No case mix group defined by this assessment.|83
345|1 - Recent decline in mental, emotional, or behavioral status|1 - Recent decline in mental, emotional, or behavioral status|83
346|2 - Multiple hospitalizations (2 or more) in the past 12 months|2 - Multiple hospitalizations (2 or more) in the past 12 months|83
347|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|83
348|4 - Taking five or more medications|4 - Taking five or more medications|83
349|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|83
350|6 - Other|6 - Other|83
351|7 - None of the above|7 - None of the above|83
352|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond tho|83
353|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable without heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable wi|83
354|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious complications and death.|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious compl|83
355|3 - The patient has serious progressive conditions that could lead to death within a year.|3 - The patient has serious progressive conditions that could lead to death within a year.|83
356|UK - The patient+s situation is unknown or unclear.|UK - The patient+s situation is unknown or unclear.|83
357|1 - Yes [ Go to M1050 ]|1 - Yes [ Go to M1050 ]|83
358|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this influenza season. [ Go to M1050 ]|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this i|83
359|1 - Received from another health care provider (e.g., physician)|1 - Received from another health care provider (e.g., physician)|83
360|2 - Received from your agency previously during this year+s flu season|2 - Received from your agency previously during this year+s flu season|83
361|3 - Offered and declined|3 - Offered and declined|83
362|4 - Assessed and determined to have medical contraindication(s)|4 - Assessed and determined to have medical contraindication(s)|83
363|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|83
364|6 - Inability to obtain vaccine due to declared shortage|6 - Inability to obtain vaccine due to declared shortage|83
365|1 - Yes [ Go to M2005 at TRN; Go to M1230 at DC ]|1 - Yes [ Go to M2005 at TRN; Go to M1230 at DC ]|83
366|1 - Patient has received PPV in the past|1 - Patient has received PPV in the past|83
367|2 - Offered and declined|2 - Offered and declined|83
368|3 - Assessed and determined to have medical contraindication(s)|3 - Assessed and determined to have medical contraindication(s)|83
369|4 - Not indicated; patient does not meet age/condition guidelines for PPV|4 - Not indicated; patient does not meet age/condition guidelines for PPV|83
370|5 - None of the above|5 - None of the above|83
371|0 - Adequate: hears normal conversation without difficulty.|0 - Adequate: hears normal conversation without difficulty.|83
372|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to increase volume or speak distinctly.|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to in|83
373|2 - Severely Impaired: absence of useful hearing.|2 - Severely Impaired: absence of useful hearing.|83
374|UK - Unable to assess hearing.|UK - Unable to assess hearing.|83
375|0 - Understands: clear comprehension without cues or repetitions.|0 - Understands: clear comprehension without cues or repetitions.|83
376|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Requires cues at times to understand.|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Req|83
377|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequently requires cues to understand.|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequentl|83
378|3 - Rarely/Never Understands|3 - Rarely/Never Understands|83
379|UK - Unable to assess understanding.|UK - Unable to assess understanding.|83
380|0 - No standardized assessment conducted|0 - No standardized assessment conducted|83
381|1 - Yes, and it does not indicate severe pain|1 - Yes, and it does not indicate severe pain|83
382|2 - Yes, and it indicates severe pain|2 - Yes, and it indicates severe pain|83
383|0 - Patient has no pain|0 - Patient has no pain|83
384|1 - Patient has pain that does not interfere with activity or movement|1 - Patient has pain that does not interfere with activity or movement|83
385|2 - Less often than daily|2 - Less often than daily|83
386|3 - Daily, but not constantly|3 - Daily, but not constantly|83
387|4 - All of the time|4 - All of the time|83
388|0 - No assessment conducted [ Go to M1306 ]|0 - No assessment conducted [ Go to M1306 ]|83
389|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc., without use of standardized tool|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc.,|83
390|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|83
391|0 - No [ Go to M1322]|0 - No [ Go to M1322]|83
392|0 v Newly epithelialized|0 v Newly epithelialized|83
393|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|83
394|2 - Yes, patient has observable stasis ulcers ONLY|2 - Yes, patient has observable stasis ulcers ONLY|83
395|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable dressing) [Go to M1340]|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable|83
396|0 - No [ Go to M1400 ]|0 - No [ Go to M1400 ]|83
397|1 - Yes, patient has at least one (observable) surgical wound|1 - Yes, patient has at least one (observable) surgical wound|83
398|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1350 ]|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1350 ]|83
399|0 - Patient is not short of breath|0 - Patient is not short of breath|83
400|3 - Continuous Bi-level positive airway pressure|3 - Continuous Bi-level positive airway pressure|83
401|0 - No [ Go to M1732 at TRN; Go to M1600 at DC ]|0 - No [ Go to M1732 at TRN; Go to M1600 at DC ]|83
402|2 - Not assessed [Go to M1732 at TRN; Go to M1600 at DC ]|2 - Not assessed [Go to M1732 at TRN; Go to M1600 at DC ]|83
403|NA - Patient does not have diagnosis of heart failure [Go to M2005 at TRN; Go to M1600 at DC]|NA - Patient does not have diagnosis of heart failure [Go to M2005 at TRN; Go to M1600 at DC]|83
404|0 - No action taken|0 - No action taken|83
405|1 - Patient+s physician (or other primary care practitioner) contacted the same day|1 - Patient+s physician (or other primary care practitioner) contacted the same day|83
406|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|83
407|3 - Implement physician-ordered patient-specific established parameters for treatment|3 - Implement physician-ordered patient-specific established parameters for treatment|83
408|4 - Patient education or other clinical interventions|4 - Patient education or other clinical interventions|83
409|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequency, telehealth, etc.)|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequ|83
410|1 - Occasional stress incontinence|1 - Occasional stress incontinence|83
411|2 - During the night only|2 - During the night only|83
412|3 - During the day only|3 - During the day only|83
413|4 - During the day and night|4 - During the day and night|83
414|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|83
415|0 - Able to manage toileting hygiene and clothing management without assistance.|0 - Able to manage toileting hygiene and clothing management without assistance.|83
416|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implements are laid out for the patient.|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implemen|83
417|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|83
418|3 - Patient depends entirely upon another person to maintain toileting hygiene.|3 - Patient depends entirely upon another person to maintain toileting hygiene.|83
419|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independent|83
420|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface|83
421|0 - No multi-factor falls risk assessment conducted.|0 - No multi-factor falls risk assessment conducted.|83
422|1 - Yes, and it does not indicate a risk for falls.|1 - Yes, and it does not indicate a risk for falls.|83
423|2 - Yes, and it indicates a risk for falls.|2 - Yes, and it indicates a risk for falls.|83
424|0 - Not assessed/reviewed [ Go to M2010 ]|0 - Not assessed/reviewed [ Go to M2010 ]|83
425|No - No issues found during review [ Go to M2010 ]|No - No issues found during review [ Go to M2010 ]|83
426|Yes - Issues found during review|Yes - Issues found during review|83
427|NA - Patient is not taking any medications [ Go to M2102 ]|NA - Patient is not taking any medications [ Go to M2102 ]|83
428|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special precautions associated with all high-risk medications|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special p|83
429|NA - Patient not taking any drugs|NA - Patient not taking any drugs|83
430|2 - Able to take medication(s) at the correct times if given reminders by another person at the appropriate times|2 - Able to take medication(s) at the correct times if given reminders by another person at the appr|83
431|3 - Unable to take medication unless administered by another person.|3 - Unable to take medication unless administered by another person.|83
432|1 - At least daily|1 - At least daily|83
433|2 - Three or more times per week|2 - Three or more times per week|83
434|3 - One to two times per week|3 - One to two times per week|83
435|4 - Received, but less often than weekly|4 - Received, but less often than weekly|83
436|5 - No assistance received|5 - No assistance received|83
437|0 - No [Go to M2401]|0 - No [Go to M2401]|83
438|1 - Yes, used hospital emergency department WITHOUT hospital admission|1 - Yes, used hospital emergency department WITHOUT hospital admission|83
439|2 - Yes, used hospital emergency department WITH hospital admission|2 - Yes, used hospital emergency department WITH hospital admission|83
440|UK - Unknown [Go to M2401]|UK - Unknown [Go to M2401]|83
441|2 - Injury caused by fall|2 - Injury caused by fall|83
442|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|83
443|4 - Other respiratory problem|4 - Other respiratory problem|83
444|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|83
445|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|83
446|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|83
447|8 - Other heart disease|8 - Other heart disease|83
448|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|83
449|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|83
450|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|83
451|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|83
452|13 - Urinary tract infection|13 - Urinary tract infection|83
453|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|83
454|15 - Wound infection or deterioration|15 - Wound infection or deterioration|83
455|16 - Uncontrolled pain|16 - Uncontrolled pain|83
456|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|83
457|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|83
458|19 - Other than above reasons|19 - Other than above reasons|83
459|2 - Patient remained in the community (with formal assistive services)|2 - Patient remained in the community (with formal assistive services)|83
460|3 - Patient transferred to a noninstitutional hospice|3 - Patient transferred to a noninstitutional hospice|83
461|4 - Unknown because patient moved to a geographic location not served by this agency|4 - Unknown because patient moved to a geographic location not served by this agency|83
462|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|83
463|4 - Other respiratory problem|4 - Other respiratory problem|83
464|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|83
465|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|83
466|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|83
467|8 - Other heart disease|8 - Other heart disease|83
468|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|83
469|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|83
470|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|83
471|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|83
472|13 - Urinary tract infection|13 - Urinary tract infection|83
473|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|83
474|15 - Wound infection or deterioration|15 - Wound infection or deterioration|83
475|16 - Uncontrolled pain|16 - Uncontrolled pain|83
476|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|83
477|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|83
478|19 - Scheduled treatment or procedure|19 - Scheduled treatment or procedure|83
479|20 - Other than above reasons|20 - Other than above reasons|83
480|UK - Reason unknown [Go to M0903]|UK - Reason unknown [Go to M0903]|83
482|01 - Patient lives alone around the clock|01 - Patient lives alone around the clock|83
483|02 - Patient lives alone regular daytime|02 - Patient lives alone regular daytime|83
484|03 - Patient lives alone regular nighttime|03 - Patient lives alone regular nighttime|83
485|04 - Patient lives alone occassional/short term assistance|04 - Patient lives alone occassional/short term assistance|83
486|05 - Patient lives alone no assisstance available|05 - Patient lives alone no assisstance available|83
487|06 - Patient lives with other person(s) in the home around the clock|06 - Patient lives with other person(s) in the home around the clock|83
488|07 - Patient lives with other person(s) in the home regular daytime|07 - Patient lives with other person(s) in the home regular daytime|83
489|08 - Patient lives with other person(s) in the home regular nighttime|08 - Patient lives with other person(s) in the home regular nighttime|83
490|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|83
491|10 - Patient lives with other person(s) in the home no assistance available|10 - Patient lives with other person(s) in the home no assistance available|83
492|1 - Was present at the most recent SOC/ROC assessment|1 - Was present at the most recent SOC/ROC assessment|83
493|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|83
494|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|83
495|0 - Newly epithelialized|0 - Newly epithelialized|83
496|0 - No [ Go to M1340 ]|0 - No [ Go to M1340 ]|83
498|0 - Independent|0 - Independent|83
499|1 - Needed Some Help|1 - Needed Some Help|83
500|2 - Dependent|2 - Dependent|83
502|0 - No assistance needed in this area|0 - No assistance needed in this area|83
503|1 - Caregiver(s) currently provide assistance|1 - Caregiver(s) currently provide assistance|83
504|2 - Caregiver(s) need training/ supportive services to provide assistance|2 - Caregiver(s) need training/ supportive services to provide assistance|83
505|3 - Caregiver(s) not likely to provide assistance|3 - Caregiver(s) not likely to provide assistance|83
506|4 - Unclear if Caregiver(s) will provide assistance|4 - Unclear if Caregiver(s) will provide assistance|83
507|5 - Assistance needed, but no Caregiver(s) available|5 - Assistance needed, but no Caregiver(s) available|83
508|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will use standardized clinical guidelines accessible for all care providers to reference|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will|83
509|NA - Patient is not diabetic or is bilateral amputee|NA - Patient is not diabetic or is bilateral amputee|83
510|NA - Patient is not assessed to be at risk for falls|NA - Patient is not assessed to be at risk for falls|83
511|NA - Patient has no diagnosis or symptoms of depression|NA - Patient has no diagnosis or symptoms of depression|83
512|NA - No pain identified|NA - No pain identified|83
513|NA - Patient is not assessed to be at risk for pressure ulcers|NA - Patient is not assessed to be at risk for pressure ulcers|83
514|NA - Patient has no pressure ulcers with need for moist wound healing|NA - Patient has no pressure ulcers with need for moist wound healing|83
515|1 - Long-term nursing facility (NF)|1 - Long-term nursing facility (NF)|83
516|2 - Skilled nursing facility (SNF / TCU)|2 - Skilled nursing facility (SNF / TCU)|83
517|3 - Short stay acute hospital (IPP S)|3 - Short stay acute hospital (IPP S)|83
518|4 - Long-term care hospital (LTCH)|4 - Long-term care hospital (LTCH)|83
519|5 - Inpatient rehabilitation hospital or unit (IRF)|5 - Inpatient rehabilitation hospital or unit (IRF)|83
520|6 - Psychiatric hospital or unit|6 - Psychiatric hospital or unit|83
521|7 - Other|7 - Other|83
522|NA - Patient was not discharged from an inpatient facility [Go to M1017]|NA - Patient was not discharged from an inpatient facility [Go to M1017]|83
523|6 - Unable to participate effectively in bathing and is bathed totally by another person|6 - Unable to participate effectively in bathing and is bathed totally by another person|83
524|4 - Chairfast, unable to ambulate but is able to wheel self independently.|4 - Chairfast, unable to ambulate but is able to wheel self independently.|83
525|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask patient: "Over the last two weeks, how often have you been bothered by any of the following problems")  *Copyright+ Pfizer Inc. All rights reserved. Reproduced with permission.|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask|83
526|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluation for depression.|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluat|83
527|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet criteria for further evaluation for depression.|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet|83
528|0 - Not at all  0 - 1 day|0 - Not at all  0 - 1 day|83
529|1 - Several days  2 - 6 days|1 - Several days  2 - 6 days|83
530|2 - More than half of the days  7 - 11 days|2 - More than half of the days  7 - 11 days|83
531|3 - Nearly every day  12 - 14 days|3 - Nearly every day  12 - 14 days|83
532|NA - N/A  Unable to respond|NA - N/A  Unable to respond|83
533|2 - Able to take medication(s) at the correct times if given reminders by another person based on the frequency of the injection|2 - Able to take medication(s) at the correct times if given reminders by another person based on th|83
534|3 - Unable to take injectable medication unless administered by another person.|3 - Unable to take injectable medication unless administered by another person.|83
540|11 - Patient lives in congregate situation (e.g., assisted living) around the clock|11 - Patient lives in congregate situation (e.g., assisted living) around the clock|83
541|12 - Patient lives in congregate situation (e.g., assisted living) regular daytime|12 - Patient lives in congregate situation (e.g., assisted living) regular daytime|83
542|13 - Patient lives in congregate situation (e.g., assisted living) regular nighttime|13 - Patient lives in congregate situation (e.g., assisted living) regular nighttime|83
543|14 - Patient lives in congregate situation (e.g., assisted living) occasional / short-term assistance|14 - Patient lives in congregate situation (e.g., assisted living) occasional / short-term assistanc|83
544|15 - Patient lives in congregate situation (e.g., assisted living) no available assistance|15 - Patient lives in congregate situation (e.g., assisted living) no available assistance|83
546|NA - No observable pressure ulcer|NA - No observable pressure ulcer|83
583|NA - No specific SOC date ordered by physician|NA - No specific SOC date ordered by physician|83
586|UK - Inpatient Discharge Date Unknown|UK - Inpatient Discharge Date Unknown|83
601|1 - History of falls (2 or more falls - or any fall with an injury - in the past 12 months) |1 - History of falls (2 or more falls - or any fall with an injury - in the past 12 months) |83
603|2 - Unintentional weight loss of a total of 10 pounds or more in the past 12 months |2 - Unintentional weight loss of a total of 10 pounds or more in the past 12 months |83
605|3 - Multiple hospitalizations (2 or more) in the past 6 months|3 - Multiple hospitalizations (2 or more) in the past 6 months|83
607|4 - Multiple emergency department visits (2 or more) in the past 6 months|4 - Multiple emergency department visits (2 or more) in the past 6 months|83
609|5 - Decline in mental emotional or behavioral status in the past 3 months |5 - Decline in mental emotional or behavioral status in the past 3 months |83
611|6 - Reported or observed history of difficulty complying with any medical instructions (for example,medications, diet, exercise) in the past 3 months|6 - Reported or observed history of difficulty complying with any medical instructions (for example |83
613|7 - Currently taking 5 or more medications|7 - Currently taking 5 or more medications|83
615|8 - Currently reports exhaustion|8 - Currently reports exhaustion|83
617|9 - Other risk(s) not listed in 1 - 8|9 - Other risk(s) not listed in 1 - 8|83
619|10 - None of the above |10 - None of the above |83
632|0 - No assistance needed v patient is independent or does not have needs in this area|0 - No assistance needed v patient is independent or does not have needs in this area|83
633|1 - Non-agency caregiver(s) currently provide assistance |1 - Non-agency caregiver(s) currently provide assistance |83
634|2 - Non-agency caregiver(s) need training/ supportive services to provide assistance|2 - Non-agency caregiver(s) need training/ supportive services to provide assistance|83
635|3 - Non-agency caregiver(s) are not likely to provide assistance OR it is unclear if they will provide assistance|3 - Non-agency caregiver(s) are not likely to provide assistance OR unclear if will provide asst|83
636|4 - Assistance needed but no non-agency caregiver(s) available|4 - Assistance needed but no non-agency caregiver(s) available|83
2|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; OR (b) Is physically, cognitively, and mentally able to prepare light meals on a regular basis but has not routinely performed light meal preparation in the past (i.e., prior to this home care admission).|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; O|84
3|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and mentally able to perform all housekeeping tasks .|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and menta|84
4|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and mentally able to do laundry and access facilities.|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and menta|84
5|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying packages OR b) Physically, cognitively, and mentally able to take care of shopping, but has not done shopping in the past (i.e., prior to this home care admission).|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying|84
6|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|84
7|0 - Able to dial numbers and answer calls appropriately and as desired.|0 - Able to dial numbers and answer calls appropriately and as desired.|84
8|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body without assistance.|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body|84
9|0 - Able to get to and from the toilet and transfer independently with or without a device.|0 - Able to get to and from the toilet and transfer independently with or without a device.|84
10|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|84
539|06 - Independent - Patient completes the activity by him/herself with no assistance from a helper.|06 - Independent - Patient completes the activity by him/herself with no assistance from a helper.|84
540|05 - Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity.|05 - Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper|84
541|04 - Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently.|04 - Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/|84
542|03 - Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort.|03 - Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or sup|84
543|02 - Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.|02 - Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds t|84
544|01 - Dependent - Helper does ALL of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity.|01 - Dependent - Helper does ALL of the effort. Patient does none of the effort to complete the acti|84
545|07 - Patient refused|07 - Patient refused|84
546|09 - Not applicable - Not attempted and the patient did not perform this activity prior to the current illness,exacerbation or injury.|09 - Not applicable - Not attempted and the patient did not perform this activity prior to the curre|84
547|10 - Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)|10 - Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)|84
548|88 - Not attempted due to medical conditions or safety concerns|88 - Not attempted due to medical conditions or safety concerns|84
549|0 - No [STOP]|0 - No [STOP]|84
550|0 - No [STOP]|0 - No [Skip GG0170R]|84
551|1 - Yes [Continue to GG0170R, Wheel 50 feet with two turns.]|1 - Yes [Continue to GG0170R, Wheel 50 feet with two turns.]|84
552|1 - Manual|1 - Manual|84
553|2 - Motorized|2 - Motorized|84
554|0 - No [Skip to J1800 Any falls since SOC/ROC, whichever is more recent.]|0 - No [Skip to J1800 Any falls since SOC/ROC, whichever is more recent.]|84
555|0 - No [STOP]|0 - No [STOP]|84
556|1 - Yes [Continue to J1900, Number of Falls Since SOC/ROC, whichever is more recent]|1 - Yes [Continue to J1900, Number of Falls Since SOC/ROC, whichever is more recent]|84
557|0 - None|0 - None|84
558|1 - One|1 - One|84
559|2 - Two or More|2 - Two or More|84
560|3 - Independent - Patient completed the activities by him/herself, with or without an assistive device, with no assistance from a helper.|3 - Independent - Patient completed the activities by him/herself, with or without an assistive devi|84
561|2 - Needed Some Help - Patient needed partial assistance from another person to complete activities.|2 - Needed Some Help - Patient needed partial assistance from another person to complete activities.|84
562|1 - Dependent - A helper completed the activities for the patient.|1 - Dependent - A helper completed the activities for the patient.|84
563|8 - Unknown|8 - Unknown|84
564|9 - Not Applicable|9 - Not Applicable|84
565|A - Manual wheelchair|A - Manual wheelchair|84
566|B - Motorized wheelchair and/or scooter|B - Motorized wheelchair and/or scooter|84
567|C - Mechanical lift|C - Mechanical lift|84
568|D - Walker|D - Walker|84
569|E - Orthotics/Prosthetics|E - Orthotics/Prosthetics|84
570|Z - None of the above|Z - None of the above|84
11|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible public bus.|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible p|84
12|0 - Able to independently feed self.|0 - Able to independently feed self.|84
13|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|84
14|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct times.|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct ti|84
15|0 - Able to independently transfer.|0 - Able to independently transfer.|84
16|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without rail|84
17|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings|84
18|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|84
19|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions independently.|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions indep|84
20|0 - Asymptomatic, no treatment needed at this time|0 - Asymptomatic, no treatment needed at this time|84
21|0 - Caregiver manages all tasks related to equipment completely independently.|0 - Caregiver manages all tasks related to equipment completely independently.|84
22|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations with no observable impairment.|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations w|84
23|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|84
24|0 - Life expectancy is greater than 6 months|0 - Life expectancy is greater than 6 months|84
25|0 - Never|0 - Never|84
26|0 - Patient is not short of breath|0 - Patient is not short of breath|84
27|0 - No|0 - No|84
28|0 - No emergent care services|0 - No emergent care services|84
29|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [Goto M1620]|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [Goto M1620]|84
30|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and extended or abstract conversation.|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and exte|84
31|0 - No one person|0 - No one person|84
32|0 - None of the time|0 - None of the time|84
33|0 - None, no charge for current services|0 - None, no charge for current services|84
34|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|84
35|0 - Patient does NOT have an ostomy for bowel elimination.|0 - Patient does NOT have an ostomy for bowel elimination.|84
36|0 - Patient has no pain|0 - Patient has no pain|84
37|0 - Patient manages all tasks related to equipment completely independently.|0 - Patient manages all tasks related to equipment completely independently.|84
38|0 - Poor:  little or no recovery is expected and/or further decline is imminent|0 - Poor:  little or no recovery is expected and/or further decline is imminent|84
39|0 - Timed-voiding defers incontinence|0 - Timed-voiding defers incontinence|84
40|0 - Very rarely or never has bowel incontinence|0 - Very rarely or never has bowel incontinence|84
41|0 - Zero|0 - Zero|84
42|00 - No|00 - No|84
43|01 - Yes|01 - Yes|84
44|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or mental limitations, needs assistance with heavy laundry.|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or|84
45|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the patient.|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the|84
46|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|84
47|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or supervision from another person OR c) a liquid, pureed or ground meat diet.|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or su|84
48|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|84
49|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|84
50|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independently.|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independe|84
51|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only when assisted or accompanied by another person.|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only w|84
52|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepa|84
53|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance by another person OR b) given daily reminders.|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance b|84
54|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advan|84
55|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advan|84
56|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for the deaf) and call essential numbers.|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for t|84
57|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|84
58|1 - American Indian or Alaska Native|1 - American Indian or Alaska Native|84
59|1 - Depressed mood (e.g., feeling sad, tearful)|1 - Depressed mood (e.g., feeling sad, tearful)|84
60|1 - During the night only|1 - During the night only|84
61|1 - Fully granulating|1 - Fully granulating|84
62|1 - Good/Fair:  partial to full recovery is expected|1 - Good/Fair:  partial to full recovery is expected|84
63|1 - Good:  marked improvement in functional status is expected|1 - Good:  marked improvement in functional status is expected|84
64|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|84
65|1 - Smoking|1 - Smoking|84
66|1 - Hospital|1 - Hospital|84
67|1 - Hospital emergency room (includes 23-hour holding)|1 - Hospital emergency room (includes 23-hour holding)|84
68|1 - Hospitalization for EMERGENT (unscheduled) care|1 - Hospitalization for EMERGENT (unscheduled) care|84
69|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepared solutions), patient is able to manage all other aspects of equipment.|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepar|84
70|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|84
71|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|84
72|1 - In new or complex situations only|1 - In new or complex situations only|84
73|1 - Intravenous or infusion therapy (excludes TPN)|1 - Intravenous or infusion therapy (excludes TPN)|84
74|1 - Less often than daily|1 - Less often than daily|84
75|1 - Less than once a month|1 - Less than once a month|84
76|1 - Less than once weekly|1 - Less than once weekly|84
77|1 - Life expectancy is 6 months or fewer|1 - Life expectancy is 6 months or fewer|84
78|1 - Lives alone|1 - Lives alone|84
79|1 - Male|1 - Male|84
80|1 - Medicare (traditional fee-for-service)|1 - Medicare (traditional fee-for-service)|84
81|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of past 24 hours, significant memory loss so that supervision is required|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of pas|84
82|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors in word choice, grammar or speech intelligibility, needs minimal prompting or assistance).|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors i|84
83|1 - No assistance or services received|1 - No assistance or services received|84
84|1 - One|1 - One|84
85|1 - Oxygen (intermittent or continuous)|1 - Oxygen (intermittent or continuous)|84
86|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, and the surrounding layout, can count fingers at arm's length.|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, a|84
87|1 - Patient is incontinent|1 - Patient is incontinent|84
88|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|84
89|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical or treatment regimen.|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical|84
90|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient/couple/significant other)|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient|84
91|1 - Relatives, friends, or neighbors living outside the home|1 - Relatives, friends, or neighbors living outside the home|84
92|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions.|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions|84
93|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independentl|84
94|1 - Several times during day and night|1 - Several times during day and night|84
95|1 - Spouse or significant other|1 - Spouse or significant other|84
96|1 - Stage 1|1 - Stage 1|84
97|1 - Start of care - further visits planned|1 - Start of care - further visits planned|84
98|1 - Symptoms well controlled with current therapy|1 - Symptoms well controlled with current therapy|84
99|1 - Therapy services|1 - Therapy services|84
100|1 - Able to transfer with minimal human assistance or with use of an assistive device.|1 - Able to transfer with minimal human assistance or with use of an assistive device.|84
101|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitations.|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitatio|84
102|1 - Urinary incontinence|1 - Urinary incontinence|84
103|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and transfer.|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and|84
104|1 - When walking more than 20 feet, climbing stairs|1 - When walking more than 20 feet, climbing stairs|84
105|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary conversation. May need occasional repetition, extra time, or louder voice.|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary c|84
106|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting in and out of tub/shower|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting|84
107|1 - Yes|1 - Yes|84
108|1-RN|1-RN|84
109|10 - Discharge from agency - no visits completed after start/resumption of care assessment|10 - Discharge from agency - no visits completed after start/resumption of care assessment|84
110|10 - Scheduled surgical procedure|10 - Scheduled surgical procedure|84
111|10 - Self-pay|10 - Self-pay|84
112|11 - Other|11 - Other|84
113|11 - Urinary tract infection|11 - Urinary tract infection|84
114|12 - IV catheter-related infection|12 - IV catheter-related infection|84
115|13 - Deep vein thrombosis, pulmonary embolus|13 - Deep vein thrombosis, pulmonary embolus|84
116|14 - Uncontrolled pain|14 - Uncontrolled pain|84
117|15 - Psychotic episode|15 - Psychotic episode|84
118|16 - Other than above reasons|16 - Other than above reasons|84
119|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing calls.|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing|84
120|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another person.|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another pers|84
121|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface a|84
122|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for intermittent supervision or encouragement or reminders, OR (b) to get in and out of the shower or tub, OR (c) for washing difficult to reach areas.|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for inter|84
123|2 - Asian|2 - Asian|84
124|2 - Caregiver requires considerable assistance from another person to manage equipment, but independently completes significant portions of task.|2 - Caregiver requires considerable assistance from another person to manage equipment, but independ|84
125|2 - Daily, but not constantly|2 - Daily, but not constantly|84
126|2 - Daughter or son|2 - Daughter or son|84
127|2 - Doctor's office emergency visit/house call|2 - Doctor's office emergency visit/house call|84
128|2 - During the day and night|2 - During the day and night|84
129|2 - Early/partial granulation|2 - Early/partial granulation|84
130|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors in word choice, organization or speech intelligibility). Speaks in phrases or short sentences.|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors|84
131|2 - Family member's residence|2 - Family member's residence|84
132|2 - Female|2 - Female|84
133|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conversation, needs frequent prompting or assistance.|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conver|84
134|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|84
135|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|84
136|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately stop activities, jeopardizes safety through actions|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately st|84
137|2 - Indwelling/suprapubic catheter|2 - Indwelling/suprapubic catheter|84
138|2 - Injury caused by fall or accident at home|2 - Injury caused by fall or accident at home|84
139|2 - Medicare (HMO/managed care/Advantage plan)|2 - Medicare (HMO/managed care/Advantage plan)|84
140|2 - Nausea, dehydration, malnutrition, constipation, impaction|2 - Nausea, dehydration, malnutrition, constipation, impaction|84
141|2 - Obesity|2 - Obesity|84
142|2 - On awakening or at night only|2 - On awakening or at night only|84
143|2 - Once a month|2 - Once a month|84
144|2 - One to three times weekly|2 - One to three times weekly|84
145|2 - Parenteral nutrition (TPN or lipids)|2 - Parenteral nutrition (TPN or lipids)|84
146|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic) [ Go to M1620 ]|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic) [ Go|84
147|2 - Patient requires considerable assistance from another person to manage equipment, but independently completes portions of the task.|2 - Patient requires considerable assistance from another person to manage equipment, but independen|84
148|2 - Patient transferred to a noninstitutional hospice|2 - Patient transferred to a noninstitutional hospice|84
149|2 - Person residing in the home (EXCLUDING paid help)|2 - Person residing in the home (EXCLUDING paid help)|84
150|2 - Rehabilitation facility|2 - Rehabilitation facility|84
151|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifting of attention) or consistently requires low stimulus environment due to distractibility.|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifti|84
152|2 - Respite care|2 - Respite care|84
153|2 - Sense of failure or self reproach|2 - Sense of failure or self reproach|84
154|2 - Several times during day|2 - Several times during day|84
155|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonresponsive.|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonrespons|84
156|2 - Someone must assist the patient to groom self.|2 - Someone must assist the patient to groom self.|84
157|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|84
158|2 - Someone must help the patient put on upper body clothing.|2 - Someone must help the patient put on upper body clothing.|84
159|2 - Stage 2|2 - Stage 2|84
160|2 - Start of care - no further visits planned|2 - Start of care - no further visits planned|84
161|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitoring|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitori|84
162|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment regimen.|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment re|84
163|2 - Two|2 - Two|84
164|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistance due to cognitive or mental limitation.|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistanc|84
165|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|84
166|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assistance).|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assis|84
167|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home delivery.|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home deli|84
168|2 - Unable to prepare any light meals or reheat any delivered meals.|2 - Unable to prepare any light meals or reheat any delivered meals.|84
169|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|84
170|2 - UNABLE to take injectable medications unless administered by someone else.|2 - UNABLE to take injectable medications unless administered by someone else.|84
171|2 - UNABLE to take medication unless administered by someone else.|2 - UNABLE to take medication unless administered by someone else.|84
172|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|84
173|2 - Ventilator (continually or at night)|2 - Ventilator (continually or at night)|84
174|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less than 20 feet)|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less th|84
175|2 - With spouse or significant other|2 - With spouse or significant other|84
176|2 - Yes, assistance or services provided by family or friends|2 - Yes, assistance or services provided by family or friends|84
177|2-PT|2-PT|84
178|3 - Able to answer the telephone only some of the time or is able to carry on only a limited conversation.|3 - Able to answer the telephone only some of the time or is able to carry on only a limited convers|84
179|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube or gastrostomy.|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube|84
180|3 - Alcohol dependency|3 - Alcohol dependency|84
181|3 - All of the time|3 - All of the time|84
182|3 - Black or African-American|3 - Black or African-American|84
183|3 - Boarding home or rented room|3 - Boarding home or rented room|84
184|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment, clean/store/dispose of equipment or supplies).|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment,|84
185|3 -Able to walk only with the supervision or assistance of another person at all times.|3 -Able to walk only with the supervision or assistance of another person at all times.|84
186|3 - Continuous / Bi-level positive airway pressure|3 - Continuous / Bi-level positive airway pressure|84
187|3 - During the day and evening, but not constantly|3 - During the day and evening, but not constantly|84
188|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the alimentary canal)|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the|84
189|3 - Environmental support (e.g., housing, home maintenance)|3 - Environmental support (e.g., housing, home maintenance)|84
190|3 - Four to six times weekly|3 - Four to six times weekly|84
191|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessing by listener.  Speech limited to single words or short phrases.|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessin|84
192|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires multiple repetitions, restatements, demonstrations, additional time.|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires m|84
193|3 - Hopelessness|3 - Hopelessness|84
194|3 - Hospice care|3 - Hospice care|84
195|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|84
196|3 - Injury caused by fall or accident at home|3 - Injury caused by fall or accident at home|84
197|3 - Intractable pain|3 - Intractable pain|84
198|3 - Medicaid (traditional fee-for-service)|3 - Medicaid (traditional fee-for-service)|84
199|3 - Needs someone to do all shopping and errands.|3 - Needs someone to do all shopping and errands.|84
200|3 - Not healing|3 - Not healing|84
201|3 - Nursing home|3 - Nursing home|84
202|3 - Once daily|3 - Once daily|84
203|3 - Other family member|3 - Other family member|84
204|3 - Outpatient department/clinic emergency (includes urgicenter sites)|3 - Outpatient department/clinic emergency (includes urgicenter sites)|84
205|3 - Paid help|3 - Paid help|84
206|3 - Able to participate in bathing self in shower or tub, but requires presence of another person throughout the bath for assistance or supervision.|3 - Able to participate in bathing self in shower or tub, but requires presence of another person th|84
207|3 - Patient depends entirely upon another person to dress lower body.|3 - Patient depends entirely upon another person to dress lower body.|84
208|3 - Patient depends entirely upon another person to dress the upper body.|3 - Patient depends entirely upon another person to dress the upper body.|84
209|3 - Patient depends entirely upon someone else for grooming needs.|3 - Patient depends entirely upon someone else for grooming needs.|84
210|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone else to manage the equipment.|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone|84
211|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable to shift attention and recall directions more than half the time.|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable|84
212|3 - Respiratory problems (SOB, infection, obstruction)|3 - Respiratory problems (SOB, infection, obstruction)|84
213|3 - Resumption of care (after inpatient stay)|3 - Resumption of care (after inpatient stay)|84
214|3 - Several times each month|3 - Several times each month|84
215|3 - Skilled Nursing Facility|3 - Skilled Nursing Facility|84
216|3 - Stage 3|3 - Stage 3|84
217|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|84
218|3 - Three|3 - Three|84
219|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person throughout the process.|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person through|84
220|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal independently.|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal indep|84
221|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person.|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person|84
222|3 - Unknown because patient moved to a geographic location not served by this agency|3 - Unknown because patient moved to a geographic location not served by this agency|84
223|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|84
224|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|84
225|3 - With other family member|3 - With other family member|84
226|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home health services, homemaker assistance, transportation assistance, assisted living, board and care)|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home h|84
227|3-SLP/ST|3-SLP/ST|84
228|4 - At rest (during day or night)|4 - At rest (during day or night)|84
229|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|84
230|4 - Board and care or assisted living facility|4 - Board and care or assisted living facility|84
231|4 - Caregiver is completely dependent on someone else to manage all equipment.|4 - Caregiver is completely dependent on someone else to manage all equipment.|84
232|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|84
233|4 - Constantly|4 - Constantly|84
234|4 - Drug dependency|4 - Drug dependency|84
235|4 - Four or more|4 - Four or more|84
236|4 - Friend or neighbor or community or church member|4 - Friend or neighbor or community or church member|84
237|4 - Hispanic or Latino|4 - Hispanic or Latino|84
238|4 - Hospice|4 - Hospice|84
239|4 - Impaired decision-making|4 - Impaired decision-making|84
240|4 - Is totally dependent in toileting.|4 - Is totally dependent in toileting.|84
241|4 - Medicaid (HMO/managed care)|4 - Medicaid (HMO/managed care)|84
242|4 - None of the above|4 - None of the above|84
243|4 - Nursing home|4 - Nursing home|84
244|4 - On a daily basis|4 - On a daily basis|84
245|4 - Patient is completely dependent on someone else to manage all equipment.|4 - Patient is completely dependent on someone else to manage all equipment.|84
246|4 - Permanent placement|4 - Permanent placement|84
247|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, punches, dangerous maneuvers w/ wheelchair or other objects)|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, pu|84
248|4 - Psychosocial support (e.g., socialization, companionship, recreation)|4 - Psychosocial support (e.g., socialization, companionship, recreation)|84
249|4 - Recertification (follow-up) reassessment|4 - Recertification (follow-up) reassessment|84
250|4 - Recurrent thoughts of death|4 - Recurrent thoughts of death|84
251|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruction)|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruc|84
252|4 - Several times a week|4 - Several times a week|84
253|4 - Stage 4|4 - Stage 4|84
254|4 - Symptoms poorly controlled, history of re-hospitalizations|4 - Symptoms poorly controlled, history of re-hospitalizations|84
255|4 - Three or more times per week|4 - Three or more times per week|84
256|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetative state, or delirium.|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetati|84
257|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|84
258|4 - Unable to effectively participate in any housekeeping tasks.|4 - Unable to effectively participate in any housekeeping tasks.|84
259|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or unresponsive (e.g., speech is nonsensical or unintelligible).|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or u|84
260|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonresponsive.|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonr|84
261|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostomy.|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostom|84
262|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of devices at the sink, in chair, or on commode|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of|84
263|4 - With a friend|4 - With a friend|84
264|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|84
265|4-OT|4-OT|84
266|5 - Advocates or facilitates patient's participation in appropriate medical care|5 - Advocates or facilitates patient's participation in appropriate medical care|84
267|5 - At least daily|5 - At least daily|84
268|6 - Bedfast, unable to ambulate or be up in a chair.|6 - Bedfast, unable to ambulate or be up in a chair.|84
269|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|84
270|5 - Disruptive or socially inappropriate behavior|5 - Disruptive or socially inappropriate behavior|84
271|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|84
272|5 - Hypo/Hyperglycemia, diabetes out of control|5 - Hypo/Hyperglycemia, diabetes out of control|84
273|5 - More often than once daily|5 - More often than once daily|84
274|5 - Native Hawaiian or Pacific Islander|5 - Native Hawaiian or Pacific Islander|84
275|5 - None of the above|5 - None of the above|84
276|5 - One to two times per week|5 - One to two times per week|84
277|5 - Other|5 - Other|84
278|5 - Other follow-up|5 - Other follow-up|84
279|5 - Paid help|5 - Paid help|84
280|5 - Patient nonresponsive or unable to speak.|5 - Patient nonresponsive or unable to speak.|84
281|5 - Thoughts of suicide|5 - Thoughts of suicide|84
282|5 - Totally unable to use the telephone.|5 - Totally unable to use the telephone.|84
283|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|84
284|5 - Unable to take in nutrients orally or by tube feeding.|5 - Unable to take in nutrients orally or by tube feeding.|84
285|5 - Unsafe for care at home|5 - Unsafe for care at home|84
286|5 - With paid help (other than home care agency staff)|5 - With paid help (other than home care agency staff)|84
287|5 - Workers' compensation|5 - Workers' compensation|84
288|5 - Wound infection, deteriorating wound status, new lesion/ulcer|5 - Wound infection, deteriorating wound status, new lesion/ulcer|84
289|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|84
290|6 - Delusional, hallucinatory, or paranoid behavior|6 - Delusional, hallucinatory, or paranoid behavior|84
291|6 - Financial agent, power of attorney, or conservator of finance|6 - Financial agent, power of attorney, or conservator of finance|84
292|6 - GI bleeding, obstruction|6 - GI bleeding, obstruction|84
293|6 - Less often than weekly|6 - Less often than weekly|84
294|6 - Memory loss to the extent that supervision required|6 - Memory loss to the extent that supervision required|84
295|6 - None of the above feelings observed or reported|6 - None of the above feelings observed or reported|84
296|6 - Other|6 - Other|84
297|6 - Title programs (e.g., Title III, V, or XX)|6 - Title programs (e.g., Title III, V, or XX)|84
298|6 - Transferred to an inpatient facility - patient not discharged from agency|6 - Transferred to an inpatient facility - patient not discharged from agency|84
299|6 - White|6 - White|84
300|6 - With other than above|6 - With other than above|84
301|7 - Exacerbation of CHF, fluid overload, heart failure|7 - Exacerbation of CHF, fluid overload, heart failure|84
302|7 - Health care agent, conservator of person, or medical power of attorney|7 - Health care agent, conservator of person, or medical power of attorney|84
303|7 - Hypo/Hyperglycemia, diabetes out of control|7 - Hypo/Hyperglycemia, diabetes out of control|84
304|7 - None of the above|7 - None of the above|84
305|7 - None of the above behaviors demonstrated|7 - None of the above behaviors demonstrated|84
306|7 - Other government (e.g., TriCare, VA, etc.)|7 - Other government (e.g., TriCare, VA, etc.)|84
307|7 - Transferred to an inpatient facility - patient discharged from agency|7 - Transferred to an inpatient facility - patient discharged from agency|84
308|8 - Death at home|8 - Death at home|84
309|8 - GI bleeding, obstruction|8 - GI bleeding, obstruction|84
310|8 - Myocardial infarction, stroke|8 - Myocardial infarction, stroke|84
311|8 - Private insurance|8 - Private insurance|84
312|9 - Chemotherapy|9 - Chemotherapy|84
313|9 - Discharge from agency|9 - Discharge from agency|84
314|9 - Other than above reasons|9 - Other than above reasons|84
315|9 - Private HMO/managed care|9 - Private HMO/managed care|84
316|NA - No caregiver|NA - No caregiver|84
317|NA - No equipment of this type used in care.|NA - No equipment of this type used in care.|84
318|NA - No inhalant/mist medications prescribed.|NA - No inhalant/mist medications prescribed.|84
319|NA - No injectable medications prescribed.|NA - No injectable medications prescribed.|84
320|NA - No inpatient facility admission|NA - No inpatient facility admission|84
321|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|84
322|NA - No Medicaid|NA - No Medicaid|84
323|NA - No Medicare|NA - No Medicare|84
324|NA - No observable pressure ulcer or unhealed pressure ulcer|NA - No observable pressure ulcer or unhealed pressure ulcer|84
325|NA - No observable stasis ulcer|NA - No observable stasis ulcer|84
326|NA - No observable surgical wound|NA - No observable surgical wound|84
327|NA - No oral medications prescribed.|NA - No oral medications prescribed.|84
328|NA - Not applicable|NA - Not applicable|84
329|NA - Patient does not have a telephone.|NA - Patient does not have a telephone.|84
330|NA - Patient has ostomy for bowel elimination|NA - Patient has ostomy for bowel elimination|84
331|NA - Patient nonresponsive|NA - Patient nonresponsive|84
332|NA - Patient on prophylactic treatment|NA - Patient on prophylactic treatment|84
333|NA - Patient was not discharged from an inpatient facility [Go to M1017]|NA - Patient was not discharged from an inpatient facility [Go to M1017]|84
334|UK - Other unknown|UK - Other unknown|84
335|UK - Reason unknown|UK - Reason unknown|84
336|UK - Unknown|UK - Unknown|84
337|UK - Unknown or Not Available|UK - Unknown or Not Available|84
341|01 - Early|01 - Early|84
342|02 - Late|02 - Late|84
343|NA - Not Applicable. No case mix group defined for this assessment.|NA - Not Applicable. No case mix group defined for this assessment.|84
344|NA - No case mix group defined by this assessment.|NA - No case mix group defined by this assessment.|84
345|1 - Recent decline in mental, emotional, or behavioral status|1 - Recent decline in mental, emotional, or behavioral status|84
346|2 - Multiple hospitalizations (2 or more) in the past 12 months|2 - Multiple hospitalizations (2 or more) in the past 12 months|84
347|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|84
348|4 - Taking five or more medications|4 - Taking five or more medications|84
349|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|84
350|6 - Other|6 - Other|84
351|7 - None of the above|7 - None of the above|84
352|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond tho|84
353|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable without heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable wi|84
354|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious complications and death.|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious compl|84
355|3 - The patient has serious progressive conditions that could lead to death within a year.|3 - The patient has serious progressive conditions that could lead to death within a year.|84
356|UK - The patient+s situation is unknown or unclear.|UK - The patient+s situation is unknown or unclear.|84
357|1 - Yes [ Go to M1050 ]|1 - Yes [ Go to M1050 ]|84
358|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this influenza season. [ Go to M1050 ]|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this i|84
359|1 - Received from another health care provider (e.g., physician)|1 - Received from another health care provider (e.g., physician)|84
360|2 - Received from your agency previously during this year+s flu season|2 - Received from your agency previously during this year+s flu season|84
361|3 - Offered and declined|3 - Offered and declined|84
362|4 - Assessed and determined to have medical contraindication(s)|4 - Assessed and determined to have medical contraindication(s)|84
363|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|84
364|6 - Inability to obtain vaccine due to declared shortage|6 - Inability to obtain vaccine due to declared shortage|84
365|1 - Yes [ Go to M2005 at TRN; Go to M1230 at DC ]|1 - Yes [ Go to M2005 at TRN; Go to M1230 at DC ]|84
366|1 - Patient has received PPV in the past|1 - Patient has received PPV in the past|84
367|2 - Offered and declined|2 - Offered and declined|84
368|3 - Assessed and determined to have medical contraindication(s)|3 - Assessed and determined to have medical contraindication(s)|84
369|4 - Not indicated; patient does not meet age/condition guidelines for PPV|4 - Not indicated; patient does not meet age/condition guidelines for PPV|84
370|5 - None of the above|5 - None of the above|84
371|0 - Adequate: hears normal conversation without difficulty.|0 - Adequate: hears normal conversation without difficulty.|84
372|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to increase volume or speak distinctly.|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to in|84
373|2 - Severely Impaired: absence of useful hearing.|2 - Severely Impaired: absence of useful hearing.|84
374|UK - Unable to assess hearing.|UK - Unable to assess hearing.|84
375|0 - Understands: clear comprehension without cues or repetitions.|0 - Understands: clear comprehension without cues or repetitions.|84
376|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Requires cues at times to understand.|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Req|84
377|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequently requires cues to understand.|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequentl|84
378|3 - Rarely/Never Understands|3 - Rarely/Never Understands|84
379|UK - Unable to assess understanding.|UK - Unable to assess understanding.|84
380|0 - No standardized assessment conducted|0 - No standardized assessment conducted|84
381|1 - Yes, and it does not indicate severe pain|1 - Yes, and it does not indicate severe pain|84
382|2 - Yes, and it indicates severe pain|2 - Yes, and it indicates severe pain|84
383|0 - Patient has no pain|0 - Patient has no pain|84
384|1 - Patient has pain that does not interfere with activity or movement|1 - Patient has pain that does not interfere with activity or movement|84
385|2 - Less often than daily|2 - Less often than daily|84
386|3 - Daily, but not constantly|3 - Daily, but not constantly|84
387|4 - All of the time|4 - All of the time|84
388|0 - No assessment conducted [ Go to M1306 ]|0 - No assessment conducted [ Go to M1306 ]|84
389|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc., without use of standardized tool|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc.,|84
390|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|84
391|0 - No [ Go to M1322]|0 - No [ Go to M1322]|84
392|0 v Newly epithelialized|0 v Newly epithelialized|84
393|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|84
394|2 - Yes, patient has observable stasis ulcers ONLY|2 - Yes, patient has observable stasis ulcers ONLY|84
395|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable dressing) [Go to M1340]|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable|84
396|0 - No [ Go to M1400 ]|0 - No [ Go to M1400 ]|84
397|1 - Yes, patient has at least one (observable) surgical wound|1 - Yes, patient has at least one (observable) surgical wound|84
398|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1400 ]|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1400 ]|84
399|0 - Patient is not short of breath|0 - Patient is not short of breath|84
400|3 - Continuous Bi-level positive airway pressure|3 - Continuous Bi-level positive airway pressure|84
401|0 - No [ Go to M1732 at TRN; Go to M1600 at DC ]|0 - No [ Go to M1732 at TRN; Go to M1600 at DC ]|84
402|2 - Not assessed [Go to M1732 at TRN; Go to M1600 at DC ]|2 - Not assessed [Go to M1732 at TRN; Go to M1600 at DC ]|84
403|NA - Patient does not have diagnosis of heart failure [Go to M2005 at TRN; Go to M1600 at DC]|NA - Patient does not have diagnosis of heart failure [Go to M2005 at TRN; Go to M1600 at DC]|84
404|0 - No action taken|0 - No action taken|84
405|1 - Patient+s physician (or other primary care practitioner) contacted the same day|1 - Patient+s physician (or other primary care practitioner) contacted the same day|84
406|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|84
407|3 - Implement physician-ordered patient-specific established parameters for treatment|3 - Implement physician-ordered patient-specific established parameters for treatment|84
408|4 - Patient education or other clinical interventions|4 - Patient education or other clinical interventions|84
409|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequency, telehealth, etc.)|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequ|84
410|1 - Occasional stress incontinence|1 - Occasional stress incontinence|84
411|2 - During the night only|2 - During the night only|84
412|3 - During the day only|3 - During the day only|84
413|4 - During the day and night|4 - During the day and night|84
414|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|84
415|0 - Able to manage toileting hygiene and clothing management without assistance.|0 - Able to manage toileting hygiene and clothing management without assistance.|84
416|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implements are laid out for the patient.|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implemen|84
417|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|84
418|3 - Patient depends entirely upon another person to maintain toileting hygiene.|3 - Patient depends entirely upon another person to maintain toileting hygiene.|84
419|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independent|84
420|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface|84
421|0 - No multi-factor falls risk assessment conducted.|0 - No multi-factor falls risk assessment conducted.|84
422|1 - Yes, and it does not indicate a risk for falls.|1 - Yes, and it does not indicate a risk for falls.|84
423|2 - Yes, and it indicates a risk for falls.|2 - Yes, and it indicates a risk for falls.|84
424|0 - Not assessed/reviewed [ Go to M2010 ]|0 - Not assessed/reviewed [ Go to M2010 ]|84
425|1 - No problems found during review [ Go to M2010 ]|1 - No problems found during review [ Go to M2010 ]|84
426|2 - Problems found during review|2 - Problems found during review|84
427|NA - Patient is not taking any medications [ Go to M2040 ]|NA - Patient is not taking any medications [ Go to M2040 ]|84
428|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special precautions associated with all high-risk medications|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special p|84
429|NA - Patient not taking any drugs|NA - Patient not taking any drugs|84
430|2 - Able to take medication(s) at the correct times if given reminders by another person at the appropriate times|2 - Able to take medication(s) at the correct times if given reminders by another person at the appr|84
431|3 - Unable to take medication unless administered by another person.|3 - Unable to take medication unless administered by another person.|84
432|1 - At least daily|1 - At least daily|84
433|2 - Three or more times per week|2 - Three or more times per week|84
434|3 - One to two times per week|3 - One to two times per week|84
435|4 - Received, but less often than weekly|4 - Received, but less often than weekly|84
436|5 - No assistance received|5 - No assistance received|84
437|0 - No [Go to M2401]|0 - No [Go to M2401]|84
438|1 - Yes, used hospital emergency department WITHOUT hospital admission|1 - Yes, used hospital emergency department WITHOUT hospital admission|84
439|2 - Yes, used hospital emergency department WITH hospital admission|2 - Yes, used hospital emergency department WITH hospital admission|84
440|UK - Unknown [Go to M2401]|UK - Unknown [Go to M2401]|84
441|2 - Injury caused by fall|2 - Injury caused by fall|84
442|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|84
443|4 - Other respiratory problem|4 - Other respiratory problem|84
444|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|84
445|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|84
446|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|84
447|8 - Other heart disease|8 - Other heart disease|84
448|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|84
449|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|84
450|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|84
451|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|84
452|13 - Urinary tract infection|13 - Urinary tract infection|84
453|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|84
454|15 - Wound infection or deterioration|15 - Wound infection or deterioration|84
455|16 - Uncontrolled pain|16 - Uncontrolled pain|84
456|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|84
457|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|84
458|19 - Other than above reasons|19 - Other than above reasons|84
459|2 - Patient remained in the community (with formal assistive services)|2 - Patient remained in the community (with formal assistive services)|84
460|3 - Patient transferred to a noninstitutional hospice|3 - Patient transferred to a noninstitutional hospice|84
461|4 - Unknown because patient moved to a geographic location not served by this agency|4 - Unknown because patient moved to a geographic location not served by this agency|84
462|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|84
463|4 - Other respiratory problem|4 - Other respiratory problem|84
464|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|84
465|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|84
466|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|84
467|8 - Other heart disease|8 - Other heart disease|84
468|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|84
469|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|84
470|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|84
471|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|84
472|13 - Urinary tract infection|13 - Urinary tract infection|84
473|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|84
474|15 - Wound infection or deterioration|15 - Wound infection or deterioration|84
475|16 - Uncontrolled pain|16 - Uncontrolled pain|84
476|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|84
477|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|84
478|19 - Scheduled treatment or procedure|19 - Scheduled treatment or procedure|84
479|20 - Other than above reasons|20 - Other than above reasons|84
480|UK - Reason unknown [Go to M0903]|UK - Reason unknown [Go to M0903]|84
482|01 - Patient lives alone around the clock|01 - Patient lives alone around the clock|84
483|02 - Patient lives alone regular daytime|02 - Patient lives alone regular daytime|84
484|03 - Patient lives alone regular nighttime|03 - Patient lives alone regular nighttime|84
485|04 - Patient lives alone occassional/short term assistance|04 - Patient lives alone occassional/short term assistance|84
486|05 - Patient lives alone no assisstance available|05 - Patient lives alone no assisstance available|84
487|06 - Patient lives with other person(s) in the home around the clock|06 - Patient lives with other person(s) in the home around the clock|84
488|07 - Patient lives with other person(s) in the home regular daytime|07 - Patient lives with other person(s) in the home regular daytime|84
489|08 - Patient lives with other person(s) in the home regular nighttime|08 - Patient lives with other person(s) in the home regular nighttime|84
490|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|84
491|10 - Patient lives with other person(s) in the home no assistance available|10 - Patient lives with other person(s) in the home no assistance available|84
492|1 - Was present at the most recent SOC/ROC assessment|1 - Was present at the most recent SOC/ROC assessment|84
493|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|84
494|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|84
495|0 - Newly epithelialized|0 - Newly epithelialized|84
496|0 - No [ Go to M1340 ]|0 - No [ Go to M1340 ]|84
498|0 - Independent|0 - Independent|84
499|1 - Needed Some Help|1 - Needed Some Help|84
500|2 - Dependent|2 - Dependent|84
502|0 - No assistance needed in this area|0 - No assistance needed in this area|84
503|1 - Caregiver(s) currently provide assistance|1 - Caregiver(s) currently provide assistance|84
504|2 - Caregiver(s) need training/ supportive services to provide assistance|2 - Caregiver(s) need training/ supportive services to provide assistance|84
505|3 - Caregiver(s) not likely to provide assistance|3 - Caregiver(s) not likely to provide assistance|84
506|4 - Unclear if Caregiver(s) will provide assistance|4 - Unclear if Caregiver(s) will provide assistance|84
507|5 - Assistance needed, but no Caregiver(s) available|5 - Assistance needed, but no Caregiver(s) available|84
508|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will use standardized clinical guidelines accessible for all care providers to reference|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will|84
510|NA - Patient is not assessed to be at risk for falls|NA - Patient is not assessed to be at risk for falls|84
511|NA - Patient has no diagnosis or symptoms of depression|NA - Patient has no diagnosis or symptoms of depression|84
512|NA - No pain identified|NA - No pain identified|84
513|NA - Patient is not assessed to be at risk for pressure ulcers|NA - Patient is not assessed to be at risk for pressure ulcers|84
514|NA - Patient has no pressure ulcers with need for moist wound healing|NA - Patient has no pressure ulcers with need for moist wound healing|84
515|1 - Long-term nursing facility (NF)|1 - Long-term nursing facility (NF)|84
516|2 - Skilled nursing facility (SNF / TCU)|2 - Skilled nursing facility (SNF / TCU)|84
517|3 - Short stay acute hospital (IPP S)|3 - Short stay acute hospital (IPP S)|84
518|4 - Long-term care hospital (LTCH)|4 - Long-term care hospital (LTCH)|84
519|5 - Inpatient rehabilitation hospital or unit (IRF)|5 - Inpatient rehabilitation hospital or unit (IRF)|84
520|6 - Psychiatric hospital or unit|6 - Psychiatric hospital or unit|84
521|7 - Other|7 - Other|84
522|NA - Patient was not discharged from an inpatient facility [Go to M1017]|NA - Patient was not discharged from an inpatient facility [Go to M1017]|84
523|6 - Unable to participate effectively in bathing and is bathed totally by another person|6 - Unable to participate effectively in bathing and is bathed totally by another person|84
524|4 - Chairfast, unable to ambulate but is able to wheel self independently.|4 - Chairfast, unable to ambulate but is able to wheel self independently.|84
525|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask patient: "Over the last two weeks, how often have you been bothered by any of the following problems")  *Copyright+ Pfizer Inc. All rights reserved. Reproduced with permission.|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask|84
526|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluation for depression.|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluat|84
527|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet criteria for further evaluation for depression.|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet|84
528|0 - Not at all  0 - 1 day|0 - Not at all  0 - 1 day|84
529|1 - Several days  2 - 6 days|1 - Several days  2 - 6 days|84
530|2 - More than half of the days  7 - 11 days|2 - More than half of the days  7 - 11 days|84
531|3 - Nearly every day  12 - 14 days|3 - Nearly every day  12 - 14 days|84
532|NA - N/A  Unable to respond|NA - N/A  Unable to respond|84
533|2 - Able to take medication(s) at the correct times if given reminders by another person based on the frequency of the injection|2 - Able to take medication(s) at the correct times if given reminders by another person based on th|84
534|3 - Unable to take injectable medication unless administered by another person.|3 - Unable to take injectable medication unless administered by another person.|84
535|UK - Inpatient Discharge Date Unknown|UK - Inpatient Discharge Date Unknown|84
538|NA - Inpatient stay within last 14 days Not Applicable|NA - Inpatient stay within last 14 days Not Applicable|84
571|1 - History of falls (2 or more falls - or any fall with an injury - in the past 12 months) |1 - History of falls (2 or more falls - or any fall with an injury - in the past 12 months) |84
572|2 - Unintentional weight loss of a total of 10 pounds or more in the past 12 months |2 - Unintentional weight loss of a total of 10 pounds or more in the past 12 months |84
573|3 - Multiple hospitalizations (2 or more) in the past 6 months|3 - Multiple hospitalizations (2 or more) in the past 6 months|84
574|4 - Multiple emergency department visits (2 or more) in the past 6 months|4 - Multiple emergency department visits (2 or more) in the past 6 months|84
575|5 - Decline in mental emotional or behavioral status in the past 3 months |5 - Decline in mental emotional or behavioral status in the past 3 months |84
576|6 - Reported or observed history of difficulty complying with any medical instructions (for example,medications, diet, exercise) in the past 3 months|6 - Reported or observed history of difficulty complying with any medical instructions (for example |84
577|7 - Currently taking 5 or more medications|7 - Currently taking 5 or more medications|84
578|8 - Currently reports exhaustion|8 - Currently reports exhaustion|84
579|9 - Other risk(s) not listed in 1 - 8|9 - Other risk(s) not listed in 1 - 8|84
580|10 - None of the above |10 - None of the above |84
580|10 - None of the above |10 - None of the above |85
579|9 - Other risk(s) not listed in 1 - 8|9 - Other risk(s) not listed in 1 - 8|85
578|8 - Currently reports exhaustion|8 - Currently reports exhaustion|85
577|7 - Currently taking 5 or more medications|7 - Currently taking 5 or more medications|85
576|6 - Reported or observed history of difficulty complying with any medical instructions (for example,medications, diet, exercise) in the past 3 months|6 - Reported or observed history of difficulty complying with any medical instructions (for example |85
575|5 - Decline in mental emotional or behavioral status in the past 3 months |5 - Decline in mental emotional or behavioral status in the past 3 months |85
574|4 - Multiple emergency department visits (2 or more) in the past 6 months|4 - Multiple emergency department visits (2 or more) in the past 6 months|85
573|3 - Multiple hospitalizations (2 or more) in the past 6 months|3 - Multiple hospitalizations (2 or more) in the past 6 months|85
572|2 - Unintentional weight loss of a total of 10 pounds or more in the past 12 months |2 - Unintentional weight loss of a total of 10 pounds or more in the past 12 months |85
571|1 - History of falls (2 or more falls - or any fall with an injury - in the past 12 months) |1 - History of falls (2 or more falls - or any fall with an injury - in the past 12 months) |85
47|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or supervision from another person OR c) a liquid, pureed or ground meat diet.|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or su|85
48|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|85
2|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; OR (b) Is physically, cognitively, and mentally able to prepare light meals on a regular basis but has not routinely performed light meal preparation in the past (i.e., prior to this home care admission).|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; O|85
3|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and mentally able to perform all housekeeping tasks .|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and menta|85
4|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and mentally able to do laundry and access facilities.|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and menta|85
5|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying packages OR b) Physically, cognitively, and mentally able to take care of shopping, but has not done shopping in the past (i.e., prior to this home care admission).|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying|85
6|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|85
7|0 - Able to dial numbers and answer calls appropriately and as desired.|0 - Able to dial numbers and answer calls appropriately and as desired.|85
8|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body without assistance.|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body|85
9|0 - Able to get to and from the toilet and transfer independently with or without a device.|0 - Able to get to and from the toilet and transfer independently with or without a device.|85
10|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|85
11|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible public bus.|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible p|85
12|0 - Able to independently feed self.|0 - Able to independently feed self.|85
13|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|85
14|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct times.|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct ti|85
15|0 - Able to independently transfer.|0 - Able to independently transfer.|85
16|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without rail|85
17|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings|85
18|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|85
19|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions independently.|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions indep|85
20|0 - Asymptomatic, no treatment needed at this time|0 - Asymptomatic, no treatment needed at this time|85
21|0 - Caregiver manages all tasks related to equipment completely independently.|0 - Caregiver manages all tasks related to equipment completely independently.|85
22|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations with no observable impairment.|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations w|85
23|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|85
24|0 - Life expectancy is greater than 6 months|0 - Life expectancy is greater than 6 months|85
25|0 - Never|0 - Never|85
26|0 - Patient is not short of breath|0 - Patient is not short of breath|85
27|0 - No|0 - No|85
28|0 - No emergent care services|0 - No emergent care services|85
29|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [Goto M1620]|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [Goto M1620]|85
30|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and extended or abstract conversation.|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and exte|85
31|0 - No one person|0 - No one person|85
32|0 - None of the time|0 - None of the time|85
33|0 - None, no charge for current services|0 - None, no charge for current services|85
34|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|85
35|0 - Patient does NOT have an ostomy for bowel elimination.|0 - Patient does NOT have an ostomy for bowel elimination.|85
36|0 - Patient has no pain|0 - Patient has no pain|85
37|0 - Patient manages all tasks related to equipment completely independently.|0 - Patient manages all tasks related to equipment completely independently.|85
38|0 - Poor:  little or no recovery is expected and/or further decline is imminent|0 - Poor:  little or no recovery is expected and/or further decline is imminent|85
39|0 - Timed-voiding defers incontinence|0 - Timed-voiding defers incontinence|85
40|0 - Very rarely or never has bowel incontinence|0 - Very rarely or never has bowel incontinence|85
41|0 - Zero|0 - Zero|85
42|00 - No|00 - No|85
43|01 - Yes|01 - Yes|85
44|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or mental limitations, needs assistance with heavy laundry.|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or|85
45|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the patient.|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the|85
46|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|85
49|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|85
50|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independently.|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independe|85
51|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only when assisted or accompanied by another person.|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only w|85
52|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepa|85
53|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance by another person OR b) given daily reminders.|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance b|85
54|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advan|85
55|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advan|85
56|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for the deaf) and call essential numbers.|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for t|85
57|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|85
58|1 - American Indian or Alaska Native|1 - American Indian or Alaska Native|85
59|1 - Depressed mood (e.g., feeling sad, tearful)|1 - Depressed mood (e.g., feeling sad, tearful)|85
60|1 - During the night only|1 - During the night only|85
61|1 - Fully granulating|1 - Fully granulating|85
62|1 - Good/Fair:  partial to full recovery is expected|1 - Good/Fair:  partial to full recovery is expected|85
63|1 - Good:  marked improvement in functional status is expected|1 - Good:  marked improvement in functional status is expected|85
64|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|85
65|1 - Smoking|1 - Smoking|85
66|1 - Hospital|1 - Hospital|85
67|1 - Hospital emergency room (includes 23-hour holding)|1 - Hospital emergency room (includes 23-hour holding)|85
68|1 - Hospitalization for EMERGENT (unscheduled) care|1 - Hospitalization for EMERGENT (unscheduled) care|85
69|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepared solutions), patient is able to manage all other aspects of equipment.|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepar|85
70|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|85
71|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|85
72|1 - In new or complex situations only|1 - In new or complex situations only|85
73|1 - Intravenous or infusion therapy (excludes TPN)|1 - Intravenous or infusion therapy (excludes TPN)|85
74|1 - Less often than daily|1 - Less often than daily|85
75|1 - Less than once a month|1 - Less than once a month|85
76|1 - Less than once weekly|1 - Less than once weekly|85
77|1 - Life expectancy is 6 months or fewer|1 - Life expectancy is 6 months or fewer|85
78|1 - Lives alone|1 - Lives alone|85
79|1 - Male|1 - Male|85
80|1 - Medicare (traditional fee-for-service)|1 - Medicare (traditional fee-for-service)|85
81|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of past 24 hours, significant memory loss so that supervision is required|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of pas|85
82|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors in word choice, grammar or speech intelligibility, needs minimal prompting or assistance).|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors i|85
83|1 - No assistance or services received|1 - No assistance or services received|85
84|1 - One|1 - One|85
85|1 - Oxygen (intermittent or continuous)|1 - Oxygen (intermittent or continuous)|85
86|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, and the surrounding layout, can count fingers at arm's length.|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, a|85
87|1 - Patient is incontinent|1 - Patient is incontinent|85
88|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|85
89|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical or treatment regimen.|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical|85
90|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient/couple/significant other)|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient|85
91|1 - Relatives, friends, or neighbors living outside the home|1 - Relatives, friends, or neighbors living outside the home|85
92|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions.|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions|85
93|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independentl|85
94|1 - Several times during day and night|1 - Several times during day and night|85
95|1 - Spouse or significant other|1 - Spouse or significant other|85
96|1 - Stage 1|1 - Stage 1|85
97|1 - Start of care - further visits planned|1 - Start of care - further visits planned|85
98|1 - Symptoms well controlled with current therapy|1 - Symptoms well controlled with current therapy|85
99|1 - Therapy services|1 - Therapy services|85
100|1 - Able to transfer with minimal human assistance or with use of an assistive device.|1 - Able to transfer with minimal human assistance or with use of an assistive device.|85
101|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitations.|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitatio|85
102|1 - Urinary incontinence|1 - Urinary incontinence|85
103|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and transfer.|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and|85
104|1 - When walking more than 20 feet, climbing stairs|1 - When walking more than 20 feet, climbing stairs|85
105|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary conversation. May need occasional repetition, extra time, or louder voice.|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary c|85
106|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting in and out of tub/shower|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting|85
107|1 - Yes|1 - Yes|85
108|1-RN|1-RN|85
109|10 - Discharge from agency - no visits completed after start/resumption of care assessment|10 - Discharge from agency - no visits completed after start/resumption of care assessment|85
110|10 - Scheduled surgical procedure|10 - Scheduled surgical procedure|85
111|10 - Self-pay|10 - Self-pay|85
112|11 - Other|11 - Other|85
113|11 - Urinary tract infection|11 - Urinary tract infection|85
114|12 - IV catheter-related infection|12 - IV catheter-related infection|85
115|13 - Deep vein thrombosis, pulmonary embolus|13 - Deep vein thrombosis, pulmonary embolus|85
116|14 - Uncontrolled pain|14 - Uncontrolled pain|85
117|15 - Psychotic episode|15 - Psychotic episode|85
118|16 - Other than above reasons|16 - Other than above reasons|85
119|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing calls.|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing|85
120|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another person.|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another pers|85
121|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface a|85
122|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for intermittent supervision or encouragement or reminders, OR (b) to get in and out of the shower or tub, OR (c) for washing difficult to reach areas.|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for inter|85
123|2 - Asian|2 - Asian|85
124|2 - Caregiver requires considerable assistance from another person to manage equipment, but independently completes significant portions of task.|2 - Caregiver requires considerable assistance from another person to manage equipment, but independ|85
125|2 - Daily, but not constantly|2 - Daily, but not constantly|85
126|2 - Daughter or son|2 - Daughter or son|85
127|2 - Doctor's office emergency visit/house call|2 - Doctor's office emergency visit/house call|85
128|2 - During the day and night|2 - During the day and night|85
129|2 - Early/partial granulation|2 - Early/partial granulation|85
130|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors in word choice, organization or speech intelligibility). Speaks in phrases or short sentences.|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors|85
131|2 - Family member's residence|2 - Family member's residence|85
132|2 - Female|2 - Female|85
133|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conversation, needs frequent prompting or assistance.|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conver|85
134|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|85
135|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|85
136|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately stop activities, jeopardizes safety through actions|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately st|85
137|2 - Indwelling/suprapubic catheter|2 - Indwelling/suprapubic catheter|85
138|2 - Injury caused by fall or accident at home|2 - Injury caused by fall or accident at home|85
139|2 - Medicare (HMO/managed care/Advantage plan)|2 - Medicare (HMO/managed care/Advantage plan)|85
140|2 - Nausea, dehydration, malnutrition, constipation, impaction|2 - Nausea, dehydration, malnutrition, constipation, impaction|85
141|2 - Obesity|2 - Obesity|85
142|2 - On awakening or at night only|2 - On awakening or at night only|85
143|2 - Once a month|2 - Once a month|85
144|2 - One to three times weekly|2 - One to three times weekly|85
145|2 - Parenteral nutrition (TPN or lipids)|2 - Parenteral nutrition (TPN or lipids)|85
146|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic) [ Go to M1620 ]|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic) [ Go|85
147|2 - Patient requires considerable assistance from another person to manage equipment, but independently completes portions of the task.|2 - Patient requires considerable assistance from another person to manage equipment, but independen|85
148|2 - Patient transferred to a noninstitutional hospice|2 - Patient transferred to a noninstitutional hospice|85
149|2 - Person residing in the home (EXCLUDING paid help)|2 - Person residing in the home (EXCLUDING paid help)|85
150|2 - Rehabilitation facility|2 - Rehabilitation facility|85
151|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifting of attention) or consistently requires low stimulus environment due to distractibility.|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifti|85
152|2 - Respite care|2 - Respite care|85
153|2 - Sense of failure or self reproach|2 - Sense of failure or self reproach|85
154|2 - Several times during day|2 - Several times during day|85
155|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonresponsive.|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonrespons|85
156|2 - Someone must assist the patient to groom self.|2 - Someone must assist the patient to groom self.|85
157|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|85
158|2 - Someone must help the patient put on upper body clothing.|2 - Someone must help the patient put on upper body clothing.|85
159|2 - Stage 2|2 - Stage 2|85
160|2 - Start of care - no further visits planned|2 - Start of care - no further visits planned|85
161|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitoring|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitori|85
162|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment regimen.|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment re|85
163|2 - Two|2 - Two|85
164|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistance due to cognitive or mental limitation.|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistanc|85
165|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|85
166|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assistance).|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assis|85
167|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home delivery.|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home deli|85
168|2 - Unable to prepare any light meals or reheat any delivered meals.|2 - Unable to prepare any light meals or reheat any delivered meals.|85
169|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|85
170|2 - UNABLE to take injectable medications unless administered by someone else.|2 - UNABLE to take injectable medications unless administered by someone else.|85
171|2 - UNABLE to take medication unless administered by someone else.|2 - UNABLE to take medication unless administered by someone else.|85
172|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|85
173|2 - Ventilator (continually or at night)|2 - Ventilator (continually or at night)|85
174|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less than 20 feet)|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less th|85
175|2 - With spouse or significant other|2 - With spouse or significant other|85
176|2 - Yes, assistance or services provided by family or friends|2 - Yes, assistance or services provided by family or friends|85
177|2-PT|2-PT|85
178|3 - Able to answer the telephone only some of the time or is able to carry on only a limited conversation.|3 - Able to answer the telephone only some of the time or is able to carry on only a limited convers|85
179|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube or gastrostomy.|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube|85
180|3 - Alcohol dependency|3 - Alcohol dependency|85
181|3 - All of the time|3 - All of the time|85
182|3 - Black or African-American|3 - Black or African-American|85
183|3 - Boarding home or rented room|3 - Boarding home or rented room|85
184|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment, clean/store/dispose of equipment or supplies).|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment,|85
185|3 -Able to walk only with the supervision or assistance of another person at all times.|3 -Able to walk only with the supervision or assistance of another person at all times.|85
186|3 - Continuous / Bi-level positive airway pressure|3 - Continuous / Bi-level positive airway pressure|85
187|3 - During the day and evening, but not constantly|3 - During the day and evening, but not constantly|85
188|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the alimentary canal)|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the|85
189|3 - Environmental support (e.g., housing, home maintenance)|3 - Environmental support (e.g., housing, home maintenance)|85
190|3 - Four to six times weekly|3 - Four to six times weekly|85
191|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessing by listener.  Speech limited to single words or short phrases.|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessin|85
192|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires multiple repetitions, restatements, demonstrations, additional time.|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires m|85
193|3 - Hopelessness|3 - Hopelessness|85
194|3 - Hospice care|3 - Hospice care|85
195|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|85
196|3 - Injury caused by fall or accident at home|3 - Injury caused by fall or accident at home|85
197|3 - Intractable pain|3 - Intractable pain|85
198|3 - Medicaid (traditional fee-for-service)|3 - Medicaid (traditional fee-for-service)|85
199|3 - Needs someone to do all shopping and errands.|3 - Needs someone to do all shopping and errands.|85
200|3 - Not healing|3 - Not healing|85
201|3 - Nursing home|3 - Nursing home|85
202|3 - Once daily|3 - Once daily|85
203|3 - Other family member|3 - Other family member|85
204|3 - Outpatient department/clinic emergency (includes urgicenter sites)|3 - Outpatient department/clinic emergency (includes urgicenter sites)|85
205|3 - Paid help|3 - Paid help|85
206|3 - Able to participate in bathing self in shower or tub, but requires presence of another person throughout the bath for assistance or supervision.|3 - Able to participate in bathing self in shower or tub, but requires presence of another person th|85
207|3 - Patient depends entirely upon another person to dress lower body.|3 - Patient depends entirely upon another person to dress lower body.|85
208|3 - Patient depends entirely upon another person to dress the upper body.|3 - Patient depends entirely upon another person to dress the upper body.|85
209|3 - Patient depends entirely upon someone else for grooming needs.|3 - Patient depends entirely upon someone else for grooming needs.|85
210|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone else to manage the equipment.|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone|85
211|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable to shift attention and recall directions more than half the time.|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable|85
212|3 - Respiratory problems (SOB, infection, obstruction)|3 - Respiratory problems (SOB, infection, obstruction)|85
213|3 - Resumption of care (after inpatient stay)|3 - Resumption of care (after inpatient stay)|85
214|3 - Several times each month|3 - Several times each month|85
215|3 - Skilled Nursing Facility|3 - Skilled Nursing Facility|85
216|3 - Stage 3|3 - Stage 3|85
217|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|85
218|3 - Three|3 - Three|85
219|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person throughout the process.|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person through|85
220|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal independently.|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal indep|85
221|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person.|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person|85
222|3 - Unknown because patient moved to a geographic location not served by this agency|3 - Unknown because patient moved to a geographic location not served by this agency|85
223|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|85
224|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|85
225|3 - With other family member|3 - With other family member|85
226|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home health services, homemaker assistance, transportation assistance, assisted living, board and care)|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home h|85
227|3-SLP/ST|3-SLP/ST|85
228|4 - At rest (during day or night)|4 - At rest (during day or night)|85
229|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|85
230|4 - Board and care or assisted living facility|4 - Board and care or assisted living facility|85
231|4 - Caregiver is completely dependent on someone else to manage all equipment.|4 - Caregiver is completely dependent on someone else to manage all equipment.|85
232|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|85
233|4 - Constantly|4 - Constantly|85
234|4 - Drug dependency|4 - Drug dependency|85
235|4 - Four or more|4 - Four or more|85
236|4 - Friend or neighbor or community or church member|4 - Friend or neighbor or community or church member|85
237|4 - Hispanic or Latino|4 - Hispanic or Latino|85
238|4 - Hospice|4 - Hospice|85
239|4 - Impaired decision-making|4 - Impaired decision-making|85
240|4 - Is totally dependent in toileting.|4 - Is totally dependent in toileting.|85
241|4 - Medicaid (HMO/managed care)|4 - Medicaid (HMO/managed care)|85
242|4 - None of the above|4 - None of the above|85
243|4 - Nursing home|4 - Nursing home|85
244|4 - On a daily basis|4 - On a daily basis|85
245|4 - Patient is completely dependent on someone else to manage all equipment.|4 - Patient is completely dependent on someone else to manage all equipment.|85
246|4 - Permanent placement|4 - Permanent placement|85
247|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, punches, dangerous maneuvers w/ wheelchair or other objects)|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, pu|85
248|4 - Psychosocial support (e.g., socialization, companionship, recreation)|4 - Psychosocial support (e.g., socialization, companionship, recreation)|85
249|4 - Recertification (follow-up) reassessment|4 - Recertification (follow-up) reassessment|85
250|4 - Recurrent thoughts of death|4 - Recurrent thoughts of death|85
251|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruction)|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruc|85
252|4 - Several times a week|4 - Several times a week|85
253|4 - Stage 4|4 - Stage 4|85
254|4 - Symptoms poorly controlled, history of re-hospitalizations|4 - Symptoms poorly controlled, history of re-hospitalizations|85
255|4 - Three or more times per week|4 - Three or more times per week|85
256|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetative state, or delirium.|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetati|85
257|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|85
258|4 - Unable to effectively participate in any housekeeping tasks.|4 - Unable to effectively participate in any housekeeping tasks.|85
259|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or unresponsive (e.g., speech is nonsensical or unintelligible).|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or u|85
260|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonresponsive.|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonr|85
261|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostomy.|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostom|85
262|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of devices at the sink, in chair, or on commode|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of|85
263|4 - With a friend|4 - With a friend|85
264|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|85
265|4-OT|4-OT|85
266|5 - Advocates or facilitates patient's participation in appropriate medical care|5 - Advocates or facilitates patient's participation in appropriate medical care|85
267|5 - At least daily|5 - At least daily|85
268|6 - Bedfast, unable to ambulate or be up in a chair.|6 - Bedfast, unable to ambulate or be up in a chair.|85
269|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|85
270|5 - Disruptive or socially inappropriate behavior|5 - Disruptive or socially inappropriate behavior|85
271|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|85
272|5 - Hypo/Hyperglycemia, diabetes out of control|5 - Hypo/Hyperglycemia, diabetes out of control|85
273|5 - More often than once daily|5 - More often than once daily|85
274|5 - Native Hawaiian or Pacific Islander|5 - Native Hawaiian or Pacific Islander|85
275|5 - None of the above|5 - None of the above|85
276|5 - One to two times per week|5 - One to two times per week|85
277|5 - Other|5 - Other|85
278|5 - Other follow-up|5 - Other follow-up|85
279|5 - Paid help|5 - Paid help|85
280|5 - Patient nonresponsive or unable to speak.|5 - Patient nonresponsive or unable to speak.|85
281|5 - Thoughts of suicide|5 - Thoughts of suicide|85
282|5 - Totally unable to use the telephone.|5 - Totally unable to use the telephone.|85
283|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|85
284|5 - Unable to take in nutrients orally or by tube feeding.|5 - Unable to take in nutrients orally or by tube feeding.|85
285|5 - Unsafe for care at home|5 - Unsafe for care at home|85
286|5 - With paid help (other than home care agency staff)|5 - With paid help (other than home care agency staff)|85
287|5 - Workers' compensation|5 - Workers' compensation|85
288|5 - Wound infection, deteriorating wound status, new lesion/ulcer|5 - Wound infection, deteriorating wound status, new lesion/ulcer|85
289|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|85
290|6 - Delusional, hallucinatory, or paranoid behavior|6 - Delusional, hallucinatory, or paranoid behavior|85
291|6 - Financial agent, power of attorney, or conservator of finance|6 - Financial agent, power of attorney, or conservator of finance|85
292|6 - GI bleeding, obstruction|6 - GI bleeding, obstruction|85
293|6 - Less often than weekly|6 - Less often than weekly|85
294|6 - Memory loss to the extent that supervision required|6 - Memory loss to the extent that supervision required|85
295|6 - None of the above feelings observed or reported|6 - None of the above feelings observed or reported|85
296|6 - Other|6 - Other|85
297|6 - Title programs (e.g., Title III, V, or XX)|6 - Title programs (e.g., Title III, V, or XX)|85
298|6 - Transferred to an inpatient facility - patient not discharged from agency|6 - Transferred to an inpatient facility - patient not discharged from agency|85
299|6 - White|6 - White|85
300|6 - With other than above|6 - With other than above|85
301|7 - Exacerbation of CHF, fluid overload, heart failure|7 - Exacerbation of CHF, fluid overload, heart failure|85
302|7 - Health care agent, conservator of person, or medical power of attorney|7 - Health care agent, conservator of person, or medical power of attorney|85
303|7 - Hypo/Hyperglycemia, diabetes out of control|7 - Hypo/Hyperglycemia, diabetes out of control|85
304|7 - None of the above|7 - None of the above|85
305|7 - None of the above behaviors demonstrated|7 - None of the above behaviors demonstrated|85
306|7 - Other government (e.g., TriCare, VA, etc.)|7 - Other government (e.g., TriCare, VA, etc.)|85
307|7 - Transferred to an inpatient facility - patient discharged from agency|7 - Transferred to an inpatient facility - patient discharged from agency|85
308|8 - Death at home|8 - Death at home|85
309|8 - GI bleeding, obstruction|8 - GI bleeding, obstruction|85
310|8 - Myocardial infarction, stroke|8 - Myocardial infarction, stroke|85
311|8 - Private insurance|8 - Private insurance|85
312|9 - Chemotherapy|9 - Chemotherapy|85
313|9 - Discharge from agency|9 - Discharge from agency|85
314|9 - Other than above reasons|9 - Other than above reasons|85
315|9 - Private HMO/managed care|9 - Private HMO/managed care|85
316|NA - No caregiver|NA - No caregiver|85
317|NA - No equipment of this type used in care.|NA - No equipment of this type used in care.|85
318|NA - No inhalant/mist medications prescribed.|NA - No inhalant/mist medications prescribed.|85
319|NA - No injectable medications prescribed.|NA - No injectable medications prescribed.|85
320|NA - No inpatient facility admission|NA - No inpatient facility admission|85
321|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|85
322|NA - No Medicaid|NA - No Medicaid|85
323|NA - No Medicare|NA - No Medicare|85
324|NA - No observable pressure ulcer or unhealed pressure ulcer|NA - No observable pressure ulcer or unhealed pressure ulcer|85
325|NA - No observable stasis ulcer|NA - No observable stasis ulcer|85
326|NA - No observable surgical wound|NA - No observable surgical wound|85
327|NA - No oral medications prescribed.|NA - No oral medications prescribed.|85
328|NA - Not applicable|NA - Not applicable|85
329|NA - Patient does not have a telephone.|NA - Patient does not have a telephone.|85
330|NA - Patient has ostomy for bowel elimination|NA - Patient has ostomy for bowel elimination|85
331|NA - Patient nonresponsive|NA - Patient nonresponsive|85
332|NA - Patient on prophylactic treatment|NA - Patient on prophylactic treatment|85
333|NA - Patient was not discharged from an inpatient facility [Go to M1017]|NA - Patient was not discharged from an inpatient facility [Go to M1017]|85
334|UK - Other unknown|UK - Other unknown|85
335|UK - Reason unknown|UK - Reason unknown|85
336|UK - Unknown|UK - Unknown|85
337|UK - Unknown or Not Available|UK - Unknown or Not Available|85
341|01 - Early|01 - Early|85
342|02 - Late|02 - Late|85
343|NA - Not Applicable. No case mix group defined for this assessment.|NA - Not Applicable. No case mix group defined for this assessment.|85
344|NA - No case mix group defined by this assessment.|NA - No case mix group defined by this assessment.|85
345|1 - Recent decline in mental, emotional, or behavioral status|1 - Recent decline in mental, emotional, or behavioral status|85
346|2 - Multiple hospitalizations (2 or more) in the past 12 months|2 - Multiple hospitalizations (2 or more) in the past 12 months|85
347|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|85
348|4 - Taking five or more medications|4 - Taking five or more medications|85
349|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|85
350|6 - Other|6 - Other|85
351|7 - None of the above|7 - None of the above|85
352|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond tho|85
353|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable without heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable wi|85
354|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious complications and death.|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious compl|85
355|3 - The patient has serious progressive conditions that could lead to death within a year.|3 - The patient has serious progressive conditions that could lead to death within a year.|85
356|UK - The patient+s situation is unknown or unclear.|UK - The patient+s situation is unknown or unclear.|85
357|1 - Yes [ Go to M1050 ]|1 - Yes [ Go to M1050 ]|85
358|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this influenza season. [ Go to M1050 ]|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this i|85
359|1 - Received from another health care provider (e.g., physician)|1 - Received from another health care provider (e.g., physician)|85
360|2 - Received from your agency previously during this year+s flu season|2 - Received from your agency previously during this year+s flu season|85
361|3 - Offered and declined|3 - Offered and declined|85
362|4 - Assessed and determined to have medical contraindication(s)|4 - Assessed and determined to have medical contraindication(s)|85
363|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|85
364|6 - Inability to obtain vaccine due to declared shortage|6 - Inability to obtain vaccine due to declared shortage|85
365|1 - Yes [ Go to M2005 at TRN; Go to M1230 at DC ]|1 - Yes [ Go to M2005 at TRN; Go to M1230 at DC ]|85
366|1 - Patient has received PPV in the past|1 - Patient has received PPV in the past|85
367|2 - Offered and declined|2 - Offered and declined|85
368|3 - Assessed and determined to have medical contraindication(s)|3 - Assessed and determined to have medical contraindication(s)|85
369|4 - Not indicated; patient does not meet age/condition guidelines for PPV|4 - Not indicated; patient does not meet age/condition guidelines for PPV|85
370|5 - None of the above|5 - None of the above|85
371|0 - Adequate: hears normal conversation without difficulty.|0 - Adequate: hears normal conversation without difficulty.|85
372|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to increase volume or speak distinctly.|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to in|85
373|2 - Severely Impaired: absence of useful hearing.|2 - Severely Impaired: absence of useful hearing.|85
374|UK - Unable to assess hearing.|UK - Unable to assess hearing.|85
375|0 - Understands: clear comprehension without cues or repetitions.|0 - Understands: clear comprehension without cues or repetitions.|85
376|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Requires cues at times to understand.|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Req|85
377|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequently requires cues to understand.|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequentl|85
378|3 - Rarely/Never Understands|3 - Rarely/Never Understands|85
379|UK - Unable to assess understanding.|UK - Unable to assess understanding.|85
380|0 - No standardized assessment conducted|0 - No standardized assessment conducted|85
381|1 - Yes, and it does not indicate severe pain|1 - Yes, and it does not indicate severe pain|85
382|2 - Yes, and it indicates severe pain|2 - Yes, and it indicates severe pain|85
383|0 - Patient has no pain|0 - Patient has no pain|85
384|1 - Patient has pain that does not interfere with activity or movement|1 - Patient has pain that does not interfere with activity or movement|85
385|2 - Less often than daily|2 - Less often than daily|85
386|3 - Daily, but not constantly|3 - Daily, but not constantly|85
387|4 - All of the time|4 - All of the time|85
388|0 - No assessment conducted [ Go to M1306 ]|0 - No assessment conducted [ Go to M1306 ]|85
389|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc., without use of standardized tool|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc.,|85
390|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|85
391|0 - No [ Go to M1322]|0 - No [ Go to M1322]|85
392|0 v Newly epithelialized|0 v Newly epithelialized|85
393|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|85
394|2 - Yes, patient has observable stasis ulcers ONLY|2 - Yes, patient has observable stasis ulcers ONLY|85
395|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable dressing) [Go to M1340]|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable|85
396|0 - No [ Go to M1400 ]|0 - No [ Go to M1400 ]|85
397|1 - Yes, patient has at least one (observable) surgical wound|1 - Yes, patient has at least one (observable) surgical wound|85
398|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1400 ]|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1400 ]|85
399|0 - Patient is not short of breath|0 - Patient is not short of breath|85
400|3 - Continuous Bi-level positive airway pressure|3 - Continuous Bi-level positive airway pressure|85
401|0 - No [ Go to M1732 at TRN; Go to M1600 at DC ]|0 - No [ Go to M1732 at TRN; Go to M1600 at DC ]|85
402|2 - Not assessed [Go to M1732 at TRN; Go to M1600 at DC ]|2 - Not assessed [Go to M1732 at TRN; Go to M1600 at DC ]|85
570|Z - None of the above|Z - None of the above|85
569|E - Orthotics/Prosthetics|E - Orthotics/Prosthetics|85
568|D - Walker|D - Walker|85
567|C - Mechanical lift|C - Mechanical lift|85
566|B - Motorized wheelchair and/or scooter|B - Motorized wheelchair and/or scooter|85
565|A - Manual wheelchair|A - Manual wheelchair|85
564|9 - Not Applicable|9 - Not Applicable|85
563|8 - Unknown|8 - Unknown|85
562|1 - Dependent - A helper completed the activities for the patient.|1 - Dependent - A helper completed the activities for the patient.|85
561|2 - Needed Some Help - Patient needed partial assistance from another person to complete activities.|2 - Needed Some Help - Patient needed partial assistance from another person to complete activities.|85
560|3 - Independent - Patient completed the activities by him/herself, with or without an assistive device, with no assistance from a helper.|3 - Independent - Patient completed the activities by him/herself, with or without an assistive devi|85
559|2 - Two or More|2 - Two or More|85
558|1 - One|1 - One|85
557|0 - None|0 - None|85
556|1 - Yes [Continue to J1900, Number of Falls Since SOC/ROC, whichever is more recent]|1 - Yes [Continue to J1900, Number of Falls Since SOC/ROC, whichever is more recent]|85
555|0 - No [STOP]|0 - No [STOP]|85
554|0 - No [Skip to J1800 Any falls since SOC/ROC, whichever is more recent.]|0 - No [Skip to J1800 Any falls since SOC/ROC, whichever is more recent.]|85
553|2 - Motorized|2 - Motorized|85
552|1 - Manual|1 - Manual|85
551|1 - Yes [Continue to GG0170R, Wheel 50 feet with two turns.]|1 - Yes [Continue to GG0170R, Wheel 50 feet with two turns.]|85
550|0 - No [STOP]|0 - No [Skip GG0170R]|85
549|0 - No [STOP]|0 - No [STOP]|85
548|88 - Not attempted due to medical conditions or safety concerns|88 - Not attempted due to medical conditions or safety concerns|85
547|10 - Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)|10 - Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)|85
546|09 - Not applicable - Not attempted and the patient did not perform this activity prior to the current illness,exacerbation or injury.|09 - Not applicable - Not attempted and the patient did not perform this activity prior to the curre|85
545|07 - Patient refused|07 - Patient refused|85
544|01 - Dependent - Helper does ALL of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity.|01 - Dependent - Helper does ALL of the effort. Patient does none of the effort to complete the acti|85
543|02 - Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.|02 - Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds t|85
542|03 - Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort.|03 - Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or sup|85
541|04 - Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently.|04 - Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/|85
540|05 - Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity.|05 - Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper|85
539|06 - Independent - Patient completes the activity by him/herself with no assistance from a helper.|06 - Independent - Patient completes the activity by him/herself with no assistance from a helper.|85
403|NA - Patient does not have diagnosis of heart failure [Go to M2005 at TRN; Go to M1600 at DC]|NA - Patient does not have diagnosis of heart failure [Go to M2005 at TRN; Go to M1600 at DC]|85
404|0 - No action taken|0 - No action taken|85
405|1 - Patient+s physician (or other primary care practitioner) contacted the same day|1 - Patient+s physician (or other primary care practitioner) contacted the same day|85
406|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|85
407|3 - Implement physician-ordered patient-specific established parameters for treatment|3 - Implement physician-ordered patient-specific established parameters for treatment|85
408|4 - Patient education or other clinical interventions|4 - Patient education or other clinical interventions|85
409|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequency, telehealth, etc.)|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequ|85
410|1 - Occasional stress incontinence|1 - Occasional stress incontinence|85
411|2 - During the night only|2 - During the night only|85
412|3 - During the day only|3 - During the day only|85
413|4 - During the day and night|4 - During the day and night|85
414|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|85
415|0 - Able to manage toileting hygiene and clothing management without assistance.|0 - Able to manage toileting hygiene and clothing management without assistance.|85
416|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implements are laid out for the patient.|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implemen|85
417|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|85
418|3 - Patient depends entirely upon another person to maintain toileting hygiene.|3 - Patient depends entirely upon another person to maintain toileting hygiene.|85
419|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independent|85
420|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface|85
421|0 - No multi-factor falls risk assessment conducted.|0 - No multi-factor falls risk assessment conducted.|85
422|1 - Yes, and it does not indicate a risk for falls.|1 - Yes, and it does not indicate a risk for falls.|85
423|2 - Yes, and it indicates a risk for falls.|2 - Yes, and it indicates a risk for falls.|85
424|0 - Not assessed/reviewed [ Go to M2010 ]|0 - Not assessed/reviewed [ Go to M2010 ]|85
425|1 - No problems found during review [ Go to M2010 ]|1 - No problems found during review [ Go to M2010 ]|85
426|2 - Problems found during review|2 - Problems found during review|85
427|NA - Patient is not taking any medications [ Go to M2040 ]|NA - Patient is not taking any medications [ Go to M2040 ]|85
428|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special precautions associated with all high-risk medications|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special p|85
429|NA - Patient not taking any drugs|NA - Patient not taking any drugs|85
430|2 - Able to take medication(s) at the correct times if given reminders by another person at the appropriate times|2 - Able to take medication(s) at the correct times if given reminders by another person at the appr|85
431|3 - Unable to take medication unless administered by another person.|3 - Unable to take medication unless administered by another person.|85
432|1 - At least daily|1 - At least daily|85
433|2 - Three or more times per week|2 - Three or more times per week|85
434|3 - One to two times per week|3 - One to two times per week|85
435|4 - Received, but less often than weekly|4 - Received, but less often than weekly|85
436|5 - No assistance received|5 - No assistance received|85
437|0 - No [Go to M2401]|0 - No [Go to M2401]|85
438|1 - Yes, used hospital emergency department WITHOUT hospital admission|1 - Yes, used hospital emergency department WITHOUT hospital admission|85
439|2 - Yes, used hospital emergency department WITH hospital admission|2 - Yes, used hospital emergency department WITH hospital admission|85
440|UK - Unknown [Go to M2401]|UK - Unknown [Go to M2401]|85
441|2 - Injury caused by fall|2 - Injury caused by fall|85
442|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|85
443|4 - Other respiratory problem|4 - Other respiratory problem|85
444|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|85
445|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|85
446|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|85
447|8 - Other heart disease|8 - Other heart disease|85
448|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|85
449|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|85
450|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|85
451|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|85
452|13 - Urinary tract infection|13 - Urinary tract infection|85
453|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|85
454|15 - Wound infection or deterioration|15 - Wound infection or deterioration|85
455|16 - Uncontrolled pain|16 - Uncontrolled pain|85
456|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|85
457|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|85
458|19 - Other than above reasons|19 - Other than above reasons|85
459|2 - Patient remained in the community (with formal assistive services)|2 - Patient remained in the community (with formal assistive services)|85
460|3 - Patient transferred to a noninstitutional hospice|3 - Patient transferred to a noninstitutional hospice|85
461|4 - Unknown because patient moved to a geographic location not served by this agency|4 - Unknown because patient moved to a geographic location not served by this agency|85
462|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|85
463|4 - Other respiratory problem|4 - Other respiratory problem|85
464|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|85
465|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|85
466|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|85
467|8 - Other heart disease|8 - Other heart disease|85
468|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|85
469|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|85
470|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|85
471|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|85
472|13 - Urinary tract infection|13 - Urinary tract infection|85
473|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|85
474|15 - Wound infection or deterioration|15 - Wound infection or deterioration|85
475|16 - Uncontrolled pain|16 - Uncontrolled pain|85
476|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|85
477|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|85
478|19 - Scheduled treatment or procedure|19 - Scheduled treatment or procedure|85
479|20 - Other than above reasons|20 - Other than above reasons|85
480|UK - Reason unknown [Go to M0903]|UK - Reason unknown [Go to M0903]|85
482|01 - Patient lives alone around the clock|01 - Patient lives alone around the clock|85
483|02 - Patient lives alone regular daytime|02 - Patient lives alone regular daytime|85
484|03 - Patient lives alone regular nighttime|03 - Patient lives alone regular nighttime|85
485|04 - Patient lives alone occassional/short term assistance|04 - Patient lives alone occassional/short term assistance|85
486|05 - Patient lives alone no assisstance available|05 - Patient lives alone no assisstance available|85
487|06 - Patient lives with other person(s) in the home around the clock|06 - Patient lives with other person(s) in the home around the clock|85
488|07 - Patient lives with other person(s) in the home regular daytime|07 - Patient lives with other person(s) in the home regular daytime|85
489|08 - Patient lives with other person(s) in the home regular nighttime|08 - Patient lives with other person(s) in the home regular nighttime|85
490|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|85
491|10 - Patient lives with other person(s) in the home no assistance available|10 - Patient lives with other person(s) in the home no assistance available|85
492|1 - Was present at the most recent SOC/ROC assessment|1 - Was present at the most recent SOC/ROC assessment|85
493|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|85
494|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|85
495|0 - Newly epithelialized|0 - Newly epithelialized|85
496|0 - No [ Go to M1340 ]|0 - No [ Go to M1340 ]|85
498|0 - Independent|0 - Independent|85
499|1 - Needed Some Help|1 - Needed Some Help|85
500|2 - Dependent|2 - Dependent|85
502|0 - No assistance needed in this area|0 - No assistance needed in this area|85
503|1 - Caregiver(s) currently provide assistance|1 - Caregiver(s) currently provide assistance|85
504|2 - Caregiver(s) need training/ supportive services to provide assistance|2 - Caregiver(s) need training/ supportive services to provide assistance|85
505|3 - Caregiver(s) not likely to provide assistance|3 - Caregiver(s) not likely to provide assistance|85
506|4 - Unclear if Caregiver(s) will provide assistance|4 - Unclear if Caregiver(s) will provide assistance|85
507|5 - Assistance needed, but no Caregiver(s) available|5 - Assistance needed, but no Caregiver(s) available|85
508|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will use standardized clinical guidelines accessible for all care providers to reference|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will|85
510|NA - Patient is not assessed to be at risk for falls|NA - Patient is not assessed to be at risk for falls|85
511|NA - Patient has no diagnosis or symptoms of depression|NA - Patient has no diagnosis or symptoms of depression|85
512|NA - No pain identified|NA - No pain identified|85
513|NA - Patient is not assessed to be at risk for pressure ulcers|NA - Patient is not assessed to be at risk for pressure ulcers|85
514|NA - Patient has no pressure ulcers with need for moist wound healing|NA - Patient has no pressure ulcers with need for moist wound healing|85
515|1 - Long-term nursing facility (NF)|1 - Long-term nursing facility (NF)|85
516|2 - Skilled nursing facility (SNF / TCU)|2 - Skilled nursing facility (SNF / TCU)|85
517|3 - Short stay acute hospital (IPP S)|3 - Short stay acute hospital (IPP S)|85
518|4 - Long-term care hospital (LTCH)|4 - Long-term care hospital (LTCH)|85
519|5 - Inpatient rehabilitation hospital or unit (IRF)|5 - Inpatient rehabilitation hospital or unit (IRF)|85
520|6 - Psychiatric hospital or unit|6 - Psychiatric hospital or unit|85
521|7 - Other|7 - Other|85
522|NA - Patient was not discharged from an inpatient facility [Go to M1017]|NA - Patient was not discharged from an inpatient facility [Go to M1017]|85
523|6 - Unable to participate effectively in bathing and is bathed totally by another person|6 - Unable to participate effectively in bathing and is bathed totally by another person|85
524|4 - Chairfast, unable to ambulate but is able to wheel self independently.|4 - Chairfast, unable to ambulate but is able to wheel self independently.|85
525|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask patient: "Over the last two weeks, how often have you been bothered by any of the following problems")   *Copyright+ Pfizer Inc. All rights reserved. Reproduced with permission.|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask|85
526|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluation for depression.|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluat|85
527|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet criteria for further evaluation for depression.|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet|85
528|0 - Not at all  0 - 1 day|0 - Not at all  0 - 1 day|85
529|1 - Several days  2 - 6 days|1 - Several days  2 - 6 days|85
530|2 - More than half of the days  7 - 11 days|2 - More than half of the days  7 - 11 days|85
531|3 - Nearly every day  12 - 14 days|3 - Nearly every day  12 - 14 days|85
532|NA - N/A  Unable to respond|NA - N/A  Unable to respond|85
533|2 - Able to take medication(s) at the correct times if given reminders by another person based on the frequency of the injection|2 - Able to take medication(s) at the correct times if given reminders by another person based on th|85
534|3 - Unable to take injectable medication unless administered by another person.|3 - Unable to take injectable medication unless administered by another person.|85
536|UK - Inpatient Discharge Date Unknown|UK - Inpatient Discharge Date Unknown|85
537|NA - Inpatient stay within last 14 days Not Applicable|NA - Inpatient stay within last 14 days Not Applicable|85
2|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; OR (b) Is physically, cognitively, and mentally able to prepare light meals on a regular basis but has not routinely performed light meal preparation in the past (i.e., prior to this home care admission).|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; O|86
3|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and mentally able to perform all housekeeping tasks .|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and menta|86
4|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and mentally able to do laundry and access facilities.|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and menta|86
5|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying packages OR b) Physically, cognitively, and mentally able to take care of shopping, but has not done shopping in the past (i.e., prior to this home care admission).|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying|86
6|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|86
7|0 - Able to dial numbers and answer calls appropriately and as desired.|0 - Able to dial numbers and answer calls appropriately and as desired.|86
8|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body without assistance.|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body|86
9|0 - Able to get to and from the toilet and transfer independently with or without a device.|0 - Able to get to and from the toilet and transfer independently with or without a device.|86
10|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|86
11|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible public bus.|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible p|86
12|0 - Able to independently feed self.|0 - Able to independently feed self.|86
13|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|86
14|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct times.|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct ti|86
15|0 - Able to independently transfer.|0 - Able to independently transfer.|86
16|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without rail|86
17|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings|86
18|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|86
19|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions independently.|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions indep|86
20|0 - Asymptomatic, no treatment needed at this time|0 - Asymptomatic, no treatment needed at this time|86
21|0 - Caregiver manages all tasks related to equipment completely independently.|0 - Caregiver manages all tasks related to equipment completely independently.|86
22|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations with no observable impairment.|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations w|86
23|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|86
24|0 - Life expectancy is greater than 6 months|0 - Life expectancy is greater than 6 months|86
25|0 - Never|0 - Never|86
26|0 - Patient is not short of breath|0 - Patient is not short of breath|86
27|0 - No|0 - No|86
28|0 - No emergent care services|0 - No emergent care services|86
29|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [Goto 1620]|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [Goto 1620]|86
30|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and extended or abstract conversation.|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and exte|86
31|0 - No one person|0 - No one person|86
32|0 - None of the time|0 - None of the time|86
33|0 - None, no charge for current services|0 - None, no charge for current services|86
34|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|86
35|0 - Patient does NOT have an ostomy for bowel elimination.|0 - Patient does NOT have an ostomy for bowel elimination.|86
36|0 - Patient has no pain|0 - Patient has no pain|86
37|0 - Patient manages all tasks related to equipment completely independently.|0 - Patient manages all tasks related to equipment completely independently.|86
38|0 - Poor:  little or no recovery is expected and/or further decline is imminent|0 - Poor:  little or no recovery is expected and/or further decline is imminent|86
39|0 - Timed-voiding defers incontinence|0 - Timed-voiding defers incontinence|86
40|0 - Very rarely or never has bowel incontinence|0 - Very rarely or never has bowel incontinence|86
41|0 - Zero|0 - Zero|86
42|00 - No|00 - No|86
43|01 - Yes|01 - Yes|86
44|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or mental limitations, needs assistance with heavy laundry.|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or|86
45|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the patient.|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the|86
46|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|86
47|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or supervision from another person OR c) a liquid, pureed or ground meat diet.|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or su|86
48|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|86
49|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|86
50|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independently.|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independe|86
51|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only when assisted or accompanied by another person.|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only w|86
52|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepa|86
53|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance by another person OR b) given daily reminders.|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance b|86
54|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advan|86
55|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advan|86
56|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for the deaf) and call essential numbers.|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for t|86
57|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|86
58|1 - American Indian or Alaska Native|1 - American Indian or Alaska Native|86
59|1 - Depressed mood (e.g., feeling sad, tearful)|1 - Depressed mood (e.g., feeling sad, tearful)|86
60|1 - During the night only|1 - During the night only|86
61|1 - Fully granulating|1 - Fully granulating|86
62|1 - Good/Fair:  partial to full recovery is expected|1 - Good/Fair:  partial to full recovery is expected|86
63|1 - Good:  marked improvement in functional status is expected|1 - Good:  marked improvement in functional status is expected|86
64|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|86
65|1 - Smoking|1 - Smoking|86
66|1 - Hospital|1 - Hospital|86
67|1 - Hospital emergency room (includes 23-hour holding)|1 - Hospital emergency room (includes 23-hour holding)|86
68|1 - Hospitalization for EMERGENT (unscheduled) care|1 - Hospitalization for EMERGENT (unscheduled) care|86
69|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepared solutions), patient is able to manage all other aspects of equipment.|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepar|86
70|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|86
71|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|86
72|1 - In new or complex situations only|1 - In new or complex situations only|86
73|1 - Intravenous or infusion therapy (excludes TPN)|1 - Intravenous or infusion therapy (excludes TPN)|86
74|1 - Less often than daily|1 - Less often than daily|86
75|1 - Less than once a month|1 - Less than once a month|86
76|1 - Less than once weekly|1 - Less than once weekly|86
77|1 - Life expectancy is 6 months or fewer|1 - Life expectancy is 6 months or fewer|86
78|1 - Lives alone|1 - Lives alone|86
79|1 - Male|1 - Male|86
80|1 - Medicare (traditional fee-for-service)|1 - Medicare (traditional fee-for-service)|86
81|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of past 24 hours, significant memory loss so that supervision is required|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of pas|86
82|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors in word choice, grammar or speech intelligibility, needs minimal prompting or assistance).|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors i|86
83|1 - No assistance or services received|1 - No assistance or services received|86
84|1 - One|1 - One|86
85|1 - Oxygen (intermittent or continuous)|1 - Oxygen (intermittent or continuous)|86
86|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, and the surrounding layout, can count fingers at arm's length.|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, a|86
87|1 - Patient is incontinent|1 - Patient is incontinent|86
88|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|86
89|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical or treatment regimen.|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical|86
90|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient/couple/significant other)|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient|86
91|1 - Relatives, friends, or neighbors living outside the home|1 - Relatives, friends, or neighbors living outside the home|86
92|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions.|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions|86
93|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independentl|86
94|1 - Several times during day and night|1 - Several times during day and night|86
95|1 - Spouse or significant other|1 - Spouse or significant other|86
96|1 - Stage 1|1 - Stage 1|86
97|1 - Start of care - further visits planned|1 - Start of care - further visits planned|86
98|1 - Symptoms well controlled with current therapy|1 - Symptoms well controlled with current therapy|86
99|1 - Therapy services|1 - Therapy services|86
100|1 - Able to transfer with minimal human assistance or with use of an assistive device.|1 - Able to transfer with minimal human assistance or with use of an assistive device.|86
101|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitations.|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitatio|86
102|1 - Urinary incontinence|1 - Urinary incontinence|86
103|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and transfer.|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and|86
104|1 - When walking more than 20 feet, climbing stairs|1 - When walking more than 20 feet, climbing stairs|86
105|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary conversation. May need occasional repetition, extra time, or louder voice.|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary c|86
106|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting in and out of tub/shower|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting|86
107|1 - Yes|1 - Yes|86
108|1-RN|1-RN|86
109|10 - Discharge from agency - no visits completed after start/resumption of care assessment|10 - Discharge from agency - no visits completed after start/resumption of care assessment|86
110|10 - Scheduled surgical procedure|10 - Scheduled surgical procedure|86
111|10 - Self-pay|10 - Self-pay|86
112|11 - Other|11 - Other|86
113|11 - Urinary tract infection|11 - Urinary tract infection|86
114|12 - IV catheter-related infection|12 - IV catheter-related infection|86
115|13 - Deep vein thrombosis, pulmonary embolus|13 - Deep vein thrombosis, pulmonary embolus|86
116|14 - Uncontrolled pain|14 - Uncontrolled pain|86
117|15 - Psychotic episode|15 - Psychotic episode|86
118|16 - Other than above reasons|16 - Other than above reasons|86
119|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing calls.|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing|86
120|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another person.|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another pers|86
121|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface a|86
122|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for intermittent supervision or encouragement or reminders, OR (b) to get in and out of the shower or tub, OR (c) for washing difficult to reach areas.|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for inter|86
123|2 - Asian|2 - Asian|86
124|2 - Caregiver requires considerable assistance from another person to manage equipment, but independently completes significant portions of task.|2 - Caregiver requires considerable assistance from another person to manage equipment, but independ|86
125|2 - Daily, but not constantly|2 - Daily, but not constantly|86
126|2 - Daughter or son|2 - Daughter or son|86
127|2 - Doctor's office emergency visit/house call|2 - Doctor's office emergency visit/house call|86
128|2 - During the day and night|2 - During the day and night|86
129|2 - Early/partial granulation|2 - Early/partial granulation|86
130|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors in word choice, organization or speech intelligibility). Speaks in phrases or short sentences.|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors|86
131|2 - Family member's residence|2 - Family member's residence|86
132|2 - Female|2 - Female|86
133|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conversation, needs frequent prompting or assistance.|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conver|86
134|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|86
135|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|86
136|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately stop activities, jeopardizes safety through actions|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately st|86
137|2 - Indwelling/suprapubic catheter|2 - Indwelling/suprapubic catheter|86
138|2 - Injury caused by fall|2 - Injury caused by fall|86
139|2 - Medicare (HMO/managed care/Advantage plan)|2 - Medicare (HMO/managed care/Advantage plan)|86
140|2 - Nausea, dehydration, malnutrition, constipation, impaction|2 - Nausea, dehydration, malnutrition, constipation, impaction|86
141|2 - Obesity|2 - Obesity|86
142|2 - On awakening or at night only|2 - On awakening or at night only|86
143|2 - Once a month|2 - Once a month|86
144|2 - One to three times weekly|2 - One to three times weekly|86
145|2 - Parenteral nutrition (TPN or lipids)|2 - Parenteral nutrition (TPN or lipids)|86
146|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic) [ Go to M1620]|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic) [ Go|86
147|2 - Patient requires considerable assistance from another person to manage equipment, but independently completes portions of the task.|2 - Patient requires considerable assistance from another person to manage equipment, but independen|86
148|2 - Patient transferred to a noninstitutional hospice|2 - Patient transferred to a noninstitutional hospice|86
149|2 - Person residing in the home (EXCLUDING paid help)|2 - Person residing in the home (EXCLUDING paid help)|86
150|2 - Rehabilitation facility|2 - Rehabilitation facility|86
151|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifting of attention) or consistently requires low stimulus environment due to distractibility.|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifti|86
152|2 - Respite care|2 - Respite care|86
153|2 - Sense of failure or self reproach|2 - Sense of failure or self reproach|86
154|2 - Several times during day|2 - Several times during day|86
155|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonresponsive.|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonrespons|86
156|2 - Someone must assist the patient to groom self.|2 - Someone must assist the patient to groom self.|86
157|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|86
158|2 - Someone must help the patient put on upper body clothing.|2 - Someone must help the patient put on upper body clothing.|86
159|2 - Stage 2|2 - Stage 2|86
160|2 - Start of care - no further visits planned|2 - Start of care - no further visits planned|86
161|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitoring|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitori|86
162|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment regimen.|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment re|86
163|2 - Two|2 - Two|86
164|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistance due to cognitive or mental limitation.|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistanc|86
165|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|86
166|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assistance).|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assis|86
167|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home delivery.|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home deli|86
168|2 - Unable to prepare any light meals or reheat any delivered meals.|2 - Unable to prepare any light meals or reheat any delivered meals.|86
169|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|86
170|2 - UNABLE to take injectable medications unless administered by someone else.|2 - UNABLE to take injectable medications unless administered by someone else.|86
171|2 - UNABLE to take medication unless administered by someone else.|2 - UNABLE to take medication unless administered by someone else.|86
172|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|86
173|2 - Ventilator (continually or at night)|2 - Ventilator (continually or at night)|86
174|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less than 20 feet)|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less th|86
175|2 - With spouse or significant other|2 - With spouse or significant other|86
176|2 - Yes, assistance or services provided by family or friends|2 - Yes, assistance or services provided by family or friends|86
177|2-PT|2-PT|86
178|3 - Able to answer the telephone only some of the time or is able to carry on only a limited conversation.|3 - Able to answer the telephone only some of the time or is able to carry on only a limited convers|86
179|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube or gastrostomy.|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube|86
180|3 - Alcohol dependency|3 - Alcohol dependency|86
181|3 - All of the time|3 - All of the time|86
182|3 - Black or African-American|3 - Black or African-American|86
183|3 - Boarding home or rented room|3 - Boarding home or rented room|86
184|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment, clean/store/dispose of equipment or supplies).|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment,|86
185|3 -Able to walk only with the supervision or assistance of another person at all times.|3 -Able to walk only with the supervision or assistance of another person at all times.|86
186|3 - Continuous / Bi-level positive airway pressure|3 - Continuous / Bi-level positive airway pressure|86
187|3 - During the day and evening, but not constantly|3 - During the day and evening, but not constantly|86
188|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the alimentary canal)|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the|86
189|3 - Environmental support (e.g., housing, home maintenance)|3 - Environmental support (e.g., housing, home maintenance)|86
190|3 - Four to six times weekly|3 - Four to six times weekly|86
191|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessing by listener.  Speech limited to single words or short phrases.|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessin|86
192|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires multiple repetitions, restatements, demonstrations, additional time.|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires m|86
193|3 - Hopelessness|3 - Hopelessness|86
194|3 - Hospice care|3 - Hospice care|86
195|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|86
196|3 - Injury caused by fall or accident at home|3 - Injury caused by fall or accident at home|86
197|3 - Intractable pain|3 - Intractable pain|86
198|3 - Medicaid (traditional fee-for-service)|3 - Medicaid (traditional fee-for-service)|86
199|3 - Needs someone to do all shopping and errands.|3 - Needs someone to do all shopping and errands.|86
200|3 - Not healing|3 - Not healing|86
201|3 - Nursing home|3 - Nursing home|86
202|3 - Once daily|3 - Once daily|86
203|3 - Other family member|3 - Other family member|86
204|3 - Outpatient department/clinic emergency (includes urgicenter sites)|3 - Outpatient department/clinic emergency (includes urgicenter sites)|86
205|3 - Paid help|3 - Paid help|86
206|3 - Able to participate in bathing self in shower or tub, but requires presence of another person throughout the bath for assistance or supervision.|3 - Able to participate in bathing self in shower or tub, but requires presence of another person th|86
207|3 - Patient depends entirely upon another person to dress lower body.|3 - Patient depends entirely upon another person to dress lower body.|86
208|3 - Patient depends entirely upon another person to dress the upper body.|3 - Patient depends entirely upon another person to dress the upper body.|86
209|3 - Patient depends entirely upon someone else for grooming needs.|3 - Patient depends entirely upon someone else for grooming needs.|86
210|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone else to manage the equipment.|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone|86
211|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable to shift attention and recall directions more than half the time.|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable|86
212|3 - Respiratory problems (SOB, infection, obstruction)|3 - Respiratory problems (SOB, infection, obstruction)|86
213|3 - Resumption of care (after inpatient stay)|3 - Resumption of care (after inpatient stay)|86
214|3 - Several times each month|3 - Several times each month|86
215|3 - Skilled Nursing Facility|3 - Skilled Nursing Facility|86
216|3 - Stage 3|3 - Stage 3|86
217|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|86
218|3 - Three|3 - Three|86
219|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person throughout the process.|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person through|86
220|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal independently.|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal indep|86
221|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person.|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person|86
222|3 - Unknown because patient moved to a geographic location not served by this agency|3 - Unknown because patient moved to a geographic location not served by this agency|86
223|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|86
224|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|86
225|3 - With other family member|3 - With other family member|86
226|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home health services, homemaker assistance, transportation assistance, assisted living, board and care)|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home h|86
227|3-SLP/ST|3-SLP/ST|86
228|4 - At rest (during day or night)|4 - At rest (during day or night)|86
229|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|86
230|4 - Board and care or assisted living facility|4 - Board and care or assisted living facility|86
231|4 - Caregiver is completely dependent on someone else to manage all equipment.|4 - Caregiver is completely dependent on someone else to manage all equipment.|86
232|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|86
233|4 - Constantly|4 - Constantly|86
234|4 - Drug dependency|4 - Drug dependency|86
235|4 - Four or more|4 - Four or more|86
236|4 - Friend or neighbor or community or church member|4 - Friend or neighbor or community or church member|86
237|4 - Hispanic or Latino|4 - Hispanic or Latino|86
238|4 - Hospice|4 - Hospice|86
239|4 - Impaired decision-making|4 - Impaired decision-making|86
240|4 - Is totally dependent in toileting.|4 - Is totally dependent in toileting.|86
241|4 - Medicaid (HMO/managed care)|4 - Medicaid (HMO/managed care)|86
242|4 - None of the above|4 - None of the above|86
243|4 - Nursing home|4 - Nursing home|86
244|4 - On a daily basis|4 - On a daily basis|86
245|4 - Patient is completely dependent on someone else to manage all equipment.|4 - Patient is completely dependent on someone else to manage all equipment.|86
246|4 - Permanent placement|4 - Permanent placement|86
247|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, punches, dangerous maneuvers w/ wheelchair or other objects)|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, pu|86
248|4 - Psychosocial support (e.g., socialization, companionship, recreation)|4 - Psychosocial support (e.g., socialization, companionship, recreation)|86
249|4 - Recertification (follow-up) reassessment|4 - Recertification (follow-up) reassessment|86
250|4 - Recurrent thoughts of death|4 - Recurrent thoughts of death|86
251|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruction)|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruc|86
252|4 - Several times a week|4 - Several times a week|86
253|4 - Stage 4|4 - Stage 4|86
254|4 - Symptoms poorly controlled, history of rehospitalizations|4 - Symptoms poorly controlled, history of rehospitalizations|86
255|4 - Three or more times per week|4 - Three or more times per week|86
256|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetative state, or delirium.|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetati|86
257|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|86
258|4 - Unable to effectively participate in any housekeeping tasks.|4 - Unable to effectively participate in any housekeeping tasks.|86
259|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or unresponsive (e.g., speech is nonsensical or unintelligible).|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or u|86
260|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonresponsive.|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonr|86
261|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostomy.|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostom|86
262|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of devices at the sink, in chair, or on commode|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of|86
263|4 - With a friend|4 - With a friend|86
264|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|86
265|4-OT|4-OT|86
266|5 - Advocates or facilitates patient's participation in appropriate medical care|5 - Advocates or facilitates patient's participation in appropriate medical care|86
267|5 - At least daily|5 - At least daily|86
268|6 - Bedfast, unable to ambulate or be up in a chair.|6 - Bedfast, unable to ambulate or be up in a chair.|86
269|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|86
270|5 - Disruptive or socially inappropriate behavior|5 - Disruptive or socially inappropriate behavior|86
271|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|86
272|5 - Hypo/Hyperglycemia, diabetes out of control|5 - Hypo/Hyperglycemia, diabetes out of control|86
273|5 - More often than once daily|5 - More often than once daily|86
274|5 - Native Hawaiian or Pacific Islander|5 - Native Hawaiian or Pacific Islander|86
275|5 - None of the above|5 - None of the above|86
276|5 - One to two times per week|5 - One to two times per week|86
277|5 - Other|5 - Other|86
278|5 - Other follow-up|5 - Other follow-up|86
279|5 - Paid help|5 - Paid help|86
280|5 - Patient nonresponsive or unable to speak.|5 - Patient nonresponsive or unable to speak.|86
281|5 - Thoughts of suicide|5 - Thoughts of suicide|86
282|5 - Totally unable to use the telephone.|5 - Totally unable to use the telephone.|86
283|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|86
284|5 - Unable to take in nutrients orally or by tube feeding.|5 - Unable to take in nutrients orally or by tube feeding.|86
285|5 - Unsafe for care at home|5 - Unsafe for care at home|86
286|5 - With paid help (other than home care agency staff)|5 - With paid help (other than home care agency staff)|86
287|5 - Workers' compensation|5 - Workers' compensation|86
288|5 - Wound infection, deteriorating wound status, new lesion/ulcer|5 - Wound infection, deteriorating wound status, new lesion/ulcer|86
289|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|86
290|6 - Delusional, hallucinatory, or paranoid behavior|6 - Delusional, hallucinatory, or paranoid behavior|86
291|6 - Financial agent, power of attorney, or conservator of finance|6 - Financial agent, power of attorney, or conservator of finance|86
292|6 - GI bleeding, obstruction|6 - GI bleeding, obstruction|86
293|6 - Less often than weekly|6 - Less often than weekly|86
294|6 - Memory loss to the extent that supervision required|6 - Memory loss to the extent that supervision required|86
295|6 - None of the above feelings observed or reported|6 - None of the above feelings observed or reported|86
296|6 - Other|6 - Other|86
297|6 - Title programs (e.g., Title III, V, or XX)|6 - Title programs (e.g., Title III, V, or XX)|86
298|6 - Transferred to an inpatient facility - patient not discharged from agency|6 - Transferred to an inpatient facility - patient not discharged from agency|86
299|6 - White|6 - White|86
300|6 - With other than above|6 - With other than above|86
301|7 - Exacerbation of CHF, fluid overload, heart failure|7 - Exacerbation of CHF, fluid overload, heart failure|86
302|7 - Health care agent, conservator of person, or medical power of attorney|7 - Health care agent, conservator of person, or medical power of attorney|86
303|7 - Hypo/Hyperglycemia, diabetes out of control|7 - Hypo/Hyperglycemia, diabetes out of control|86
304|7 - None of the above|7 - None of the above|86
305|7 - None of the above behaviors demonstrated|7 - None of the above behaviors demonstrated|86
306|7 - Other government (e.g., TriCare, VA, etc.)|7 - Other government (e.g., TriCare, VA, etc.)|86
307|7 - Transferred to an inpatient facility - patient discharged from agency|7 - Transferred to an inpatient facility - patient discharged from agency|86
308|8 - Death at home|8 - Death at home|86
309|8 - GI bleeding, obstruction|8 - GI bleeding, obstruction|86
310|8 - Myocardial infarction, stroke|8 - Myocardial infarction, stroke|86
311|8 - Private insurance|8 - Private insurance|86
312|9 - Chemotherapy|9 - Chemotherapy|86
313|9 - Discharge from agency|9 - Discharge from agency|86
314|9 - Other than above reasons|9 - Other than above reasons|86
315|9 - Private HMO/managed care|9 - Private HMO/managed care|86
316|NA - No caregiver|NA - No caregiver|86
317|NA - No equipment of this type used in care.|NA - No equipment of this type used in care.|86
318|NA - No inhalant/mist medications prescribed.|NA - No inhalant/mist medications prescribed.|86
319|NA - No injectable medications prescribed.|NA - No injectable medications prescribed.|86
320|NA - No inpatient facility admission|NA - No inpatient facility admission|86
321|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|86
322|NA - No Medicaid|NA - No Medicaid|86
323|NA - No Medicare|NA - No Medicare|86
324|NA - No observable pressure ulcer or unhealed pressure ulcer|NA - No observable pressure ulcer or unhealed pressure ulcer|86
325|NA - No observable stasis ulcer|NA - No observable stasis ulcer|86
326|NA - No observable surgical wound|NA - No observable surgical wound|86
327|NA - No oral medications prescribed.|NA - No oral medications prescribed.|86
328|NA - Not applicable|NA - Not applicable|86
329|NA - Patient does not have a telephone.|NA - Patient does not have a telephone.|86
330|NA - Patient has ostomy for bowel elimination|NA - Patient has ostomy for bowel elimination|86
331|NA - Patient nonresponsive|NA - Patient nonresponsive|86
332|NA - Patient on prophylactic treatment|NA - Patient on prophylactic treatment|86
333|NA - Patient was not discharged from an inpatient facility [Go to M1017]|NA - Patient was not discharged from an inpatient facility [Go to M1017]|86
334|UK - Other unknown|UK - Other unknown|86
335|UK - Reason unknown|UK - Reason unknown|86
336|UK - Unknown|UK - Unknown|86
337|UK - Unknown or Not Available|UK - Unknown or Not Available|86
341|01 - Early|01 - Early|86
342|02 - Late|02 - Late|86
343|NA - Not Applicable. No case mix group defined for this assessment.|NA - Not Applicable. No case mix group defined for this assessment.|86
344|NA - No case mix group defined by this assessment.|NA - No case mix group defined by this assessment.|86
345|1 - Recent decline in mental, emotional, or behavioral status|1 - Recent decline in mental, emotional, or behavioral status|86
346|2 - Multiple hospitalizations (2 or more) in the past 12 months|2 - Multiple hospitalizations (2 or more) in the past 12 months|86
347|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|86
348|4 - Taking five or more medications|4 - Taking five or more medications|86
349|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|86
350|6 - Other|6 - Other|86
351|7 - None of the above|7 - None of the above|86
352|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond tho|86
353|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable without heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable wi|86
354|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious complications and death.|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious compl|86
355|3 - The patient has serious progressive conditions that could lead to death within a year.|3 - The patient has serious progressive conditions that could lead to death within a year.|86
356|UK - The patient+s situation is unknown or unclear.|UK - The patient+s situation is unknown or unclear.|86
357|0 - No [ Go to M1051 ]|0 - No [ Go to M1051 ]|86
358|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this influenza season. [ Go to M1050 ]|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this i|86
359|1 - Received from another health care provider (e.g., physician)|1 - Received from another health care provider (e.g., physician)|86
360|2 - Received from your agency previously during this year+s flu season|2 - Received from your agency previously during this year+s flu season|86
361|3 - Offered and declined|3 - Offered and declined|86
362|4 - Assessed and determined to have medical contraindication(s)|4 - Assessed and determined to have medical contraindication(s)|86
363|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|86
364|6 - Inability to obtain vaccine due to declared shortage|6 - Inability to obtain vaccine due to declared shortage|86
365|1 - Yes [ Go to M2005 at TRN; Go to M1230 at DC ]|1 - Yes [ Go to M2005 at TRN; Go to M1230 at DC ]|86
366|1 - Patient has received PPV in the past|1 - Patient has received PPV in the past|86
367|2 - Offered and declined|2 - Offered and declined|86
368|3 - Assessed and determined to have medical contraindication(s)|3 - Assessed and determined to have medical contraindication(s)|86
369|4 - Not indicated; patient does not meet age/condition guidelines for PPV|4 - Not indicated; patient does not meet age/condition guidelines for PPV|86
370|5 - None of the above|5 - None of the above|86
371|0 - Adequate: hears normal conversation without difficulty.|0 - Adequate: hears normal conversation without difficulty.|86
372|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to increase volume or speak distinctly.|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to in|86
373|2 - Severely Impaired: absence of useful hearing.|2 - Severely Impaired: absence of useful hearing.|86
374|UK - Unable to assess hearing.|UK - Unable to assess hearing.|86
375|0 - Understands: clear comprehension without cues or repetitions.|0 - Understands: clear comprehension without cues or repetitions.|86
376|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Requires cues at times to understand.|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Req|86
377|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequently requires cues to understand.|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequentl|86
378|3 - Rarely/Never Understands|3 - Rarely/Never Understands|86
379|UK - Unable to assess understanding.|UK - Unable to assess understanding.|86
380|0 - No standardized assessment conducted|0 - No standardized assessment conducted|86
381|1 - Yes, and it does not indicate severe pain|1 - Yes, and it does not indicate severe pain|86
382|2 - Yes, and it indicates severe pain|2 - Yes, and it indicates severe pain|86
383|0 - Patient has no pain|0 - Patient has no pain|86
384|1 - Patient has pain that does not interfere with activity or movement|1 - Patient has pain that does not interfere with activity or movement|86
385|2 - Less often than daily|2 - Less often than daily|86
386|3 - Daily, but not constantly|3 - Daily, but not constantly|86
387|4 - All of the time|4 - All of the time|86
388|0 - No assessment conducted [ Go to M1306 ]|0 - No assessment conducted [ Go to M1306 ]|86
389|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc., without use of standardized tool|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc.,|86
390|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|86
391|0 - No [ Go to M1322]|0 - No [ Go to M1322]|86
392|0 v Newly epithelialized|0 v Newly epithelialized|86
393|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|86
394|2 - Yes, patient has observable stasis ulcers ONLY|2 - Yes, patient has observable stasis ulcers ONLY|86
395|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable dressing) [Go to M1340]|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable|86
396|0 - No [ Go to M1350 ]|0 - No [ Go to M1350 ]|86
397|1 - Yes, patient has at least one (observable) surgical wound|1 - Yes, patient has at least one (observable) surgical wound|86
398|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1350 ]|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1350 ]|86
399|0 - Patient is not short of breath|0 - Patient is not short of breath|86
400|3 - Continuous Bi-level positive airway pressure|3 - Continuous Bi-level positive airway pressure|86
401|0 - No [ Go to M2005 at TRN; Go to M1600 at DC ]|0 - No [ Go to M2005 at TRN; Go to M1600 at DC ]|86
402|2 - Not assessed [Go to M2005 at TRN; Go to M1600 at DC ]|2 - Not assessed [Go to M2005 at TRN; Go to M1600 at DC ]|86
403|NA - Patient does not have diagnosis of heart failure [Go to M2005 at TRN; Go to M1600 at DC]|NA - Patient does not have diagnosis of heart failure [Go to M2005 at TRN; Go to M1600 at DC]|86
404|0 - No action taken|0 - No action taken|86
405|1 - Patient+s physician (or other primary care practitioner) contacted the same day|1 - Patient+s physician (or other primary care practitioner) contacted the same day|86
406|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|86
407|3 - Implement physician-ordered patient-specific established parameters for treatment|3 - Implement physician-ordered patient-specific established parameters for treatment|86
408|4 - Patient education or other clinical interventions|4 - Patient education or other clinical interventions|86
409|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequency, telehealth, etc.)|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequ|86
410|1 - Occasional stress incontinence|1 - Occasional stress incontinence|86
411|2 - During the night only|2 - During the night only|86
412|3 - During the day only|3 - During the day only|86
413|4 - During the day and night|4 - During the day and night|86
414|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|86
415|0 - Able to manage toileting hygiene and clothing management without assistance.|0 - Able to manage toileting hygiene and clothing management without assistance.|86
416|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implements are laid out for the patient.|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implemen|86
417|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|86
418|3 - Patient depends entirely upon another person to maintain toileting hygiene.|3 - Patient depends entirely upon another person to maintain toileting hygiene.|86
419|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independent|86
420|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface|86
421|0 - No multi-factor falls risk assessment conducted.|0 - No multi-factor falls risk assessment conducted.|86
422|1 - Yes, and it does not indicate a risk for falls.|1 - Yes, and it does not indicate a risk for falls.|86
423|2 - Yes, and it indicates a risk for falls.|2 - Yes, and it indicates a risk for falls.|86
424|0 - Not assessed/reviewed [ Go to M2010 ]|0 - Not assessed/reviewed [ Go to M2010 ]|86
425|1 - No problems found during review [ Go to M2010 ]|1 - No problems found during review [ Go to M2010 ]|86
426|2 - Problems found during review|2 - Problems found during review|86
427|NA - Patient is not taking any medications [ Go to M2040 ]|NA - Patient is not taking any medications [ Go to M2040 ]|86
428|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special precautions associated with all high-risk medications|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special p|86
429|NA - Patient not taking any drugs|NA - Patient not taking any drugs|86
430|2 - Able to take medication(s) at the correct times if given reminders by another person at the appropriate times|2 - Able to take medication(s) at the correct times if given reminders by another person at the appr|86
431|3 - Unable to take medication unless administered by another person.|3 - Unable to take medication unless administered by another person.|86
432|1 - At least daily|1 - At least daily|86
433|2 - Three or more times per week|2 - Three or more times per week|86
434|3 - One to two times per week|3 - One to two times per week|86
435|4 - Received, but less often than weekly|4 - Received, but less often than weekly|86
436|5 - No assistance received|5 - No assistance received|86
437|0 - No [Go to M2401]|0 - No [Go to M2401]|86
438|1 - Yes, used hospital emergency department WITHOUT hospital admission|1 - Yes, used hospital emergency department WITHOUT hospital admission|86
439|2 - Yes, used hospital emergency department WITH hospital admission|2 - Yes, used hospital emergency department WITH hospital admission|86
440|UK - Unknown [Go to M2401]|UK - Unknown [Go to M2401]|86
441|2 - Injury caused by fall|2 - Injury caused by fall|86
442|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|86
443|4 - Other respiratory problem|4 - Other respiratory problem|86
444|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|86
445|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|86
446|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|86
447|8 - Other heart disease|8 - Other heart disease|86
448|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|86
449|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|86
450|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|86
451|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|86
452|13 - Urinary tract infection|13 - Urinary tract infection|86
453|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|86
454|15 - Wound infection or deterioration|15 - Wound infection or deterioration|86
455|16 - Uncontrolled pain|16 - Uncontrolled pain|86
456|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|86
457|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|86
458|19 - Other than above reasons|19 - Other than above reasons|86
459|2 - Patient remained in the community (with formal assistive services)|2 - Patient remained in the community (with formal assistive services)|86
460|3 - Patient transferred to a noninstitutional hospice|3 - Patient transferred to a noninstitutional hospice|86
461|4 - Unknown because patient moved to a geographic location not served by this agency|4 - Unknown because patient moved to a geographic location not served by this agency|86
462|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|86
463|4 - Other respiratory problem|4 - Other respiratory problem|86
464|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|86
465|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|86
466|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|86
467|8 - Other heart disease|8 - Other heart disease|86
468|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|86
469|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|86
470|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|86
471|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|86
472|13 - Urinary tract infection|13 - Urinary tract infection|86
473|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|86
474|15 - Wound infection or deterioration|15 - Wound infection or deterioration|86
475|16 - Uncontrolled pain|16 - Uncontrolled pain|86
476|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|86
477|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|86
478|19 - Scheduled treatment or procedure|19 - Scheduled treatment or procedure|86
479|20 - Other than above reasons|20 - Other than above reasons|86
480|UK - Reason unknown [Go to M0903]|UK - Reason unknown [Go to M0903]|86
482|01 - Patient lives alone around the clock|01 - Patient lives alone around the clock|86
483|02 - Patient lives alone regular daytime|02 - Patient lives alone regular daytime|86
484|03 - Patient lives alone regular nighttime|03 - Patient lives alone regular nighttime|86
485|04 - Patient lives alone occassional/short term assistance|04 - Patient lives alone occassional/short term assistance|86
486|05 - Patient lives alone no assisstance available|05 - Patient lives alone no assisstance available|86
487|06 - Patient lives with other person(s) in the home around the clock|06 - Patient lives with other person(s) in the home around the clock|86
488|07 - Patient lives with other person(s) in the home regular daytime|07 - Patient lives with other person(s) in the home regular daytime|86
489|08 - Patient lives with other person(s) in the home regular nighttime|08 - Patient lives with other person(s) in the home regular nighttime|86
490|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|86
491|10 - Patient lives with other person(s) in the home no assistance available|10 - Patient lives with other person(s) in the home no assistance available|86
492|1 - Was present at the most recent SOC/ROC assessment|1 - Was present at the most recent SOC/ROC assessment|86
493|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|86
494|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|86
495|0 - Newly epithelialized|0 - Newly epithelialized|86
496|0 - No [ Go to M1340 ]|0 - No [ Go to M1340 ]|86
498|0 - Independent|0 - Independent|86
499|1 - Needed Some Help|1 - Needed Some Help|86
500|2 - Dependent|2 - Dependent|86
502|0 - No assistance needed in this area|0 - No assistance needed in this area|86
503|1 - Caregiver(s) currently provide assistance|1 - Caregiver(s) currently provide assistance|86
504|2 - Caregiver(s) need training/ supportive services to provide assistance|2 - Caregiver(s) need training/ supportive services to provide assistance|86
505|3 - Caregiver(s) not likely to provide assistance|3 - Caregiver(s) not likely to provide assistance|86
506|4 - Unclear if Caregiver(s) will provide assistance|4 - Unclear if Caregiver(s) will provide assistance|86
507|5 - Assistance needed, but no Caregiver(s) available|5 - Assistance needed, but no Caregiver(s) available|86
508|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will use standardized clinical guidelines accessible for all care providers to reference|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will|86
510|NA - Patient is not assessed to be at risk for falls|NA - Patient is not assessed to be at risk for falls|86
511|NA - Patient has no diagnosis or symptoms of depression|NA - Patient has no diagnosis or symptoms of depression|86
512|NA - No pain identified|NA - No pain identified|86
513|NA - Patient is not assessed to be at risk for pressure ulcers|NA - Patient is not assessed to be at risk for pressure ulcers|86
514|NA - Patient has no pressure ulcers with need for moist wound healing|NA - Patient has no pressure ulcers with need for moist wound healing|86
515|1 - Long-term nursing facility (NF)|1 - Long-term nursing facility (NF)|86
516|2 - Skilled nursing facility (SNF / TCU)|2 - Skilled nursing facility (SNF / TCU)|86
517|3 - Short stay acute hospital (IPP S)|3 - Short stay acute hospital (IPP S)|86
518|4 - Long-term care hospital (LTCH)|4 - Long-term care hospital (LTCH)|86
519|5 - Inpatient rehabilitation hospital or unit (IRF)|5 - Inpatient rehabilitation hospital or unit (IRF)|86
520|6 - Psychiatric hospital or unit|6 - Psychiatric hospital or unit|86
521|7 - Other|7 - Other|86
522|NA - Patient was not discharged from an inpatient facility [Go to M1017]|NA - Patient was not discharged from an inpatient facility [Go to M1017]|86
523|6 - Unable to participate effectively in bathing and is bathed totally by another person|6 - Unable to participate effectively in bathing and is bathed totally by another person|86
524|4 - Chairfast, unable to ambulate but is able to wheel self independently.|4 - Chairfast, unable to ambulate but is able to wheel self independently.|86
525|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask patient: "Over the last two weeks, how often have you been bothered by any of the following problems")|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask|86
526|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluation for depression.|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluat|86
527|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet criteria for further evaluation for depression.|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet|86
528|0 - Not at all  0 - 1 day|0 - Not at all  0 - 1 day|86
529|1 - Several days  2 - 6 days|1 - Several days  2 - 6 days|86
530|2 - More than half of the days  7 - 11 days|2 - More than half of the days  7 - 11 days|86
531|3 - Nearly every day  12 - 14 days|3 - Nearly every day  12 - 14 days|86
532|NA - N/A  Unable to respond|NA - N/A  Unable to respond|86
533|2 - Able to take medication(s) at the correct times if given reminders by another person based on the frequency of the injection|2 - Able to take medication(s) at the correct times if given reminders by another person based on th|86
534|3 - Unable to take injectable medication unless administered by another person.|3 - Unable to take injectable medication unless administered by another person.|86
547|NA - There were no potential clinically significant medication issues identified since SOC/ROC or patient is not taking any medications|NA -  There were no potential clinically significant medication issues identified since SOC/ROC |86
552|1 - Hospital|1 - Hospital [ Go to M2430 ]|86
553|2 - Rehabilitation facility |2 - Rehabilitation facility [ Go to M0903 ]|86
554|3 - Nursing home|3 - Nursing home [ Go to M2440 ]|86
555|4 - Hospice|4 - Hospice [ Go to M0903 ]|86
557|NA - Patient is not diabetic or is bilateral amputee|NA - Patient is not diabetic or is bilateral amputee|86
558|NA - Every standardized,validated multifactor fall risk assessment conducted at or since the most recent SOC/ROC assessment indicates the patient has no risk for falls.|NA - Every standardized,validated multifactor fall risk assessment condition|86
559|NA - Patient has no diagnosis of depression AND every standardized, validated depression screening conducted at or since the most recent SOC/ROC assessment indicates the patient has: 1) no symptoms of depression; or 2) has some symptoms of depression but does not meet criteria for further evaluation of depression based on screening tool used.|NA - Patient has no diagnosis of depression AND every standardized, validated |86
560|NA - Every standardized, validated pain assessment conducted at or since the most recent SOC/ROC assessment indicates the patient has no pain.|NA - Every standardized, validated pain assessment conducted at or since the most|86
561|NA - Every standardized, validated pressure ulcer risk assessment conducted at or since the most recent SOC/ROC assessment indicates the patient is not at risk of developing pressure ulcers.|NA - Every standardized, validated pressure ulcer risk assessment conducted|86
562|NA - Dressings that support the principles of moist wound healing not indicated for this patient's pressure ulcers OR patient has no pressure ulcers with need for moist wound healing|NA - Dressings that support the principles of moist wound healing not indicated for this patient's p|86
620|1 - Yes; received from your agency during this episode of care (SOC/ROC to Transfer/Discharge)|1 - Yes; received from your agency during this episode of care (SOC/ROC to Transfer/Discharge)|86
621|2 - Yes; received from your agency during a prior episode of care (SOC/ROC to Transfer/Discharge)|2 - Yes; received from your agency during a prior episode of care (SOC/ROC to Transfer/Discharge)|86
622|3 - Yes; received from another health care provider (for example physician pharmacist)|3 - Yes; received from another health care provider (for example physician pharmacist)|86
623|4 - No; patient offered and declined |4 - No; patient offered and declined |86
624|5 - No; patient assessed and determined to have medical contraindication(s)|5 - No; patient assessed and determined to have medical contraindication(s)|86
625|6 - No; not indicated - patient does not meet age/condition guidelines for influenza vaccine|6 - No; not indicated - patient does not meet age/condition guidelines for influenza vaccine|86
626|7 - No; inability to obtain vaccine due to declared shortage |7 - No; inability to obtain vaccine due to declared shortage |86
627|8 - No; patient did not receive the vaccine due to reasons other than those listed in responses 4 v 7. |8 - No; patient did not receive the vaccine due to reasons other than those listed in responses 4v7.|86
628|1 - Offered and declined|1 - Offered and declined|86
629|2 - Assessed and determined to have medical contraindication(s) |2 - Assessed and determined to have medical contraindication(s) |86
630|3 - Not indicated; patient does not meet age/condition guidelines for Pneumococcal Vaccine|3 - Not indicated; patient does not meet age/condition guidelines for Pneumococcal Vaccine|86
631|4 - None of the above|4 - None of the above|86
653|0 - No [STOP]|0 - No [STOP]|86
654|1 - Yes |1 - Yes|86
655|0 - None|0 - None|86
656|1 - One|1 - One|86
657|2 - Two or More|2 - Two or More|86
653|0 - No [STOP]|0 - No [STOP]|87
654|1 - Yes |1 - Yes|87
655|0 - None|0 - None|87
656|1 - One|1 - One|87
657|2 - Two or More|2 - Two or More|87
2|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; OR (b) Is physically, cognitively, and mentally able to prepare light meals on a regular basis but has not routinely performed light meal preparation in the past (i.e., prior to this home care admission).|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; O|87
3|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and mentally able to perform all housekeeping tasks .|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and menta|87
4|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and mentally able to do laundry and access facilities.|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and menta|87
5|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying packages OR b) Physically, cognitively, and mentally able to take care of shopping, but has not done shopping in the past (i.e., prior to this home care admission).|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying|87
6|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|87
7|0 - Able to dial numbers and answer calls appropriately and as desired.|0 - Able to dial numbers and answer calls appropriately and as desired.|87
8|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body without assistance.|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body|87
9|0 - Able to get to and from the toilet and transfer independently with or without a device.|0 - Able to get to and from the toilet and transfer independently with or without a device.|87
10|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|87
11|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible public bus.|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible p|87
12|0 - Able to independently feed self.|0 - Able to independently feed self.|87
13|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|87
14|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct times.|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct ti|87
15|0 - Able to independently transfer.|0 - Able to independently transfer.|87
16|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without rail|87
17|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings|87
18|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|87
19|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions independently.|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions indep|87
20|0 - Asymptomatic, no treatment needed at this time|0 - Asymptomatic, no treatment needed at this time|87
21|0 - Caregiver manages all tasks related to equipment completely independently.|0 - Caregiver manages all tasks related to equipment completely independently.|87
22|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations with no observable impairment.|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations w|87
23|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|87
24|0 - Life expectancy is greater than 6 months|0 - Life expectancy is greater than 6 months|87
25|0 - Never|0 - Never|87
26|0 - Patient is not short of breath|0 - Patient is not short of breath|87
27|0 - No|0 - No|87
28|0 - No emergent care services|0 - No emergent care services|87
29|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [Goto 1620]|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [Goto 1620]|87
30|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and extended or abstract conversation.|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and exte|87
31|0 - No one person|0 - No one person|87
32|0 - None of the time|0 - None of the time|87
33|0 - None, no charge for current services|0 - None, no charge for current services|87
34|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|87
35|0 - Patient does NOT have an ostomy for bowel elimination.|0 - Patient does NOT have an ostomy for bowel elimination.|87
36|0 - Patient has no pain|0 - Patient has no pain|87
37|0 - Patient manages all tasks related to equipment completely independently.|0 - Patient manages all tasks related to equipment completely independently.|87
38|0 - Poor:  little or no recovery is expected and/or further decline is imminent|0 - Poor:  little or no recovery is expected and/or further decline is imminent|87
39|0 - Timed-voiding defers incontinence|0 - Timed-voiding defers incontinence|87
40|0 - Very rarely or never has bowel incontinence|0 - Very rarely or never has bowel incontinence|87
41|0 - Zero|0 - Zero|87
42|00 - No|00 - No|87
43|01 - Yes|01 - Yes|87
44|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or mental limitations, needs assistance with heavy laundry.|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or|87
45|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the patient.|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the|87
46|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|87
47|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or supervision from another person OR c) a liquid, pureed or ground meat diet.|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or su|87
48|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|87
49|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|87
50|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independently.|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independe|87
51|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only when assisted or accompanied by another person.|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only w|87
52|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepa|87
53|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance by another person OR b) given daily reminders.|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance b|87
54|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advan|87
55|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advan|87
56|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for the deaf) and call essential numbers.|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for t|87
57|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|87
58|1 - American Indian or Alaska Native|1 - American Indian or Alaska Native|87
59|1 - Depressed mood (e.g., feeling sad, tearful)|1 - Depressed mood (e.g., feeling sad, tearful)|87
60|1 - During the night only|1 - During the night only|87
61|1 - Fully granulating|1 - Fully granulating|87
62|1 - Good/Fair:  partial to full recovery is expected|1 - Good/Fair:  partial to full recovery is expected|87
63|1 - Good:  marked improvement in functional status is expected|1 - Good:  marked improvement in functional status is expected|87
64|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|87
65|1 - Smoking|1 - Smoking|87
66|1 - Hospital|1 - Hospital|87
67|1 - Hospital emergency room (includes 23-hour holding)|1 - Hospital emergency room (includes 23-hour holding)|87
68|1 - Hospitalization for EMERGENT (unscheduled) care|1 - Hospitalization for EMERGENT (unscheduled) care|87
69|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepared solutions), patient is able to manage all other aspects of equipment.|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepar|87
70|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|87
71|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|87
72|1 - In new or complex situations only|1 - In new or complex situations only|87
73|1 - Intravenous or infusion therapy (excludes TPN)|1 - Intravenous or infusion therapy (excludes TPN)|87
74|1 - Less often than daily|1 - Less often than daily|87
75|1 - Less than once a month|1 - Less than once a month|87
76|1 - Less than once weekly|1 - Less than once weekly|87
77|1 - Life expectancy is 6 months or fewer|1 - Life expectancy is 6 months or fewer|87
78|1 - Lives alone|1 - Lives alone|87
79|1 - Male|1 - Male|87
80|1 - Medicare (traditional fee-for-service)|1 - Medicare (traditional fee-for-service)|87
81|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of past 24 hours, significant memory loss so that supervision is required|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of pas|87
82|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors in word choice, grammar or speech intelligibility, needs minimal prompting or assistance).|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors i|87
83|1 - No assistance or services received|1 - No assistance or services received|87
84|1 - One|1 - One|87
85|1 - Oxygen (intermittent or continuous)|1 - Oxygen (intermittent or continuous)|87
86|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, and the surrounding layout, can count fingers at arm's length.|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, a|87
87|1 - Patient is incontinent|1 - Patient is incontinent|87
88|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|87
89|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical or treatment regimen.|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical|87
90|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient/couple/significant other)|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient|87
91|1 - Relatives, friends, or neighbors living outside the home|1 - Relatives, friends, or neighbors living outside the home|87
92|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions.|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions|87
93|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independentl|87
94|1 - Several times during day and night|1 - Several times during day and night|87
95|1 - Spouse or significant other|1 - Spouse or significant other|87
96|1 - Stage 1|1 - Stage 1|87
97|1 - Start of care - further visits planned|1 - Start of care - further visits planned|87
98|1 - Symptoms well controlled with current therapy|1 - Symptoms well controlled with current therapy|87
99|1 - Therapy services|1 - Therapy services|87
100|1 - Able to transfer with minimal human assistance or with use of an assistive device.|1 - Able to transfer with minimal human assistance or with use of an assistive device.|87
101|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitations.|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitatio|87
102|1 - Urinary incontinence|1 - Urinary incontinence|87
103|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and transfer.|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and|87
104|1 - When walking more than 20 feet, climbing stairs|1 - When walking more than 20 feet, climbing stairs|87
105|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary conversation. May need occasional repetition, extra time, or louder voice.|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary c|87
106|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting in and out of tub/shower|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting|87
107|1 - Yes|1 - Yes|87
108|1-RN|1-RN|87
109|10 - Discharge from agency - no visits completed after start/resumption of care assessment|10 - Discharge from agency - no visits completed after start/resumption of care assessment|87
110|10 - Scheduled surgical procedure|10 - Scheduled surgical procedure|87
111|10 - Self-pay|10 - Self-pay|87
112|11 - Other|11 - Other|87
113|11 - Urinary tract infection|11 - Urinary tract infection|87
114|12 - IV catheter-related infection|12 - IV catheter-related infection|87
115|13 - Deep vein thrombosis, pulmonary embolus|13 - Deep vein thrombosis, pulmonary embolus|87
116|14 - Uncontrolled pain|14 - Uncontrolled pain|87
117|15 - Psychotic episode|15 - Psychotic episode|87
118|16 - Other than above reasons|16 - Other than above reasons|87
119|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing calls.|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing|87
120|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another person.|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another pers|87
121|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface a|87
122|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for intermittent supervision or encouragement or reminders, OR (b) to get in and out of the shower or tub, OR (c) for washing difficult to reach areas.|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for inter|87
123|2 - Asian|2 - Asian|87
124|2 - Caregiver requires considerable assistance from another person to manage equipment, but independently completes significant portions of task.|2 - Caregiver requires considerable assistance from another person to manage equipment, but independ|87
125|2 - Daily, but not constantly|2 - Daily, but not constantly|87
126|2 - Daughter or son|2 - Daughter or son|87
127|2 - Doctor's office emergency visit/house call|2 - Doctor's office emergency visit/house call|87
128|2 - During the day and night|2 - During the day and night|87
129|2 - Early/partial granulation|2 - Early/partial granulation|87
130|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors in word choice, organization or speech intelligibility). Speaks in phrases or short sentences.|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors|87
131|2 - Family member's residence|2 - Family member's residence|87
132|2 - Female|2 - Female|87
133|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conversation, needs frequent prompting or assistance.|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conver|87
134|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|87
135|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|87
136|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately stop activities, jeopardizes safety through actions|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately st|87
137|2 - Indwelling/suprapubic catheter|2 - Indwelling/suprapubic catheter|87
138|2 - Injury caused by fall|2 - Injury caused by fall|87
139|2 - Medicare (HMO/managed care/Advantage plan)|2 - Medicare (HMO/managed care/Advantage plan)|87
140|2 - Nausea, dehydration, malnutrition, constipation, impaction|2 - Nausea, dehydration, malnutrition, constipation, impaction|87
141|2 - Obesity|2 - Obesity|87
142|2 - On awakening or at night only|2 - On awakening or at night only|87
143|2 - Once a month|2 - Once a month|87
144|2 - One to three times weekly|2 - One to three times weekly|87
145|2 - Parenteral nutrition (TPN or lipids)|2 - Parenteral nutrition (TPN or lipids)|87
146|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic) [ Go to M1620]|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic) [ Go|87
147|2 - Patient requires considerable assistance from another person to manage equipment, but independently completes portions of the task.|2 - Patient requires considerable assistance from another person to manage equipment, but independen|87
148|2 - Patient transferred to a noninstitutional hospice|2 - Patient transferred to a noninstitutional hospice|87
149|2 - Person residing in the home (EXCLUDING paid help)|2 - Person residing in the home (EXCLUDING paid help)|87
150|2 - Rehabilitation facility|2 - Rehabilitation facility|87
151|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifting of attention) or consistently requires low stimulus environment due to distractibility.|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifti|87
152|2 - Respite care|2 - Respite care|87
153|2 - Sense of failure or self reproach|2 - Sense of failure or self reproach|87
154|2 - Several times during day|2 - Several times during day|87
155|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonresponsive.|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonrespons|87
156|2 - Someone must assist the patient to groom self.|2 - Someone must assist the patient to groom self.|87
157|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|87
158|2 - Someone must help the patient put on upper body clothing.|2 - Someone must help the patient put on upper body clothing.|87
159|2 - Stage 2|2 - Stage 2|87
160|2 - Start of care - no further visits planned|2 - Start of care - no further visits planned|87
161|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitoring|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitori|87
162|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment regimen.|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment re|87
163|2 - Two|2 - Two|87
164|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistance due to cognitive or mental limitation.|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistanc|87
165|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|87
166|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assistance).|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assis|87
167|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home delivery.|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home deli|87
168|2 - Unable to prepare any light meals or reheat any delivered meals.|2 - Unable to prepare any light meals or reheat any delivered meals.|87
169|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|87
170|2 - UNABLE to take injectable medications unless administered by someone else.|2 - UNABLE to take injectable medications unless administered by someone else.|87
171|2 - UNABLE to take medication unless administered by someone else.|2 - UNABLE to take medication unless administered by someone else.|87
172|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|87
173|2 - Ventilator (continually or at night)|2 - Ventilator (continually or at night)|87
174|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less than 20 feet)|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less th|87
175|2 - With spouse or significant other|2 - With spouse or significant other|87
176|2 - Yes, assistance or services provided by family or friends|2 - Yes, assistance or services provided by family or friends|87
177|2-PT|2-PT|87
178|3 - Able to answer the telephone only some of the time or is able to carry on only a limited conversation.|3 - Able to answer the telephone only some of the time or is able to carry on only a limited convers|87
179|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube or gastrostomy.|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube|87
180|3 - Alcohol dependency|3 - Alcohol dependency|87
181|3 - All of the time|3 - All of the time|87
182|3 - Black or African-American|3 - Black or African-American|87
183|3 - Boarding home or rented room|3 - Boarding home or rented room|87
184|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment, clean/store/dispose of equipment or supplies).|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment,|87
185|3 -Able to walk only with the supervision or assistance of another person at all times.|3 -Able to walk only with the supervision or assistance of another person at all times.|87
186|3 - Continuous / Bi-level positive airway pressure|3 - Continuous / Bi-level positive airway pressure|87
187|3 - During the day and evening, but not constantly|3 - During the day and evening, but not constantly|87
188|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the alimentary canal)|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the|87
189|3 - Environmental support (e.g., housing, home maintenance)|3 - Environmental support (e.g., housing, home maintenance)|87
190|3 - Four to six times weekly|3 - Four to six times weekly|87
191|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessing by listener.  Speech limited to single words or short phrases.|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessin|87
192|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires multiple repetitions, restatements, demonstrations, additional time.|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires m|87
193|3 - Hopelessness|3 - Hopelessness|87
194|3 - Hospice care|3 - Hospice care|87
195|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|87
196|3 - Injury caused by fall or accident at home|3 - Injury caused by fall or accident at home|87
197|3 - Intractable pain|3 - Intractable pain|87
198|3 - Medicaid (traditional fee-for-service)|3 - Medicaid (traditional fee-for-service)|87
199|3 - Needs someone to do all shopping and errands.|3 - Needs someone to do all shopping and errands.|87
200|3 - Not healing|3 - Not healing|87
201|3 - Nursing home|3 - Nursing home|87
202|3 - Once daily|3 - Once daily|87
203|3 - Other family member|3 - Other family member|87
204|3 - Outpatient department/clinic emergency (includes urgicenter sites)|3 - Outpatient department/clinic emergency (includes urgicenter sites)|87
205|3 - Paid help|3 - Paid help|87
206|3 - Able to participate in bathing self in shower or tub, but requires presence of another person throughout the bath for assistance or supervision.|3 - Able to participate in bathing self in shower or tub, but requires presence of another person th|87
207|3 - Patient depends entirely upon another person to dress lower body.|3 - Patient depends entirely upon another person to dress lower body.|87
208|3 - Patient depends entirely upon another person to dress the upper body.|3 - Patient depends entirely upon another person to dress the upper body.|87
209|3 - Patient depends entirely upon someone else for grooming needs.|3 - Patient depends entirely upon someone else for grooming needs.|87
210|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone else to manage the equipment.|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone|87
211|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable to shift attention and recall directions more than half the time.|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable|87
212|3 - Respiratory problems (SOB, infection, obstruction)|3 - Respiratory problems (SOB, infection, obstruction)|87
213|3 - Resumption of care (after inpatient stay)|3 - Resumption of care (after inpatient stay)|87
214|3 - Several times each month|3 - Several times each month|87
215|3 - Skilled Nursing Facility|3 - Skilled Nursing Facility|87
216|3 - Stage 3|3 - Stage 3|87
217|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|87
218|3 - Three|3 - Three|87
219|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person throughout the process.|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person through|87
220|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal independently.|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal indep|87
221|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person.|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person|87
222|3 - Unknown because patient moved to a geographic location not served by this agency|3 - Unknown because patient moved to a geographic location not served by this agency|87
223|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|87
224|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|87
225|3 - With other family member|3 - With other family member|87
226|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home health services, homemaker assistance, transportation assistance, assisted living, board and care)|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home h|87
227|3-SLP/ST|3-SLP/ST|87
228|4 - At rest (during day or night)|4 - At rest (during day or night)|87
229|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|87
230|4 - Board and care or assisted living facility|4 - Board and care or assisted living facility|87
231|4 - Caregiver is completely dependent on someone else to manage all equipment.|4 - Caregiver is completely dependent on someone else to manage all equipment.|87
232|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|87
233|4 - Constantly|4 - Constantly|87
234|4 - Drug dependency|4 - Drug dependency|87
235|4 - Four or more|4 - Four or more|87
236|4 - Friend or neighbor or community or church member|4 - Friend or neighbor or community or church member|87
237|4 - Hispanic or Latino|4 - Hispanic or Latino|87
238|4 - Hospice|4 - Hospice|87
239|4 - Impaired decision-making|4 - Impaired decision-making|87
240|4 - Is totally dependent in toileting.|4 - Is totally dependent in toileting.|87
241|4 - Medicaid (HMO/managed care)|4 - Medicaid (HMO/managed care)|87
242|4 - None of the above|4 - None of the above|87
243|4 - Nursing home|4 - Nursing home|87
244|4 - On a daily basis|4 - On a daily basis|87
245|4 - Patient is completely dependent on someone else to manage all equipment.|4 - Patient is completely dependent on someone else to manage all equipment.|87
246|4 - Permanent placement|4 - Permanent placement|87
247|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, punches, dangerous maneuvers w/ wheelchair or other objects)|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, pu|87
248|4 - Psychosocial support (e.g., socialization, companionship, recreation)|4 - Psychosocial support (e.g., socialization, companionship, recreation)|87
249|4 - Recertification (follow-up) reassessment|4 - Recertification (follow-up) reassessment|87
250|4 - Recurrent thoughts of death|4 - Recurrent thoughts of death|87
251|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruction)|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruc|87
252|4 - Several times a week|4 - Several times a week|87
253|4 - Stage 4|4 - Stage 4|87
254|4 - Symptoms poorly controlled, history of rehospitalizations|4 - Symptoms poorly controlled, history of rehospitalizations|87
255|4 - Three or more times per week|4 - Three or more times per week|87
256|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetative state, or delirium.|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetati|87
257|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|87
258|4 - Unable to effectively participate in any housekeeping tasks.|4 - Unable to effectively participate in any housekeeping tasks.|87
259|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or unresponsive (e.g., speech is nonsensical or unintelligible).|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or u|87
260|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonresponsive.|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonr|87
261|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostomy.|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostom|87
262|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of devices at the sink, in chair, or on commode|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of|87
263|4 - With a friend|4 - With a friend|87
264|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|87
265|4-OT|4-OT|87
266|5 - Advocates or facilitates patient's participation in appropriate medical care|5 - Advocates or facilitates patient's participation in appropriate medical care|87
267|5 - At least daily|5 - At least daily|87
268|6 - Bedfast, unable to ambulate or be up in a chair.|6 - Bedfast, unable to ambulate or be up in a chair.|87
269|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|87
270|5 - Disruptive or socially inappropriate behavior|5 - Disruptive or socially inappropriate behavior|87
271|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|87
272|5 - Hypo/Hyperglycemia, diabetes out of control|5 - Hypo/Hyperglycemia, diabetes out of control|87
273|5 - More often than once daily|5 - More often than once daily|87
274|5 - Native Hawaiian or Pacific Islander|5 - Native Hawaiian or Pacific Islander|87
275|5 - None of the above|5 - None of the above|87
276|5 - One to two times per week|5 - One to two times per week|87
277|5 - Other|5 - Other|87
278|5 - Other follow-up|5 - Other follow-up|87
279|5 - Paid help|5 - Paid help|87
280|5 - Patient nonresponsive or unable to speak.|5 - Patient nonresponsive or unable to speak.|87
281|5 - Thoughts of suicide|5 - Thoughts of suicide|87
282|5 - Totally unable to use the telephone.|5 - Totally unable to use the telephone.|87
283|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|87
284|5 - Unable to take in nutrients orally or by tube feeding.|5 - Unable to take in nutrients orally or by tube feeding.|87
285|5 - Unsafe for care at home|5 - Unsafe for care at home|87
286|5 - With paid help (other than home care agency staff)|5 - With paid help (other than home care agency staff)|87
287|5 - Workers' compensation|5 - Workers' compensation|87
288|5 - Wound infection, deteriorating wound status, new lesion/ulcer|5 - Wound infection, deteriorating wound status, new lesion/ulcer|87
289|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|87
290|6 - Delusional, hallucinatory, or paranoid behavior|6 - Delusional, hallucinatory, or paranoid behavior|87
291|6 - Financial agent, power of attorney, or conservator of finance|6 - Financial agent, power of attorney, or conservator of finance|87
292|6 - GI bleeding, obstruction|6 - GI bleeding, obstruction|87
293|6 - Less often than weekly|6 - Less often than weekly|87
294|6 - Memory loss to the extent that supervision required|6 - Memory loss to the extent that supervision required|87
295|6 - None of the above feelings observed or reported|6 - None of the above feelings observed or reported|87
296|6 - Other|6 - Other|87
297|6 - Title programs (e.g., Title III, V, or XX)|6 - Title programs (e.g., Title III, V, or XX)|87
298|6 - Transferred to an inpatient facility - patient not discharged from agency|6 - Transferred to an inpatient facility - patient not discharged from agency|87
299|6 - White|6 - White|87
300|6 - With other than above|6 - With other than above|87
301|7 - Exacerbation of CHF, fluid overload, heart failure|7 - Exacerbation of CHF, fluid overload, heart failure|87
302|7 - Health care agent, conservator of person, or medical power of attorney|7 - Health care agent, conservator of person, or medical power of attorney|87
303|7 - Hypo/Hyperglycemia, diabetes out of control|7 - Hypo/Hyperglycemia, diabetes out of control|87
304|7 - None of the above|7 - None of the above|87
305|7 - None of the above behaviors demonstrated|7 - None of the above behaviors demonstrated|87
306|7 - Other government (e.g., TriCare, VA, etc.)|7 - Other government (e.g., TriCare, VA, etc.)|87
307|7 - Transferred to an inpatient facility - patient discharged from agency|7 - Transferred to an inpatient facility - patient discharged from agency|87
308|8 - Death at home|8 - Death at home|87
309|8 - GI bleeding, obstruction|8 - GI bleeding, obstruction|87
310|8 - Myocardial infarction, stroke|8 - Myocardial infarction, stroke|87
311|8 - Private insurance|8 - Private insurance|87
312|9 - Chemotherapy|9 - Chemotherapy|87
313|9 - Discharge from agency|9 - Discharge from agency|87
314|9 - Other than above reasons|9 - Other than above reasons|87
315|9 - Private HMO/managed care|9 - Private HMO/managed care|87
316|NA - No caregiver|NA - No caregiver|87
317|NA - No equipment of this type used in care.|NA - No equipment of this type used in care.|87
318|NA - No inhalant/mist medications prescribed.|NA - No inhalant/mist medications prescribed.|87
319|NA - No injectable medications prescribed.|NA - No injectable medications prescribed.|87
320|NA - No inpatient facility admission|NA - No inpatient facility admission|87
321|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|87
322|NA - No Medicaid|NA - No Medicaid|87
323|NA - No Medicare|NA - No Medicare|87
324|NA - No observable pressure ulcer or unhealed pressure ulcer|NA - No observable pressure ulcer or unhealed pressure ulcer|87
325|NA - No observable stasis ulcer|NA - No observable stasis ulcer|87
326|NA - No observable surgical wound|NA - No observable surgical wound|87
327|NA - No oral medications prescribed.|NA - No oral medications prescribed.|87
328|NA - Not applicable|NA - Not applicable|87
329|NA - Patient does not have a telephone.|NA - Patient does not have a telephone.|87
330|NA - Patient has ostomy for bowel elimination|NA - Patient has ostomy for bowel elimination|87
331|NA - Patient nonresponsive|NA - Patient nonresponsive|87
332|NA - Patient on prophylactic treatment|NA - Patient on prophylactic treatment|87
333|NA - Patient was not discharged from an inpatient facility [Go to M1017]|NA - Patient was not discharged from an inpatient facility [Go to M1017]|87
334|UK - Other unknown|UK - Other unknown|87
335|UK - Reason unknown|UK - Reason unknown|87
336|UK - Unknown|UK - Unknown|87
337|UK - Unknown or Not Available|UK - Unknown or Not Available|87
341|01 - Early|01 - Early|87
342|02 - Late|02 - Late|87
343|NA - Not Applicable. No case mix group defined for this assessment.|NA - Not Applicable. No case mix group defined for this assessment.|87
344|NA - No case mix group defined by this assessment.|NA - No case mix group defined by this assessment.|87
345|1 - Recent decline in mental, emotional, or behavioral status|1 - Recent decline in mental, emotional, or behavioral status|87
346|2 - Multiple hospitalizations (2 or more) in the past 12 months|2 - Multiple hospitalizations (2 or more) in the past 12 months|87
347|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|87
348|4 - Taking five or more medications|4 - Taking five or more medications|87
349|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|87
350|6 - Other|6 - Other|87
351|7 - None of the above|7 - None of the above|87
352|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond tho|87
353|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable without heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable wi|87
354|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious complications and death.|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious compl|87
355|3 - The patient has serious progressive conditions that could lead to death within a year.|3 - The patient has serious progressive conditions that could lead to death within a year.|87
356|UK - The patient+s situation is unknown or unclear.|UK - The patient+s situation is unknown or unclear.|87
357|0 - No [ Go to M1051 ]|0 - No [ Go to M1051 ]|87
358|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this influenza season. [ Go to M1050 ]|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this i|87
359|1 - Received from another health care provider (e.g., physician)|1 - Received from another health care provider (e.g., physician)|87
360|2 - Received from your agency previously during this year+s flu season|2 - Received from your agency previously during this year+s flu season|87
361|3 - Offered and declined|3 - Offered and declined|87
362|4 - Assessed and determined to have medical contraindication(s)|4 - Assessed and determined to have medical contraindication(s)|87
363|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|87
364|6 - Inability to obtain vaccine due to declared shortage|6 - Inability to obtain vaccine due to declared shortage|87
365|1 - Yes [ Go to M2005 at TRN; Go to M1230 at DC ]|1 - Yes [ Go to M2005 at TRN; Go to M1230 at DC ]|87
366|1 - Patient has received PPV in the past|1 - Patient has received PPV in the past|87
367|2 - Offered and declined|2 - Offered and declined|87
368|3 - Assessed and determined to have medical contraindication(s)|3 - Assessed and determined to have medical contraindication(s)|87
369|4 - Not indicated; patient does not meet age/condition guidelines for PPV|4 - Not indicated; patient does not meet age/condition guidelines for PPV|87
370|5 - None of the above|5 - None of the above|87
371|0 - Adequate: hears normal conversation without difficulty.|0 - Adequate: hears normal conversation without difficulty.|87
372|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to increase volume or speak distinctly.|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to in|87
373|2 - Severely Impaired: absence of useful hearing.|2 - Severely Impaired: absence of useful hearing.|87
374|UK - Unable to assess hearing.|UK - Unable to assess hearing.|87
375|0 - Understands: clear comprehension without cues or repetitions.|0 - Understands: clear comprehension without cues or repetitions.|87
376|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Requires cues at times to understand.|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Req|87
377|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequently requires cues to understand.|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequentl|87
378|3 - Rarely/Never Understands|3 - Rarely/Never Understands|87
379|UK - Unable to assess understanding.|UK - Unable to assess understanding.|87
380|0 - No standardized assessment conducted|0 - No standardized assessment conducted|87
381|1 - Yes, and it does not indicate severe pain|1 - Yes, and it does not indicate severe pain|87
382|2 - Yes, and it indicates severe pain|2 - Yes, and it indicates severe pain|87
383|0 - Patient has no pain|0 - Patient has no pain|87
384|1 - Patient has pain that does not interfere with activity or movement|1 - Patient has pain that does not interfere with activity or movement|87
385|2 - Less often than daily|2 - Less often than daily|87
386|3 - Daily, but not constantly|3 - Daily, but not constantly|87
387|4 - All of the time|4 - All of the time|87
388|0 - No assessment conducted [ Go to M1306 ]|0 - No assessment conducted [ Go to M1306 ]|87
389|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc., without use of standardized tool|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc.,|87
390|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|87
391|0 - No [ Go to M1322]|0 - No [ Go to M1322]|87
392|0 v Newly epithelialized|0 v Newly epithelialized|87
393|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|87
394|2 - Yes, patient has observable stasis ulcers ONLY|2 - Yes, patient has observable stasis ulcers ONLY|87
395|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable dressing) [Go to M1340]|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable|87
396|0 - No [ Go to M1350 ]|0 - No [ Go to M1350 ]|87
397|1 - Yes, patient has at least one (observable) surgical wound|1 - Yes, patient has at least one (observable) surgical wound|87
398|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1350 ]|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1350 ]|87
399|0 - Patient is not short of breath|0 - Patient is not short of breath|87
400|3 - Continuous Bi-level positive airway pressure|3 - Continuous Bi-level positive airway pressure|87
401|0 - No [ Go to M2005 at TRN; Go to M1600 at DC ]|0 - No [ Go to M2005 at TRN; Go to M1600 at DC ]|87
402|2 - Not assessed [Go to M2005 at TRN; Go to M1600 at DC ]|2 - Not assessed [Go to M2005 at TRN; Go to M1600 at DC ]|87
403|NA - Patient does not have diagnosis of heart failure [Go to M2005 at TRN; Go to M1600 at DC]|NA - Patient does not have diagnosis of heart failure [Go to M2005 at TRN; Go to M1600 at DC]|87
404|0 - No action taken|0 - No action taken|87
405|1 - Patient+s physician (or other primary care practitioner) contacted the same day|1 - Patient+s physician (or other primary care practitioner) contacted the same day|87
406|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|87
407|3 - Implement physician-ordered patient-specific established parameters for treatment|3 - Implement physician-ordered patient-specific established parameters for treatment|87
408|4 - Patient education or other clinical interventions|4 - Patient education or other clinical interventions|87
409|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequency, telehealth, etc.)|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequ|87
410|1 - Occasional stress incontinence|1 - Occasional stress incontinence|87
411|2 - During the night only|2 - During the night only|87
412|3 - During the day only|3 - During the day only|87
413|4 - During the day and night|4 - During the day and night|87
414|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|87
415|0 - Able to manage toileting hygiene and clothing management without assistance.|0 - Able to manage toileting hygiene and clothing management without assistance.|87
416|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implements are laid out for the patient.|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implemen|87
417|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|87
418|3 - Patient depends entirely upon another person to maintain toileting hygiene.|3 - Patient depends entirely upon another person to maintain toileting hygiene.|87
419|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independent|87
420|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface|87
421|0 - No multi-factor falls risk assessment conducted.|0 - No multi-factor falls risk assessment conducted.|87
422|1 - Yes, and it does not indicate a risk for falls.|1 - Yes, and it does not indicate a risk for falls.|87
423|2 - Yes, and it indicates a risk for falls.|2 - Yes, and it indicates a risk for falls.|87
424|0 - Not assessed/reviewed [ Go to M2010 ]|0 - Not assessed/reviewed [ Go to M2010 ]|87
425|1 - No problems found during review [ Go to M2010 ]|1 - No problems found during review [ Go to M2010 ]|87
426|2 - Problems found during review|2 - Problems found during review|87
427|NA - Patient is not taking any medications [ Go to M2040 ]|NA - Patient is not taking any medications [ Go to M2040 ]|87
428|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special precautions associated with all high-risk medications|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special p|87
429|NA - Patient not taking any drugs|NA - Patient not taking any drugs|87
430|2 - Able to take medication(s) at the correct times if given reminders by another person at the appropriate times|2 - Able to take medication(s) at the correct times if given reminders by another person at the appr|87
431|3 - Unable to take medication unless administered by another person.|3 - Unable to take medication unless administered by another person.|87
432|1 - At least daily|1 - At least daily|87
433|2 - Three or more times per week|2 - Three or more times per week|87
434|3 - One to two times per week|3 - One to two times per week|87
435|4 - Received, but less often than weekly|4 - Received, but less often than weekly|87
436|5 - No assistance received|5 - No assistance received|87
437|0 - No [Go to M2401]|0 - No [Go to M2401]|87
438|1 - Yes, used hospital emergency department WITHOUT hospital admission|1 - Yes, used hospital emergency department WITHOUT hospital admission|87
439|2 - Yes, used hospital emergency department WITH hospital admission|2 - Yes, used hospital emergency department WITH hospital admission|87
440|UK - Unknown [Go to M2401]|UK - Unknown [Go to M2401]|87
441|2 - Injury caused by fall|2 - Injury caused by fall|87
442|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|87
443|4 - Other respiratory problem|4 - Other respiratory problem|87
444|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|87
445|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|87
446|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|87
447|8 - Other heart disease|8 - Other heart disease|87
448|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|87
449|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|87
450|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|87
451|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|87
452|13 - Urinary tract infection|13 - Urinary tract infection|87
453|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|87
454|15 - Wound infection or deterioration|15 - Wound infection or deterioration|87
455|16 - Uncontrolled pain|16 - Uncontrolled pain|87
456|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|87
457|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|87
458|19 - Other than above reasons|19 - Other than above reasons|87
459|2 - Patient remained in the community (with formal assistive services)|2 - Patient remained in the community (with formal assistive services)|87
460|3 - Patient transferred to a noninstitutional hospice|3 - Patient transferred to a noninstitutional hospice|87
461|4 - Unknown because patient moved to a geographic location not served by this agency|4 - Unknown because patient moved to a geographic location not served by this agency|87
462|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|87
463|4 - Other respiratory problem|4 - Other respiratory problem|87
464|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|87
465|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|87
466|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|87
467|8 - Other heart disease|8 - Other heart disease|87
468|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|87
469|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|87
470|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|87
471|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|87
472|13 - Urinary tract infection|13 - Urinary tract infection|87
473|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|87
474|15 - Wound infection or deterioration|15 - Wound infection or deterioration|87
475|16 - Uncontrolled pain|16 - Uncontrolled pain|87
476|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|87
477|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|87
478|19 - Scheduled treatment or procedure|19 - Scheduled treatment or procedure|87
479|20 - Other than above reasons|20 - Other than above reasons|87
480|UK - Reason unknown [Go to M0903]|UK - Reason unknown [Go to M0903]|87
482|01 - Patient lives alone around the clock|01 - Patient lives alone around the clock|87
483|02 - Patient lives alone regular daytime|02 - Patient lives alone regular daytime|87
484|03 - Patient lives alone regular nighttime|03 - Patient lives alone regular nighttime|87
485|04 - Patient lives alone occassional/short term assistance|04 - Patient lives alone occassional/short term assistance|87
486|05 - Patient lives alone no assisstance available|05 - Patient lives alone no assisstance available|87
487|06 - Patient lives with other person(s) in the home around the clock|06 - Patient lives with other person(s) in the home around the clock|87
488|07 - Patient lives with other person(s) in the home regular daytime|07 - Patient lives with other person(s) in the home regular daytime|87
489|08 - Patient lives with other person(s) in the home regular nighttime|08 - Patient lives with other person(s) in the home regular nighttime|87
490|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|87
491|10 - Patient lives with other person(s) in the home no assistance available|10 - Patient lives with other person(s) in the home no assistance available|87
492|1 - Was present at the most recent SOC/ROC assessment|1 - Was present at the most recent SOC/ROC assessment|87
493|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|87
494|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|87
495|0 - Newly epithelialized|0 - Newly epithelialized|87
496|0 - No [ Go to M1340 ]|0 - No [ Go to M1340 ]|87
498|0 - Independent|0 - Independent|87
499|1 - Needed Some Help|1 - Needed Some Help|87
500|2 - Dependent|2 - Dependent|87
502|0 - No assistance needed in this area|0 - No assistance needed in this area|87
503|1 - Caregiver(s) currently provide assistance|1 - Caregiver(s) currently provide assistance|87
504|2 - Caregiver(s) need training/ supportive services to provide assistance|2 - Caregiver(s) need training/ supportive services to provide assistance|87
505|3 - Caregiver(s) not likely to provide assistance|3 - Caregiver(s) not likely to provide assistance|87
506|4 - Unclear if Caregiver(s) will provide assistance|4 - Unclear if Caregiver(s) will provide assistance|87
507|5 - Assistance needed, but no Caregiver(s) available|5 - Assistance needed, but no Caregiver(s) available|87
508|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will use standardized clinical guidelines accessible for all care providers to reference|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will|87
510|NA - Patient is not assessed to be at risk for falls|NA - Patient is not assessed to be at risk for falls|87
511|NA - Patient has no diagnosis or symptoms of depression|NA - Patient has no diagnosis or symptoms of depression|87
512|NA - No pain identified|NA - No pain identified|87
513|NA - Patient is not assessed to be at risk for pressure ulcers|NA - Patient is not assessed to be at risk for pressure ulcers|87
514|NA - Patient has no pressure ulcers with need for moist wound healing|NA - Patient has no pressure ulcers with need for moist wound healing|87
515|1 - Long-term nursing facility (NF)|1 - Long-term nursing facility (NF)|87
516|2 - Skilled nursing facility (SNF / TCU)|2 - Skilled nursing facility (SNF / TCU)|87
517|3 - Short stay acute hospital (IPP S)|3 - Short stay acute hospital (IPP S)|87
518|4 - Long-term care hospital (LTCH)|4 - Long-term care hospital (LTCH)|87
519|5 - Inpatient rehabilitation hospital or unit (IRF)|5 - Inpatient rehabilitation hospital or unit (IRF)|87
520|6 - Psychiatric hospital or unit|6 - Psychiatric hospital or unit|87
521|7 - Other|7 - Other|87
522|NA - Patient was not discharged from an inpatient facility [Go to M1017]|NA - Patient was not discharged from an inpatient facility [Go to M1017]|87
523|6 - Unable to participate effectively in bathing and is bathed totally by another person|6 - Unable to participate effectively in bathing and is bathed totally by another person|87
524|4 - Chairfast, unable to ambulate but is able to wheel self independently.|4 - Chairfast, unable to ambulate but is able to wheel self independently.|87
525|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask patient: "Over the last two weeks, how often have you been bothered by any of the following problems")|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask|87
526|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluation for depression.|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluat|87
527|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet criteria for further evaluation for depression.|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet|87
528|0 - Not at all  0 - 1 day|0 - Not at all  0 - 1 day|87
529|1 - Several days  2 - 6 days|1 - Several days  2 - 6 days|87
530|2 - More than half of the days  7 - 11 days|2 - More than half of the days  7 - 11 days|87
531|3 - Nearly every day  12 - 14 days|3 - Nearly every day  12 - 14 days|87
532|NA - N/A  Unable to respond|NA - N/A  Unable to respond|87
533|2 - Able to take medication(s) at the correct times if given reminders by another person based on the frequency of the injection|2 - Able to take medication(s) at the correct times if given reminders by another person based on th|87
534|3 - Unable to take injectable medication unless administered by another person.|3 - Unable to take injectable medication unless administered by another person.|87
547|NA - There were no potential clinically significant medication issues identified since SOC/ROC or patient is not taking any medications|NA v There were no potential clinically significant medication issues identified since SOC/ROC |87
552|1 - Hospital|1 - Hospital [ Go to M2430 ]|87
553|2 - Rehabilitation facility |2 - Rehabilitation facility [ Go to M0903 ]|87
554|3 - Nursing home|3 - Nursing home [ Go to M2440 ]|87
555|4 - Hospice|4 - Hospice [ Go to M0903 ]|87
564|NA - Patient is not diabetic or is bilateral amputee|NA - Patient is not diabetic or is bilateral amputee|87
565|NA - Every standardized,validated multifactor fall risk assessment conducted at or since the most recent SOC/ROC assessment indicates the patient has no risk for falls.|NA - Every standardized,validated multifactor fall risk assessment condition|87
566|NA - Patient has no diagnosis of depression AND every standardized, validated depression screening conducted at or since the most recent SOC/ROC assessment indicates the patient has: 1) no symptoms of depression; or 2) has some symptoms of depression but does not meet criteria for further evaluation of depression based on screening tool used.|NA - Patient has no diagnosis of depression AND every standardized, validated |87
567|NA - Every standardized, validated pain assessment conducted at or since the most recent SOC/ROC assessment indicates the patient has no pain.|NA - Every standardized, validated pain assessment conducted at or since the most|87
568|NA - Every standardized, validated pressure ulcer risk assessment conducted at or since the most recent SOC/ROC assessment indicates the patient is not at risk of developing pressure ulcers.|NA - Every standardized, validated pressure ulcer risk assessment conducted|87
569|NA - Dressings that support the principles of moist wound healing not indicated for this patient's pressure ulcers OR patient has no pressure ulcers with need for moist wound healing|NA - Dressings that support the principles of moist wound healing not indicated for this patient's p|87
620|1 - Yes; received from your agency during this episode of care (SOC/ROC to Transfer/Discharge)|1 - Yes; received from your agency during this episode of care (SOC/ROC to Transfer/Discharge)|87
621|2 - Yes; received from your agency during a prior episode of care (SOC/ROC to Transfer/Discharge)|2 - Yes; received from your agency during a prior episode of care (SOC/ROC to Transfer/Discharge)|87
622|3 - Yes; received from another health care provider (for example physician pharmacist)|3 - Yes; received from another health care provider (for example physician pharmacist)|87
623|4 - No; patient offered and declined |4 - No; patient offered and declined |87
624|5 - No; patient assessed and determined to have medical contraindication(s)|5 - No; patient assessed and determined to have medical contraindication(s)|87
625|6 - No; not indicated - patient does not meet age/condition guidelines for influenza vaccine|6 - No; not indicated - patient does not meet age/condition guidelines for influenza vaccine|87
626|7 - No; inability to obtain vaccine due to declared shortage |7 - No; inability to obtain vaccine due to declared shortage |87
627|8 - No; patient did not receive the vaccine due to reasons other than those listed in responses 4 v 7. |8 - No; patient did not receive the vaccine due to reasons other than those listed in responses 4v7.|87
628|1 - Offered and declined|1 - Offered and declined|87
629|2 - Assessed and determined to have medical contraindication(s) |2 - Assessed and determined to have medical contraindication(s) |87
630|3 - Not indicated; patient does not meet age/condition guidelines for Pneumococcal Vaccine|3 - Not indicated; patient does not meet age/condition guidelines for Pneumococcal Vaccine|87
631|4 - None of the above|4 - None of the above|87
2|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; OR (b) Is physically, cognitively, and mentally able to prepare light meals on a regular basis but has not routinely performed light meal preparation in the past (i.e., prior to this home care admission).|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; O|88
3|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and mentally able to perform all housekeeping tasks .|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and menta|88
4|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and mentally able to do laundry and access facilities.|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and menta|88
5|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying packages OR b) Physically, cognitively, and mentally able to take care of shopping, but has not done shopping in the past (i.e., prior to this home care admission).|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying|88
6|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|88
7|0 - Able to dial numbers and answer calls appropriately and as desired.|0 - Able to dial numbers and answer calls appropriately and as desired.|88
8|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body without assistance.|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body|88
9|0 - Able to get to and from the toilet and transfer independently with or without a device.|0 - Able to get to and from the toilet and transfer independently with or without a device.|88
10|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|88
11|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible public bus.|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible p|88
12|0 - Able to independently feed self.|0 - Able to independently feed self.|88
13|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|88
14|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct times.|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct ti|88
15|0 - Able to independently transfer.|0 - Able to independently transfer.|88
16|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without rail|88
17|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings|88
18|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|88
19|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions independently.|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions indep|88
20|0 - Asymptomatic, no treatment needed at this time|0 - Asymptomatic, no treatment needed at this time|88
21|0 - Caregiver manages all tasks related to equipment completely independently.|0 - Caregiver manages all tasks related to equipment completely independently.|88
22|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations with no observable impairment.|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations w|88
23|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|88
24|0 - Life expectancy is greater than 6 months|0 - Life expectancy is greater than 6 months|88
25|0 - Never|0 - Never|88
26|0 - Patient is not short of breath|0 - Patient is not short of breath|88
27|0 - No|0 - No|88
28|0 - No emergent care services|0 - No emergent care services|88
29|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [Goto 1620]|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [Goto 1620]|88
30|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and extended or abstract conversation.|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and exte|88
31|0 - No one person|0 - No one person|88
32|0 - None of the time|0 - None of the time|88
33|0 - None, no charge for current services|0 - None, no charge for current services|88
34|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|88
35|0 - Patient does NOT have an ostomy for bowel elimination.|0 - Patient does NOT have an ostomy for bowel elimination.|88
36|0 - Patient has no pain|0 - Patient has no pain|88
37|0 - Patient manages all tasks related to equipment completely independently.|0 - Patient manages all tasks related to equipment completely independently.|88
38|0 - Poor:  little or no recovery is expected and/or further decline is imminent|0 - Poor:  little or no recovery is expected and/or further decline is imminent|88
39|0 - Timed-voiding defers incontinence|0 - Timed-voiding defers incontinence|88
40|0 - Very rarely or never has bowel incontinence|0 - Very rarely or never has bowel incontinence|88
41|0 - Zero|0 - Zero|88
42|00 - No|00 - No|88
43|01 - Yes|01 - Yes|88
44|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or mental limitations, needs assistance with heavy laundry.|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or|88
45|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the patient.|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the|88
46|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|88
47|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or supervision from another person OR c) a liquid, pureed or ground meat diet.|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or su|88
48|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|88
49|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|88
50|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independently.|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independe|88
51|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only when assisted or accompanied by another person.|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only w|88
52|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepa|88
53|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance by another person OR b) given daily reminders.|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance b|88
54|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advan|88
55|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advan|88
56|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for the deaf) and call essential numbers.|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for t|88
57|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|88
58|1 - American Indian or Alaska Native|1 - American Indian or Alaska Native|88
59|1 - Depressed mood (e.g., feeling sad, tearful)|1 - Depressed mood (e.g., feeling sad, tearful)|88
60|1 - During the night only|1 - During the night only|88
61|1 - Fully granulating|1 - Fully granulating|88
62|1 - Good/Fair:  partial to full recovery is expected|1 - Good/Fair:  partial to full recovery is expected|88
63|1 - Good:  marked improvement in functional status is expected|1 - Good:  marked improvement in functional status is expected|88
64|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|88
65|1 - Smoking|1 - Smoking|88
66|1 - Hospital|1 - Hospital|88
67|1 - Hospital emergency room (includes 23-hour holding)|1 - Hospital emergency room (includes 23-hour holding)|88
68|1 - Hospitalization for EMERGENT (unscheduled) care|1 - Hospitalization for EMERGENT (unscheduled) care|88
69|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepared solutions), patient is able to manage all other aspects of equipment.|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepar|88
70|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|88
71|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|88
72|1 - In new or complex situations only|1 - In new or complex situations only|88
73|1 - Intravenous or infusion therapy (excludes TPN)|1 - Intravenous or infusion therapy (excludes TPN)|88
74|1 - Less often than daily|1 - Less often than daily|88
75|1 - Less than once a month|1 - Less than once a month|88
76|1 - Less than once weekly|1 - Less than once weekly|88
77|1 - Life expectancy is 6 months or fewer|1 - Life expectancy is 6 months or fewer|88
78|1 - Lives alone|1 - Lives alone|88
79|1 - Male|1 - Male|88
80|1 - Medicare (traditional fee-for-service)|1 - Medicare (traditional fee-for-service)|88
81|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of past 24 hours, significant memory loss so that supervision is required|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of pas|88
82|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors in word choice, grammar or speech intelligibility, needs minimal prompting or assistance).|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors i|88
83|1 - No assistance or services received|1 - No assistance or services received|88
84|1 - One|1 - One|88
85|1 - Oxygen (intermittent or continuous)|1 - Oxygen (intermittent or continuous)|88
86|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, and the surrounding layout, can count fingers at arm's length.|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, a|88
87|1 - Patient is incontinent|1 - Patient is incontinent|88
88|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|88
89|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical or treatment regimen.|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical|88
90|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient/couple/significant other)|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient|88
91|1 - Relatives, friends, or neighbors living outside the home|1 - Relatives, friends, or neighbors living outside the home|88
92|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions.|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions|88
93|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independentl|88
94|1 - Several times during day and night|1 - Several times during day and night|88
95|1 - Spouse or significant other|1 - Spouse or significant other|88
96|1 - Stage 1|1 - Stage 1|88
97|1 - Start of care - further visits planned|1 - Start of care - further visits planned|88
98|1 - Symptoms well controlled with current therapy|1 - Symptoms well controlled with current therapy|88
99|1 - Therapy services|1 - Therapy services|88
100|1 - Able to transfer with minimal human assistance or with use of an assistive device.|1 - Able to transfer with minimal human assistance or with use of an assistive device.|88
101|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitations.|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitatio|88
102|1 - Urinary incontinence|1 - Urinary incontinence|88
103|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and transfer.|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and|88
104|1 - When walking more than 20 feet, climbing stairs|1 - When walking more than 20 feet, climbing stairs|88
105|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary conversation. May need occasional repetition, extra time, or louder voice.|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary c|88
106|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting in and out of tub/shower|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting|88
107|1 - Yes|1 - Yes|88
108|1-RN|1-RN|88
109|10 - Discharge from agency - no visits completed after start/resumption of care assessment|10 - Discharge from agency - no visits completed after start/resumption of care assessment|88
110|10 - Scheduled surgical procedure|10 - Scheduled surgical procedure|88
111|10 - Self-pay|10 - Self-pay|88
112|11 - Other|11 - Other|88
113|11 - Urinary tract infection|11 - Urinary tract infection|88
114|12 - IV catheter-related infection|12 - IV catheter-related infection|88
115|13 - Deep vein thrombosis, pulmonary embolus|13 - Deep vein thrombosis, pulmonary embolus|88
116|14 - Uncontrolled pain|14 - Uncontrolled pain|88
117|15 - Psychotic episode|15 - Psychotic episode|88
118|16 - Other than above reasons|16 - Other than above reasons|88
119|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing calls.|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing|88
120|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another person.|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another pers|88
121|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface a|88
122|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for intermittent supervision or encouragement or reminders, OR (b) to get in and out of the shower or tub, OR (c) for washing difficult to reach areas.|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for inter|88
123|2 - Asian|2 - Asian|88
124|2 - Caregiver requires considerable assistance from another person to manage equipment, but independently completes significant portions of task.|2 - Caregiver requires considerable assistance from another person to manage equipment, but independ|88
125|2 - Daily, but not constantly|2 - Daily, but not constantly|88
126|2 - Daughter or son|2 - Daughter or son|88
127|2 - Doctor's office emergency visit/house call|2 - Doctor's office emergency visit/house call|88
128|2 - During the day and night|2 - During the day and night|88
129|2 - Early/partial granulation|2 - Early/partial granulation|88
130|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors in word choice, organization or speech intelligibility). Speaks in phrases or short sentences.|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors|88
131|2 - Family member's residence|2 - Family member's residence|88
132|2 - Female|2 - Female|88
133|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conversation, needs frequent prompting or assistance.|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conver|88
134|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|88
135|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|88
136|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately stop activities, jeopardizes safety through actions|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately st|88
137|2 - Indwelling/suprapubic catheter|2 - Indwelling/suprapubic catheter|88
138|2 - Injury caused by fall or accident at home|2 - Injury caused by fall or accident at home|88
139|2 - Medicare (HMO/managed care/Advantage plan)|2 - Medicare (HMO/managed care/Advantage plan)|88
140|2 - Nausea, dehydration, malnutrition, constipation, impaction|2 - Nausea, dehydration, malnutrition, constipation, impaction|88
141|2 - Obesity|2 - Obesity|88
142|2 - On awakening or at night only|2 - On awakening or at night only|88
143|2 - Once a month|2 - Once a month|88
144|2 - One to three times weekly|2 - One to three times weekly|88
145|2 - Parenteral nutrition (TPN or lipids)|2 - Parenteral nutrition (TPN or lipids)|88
146|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic) [ Go to M1620]|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic) [ Go|88
147|2 - Patient requires considerable assistance from another person to manage equipment, but independently completes portions of the task.|2 - Patient requires considerable assistance from another person to manage equipment, but independen|88
148|2 - Patient transferred to a noninstitutional hospice|2 - Patient transferred to a noninstitutional hospice|88
149|2 - Person residing in the home (EXCLUDING paid help)|2 - Person residing in the home (EXCLUDING paid help)|88
150|2 - Rehabilitation facility|2 - Rehabilitation facility|88
151|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifting of attention) or consistently requires low stimulus environment due to distractibility.|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifti|88
152|2 - Respite care|2 - Respite care|88
153|2 - Sense of failure or self reproach|2 - Sense of failure or self reproach|88
154|2 - Several times during day|2 - Several times during day|88
155|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonresponsive.|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonrespons|88
156|2 - Someone must assist the patient to groom self.|2 - Someone must assist the patient to groom self.|88
157|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|88
158|2 - Someone must help the patient put on upper body clothing.|2 - Someone must help the patient put on upper body clothing.|88
159|2 - Stage 2|2 - Stage 2|88
160|2 - Start of care - no further visits planned|2 - Start of care - no further visits planned|88
161|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitoring|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitori|88
162|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment regimen.|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment re|88
163|2 - Two|2 - Two|88
164|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistance due to cognitive or mental limitation.|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistanc|88
165|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|88
166|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assistance).|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assis|88
167|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home delivery.|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home deli|88
168|2 - Unable to prepare any light meals or reheat any delivered meals.|2 - Unable to prepare any light meals or reheat any delivered meals.|88
169|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|88
170|2 - UNABLE to take injectable medications unless administered by someone else.|2 - UNABLE to take injectable medications unless administered by someone else.|88
171|2 - UNABLE to take medication unless administered by someone else.|2 - UNABLE to take medication unless administered by someone else.|88
172|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|88
173|2 - Ventilator (continually or at night)|2 - Ventilator (continually or at night)|88
174|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less than 20 feet)|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less th|88
175|2 - With spouse or significant other|2 - With spouse or significant other|88
176|2 - Yes, assistance or services provided by family or friends|2 - Yes, assistance or services provided by family or friends|88
177|2-PT|2-PT|88
178|3 - Able to answer the telephone only some of the time or is able to carry on only a limited conversation.|3 - Able to answer the telephone only some of the time or is able to carry on only a limited convers|88
179|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube or gastrostomy.|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube|88
180|3 - Alcohol dependency|3 - Alcohol dependency|88
181|3 - All of the time|3 - All of the time|88
182|3 - Black or African-American|3 - Black or African-American|88
183|3 - Boarding home or rented room|3 - Boarding home or rented room|88
184|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment, clean/store/dispose of equipment or supplies).|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment,|88
185|3 -Able to walk only with the supervision or assistance of another person at all times.|3 -Able to walk only with the supervision or assistance of another person at all times.|88
186|3 - Continuous / Bi-level positive airway pressure|3 - Continuous / Bi-level positive airway pressure|88
187|3 - During the day and evening, but not constantly|3 - During the day and evening, but not constantly|88
188|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the alimentary canal)|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the|88
189|3 - Environmental support (e.g., housing, home maintenance)|3 - Environmental support (e.g., housing, home maintenance)|88
190|3 - Four to six times weekly|3 - Four to six times weekly|88
191|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessing by listener.  Speech limited to single words or short phrases.|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessin|88
192|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires multiple repetitions, restatements, demonstrations, additional time.|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires m|88
193|3 - Hopelessness|3 - Hopelessness|88
194|3 - Hospice care|3 - Hospice care|88
195|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|88
196|3 - Injury caused by fall or accident at home|3 - Injury caused by fall or accident at home|88
197|3 - Intractable pain|3 - Intractable pain|88
198|3 - Medicaid (traditional fee-for-service)|3 - Medicaid (traditional fee-for-service)|88
199|3 - Needs someone to do all shopping and errands.|3 - Needs someone to do all shopping and errands.|88
200|3 - Not healing|3 - Not healing|88
201|3 - Nursing home|3 - Nursing home|88
202|3 - Once daily|3 - Once daily|88
203|3 - Other family member|3 - Other family member|88
204|3 - Outpatient department/clinic emergency (includes urgicenter sites)|3 - Outpatient department/clinic emergency (includes urgicenter sites)|88
205|3 - Paid help|3 - Paid help|88
206|3 - Able to participate in bathing self in shower or tub, but requires presence of another person throughout the bath for assistance or supervision.|3 - Able to participate in bathing self in shower or tub, but requires presence of another person th|88
207|3 - Patient depends entirely upon another person to dress lower body.|3 - Patient depends entirely upon another person to dress lower body.|88
208|3 - Patient depends entirely upon another person to dress the upper body.|3 - Patient depends entirely upon another person to dress the upper body.|88
209|3 - Patient depends entirely upon someone else for grooming needs.|3 - Patient depends entirely upon someone else for grooming needs.|88
210|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone else to manage the equipment.|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone|88
211|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable to shift attention and recall directions more than half the time.|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable|88
212|3 - Respiratory problems (SOB, infection, obstruction)|3 - Respiratory problems (SOB, infection, obstruction)|88
213|3 - Resumption of care (after inpatient stay)|3 - Resumption of care (after inpatient stay)|88
214|3 - Several times each month|3 - Several times each month|88
215|3 - Skilled Nursing Facility|3 - Skilled Nursing Facility|88
216|3 - Stage 3|3 - Stage 3|88
217|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|88
218|3 - Three|3 - Three|88
219|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person throughout the process.|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person through|88
220|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal independently.|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal indep|88
221|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person.|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person|88
222|3 - Unknown because patient moved to a geographic location not served by this agency|3 - Unknown because patient moved to a geographic location not served by this agency|88
223|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|88
224|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|88
225|3 - With other family member|3 - With other family member|88
226|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home health services, homemaker assistance, transportation assistance, assisted living, board and care)|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home h|88
227|3-SLP/ST|3-SLP/ST|88
228|4 - At rest (during day or night)|4 - At rest (during day or night)|88
229|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|88
230|4 - Board and care or assisted living facility|4 - Board and care or assisted living facility|88
231|4 - Caregiver is completely dependent on someone else to manage all equipment.|4 - Caregiver is completely dependent on someone else to manage all equipment.|88
232|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|88
233|4 - Constantly|4 - Constantly|88
234|4 - Drug dependency|4 - Drug dependency|88
235|4 - Four or more|4 - Four or more|88
236|4 - Friend or neighbor or community or church member|4 - Friend or neighbor or community or church member|88
237|4 - Hispanic or Latino|4 - Hispanic or Latino|88
238|4 - Hospice|4 - Hospice|88
239|4 - Impaired decision-making|4 - Impaired decision-making|88
240|4 - Is totally dependent in toileting.|4 - Is totally dependent in toileting.|88
241|4 - Medicaid (HMO/managed care)|4 - Medicaid (HMO/managed care)|88
242|4 - None of the above|4 - None of the above|88
243|4 - Nursing home|4 - Nursing home|88
244|4 - On a daily basis|4 - On a daily basis|88
245|4 - Patient is completely dependent on someone else to manage all equipment.|4 - Patient is completely dependent on someone else to manage all equipment.|88
246|4 - Permanent placement|4 - Permanent placement|88
247|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, punches, dangerous maneuvers w/ wheelchair or other objects)|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, pu|88
248|4 - Psychosocial support (e.g., socialization, companionship, recreation)|4 - Psychosocial support (e.g., socialization, companionship, recreation)|88
249|4 - Recertification (follow-up) reassessment|4 - Recertification (follow-up) reassessment|88
250|4 - Recurrent thoughts of death|4 - Recurrent thoughts of death|88
251|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruction)|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruc|88
252|4 - Several times a week|4 - Several times a week|88
253|4 - Stage 4|4 - Stage 4|88
254|4 - Symptoms poorly controlled, history of rehospitalizations|4 - Symptoms poorly controlled, history of rehospitalizations|88
255|4 - Three or more times per week|4 - Three or more times per week|88
256|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetative state, or delirium.|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetati|88
257|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|88
258|4 - Unable to effectively participate in any housekeeping tasks.|4 - Unable to effectively participate in any housekeeping tasks.|88
259|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or unresponsive (e.g., speech is nonsensical or unintelligible).|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or u|88
260|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonresponsive.|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonr|88
261|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostomy.|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostom|88
262|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of devices at the sink, in chair, or on commode|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of|88
263|4 - With a friend|4 - With a friend|88
264|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|88
265|4-OT|4-OT|88
266|5 - Advocates or facilitates patient's participation in appropriate medical care|5 - Advocates or facilitates patient's participation in appropriate medical care|88
267|5 - At least daily|5 - At least daily|88
268|6 - Bedfast, unable to ambulate or be up in a chair.|6 - Bedfast, unable to ambulate or be up in a chair.|88
269|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|88
270|5 - Disruptive or socially inappropriate behavior|5 - Disruptive or socially inappropriate behavior|88
271|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|88
272|5 - Hypo/Hyperglycemia, diabetes out of control|5 - Hypo/Hyperglycemia, diabetes out of control|88
273|5 - More often than once daily|5 - More often than once daily|88
274|5 - Native Hawaiian or Pacific Islander|5 - Native Hawaiian or Pacific Islander|88
275|5 - None of the above|5 - None of the above|88
276|5 - One to two times per week|5 - One to two times per week|88
277|5 - Other|5 - Other|88
278|5 - Other follow-up|5 - Other follow-up|88
279|5 - Paid help|5 - Paid help|88
280|5 - Patient nonresponsive or unable to speak.|5 - Patient nonresponsive or unable to speak.|88
281|5 - Thoughts of suicide|5 - Thoughts of suicide|88
282|5 - Totally unable to use the telephone.|5 - Totally unable to use the telephone.|88
283|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|88
284|5 - Unable to take in nutrients orally or by tube feeding.|5 - Unable to take in nutrients orally or by tube feeding.|88
285|5 - Unsafe for care at home|5 - Unsafe for care at home|88
286|5 - With paid help (other than home care agency staff)|5 - With paid help (other than home care agency staff)|88
287|5 - Workers' compensation|5 - Workers' compensation|88
288|5 - Wound infection, deteriorating wound status, new lesion/ulcer|5 - Wound infection, deteriorating wound status, new lesion/ulcer|88
289|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|88
290|6 - Delusional, hallucinatory, or paranoid behavior|6 - Delusional, hallucinatory, or paranoid behavior|88
291|6 - Financial agent, power of attorney, or conservator of finance|6 - Financial agent, power of attorney, or conservator of finance|88
292|6 - GI bleeding, obstruction|6 - GI bleeding, obstruction|88
293|6 - Less often than weekly|6 - Less often than weekly|88
294|6 - Memory loss to the extent that supervision required|6 - Memory loss to the extent that supervision required|88
295|6 - None of the above feelings observed or reported|6 - None of the above feelings observed or reported|88
296|6 - Other|6 - Other|88
297|6 - Title programs (e.g., Title III, V, or XX)|6 - Title programs (e.g., Title III, V, or XX)|88
298|6 - Transferred to an inpatient facility - patient not discharged from agency|6 - Transferred to an inpatient facility - patient not discharged from agency|88
299|6 - White|6 - White|88
300|6 - With other than above|6 - With other than above|88
301|7 - Exacerbation of CHF, fluid overload, heart failure|7 - Exacerbation of CHF, fluid overload, heart failure|88
302|7 - Health care agent, conservator of person, or medical power of attorney|7 - Health care agent, conservator of person, or medical power of attorney|88
303|7 - Hypo/Hyperglycemia, diabetes out of control|7 - Hypo/Hyperglycemia, diabetes out of control|88
304|7 - None of the above|7 - None of the above|88
305|7 - None of the above behaviors demonstrated|7 - None of the above behaviors demonstrated|88
306|7 - Other government (e.g., TriCare, VA, etc.)|7 - Other government (e.g., TriCare, VA, etc.)|88
307|7 - Transferred to an inpatient facility - patient discharged from agency|7 - Transferred to an inpatient facility - patient discharged from agency|88
308|8 - Death at home|8 - Death at home|88
309|8 - GI bleeding, obstruction|8 - GI bleeding, obstruction|88
310|8 - Myocardial infarction, stroke|8 - Myocardial infarction, stroke|88
311|8 - Private insurance|8 - Private insurance|88
312|9 - Chemotherapy|9 - Chemotherapy|88
313|9 - Discharge from agency|9 - Discharge from agency|88
314|9 - Other than above reasons|9 - Other than above reasons|88
315|9 - Private HMO/managed care|9 - Private HMO/managed care|88
316|NA - No caregiver|NA - No caregiver|88
317|NA - No equipment of this type used in care.|NA - No equipment of this type used in care.|88
318|NA - No inhalant/mist medications prescribed.|NA - No inhalant/mist medications prescribed.|88
319|NA - No injectable medications prescribed.|NA - No injectable medications prescribed.|88
320|NA - No inpatient facility admission|NA - No inpatient facility admission|88
321|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|88
322|NA - No Medicaid|NA - No Medicaid|88
323|NA - No Medicare|NA - No Medicare|88
324|NA - No observable pressure ulcer or unhealed pressure ulcer|NA - No observable pressure ulcer or unhealed pressure ulcer|88
325|NA - No observable stasis ulcer|NA - No observable stasis ulcer|88
326|NA - No observable surgical wound|NA - No observable surgical wound|88
327|NA - No oral medications prescribed.|NA - No oral medications prescribed.|88
328|NA - Not applicable|NA - Not applicable|88
329|NA - Patient does not have a telephone.|NA - Patient does not have a telephone.|88
330|NA - Patient has ostomy for bowel elimination|NA - Patient has ostomy for bowel elimination|88
331|NA - Patient nonresponsive|NA - Patient nonresponsive|88
332|NA - Patient on prophylactic treatment|NA - Patient on prophylactic treatment|88
333|NA - Patient was not discharged from an inpatient facility [Go to M1017]|NA - Patient was not discharged from an inpatient facility [Go to M1017]|88
334|UK - Other unknown|UK - Other unknown|88
335|UK - Reason unknown|UK - Reason unknown|88
336|UK - Unknown|UK - Unknown|88
337|UK - Unknown or Not Available|UK - Unknown or Not Available|88
341|01 - Early|01 - Early|88
342|02 - Late|02 - Late|88
343|NA - Not Applicable. No case mix group defined for this assessment.|NA - Not Applicable. No case mix group defined for this assessment.|88
344|NA - No case mix group defined by this assessment.|NA - No case mix group defined by this assessment.|88
345|1 - Recent decline in mental, emotional, or behavioral status|1 - Recent decline in mental, emotional, or behavioral status|88
346|2 - Multiple hospitalizations (2 or more) in the past 12 months|2 - Multiple hospitalizations (2 or more) in the past 12 months|88
347|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|88
348|4 - Taking five or more medications|4 - Taking five or more medications|88
349|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|88
350|6 - Other|6 - Other|88
351|7 - None of the above|7 - None of the above|88
352|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond tho|88
353|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable without heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable wi|88
354|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious complications and death.|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious compl|88
355|3 - The patient has serious progressive conditions that could lead to death within a year.|3 - The patient has serious progressive conditions that could lead to death within a year.|88
356|UK - The patient+s situation is unknown or unclear.|UK - The patient+s situation is unknown or unclear.|88
357|1 - Yes [ Go to M1050 ]|1 - Yes [ Go to M1050 ]|88
358|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this influenza season. [ Go to M1050 ]|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this i|88
359|1 - Received from another health care provider (e.g., physician)|1 - Received from another health care provider (e.g., physician)|88
360|2 - Received from your agency previously during this year+s flu season|2 - Received from your agency previously during this year+s flu season|88
361|3 - Offered and declined|3 - Offered and declined|88
362|4 - Assessed and determined to have medical contraindication(s)|4 - Assessed and determined to have medical contraindication(s)|88
363|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|88
364|6 - Inability to obtain vaccine due to declared shortage|6 - Inability to obtain vaccine due to declared shortage|88
365|1 - Yes [ Go to M2005 at TRN; Go to M1230 at DC ]|1 - Yes [ Go to M2005 at TRN; Go to M1230 at DC ]|88
366|1 - Patient has received PPV in the past|1 - Patient has received PPV in the past|88
367|2 - Offered and declined|2 - Offered and declined|88
368|3 - Assessed and determined to have medical contraindication(s)|3 - Assessed and determined to have medical contraindication(s)|88
369|4 - Not indicated; patient does not meet age/condition guidelines for PPV|4 - Not indicated; patient does not meet age/condition guidelines for PPV|88
370|5 - None of the above|5 - None of the above|88
371|0 - Adequate: hears normal conversation without difficulty.|0 - Adequate: hears normal conversation without difficulty.|88
372|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to increase volume or speak distinctly.|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to in|88
373|2 - Severely Impaired: absence of useful hearing.|2 - Severely Impaired: absence of useful hearing.|88
374|UK - Unable to assess hearing.|UK - Unable to assess hearing.|88
375|0 - Understands: clear comprehension without cues or repetitions.|0 - Understands: clear comprehension without cues or repetitions.|88
376|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Requires cues at times to understand.|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Req|88
377|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequently requires cues to understand.|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequentl|88
378|3 - Rarely/Never Understands|3 - Rarely/Never Understands|88
379|UK - Unable to assess understanding.|UK - Unable to assess understanding.|88
380|0 - No standardized assessment conducted|0 - No standardized assessment conducted|88
381|1 - Yes, and it does not indicate severe pain|1 - Yes, and it does not indicate severe pain|88
382|2 - Yes, and it indicates severe pain|2 - Yes, and it indicates severe pain|88
383|0 - Patient has no pain|0 - Patient has no pain|88
384|1 - Patient has pain that does not interfere with activity or movement|1 - Patient has pain that does not interfere with activity or movement|88
385|2 - Less often than daily|2 - Less often than daily|88
386|3 - Daily, but not constantly|3 - Daily, but not constantly|88
387|4 - All of the time|4 - All of the time|88
388|0 - No assessment conducted [ Go to M1306 ]|0 - No assessment conducted [ Go to M1306 ]|88
389|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc., without use of standardized tool|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc.,|88
390|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|88
391|0 - No [ Go to M1322]|0 - No [ Go to M1322]|88
392|0 v Newly epithelialized|0 v Newly epithelialized|88
393|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|88
394|2 - Yes, patient has observable stasis ulcers ONLY|2 - Yes, patient has observable stasis ulcers ONLY|88
395|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable dressing) [Go to M1340]|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable|88
396|0 - No [ Go to M1350 ]|0 - No [ Go to M1350 ]|88
397|1 - Yes, patient has at least one (observable) surgical wound|1 - Yes, patient has at least one (observable) surgical wound|88
398|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1350 ]|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1350 ]|88
399|0 - Patient is not short of breath|0 - Patient is not short of breath|88
400|3 - Continuous Bi-level positive airway pressure|3 - Continuous Bi-level positive airway pressure|88
401|0 - No [ Go to M2005 at TRN; Go to M1600 at DC ]|0 - No [ Go to M2005 at TRN; Go to M1600 at DC ]|88
402|2 - Not assessed [Go to M2005 at TRN; Go to M1600 at DC ]|2 - Not assessed [Go to M2005 at TRN; Go to M1600 at DC ]|88
403|NA - Patient does not have diagnosis of heart failure [Go to M2005 at TRN; Go to M1600 at DC]|NA - Patient does not have diagnosis of heart failure [Go to M2005 at TRN; Go to M1600 at DC]|88
404|0 - No action taken|0 - No action taken|88
405|1 - Patient+s physician (or other primary care practitioner) contacted the same day|1 - Patient+s physician (or other primary care practitioner) contacted the same day|88
406|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|88
407|3 - Implement physician-ordered patient-specific established parameters for treatment|3 - Implement physician-ordered patient-specific established parameters for treatment|88
408|4 - Patient education or other clinical interventions|4 - Patient education or other clinical interventions|88
409|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequency, telehealth, etc.)|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequ|88
410|1 - Occasional stress incontinence|1 - Occasional stress incontinence|88
411|2 - During the night only|2 - During the night only|88
412|3 - During the day only|3 - During the day only|88
413|4 - During the day and night|4 - During the day and night|88
414|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|88
415|0 - Able to manage toileting hygiene and clothing management without assistance.|0 - Able to manage toileting hygiene and clothing management without assistance.|88
416|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implements are laid out for the patient.|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implemen|88
417|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|88
418|3 - Patient depends entirely upon another person to maintain toileting hygiene.|3 - Patient depends entirely upon another person to maintain toileting hygiene.|88
419|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independent|88
420|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface|88
421|0 - No multi-factor falls risk assessment conducted.|0 - No multi-factor falls risk assessment conducted.|88
422|1 - Yes, and it does not indicate a risk for falls.|1 - Yes, and it does not indicate a risk for falls.|88
423|2 - Yes, and it indicates a risk for falls.|2 - Yes, and it indicates a risk for falls.|88
424|0 - Not assessed/reviewed [ Go to M2010 ]|0 - Not assessed/reviewed [ Go to M2010 ]|88
425|1 - No problems found during review [ Go to M2010 ]|1 - No problems found during review [ Go to M2010 ]|88
426|2 - Problems found during review|2 - Problems found during review|88
427|NA - Patient is not taking any medications [ Go to M2040 ]|NA - Patient is not taking any medications [ Go to M2040 ]|88
428|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special precautions associated with all high-risk medications|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special p|88
429|NA - Patient not taking any drugs|NA - Patient not taking any drugs|88
430|2 - Able to take medication(s) at the correct times if given reminders by another person at the appropriate times|2 - Able to take medication(s) at the correct times if given reminders by another person at the appr|88
431|3 - Unable to take medication unless administered by another person.|3 - Unable to take medication unless administered by another person.|88
432|1 - At least daily|1 - At least daily|88
433|2 - Three or more times per week|2 - Three or more times per week|88
434|3 - One to two times per week|3 - One to two times per week|88
435|4 - Received, but less often than weekly|4 - Received, but less often than weekly|88
436|5 - No assistance received|5 - No assistance received|88
437|0 - No [Go to M2401]|0 - No [Go to M2401]|88
438|1 - Yes, used hospital emergency department WITHOUT hospital admission|1 - Yes, used hospital emergency department WITHOUT hospital admission|88
439|2 - Yes, used hospital emergency department WITH hospital admission|2 - Yes, used hospital emergency department WITH hospital admission|88
440|UK - Unknown [Go to M2401]|UK - Unknown [Go to M2401]|88
441|2 - Injury caused by fall|2 - Injury caused by fall|88
442|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|88
443|4 - Other respiratory problem|4 - Other respiratory problem|88
444|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|88
445|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|88
446|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|88
447|8 - Other heart disease|8 - Other heart disease|88
448|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|88
449|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|88
450|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|88
451|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|88
452|13 - Urinary tract infection|13 - Urinary tract infection|88
453|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|88
454|15 - Wound infection or deterioration|15 - Wound infection or deterioration|88
455|16 - Uncontrolled pain|16 - Uncontrolled pain|88
456|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|88
457|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|88
458|19 - Other than above reasons|19 - Other than above reasons|88
459|2 - Patient remained in the community (with formal assistive services)|2 - Patient remained in the community (with formal assistive services)|88
460|3 - Patient transferred to a noninstitutional hospice|3 - Patient transferred to a noninstitutional hospice|88
461|4 - Unknown because patient moved to a geographic location not served by this agency|4 - Unknown because patient moved to a geographic location not served by this agency|88
462|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|88
463|4 - Other respiratory problem|4 - Other respiratory problem|88
464|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|88
465|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|88
466|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|88
467|8 - Other heart disease|8 - Other heart disease|88
468|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|88
469|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|88
470|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|88
471|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|88
472|13 - Urinary tract infection|13 - Urinary tract infection|88
473|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|88
474|15 - Wound infection or deterioration|15 - Wound infection or deterioration|88
475|16 - Uncontrolled pain|16 - Uncontrolled pain|88
476|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|88
477|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|88
478|19 - Scheduled treatment or procedure|19 - Scheduled treatment or procedure|88
479|20 - Other than above reasons|20 - Other than above reasons|88
480|UK - Reason unknown [Go to M0903]|UK - Reason unknown [Go to M0903]|88
482|01 - Patient lives alone around the clock|01 - Patient lives alone around the clock|88
483|02 - Patient lives alone regular daytime|02 - Patient lives alone regular daytime|88
484|03 - Patient lives alone regular nighttime|03 - Patient lives alone regular nighttime|88
485|04 - Patient lives alone occassional/short term assistance|04 - Patient lives alone occassional/short term assistance|88
486|05 - Patient lives alone no assisstance available|05 - Patient lives alone no assisstance available|88
487|06 - Patient lives with other person(s) in the home around the clock|06 - Patient lives with other person(s) in the home around the clock|88
488|07 - Patient lives with other person(s) in the home regular daytime|07 - Patient lives with other person(s) in the home regular daytime|88
489|08 - Patient lives with other person(s) in the home regular nighttime|08 - Patient lives with other person(s) in the home regular nighttime|88
490|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|88
491|10 - Patient lives with other person(s) in the home no assistance available|10 - Patient lives with other person(s) in the home no assistance available|88
492|1 - Was present at the most recent SOC/ROC assessment|1 - Was present at the most recent SOC/ROC assessment|88
493|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|88
494|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|88
495|0 - Newly epithelialized|0 - Newly epithelialized|88
496|0 - No [ Go to M1340 ]|0 - No [ Go to M1340 ]|88
498|0 - Independent|0 - Independent|88
499|1 - Needed Some Help|1 - Needed Some Help|88
500|2 - Dependent|2 - Dependent|88
502|0 - No assistance needed in this area|0 - No assistance needed in this area|88
503|1 - Caregiver(s) currently provide assistance|1 - Caregiver(s) currently provide assistance|88
504|2 - Caregiver(s) need training/ supportive services to provide assistance|2 - Caregiver(s) need training/ supportive services to provide assistance|88
505|3 - Caregiver(s) not likely to provide assistance|3 - Caregiver(s) not likely to provide assistance|88
506|4 - Unclear if Caregiver(s) will provide assistance|4 - Unclear if Caregiver(s) will provide assistance|88
507|5 - Assistance needed, but no Caregiver(s) available|5 - Assistance needed, but no Caregiver(s) available|88
508|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will use standardized clinical guidelines accessible for all care providers to reference|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will|88
510|NA - Patient is not assessed to be at risk for falls|NA - Patient is not assessed to be at risk for falls|88
511|NA - Patient has no diagnosis or symptoms of depression|NA - Patient has no diagnosis or symptoms of depression|88
512|NA - No pain identified|NA - No pain identified|88
513|NA - Patient is not assessed to be at risk for pressure ulcers|NA - Patient is not assessed to be at risk for pressure ulcers|88
514|NA - Patient has no pressure ulcers with need for moist wound healing|NA - Patient has no pressure ulcers with need for moist wound healing|88
515|1 - Long-term nursing facility (NF)|1 - Long-term nursing facility (NF)|88
516|2 - Skilled nursing facility (SNF / TCU)|2 - Skilled nursing facility (SNF / TCU)|88
517|3 - Short stay acute hospital (IPP S)|3 - Short stay acute hospital (IPP S)|88
518|4 - Long-term care hospital (LTCH)|4 - Long-term care hospital (LTCH)|88
519|5 - Inpatient rehabilitation hospital or unit (IRF)|5 - Inpatient rehabilitation hospital or unit (IRF)|88
520|6 - Psychiatric hospital or unit|6 - Psychiatric hospital or unit|88
521|7 - Other|7 - Other|88
522|NA - Patient was not discharged from an inpatient facility [Go to M1017]|NA - Patient was not discharged from an inpatient facility [Go to M1017]|88
523|6 - Unable to participate effectively in bathing and is bathed totally by another person|6 - Unable to participate effectively in bathing and is bathed totally by another person|88
524|4 - Chairfast, unable to ambulate but is able to wheel self independently.|4 - Chairfast, unable to ambulate but is able to wheel self independently.|88
525|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask patient: "Over the last two weeks, how often have you been bothered by any of the following problems")|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask|88
526|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluation for depression.|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluat|88
527|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet criteria for further evaluation for depression.|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet|88
528|0 - Not at all  0 - 1 day|0 - Not at all  0 - 1 day|88
529|1 - Several days  2 - 6 days|1 - Several days  2 - 6 days|88
530|2 - More than half of the days  7 - 11 days|2 - More than half of the days  7 - 11 days|88
531|3 - Nearly every day  12 - 14 days|3 - Nearly every day  12 - 14 days|88
532|NA - N/A  Unable to respond|NA - N/A  Unable to respond|88
533|2 - Able to take medication(s) at the correct times if given reminders by another person based on the frequency of the injection|2 - Able to take medication(s) at the correct times if given reminders by another person based on th|88
534|3 - Unable to take injectable medication unless administered by another person.|3 - Unable to take injectable medication unless administered by another person.|88
547|NA - There were no potential clinically significant medication issues identified since SOC/ROC or patient is not taking any medications|NA v There were no potential clinically significant medication issues identified since SOC/ROC |88
552|1 - Hospital|1 - Hospital [ Go to M2430 ]|88
553|2 - Rehabilitation facility|2 - Rehabilitation facility [ Go to M0903 ]|88
554|3 - Nursing home|3 - Nursing home [ Go to M2440 ]|88
555|4 - Hospice|4 - Hospice [ Go to M0903 ]|88
653|0 - No [STOP]|0 - No [STOP]|88
654|1 - Yes |1 - Yes|88
655|0 - None|0 - None|88
656|1 - One|1 - One|88
657|2 - Two or More|2 - Two or More|88
660|1 - Dependent - A helper completed the activities for the patient.|1 - Dependent - A helper completed the activities for the patient.|89
659|2 - Needed Some Help - Patient needed partial assistance from another person to complete activities.|2 - Needed Some Help - Patient needed partial assistance from another person to complete activities.|89
657|2 - Two or More|2 - Two or More|89
658|3 - Independent - Patient completed the activities by him/herself, with or without an assistive device, with no assistance from a helper.|3 - Independent - Patient completed the activities by him/herself, with or without an assistive devi|89
653|0 - No [STOP]|0 - No [STOP]|89
654|1 - Yes |1 - Yes|89
655|0 - None|0 - None|89
656|1 - One|1 - One|89
661|8 - Unknown|8 - Unknown|89
662|9 - Not Applicable|9 - Not Applicable|89
663|A - Manual wheelchair|A - Manual wheelchair|89
664|B - Motorized wheelchair and/or scooter|B - Motorized wheelchair and/or scooter|89
665|C - Mechanical lift|C - Mechanical lift|89
666|D - Walker|D - Walker|89
667|E - Orthotics/Prosthetics|E - Orthotics/Prosthetics|89
668|Z - None of the above|Z - None of the above|89
637|06 - Independent - Patient completes the activity by him/herself with no assistance from a helper.|06 - Independent - Patient completes the activity by him/herself with no assistance from a helper.|89
638|05 - Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity.|05 - Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper|89
639|04 - Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently.|04 - Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/|89
640|03 - Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort.|03 - Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or sup|89
641|02 - Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.|02 - Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds t|89
642|01 - Dependent - Helper does ALL of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity.|01 - Dependent - Helper does ALL of the effort. Patient does none of the effort to complete the acti|89
643|07 - Patient refused|07 - Patient refused|89
644|09 - Not applicable - Not attempted and the patient did not perform this activity prior to the current illness,exacerbation or injury.|09 - Not applicable - Not attempted and the patient did not perform this activity prior to the curre|89
645|10 - Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)|10 - Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)|89
646|88 - Not attempted due to medical conditions or safety concerns|88 - Not attempted due to medical conditions or safety concerns|89
647|0 - No [Skip GG0170R, GG0170RR, GG0170S, and GG0170SS]|0 - No [Skip GG0170R, GG0170RR1, GG0170S, and GG0170SS1.]|89
648|0 - No [Skip GG0170R]|0 - No [Skip GG0170R]|89
649|1 - Yes |1 - Yes [Continue to GG0170R, Wheel 50 feet with two turns.]|89
650|1 - Manual|1 - Manual|89
651|2 - Motorized|2 - Motorized|89
652|0 - No [Skip to J1800 Any falls since SOC/ROC, whichever is more recent.]|0 - No [Skip to J1800 Any falls since SOC/ROC, whichever is more recent.]|89
47|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or supervision from another person OR c) a liquid, pureed or ground meat diet.|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or su|89
2|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; OR (b) Is physically, cognitively, and mentally able to prepare light meals on a regular basis but has not routinely performed light meal preparation in the past (i.e., prior to this home care admission).|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; O|89
3|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and mentally able to perform all housekeeping tasks .|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and menta|89
4|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and mentally able to do laundry and access facilities.|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and menta|89
5|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying packages OR b) Physically, cognitively, and mentally able to take care of shopping, but has not done shopping in the past (i.e., prior to this home care admission).|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying|89
6|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|89
7|0 - Able to dial numbers and answer calls appropriately and as desired.|0 - Able to dial numbers and answer calls appropriately and as desired.|89
8|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body without assistance.|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body|89
9|0 - Able to get to and from the toilet and transfer independently with or without a device.|0 - Able to get to and from the toilet and transfer independently with or without a device.|89
10|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|89
11|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible public bus.|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible p|89
12|0 - Able to independently feed self.|0 - Able to independently feed self.|89
13|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|89
14|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct times.|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct ti|89
15|0 - Able to independently transfer.|0 - Able to independently transfer.|89
16|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without rail|89
17|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings|89
18|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|89
19|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions independently.|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions indep|89
20|0 - Asymptomatic, no treatment needed at this time|0 - Asymptomatic, no treatment needed at this time|89
21|0 - Caregiver manages all tasks related to equipment completely independently.|0 - Caregiver manages all tasks related to equipment completely independently.|89
22|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations with no observable impairment.|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations w|89
23|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|89
24|0 - Life expectancy is greater than 6 months|0 - Life expectancy is greater than 6 months|89
25|0 - Never|0 - Never|89
26|0 - Patient is not short of breath|0 - Patient is not short of breath|89
27|0 - No|0 - No|89
28|0 - No emergent care services|0 - No emergent care services|89
29|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [Goto M1620]|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [Goto M1620]|89
30|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and extended or abstract conversation.|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and exte|89
31|0 - No one person|0 - No one person|89
32|0 - None of the time|0 - None of the time|89
33|0 - None, no charge for current services|0 - None, no charge for current services|89
34|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|89
35|0 - Patient does NOT have an ostomy for bowel elimination.|0 - Patient does NOT have an ostomy for bowel elimination.|89
36|0 - Patient has no pain|0 - Patient has no pain|89
37|0 - Patient manages all tasks related to equipment completely independently.|0 - Patient manages all tasks related to equipment completely independently.|89
38|0 - Poor:  little or no recovery is expected and/or further decline is imminent|0 - Poor:  little or no recovery is expected and/or further decline is imminent|89
39|0 - Timed-voiding defers incontinence|0 - Timed-voiding defers incontinence|89
40|0 - Very rarely or never has bowel incontinence|0 - Very rarely or never has bowel incontinence|89
41|0 - Zero|0 - Zero|89
42|00 - No|00 - No|89
43|01 - Yes|01 - Yes|89
44|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or mental limitations, needs assistance with heavy laundry.|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or|89
45|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the patient.|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the|89
46|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|89
48|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|89
49|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|89
50|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independently.|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independe|89
51|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only when assisted or accompanied by another person.|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only w|89
52|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepa|89
53|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance by another person OR b) given daily reminders.|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance b|89
54|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advan|89
55|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advan|89
56|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for the deaf) and call essential numbers.|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for t|89
57|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|89
58|1 - American Indian or Alaska Native|1 - American Indian or Alaska Native|89
59|1 - Depressed mood (e.g., feeling sad, tearful)|1 - Depressed mood (e.g., feeling sad, tearful)|89
60|1 - During the night only|1 - During the night only|89
61|1 - Fully granulating|1 - Fully granulating|89
62|1 - Good/Fair:  partial to full recovery is expected|1 - Good/Fair:  partial to full recovery is expected|89
63|1 - Good:  marked improvement in functional status is expected|1 - Good:  marked improvement in functional status is expected|89
64|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|89
65|1 - Smoking|1 - Smoking|89
66|1 - Hospital|1 - Hospital [ Go to M2430 ]|89
67|1 - Hospital emergency room (includes 23-hour holding)|1 - Hospital emergency room (includes 23-hour holding)|89
68|1 - Hospitalization for EMERGENT (unscheduled) care|1 - Hospitalization for EMERGENT (unscheduled) care|89
69|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepared solutions), patient is able to manage all other aspects of equipment.|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepar|89
70|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|89
71|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|89
72|1 - In new or complex situations only|1 - In new or complex situations only|89
73|1 - Intravenous or infusion therapy (excludes TPN)|1 - Intravenous or infusion therapy (excludes TPN)|89
74|1 - Less often than daily|1 - Less often than daily|89
75|1 - Less than once a month|1 - Less than once a month|89
76|1 - Less than once weekly|1 - Less than once weekly|89
77|1 - Life expectancy is 6 months or fewer|1 - Life expectancy is 6 months or fewer|89
78|1 - Lives alone|1 - Lives alone|89
79|1 - Male|1 - Male|89
80|1 - Medicare (traditional fee-for-service)|1 - Medicare (traditional fee-for-service)|89
81|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of past 24 hours, significant memory loss so that supervision is required|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of pas|89
82|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors in word choice, grammar or speech intelligibility, needs minimal prompting or assistance).|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors i|89
83|1 - No assistance or services received|1 - No assistance or services received|89
84|1 - One|1 - One|89
85|1 - Oxygen (intermittent or continuous)|1 - Oxygen (intermittent or continuous)|89
86|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, and the surrounding layout, can count fingers at arm's length.|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, a|89
87|1 - Patient is incontinent|1 - Patient is incontinent|89
88|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|89
89|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical or treatment regimen.|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical|89
90|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient/couple/significant other)|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient|89
91|1 - Relatives, friends, or neighbors living outside the home|1 - Relatives, friends, or neighbors living outside the home|89
92|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions.|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions|89
93|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independentl|89
94|1 - Several times during day and night|1 - Several times during day and night|89
95|1 - Spouse or significant other|1 - Spouse or significant other|89
96|1 - Stage 1|1 - Stage 1|89
97|1 - Start of care - further visits planned|1 - Start of care - further visits planned|89
98|1 - Symptoms well controlled with current therapy|1 - Symptoms well controlled with current therapy|89
99|1 - Therapy services|1 - Therapy services|89
100|1 - Able to transfer with minimal human assistance or with use of an assistive device.|1 - Able to transfer with minimal human assistance or with use of an assistive device.|89
101|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitations.|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitatio|89
102|1 - Urinary incontinence|1 - Urinary incontinence|89
103|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and transfer.|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and|89
104|1 - When walking more than 20 feet, climbing stairs|1 - When walking more than 20 feet, climbing stairs|89
105|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary conversation. May need occasional repetition, extra time, or louder voice.|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary c|89
106|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting in and out of tub/shower|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting|89
107|1 - Yes|1 - Yes|89
108|1-RN|1-RN|89
109|10 - Discharge from agency - no visits completed after start/resumption of care assessment|10 - Discharge from agency - no visits completed after start/resumption of care assessment|89
110|10 - Scheduled surgical procedure|10 - Scheduled surgical procedure|89
111|10 - Self-pay|10 - Self-pay|89
112|11 - Other|11 - Other|89
113|11 - Urinary tract infection|11 - Urinary tract infection|89
114|12 - IV catheter-related infection|12 - IV catheter-related infection|89
115|13 - Deep vein thrombosis, pulmonary embolus|13 - Deep vein thrombosis, pulmonary embolus|89
116|14 - Uncontrolled pain|14 - Uncontrolled pain|89
117|15 - Psychotic episode|15 - Psychotic episode|89
118|16 - Other than above reasons|16 - Other than above reasons|89
119|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing calls.|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing|89
120|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another person.|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another pers|89
121|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface a|89
122|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for intermittent supervision or encouragement or reminders, OR (b) to get in and out of the shower or tub, OR (c) for washing difficult to reach areas.|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for inter|89
123|2 - Asian|2 - Asian|89
124|2 - Caregiver requires considerable assistance from another person to manage equipment, but independently completes significant portions of task.|2 - Caregiver requires considerable assistance from another person to manage equipment, but independ|89
125|2 - Daily, but not constantly|2 - Daily, but not constantly|89
126|2 - Daughter or son|2 - Daughter or son|89
127|2 - Doctor's office emergency visit/house call|2 - Doctor's office emergency visit/house call|89
128|2 - During the day and night|2 - During the day and night|89
129|2 - Early/partial granulation|2 - Early/partial granulation|89
130|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors in word choice, organization or speech intelligibility). Speaks in phrases or short sentences.|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors|89
131|2 - Family member's residence|2 - Family member's residence|89
132|2 - Female|2 - Female|89
133|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conversation, needs frequent prompting or assistance.|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conver|89
134|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|89
135|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|89
136|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately stop activities, jeopardizes safety through actions|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately st|89
137|2 - Indwelling/suprapubic catheter|2 - Indwelling/suprapubic catheter|89
138|2 - Injury caused by fall or accident at home|2 - Injury caused by fall or accident at home|89
139|2 - Medicare (HMO/managed care/Advantage plan)|2 - Medicare (HMO/managed care/Advantage plan)|89
140|2 - Nausea, dehydration, malnutrition, constipation, impaction|2 - Nausea, dehydration, malnutrition, constipation, impaction|89
141|2 - Obesity|2 - Obesity|89
142|2 - On awakening or at night only|2 - On awakening or at night only|89
143|2 - Once a month|2 - Once a month|89
144|2 - One to three times weekly|2 - One to three times weekly|89
145|2 - Parenteral nutrition (TPN or lipids)|2 - Parenteral nutrition (TPN or lipids)|89
146|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic) [ Go to M1620 ]|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic) [ Go|89
147|2 - Patient requires considerable assistance from another person to manage equipment, but independently completes portions of the task.|2 - Patient requires considerable assistance from another person to manage equipment, but independen|89
148|2 - Patient transferred to a noninstitutional hospice|2 - Patient transferred to a noninstitutional hospice|89
149|2 - Person residing in the home (EXCLUDING paid help)|2 - Person residing in the home (EXCLUDING paid help)|89
150|2 - Rehabilitation facility|2 - Rehabilitation facility [ Go to M0906 ]|89
151|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifting of attention) or consistently requires low stimulus environment due to distractibility.|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifti|89
152|2 - Respite care|2 - Respite care|89
153|2 - Sense of failure or self reproach|2 - Sense of failure or self reproach|89
154|2 - Several times during day|2 - Several times during day|89
155|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonresponsive.|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonrespons|89
156|2 - Someone must assist the patient to groom self.|2 - Someone must assist the patient to groom self.|89
157|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|89
158|2 - Someone must help the patient put on upper body clothing.|2 - Someone must help the patient put on upper body clothing.|89
159|2 - Stage 2|2 - Stage 2|89
160|2 - Start of care - no further visits planned|2 - Start of care - no further visits planned|89
161|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitoring|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitori|89
162|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment regimen.|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment re|89
163|2 - Two|2 - Two|89
164|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistance due to cognitive or mental limitation.|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistanc|89
165|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|89
166|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assistance).|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assis|89
167|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home delivery.|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home deli|89
168|2 - Unable to prepare any light meals or reheat any delivered meals.|2 - Unable to prepare any light meals or reheat any delivered meals.|89
169|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|89
170|2 - UNABLE to take injectable medications unless administered by someone else.|2 - UNABLE to take injectable medications unless administered by someone else.|89
171|2 - UNABLE to take medication unless administered by someone else.|2 - UNABLE to take medication unless administered by someone else.|89
172|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|89
173|2 - Ventilator (continually or at night)|2 - Ventilator (continually or at night)|89
174|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less than 20 feet)|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less th|89
175|2 - With spouse or significant other|2 - With spouse or significant other|89
176|2 - Yes, assistance or services provided by family or friends|2 - Yes, assistance or services provided by family or friends|89
177|2-PT|2-PT|89
178|3 - Able to answer the telephone only some of the time or is able to carry on only a limited conversation.|3 - Able to answer the telephone only some of the time or is able to carry on only a limited convers|89
179|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube or gastrostomy.|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube|89
180|3 - Alcohol dependency|3 - Alcohol dependency|89
181|3 - All of the time|3 - All of the time|89
182|3 - Black or African-American|3 - Black or African-American|89
183|3 - Boarding home or rented room|3 - Boarding home or rented room|89
184|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment, clean/store/dispose of equipment or supplies).|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment,|89
185|3 -Able to walk only with the supervision or assistance of another person at all times.|3 -Able to walk only with the supervision or assistance of another person at all times.|89
186|3 - Continuous / Bi-level positive airway pressure|3 - Continuous / Bi-level positive airway pressure|89
187|3 - During the day and evening, but not constantly|3 - During the day and evening, but not constantly|89
188|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the alimentary canal)|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the|89
189|3 - Environmental support (e.g., housing, home maintenance)|3 - Environmental support (e.g., housing, home maintenance)|89
190|3 - Four to six times weekly|3 - Four to six times weekly|89
191|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessing by listener.  Speech limited to single words or short phrases.|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessin|89
192|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires multiple repetitions, restatements, demonstrations, additional time.|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires m|89
193|3 - Hopelessness|3 - Hopelessness|89
194|3 - Hospice care|3 - Hospice care|89
195|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|89
196|3 - Injury caused by fall or accident at home|3 - Injury caused by fall or accident at home|89
197|3 - Intractable pain|3 - Intractable pain|89
198|3 - Medicaid (traditional fee-for-service)|3 - Medicaid (traditional fee-for-service)|89
199|3 - Needs someone to do all shopping and errands.|3 - Needs someone to do all shopping and errands.|89
200|3 - Not healing|3 - Not healing|89
201|3 - Nursing home|3 - Nursing home [ Go to M2440 ]|89
202|3 - Once daily|3 - Once daily|89
203|3 - Other family member|3 - Other family member|89
204|3 - Outpatient department/clinic emergency (includes urgicenter sites)|3 - Outpatient department/clinic emergency (includes urgicenter sites)|89
205|3 - Paid help|3 - Paid help|89
206|3 - Able to participate in bathing self in shower or tub, but requires presence of another person throughout the bath for assistance or supervision.|3 - Able to participate in bathing self in shower or tub, but requires presence of another person th|89
207|3 - Patient depends entirely upon another person to dress lower body.|3 - Patient depends entirely upon another person to dress lower body.|89
208|3 - Patient depends entirely upon another person to dress the upper body.|3 - Patient depends entirely upon another person to dress the upper body.|89
209|3 - Patient depends entirely upon someone else for grooming needs.|3 - Patient depends entirely upon someone else for grooming needs.|89
210|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone else to manage the equipment.|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone|89
211|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable to shift attention and recall directions more than half the time.|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable|89
212|3 - Respiratory problems (SOB, infection, obstruction)|3 - Respiratory problems (SOB, infection, obstruction)|89
213|3 - Resumption of care (after inpatient stay)|3 - Resumption of care (after inpatient stay)|89
214|3 - Several times each month|3 - Several times each month|89
215|3 - Skilled Nursing Facility|3 - Skilled Nursing Facility|89
216|3 - Stage 3|3 - Stage 3|89
217|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|89
218|3 - Three|3 - Three|89
219|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person throughout the process.|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person through|89
220|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal independently.|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal indep|89
221|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person.|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person|89
222|3 - Unknown because patient moved to a geographic location not served by this agency|3 - Unknown because patient moved to a geographic location not served by this agency|89
223|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|89
224|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|89
225|3 - With other family member|3 - With other family member|89
226|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home health services, homemaker assistance, transportation assistance, assisted living, board and care)|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home h|89
227|3-SLP/ST|3-SLP/ST|89
228|4 - At rest (during day or night)|4 - At rest (during day or night)|89
229|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|89
230|4 - Board and care or assisted living facility|4 - Board and care or assisted living facility|89
231|4 - Caregiver is completely dependent on someone else to manage all equipment.|4 - Caregiver is completely dependent on someone else to manage all equipment.|89
232|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|89
233|4 - Constantly|4 - Constantly|89
234|4 - Drug dependency|4 - Drug dependency|89
235|4 - Four or more|4 - Four or more|89
236|4 - Friend or neighbor or community or church member|4 - Friend or neighbor or community or church member|89
237|4 - Hispanic or Latino|4 - Hispanic or Latino|89
238|4 - Hospice|4 - Hospice [ Go to M0906 ]|89
239|4 - Impaired decision-making|4 - Impaired decision-making|89
240|4 - Is totally dependent in toileting.|4 - Is totally dependent in toileting.|89
241|4 - Medicaid (HMO/managed care)|4 - Medicaid (HMO/managed care)|89
242|4 - None of the above|4 - None of the above|89
243|4 - Nursing home|4 - Nursing home|89
244|4 - On a daily basis|4 - On a daily basis|89
245|4 - Patient is completely dependent on someone else to manage all equipment.|4 - Patient is completely dependent on someone else to manage all equipment.|89
246|4 - Permanent placement|4 - Permanent placement|89
247|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, punches, dangerous maneuvers w/ wheelchair or other objects)|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, pu|89
248|4 - Psychosocial support (e.g., socialization, companionship, recreation)|4 - Psychosocial support (e.g., socialization, companionship, recreation)|89
249|4 - Recertification (follow-up) reassessment|4 - Recertification (follow-up) reassessment|89
250|4 - Recurrent thoughts of death|4 - Recurrent thoughts of death|89
251|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruction)|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruc|89
252|4 - Several times a week|4 - Several times a week|89
253|4 - Stage 4|4 - Stage 4|89
254|4 - Symptoms poorly controlled, history of re-hospitalizations|4 - Symptoms poorly controlled, history of re-hospitalizations|89
255|4 - Three or more times per week|4 - Three or more times per week|89
256|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetative state, or delirium.|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetati|89
257|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|89
258|4 - Unable to effectively participate in any housekeeping tasks.|4 - Unable to effectively participate in any housekeeping tasks.|89
259|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or unresponsive (e.g., speech is nonsensical or unintelligible).|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or u|89
260|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonresponsive.|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonr|89
261|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostomy.|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostom|89
262|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of devices at the sink, in chair, or on commode|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of|89
263|4 - With a friend|4 - With a friend|89
264|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|89
265|4-OT|4-OT|89
266|5 - Advocates or facilitates patient's participation in appropriate medical care|5 - Advocates or facilitates patient's participation in appropriate medical care|89
267|5 - At least daily|5 - At least daily|89
268|6 - Bedfast, unable to ambulate or be up in a chair.|6 - Bedfast, unable to ambulate or be up in a chair.|89
269|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|89
270|5 - Disruptive or socially inappropriate behavior|5 - Disruptive or socially inappropriate behavior|89
271|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|89
272|5 - Hypo/Hyperglycemia, diabetes out of control|5 - Hypo/Hyperglycemia, diabetes out of control|89
273|5 - More often than once daily|5 - More often than once daily|89
274|5 - Native Hawaiian or Pacific Islander|5 - Native Hawaiian or Pacific Islander|89
275|5 - None of the above|5 - None of the above|89
276|5 - One to two times per week|5 - One to two times per week|89
277|5 - Other|5 - Other|89
278|5 - Other follow-up|5 - Other follow-up|89
279|5 - Paid help|5 - Paid help|89
280|5 - Patient nonresponsive or unable to speak.|5 - Patient nonresponsive or unable to speak.|89
281|5 - Thoughts of suicide|5 - Thoughts of suicide|89
282|5 - Totally unable to use the telephone.|5 - Totally unable to use the telephone.|89
283|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|89
284|5 - Unable to take in nutrients orally or by tube feeding.|5 - Unable to take in nutrients orally or by tube feeding.|89
285|5 - Unsafe for care at home|5 - Unsafe for care at home|89
286|5 - With paid help (other than home care agency staff)|5 - With paid help (other than home care agency staff)|89
287|5 - Workers' compensation|5 - Workers' compensation|89
288|5 - Wound infection, deteriorating wound status, new lesion/ulcer|5 - Wound infection, deteriorating wound status, new lesion/ulcer|89
289|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|89
290|6 - Delusional, hallucinatory, or paranoid behavior|6 - Delusional, hallucinatory, or paranoid behavior|89
291|6 - Financial agent, power of attorney, or conservator of finance|6 - Financial agent, power of attorney, or conservator of finance|89
292|6 - GI bleeding, obstruction|6 - GI bleeding, obstruction|89
293|6 - Less often than weekly|6 - Less often than weekly|89
294|6 - Memory loss to the extent that supervision required|6 - Memory loss to the extent that supervision required|89
295|6 - None of the above feelings observed or reported|6 - None of the above feelings observed or reported|89
296|6 - Other|6 - Other|89
297|6 - Title programs (e.g., Title III, V, or XX)|6 - Title programs (e.g., Title III, V, or XX)|89
298|6 - Transferred to an inpatient facility - patient not discharged from agency|6 - Transferred to an inpatient facility - patient not discharged from agency|89
299|6 - White|6 - White|89
300|6 - With other than above|6 - With other than above|89
301|7 - Exacerbation of CHF, fluid overload, heart failure|7 - Exacerbation of CHF, fluid overload, heart failure|89
302|7 - Health care agent, conservator of person, or medical power of attorney|7 - Health care agent, conservator of person, or medical power of attorney|89
303|7 - Hypo/Hyperglycemia, diabetes out of control|7 - Hypo/Hyperglycemia, diabetes out of control|89
304|7 - None of the above|7 - None of the above|89
305|7 - None of the above behaviors demonstrated|7 - None of the above behaviors demonstrated|89
306|7 - Other government (e.g., TriCare, VA, etc.)|7 - Other government (e.g., TriCare, VA, etc.)|89
307|7 - Transferred to an inpatient facility - patient discharged from agency|7 - Transferred to an inpatient facility - patient discharged from agency|89
308|8 - Death at home|8 - Death at home|89
309|8 - GI bleeding, obstruction|8 - GI bleeding, obstruction|89
310|8 - Myocardial infarction, stroke|8 - Myocardial infarction, stroke|89
311|8 - Private insurance|8 - Private insurance|89
312|9 - Chemotherapy|9 - Chemotherapy|89
313|9 - Discharge from agency|9 - Discharge from agency|89
314|9 - Other than above reasons|9 - Other than above reasons|89
315|9 - Private HMO/managed care|9 - Private HMO/managed care|89
316|NA - No caregiver|NA - No caregiver|89
317|NA - No equipment of this type used in care.|NA - No equipment of this type used in care.|89
318|NA - No inhalant/mist medications prescribed.|NA - No inhalant/mist medications prescribed.|89
319|NA - No injectable medications prescribed.|NA - No injectable medications prescribed.|89
320|NA - No inpatient facility admission|NA - No inpatient facility admission|89
321|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|89
322|NA - No Medicaid|NA - No Medicaid|89
323|NA - No Medicare|NA - No Medicare|89
324|NA - No observable pressure ulcer|NA - No observable pressure ulcer|89
325|NA - No observable stasis ulcer|NA - No observable stasis ulcer|89
326|NA - No observable surgical wound|NA - No observable surgical wound|89
327|NA - No oral medications prescribed.|NA - No oral medications prescribed.|89
328|NA - Not applicable|NA - Not applicable|89
329|NA - Patient does not have a telephone.|NA - Patient does not have a telephone.|89
330|NA - Patient has ostomy for bowel elimination|NA - Patient has ostomy for bowel elimination|89
331|NA - Patient nonresponsive|NA - Patient nonresponsive|89
332|NA - Patient on prophylactic treatment|NA - Patient on prophylactic treatment|89
333|NA - Patient was not discharged from an inpatient facility [Go to M1017]|NA - Patient was not discharged from an inpatient facility [Go to M1017]|89
334|UK - Other unknown|UK - Other unknown|89
335|UK - Reason unknown|UK - Reason unknown|89
336|UK - Unknown|UK - Unknown|89
337|UK - Unknown or Not Available|UK - Unknown or Not Available|89
341|01 - Early|01 - Early|89
342|02 - Late|02 - Late|89
343|NA - Not Applicable. No case mix group defined for this assessment.|NA - Not Applicable. No case mix group defined for this assessment.|89
344|NA - No case mix group defined by this assessment.|NA - No case mix group defined by this assessment.|89
345|1 - Recent decline in mental, emotional, or behavioral status|1 - Recent decline in mental, emotional, or behavioral status|89
346|2 - Multiple hospitalizations (2 or more) in the past 12 months|2 - Multiple hospitalizations (2 or more) in the past 12 months|89
347|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|89
348|4 - Taking five or more medications|4 - Taking five or more medications|89
349|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|89
350|6 - Other|6 - Other|89
351|7 - None of the above|7 - None of the above|89
352|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond tho|89
353|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable without heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable wi|89
354|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious complications and death.|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious compl|89
355|3 - The patient has serious progressive conditions that could lead to death within a year.|3 - The patient has serious progressive conditions that could lead to death within a year.|89
356|UK - The patient+s situation is unknown or unclear.|UK - The patient+s situation is unknown or unclear.|89
357|0 - No [ Go to M1051 ]|0 - No [ Go to M1051 ]|89
358|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this influenza season. [ Go to M1050 ]|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this i|89
359|1 - Received from another health care provider (e.g., physician)|1 - Received from another health care provider (e.g., physician)|89
360|2 - Received from your agency previously during this year+s flu season|2 - Received from your agency previously during this year+s flu season|89
361|3 - Offered and declined|3 - Offered and declined|89
362|4 - Assessed and determined to have medical contraindication(s)|4 - Assessed and determined to have medical contraindication(s)|89
363|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|89
364|6 - Inability to obtain vaccine due to declared shortage|6 - Inability to obtain vaccine due to declared shortage|89
365|1 - Yes [ Go to M2005 at TRN; Go to M1230 at DC ]|1 - Yes [ Go to M2005 at TRN; Go to M1230 at DC ]|89
366|1 - Patient has received PPV in the past|1 - Patient has received PPV in the past|89
367|2 - Offered and declined|2 - Offered and declined|89
368|3 - Assessed and determined to have medical contraindication(s)|3 - Assessed and determined to have medical contraindication(s)|89
369|4 - Not indicated; patient does not meet age/condition guidelines for PPV|4 - Not indicated; patient does not meet age/condition guidelines for PPV|89
370|5 - None of the above|5 - None of the above|89
371|0 - Adequate: hears normal conversation without difficulty.|0 - Adequate: hears normal conversation without difficulty.|89
372|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to increase volume or speak distinctly.|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to in|89
373|2 - Severely Impaired: absence of useful hearing.|2 - Severely Impaired: absence of useful hearing.|89
374|UK - Unable to assess hearing.|UK - Unable to assess hearing.|89
375|0 - Understands: clear comprehension without cues or repetitions.|0 - Understands: clear comprehension without cues or repetitions.|89
376|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Requires cues at times to understand.|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Req|89
377|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequently requires cues to understand.|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequentl|89
378|3 - Rarely/Never Understands|3 - Rarely/Never Understands|89
379|UK - Unable to assess understanding.|UK - Unable to assess understanding.|89
380|0 - No standardized assessment conducted|0 - No standardized assessment conducted|89
381|1 - Yes, and it does not indicate severe pain|1 - Yes, and it does not indicate severe pain|89
382|2 - Yes, and it indicates severe pain|2 - Yes, and it indicates severe pain|89
383|0 - Patient has no pain|0 - Patient has no pain|89
384|1 - Patient has pain that does not interfere with activity or movement|1 - Patient has pain that does not interfere with activity or movement|89
385|2 - Less often than daily|2 - Less often than daily|89
386|3 - Daily, but not constantly|3 - Daily, but not constantly|89
387|4 - All of the time|4 - All of the time|89
388|0 - No assessment conducted [ Go to M1306 ]|0 - No assessment conducted [ Go to M1306 ]|89
389|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc., without use of standardized tool|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc.,|89
390|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|89
391|0 - No [ Go to M1322]|0 - No [ Go to M1322]|89
392|0 v Newly epithelialized|0 v Newly epithelialized|89
393|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|89
394|2 - Yes, patient has observable stasis ulcers ONLY|2 - Yes, patient has observable stasis ulcers ONLY|89
395|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable dressing) [Go to M1340]|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable|89
396|0 - No [ Go to M1400 ]|0 - No [ Go to M1400 ]|89
397|1 - Yes, patient has at least one (observable) surgical wound|1 - Yes, patient has at least one (observable) surgical wound|89
398|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1400 ]|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1400 ]|89
399|0 - Patient is not short of breath|0 - Patient is not short of breath|89
400|3 - Continuous Bi-level positive airway pressure|3 - Continuous Bi-level positive airway pressure|89
401|0 - No [ Go to M2005 at TRN; Go to M1600 at DC ]|0 - No [ Go to M2005 at TRN; Go to M1600 at DC ]|89
402|2 - Not assessed [Go to M2005 at TRN; Go to M1600 at DC ]|2 - Not assessed [Go to M1732 at TRN; Go to M1600 at DC ]|89
403|NA - Patient does not have diagnosis of heart failure [Go to M2005 at TRN; Go to M1600 at DC]|NA - Patient does not have diagnosis of heart failure [Go to M2005 at TRN; Go to M1600 at DC]|89
404|0 - No action taken|0 - No action taken|89
405|1 - Patient+s physician (or other primary care practitioner) contacted the same day|1 - Patient+s physician (or other primary care practitioner) contacted the same day|89
406|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|89
407|3 - Implement physician-ordered patient-specific established parameters for treatment|3 - Implement physician-ordered patient-specific established parameters for treatment|89
408|4 - Patient education or other clinical interventions|4 - Patient education or other clinical interventions|89
409|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequency, telehealth, etc.)|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequ|89
410|1 - Occasional stress incontinence|1 - Occasional stress incontinence|89
411|2 - During the night only|2 - During the night only|89
412|3 - During the day only|3 - During the day only|89
413|4 - During the day and night|4 - During the day and night|89
414|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|89
415|0 - Able to manage toileting hygiene and clothing management without assistance.|0 - Able to manage toileting hygiene and clothing management without assistance.|89
416|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implements are laid out for the patient.|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implemen|89
417|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|89
418|3 - Patient depends entirely upon another person to maintain toileting hygiene.|3 - Patient depends entirely upon another person to maintain toileting hygiene.|89
419|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independent|89
420|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface|89
421|0 - No multi-factor falls risk assessment conducted.|0 - No multi-factor falls risk assessment conducted.|89
422|1 - Yes, and it does not indicate a risk for falls.|1 - Yes, and it does not indicate a risk for falls.|89
423|2 - Yes, and it indicates a risk for falls.|2 - Yes, and it indicates a risk for falls.|89
424|0 - Not assessed/reviewed [ Go to M2010 ]|0 - Not assessed/reviewed [ Go to M2010 ]|89
425|1 - No problems found during review [ Go to M2010 ]|1 - No problems found during review [ Go to M2010 ]|89
426|2 - Problems found during review|2 - Problems found during review|89
427|NA - Patient is not taking any medications [ Go to M2040 ]|NA - Patient is not taking any medications [ Go to M2040 ]|89
428|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special precautions associated with all high-risk medications|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special p|89
429|NA - Patient not taking any drugs|NA - Patient not taking any drugs|89
430|2 - Able to take medication(s) at the correct times if given reminders by another person at the appropriate times|2 - Able to take medication(s) at the correct times if given reminders by another person at the appr|89
431|3 - Unable to take medication unless administered by another person.|3 - Unable to take medication unless administered by another person.|89
432|1 - At least daily|1 - At least daily|89
433|2 - Three or more times per week|2 - Three or more times per week|89
434|3 - One to two times per week|3 - One to two times per week|89
435|4 - Received, but less often than weekly|4 - Received, but less often than weekly|89
436|5 - No assistance received|5 - No assistance received|89
437|0 - No [Go to M2401]|0 - No [Go to M2401]|89
438|1 - Yes, used hospital emergency department WITHOUT hospital admission|1 - Yes, used hospital emergency department WITHOUT hospital admission|89
439|2 - Yes, used hospital emergency department WITH hospital admission|2 - Yes, used hospital emergency department WITH hospital admission|89
440|UK - Unknown [Go to M2401]|UK - Unknown [Go to M2401]|89
441|2 - Injury caused by fall|2 - Injury caused by fall|89
442|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|89
443|4 - Other respiratory problem|4 - Other respiratory problem|89
444|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|89
445|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|89
446|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|89
447|8 - Other heart disease|8 - Other heart disease|89
448|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|89
449|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|89
450|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|89
451|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|89
452|13 - Urinary tract infection|13 - Urinary tract infection|89
453|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|89
454|15 - Wound infection or deterioration|15 - Wound infection or deterioration|89
455|16 - Uncontrolled pain|16 - Uncontrolled pain|89
456|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|89
457|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|89
458|19 - Other than above reasons|19 - Other than above reasons|89
459|2 - Patient remained in the community (with formal assistive services)|2 - Patient remained in the community (with formal assistive services)|89
460|3 - Patient transferred to a noninstitutional hospice|3 - Patient transferred to a noninstitutional hospice|89
461|4 - Unknown because patient moved to a geographic location not served by this agency|4 - Unknown because patient moved to a geographic location not served by this agency|89
462|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|89
463|4 - Other respiratory problem|4 - Other respiratory problem|89
464|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|89
465|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|89
466|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|89
467|8 - Other heart disease|8 - Other heart disease|89
468|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|89
469|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|89
470|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|89
471|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|89
472|13 - Urinary tract infection|13 - Urinary tract infection|89
473|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|89
474|15 - Wound infection or deterioration|15 - Wound infection or deterioration|89
475|16 - Uncontrolled pain|16 - Uncontrolled pain|89
476|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|89
477|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|89
478|19 - Scheduled treatment or procedure|19 - Scheduled treatment or procedure|89
479|20 - Other than above reasons|20 - Other than above reasons|89
480|UK - Reason unknown [Go to M0903]|UK - Reason unknown [Go to M0903]|89
482|01 - Patient lives alone around the clock|01 - Patient lives alone around the clock|89
483|02 - Patient lives alone regular daytime|02 - Patient lives alone regular daytime|89
484|03 - Patient lives alone regular nighttime|03 - Patient lives alone regular nighttime|89
485|04 - Patient lives alone occassional/short term assistance|04 - Patient lives alone occassional/short term assistance|89
486|05 - Patient lives alone no assisstance available|05 - Patient lives alone no assisstance available|89
487|06 - Patient lives with other person(s) in the home around the clock|06 - Patient lives with other person(s) in the home around the clock|89
488|07 - Patient lives with other person(s) in the home regular daytime|07 - Patient lives with other person(s) in the home regular daytime|89
489|08 - Patient lives with other person(s) in the home regular nighttime|08 - Patient lives with other person(s) in the home regular nighttime|89
490|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|89
491|10 - Patient lives with other person(s) in the home no assistance available|10 - Patient lives with other person(s) in the home no assistance available|89
492|1 - Was present at the most recent SOC/ROC assessment [Goto M1311A1]|1 - Was present at the most recent SOC/ROC assessment [Goto M1311A1]|89
493|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|89
494|NA - No non-epithelialized Stage II pressure ulcers are present at discharge [Goto M1311A1]|NA - No non-epithelialized Stage II pressure ulcers are present at discharge [Goto M1311A1]|89
495|0 - Newly epithelialized|0 - Newly epithelialized|89
496|0 - No [ Go to M1340 ]|0 - No [ Go to M1340 ]|89
498|0 - Independent|0 - Independent|89
499|1 - Needed Some Help|1 - Needed Some Help|89
500|2 - Dependent|2 - Dependent|89
502|0 - No assistance needed in this area|0 - No assistance needed in this area|89
503|1 - Caregiver(s) currently provide assistance|1 - Caregiver(s) currently provide assistance|89
504|2 - Caregiver(s) need training/ supportive services to provide assistance|2 - Caregiver(s) need training/ supportive services to provide assistance|89
505|3 - Caregiver(s) not likely to provide assistance|3 - Caregiver(s) not likely to provide assistance|89
506|4 - Unclear if Caregiver(s) will provide assistance|4 - Unclear if Caregiver(s) will provide assistance|89
507|5 - Assistance needed, but no Caregiver(s) available|5 - Assistance needed, but no Caregiver(s) available|89
508|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will use standardized clinical guidelines accessible for all care providers to reference|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will|89
510|NA - Patient is not assessed to be at risk for falls|NA - Patient is not assessed to be at risk for falls|89
511|NA - Patient has no diagnosis or symptoms of depression|NA - Patient has no diagnosis or symptoms of depression|89
512|NA - No pain identified|NA - No pain identified|89
513|NA - Patient is not assessed to be at risk for pressure ulcers|NA - Patient is not assessed to be at risk for pressure ulcers|89
514|NA - Patient has no pressure ulcers with need for moist wound healing|NA - Patient has no pressure ulcers with need for moist wound healing|89
515|1 - Long-term nursing facility (NF)|1 - Long-term nursing facility (NF)|89
516|2 - Skilled nursing facility (SNF / TCU)|2 - Skilled nursing facility (SNF / TCU)|89
517|3 - Short stay acute hospital (IPP S)|3 - Short stay acute hospital (IPP S)|89
518|4 - Long-term care hospital (LTCH)|4 - Long-term care hospital (LTCH)|89
519|5 - Inpatient rehabilitation hospital or unit (IRF)|5 - Inpatient rehabilitation hospital or unit (IRF)|89
520|6 - Psychiatric hospital or unit|6 - Psychiatric hospital or unit|89
521|7 - Other|7 - Other|89
522|NA - Patient was not discharged from an inpatient facility [Go to M1017]|NA - Patient was not discharged from an inpatient facility [Go to M1017]|89
523|6 - Unable to participate effectively in bathing and is bathed totally by another person|6 - Unable to participate effectively in bathing and is bathed totally by another person|89
524|4 - Chairfast, unable to ambulate but is able to wheel self independently.|4 - Chairfast, unable to ambulate but is able to wheel self independently.|89
525|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask patient: "Over the last two weeks, how often have you been bothered by any of the following problems")  *Copyright+ Pfizer Inc. All rights reserved. Reproduced with permission.|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask|89
526|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluation for depression.|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluat|89
527|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet criteria for further evaluation for depression.|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet|89
528|0 - Not at all  0 - 1 day|0 - Not at all  0 - 1 day|89
529|1 - Several days  2 - 6 days|1 - Several days  2 - 6 days|89
530|2 - More than half of the days  7 - 11 days|2 - More than half of the days  7 - 11 days|89
531|3 - Nearly every day  12 - 14 days|3 - Nearly every day  12 - 14 days|89
532|NA - N/A  Unable to respond|NA - N/A  Unable to respond|89
533|2 - Able to take medication(s) at the correct times if given reminders by another person based on the frequency of the injection|2 - Able to take medication(s) at the correct times if given reminders by another person based on th|89
534|3 - Unable to take injectable medication unless administered by another person.|3 - Unable to take injectable medication unless administered by another person.|89
570|NA - No observable pressure ulcer or unhealed pressure ulcer|NA - No observable pressure ulcer or unhealed pressure ulcer|89
571|NA - There were no potential clinically significant medication issues identified since SOC/ROC or patient is not taking any medications|NA - There were no potential clinically significant medication issues identified sinc|89
572|NA - Patient is not diabetic or is bilateral amputee|NA - Patient is not diabetic or is bilateral amputee|89
573|NA - Every standardized,validated multifactor fall risk assessment conducted at or since the most recent SOC/ROC assessment indicates the patient has no risk for falls.|NA - Every standardized,validated multifactor fall risk assessment condition|89
574|NA - Patient has no diagnosis of depression AND every standardized, validated depression screening conducted at or since the most recent SOC/ROC assessment indicates the patient has: 1) no symptoms of depression; or 2) has some symptoms of depression but does not meet criteria for further evaluation of depression based on screening tool used.|NA - Patient has no diagnosis of depression AND every standardized, validated |89
575|NA - Every standardized, validated pain assessment conducted at or since the most recent SOC/ROC assessment indicates the patient has no pain.|NA - Every standardized, validated pain assessment conducted at or since the most|89
576|NA - Every standardized, validated pressure ulcer risk assessment conducted at or since the most recent SOC/ROC assessment indicates the patient is not at risk of developing pressure ulcers.|NA - Every standardized, validated pressure ulcer risk assessment conducted|89
577|NA - Dressings that support the principles of moist wound healing not indicated for this patient's pressure ulcers OR patient has no pressure ulcers with need for moist wound healing|NA - Dressings that support the principles of moist wound healing not indicated for this patient's p|89
578|1 - Patient remained in the community (without formal assistive services)|1 - Patient remained in the community (without formal assistive services)|89
579|2 - Patient remained in the community (with formal assistive services)|2 - Patient remained in the community (with formal assistive services)|89
580|3 - Patient transferred to a non-institutional hospice|3 - Patient transferred to a non-institutional hospice|89
581|4 - Unknown because patient moved to a geographic location not served by this agency|4 - Unknown because patient moved to a geographic location not served by this agency|89
620|1 - Yes; received from your agency during this episode of care (SOC/ROC to Transfer/Discharge)|1 - Yes; received from your agency during this episode of care (SOC/ROC to Transfer/Discharge)|89
621|2 - Yes; received from your agency during a prior episode of care (SOC/ROC to Transfer/Discharge)|2 - Yes; received from your agency during a prior episode of care (SOC/ROC to Transfer/Discharge)|89
622|3 - Yes; received from another health care provider (for example physician pharmacist)|3 - Yes; received from another health care provider (for example physician pharmacist)|89
623|4 - No; patient offered and declined |4 - No; patient offered and declined |89
624|5 - No; patient assessed and determined to have medical contraindication(s)|5 - No; patient assessed and determined to have medical contraindication(s)|89
625|6 - No; not indicated - patient does not meet age/condition guidelines for influenza vaccine|6 - No; not indicated - patient does not meet age/condition guidelines for influenza vaccine|89
626|7 - No; inability to obtain vaccine due to declared shortage |7 - No; inability to obtain vaccine due to declared shortage |89
627|8 - No; patient did not receive the vaccine due to reasons other than those listed in responses 4 v 7. |8 - No; patient did not receive the vaccine due to reasons other than those listed in responses 4v7.|89
628|1 - Offered and declined|1 - Offered and declined|89
629|2 - Assessed and determined to have medical contraindication(s) |2 - Assessed and determined to have medical contraindication(s) |89
630|3 - Not indicated; patient does not meet age/condition guidelines for Pneumococcal Vaccine|3 - Not indicated; patient does not meet age/condition guidelines for Pneumococcal Vaccine|89
631|4 - None of the above|4 - None of the above|89
632|0 - No assistance needed v patient is independent or does not have needs in this area|0 - No assistance needed v patient is independent or does not have needs in this area|89
633|1 - Non-agency caregiver(s) currently provide assistance |1 - Non-agency caregiver(s) currently provide assistance |89
634|2 - Non-agency caregiver(s) need training/ supportive services to provide assistance|2 - Non-agency caregiver(s) need training/ supportive services to provide assistance|89
635|3 - Non-agency caregiver(s) are not likely to provide assistance OR it is unclear if they will provide assistance|3 - Non-agency caregiver(s) are not likely to provide assistance OR unclear if will provide asst|89
636|4 - Assistance needed but no non-agency caregiver(s) available|4 - Assistance needed but no non-agency caregiver(s) available|89
165|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|91
166|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assistance).|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assis|91
167|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home delivery.|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home deli|91
168|2 - Unable to prepare any light meals or reheat any delivered meals.|2 - Unable to prepare any light meals or reheat any delivered meals.|91
169|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|91
170|2 - UNABLE to take injectable medications unless administered by someone else.|2 - UNABLE to take injectable medications unless administered by someone else.|91
171|2 - UNABLE to take medication unless administered by someone else.|2 - UNABLE to take medication unless administered by someone else.|91
172|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|91
173|2 - Ventilator (continually or at night)|2 - Ventilator (continually or at night)|91
174|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less than 20 feet)|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less th|91
175|2 - With spouse or significant other|2 - With spouse or significant other|91
176|2 - Yes, assistance or services provided by family or friends|2 - Yes, assistance or services provided by family or friends|91
177|2-PT|2-PT|91
178|3 - Able to answer the telephone only some of the time or is able to carry on only a limited conversation.|3 - Able to answer the telephone only some of the time or is able to carry on only a limited convers|91
179|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube or gastrostomy.|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube|91
180|3 - Alcohol dependency|3 - Alcohol dependency|91
181|3 - All of the time|3 - All of the time|91
182|3 - Black or African-American|3 - Black or African-American|91
183|3 - Boarding home or rented room|3 - Boarding home or rented room|91
184|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment, clean/store/dispose of equipment or supplies).|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment,|91
185|3 -Able to walk only with the supervision or assistance of another person at all times.|3 -Able to walk only with the supervision or assistance of another person at all times.|91
186|3 - Continuous / Bi-level positive airway pressure|3 - Continuous / Bi-level positive airway pressure|91
187|3 - During the day and evening, but not constantly|3 - During the day and evening, but not constantly|91
188|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the alimentary canal)|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the|91
189|3 - Environmental support (e.g., housing, home maintenance)|3 - Environmental support (e.g., housing, home maintenance)|91
190|3 - Four to six times weekly|3 - Four to six times weekly|91
191|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessing by listener.  Speech limited to single words or short phrases.|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessin|91
192|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires multiple repetitions, restatements, demonstrations, additional time.|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires m|91
193|3 - Hopelessness|3 - Hopelessness|91
194|3 - Hospice care|3 - Hospice care|91
195|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|91
196|3 - Injury caused by fall or accident at home|3 - Injury caused by fall or accident at home|91
197|3 - Intractable pain|3 - Intractable pain|91
198|3 - Medicaid (traditional fee-for-service)|3 - Medicaid (traditional fee-for-service)|91
199|3 - Needs someone to do all shopping and errands.|3 - Needs someone to do all shopping and errands.|91
200|3 - Not healing|3 - Not healing|91
201|3 - Nursing home|3 - Nursing home|91
202|3 - Once daily|3 - Once daily|91
203|3 - Other family member|3 - Other family member|91
204|3 - Outpatient department/clinic emergency (includes urgicenter sites)|3 - Outpatient department/clinic emergency (includes urgicenter sites)|91
205|3 - Paid help|3 - Paid help|91
206|3 - Able to participate in bathing self in shower or tub, but requires presence of another person throughout the bath for assistance or supervision.|3 - Able to participate in bathing self in shower or tub, but requires presence of another person th|91
207|3 - Patient depends entirely upon another person to dress lower body.|3 - Patient depends entirely upon another person to dress lower body.|91
208|3 - Patient depends entirely upon another person to dress the upper body.|3 - Patient depends entirely upon another person to dress the upper body.|91
209|3 - Patient depends entirely upon someone else for grooming needs.|3 - Patient depends entirely upon someone else for grooming needs.|91
210|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone else to manage the equipment.|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone|91
211|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable to shift attention and recall directions more than half the time.|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable|91
212|3 - Respiratory problems (SOB, infection, obstruction)|3 - Respiratory problems (SOB, infection, obstruction)|91
213|3 - Resumption of care (after inpatient stay)|3 - Resumption of care (after inpatient stay)|91
214|3 - Several times each month|3 - Several times each month|91
215|3 - Skilled Nursing Facility|3 - Skilled Nursing Facility|91
216|3 - Stage 3|3 - Stage 3|91
217|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|91
218|3 - Three|3 - Three|91
219|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person throughout the process.|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person through|91
220|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal independently.|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal indep|91
221|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person.|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person|91
222|3 - Unknown because patient moved to a geographic location not served by this agency|3 - Unknown because patient moved to a geographic location not served by this agency|91
223|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|91
224|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|91
225|3 - With other family member|3 - With other family member|91
226|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home health services, homemaker assistance, transportation assistance, assisted living, board and care)|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home h|91
227|3-SLP/ST|3-SLP/ST|91
228|4 - At rest (during day or night)|4 - At rest (during day or night)|91
229|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|91
230|4 - Board and care or assisted living facility|4 - Board and care or assisted living facility|91
231|4 - Caregiver is completely dependent on someone else to manage all equipment.|4 - Caregiver is completely dependent on someone else to manage all equipment.|91
232|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|91
233|4 - Constantly|4 - Constantly|91
234|4 - Drug dependency|4 - Drug dependency|91
235|4 - Four or more|4 - Four or more|91
236|4 - Friend or neighbor or community or church member|4 - Friend or neighbor or community or church member|91
237|4 - Hispanic or Latino|4 - Hispanic or Latino|91
238|4 - Hospice|4 - Hospice|91
239|4 - Impaired decision-making|4 - Impaired decision-making|91
240|4 - Is totally dependent in toileting.|4 - Is totally dependent in toileting.|91
241|4 - Medicaid (HMO/managed care)|4 - Medicaid (HMO/managed care)|91
242|4 - None of the above|4 - None of the above|91
243|4 - Nursing home|4 - Nursing home|91
244|4 - On a daily basis|4 - On a daily basis|91
245|4 - Patient is completely dependent on someone else to manage all equipment.|4 - Patient is completely dependent on someone else to manage all equipment.|91
246|4 - Permanent placement|4 - Permanent placement|91
247|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, punches, dangerous maneuvers w/ wheelchair or other objects)|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, pu|91
248|4 - Psychosocial support (e.g., socialization, companionship, recreation)|4 - Psychosocial support (e.g., socialization, companionship, recreation)|91
249|4 - Recertification (follow-up) reassessment|4 - Recertification (follow-up) reassessment|91
250|4 - Recurrent thoughts of death|4 - Recurrent thoughts of death|91
251|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruction)|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruc|91
252|4 - Several times a week|4 - Several times a week|91
253|4 - Stage 4|4 - Stage 4|91
254|4 - Symptoms poorly controlled, history of re-hospitalizations|4 - Symptoms poorly controlled, history of re-hospitalizations|91
255|4 - Three or more times per week|4 - Three or more times per week|91
256|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetative state, or delirium.|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetati|91
257|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|91
258|4 - Unable to effectively participate in any housekeeping tasks.|4 - Unable to effectively participate in any housekeeping tasks.|91
259|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or unresponsive (e.g., speech is nonsensical or unintelligible).|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or u|91
260|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonresponsive.|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonr|91
261|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostomy.|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostom|91
262|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of devices at the sink, in chair, or on commode|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of|91
263|4 - With a friend|4 - With a friend|91
264|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|91
265|4-OT|4-OT|91
266|5 - Advocates or facilitates patient's participation in appropriate medical care|5 - Advocates or facilitates patient's participation in appropriate medical care|91
267|5 - At least daily|5 - At least daily|91
268|6 - Bedfast, unable to ambulate or be up in a chair.|6 - Bedfast, unable to ambulate or be up in a chair.|91
269|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|91
270|5 - Disruptive or socially inappropriate behavior|5 - Disruptive or socially inappropriate behavior|91
271|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|91
272|5 - Hypo/Hyperglycemia, diabetes out of control|5 - Hypo/Hyperglycemia, diabetes out of control|91
273|5 - More often than once daily|5 - More often than once daily|91
274|5 - Native Hawaiian or Pacific Islander|5 - Native Hawaiian or Pacific Islander|91
275|5 - None of the above|5 - None of the above|91
276|5 - One to two times per week|5 - One to two times per week|91
277|5 - Other|5 - Other|91
278|5 - Other follow-up|5 - Other follow-up|91
279|5 - Paid help|5 - Paid help|91
280|5 - Patient nonresponsive or unable to speak.|5 - Patient nonresponsive or unable to speak.|91
281|5 - Thoughts of suicide|5 - Thoughts of suicide|91
282|5 - Totally unable to use the telephone.|5 - Totally unable to use the telephone.|91
283|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|91
284|5 - Unable to take in nutrients orally or by tube feeding.|5 - Unable to take in nutrients orally or by tube feeding.|91
285|5 - Unsafe for care at home|5 - Unsafe for care at home|91
286|5 - With paid help (other than home care agency staff)|5 - With paid help (other than home care agency staff)|91
287|5 - Workers' compensation|5 - Workers' compensation|91
288|5 - Wound infection, deteriorating wound status, new lesion/ulcer|5 - Wound infection, deteriorating wound status, new lesion/ulcer|91
289|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|91
290|6 - Delusional, hallucinatory, or paranoid behavior|6 - Delusional, hallucinatory, or paranoid behavior|91
291|6 - Financial agent, power of attorney, or conservator of finance|6 - Financial agent, power of attorney, or conservator of finance|91
292|6 - GI bleeding, obstruction|6 - GI bleeding, obstruction|91
293|6 - Less often than weekly|6 - Less often than weekly|91
294|6 - Memory loss to the extent that supervision required|6 - Memory loss to the extent that supervision required|91
295|6 - None of the above feelings observed or reported|6 - None of the above feelings observed or reported|91
296|6 - Other|6 - Other|91
297|6 - Title programs (e.g., Title III, V, or XX)|6 - Title programs (e.g., Title III, V, or XX)|91
298|6 - Transferred to an inpatient facility - patient not discharged from agency|6 - Transferred to an inpatient facility - patient not discharged from agency|91
299|6 - White|6 - White|91
300|6 - With other than above|6 - With other than above|91
301|7 - Exacerbation of CHF, fluid overload, heart failure|7 - Exacerbation of CHF, fluid overload, heart failure|91
302|7 - Health care agent, conservator of person, or medical power of attorney|7 - Health care agent, conservator of person, or medical power of attorney|91
303|7 - Hypo/Hyperglycemia, diabetes out of control|7 - Hypo/Hyperglycemia, diabetes out of control|91
304|7 - None of the above|7 - None of the above|91
305|7 - None of the above behaviors demonstrated|7 - None of the above behaviors demonstrated|91
306|7 - Other government (e.g., TriCare, VA, etc.)|7 - Other government (e.g., TriCare, VA, etc.)|91
307|7 - Transferred to an inpatient facility - patient discharged from agency|7 - Transferred to an inpatient facility - patient discharged from agency|91
308|8 - Death at home|8 - Death at home|91
309|8 - GI bleeding, obstruction|8 - GI bleeding, obstruction|91
310|8 - Myocardial infarction, stroke|8 - Myocardial infarction, stroke|91
311|8 - Private insurance|8 - Private insurance|91
312|9 - Chemotherapy|9 - Chemotherapy|91
313|9 - Discharge from agency|9 - Discharge from agency|91
314|9 - Other than above reasons|9 - Other than above reasons|91
315|9 - Private HMO/managed care|9 - Private HMO/managed care|91
316|NA - No caregiver|NA - No caregiver|91
317|NA - No equipment of this type used in care.|NA - No equipment of this type used in care.|91
318|NA - No inhalant/mist medications prescribed.|NA - No inhalant/mist medications prescribed.|91
319|NA - No injectable medications prescribed.|NA - No injectable medications prescribed.|91
320|NA - No inpatient facility admission|NA - No inpatient facility admission|91
321|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|91
322|NA - No Medicaid|NA - No Medicaid|91
323|NA - No Medicare|NA - No Medicare|91
324|NA - No observable pressure ulcer|NA - No observable pressure ulcer|91
325|NA - No observable stasis ulcer|NA - No observable stasis ulcer|91
326|NA - No observable surgical wound|NA - No observable surgical wound|91
327|NA - No oral medications prescribed.|NA - No oral medications prescribed.|91
328|NA - Not applicable|NA - Not applicable|91
329|NA - Patient does not have a telephone.|NA - Patient does not have a telephone.|91
330|NA - Patient has ostomy for bowel elimination|NA - Patient has ostomy for bowel elimination|91
331|NA - Patient nonresponsive|NA - Patient nonresponsive|91
332|NA - Patient on prophylactic treatment|NA - Patient on prophylactic treatment|91
333|NA - Patient was not discharged from an inpatient facility [Go to M1021]|NA - Patient was not discharged from an inpatient facility [Go to M1017]|91
334|UK - Other unknown|UK - Other unknown|91
335|UK - Reason unknown|UK - Reason unknown|91
336|UK - Unknown|UK - Unknown|91
337|UK - Unknown or Not Available|UK - Unknown or Not Available|91
341|01 - Early|01 - Early|91
342|02 - Late|02 - Late|91
343|NA - Not Applicable. No case mix group defined for this assessment.|NA - Not Applicable. No case mix group defined for this assessment.|91
344|NA - No case mix group defined by this assessment.|NA - No case mix group defined by this assessment.|91
345|1 - Recent decline in mental, emotional, or behavioral status|1 - Recent decline in mental, emotional, or behavioral status|91
346|2 - Multiple hospitalizations (2 or more) in the past 12 months|2 - Multiple hospitalizations (2 or more) in the past 12 months|91
347|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|91
348|4 - Taking five or more medications|4 - Taking five or more medications|91
349|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|91
350|6 - Other|6 - Other|91
351|7 - None of the above|7 - None of the above|91
352|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond tho|91
353|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable without heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable wi|91
354|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious complications and death.|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious compl|91
355|3 - The patient has serious progressive conditions that could lead to death within a year.|3 - The patient has serious progressive conditions that could lead to death within a year.|91
356|UK - The patient+s situation is unknown or unclear.|UK - The patient+s situation is unknown or unclear.|91
357|1 - Yes [ Go to M1050 ]|1 - Yes [ Go to M1050 ]|91
358|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this influenza season. [ Go to M1050 ]|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this i|91
359|1 - Received from another health care provider (e.g., physician)|1 - Received from another health care provider (e.g., physician)|91
360|2 - Received from your agency previously during this year+s flu season|2 - Received from your agency previously during this year+s flu season|91
361|3 - Offered and declined|3 - Offered and declined|91
362|4 - Assessed and determined to have medical contraindication(s)|4 - Assessed and determined to have medical contraindication(s)|91
363|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|91
364|6 - Inability to obtain vaccine due to declared shortage|6 - Inability to obtain vaccine due to declared shortage|91
365|1 - Yes [ Go to M2005 at TRN; Go to M1230 at DC ]|1 - Yes [ Go to M2005 at TRN; Go to M1230 at DC ]|91
366|1 - Patient has received PPV in the past|1 - Patient has received PPV in the past|91
367|2 - Offered and declined|2 - Offered and declined|91
368|3 - Assessed and determined to have medical contraindication(s)|3 - Assessed and determined to have medical contraindication(s)|91
369|4 - Not indicated; patient does not meet age/condition guidelines for PPV|4 - Not indicated; patient does not meet age/condition guidelines for PPV|91
370|5 - None of the above|5 - None of the above|91
371|0 - Adequate: hears normal conversation without difficulty.|0 - Adequate: hears normal conversation without difficulty.|91
372|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to increase volume or speak distinctly.|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to in|91
373|2 - Severely Impaired: absence of useful hearing.|2 - Severely Impaired: absence of useful hearing.|91
374|UK - Unable to assess hearing.|UK - Unable to assess hearing.|91
375|0 - Understands: clear comprehension without cues or repetitions.|0 - Understands: clear comprehension without cues or repetitions.|91
376|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Requires cues at times to understand.|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Req|91
377|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequently requires cues to understand.|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequentl|91
378|3 - Rarely/Never Understands|3 - Rarely/Never Understands|91
379|UK - Unable to assess understanding.|UK - Unable to assess understanding.|91
380|0 - No standardized assessment conducted|0 - No standardized assessment conducted|91
381|1 - Yes, and it does not indicate severe pain|1 - Yes, and it does not indicate severe pain|91
382|2 - Yes, and it indicates severe pain|2 - Yes, and it indicates severe pain|91
383|0 - Patient has no pain|0 - Patient has no pain|91
384|1 - Patient has pain that does not interfere with activity or movement|1 - Patient has pain that does not interfere with activity or movement|91
385|2 - Less often than daily|2 - Less often than daily|91
386|3 - Daily, but not constantly|3 - Daily, but not constantly|91
387|4 - All of the time|4 - All of the time|91
388|0 - No assessment conducted [ Go to M1306 ]|0 - No assessment conducted [ Go to M1306 ]|91
389|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc., without use of standardized tool|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc.,|91
390|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|91
391|0 - No [ Go to M1322]|0 - No [ Go to M1322]|91
392|0 v Newly epithelialized|0 - Newly epithelialized|91
393|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|91
394|2 - Yes, patient has observable stasis ulcers ONLY|2 - Yes, patient has observable stasis ulcers ONLY|91
395|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable dressing) [Go to M1340]|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable|91
396|0 - No [ Go to M1400 ]|0 - No [ Go to M1400 ]|91
397|1 - Yes, patient has at least one (observable) surgical wound|1 - Yes, patient has at least one (observable) surgical wound|91
398|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1350 ]|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1350 ]|91
399|0 - Patient is not short of breath|0 - Patient is not short of breath|91
400|3 - Continuous Bi-level positive airway pressure|3 - Continuous Bi-level positive airway pressure|91
401|0 - No [ Go to M1732 at TRN; Go to M1600 at DC ]|0 - No [ Go to M1732 at TRN; Go to M1600 at DC ]|91
402|2 - Not assessed [Go to M1732 at TRN; Go to M1600 at DC ]|2 - Not assessed [Go to M1732 at TRN; Go to M1600 at DC ]|91
403|NA - Patient does not have diagnosis of heart failure [Go to M2005 at TRN; Go to M1600 at DC]|NA - Patient does not have diagnosis of heart failure [Go to M2005 at TRN; Go to M1600 at DC]|91
404|0 - No action taken|0 - No action taken|91
405|1 - Patient+s physician (or other primary care practitioner) contacted the same day|1 - Patient+s physician (or other primary care practitioner) contacted the same day|91
406|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|91
407|3 - Implement physician-ordered patient-specific established parameters for treatment|3 - Implement physician-ordered patient-specific established parameters for treatment|91
408|4 - Patient education or other clinical interventions|4 - Patient education or other clinical interventions|91
409|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequency, telehealth, etc.)|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequ|91
410|1 - Occasional stress incontinence|1 - Occasional stress incontinence|91
411|2 - During the night only|2 - During the night only|91
412|3 - During the day only|3 - During the day only|91
413|4 - During the day and night|4 - During the day and night|91
414|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|91
415|0 - Able to manage toileting hygiene and clothing management without assistance.|0 - Able to manage toileting hygiene and clothing management without assistance.|91
416|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implements are laid out for the patient.|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implemen|91
417|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|91
418|3 - Patient depends entirely upon another person to maintain toileting hygiene.|3 - Patient depends entirely upon another person to maintain toileting hygiene.|91
419|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independent|91
420|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface|91
421|0 - No multi-factor falls risk assessment conducted.|0 - No multi-factor falls risk assessment conducted.|91
422|1 - Yes, and it does not indicate a risk for falls.|1 - Yes, and it does not indicate a risk for falls.|91
423|2 - Yes, and it indicates a risk for falls.|2 - Yes, and it indicates a risk for falls.|91
424|0 - Not assessed/reviewed [ Go to M2010 ]|0 - Not assessed/reviewed [ Go to M2010 ]|91
425|No - No issues found during review [ Go to M2010 ]|No - No issues found during review [ Go to M2010 ]|91
426|Yes - Issues found during review|Yes - Issues found during review|91
427|NA - Patient is not taking any medications [ Go to M2102 ]|NA - Patient is not taking any medications [ Go to M2102 ]|91
428|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special precautions associated with all high-risk medications|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special p|91
429|NA - Patient not taking any drugs|NA - Patient not taking any drugs|91
430|2 - Able to take medication(s) at the correct times if given reminders by another person at the appropriate times|2 - Able to take medication(s) at the correct times if given reminders by another person at the appr|91
431|3 - Unable to take medication unless administered by another person.|3 - Unable to take medication unless administered by another person.|91
432|1 - At least daily|1 - At least daily|91
433|2 - Three or more times per week|2 - Three or more times per week|91
434|3 - One to two times per week|3 - One to two times per week|91
435|4 - Received, but less often than weekly|4 - Received, but less often than weekly|91
436|5 - No assistance received|5 - No assistance received|91
437|0 - No [Go to M2401]|0 - No [Go to M2401]|91
438|1 - Yes, used hospital emergency department WITHOUT hospital admission|1 - Yes, used hospital emergency department WITHOUT hospital admission|91
439|2 - Yes, used hospital emergency department WITH hospital admission|2 - Yes, used hospital emergency department WITH hospital admission|91
440|UK - Unknown [Go to M2401]|UK - Unknown [Go to M2401]|91
441|2 - Injury caused by fall|2 - Injury caused by fall|91
442|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|91
443|4 - Other respiratory problem|4 - Other respiratory problem|91
444|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|91
445|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|91
446|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|91
447|8 - Other heart disease|8 - Other heart disease|91
448|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|91
449|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|91
450|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|91
451|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|91
452|13 - Urinary tract infection|13 - Urinary tract infection|91
453|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|91
454|15 - Wound infection or deterioration|15 - Wound infection or deterioration|91
455|16 - Uncontrolled pain|16 - Uncontrolled pain|91
456|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|91
457|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|91
458|19 - Other than above reasons|19 - Other than above reasons|91
459|2 - Patient remained in the community (with formal assistive services)|2 - Patient remained in the community (with formal assistive services)|91
460|3 - Patient transferred to a noninstitutional hospice|3 - Patient transferred to a noninstitutional hospice|91
461|4 - Unknown because patient moved to a geographic location not served by this agency|4 - Unknown because patient moved to a geographic location not served by this agency|91
462|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|91
463|4 - Other respiratory problem|4 - Other respiratory problem|91
464|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|91
465|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|91
466|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|91
467|8 - Other heart disease|8 - Other heart disease|91
468|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|91
469|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|91
470|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|91
471|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|91
472|13 - Urinary tract infection|13 - Urinary tract infection|91
473|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|91
474|15 - Wound infection or deterioration|15 - Wound infection or deterioration|91
475|16 - Uncontrolled pain|16 - Uncontrolled pain|91
476|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|91
477|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|91
478|19 - Scheduled treatment or procedure|19 - Scheduled treatment or procedure|91
479|20 - Other than above reasons|20 - Other than above reasons|91
480|UK - Reason unknown [Go to M0903]|UK - Reason unknown [Go to M0903]|91
482|01 - Patient lives alone around the clock|01 - Patient lives alone around the clock|91
483|02 - Patient lives alone regular daytime|02 - Patient lives alone regular daytime|91
484|03 - Patient lives alone regular nighttime|03 - Patient lives alone regular nighttime|91
485|04 - Patient lives alone occassional/short term assistance|04 - Patient lives alone occassional/short term assistance|91
486|05 - Patient lives alone no assisstance available|05 - Patient lives alone no assisstance available|91
487|06 - Patient lives with other person(s) in the home around the clock|06 - Patient lives with other person(s) in the home around the clock|91
488|07 - Patient lives with other person(s) in the home regular daytime|07 - Patient lives with other person(s) in the home regular daytime|91
489|08 - Patient lives with other person(s) in the home regular nighttime|08 - Patient lives with other person(s) in the home regular nighttime|91
490|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|91
491|10 - Patient lives with other person(s) in the home no assistance available|10 - Patient lives with other person(s) in the home no assistance available|91
492|1 - Was present at the most recent SOC/ROC assessment|1 - Was present at the most recent SOC/ROC assessment|91
493|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|91
494|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|91
495|0 - Newly epithelialized|0 - Newly epithelialized|91
496|0 - No [ Go to M1340 ]|0 - No [ Go to M1340 ]|91
498|0 - Independent|0 - Independent|91
499|1 - Needed Some Help|1 - Needed Some Help|91
500|2 - Dependent|2 - Dependent|91
502|0 - No assistance needed in this area|0 - No assistance needed in this area|91
635|3 - Non-agency caregiver(s) are not likely to provide assistance OR it is unclear if they will provide assistance|3 - Non-agency caregiver(s) are not likely to provide assistance OR unclear if will provide asst|91
636|4 - Assistance needed but no non-agency caregiver(s) available|4 - Assistance needed but no non-agency caregiver(s) available|91
637|1 - Peripheral Vascular Disease (PVD) or Peripheral Arterial Disease (PAD)|1 - Peripheral Vascular Disease (PVD) or Peripheral Arterial Disease (PAD)|91
638|2 - Diabetes Mellitus (DM)|2 - Diabetes Mellitus (DM)|91
639|06 - Independent - Patient completes the activity by him/herself with no assistance from a helper.|06 Independent - Patient completes the activity by him/herself with no assistance from a helper.|91
640|05 - Setup or clean-up assistance - Helper SETS UP or CLEANS UP; patient completes activity. Helper assists only prior to or following the activity.|05 Setup or clean-up assistance - Helper SETS UP or CLEANS UP; patient completes activity. He|91
641|04 - Supervision or touching assistance - Helper provides VERBAL CUES or TOUCHING/STEADYING assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently.|04 Supervision or touching assistance - Helper provides VERBAL CUES or TOUCHING/STEADYING|91
642|03 - Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort.|03 Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or |91
643|02 - Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.|02 Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds |91
644|01 - Dependent - Helper does ALL of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity.|01 Dependent - Helper does ALL of the effort. Patient does none of the effort to complete the act|91
645|07 - Activity not attempted - Patient refused|07 Activity not attempted - Patient refused|91
646|09 - Activity not attempted - Not applicable|09 Activity not attempted - Not applicable|91
647|88 - Not attempted due to medical condition or safety concerns|88 Not attempted due to medical condition or safety concerns|91
527|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet criteria for further evaluation for depression.|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet|91
528|0 - Not at all  0 - 1 day|0 - Not at all  0 - 1 day|91
529|1 - Several days  2 - 6 days|1 - Several days  2 - 6 days|91
530|2 - More than half of the days  7 - 11 days|2 - More than half of the days  7 - 11 days|91
531|3 - Nearly every day  12 - 14 days|3 - Nearly every day  12 - 14 days|91
532|NA - N/A  Unable to respond|NA - N/A  Unable to respond|91
533|2 - Able to take medication(s) at the correct times if given reminders by another person based on the frequency of the injection|2 - Able to take medication(s) at the correct times if given reminders by another person based on th|91
2|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; OR (b) Is physically, cognitively, and mentally able to prepare light meals on a regular basis but has not routinely performed light meal preparation in the past (i.e., prior to this home care admission).|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; O|91
3|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and mentally able to perform all housekeeping tasks .|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and menta|91
4|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and mentally able to do laundry and access facilities.|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and menta|91
5|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying packages OR b) Physically, cognitively, and mentally able to take care of shopping, but has not done shopping in the past (i.e., prior to this home care admission).|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying|91
6|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|91
7|0 - Able to dial numbers and answer calls appropriately and as desired.|0 - Able to dial numbers and answer calls appropriately and as desired.|91
8|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body without assistance.|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body|91
9|0 - Able to get to and from the toilet and transfer independently with or without a device.|0 - Able to get to and from the toilet and transfer independently with or without a device.|91
10|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|91
11|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible public bus.|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible p|91
12|0 - Able to independently feed self.|0 - Able to independently feed self.|91
13|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|91
14|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct times.|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct ti|91
15|0 - Able to independently transfer.|0 - Able to independently transfer.|91
16|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without rail|91
17|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings|91
18|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|91
19|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions independently.|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions indep|91
20|0 - Asymptomatic, no treatment needed at this time|0 - Asymptomatic, no treatment needed at this time|91
21|0 - Caregiver manages all tasks related to equipment completely independently.|0 - Caregiver manages all tasks related to equipment completely independently.|91
503|1 - Caregiver(s) currently provide assistance|1 - Caregiver(s) currently provide assistance|91
504|2 - Caregiver(s) need training/ supportive services to provide assistance|2 - Caregiver(s) need training/ supportive services to provide assistance|91
505|3 - Caregiver(s) not likely to provide assistance|3 - Caregiver(s) not likely to provide assistance|91
506|4 - Unclear if Caregiver(s) will provide assistance|4 - Unclear if Caregiver(s) will provide assistance|91
507|5 - Assistance needed, but no Caregiver(s) available|5 - Assistance needed, but no Caregiver(s) available|91
508|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will use standardized clinical guidelines accessible for all care providers to reference|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will|91
509|NA - Patient is not diabetic or is bilateral amputee|NA - Patient is not diabetic or is bilateral amputee|91
510|NA - Patient is not assessed to be at risk for falls|NA - Patient is not assessed to be at risk for falls|91
511|NA - Patient has no diagnosis or symptoms of depression|NA - Patient has no diagnosis or symptoms of depression|91
512|NA - No pain identified|NA - No pain identified|91
513|NA - Patient is not assessed to be at risk for pressure ulcers|NA - Patient is not assessed to be at risk for pressure ulcers|91
514|NA - Patient has no pressure ulcers with need for moist wound healing|NA - Patient has no pressure ulcers with need for moist wound healing|91
515|1 - Long-term nursing facility (NF)|1 - Long-term nursing facility (NF)|91
516|2 - Skilled nursing facility (SNF / TCU)|2 - Skilled nursing facility (SNF / TCU)|91
517|3 - Short stay acute hospital (IPP S)|3 - Short stay acute hospital (IPP S)|91
518|4 - Long-term care hospital (LTCH)|4 - Long-term care hospital (LTCH)|91
519|5 - Inpatient rehabilitation hospital or unit (IRF)|5 - Inpatient rehabilitation hospital or unit (IRF)|91
520|6 - Psychiatric hospital or unit|6 - Psychiatric hospital or unit|91
521|7 - Other|7 - Other|91
522|NA - Patient was not discharged from an inpatient facility [Go to M1017]|NA - Patient was not discharged from an inpatient facility [Go to M1017]|91
523|6 - Unable to participate effectively in bathing and is bathed totally by another person|6 - Unable to participate effectively in bathing and is bathed totally by another person|91
524|4 - Chairfast, unable to ambulate but is able to wheel self independently.|4 - Chairfast, unable to ambulate but is able to wheel self independently.|91
525|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask patient: "Over the last two weeks, how often have you been bothered by any of the following problems")  *Copyright+ Pfizer Inc. All rights reserved. Reproduced with permission.|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask|91
526|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluation for depression.|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluat|91
534|3 - Unable to take injectable medication unless administered by another person.|3 - Unable to take injectable medication unless administered by another person.|91
535|11 - Patient lives in congregate situation (e.g., assisted living) around the clock|11 - Patient lives in congregate situation (e.g., assisted living) around the clock|91
536|12 - Patient lives in congregate situation (e.g., assisted living) regular daytime|12 - Patient lives in congregate situation (e.g., assisted living) regular daytime|91
537|13 - Patient lives in congregate situation (e.g., assisted living) regular nighttime|13 - Patient lives in congregate situation (e.g., assisted living) regular nighttime|91
538|14 - Patient lives in congregate situation (e.g., assisted living) occasional / short-term assistance|14 - Patient lives in congregate situation (e.g., assisted living) occasional / short-term assistanc|91
539|15 - Patient lives in congregate situation (e.g., assisted living) no assistance available|15 - Patient lives in congregate situation (e.g., assisted living) no assistance available|91
545|NA - No observable pressure ulcer or unhealed pressure ulcer|NA - No observable pressure ulcer or unhealed pressure ulcer|91
582|NA - No specific SOC date ordered by physician|NA - No specific SOC date ordered by physician|91
585|UK - Inpatient Discharge Date Unknown|UK - Inpatient Discharge Date Unknown|91
600|1 - History of falls (2 or more falls - or any fall with an injury - in the past 12 months) |1 - History of falls (2 or more falls - or any fall with an injury - in the past 12 months) |91
602|2 - Unintentional weight loss of a total of 10 pounds or more in the past 12 months |2 - Unintentional weight loss of a total of 10 pounds or more in the past 12 months |91
604|3 - Multiple hospitalizations (2 or more) in the past 6 months|3 - Multiple hospitalizations (2 or more) in the past 6 months|91
606|4 - Multiple emergency department visits (2 or more) in the past 6 months|4 - Multiple emergency department visits (2 or more) in the past 6 months|91
608|5 - Decline in mental emotional or behavioral status in the past 3 months |5 - Decline in mental emotional or behavioral status in the past 3 months |91
610|6 - Reported or observed history of difficulty complying with any medical instructions (for example,medications, diet, exercise) in the past 3 months|6 - Reported or observed history of difficulty complying with any medical instructions (for example |91
612|7 - Currently taking 5 or more medications|7 - Currently taking 5 or more medications|91
614|8 - Currently reports exhaustion|8 - Currently reports exhaustion|91
616|9 - Other risk(s) not listed in 1 - 8|9 - Other risk(s) not listed in 1 - 8|91
618|10 - None of the above |10 - None of the above |91
632|0 - No assistance needed v patient is independent or does not have needs in this area|0 - No assistance needed v patient is independent or does not have needs in this area|91
633|1 - Non-agency caregiver(s) currently provide assistance |1 - Non-agency caregiver(s) currently provide assistance |91
634|2 - Non-agency caregiver(s) need training/ supportive services to provide assistance|2 - Non-agency caregiver(s) need training/ supportive services to provide assistance|91
22|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations with no observable impairment.|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations w|91
23|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|91
24|0 - Life expectancy is greater than 6 months|0 - Life expectancy is greater than 6 months|91
25|0 - Never|0 - Never|91
26|0 - Patient is not short of breath|0 - Patient is not short of breath|91
27|0 - No|0 - No|91
28|0 - No emergent care services|0 - No emergent care services|91
29|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) |0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage)|91
30|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and extended or abstract conversation.|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and exte|91
31|0 - No one person|0 - No one person|91
32|0 - None of the time|0 - None of the time|91
33|0 - None, no charge for current services|0 - None, no charge for current services|91
34|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|91
35|0 - Patient does NOT have an ostomy for bowel elimination.|0 - Patient does NOT have an ostomy for bowel elimination.|91
36|0 - Patient has no pain|0 - Patient has no pain|91
37|0 - Patient manages all tasks related to equipment completely independently.|0 - Patient manages all tasks related to equipment completely independently.|91
38|0 - Poor:  little or no recovery is expected and/or further decline is imminent|0 - Poor:  little or no recovery is expected and/or further decline is imminent|91
39|0 - Timed-voiding defers incontinence|0 - Timed-voiding defers incontinence|91
40|0 - Very rarely or never has bowel incontinence|0 - Very rarely or never has bowel incontinence|91
41|0 - Zero|0 - Zero|91
42|00 - No|00 - No|91
43|01 - Yes|01 - Yes|91
44|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or mental limitations, needs assistance with heavy laundry.|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or|91
45|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the patient.|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the|91
46|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|91
47|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or supervision from another person OR c) a liquid, pureed or ground meat diet.|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or su|91
48|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|91
49|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|91
50|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independently.|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independe|91
51|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only when assisted or accompanied by another person.|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only w|91
52|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepa|91
53|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance by another person OR b) given daily reminders.|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance b|91
54|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advan|91
55|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advan|91
56|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for the deaf) and call essential numbers.|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for t|91
157|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|91
158|2 - Someone must help the patient put on upper body clothing.|2 - Someone must help the patient put on upper body clothing.|91
159|2 - Stage 2|2 - Stage 2|91
160|2 - Start of care - no further visits planned|2 - Start of care - no further visits planned|91
161|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitoring|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitori|91
162|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment regimen.|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment re|91
163|2 - Two|2 - Two|91
164|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistance due to cognitive or mental limitation.|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistanc|91
57|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|91
58|1 - American Indian or Alaska Native|1 - American Indian or Alaska Native|91
59|1 - Depressed mood (e.g., feeling sad, tearful)|1 - Depressed mood (e.g., feeling sad, tearful)|91
60|1 - During the night only|1 - During the night only|91
61|1 - Fully granulating|1 - Fully granulating|91
62|1 - Good/Fair:  partial to full recovery is expected|1 - Good/Fair:  partial to full recovery is expected|91
63|1 - Good:  marked improvement in functional status is expected|1 - Good:  marked improvement in functional status is expected|91
64|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|91
65|1 - Smoking|1 - Smoking|91
66|1 - Hospital|1 - Hospital|91
67|1 - Hospital emergency room (includes 23-hour holding)|1 - Hospital emergency room (includes 23-hour holding)|91
68|1 - Hospitalization for EMERGENT (unscheduled) care|1 - Hospitalization for EMERGENT (unscheduled) care|91
69|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepared solutions), patient is able to manage all other aspects of equipment.|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepar|91
70|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|91
71|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|91
72|1 - In new or complex situations only|1 - In new or complex situations only|91
73|1 - Intravenous or infusion therapy (excludes TPN)|1 - Intravenous or infusion therapy (excludes TPN)|91
74|1 - Less often than daily|1 - Less often than daily|91
75|1 - Less than once a month|1 - Less than once a month|91
76|1 - Less than once weekly|1 - Less than once weekly|91
77|1 - Life expectancy is 6 months or fewer|1 - Life expectancy is 6 months or fewer|91
78|1 - Lives alone|1 - Lives alone|91
79|1 - Male|1 - Male|91
80|1 - Medicare (traditional fee-for-service)|1 - Medicare (traditional fee-for-service)|91
81|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of past 24 hours, significant memory loss so that supervision is required|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of pas|91
82|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors in word choice, grammar or speech intelligibility, needs minimal prompting or assistance).|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors i|91
83|1 - No assistance or services received|1 - No assistance or services received|91
84|1 - One|1 - One|91
85|1 - Oxygen (intermittent or continuous)|1 - Oxygen (intermittent or continuous)|91
86|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, and the surrounding layout, can count fingers at arm's length.|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, a|91
87|1 - Patient is incontinent|1 - Patient is incontinent|91
88|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|91
89|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical or treatment regimen.|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical|91
90|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient/couple/significant other)|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient|91
91|1 - Relatives, friends, or neighbors living outside the home|1 - Relatives, friends, or neighbors living outside the home|91
92|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions.|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions|91
93|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independentl|91
94|1 - Several times during day and night|1 - Several times during day and night|91
95|1 - Spouse or significant other|1 - Spouse or significant other|91
96|1 - Stage 1|1 - Stage 1|91
97|1 - Start of care - further visits planned|1 - Start of care - further visits planned|91
98|1 - Symptoms well controlled with current therapy|1 - Symptoms well controlled with current therapy|91
99|1 - Therapy services|1 - Therapy services|91
100|1 - Able to transfer with minimal human assistance or with use of an assistive device.|1 - Able to transfer with minimal human assistance or with use of an assistive device.|91
101|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitations.|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitatio|91
102|1 - Urinary incontinence|1 - Urinary incontinence|91
103|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and transfer.|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and|91
104|1 - When walking more than 20 feet, climbing stairs|1 - When walking more than 20 feet, climbing stairs|91
105|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary conversation. May need occasional repetition, extra time, or louder voice.|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary c|91
106|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting in and out of tub/shower|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting|91
107|1 - Yes|1 - Yes|91
108|1-RN|1-RN|91
109|10 - Discharge from agency - no visits completed after start/resumption of care assessment|10 - Discharge from agency - no visits completed after start/resumption of care assessment|91
110|10 - Scheduled surgical procedure|10 - Scheduled surgical procedure|91
111|10 - Self-pay|10 - Self-pay|91
112|11 - Other|11 - Other|91
113|11 - Urinary tract infection|11 - Urinary tract infection|91
114|12 - IV catheter-related infection|12 - IV catheter-related infection|91
115|13 - Deep vein thrombosis, pulmonary embolus|13 - Deep vein thrombosis, pulmonary embolus|91
116|14 - Uncontrolled pain|14 - Uncontrolled pain|91
117|15 - Psychotic episode|15 - Psychotic episode|91
118|16 - Other than above reasons|16 - Other than above reasons|91
119|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing calls.|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing|91
120|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another person.|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another pers|91
121|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface a|91
122|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for intermittent supervision or encouragement or reminders, OR (b) to get in and out of the shower or tub, OR (c) for washing difficult to reach areas.|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for inter|91
123|2 - Asian|2 - Asian|91
124|2 - Caregiver requires considerable assistance from another person to manage equipment, but independently completes significant portions of task.|2 - Caregiver requires considerable assistance from another person to manage equipment, but independ|91
125|2 - Daily, but not constantly|2 - Daily, but not constantly|91
126|2 - Daughter or son|2 - Daughter or son|91
127|2 - Doctor's office emergency visit/house call|2 - Doctor's office emergency visit/house call|91
128|2 - During the day and night|2 - During the day and night|91
129|2 - Early/partial granulation|2 - Early/partial granulation|91
130|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors in word choice, organization or speech intelligibility). Speaks in phrases or short sentences.|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors|91
131|2 - Family member's residence|2 - Family member's residence|91
132|2 - Female|2 - Female|91
133|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conversation, needs frequent prompting or assistance.|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conver|91
134|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|91
135|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|91
136|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately stop activities, jeopardizes safety through actions|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately st|91
137|2 - Indwelling/suprapubic catheter|2 - Indwelling/suprapubic catheter|91
138|2 - Injury caused by fall or accident at home|2 - Injury caused by fall or accident at home|91
139|2 - Medicare (HMO/managed care/Advantage plan)|2 - Medicare (HMO/managed care/Advantage plan)|91
140|2 - Nausea, dehydration, malnutrition, constipation, impaction|2 - Nausea, dehydration, malnutrition, constipation, impaction|91
141|2 - Obesity|2 - Obesity|91
142|2 - On awakening or at night only|2 - On awakening or at night only|91
143|2 - Once a month|2 - Once a month|91
144|2 - One to three times weekly|2 - One to three times weekly|91
145|2 - Parenteral nutrition (TPN or lipids)|2 - Parenteral nutrition (TPN or lipids)|91
146|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic)  [ Go to M1620 ]|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic)  [ Go|91
147|2 - Patient requires considerable assistance from another person to manage equipment, but independently completes portions of the task.|2 - Patient requires considerable assistance from another person to manage equipment, but independen|91
148|2 - Patient transferred to a noninstitutional hospice|2 - Patient transferred to a noninstitutional hospice|91
149|2 - Person residing in the home (EXCLUDING paid help)|2 - Person residing in the home (EXCLUDING paid help)|91
150|2 - Rehabilitation facility|2 - Rehabilitation facility|91
151|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifting of attention) or consistently requires low stimulus environment due to distractibility.|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifti|91
152|2 - Respite care|2 - Respite care|91
153|2 - Sense of failure or self reproach|2 - Sense of failure or self reproach|91
154|2 - Several times during day|2 - Several times during day|91
155|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonresponsive.|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonrespons|91
156|2 - Someone must assist the patient to groom self.|2 - Someone must assist the patient to groom self.|91
648|06 - Independent - Patient completes the activity by him/herself with no assistance from a helper.|06 - Independent - Patient completes the activity by him/herself with no assistance from a helper.|91
649|05 - Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity.|05 - Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper|91
650|04 - Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently.|04 - Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/|91
651|03 - Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort.|03 - Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or sup|91
652|02 - Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.|02 - Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds t|91
653|01 - Dependent - Helper does ALL of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity.|01 - Dependent - Helper does ALL of the effort. Patient does none of the effort to complete the acti|91
654|07 - Patient refused|07 - Patient refused|91
655|09 - Not applicable - Not attempted and the patient did not perform this activity prior to the current illness,exacerbation or injury.|09 - Not applicable - Not attempted and the patient did not perform this activity prior to the curre|91
656|10 - Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)|10 - Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)|91
657|88 - Not attempted due to medical conditions or safety concerns|88 - Not attempted due to medical conditions or safety concerns|91
658|0 - No [STOP]|0 - No [STOP]|91
659|0 - No [Skip GG0170R]|0 - No [Skip GG0170R]|91
660|1 - Yes [Continue to GG0170R, Wheel 50 feet with two turns.]|1 - Yes [Continue to GG0170R, Wheel 50 feet with two turns.]|91
661|1 - Manual|1 - Manual|91
662|2 - Motorized|2 - Motorized|91
663|0 - No [Skip to J1800 Any falls since SOC/ROC, whichever is more recent.]|0 - No [Skip to J1800 Any falls since SOC/ROC, whichever is more recent.]|91
664|0 - No [STOP]|0 - No [STOP]|91
665|1 - Yes [Continue to J1900, Number of Falls Since SOC/ROC, whichever is more recent]|1 - Yes [Continue to J1900, Number of Falls Since SOC/ROC, whichever is more recent]|91
666|0 - None|0 - None|91
667|1 - One|1 - One|91
668|2 - Two or More|2 - Two or More|91
669|3 - Independent - Patient completed the activities by him/herself, with or without an assistive device, with no assistance from a helper.|3 - Independent - Patient completed the activities by him/herself, with or without an assistive devi|91
670|2 - Needed Some Help - Patient needed partial assistance from another person to complete activities.|2 - Needed Some Help - Patient needed partial assistance from another person to complete activities.|91
671|1 - Dependent - A helper completed the activities for the patient.|1 - Dependent - A helper completed the activities for the patient.|91
672|8 - Unknown|8 - Unknown|91
673|9 - Not Applicable|9 - Not Applicable|91
674|A - Manual wheelchair|A - Manual wheelchair|91
675|B - Motorized wheelchair and/or scooter|B - Motorized wheelchair and/or scooter|91
676|C - Mechanical lift|C - Mechanical lift|91
677|D - Walker|D - Walker|91
678|E - Orthotics/Prosthetics|E - Orthotics/Prosthetics|91
679|Z - None of the above|Z - None of the above|91
680|3 - None of the above|3 - None of the above|91
680|3 - None of the above|3 - None of the above|93
679|Z - None of the above|Z - None of the above|93
678|E - Orthotics/Prosthetics|E - Orthotics/Prosthetics|93
677|D - Walker|D - Walker|93
676|C - Mechanical lift|C - Mechanical lift|93
675|B - Motorized wheelchair and/or scooter|B - Motorized wheelchair and/or scooter|93
674|A - Manual wheelchair|A - Manual wheelchair|93
673|9 - Not Applicable|9 - Not Applicable|93
672|8 - Unknown|8 - Unknown|93
671|1 - Dependent - A helper completed the activities for the patient.|1 - Dependent - A helper completed the activities for the patient.|93
670|2 - Needed Some Help - Patient needed partial assistance from another person to complete activities.|2 - Needed Some Help - Patient needed partial assistance from another person to complete activities.|93
669|3 - Independent - Patient completed the activities by him/herself, with or without an assistive device, with no assistance from a helper.|3 - Independent - Patient completed the activities by him/herself, with or without an assistive devi|93
668|2 - Two or More|2 - Two or More|93
667|1 - One|1 - One|93
666|0 - None|0 - None|93
665|1 - Yes [Continue to J1900, Number of Falls Since SOC/ROC, whichever is more recent]|1 - Yes [Continue to J1900, Number of Falls Since SOC/ROC, whichever is more recent]|93
664|0 - No [STOP]|0 - No [STOP]|93
663|0 - No [Skip to J1800 Any falls since SOC/ROC, whichever is more recent.]|0 - No [Skip to J1800 Any falls since SOC/ROC, whichever is more recent.]|93
662|2 - Motorized|2 - Motorized|93
661|1 - Manual|1 - Manual|93
660|1 - Yes [Continue to GG0170R, Wheel 50 feet with two turns.]|1 - Yes [Continue to GG0170R, Wheel 50 feet with two turns.]|93
659|0 - No [Skip GG0170R]|0 - No [Skip GG0170R]|93
658|0 - No [STOP]|0 - No [STOP]|93
657|88 - Not attempted due to medical conditions or safety concerns|88 - Not attempted due to medical conditions or safety concerns|93
656|10 - Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)|10 - Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)|93
655|09 - Not applicable - Not attempted and the patient did not perform this activity prior to the current illness,exacerbation or injury.|09 - Not applicable - Not attempted and the patient did not perform this activity prior to the curre|93
654|07 - Patient refused|07 - Patient refused|93
653|01 - Dependent - Helper does ALL of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity.|01 - Dependent - Helper does ALL of the effort. Patient does none of the effort to complete the acti|93
652|02 - Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.|02 - Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds t|93
651|03 - Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort.|03 - Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or sup|93
650|04 - Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently.|04 - Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/|93
649|05 - Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity.|05 - Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper|93
648|06 - Independent - Patient completes the activity by him/herself with no assistance from a helper.|06 - Independent - Patient completes the activity by him/herself with no assistance from a helper.|93
647|88 - Not attempted due to medical condition or safety concerns|88 Not attempted due to medical condition or safety concerns|93
646|09 - Activity not attempted - Not applicable|09 Activity not attempted - Not applicable|93
645|07 - Activity not attempted - Patient refused|07 Activity not attempted - Patient refused|93
644|01 - Dependent - Helper does ALL of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity.|01 Dependent - Helper does ALL of the effort. Patient does none of the effort to complete the act|93
643|02 - Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.|02 Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds |93
642|03 - Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort.|03 Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or |93
641|04 - Supervision or touching assistance - Helper provides VERBAL CUES or TOUCHING/STEADYING assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently.|04 Supervision or touching assistance - Helper provides VERBAL CUES or TOUCHING/STEADYING |93
640|05 - Setup or clean-up assistance -  Helper SETS UP or CLEANS UP; patient completes activity. Helper assists only prior to or following the activity.|05 Setup or clean-up assistance - Helper SETS UP or CLEANS UP; patient completes activity. Hel|93
639|06 - Independent - Patient completes the activity by him/herself with no assistance from a helper.|06 Independent - Patient completes the activity by him/herself with no assistance from a helper.|93
638|2 - Diabetes Mellitus (DM)|2 - Diabetes Mellitus (DM)|93
637|1 - Peripheral Vascular Disease (PVD) or Peripheral Arterial Disease (PAD)|1 - Peripheral Vascular Disease (PVD) or Peripheral Arterial Disease (PAD)|93
2|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; OR (b) Is physically, cognitively, and mentally able to prepare light meals on a regular basis but has not routinely performed light meal preparation in the past (i.e., prior to this home care admission).|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; O|93
3|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and mentally able to perform all housekeeping tasks .|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and menta|93
4|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and mentally able to do laundry and access facilities.|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and menta|93
5|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying packages OR b) Physically, cognitively, and mentally able to take care of shopping, but has not done shopping in the past (i.e., prior to this home care admission).|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying|93
6|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|93
7|0 - Able to dial numbers and answer calls appropriately and as desired.|0 - Able to dial numbers and answer calls appropriately and as desired.|93
8|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body without assistance.|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body|93
9|0 - Able to get to and from the toilet and transfer independently with or without a device.|0 - Able to get to and from the toilet and transfer independently with or without a device.|93
10|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|93
11|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible public bus.|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible p|93
12|0 - Able to independently feed self.|0 - Able to independently feed self.|93
13|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|93
14|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct times.|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct ti|93
15|0 - Able to independently transfer.|0 - Able to independently transfer.|93
16|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without rail|93
17|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings|93
18|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|93
19|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions independently.|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions indep|93
20|0 - Asymptomatic, no treatment needed at this time|0 - Asymptomatic, no treatment needed at this time|93
21|0 - Caregiver manages all tasks related to equipment completely independently.|0 - Caregiver manages all tasks related to equipment completely independently.|93
22|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations with no observable impairment.|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations w|93
23|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|93
24|0 - Life expectancy is greater than 6 months|0 - Life expectancy is greater than 6 months|93
25|0 - Never|0 - Never|93
26|0 - Patient is not short of breath|0 - Patient is not short of breath|93
27|0 - No|0 - No|93
28|0 - No emergent care services|0 - No emergent care services|93
29|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) |0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) |93
30|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and extended or abstract conversation.|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and exte|93
31|0 - No one person|0 - No one person|93
32|0 - None of the time|0 - None of the time|93
33|0 - None, no charge for current services|0 - None, no charge for current services|93
34|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|93
35|0 - Patient does NOT have an ostomy for bowel elimination.|0 - Patient does NOT have an ostomy for bowel elimination.|93
36|0 - Patient has no pain|0 - Patient has no pain|93
37|0 - Patient manages all tasks related to equipment completely independently.|0 - Patient manages all tasks related to equipment completely independently.|93
38|0 - Poor:  little or no recovery is expected and/or further decline is imminent|0 - Poor:  little or no recovery is expected and/or further decline is imminent|93
39|0 - Timed-voiding defers incontinence|0 - Timed-voiding defers incontinence|93
40|0 - Very rarely or never has bowel incontinence|0 - Very rarely or never has bowel incontinence|93
41|0 - Zero|0 - Zero|93
42|00 - No|00 - No|93
43|01 - Yes|01 - Yes|93
44|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or mental limitations, needs assistance with heavy laundry.|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or|93
45|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the patient.|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the|93
46|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|93
47|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or supervision from another person OR c) a liquid, pureed or ground meat diet.|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or su|93
48|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|93
49|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|93
50|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independently.|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independe|93
51|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only when assisted or accompanied by another person.|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only w|93
52|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepa|93
53|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance by another person OR b) given daily reminders.|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance b|93
54|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advan|93
55|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advan|93
56|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for the deaf) and call essential numbers.|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for t|93
57|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|93
58|1 - American Indian or Alaska Native|1 - American Indian or Alaska Native|93
59|1 - Depressed mood (e.g., feeling sad, tearful)|1 - Depressed mood (e.g., feeling sad, tearful)|93
60|1 - During the night only|1 - During the night only|93
61|1 - Fully granulating|1 - Fully granulating|93
62|1 - Good/Fair:  partial to full recovery is expected|1 - Good/Fair:  partial to full recovery is expected|93
63|1 - Good:  marked improvement in functional status is expected|1 - Good:  marked improvement in functional status is expected|93
64|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|93
65|1 - Smoking|1 - Smoking|93
66|1 - Hospital|1 - Hospital|93
67|1 - Hospital emergency room (includes 23-hour holding)|1 - Hospital emergency room (includes 23-hour holding)|93
68|1 - Hospitalization for EMERGENT (unscheduled) care|1 - Hospitalization for EMERGENT (unscheduled) care|93
69|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepared solutions), patient is able to manage all other aspects of equipment.|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepar|93
70|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|93
71|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|93
72|1 - In new or complex situations only|1 - In new or complex situations only|93
73|1 - Intravenous or infusion therapy (excludes TPN)|1 - Intravenous or infusion therapy (excludes TPN)|93
74|1 - Less often than daily|1 - Less often than daily|93
75|1 - Less than once a month|1 - Less than once a month|93
76|1 - Less than once weekly|1 - Less than once weekly|93
77|1 - Life expectancy is 6 months or fewer|1 - Life expectancy is 6 months or fewer|93
78|1 - Lives alone|1 - Lives alone|93
79|1 - Male|1 - Male|93
80|1 - Medicare (traditional fee-for-service)|1 - Medicare (traditional fee-for-service)|93
81|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of past 24 hours, significant memory loss so that supervision is required|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of pas|93
82|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors in word choice, grammar or speech intelligibility, needs minimal prompting or assistance).|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors i|93
83|1 - No assistance or services received|1 - No assistance or services received|93
84|1 - One|1 - One|93
85|1 - Oxygen (intermittent or continuous)|1 - Oxygen (intermittent or continuous)|93
86|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, and the surrounding layout, can count fingers at arm's length.|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, a|93
87|1 - Patient is incontinent|1 - Patient is incontinent|93
88|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|93
89|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical or treatment regimen.|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical|93
90|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient/couple/significant other)|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient|93
91|1 - Relatives, friends, or neighbors living outside the home|1 - Relatives, friends, or neighbors living outside the home|93
92|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions.|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions|93
93|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independentl|93
94|1 - Several times during day and night|1 - Several times during day and night|93
95|1 - Spouse or significant other|1 - Spouse or significant other|93
96|1 - Stage 1|1 - Stage 1|93
97|1 - Start of care - further visits planned|1 - Start of care - further visits planned|93
98|1 - Symptoms well controlled with current therapy|1 - Symptoms well controlled with current therapy|93
99|1 - Therapy services|1 - Therapy services|93
100|1 - Able to transfer with minimal human assistance or with use of an assistive device.|1 - Able to transfer with minimal human assistance or with use of an assistive device.|93
101|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitations.|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitatio|93
102|1 - Urinary incontinence|1 - Urinary incontinence|93
103|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and transfer.|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and|93
104|1 - When walking more than 20 feet, climbing stairs|1 - When walking more than 20 feet, climbing stairs|93
105|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary conversation. May need occasional repetition, extra time, or louder voice.|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary c|93
106|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting in and out of tub/shower|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting|93
107|1 - Yes|1 - Yes|93
108|1-RN|1-RN|93
109|10 - Discharge from agency - no visits completed after start/resumption of care assessment|10 - Discharge from agency - no visits completed after start/resumption of care assessment|93
110|10 - Scheduled surgical procedure|10 - Scheduled surgical procedure|93
111|10 - Self-pay|10 - Self-pay|93
112|11 - Other|11 - Other|93
113|11 - Urinary tract infection|11 - Urinary tract infection|93
114|12 - IV catheter-related infection|12 - IV catheter-related infection|93
115|13 - Deep vein thrombosis, pulmonary embolus|13 - Deep vein thrombosis, pulmonary embolus|93
116|14 - Uncontrolled pain|14 - Uncontrolled pain|93
117|15 - Psychotic episode|15 - Psychotic episode|93
118|16 - Other than above reasons|16 - Other than above reasons|93
119|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing calls.|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing|93
120|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another person.|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another pers|93
121|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface a|93
122|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for intermittent supervision or encouragement or reminders, OR (b) to get in and out of the shower or tub, OR (c) for washing difficult to reach areas.|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for inter|93
123|2 - Asian|2 - Asian|93
124|2 - Caregiver requires considerable assistance from another person to manage equipment, but independently completes significant portions of task.|2 - Caregiver requires considerable assistance from another person to manage equipment, but independ|93
125|2 - Daily, but not constantly|2 - Daily, but not constantly|93
126|2 - Daughter or son|2 - Daughter or son|93
127|2 - Doctor's office emergency visit/house call|2 - Doctor's office emergency visit/house call|93
128|2 - During the day and night|2 - During the day and night|93
129|2 - Early/partial granulation|2 - Early/partial granulation|93
130|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors in word choice, organization or speech intelligibility). Speaks in phrases or short sentences.|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors|93
131|2 - Family member's residence|2 - Family member's residence|93
132|2 - Female|2 - Female|93
133|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conversation, needs frequent prompting or assistance.|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conver|93
134|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|93
135|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|93
136|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately stop activities, jeopardizes safety through actions|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately st|93
137|2 - Indwelling/suprapubic catheter|2 - Indwelling/suprapubic catheter|93
138|2 - Injury caused by fall or accident at home|2 - Injury caused by fall or accident at home|93
139|2 - Medicare (HMO/managed care/Advantage plan)|2 - Medicare (HMO/managed care/Advantage plan)|93
140|2 - Nausea, dehydration, malnutrition, constipation, impaction|2 - Nausea, dehydration, malnutrition, constipation, impaction|93
141|2 - Obesity|2 - Obesity|93
142|2 - On awakening or at night only|2 - On awakening or at night only|93
143|2 - Once a month|2 - Once a month|93
144|2 - One to three times weekly|2 - One to three times weekly|93
145|2 - Parenteral nutrition (TPN or lipids)|2 - Parenteral nutrition (TPN or lipids)|93
146|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic)  [ Go to M1620 ]|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic)  [ Go|93
147|2 - Patient requires considerable assistance from another person to manage equipment, but independently completes portions of the task.|2 - Patient requires considerable assistance from another person to manage equipment, but independen|93
148|2 - Patient transferred to a noninstitutional hospice|2 - Patient transferred to a noninstitutional hospice|93
149|2 - Person residing in the home (EXCLUDING paid help)|2 - Person residing in the home (EXCLUDING paid help)|93
150|2 - Rehabilitation facility|2 - Rehabilitation facility|93
151|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifting of attention) or consistently requires low stimulus environment due to distractibility.|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifti|93
152|2 - Respite care|2 - Respite care|93
153|2 - Sense of failure or self reproach|2 - Sense of failure or self reproach|93
154|2 - Several times during day|2 - Several times during day|93
155|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonresponsive.|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonrespons|93
156|2 - Someone must assist the patient to groom self.|2 - Someone must assist the patient to groom self.|93
157|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|93
158|2 - Someone must help the patient put on upper body clothing.|2 - Someone must help the patient put on upper body clothing.|93
159|2 - Stage 2|2 - Stage 2|93
160|2 - Start of care - no further visits planned|2 - Start of care - no further visits planned|93
161|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitoring|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitori|93
162|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment regimen.|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment re|93
163|2 - Two|2 - Two|93
164|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistance due to cognitive or mental limitation.|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistanc|93
165|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|93
166|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assistance).|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assis|93
167|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home delivery.|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home deli|93
168|2 - Unable to prepare any light meals or reheat any delivered meals.|2 - Unable to prepare any light meals or reheat any delivered meals.|93
169|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|93
170|2 - UNABLE to take injectable medications unless administered by someone else.|2 - UNABLE to take injectable medications unless administered by someone else.|93
171|2 - UNABLE to take medication unless administered by someone else.|2 - UNABLE to take medication unless administered by someone else.|93
172|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|93
173|2 - Ventilator (continually or at night)|2 - Ventilator (continually or at night)|93
174|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less than 20 feet)|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less th|93
175|2 - With spouse or significant other|2 - With spouse or significant other|93
176|2 - Yes, assistance or services provided by family or friends|2 - Yes, assistance or services provided by family or friends|93
177|2-PT|2-PT|93
178|3 - Able to answer the telephone only some of the time or is able to carry on only a limited conversation.|3 - Able to answer the telephone only some of the time or is able to carry on only a limited convers|93
179|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube or gastrostomy.|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube|93
180|3 - Alcohol dependency|3 - Alcohol dependency|93
181|3 - All of the time|3 - All of the time|93
182|3 - Black or African-American|3 - Black or African-American|93
183|3 - Boarding home or rented room|3 - Boarding home or rented room|93
184|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment, clean/store/dispose of equipment or supplies).|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment,|93
185|3 -Able to walk only with the supervision or assistance of another person at all times.|3 -Able to walk only with the supervision or assistance of another person at all times.|93
186|3 - Continuous / Bi-level positive airway pressure|3 - Continuous / Bi-level positive airway pressure|93
187|3 - During the day and evening, but not constantly|3 - During the day and evening, but not constantly|93
188|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the alimentary canal)|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the|93
189|3 - Environmental support (e.g., housing, home maintenance)|3 - Environmental support (e.g., housing, home maintenance)|93
190|3 - Four to six times weekly|3 - Four to six times weekly|93
191|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessing by listener.  Speech limited to single words or short phrases.|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessin|93
192|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires multiple repetitions, restatements, demonstrations, additional time.|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires m|93
193|3 - Hopelessness|3 - Hopelessness|93
194|3 - Hospice care|3 - Hospice care|93
195|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|93
196|3 - Injury caused by fall or accident at home|3 - Injury caused by fall or accident at home|93
197|3 - Intractable pain|3 - Intractable pain|93
198|3 - Medicaid (traditional fee-for-service)|3 - Medicaid (traditional fee-for-service)|93
199|3 - Needs someone to do all shopping and errands.|3 - Needs someone to do all shopping and errands.|93
200|3 - Not healing|3 - Not healing|93
201|3 - Nursing home|3 - Nursing home|93
202|3 - Once daily|3 - Once daily|93
203|3 - Other family member|3 - Other family member|93
204|3 - Outpatient department/clinic emergency (includes urgicenter sites)|3 - Outpatient department/clinic emergency (includes urgicenter sites)|93
205|3 - Paid help|3 - Paid help|93
206|3 - Able to participate in bathing self in shower or tub, but requires presence of another person throughout the bath for assistance or supervision.|3 - Able to participate in bathing self in shower or tub, but requires presence of another person th|93
207|3 - Patient depends entirely upon another person to dress lower body.|3 - Patient depends entirely upon another person to dress lower body.|93
208|3 - Patient depends entirely upon another person to dress the upper body.|3 - Patient depends entirely upon another person to dress the upper body.|93
209|3 - Patient depends entirely upon someone else for grooming needs.|3 - Patient depends entirely upon someone else for grooming needs.|93
210|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone else to manage the equipment.|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone|93
211|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable to shift attention and recall directions more than half the time.|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable|93
212|3 - Respiratory problems (SOB, infection, obstruction)|3 - Respiratory problems (SOB, infection, obstruction)|93
213|3 - Resumption of care (after inpatient stay)|3 - Resumption of care (after inpatient stay)|93
214|3 - Several times each month|3 - Several times each month|93
215|3 - Skilled Nursing Facility|3 - Skilled Nursing Facility|93
216|3 - Stage 3|3 - Stage 3|93
217|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|93
218|3 - Three|3 - Three|93
219|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person throughout the process.|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person through|93
220|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal independently.|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal indep|93
221|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person.|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person|93
222|3 - Unknown because patient moved to a geographic location not served by this agency|3 - Unknown because patient moved to a geographic location not served by this agency|93
223|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|93
224|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|93
225|3 - With other family member|3 - With other family member|93
226|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home health services, homemaker assistance, transportation assistance, assisted living, board and care)|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home h|93
227|3-SLP/ST|3-SLP/ST|93
228|4 - At rest (during day or night)|4 - At rest (during day or night)|93
229|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|93
230|4 - Board and care or assisted living facility|4 - Board and care or assisted living facility|93
231|4 - Caregiver is completely dependent on someone else to manage all equipment.|4 - Caregiver is completely dependent on someone else to manage all equipment.|93
232|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|93
233|4 - Constantly|4 - Constantly|93
234|4 - Drug dependency|4 - Drug dependency|93
235|4 - Four or more|4 - Four or more|93
236|4 - Friend or neighbor or community or church member|4 - Friend or neighbor or community or church member|93
237|4 - Hispanic or Latino|4 - Hispanic or Latino|93
238|4 - Hospice|4 - Hospice|93
239|4 - Impaired decision-making|4 - Impaired decision-making|93
240|4 - Is totally dependent in toileting.|4 - Is totally dependent in toileting.|93
241|4 - Medicaid (HMO/managed care)|4 - Medicaid (HMO/managed care)|93
242|4 - None of the above|4 - None of the above|93
243|4 - Nursing home|4 - Nursing home|93
244|4 - On a daily basis|4 - On a daily basis|93
245|4 - Patient is completely dependent on someone else to manage all equipment.|4 - Patient is completely dependent on someone else to manage all equipment.|93
246|4 - Permanent placement|4 - Permanent placement|93
247|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, punches, dangerous maneuvers w/ wheelchair or other objects)|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, pu|93
248|4 - Psychosocial support (e.g., socialization, companionship, recreation)|4 - Psychosocial support (e.g., socialization, companionship, recreation)|93
249|4 - Recertification (follow-up) reassessment|4 - Recertification (follow-up) reassessment|93
250|4 - Recurrent thoughts of death|4 - Recurrent thoughts of death|93
251|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruction)|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruc|93
252|4 - Several times a week|4 - Several times a week|93
253|4 - Stage 4|4 - Stage 4|93
254|4 - Symptoms poorly controlled, history of re-hospitalizations|4 - Symptoms poorly controlled, history of re-hospitalizations|93
255|4 - Three or more times per week|4 - Three or more times per week|93
256|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetative state, or delirium.|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetati|93
257|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|93
258|4 - Unable to effectively participate in any housekeeping tasks.|4 - Unable to effectively participate in any housekeeping tasks.|93
259|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or unresponsive (e.g., speech is nonsensical or unintelligible).|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or u|93
260|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonresponsive.|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonr|93
261|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostomy.|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostom|93
262|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of devices at the sink, in chair, or on commode|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of|93
263|4 - With a friend|4 - With a friend|93
264|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|93
265|4-OT|4-OT|93
266|5 - Advocates or facilitates patient's participation in appropriate medical care|5 - Advocates or facilitates patient's participation in appropriate medical care|93
267|5 - At least daily|5 - At least daily|93
268|6 - Bedfast, unable to ambulate or be up in a chair.|6 - Bedfast, unable to ambulate or be up in a chair.|93
269|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|93
270|5 - Disruptive or socially inappropriate behavior|5 - Disruptive or socially inappropriate behavior|93
271|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|93
272|5 - Hypo/Hyperglycemia, diabetes out of control|5 - Hypo/Hyperglycemia, diabetes out of control|93
273|5 - More often than once daily|5 - More often than once daily|93
274|5 - Native Hawaiian or Pacific Islander|5 - Native Hawaiian or Pacific Islander|93
275|5 - None of the above|5 - None of the above|93
276|5 - One to two times per week|5 - One to two times per week|93
277|5 - Other|5 - Other|93
278|5 - Other follow-up|5 - Other follow-up|93
279|5 - Paid help|5 - Paid help|93
280|5 - Patient nonresponsive or unable to speak.|5 - Patient nonresponsive or unable to speak.|93
281|5 - Thoughts of suicide|5 - Thoughts of suicide|93
282|5 - Totally unable to use the telephone.|5 - Totally unable to use the telephone.|93
283|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|93
284|5 - Unable to take in nutrients orally or by tube feeding.|5 - Unable to take in nutrients orally or by tube feeding.|93
285|5 - Unsafe for care at home|5 - Unsafe for care at home|93
286|5 - With paid help (other than home care agency staff)|5 - With paid help (other than home care agency staff)|93
287|5 - Workers' compensation|5 - Workers' compensation|93
288|5 - Wound infection, deteriorating wound status, new lesion/ulcer|5 - Wound infection, deteriorating wound status, new lesion/ulcer|93
289|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|93
290|6 - Delusional, hallucinatory, or paranoid behavior|6 - Delusional, hallucinatory, or paranoid behavior|93
291|6 - Financial agent, power of attorney, or conservator of finance|6 - Financial agent, power of attorney, or conservator of finance|93
292|6 - GI bleeding, obstruction|6 - GI bleeding, obstruction|93
293|6 - Less often than weekly|6 - Less often than weekly|93
294|6 - Memory loss to the extent that supervision required|6 - Memory loss to the extent that supervision required|93
295|6 - None of the above feelings observed or reported|6 - None of the above feelings observed or reported|93
296|6 - Other|6 - Other|93
297|6 - Title programs (e.g., Title III, V, or XX)|6 - Title programs (e.g., Title III, V, or XX)|93
298|6 - Transferred to an inpatient facility - patient not discharged from agency|6 - Transferred to an inpatient facility - patient not discharged from agency|93
299|6 - White|6 - White|93
300|6 - With other than above|6 - With other than above|93
301|7 - Exacerbation of CHF, fluid overload, heart failure|7 - Exacerbation of CHF, fluid overload, heart failure|93
302|7 - Health care agent, conservator of person, or medical power of attorney|7 - Health care agent, conservator of person, or medical power of attorney|93
303|7 - Hypo/Hyperglycemia, diabetes out of control|7 - Hypo/Hyperglycemia, diabetes out of control|93
304|7 - None of the above|7 - None of the above|93
305|7 - None of the above behaviors demonstrated|7 - None of the above behaviors demonstrated|93
306|7 - Other government (e.g., TriCare, VA, etc.)|7 - Other government (e.g., TriCare, VA, etc.)|93
307|7 - Transferred to an inpatient facility - patient discharged from agency|7 - Transferred to an inpatient facility - patient discharged from agency|93
308|8 - Death at home|8 - Death at home|93
309|8 - GI bleeding, obstruction|8 - GI bleeding, obstruction|93
310|8 - Myocardial infarction, stroke|8 - Myocardial infarction, stroke|93
311|8 - Private insurance|8 - Private insurance|93
312|9 - Chemotherapy|9 - Chemotherapy|93
313|9 - Discharge from agency|9 - Discharge from agency|93
314|9 - Other than above reasons|9 - Other than above reasons|93
315|9 - Private HMO/managed care|9 - Private HMO/managed care|93
316|NA - No caregiver|NA - No caregiver|93
317|NA - No equipment of this type used in care.|NA - No equipment of this type used in care.|93
318|NA - No inhalant/mist medications prescribed.|NA - No inhalant/mist medications prescribed.|93
319|NA - No injectable medications prescribed.|NA - No injectable medications prescribed.|93
320|NA - No inpatient facility admission|NA - No inpatient facility admission|93
321|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|93
322|NA - No Medicaid|NA - No Medicaid|93
323|NA - No Medicare|NA - No Medicare|93
324|NA - No observable pressure ulcer or unhealed pressure ulcer|NA - No observable pressure ulcer or unhealed pressure ulcer|93
325|NA - No observable stasis ulcer|NA - No observable stasis ulcer|93
326|NA - No observable surgical wound|NA - No observable surgical wound|93
327|NA - No oral medications prescribed.|NA - No oral medications prescribed.|93
328|NA - Not applicable|NA - Not applicable|93
329|NA - Patient does not have a telephone.|NA - Patient does not have a telephone.|93
330|NA - Patient has ostomy for bowel elimination|NA - Patient has ostomy for bowel elimination|93
331|NA - Patient nonresponsive|NA - Patient nonresponsive|93
332|NA - Patient on prophylactic treatment|NA - Patient on prophylactic treatment|93
333|NA - Patient was not discharged from an inpatient facility [Go to M1021]|NA - Patient was not discharged from an inpatient facility [Go to M1017]|93
334|UK - Other unknown|UK - Other unknown|93
335|UK - Reason unknown|UK - Reason unknown|93
336|UK - Unknown|UK - Unknown|93
337|UK - Unknown or Not Available|UK - Unknown or Not Available|93
341|01 - Early|01 - Early|93
342|02 - Late|02 - Late|93
343|NA - Not Applicable. No case mix group defined for this assessment.|NA - Not Applicable. No case mix group defined for this assessment.|93
344|NA - No case mix group defined by this assessment.|NA - No case mix group defined by this assessment.|93
345|1 - Recent decline in mental, emotional, or behavioral status|1 - Recent decline in mental, emotional, or behavioral status|93
346|2 - Multiple hospitalizations (2 or more) in the past 12 months|2 - Multiple hospitalizations (2 or more) in the past 12 months|93
347|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|93
348|4 - Taking five or more medications|4 - Taking five or more medications|93
349|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|93
350|6 - Other|6 - Other|93
351|7 - None of the above|7 - None of the above|93
352|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond tho|93
353|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable without heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable wi|93
354|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious complications and death.|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious compl|93
355|3 - The patient has serious progressive conditions that could lead to death within a year.|3 - The patient has serious progressive conditions that could lead to death within a year.|93
356|UK - The patient+s situation is unknown or unclear.|UK - The patient+s situation is unknown or unclear.|93
357|1 - Yes [ Go to M1050 ]|1 - Yes [ Go to M1050 ]|93
358|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this influenza season. [ Go to M1050 ]|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this i|93
359|1 - Received from another health care provider (e.g., physician)|1 - Received from another health care provider (e.g., physician)|93
360|2 - Received from your agency previously during this year+s flu season|2 - Received from your agency previously during this year+s flu season|93
361|3 - Offered and declined|3 - Offered and declined|93
362|4 - Assessed and determined to have medical contraindication(s)|4 - Assessed and determined to have medical contraindication(s)|93
363|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|93
364|6 - Inability to obtain vaccine due to declared shortage|6 - Inability to obtain vaccine due to declared shortage|93
365|1 - Yes [ Go to M2005 at TRN; Go to M1230 at DC ]|1 - Yes [ Go to M2005 at TRN; Go to M1230 at DC ]|93
366|1 - Patient has received PPV in the past|1 - Patient has received PPV in the past|93
367|2 - Offered and declined|2 - Offered and declined|93
368|3 - Assessed and determined to have medical contraindication(s)|3 - Assessed and determined to have medical contraindication(s)|93
369|4 - Not indicated; patient does not meet age/condition guidelines for PPV|4 - Not indicated; patient does not meet age/condition guidelines for PPV|93
370|5 - None of the above|5 - None of the above|93
371|0 - Adequate: hears normal conversation without difficulty.|0 - Adequate: hears normal conversation without difficulty.|93
372|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to increase volume or speak distinctly.|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to in|93
373|2 - Severely Impaired: absence of useful hearing.|2 - Severely Impaired: absence of useful hearing.|93
374|UK - Unable to assess hearing.|UK - Unable to assess hearing.|93
375|0 - Understands: clear comprehension without cues or repetitions.|0 - Understands: clear comprehension without cues or repetitions.|93
376|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Requires cues at times to understand.|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Req|93
377|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequently requires cues to understand.|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequentl|93
378|3 - Rarely/Never Understands|3 - Rarely/Never Understands|93
379|UK - Unable to assess understanding.|UK - Unable to assess understanding.|93
380|0 - No standardized assessment conducted|0 - No standardized assessment conducted|93
381|1 - Yes, and it does not indicate severe pain|1 - Yes, and it does not indicate severe pain|93
382|2 - Yes, and it indicates severe pain|2 - Yes, and it indicates severe pain|93
383|0 - Patient has no pain|0 - Patient has no pain|93
384|1 - Patient has pain that does not interfere with activity or movement|1 - Patient has pain that does not interfere with activity or movement|93
385|2 - Less often than daily|2 - Less often than daily|93
386|3 - Daily, but not constantly|3 - Daily, but not constantly|93
387|4 - All of the time|4 - All of the time|93
388|0 - No assessment conducted [ Go to M1306 ]|0 - No assessment conducted [ Go to M1306 ]|93
389|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc., without use of standardized tool|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc.,|93
390|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|93
391|0 - No [ Go to M1322]|0 - No [ Go to M1322]|93
392|0 v Newly epithelialized|0 v Newly epithelialized|93
393|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|93
394|2 - Yes, patient has observable stasis ulcers ONLY|2 - Yes, patient has observable stasis ulcers ONLY|93
395|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable dressing) [Go to M1340]|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable|93
396|0 - No [ Go to M1400 ]|0 - No [ Go to M1400 ]|93
397|1 - Yes, patient has at least one (observable) surgical wound|1 - Yes, patient has at least one (observable) surgical wound|93
398|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1350 ]|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1350 ]|93
399|0 - Patient is not short of breath|0 - Patient is not short of breath|93
400|3 - Continuous Bi-level positive airway pressure|3 - Continuous Bi-level positive airway pressure|93
401|0 - No [ Go to M1732 at TRN; Go to M1600 at DC ]|0 - No [ Go to M1732 at TRN; Go to M1600 at DC ]|93
402|2 - Not assessed [Go to M1732 at TRN; Go to M1600 at DC ]|2 - Not assessed [Go to M1732 at TRN; Go to M1600 at DC ]|93
403|NA - Patient does not have diagnosis of heart failure [Go to M2005 at TRN; Go to M1600 at DC]|NA - Patient does not have diagnosis of heart failure [Go to M2005 at TRN; Go to M1600 at DC]|93
404|0 - No action taken|0 - No action taken|93
405|1 - Patient+s physician (or other primary care practitioner) contacted the same day|1 - Patient+s physician (or other primary care practitioner) contacted the same day|93
406|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|93
407|3 - Implement physician-ordered patient-specific established parameters for treatment|3 - Implement physician-ordered patient-specific established parameters for treatment|93
408|4 - Patient education or other clinical interventions|4 - Patient education or other clinical interventions|93
409|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequency, telehealth, etc.)|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequ|93
410|1 - Occasional stress incontinence|1 - Occasional stress incontinence|93
411|2 - During the night only|2 - During the night only|93
412|3 - During the day only|3 - During the day only|93
413|4 - During the day and night|4 - During the day and night|93
414|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|93
415|0 - Able to manage toileting hygiene and clothing management without assistance.|0 - Able to manage toileting hygiene and clothing management without assistance.|93
416|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implements are laid out for the patient.|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implemen|93
417|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|93
418|3 - Patient depends entirely upon another person to maintain toileting hygiene.|3 - Patient depends entirely upon another person to maintain toileting hygiene.|93
419|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independent|93
420|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface|93
421|0 - No multi-factor falls risk assessment conducted.|0 - No multi-factor falls risk assessment conducted.|93
422|1 - Yes, and it does not indicate a risk for falls.|1 - Yes, and it does not indicate a risk for falls.|93
423|2 - Yes, and it indicates a risk for falls.|2 - Yes, and it indicates a risk for falls.|93
424|0 - Not assessed/reviewed [ Go to M2010 ]|0 - Not assessed/reviewed [ Go to M2010 ]|93
425|No - No issues found during review [ Go to M2010 ]|No - No issues found during review [ Go to M2010 ]|93
426|Yes - Issues found during review|Yes - Issues found during review|93
427|NA - Patient is not taking any medications [ Go to M2102 ]|NA - Patient is not taking any medications [ Go to M2102 ]|93
428|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special precautions associated with all high-risk medications|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special p|93
429|NA - Patient not taking any drugs|NA - Patient not taking any drugs|93
430|2 - Able to take medication(s) at the correct times if given reminders by another person at the appropriate times|2 - Able to take medication(s) at the correct times if given reminders by another person at the appr|93
431|3 - Unable to take medication unless administered by another person.|3 - Unable to take medication unless administered by another person.|93
432|1 - At least daily|1 - At least daily|93
433|2 - Three or more times per week|2 - Three or more times per week|93
434|3 - One to two times per week|3 - One to two times per week|93
435|4 - Received, but less often than weekly|4 - Received, but less often than weekly|93
436|5 - No assistance received|5 - No assistance received|93
437|0 - No [Go to M2401]|0 - No [Go to M2401]|93
438|1 - Yes, used hospital emergency department WITHOUT hospital admission|1 - Yes, used hospital emergency department WITHOUT hospital admission|93
439|2 - Yes, used hospital emergency department WITH hospital admission|2 - Yes, used hospital emergency department WITH hospital admission|93
440|UK - Unknown [Go to M2401]|UK - Unknown [Go to M2401]|93
441|2 - Injury caused by fall|2 - Injury caused by fall|93
442|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|93
443|4 - Other respiratory problem|4 - Other respiratory problem|93
444|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|93
445|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|93
446|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|93
447|8 - Other heart disease|8 - Other heart disease|93
448|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|93
449|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|93
450|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|93
451|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|93
452|13 - Urinary tract infection|13 - Urinary tract infection|93
453|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|93
454|15 - Wound infection or deterioration|15 - Wound infection or deterioration|93
455|16 - Uncontrolled pain|16 - Uncontrolled pain|93
456|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|93
457|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|93
458|19 - Other than above reasons|19 - Other than above reasons|93
459|2 - Patient remained in the community (with formal assistive services)|2 - Patient remained in the community (with formal assistive services)|93
460|3 - Patient transferred to a noninstitutional hospice|3 - Patient transferred to a noninstitutional hospice|93
461|4 - Unknown because patient moved to a geographic location not served by this agency|4 - Unknown because patient moved to a geographic location not served by this agency|93
462|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|93
463|4 - Other respiratory problem|4 - Other respiratory problem|93
464|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|93
465|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|93
466|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|93
467|8 - Other heart disease|8 - Other heart disease|93
468|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|93
469|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|93
470|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|93
471|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|93
472|13 - Urinary tract infection|13 - Urinary tract infection|93
473|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|93
474|15 - Wound infection or deterioration|15 - Wound infection or deterioration|93
475|16 - Uncontrolled pain|16 - Uncontrolled pain|93
476|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|93
477|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|93
478|19 - Scheduled treatment or procedure|19 - Scheduled treatment or procedure|93
479|20 - Other than above reasons|20 - Other than above reasons|93
480|UK - Reason unknown [Go to M0903]|UK - Reason unknown [Go to M0903]|93
482|01 - Patient lives alone around the clock|01 - Patient lives alone around the clock|93
483|02 - Patient lives alone regular daytime|02 - Patient lives alone regular daytime|93
484|03 - Patient lives alone regular nighttime|03 - Patient lives alone regular nighttime|93
485|04 - Patient lives alone occassional/short term assistance|04 - Patient lives alone occassional/short term assistance|93
486|05 - Patient lives alone no assisstance available|05 - Patient lives alone no assisstance available|93
487|06 - Patient lives with other person(s) in the home around the clock|06 - Patient lives with other person(s) in the home around the clock|93
488|07 - Patient lives with other person(s) in the home regular daytime|07 - Patient lives with other person(s) in the home regular daytime|93
489|08 - Patient lives with other person(s) in the home regular nighttime|08 - Patient lives with other person(s) in the home regular nighttime|93
490|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|93
491|10 - Patient lives with other person(s) in the home no assistance available|10 - Patient lives with other person(s) in the home no assistance available|93
492|1 - Was present at the most recent SOC/ROC assessment|1 - Was present at the most recent SOC/ROC assessment|93
493|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|93
494|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|93
495|0 - Newly epithelialized|0 - Newly epithelialized|93
496|0 - No [ Go to M1340 ]|0 - No [ Go to M1340 ]|93
498|0 - Independent|0 - Independent|93
499|1 - Needed Some Help|1 - Needed Some Help|93
500|2 - Dependent|2 - Dependent|93
502|0 - No assistance needed in this area|0 - No assistance needed in this area|93
503|1 - Caregiver(s) currently provide assistance|1 - Caregiver(s) currently provide assistance|93
504|2 - Caregiver(s) need training/ supportive services to provide assistance|2 - Caregiver(s) need training/ supportive services to provide assistance|93
505|3 - Caregiver(s) not likely to provide assistance|3 - Caregiver(s) not likely to provide assistance|93
506|4 - Unclear if Caregiver(s) will provide assistance|4 - Unclear if Caregiver(s) will provide assistance|93
507|5 - Assistance needed, but no Caregiver(s) available|5 - Assistance needed, but no Caregiver(s) available|93
508|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will use standardized clinical guidelines accessible for all care providers to reference|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will|93
509|NA - Patient is not diabetic or is bilateral amputee|NA - Patient is not diabetic or is bilateral amputee|93
510|NA - Patient is not assessed to be at risk for falls|NA - Patient is not assessed to be at risk for falls|93
511|NA - Patient has no diagnosis or symptoms of depression|NA - Patient has no diagnosis or symptoms of depression|93
512|NA - No pain identified|NA - No pain identified|93
513|NA - Patient is not assessed to be at risk for pressure ulcers|NA - Patient is not assessed to be at risk for pressure ulcers|93
514|NA - Patient has no pressure ulcers with need for moist wound healing|NA - Patient has no pressure ulcers with need for moist wound healing|93
515|1 - Long-term nursing facility (NF)|1 - Long-term nursing facility (NF)|93
516|2 - Skilled nursing facility (SNF / TCU)|2 - Skilled nursing facility (SNF / TCU)|93
517|3 - Short stay acute hospital (IPP S)|3 - Short stay acute hospital (IPP S)|93
518|4 - Long-term care hospital (LTCH)|4 - Long-term care hospital (LTCH)|93
519|5 - Inpatient rehabilitation hospital or unit (IRF)|5 - Inpatient rehabilitation hospital or unit (IRF)|93
520|6 - Psychiatric hospital or unit|6 - Psychiatric hospital or unit|93
521|7 - Other|7 - Other|93
522|NA - Patient was not discharged from an inpatient facility [Go to M1017]|NA - Patient was not discharged from an inpatient facility [Go to M1017]|93
523|6 - Unable to participate effectively in bathing and is bathed totally by another person|6 - Unable to participate effectively in bathing and is bathed totally by another person|93
524|4 - Chairfast, unable to ambulate but is able to wheel self independently.|4 - Chairfast, unable to ambulate but is able to wheel self independently.|93
525|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask patient: "Over the last two weeks, how often have you been bothered by any of the following problems")  *Copyright+ Pfizer Inc. All rights reserved. Reproduced with permission.|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask|93
526|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluation for depression.|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluat|93
527|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet criteria for further evaluation for depression.|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet|93
528|0 - Not at all  0 - 1 day|0 - Not at all  0 - 1 day|93
529|1 - Several days  2 - 6 days|1 - Several days  2 - 6 days|93
530|2 - More than half of the days  7 - 11 days|2 - More than half of the days  7 - 11 days|93
531|3 - Nearly every day  12 - 14 days|3 - Nearly every day  12 - 14 days|93
532|NA - N/A  Unable to respond|NA - N/A  Unable to respond|93
533|2 - Able to take medication(s) at the correct times if given reminders by another person based on the frequency of the injection|2 - Able to take medication(s) at the correct times if given reminders by another person based on th|93
534|3 - Unable to take injectable medication unless administered by another person.|3 - Unable to take injectable medication unless administered by another person.|93
540|11 - Patient lives in congregate situation (e.g., assisted living) around the clock|11 - Patient lives in congregate situation (e.g., assisted living) around the clock|93
541|12 - Patient lives in congregate situation (e.g., assisted living) regular daytime|12 - Patient lives in congregate situation (e.g., assisted living) regular daytime|93
542|13 - Patient lives in congregate situation (e.g., assisted living) regular nighttime|13 - Patient lives in congregate situation (e.g., assisted living) regular nighttime|93
543|14 - Patient lives in congregate situation (e.g., assisted living) occasional / short-term assistance|14 - Patient lives in congregate situation (e.g., assisted living) occasional / short-term assistanc|93
544|15 - Patient lives in congregate situation (e.g., assisted living) no available assistance|15 - Patient lives in congregate situation (e.g., assisted living) no available assistance|93
546|NA - No observable pressure ulcer|NA - No observable pressure ulcer|93
583|NA - No specific SOC date ordered by physician|NA - No specific SOC date ordered by physician|93
586|UK - Inpatient Discharge Date Unknown|UK - Inpatient Discharge Date Unknown|93
601|1 - History of falls (2 or more falls - or any fall with an injury - in the past 12 months) |1 - History of falls (2 or more falls - or any fall with an injury - in the past 12 months) |93
603|2 - Unintentional weight loss of a total of 10 pounds or more in the past 12 months |2 - Unintentional weight loss of a total of 10 pounds or more in the past 12 months |93
605|3 - Multiple hospitalizations (2 or more) in the past 6 months|3 - Multiple hospitalizations (2 or more) in the past 6 months|93
607|4 - Multiple emergency department visits (2 or more) in the past 6 months|4 - Multiple emergency department visits (2 or more) in the past 6 months|93
609|5 - Decline in mental emotional or behavioral status in the past 3 months |5 - Decline in mental emotional or behavioral status in the past 3 months |93
611|6 - Reported or observed history of difficulty complying with any medical instructions (for example,medications, diet, exercise) in the past 3 months|6 - Reported or observed history of difficulty complying with any medical instructions (for example |93
613|7 - Currently taking 5 or more medications|7 - Currently taking 5 or more medications|93
615|8 - Currently reports exhaustion|8 - Currently reports exhaustion|93
617|9 - Other risk(s) not listed in 1 - 8|9 - Other risk(s) not listed in 1 - 8|93
619|10 - None of the above |10 - None of the above |93
632|0 - No assistance needed v patient is independent or does not have needs in this area|0 - No assistance needed v patient is independent or does not have needs in this area|93
633|1 - Non-agency caregiver(s) currently provide assistance |1 - Non-agency caregiver(s) currently provide assistance |93
634|2 - Non-agency caregiver(s) need training/ supportive services to provide assistance|2 - Non-agency caregiver(s) need training/ supportive services to provide assistance|93
635|3 - Non-agency caregiver(s) are not likely to provide assistance OR it is unclear if they will provide assistance|3 - Non-agency caregiver(s) are not likely to provide assistance OR unclear if will provide asst|93
636|4 - Assistance needed but no non-agency caregiver(s) available|4 - Assistance needed but no non-agency caregiver(s) available|93
2|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; OR (b) Is physically, cognitively, and mentally able to prepare light meals on a regular basis but has not routinely performed light meal preparation in the past (i.e., prior to this home care admission).|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; O|94
3|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and mentally able to perform all housekeeping tasks .|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and menta|94
4|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and mentally able to do laundry and access facilities.|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and menta|94
5|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying packages OR b) Physically, cognitively, and mentally able to take care of shopping, but has not done shopping in the past (i.e., prior to this home care admission).|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying|94
6|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|94
7|0 - Able to dial numbers and answer calls appropriately and as desired.|0 - Able to dial numbers and answer calls appropriately and as desired.|94
8|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body without assistance.|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body|94
9|0 - Able to get to and from the toilet and transfer independently with or without a device.|0 - Able to get to and from the toilet and transfer independently with or without a device.|94
10|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|94
539|06 - Independent - Patient completes the activity by him/herself with no assistance from a helper.|06 - Independent - Patient completes the activity by him/herself with no assistance from a helper.|94
540|05 - Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity.|05 - Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper|94
541|04 - Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently.|04 - Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/|94
542|03 - Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort.|03 - Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or sup|94
543|02 - Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.|02 - Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds t|94
544|01 - Dependent - Helper does ALL of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity.|01 - Dependent - Helper does ALL of the effort. Patient does none of the effort to complete the acti|94
545|07 - Patient refused|07 - Patient refused|94
546|09 - Not applicable - Not attempted and the patient did not perform this activity prior to the current illness,exacerbation or injury.|09 - Not applicable - Not attempted and the patient did not perform this activity prior to the curre|94
547|10 - Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)|10 - Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)|94
548|88 - Not attempted due to medical conditions or safety concerns|88 - Not attempted due to medical conditions or safety concerns|94
549|0 - No [STOP]|0 - No [STOP]|94
550|0 - No [STOP]|0 - No [Skip GG0170R]|94
551|1 - Yes [Continue to GG0170R, Wheel 50 feet with two turns.]|1 - Yes [Continue to GG0170R, Wheel 50 feet with two turns.]|94
552|1 - Manual|1 - Manual|94
553|2 - Motorized|2 - Motorized|94
554|0 - No [Skip to J1800 Any falls since SOC/ROC, whichever is more recent.]|0 - No [Skip to J1800 Any falls since SOC/ROC, whichever is more recent.]|94
555|0 - No [STOP]|0 - No [STOP]|94
556|1 - Yes [Continue to J1900, Number of Falls Since SOC/ROC, whichever is more recent]|1 - Yes [Continue to J1900, Number of Falls Since SOC/ROC, whichever is more recent]|94
557|0 - None|0 - None|94
558|1 - One|1 - One|94
559|2 - Two or More|2 - Two or More|94
560|3 - Independent - Patient completed the activities by him/herself, with or without an assistive device, with no assistance from a helper.|3 - Independent - Patient completed the activities by him/herself, with or without an assistive devi|94
561|2 - Needed Some Help - Patient needed partial assistance from another person to complete activities.|2 - Needed Some Help - Patient needed partial assistance from another person to complete activities.|94
562|1 - Dependent - A helper completed the activities for the patient.|1 - Dependent - A helper completed the activities for the patient.|94
563|8 - Unknown|8 - Unknown|94
564|9 - Not Applicable|9 - Not Applicable|94
565|A - Manual wheelchair|A - Manual wheelchair|94
566|B - Motorized wheelchair and/or scooter|B - Motorized wheelchair and/or scooter|94
567|C - Mechanical lift|C - Mechanical lift|94
568|D - Walker|D - Walker|94
569|E - Orthotics/Prosthetics|E - Orthotics/Prosthetics|94
570|Z - None of the above|Z - None of the above|94
11|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible public bus.|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible p|94
12|0 - Able to independently feed self.|0 - Able to independently feed self.|94
13|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|94
14|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct times.|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct ti|94
15|0 - Able to independently transfer.|0 - Able to independently transfer.|94
16|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without rail|94
17|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings|94
18|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|94
19|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions independently.|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions indep|94
20|0 - Asymptomatic, no treatment needed at this time|0 - Asymptomatic, no treatment needed at this time|94
21|0 - Caregiver manages all tasks related to equipment completely independently.|0 - Caregiver manages all tasks related to equipment completely independently.|94
22|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations with no observable impairment.|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations w|94
23|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|94
24|0 - Life expectancy is greater than 6 months|0 - Life expectancy is greater than 6 months|94
25|0 - Never|0 - Never|94
26|0 - Patient is not short of breath|0 - Patient is not short of breath|94
27|0 - No|0 - No|94
28|0 - No emergent care services|0 - No emergent care services|94
29|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [Goto M1620]|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [Goto M1620]|94
30|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and extended or abstract conversation.|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and exte|94
31|0 - No one person|0 - No one person|94
32|0 - None of the time|0 - None of the time|94
33|0 - None, no charge for current services|0 - None, no charge for current services|94
34|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|94
35|0 - Patient does NOT have an ostomy for bowel elimination.|0 - Patient does NOT have an ostomy for bowel elimination.|94
36|0 - Patient has no pain|0 - Patient has no pain|94
37|0 - Patient manages all tasks related to equipment completely independently.|0 - Patient manages all tasks related to equipment completely independently.|94
38|0 - Poor:  little or no recovery is expected and/or further decline is imminent|0 - Poor:  little or no recovery is expected and/or further decline is imminent|94
39|0 - Timed-voiding defers incontinence|0 - Timed-voiding defers incontinence|94
40|0 - Very rarely or never has bowel incontinence|0 - Very rarely or never has bowel incontinence|94
41|0 - Zero|0 - Zero|94
42|00 - No|00 - No|94
43|01 - Yes|01 - Yes|94
44|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or mental limitations, needs assistance with heavy laundry.|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or|94
45|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the patient.|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the|94
46|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|94
47|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or supervision from another person OR c) a liquid, pureed or ground meat diet.|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or su|94
48|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|94
49|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|94
50|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independently.|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independe|94
51|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only when assisted or accompanied by another person.|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only w|94
52|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepa|94
53|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance by another person OR b) given daily reminders.|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance b|94
54|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advan|94
55|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advan|94
56|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for the deaf) and call essential numbers.|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for t|94
57|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|94
58|1 - American Indian or Alaska Native|1 - American Indian or Alaska Native|94
59|1 - Depressed mood (e.g., feeling sad, tearful)|1 - Depressed mood (e.g., feeling sad, tearful)|94
60|1 - During the night only|1 - During the night only|94
61|1 - Fully granulating|1 - Fully granulating|94
62|1 - Good/Fair:  partial to full recovery is expected|1 - Good/Fair:  partial to full recovery is expected|94
63|1 - Good:  marked improvement in functional status is expected|1 - Good:  marked improvement in functional status is expected|94
64|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|94
65|1 - Smoking|1 - Smoking|94
66|1 - Hospital|1 - Hospital|94
67|1 - Hospital emergency room (includes 23-hour holding)|1 - Hospital emergency room (includes 23-hour holding)|94
68|1 - Hospitalization for EMERGENT (unscheduled) care|1 - Hospitalization for EMERGENT (unscheduled) care|94
69|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepared solutions), patient is able to manage all other aspects of equipment.|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepar|94
70|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|94
71|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|94
72|1 - In new or complex situations only|1 - In new or complex situations only|94
73|1 - Intravenous or infusion therapy (excludes TPN)|1 - Intravenous or infusion therapy (excludes TPN)|94
74|1 - Less often than daily|1 - Less often than daily|94
75|1 - Less than once a month|1 - Less than once a month|94
76|1 - Less than once weekly|1 - Less than once weekly|94
77|1 - Life expectancy is 6 months or fewer|1 - Life expectancy is 6 months or fewer|94
78|1 - Lives alone|1 - Lives alone|94
79|1 - Male|1 - Male|94
80|1 - Medicare (traditional fee-for-service)|1 - Medicare (traditional fee-for-service)|94
81|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of past 24 hours, significant memory loss so that supervision is required|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of pas|94
82|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors in word choice, grammar or speech intelligibility, needs minimal prompting or assistance).|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors i|94
83|1 - No assistance or services received|1 - No assistance or services received|94
84|1 - One|1 - One|94
85|1 - Oxygen (intermittent or continuous)|1 - Oxygen (intermittent or continuous)|94
86|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, and the surrounding layout, can count fingers at arm's length.|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, a|94
87|1 - Patient is incontinent|1 - Patient is incontinent|94
88|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|94
89|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical or treatment regimen.|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical|94
90|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient/couple/significant other)|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient|94
91|1 - Relatives, friends, or neighbors living outside the home|1 - Relatives, friends, or neighbors living outside the home|94
92|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions.|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions|94
93|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independentl|94
94|1 - Several times during day and night|1 - Several times during day and night|94
95|1 - Spouse or significant other|1 - Spouse or significant other|94
96|1 - Stage 1|1 - Stage 1|94
97|1 - Start of care - further visits planned|1 - Start of care - further visits planned|94
98|1 - Symptoms well controlled with current therapy|1 - Symptoms well controlled with current therapy|94
99|1 - Therapy services|1 - Therapy services|94
100|1 - Able to transfer with minimal human assistance or with use of an assistive device.|1 - Able to transfer with minimal human assistance or with use of an assistive device.|94
101|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitations.|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitatio|94
102|1 - Urinary incontinence|1 - Urinary incontinence|94
103|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and transfer.|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and|94
104|1 - When walking more than 20 feet, climbing stairs|1 - When walking more than 20 feet, climbing stairs|94
105|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary conversation. May need occasional repetition, extra time, or louder voice.|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary c|94
106|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting in and out of tub/shower|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting|94
107|1 - Yes|1 - Yes|94
108|1-RN|1-RN|94
109|10 - Discharge from agency - no visits completed after start/resumption of care assessment|10 - Discharge from agency - no visits completed after start/resumption of care assessment|94
110|10 - Scheduled surgical procedure|10 - Scheduled surgical procedure|94
111|10 - Self-pay|10 - Self-pay|94
112|11 - Other|11 - Other|94
113|11 - Urinary tract infection|11 - Urinary tract infection|94
114|12 - IV catheter-related infection|12 - IV catheter-related infection|94
115|13 - Deep vein thrombosis, pulmonary embolus|13 - Deep vein thrombosis, pulmonary embolus|94
116|14 - Uncontrolled pain|14 - Uncontrolled pain|94
117|15 - Psychotic episode|15 - Psychotic episode|94
118|16 - Other than above reasons|16 - Other than above reasons|94
119|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing calls.|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing|94
120|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another person.|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another pers|94
121|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface a|94
122|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for intermittent supervision or encouragement or reminders, OR (b) to get in and out of the shower or tub, OR (c) for washing difficult to reach areas.|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for inter|94
123|2 - Asian|2 - Asian|94
124|2 - Caregiver requires considerable assistance from another person to manage equipment, but independently completes significant portions of task.|2 - Caregiver requires considerable assistance from another person to manage equipment, but independ|94
125|2 - Daily, but not constantly|2 - Daily, but not constantly|94
126|2 - Daughter or son|2 - Daughter or son|94
127|2 - Doctor's office emergency visit/house call|2 - Doctor's office emergency visit/house call|94
128|2 - During the day and night|2 - During the day and night|94
129|2 - Early/partial granulation|2 - Early/partial granulation|94
130|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors in word choice, organization or speech intelligibility). Speaks in phrases or short sentences.|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors|94
131|2 - Family member's residence|2 - Family member's residence|94
132|2 - Female|2 - Female|94
133|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conversation, needs frequent prompting or assistance.|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conver|94
134|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|94
135|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|94
136|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately stop activities, jeopardizes safety through actions|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately st|94
137|2 - Indwelling/suprapubic catheter|2 - Indwelling/suprapubic catheter|94
138|2 - Injury caused by fall or accident at home|2 - Injury caused by fall or accident at home|94
139|2 - Medicare (HMO/managed care/Advantage plan)|2 - Medicare (HMO/managed care/Advantage plan)|94
140|2 - Nausea, dehydration, malnutrition, constipation, impaction|2 - Nausea, dehydration, malnutrition, constipation, impaction|94
141|2 - Obesity|2 - Obesity|94
142|2 - On awakening or at night only|2 - On awakening or at night only|94
143|2 - Once a month|2 - Once a month|94
144|2 - One to three times weekly|2 - One to three times weekly|94
145|2 - Parenteral nutrition (TPN or lipids)|2 - Parenteral nutrition (TPN or lipids)|94
146|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic) [ Go to M1620 ]|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic) [ Go|94
147|2 - Patient requires considerable assistance from another person to manage equipment, but independently completes portions of the task.|2 - Patient requires considerable assistance from another person to manage equipment, but independen|94
148|2 - Patient transferred to a noninstitutional hospice|2 - Patient transferred to a noninstitutional hospice|94
149|2 - Person residing in the home (EXCLUDING paid help)|2 - Person residing in the home (EXCLUDING paid help)|94
150|2 - Rehabilitation facility|2 - Rehabilitation facility|94
151|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifting of attention) or consistently requires low stimulus environment due to distractibility.|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifti|94
152|2 - Respite care|2 - Respite care|94
153|2 - Sense of failure or self reproach|2 - Sense of failure or self reproach|94
154|2 - Several times during day|2 - Several times during day|94
155|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonresponsive.|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonrespons|94
156|2 - Someone must assist the patient to groom self.|2 - Someone must assist the patient to groom self.|94
157|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|94
158|2 - Someone must help the patient put on upper body clothing.|2 - Someone must help the patient put on upper body clothing.|94
159|2 - Stage 2|2 - Stage 2|94
160|2 - Start of care - no further visits planned|2 - Start of care - no further visits planned|94
161|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitoring|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitori|94
162|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment regimen.|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment re|94
163|2 - Two|2 - Two|94
164|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistance due to cognitive or mental limitation.|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistanc|94
165|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|94
166|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assistance).|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assis|94
167|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home delivery.|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home deli|94
168|2 - Unable to prepare any light meals or reheat any delivered meals.|2 - Unable to prepare any light meals or reheat any delivered meals.|94
169|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|94
170|2 - UNABLE to take injectable medications unless administered by someone else.|2 - UNABLE to take injectable medications unless administered by someone else.|94
171|2 - UNABLE to take medication unless administered by someone else.|2 - UNABLE to take medication unless administered by someone else.|94
172|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|94
173|2 - Ventilator (continually or at night)|2 - Ventilator (continually or at night)|94
174|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less than 20 feet)|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less th|94
175|2 - With spouse or significant other|2 - With spouse or significant other|94
176|2 - Yes, assistance or services provided by family or friends|2 - Yes, assistance or services provided by family or friends|94
177|2-PT|2-PT|94
178|3 - Able to answer the telephone only some of the time or is able to carry on only a limited conversation.|3 - Able to answer the telephone only some of the time or is able to carry on only a limited convers|94
179|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube or gastrostomy.|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube|94
180|3 - Alcohol dependency|3 - Alcohol dependency|94
181|3 - All of the time|3 - All of the time|94
182|3 - Black or African-American|3 - Black or African-American|94
183|3 - Boarding home or rented room|3 - Boarding home or rented room|94
184|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment, clean/store/dispose of equipment or supplies).|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment,|94
185|3 -Able to walk only with the supervision or assistance of another person at all times.|3 -Able to walk only with the supervision or assistance of another person at all times.|94
186|3 - Continuous / Bi-level positive airway pressure|3 - Continuous / Bi-level positive airway pressure|94
187|3 - During the day and evening, but not constantly|3 - During the day and evening, but not constantly|94
188|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the alimentary canal)|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the|94
189|3 - Environmental support (e.g., housing, home maintenance)|3 - Environmental support (e.g., housing, home maintenance)|94
190|3 - Four to six times weekly|3 - Four to six times weekly|94
191|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessing by listener.  Speech limited to single words or short phrases.|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessin|94
192|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires multiple repetitions, restatements, demonstrations, additional time.|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires m|94
193|3 - Hopelessness|3 - Hopelessness|94
194|3 - Hospice care|3 - Hospice care|94
195|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|94
196|3 - Injury caused by fall or accident at home|3 - Injury caused by fall or accident at home|94
197|3 - Intractable pain|3 - Intractable pain|94
198|3 - Medicaid (traditional fee-for-service)|3 - Medicaid (traditional fee-for-service)|94
199|3 - Needs someone to do all shopping and errands.|3 - Needs someone to do all shopping and errands.|94
200|3 - Not healing|3 - Not healing|94
201|3 - Nursing home|3 - Nursing home|94
202|3 - Once daily|3 - Once daily|94
203|3 - Other family member|3 - Other family member|94
204|3 - Outpatient department/clinic emergency (includes urgicenter sites)|3 - Outpatient department/clinic emergency (includes urgicenter sites)|94
205|3 - Paid help|3 - Paid help|94
206|3 - Able to participate in bathing self in shower or tub, but requires presence of another person throughout the bath for assistance or supervision.|3 - Able to participate in bathing self in shower or tub, but requires presence of another person th|94
207|3 - Patient depends entirely upon another person to dress lower body.|3 - Patient depends entirely upon another person to dress lower body.|94
208|3 - Patient depends entirely upon another person to dress the upper body.|3 - Patient depends entirely upon another person to dress the upper body.|94
209|3 - Patient depends entirely upon someone else for grooming needs.|3 - Patient depends entirely upon someone else for grooming needs.|94
210|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone else to manage the equipment.|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone|94
211|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable to shift attention and recall directions more than half the time.|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable|94
212|3 - Respiratory problems (SOB, infection, obstruction)|3 - Respiratory problems (SOB, infection, obstruction)|94
213|3 - Resumption of care (after inpatient stay)|3 - Resumption of care (after inpatient stay)|94
214|3 - Several times each month|3 - Several times each month|94
215|3 - Skilled Nursing Facility|3 - Skilled Nursing Facility|94
216|3 - Stage 3|3 - Stage 3|94
217|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|94
218|3 - Three|3 - Three|94
219|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person throughout the process.|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person through|94
220|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal independently.|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal indep|94
221|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person.|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person|94
222|3 - Unknown because patient moved to a geographic location not served by this agency|3 - Unknown because patient moved to a geographic location not served by this agency|94
223|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|94
224|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|94
225|3 - With other family member|3 - With other family member|94
226|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home health services, homemaker assistance, transportation assistance, assisted living, board and care)|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home h|94
227|3-SLP/ST|3-SLP/ST|94
228|4 - At rest (during day or night)|4 - At rest (during day or night)|94
229|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|94
230|4 - Board and care or assisted living facility|4 - Board and care or assisted living facility|94
231|4 - Caregiver is completely dependent on someone else to manage all equipment.|4 - Caregiver is completely dependent on someone else to manage all equipment.|94
232|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|94
233|4 - Constantly|4 - Constantly|94
234|4 - Drug dependency|4 - Drug dependency|94
235|4 - Four or more|4 - Four or more|94
236|4 - Friend or neighbor or community or church member|4 - Friend or neighbor or community or church member|94
237|4 - Hispanic or Latino|4 - Hispanic or Latino|94
238|4 - Hospice|4 - Hospice|94
239|4 - Impaired decision-making|4 - Impaired decision-making|94
240|4 - Is totally dependent in toileting.|4 - Is totally dependent in toileting.|94
241|4 - Medicaid (HMO/managed care)|4 - Medicaid (HMO/managed care)|94
242|4 - None of the above|4 - None of the above|94
243|4 - Nursing home|4 - Nursing home|94
244|4 - On a daily basis|4 - On a daily basis|94
245|4 - Patient is completely dependent on someone else to manage all equipment.|4 - Patient is completely dependent on someone else to manage all equipment.|94
246|4 - Permanent placement|4 - Permanent placement|94
247|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, punches, dangerous maneuvers w/ wheelchair or other objects)|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, pu|94
248|4 - Psychosocial support (e.g., socialization, companionship, recreation)|4 - Psychosocial support (e.g., socialization, companionship, recreation)|94
249|4 - Recertification (follow-up) reassessment|4 - Recertification (follow-up) reassessment|94
250|4 - Recurrent thoughts of death|4 - Recurrent thoughts of death|94
251|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruction)|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruc|94
252|4 - Several times a week|4 - Several times a week|94
253|4 - Stage 4|4 - Stage 4|94
254|4 - Symptoms poorly controlled, history of re-hospitalizations|4 - Symptoms poorly controlled, history of re-hospitalizations|94
255|4 - Three or more times per week|4 - Three or more times per week|94
256|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetative state, or delirium.|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetati|94
257|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|94
258|4 - Unable to effectively participate in any housekeeping tasks.|4 - Unable to effectively participate in any housekeeping tasks.|94
259|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or unresponsive (e.g., speech is nonsensical or unintelligible).|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or u|94
260|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonresponsive.|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonr|94
261|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostomy.|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostom|94
262|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of devices at the sink, in chair, or on commode|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of|94
263|4 - With a friend|4 - With a friend|94
264|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|94
265|4-OT|4-OT|94
266|5 - Advocates or facilitates patient's participation in appropriate medical care|5 - Advocates or facilitates patient's participation in appropriate medical care|94
267|5 - At least daily|5 - At least daily|94
268|6 - Bedfast, unable to ambulate or be up in a chair.|6 - Bedfast, unable to ambulate or be up in a chair.|94
269|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|94
270|5 - Disruptive or socially inappropriate behavior|5 - Disruptive or socially inappropriate behavior|94
271|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|94
272|5 - Hypo/Hyperglycemia, diabetes out of control|5 - Hypo/Hyperglycemia, diabetes out of control|94
273|5 - More often than once daily|5 - More often than once daily|94
274|5 - Native Hawaiian or Pacific Islander|5 - Native Hawaiian or Pacific Islander|94
275|5 - None of the above|5 - None of the above|94
276|5 - One to two times per week|5 - One to two times per week|94
277|5 - Other|5 - Other|94
278|5 - Other follow-up|5 - Other follow-up|94
279|5 - Paid help|5 - Paid help|94
280|5 - Patient nonresponsive or unable to speak.|5 - Patient nonresponsive or unable to speak.|94
281|5 - Thoughts of suicide|5 - Thoughts of suicide|94
282|5 - Totally unable to use the telephone.|5 - Totally unable to use the telephone.|94
283|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|94
284|5 - Unable to take in nutrients orally or by tube feeding.|5 - Unable to take in nutrients orally or by tube feeding.|94
285|5 - Unsafe for care at home|5 - Unsafe for care at home|94
286|5 - With paid help (other than home care agency staff)|5 - With paid help (other than home care agency staff)|94
287|5 - Workers' compensation|5 - Workers' compensation|94
288|5 - Wound infection, deteriorating wound status, new lesion/ulcer|5 - Wound infection, deteriorating wound status, new lesion/ulcer|94
289|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|94
290|6 - Delusional, hallucinatory, or paranoid behavior|6 - Delusional, hallucinatory, or paranoid behavior|94
291|6 - Financial agent, power of attorney, or conservator of finance|6 - Financial agent, power of attorney, or conservator of finance|94
292|6 - GI bleeding, obstruction|6 - GI bleeding, obstruction|94
293|6 - Less often than weekly|6 - Less often than weekly|94
294|6 - Memory loss to the extent that supervision required|6 - Memory loss to the extent that supervision required|94
295|6 - None of the above feelings observed or reported|6 - None of the above feelings observed or reported|94
296|6 - Other|6 - Other|94
297|6 - Title programs (e.g., Title III, V, or XX)|6 - Title programs (e.g., Title III, V, or XX)|94
298|6 - Transferred to an inpatient facility - patient not discharged from agency|6 - Transferred to an inpatient facility - patient not discharged from agency|94
299|6 - White|6 - White|94
300|6 - With other than above|6 - With other than above|94
301|7 - Exacerbation of CHF, fluid overload, heart failure|7 - Exacerbation of CHF, fluid overload, heart failure|94
302|7 - Health care agent, conservator of person, or medical power of attorney|7 - Health care agent, conservator of person, or medical power of attorney|94
303|7 - Hypo/Hyperglycemia, diabetes out of control|7 - Hypo/Hyperglycemia, diabetes out of control|94
304|7 - None of the above|7 - None of the above|94
305|7 - None of the above behaviors demonstrated|7 - None of the above behaviors demonstrated|94
306|7 - Other government (e.g., TriCare, VA, etc.)|7 - Other government (e.g., TriCare, VA, etc.)|94
307|7 - Transferred to an inpatient facility - patient discharged from agency|7 - Transferred to an inpatient facility - patient discharged from agency|94
308|8 - Death at home|8 - Death at home|94
309|8 - GI bleeding, obstruction|8 - GI bleeding, obstruction|94
310|8 - Myocardial infarction, stroke|8 - Myocardial infarction, stroke|94
311|8 - Private insurance|8 - Private insurance|94
312|9 - Chemotherapy|9 - Chemotherapy|94
313|9 - Discharge from agency|9 - Discharge from agency|94
314|9 - Other than above reasons|9 - Other than above reasons|94
315|9 - Private HMO/managed care|9 - Private HMO/managed care|94
316|NA - No caregiver|NA - No caregiver|94
317|NA - No equipment of this type used in care.|NA - No equipment of this type used in care.|94
318|NA - No inhalant/mist medications prescribed.|NA - No inhalant/mist medications prescribed.|94
319|NA - No injectable medications prescribed.|NA - No injectable medications prescribed.|94
320|NA - No inpatient facility admission|NA - No inpatient facility admission|94
321|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|94
322|NA - No Medicaid|NA - No Medicaid|94
323|NA - No Medicare|NA - No Medicare|94
324|NA - No observable pressure ulcer or unhealed pressure ulcer|NA - No observable pressure ulcer or unhealed pressure ulcer|94
325|NA - No observable stasis ulcer|NA - No observable stasis ulcer|94
326|NA - No observable surgical wound|NA - No observable surgical wound|94
327|NA - No oral medications prescribed.|NA - No oral medications prescribed.|94
328|NA - Not applicable|NA - Not applicable|94
329|NA - Patient does not have a telephone.|NA - Patient does not have a telephone.|94
330|NA - Patient has ostomy for bowel elimination|NA - Patient has ostomy for bowel elimination|94
331|NA - Patient nonresponsive|NA - Patient nonresponsive|94
332|NA - Patient on prophylactic treatment|NA - Patient on prophylactic treatment|94
333|NA - Patient was not discharged from an inpatient facility [Go to M1017]|NA - Patient was not discharged from an inpatient facility [Go to M1017]|94
334|UK - Other unknown|UK - Other unknown|94
335|UK - Reason unknown|UK - Reason unknown|94
336|UK - Unknown|UK - Unknown|94
337|UK - Unknown or Not Available|UK - Unknown or Not Available|94
341|01 - Early|01 - Early|94
342|02 - Late|02 - Late|94
343|NA - Not Applicable. No case mix group defined for this assessment.|NA - Not Applicable. No case mix group defined for this assessment.|94
344|NA - No case mix group defined by this assessment.|NA - No case mix group defined by this assessment.|94
345|1 - Recent decline in mental, emotional, or behavioral status|1 - Recent decline in mental, emotional, or behavioral status|94
346|2 - Multiple hospitalizations (2 or more) in the past 12 months|2 - Multiple hospitalizations (2 or more) in the past 12 months|94
347|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|94
348|4 - Taking five or more medications|4 - Taking five or more medications|94
349|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|94
350|6 - Other|6 - Other|94
351|7 - None of the above|7 - None of the above|94
352|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond tho|94
353|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable without heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable wi|94
354|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious complications and death.|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious compl|94
355|3 - The patient has serious progressive conditions that could lead to death within a year.|3 - The patient has serious progressive conditions that could lead to death within a year.|94
356|UK - The patient+s situation is unknown or unclear.|UK - The patient+s situation is unknown or unclear.|94
357|1 - Yes [ Go to M1050 ]|1 - Yes [ Go to M1050 ]|94
358|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this influenza season. [ Go to M1050 ]|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this i|94
359|1 - Received from another health care provider (e.g., physician)|1 - Received from another health care provider (e.g., physician)|94
360|2 - Received from your agency previously during this year+s flu season|2 - Received from your agency previously during this year+s flu season|94
361|3 - Offered and declined|3 - Offered and declined|94
362|4 - Assessed and determined to have medical contraindication(s)|4 - Assessed and determined to have medical contraindication(s)|94
363|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|94
364|6 - Inability to obtain vaccine due to declared shortage|6 - Inability to obtain vaccine due to declared shortage|94
365|1 - Yes [ Go to M2005 at TRN; Go to M1230 at DC ]|1 - Yes [ Go to M2005 at TRN; Go to M1230 at DC ]|94
366|1 - Patient has received PPV in the past|1 - Patient has received PPV in the past|94
367|2 - Offered and declined|2 - Offered and declined|94
368|3 - Assessed and determined to have medical contraindication(s)|3 - Assessed and determined to have medical contraindication(s)|94
369|4 - Not indicated; patient does not meet age/condition guidelines for PPV|4 - Not indicated; patient does not meet age/condition guidelines for PPV|94
370|5 - None of the above|5 - None of the above|94
371|0 - Adequate: hears normal conversation without difficulty.|0 - Adequate: hears normal conversation without difficulty.|94
372|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to increase volume or speak distinctly.|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to in|94
373|2 - Severely Impaired: absence of useful hearing.|2 - Severely Impaired: absence of useful hearing.|94
374|UK - Unable to assess hearing.|UK - Unable to assess hearing.|94
375|0 - Understands: clear comprehension without cues or repetitions.|0 - Understands: clear comprehension without cues or repetitions.|94
376|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Requires cues at times to understand.|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Req|94
377|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequently requires cues to understand.|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequentl|94
378|3 - Rarely/Never Understands|3 - Rarely/Never Understands|94
379|UK - Unable to assess understanding.|UK - Unable to assess understanding.|94
380|0 - No standardized assessment conducted|0 - No standardized assessment conducted|94
381|1 - Yes, and it does not indicate severe pain|1 - Yes, and it does not indicate severe pain|94
382|2 - Yes, and it indicates severe pain|2 - Yes, and it indicates severe pain|94
383|0 - Patient has no pain|0 - Patient has no pain|94
384|1 - Patient has pain that does not interfere with activity or movement|1 - Patient has pain that does not interfere with activity or movement|94
385|2 - Less often than daily|2 - Less often than daily|94
386|3 - Daily, but not constantly|3 - Daily, but not constantly|94
387|4 - All of the time|4 - All of the time|94
388|0 - No assessment conducted [ Go to M1306 ]|0 - No assessment conducted [ Go to M1306 ]|94
389|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc., without use of standardized tool|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc.,|94
390|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|94
391|0 - No [ Go to M1322]|0 - No [ Go to M1322]|94
392|0 v Newly epithelialized|0 v Newly epithelialized|94
393|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|94
394|2 - Yes, patient has observable stasis ulcers ONLY|2 - Yes, patient has observable stasis ulcers ONLY|94
395|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable dressing) [Go to M1340]|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable|94
396|0 - No [ Go to M1400 ]|0 - No [ Go to M1400 ]|94
397|1 - Yes, patient has at least one (observable) surgical wound|1 - Yes, patient has at least one (observable) surgical wound|94
398|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1400 ]|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1400 ]|94
399|0 - Patient is not short of breath|0 - Patient is not short of breath|94
400|3 - Continuous Bi-level positive airway pressure|3 - Continuous Bi-level positive airway pressure|94
401|0 - No [ Go to M1732 at TRN; Go to M1600 at DC ]|0 - No [ Go to M1732 at TRN; Go to M1600 at DC ]|94
402|2 - Not assessed [Go to M1732 at TRN; Go to M1600 at DC ]|2 - Not assessed [Go to M1732 at TRN; Go to M1600 at DC ]|94
403|NA - Patient does not have diagnosis of heart failure [Go to M2005 at TRN; Go to M1600 at DC]|NA - Patient does not have diagnosis of heart failure [Go to M2005 at TRN; Go to M1600 at DC]|94
404|0 - No action taken|0 - No action taken|94
405|1 - Patient+s physician (or other primary care practitioner) contacted the same day|1 - Patient+s physician (or other primary care practitioner) contacted the same day|94
406|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|94
407|3 - Implement physician-ordered patient-specific established parameters for treatment|3 - Implement physician-ordered patient-specific established parameters for treatment|94
408|4 - Patient education or other clinical interventions|4 - Patient education or other clinical interventions|94
409|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequency, telehealth, etc.)|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequ|94
410|1 - Occasional stress incontinence|1 - Occasional stress incontinence|94
411|2 - During the night only|2 - During the night only|94
412|3 - During the day only|3 - During the day only|94
413|4 - During the day and night|4 - During the day and night|94
414|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|94
415|0 - Able to manage toileting hygiene and clothing management without assistance.|0 - Able to manage toileting hygiene and clothing management without assistance.|94
416|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implements are laid out for the patient.|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implemen|94
417|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|94
418|3 - Patient depends entirely upon another person to maintain toileting hygiene.|3 - Patient depends entirely upon another person to maintain toileting hygiene.|94
419|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independent|94
420|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface|94
421|0 - No multi-factor falls risk assessment conducted.|0 - No multi-factor falls risk assessment conducted.|94
422|1 - Yes, and it does not indicate a risk for falls.|1 - Yes, and it does not indicate a risk for falls.|94
423|2 - Yes, and it indicates a risk for falls.|2 - Yes, and it indicates a risk for falls.|94
424|0 - Not assessed/reviewed [ Go to M2010 ]|0 - Not assessed/reviewed [ Go to M2010 ]|94
425|1 - No problems found during review [ Go to M2010 ]|1 - No problems found during review [ Go to M2010 ]|94
426|2 - Problems found during review|2 - Problems found during review|94
427|NA - Patient is not taking any medications [ Go to M2040 ]|NA - Patient is not taking any medications [ Go to M2040 ]|94
428|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special precautions associated with all high-risk medications|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special p|94
429|NA - Patient not taking any drugs|NA - Patient not taking any drugs|94
430|2 - Able to take medication(s) at the correct times if given reminders by another person at the appropriate times|2 - Able to take medication(s) at the correct times if given reminders by another person at the appr|94
431|3 - Unable to take medication unless administered by another person.|3 - Unable to take medication unless administered by another person.|94
432|1 - At least daily|1 - At least daily|94
433|2 - Three or more times per week|2 - Three or more times per week|94
434|3 - One to two times per week|3 - One to two times per week|94
435|4 - Received, but less often than weekly|4 - Received, but less often than weekly|94
436|5 - No assistance received|5 - No assistance received|94
437|0 - No [Go to M2401]|0 - No [Go to M2401]|94
438|1 - Yes, used hospital emergency department WITHOUT hospital admission|1 - Yes, used hospital emergency department WITHOUT hospital admission|94
439|2 - Yes, used hospital emergency department WITH hospital admission|2 - Yes, used hospital emergency department WITH hospital admission|94
440|UK - Unknown [Go to M2401]|UK - Unknown [Go to M2401]|94
441|2 - Injury caused by fall|2 - Injury caused by fall|94
442|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|94
443|4 - Other respiratory problem|4 - Other respiratory problem|94
444|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|94
445|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|94
446|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|94
447|8 - Other heart disease|8 - Other heart disease|94
448|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|94
449|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|94
450|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|94
451|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|94
452|13 - Urinary tract infection|13 - Urinary tract infection|94
453|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|94
454|15 - Wound infection or deterioration|15 - Wound infection or deterioration|94
455|16 - Uncontrolled pain|16 - Uncontrolled pain|94
456|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|94
457|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|94
458|19 - Other than above reasons|19 - Other than above reasons|94
459|2 - Patient remained in the community (with formal assistive services)|2 - Patient remained in the community (with formal assistive services)|94
460|3 - Patient transferred to a noninstitutional hospice|3 - Patient transferred to a noninstitutional hospice|94
461|4 - Unknown because patient moved to a geographic location not served by this agency|4 - Unknown because patient moved to a geographic location not served by this agency|94
462|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|94
463|4 - Other respiratory problem|4 - Other respiratory problem|94
464|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|94
465|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|94
466|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|94
467|8 - Other heart disease|8 - Other heart disease|94
468|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|94
469|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|94
470|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|94
471|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|94
472|13 - Urinary tract infection|13 - Urinary tract infection|94
473|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|94
474|15 - Wound infection or deterioration|15 - Wound infection or deterioration|94
475|16 - Uncontrolled pain|16 - Uncontrolled pain|94
476|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|94
477|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|94
478|19 - Scheduled treatment or procedure|19 - Scheduled treatment or procedure|94
479|20 - Other than above reasons|20 - Other than above reasons|94
480|UK - Reason unknown [Go to M0903]|UK - Reason unknown [Go to M0903]|94
482|01 - Patient lives alone around the clock|01 - Patient lives alone around the clock|94
483|02 - Patient lives alone regular daytime|02 - Patient lives alone regular daytime|94
484|03 - Patient lives alone regular nighttime|03 - Patient lives alone regular nighttime|94
485|04 - Patient lives alone occassional/short term assistance|04 - Patient lives alone occassional/short term assistance|94
486|05 - Patient lives alone no assisstance available|05 - Patient lives alone no assisstance available|94
487|06 - Patient lives with other person(s) in the home around the clock|06 - Patient lives with other person(s) in the home around the clock|94
488|07 - Patient lives with other person(s) in the home regular daytime|07 - Patient lives with other person(s) in the home regular daytime|94
489|08 - Patient lives with other person(s) in the home regular nighttime|08 - Patient lives with other person(s) in the home regular nighttime|94
490|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|94
491|10 - Patient lives with other person(s) in the home no assistance available|10 - Patient lives with other person(s) in the home no assistance available|94
492|1 - Was present at the most recent SOC/ROC assessment|1 - Was present at the most recent SOC/ROC assessment|94
493|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|94
494|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|94
495|0 - Newly epithelialized|0 - Newly epithelialized|94
496|0 - No [ Go to M1340 ]|0 - No [ Go to M1340 ]|94
498|0 - Independent|0 - Independent|94
499|1 - Needed Some Help|1 - Needed Some Help|94
500|2 - Dependent|2 - Dependent|94
502|0 - No assistance needed in this area|0 - No assistance needed in this area|94
503|1 - Caregiver(s) currently provide assistance|1 - Caregiver(s) currently provide assistance|94
504|2 - Caregiver(s) need training/ supportive services to provide assistance|2 - Caregiver(s) need training/ supportive services to provide assistance|94
505|3 - Caregiver(s) not likely to provide assistance|3 - Caregiver(s) not likely to provide assistance|94
506|4 - Unclear if Caregiver(s) will provide assistance|4 - Unclear if Caregiver(s) will provide assistance|94
507|5 - Assistance needed, but no Caregiver(s) available|5 - Assistance needed, but no Caregiver(s) available|94
508|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will use standardized clinical guidelines accessible for all care providers to reference|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will|94
510|NA - Patient is not assessed to be at risk for falls|NA - Patient is not assessed to be at risk for falls|94
511|NA - Patient has no diagnosis or symptoms of depression|NA - Patient has no diagnosis or symptoms of depression|94
512|NA - No pain identified|NA - No pain identified|94
513|NA - Patient is not assessed to be at risk for pressure ulcers|NA - Patient is not assessed to be at risk for pressure ulcers|94
514|NA - Patient has no pressure ulcers with need for moist wound healing|NA - Patient has no pressure ulcers with need for moist wound healing|94
515|1 - Long-term nursing facility (NF)|1 - Long-term nursing facility (NF)|94
516|2 - Skilled nursing facility (SNF / TCU)|2 - Skilled nursing facility (SNF / TCU)|94
517|3 - Short stay acute hospital (IPP S)|3 - Short stay acute hospital (IPP S)|94
518|4 - Long-term care hospital (LTCH)|4 - Long-term care hospital (LTCH)|94
519|5 - Inpatient rehabilitation hospital or unit (IRF)|5 - Inpatient rehabilitation hospital or unit (IRF)|94
520|6 - Psychiatric hospital or unit|6 - Psychiatric hospital or unit|94
521|7 - Other|7 - Other|94
522|NA - Patient was not discharged from an inpatient facility [Go to M1017]|NA - Patient was not discharged from an inpatient facility [Go to M1017]|94
523|6 - Unable to participate effectively in bathing and is bathed totally by another person|6 - Unable to participate effectively in bathing and is bathed totally by another person|94
524|4 - Chairfast, unable to ambulate but is able to wheel self independently.|4 - Chairfast, unable to ambulate but is able to wheel self independently.|94
525|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask patient: "Over the last two weeks, how often have you been bothered by any of the following problems")  *Copyright+ Pfizer Inc. All rights reserved. Reproduced with permission.|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask|94
526|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluation for depression.|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluat|94
527|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet criteria for further evaluation for depression.|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet|94
528|0 - Not at all  0 - 1 day|0 - Not at all  0 - 1 day|94
529|1 - Several days  2 - 6 days|1 - Several days  2 - 6 days|94
530|2 - More than half of the days  7 - 11 days|2 - More than half of the days  7 - 11 days|94
531|3 - Nearly every day  12 - 14 days|3 - Nearly every day  12 - 14 days|94
532|NA - N/A  Unable to respond|NA - N/A  Unable to respond|94
533|2 - Able to take medication(s) at the correct times if given reminders by another person based on the frequency of the injection|2 - Able to take medication(s) at the correct times if given reminders by another person based on th|94
534|3 - Unable to take injectable medication unless administered by another person.|3 - Unable to take injectable medication unless administered by another person.|94
535|UK - Inpatient Discharge Date Unknown|UK - Inpatient Discharge Date Unknown|94
538|NA - Inpatient stay within last 14 days Not Applicable|NA - Inpatient stay within last 14 days Not Applicable|94
571|1 - History of falls (2 or more falls - or any fall with an injury - in the past 12 months) |1 - History of falls (2 or more falls - or any fall with an injury - in the past 12 months) |94
572|2 - Unintentional weight loss of a total of 10 pounds or more in the past 12 months |2 - Unintentional weight loss of a total of 10 pounds or more in the past 12 months |94
573|3 - Multiple hospitalizations (2 or more) in the past 6 months|3 - Multiple hospitalizations (2 or more) in the past 6 months|94
574|4 - Multiple emergency department visits (2 or more) in the past 6 months|4 - Multiple emergency department visits (2 or more) in the past 6 months|94
575|5 - Decline in mental emotional or behavioral status in the past 3 months |5 - Decline in mental emotional or behavioral status in the past 3 months |94
576|6 - Reported or observed history of difficulty complying with any medical instructions (for example,medications, diet, exercise) in the past 3 months|6 - Reported or observed history of difficulty complying with any medical instructions (for example |94
577|7 - Currently taking 5 or more medications|7 - Currently taking 5 or more medications|94
578|8 - Currently reports exhaustion|8 - Currently reports exhaustion|94
579|9 - Other risk(s) not listed in 1 - 8|9 - Other risk(s) not listed in 1 - 8|94
580|10 - None of the above |10 - None of the above |94
580|10 - None of the above |10 - None of the above |95
579|9 - Other risk(s) not listed in 1 - 8|9 - Other risk(s) not listed in 1 - 8|95
578|8 - Currently reports exhaustion|8 - Currently reports exhaustion|95
577|7 - Currently taking 5 or more medications|7 - Currently taking 5 or more medications|95
576|6 - Reported or observed history of difficulty complying with any medical instructions (for example,medications, diet, exercise) in the past 3 months|6 - Reported or observed history of difficulty complying with any medical instructions (for example |95
575|5 - Decline in mental emotional or behavioral status in the past 3 months |5 - Decline in mental emotional or behavioral status in the past 3 months |95
574|4 - Multiple emergency department visits (2 or more) in the past 6 months|4 - Multiple emergency department visits (2 or more) in the past 6 months|95
573|3 - Multiple hospitalizations (2 or more) in the past 6 months|3 - Multiple hospitalizations (2 or more) in the past 6 months|95
572|2 - Unintentional weight loss of a total of 10 pounds or more in the past 12 months |2 - Unintentional weight loss of a total of 10 pounds or more in the past 12 months |95
571|1 - History of falls (2 or more falls - or any fall with an injury - in the past 12 months) |1 - History of falls (2 or more falls - or any fall with an injury - in the past 12 months) |95
47|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or supervision from another person OR c) a liquid, pureed or ground meat diet.|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or su|95
48|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|95
2|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; OR (b) Is physically, cognitively, and mentally able to prepare light meals on a regular basis but has not routinely performed light meal preparation in the past (i.e., prior to this home care admission).|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; O|95
3|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and mentally able to perform all housekeeping tasks .|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and menta|95
4|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and mentally able to do laundry and access facilities.|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and menta|95
5|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying packages OR b) Physically, cognitively, and mentally able to take care of shopping, but has not done shopping in the past (i.e., prior to this home care admission).|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying|95
6|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|95
7|0 - Able to dial numbers and answer calls appropriately and as desired.|0 - Able to dial numbers and answer calls appropriately and as desired.|95
8|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body without assistance.|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body|95
9|0 - Able to get to and from the toilet and transfer independently with or without a device.|0 - Able to get to and from the toilet and transfer independently with or without a device.|95
10|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|95
11|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible public bus.|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible p|95
12|0 - Able to independently feed self.|0 - Able to independently feed self.|95
13|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|95
14|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct times.|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct ti|95
15|0 - Able to independently transfer.|0 - Able to independently transfer.|95
16|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without rail|95
17|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings|95
18|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|95
19|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions independently.|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions indep|95
20|0 - Asymptomatic, no treatment needed at this time|0 - Asymptomatic, no treatment needed at this time|95
21|0 - Caregiver manages all tasks related to equipment completely independently.|0 - Caregiver manages all tasks related to equipment completely independently.|95
22|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations with no observable impairment.|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations w|95
23|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|95
24|0 - Life expectancy is greater than 6 months|0 - Life expectancy is greater than 6 months|95
25|0 - Never|0 - Never|95
26|0 - Patient is not short of breath|0 - Patient is not short of breath|95
27|0 - No|0 - No|95
28|0 - No emergent care services|0 - No emergent care services|95
29|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [Goto M1620]|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [Goto M1620]|95
30|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and extended or abstract conversation.|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and exte|95
31|0 - No one person|0 - No one person|95
32|0 - None of the time|0 - None of the time|95
33|0 - None, no charge for current services|0 - None, no charge for current services|95
34|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|95
35|0 - Patient does NOT have an ostomy for bowel elimination.|0 - Patient does NOT have an ostomy for bowel elimination.|95
36|0 - Patient has no pain|0 - Patient has no pain|95
37|0 - Patient manages all tasks related to equipment completely independently.|0 - Patient manages all tasks related to equipment completely independently.|95
38|0 - Poor:  little or no recovery is expected and/or further decline is imminent|0 - Poor:  little or no recovery is expected and/or further decline is imminent|95
39|0 - Timed-voiding defers incontinence|0 - Timed-voiding defers incontinence|95
40|0 - Very rarely or never has bowel incontinence|0 - Very rarely or never has bowel incontinence|95
41|0 - Zero|0 - Zero|95
42|00 - No|00 - No|95
43|01 - Yes|01 - Yes|95
44|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or mental limitations, needs assistance with heavy laundry.|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or|95
45|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the patient.|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the|95
46|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|95
49|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|95
50|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independently.|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independe|95
51|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only when assisted or accompanied by another person.|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only w|95
52|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepa|95
53|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance by another person OR b) given daily reminders.|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance b|95
54|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advan|95
55|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advan|95
56|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for the deaf) and call essential numbers.|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for t|95
57|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|95
58|1 - American Indian or Alaska Native|1 - American Indian or Alaska Native|95
59|1 - Depressed mood (e.g., feeling sad, tearful)|1 - Depressed mood (e.g., feeling sad, tearful)|95
60|1 - During the night only|1 - During the night only|95
61|1 - Fully granulating|1 - Fully granulating|95
62|1 - Good/Fair:  partial to full recovery is expected|1 - Good/Fair:  partial to full recovery is expected|95
63|1 - Good:  marked improvement in functional status is expected|1 - Good:  marked improvement in functional status is expected|95
64|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|95
65|1 - Smoking|1 - Smoking|95
66|1 - Hospital|1 - Hospital|95
67|1 - Hospital emergency room (includes 23-hour holding)|1 - Hospital emergency room (includes 23-hour holding)|95
68|1 - Hospitalization for EMERGENT (unscheduled) care|1 - Hospitalization for EMERGENT (unscheduled) care|95
69|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepared solutions), patient is able to manage all other aspects of equipment.|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepar|95
70|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|95
71|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|95
72|1 - In new or complex situations only|1 - In new or complex situations only|95
73|1 - Intravenous or infusion therapy (excludes TPN)|1 - Intravenous or infusion therapy (excludes TPN)|95
74|1 - Less often than daily|1 - Less often than daily|95
75|1 - Less than once a month|1 - Less than once a month|95
76|1 - Less than once weekly|1 - Less than once weekly|95
77|1 - Life expectancy is 6 months or fewer|1 - Life expectancy is 6 months or fewer|95
78|1 - Lives alone|1 - Lives alone|95
79|1 - Male|1 - Male|95
80|1 - Medicare (traditional fee-for-service)|1 - Medicare (traditional fee-for-service)|95
81|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of past 24 hours, significant memory loss so that supervision is required|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of pas|95
82|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors in word choice, grammar or speech intelligibility, needs minimal prompting or assistance).|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors i|95
83|1 - No assistance or services received|1 - No assistance or services received|95
84|1 - One|1 - One|95
85|1 - Oxygen (intermittent or continuous)|1 - Oxygen (intermittent or continuous)|95
86|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, and the surrounding layout, can count fingers at arm's length.|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, a|95
87|1 - Patient is incontinent|1 - Patient is incontinent|95
88|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|95
89|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical or treatment regimen.|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical|95
90|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient/couple/significant other)|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient|95
91|1 - Relatives, friends, or neighbors living outside the home|1 - Relatives, friends, or neighbors living outside the home|95
92|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions.|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions|95
93|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independentl|95
94|1 - Several times during day and night|1 - Several times during day and night|95
95|1 - Spouse or significant other|1 - Spouse or significant other|95
96|1 - Stage 1|1 - Stage 1|95
97|1 - Start of care - further visits planned|1 - Start of care - further visits planned|95
98|1 - Symptoms well controlled with current therapy|1 - Symptoms well controlled with current therapy|95
99|1 - Therapy services|1 - Therapy services|95
100|1 - Able to transfer with minimal human assistance or with use of an assistive device.|1 - Able to transfer with minimal human assistance or with use of an assistive device.|95
101|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitations.|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitatio|95
102|1 - Urinary incontinence|1 - Urinary incontinence|95
103|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and transfer.|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and|95
104|1 - When walking more than 20 feet, climbing stairs|1 - When walking more than 20 feet, climbing stairs|95
105|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary conversation. May need occasional repetition, extra time, or louder voice.|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary c|95
106|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting in and out of tub/shower|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting|95
107|1 - Yes|1 - Yes|95
108|1-RN|1-RN|95
109|10 - Discharge from agency - no visits completed after start/resumption of care assessment|10 - Discharge from agency - no visits completed after start/resumption of care assessment|95
110|10 - Scheduled surgical procedure|10 - Scheduled surgical procedure|95
111|10 - Self-pay|10 - Self-pay|95
112|11 - Other|11 - Other|95
113|11 - Urinary tract infection|11 - Urinary tract infection|95
114|12 - IV catheter-related infection|12 - IV catheter-related infection|95
115|13 - Deep vein thrombosis, pulmonary embolus|13 - Deep vein thrombosis, pulmonary embolus|95
116|14 - Uncontrolled pain|14 - Uncontrolled pain|95
117|15 - Psychotic episode|15 - Psychotic episode|95
118|16 - Other than above reasons|16 - Other than above reasons|95
119|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing calls.|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing|95
120|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another person.|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another pers|95
121|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface a|95
122|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for intermittent supervision or encouragement or reminders, OR (b) to get in and out of the shower or tub, OR (c) for washing difficult to reach areas.|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for inter|95
123|2 - Asian|2 - Asian|95
124|2 - Caregiver requires considerable assistance from another person to manage equipment, but independently completes significant portions of task.|2 - Caregiver requires considerable assistance from another person to manage equipment, but independ|95
125|2 - Daily, but not constantly|2 - Daily, but not constantly|95
126|2 - Daughter or son|2 - Daughter or son|95
127|2 - Doctor's office emergency visit/house call|2 - Doctor's office emergency visit/house call|95
128|2 - During the day and night|2 - During the day and night|95
129|2 - Early/partial granulation|2 - Early/partial granulation|95
130|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors in word choice, organization or speech intelligibility). Speaks in phrases or short sentences.|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors|95
131|2 - Family member's residence|2 - Family member's residence|95
132|2 - Female|2 - Female|95
133|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conversation, needs frequent prompting or assistance.|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conver|95
134|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|95
135|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|95
136|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately stop activities, jeopardizes safety through actions|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately st|95
137|2 - Indwelling/suprapubic catheter|2 - Indwelling/suprapubic catheter|95
138|2 - Injury caused by fall or accident at home|2 - Injury caused by fall or accident at home|95
139|2 - Medicare (HMO/managed care/Advantage plan)|2 - Medicare (HMO/managed care/Advantage plan)|95
140|2 - Nausea, dehydration, malnutrition, constipation, impaction|2 - Nausea, dehydration, malnutrition, constipation, impaction|95
141|2 - Obesity|2 - Obesity|95
142|2 - On awakening or at night only|2 - On awakening or at night only|95
143|2 - Once a month|2 - Once a month|95
144|2 - One to three times weekly|2 - One to three times weekly|95
145|2 - Parenteral nutrition (TPN or lipids)|2 - Parenteral nutrition (TPN or lipids)|95
146|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic) [ Go to M1620 ]|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic) [ Go|95
147|2 - Patient requires considerable assistance from another person to manage equipment, but independently completes portions of the task.|2 - Patient requires considerable assistance from another person to manage equipment, but independen|95
148|2 - Patient transferred to a noninstitutional hospice|2 - Patient transferred to a noninstitutional hospice|95
149|2 - Person residing in the home (EXCLUDING paid help)|2 - Person residing in the home (EXCLUDING paid help)|95
150|2 - Rehabilitation facility|2 - Rehabilitation facility|95
151|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifting of attention) or consistently requires low stimulus environment due to distractibility.|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifti|95
152|2 - Respite care|2 - Respite care|95
153|2 - Sense of failure or self reproach|2 - Sense of failure or self reproach|95
154|2 - Several times during day|2 - Several times during day|95
155|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonresponsive.|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonrespons|95
156|2 - Someone must assist the patient to groom self.|2 - Someone must assist the patient to groom self.|95
157|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|95
158|2 - Someone must help the patient put on upper body clothing.|2 - Someone must help the patient put on upper body clothing.|95
159|2 - Stage 2|2 - Stage 2|95
160|2 - Start of care - no further visits planned|2 - Start of care - no further visits planned|95
161|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitoring|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitori|95
162|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment regimen.|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment re|95
163|2 - Two|2 - Two|95
164|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistance due to cognitive or mental limitation.|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistanc|95
165|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|95
166|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assistance).|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assis|95
167|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home delivery.|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home deli|95
168|2 - Unable to prepare any light meals or reheat any delivered meals.|2 - Unable to prepare any light meals or reheat any delivered meals.|95
169|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|95
170|2 - UNABLE to take injectable medications unless administered by someone else.|2 - UNABLE to take injectable medications unless administered by someone else.|95
171|2 - UNABLE to take medication unless administered by someone else.|2 - UNABLE to take medication unless administered by someone else.|95
172|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|95
173|2 - Ventilator (continually or at night)|2 - Ventilator (continually or at night)|95
174|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less than 20 feet)|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less th|95
175|2 - With spouse or significant other|2 - With spouse or significant other|95
176|2 - Yes, assistance or services provided by family or friends|2 - Yes, assistance or services provided by family or friends|95
177|2-PT|2-PT|95
178|3 - Able to answer the telephone only some of the time or is able to carry on only a limited conversation.|3 - Able to answer the telephone only some of the time or is able to carry on only a limited convers|95
179|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube or gastrostomy.|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube|95
180|3 - Alcohol dependency|3 - Alcohol dependency|95
181|3 - All of the time|3 - All of the time|95
182|3 - Black or African-American|3 - Black or African-American|95
183|3 - Boarding home or rented room|3 - Boarding home or rented room|95
184|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment, clean/store/dispose of equipment or supplies).|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment,|95
185|3 -Able to walk only with the supervision or assistance of another person at all times.|3 -Able to walk only with the supervision or assistance of another person at all times.|95
186|3 - Continuous / Bi-level positive airway pressure|3 - Continuous / Bi-level positive airway pressure|95
187|3 - During the day and evening, but not constantly|3 - During the day and evening, but not constantly|95
188|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the alimentary canal)|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the|95
189|3 - Environmental support (e.g., housing, home maintenance)|3 - Environmental support (e.g., housing, home maintenance)|95
190|3 - Four to six times weekly|3 - Four to six times weekly|95
191|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessing by listener.  Speech limited to single words or short phrases.|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessin|95
192|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires multiple repetitions, restatements, demonstrations, additional time.|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires m|95
193|3 - Hopelessness|3 - Hopelessness|95
194|3 - Hospice care|3 - Hospice care|95
195|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|95
196|3 - Injury caused by fall or accident at home|3 - Injury caused by fall or accident at home|95
197|3 - Intractable pain|3 - Intractable pain|95
198|3 - Medicaid (traditional fee-for-service)|3 - Medicaid (traditional fee-for-service)|95
199|3 - Needs someone to do all shopping and errands.|3 - Needs someone to do all shopping and errands.|95
200|3 - Not healing|3 - Not healing|95
201|3 - Nursing home|3 - Nursing home|95
202|3 - Once daily|3 - Once daily|95
203|3 - Other family member|3 - Other family member|95
204|3 - Outpatient department/clinic emergency (includes urgicenter sites)|3 - Outpatient department/clinic emergency (includes urgicenter sites)|95
205|3 - Paid help|3 - Paid help|95
206|3 - Able to participate in bathing self in shower or tub, but requires presence of another person throughout the bath for assistance or supervision.|3 - Able to participate in bathing self in shower or tub, but requires presence of another person th|95
207|3 - Patient depends entirely upon another person to dress lower body.|3 - Patient depends entirely upon another person to dress lower body.|95
208|3 - Patient depends entirely upon another person to dress the upper body.|3 - Patient depends entirely upon another person to dress the upper body.|95
209|3 - Patient depends entirely upon someone else for grooming needs.|3 - Patient depends entirely upon someone else for grooming needs.|95
210|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone else to manage the equipment.|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone|95
211|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable to shift attention and recall directions more than half the time.|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable|95
212|3 - Respiratory problems (SOB, infection, obstruction)|3 - Respiratory problems (SOB, infection, obstruction)|95
213|3 - Resumption of care (after inpatient stay)|3 - Resumption of care (after inpatient stay)|95
214|3 - Several times each month|3 - Several times each month|95
215|3 - Skilled Nursing Facility|3 - Skilled Nursing Facility|95
216|3 - Stage 3|3 - Stage 3|95
217|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|95
218|3 - Three|3 - Three|95
219|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person throughout the process.|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person through|95
220|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal independently.|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal indep|95
221|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person.|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person|95
222|3 - Unknown because patient moved to a geographic location not served by this agency|3 - Unknown because patient moved to a geographic location not served by this agency|95
223|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|95
224|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|95
225|3 - With other family member|3 - With other family member|95
226|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home health services, homemaker assistance, transportation assistance, assisted living, board and care)|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home h|95
227|3-SLP/ST|3-SLP/ST|95
228|4 - At rest (during day or night)|4 - At rest (during day or night)|95
229|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|95
230|4 - Board and care or assisted living facility|4 - Board and care or assisted living facility|95
231|4 - Caregiver is completely dependent on someone else to manage all equipment.|4 - Caregiver is completely dependent on someone else to manage all equipment.|95
232|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|95
233|4 - Constantly|4 - Constantly|95
234|4 - Drug dependency|4 - Drug dependency|95
235|4 - Four or more|4 - Four or more|95
236|4 - Friend or neighbor or community or church member|4 - Friend or neighbor or community or church member|95
237|4 - Hispanic or Latino|4 - Hispanic or Latino|95
238|4 - Hospice|4 - Hospice|95
239|4 - Impaired decision-making|4 - Impaired decision-making|95
240|4 - Is totally dependent in toileting.|4 - Is totally dependent in toileting.|95
241|4 - Medicaid (HMO/managed care)|4 - Medicaid (HMO/managed care)|95
242|4 - None of the above|4 - None of the above|95
243|4 - Nursing home|4 - Nursing home|95
244|4 - On a daily basis|4 - On a daily basis|95
245|4 - Patient is completely dependent on someone else to manage all equipment.|4 - Patient is completely dependent on someone else to manage all equipment.|95
246|4 - Permanent placement|4 - Permanent placement|95
247|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, punches, dangerous maneuvers w/ wheelchair or other objects)|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, pu|95
248|4 - Psychosocial support (e.g., socialization, companionship, recreation)|4 - Psychosocial support (e.g., socialization, companionship, recreation)|95
249|4 - Recertification (follow-up) reassessment|4 - Recertification (follow-up) reassessment|95
250|4 - Recurrent thoughts of death|4 - Recurrent thoughts of death|95
251|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruction)|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruc|95
252|4 - Several times a week|4 - Several times a week|95
253|4 - Stage 4|4 - Stage 4|95
254|4 - Symptoms poorly controlled, history of re-hospitalizations|4 - Symptoms poorly controlled, history of re-hospitalizations|95
255|4 - Three or more times per week|4 - Three or more times per week|95
256|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetative state, or delirium.|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetati|95
257|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|95
258|4 - Unable to effectively participate in any housekeeping tasks.|4 - Unable to effectively participate in any housekeeping tasks.|95
259|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or unresponsive (e.g., speech is nonsensical or unintelligible).|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or u|95
260|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonresponsive.|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonr|95
261|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostomy.|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostom|95
262|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of devices at the sink, in chair, or on commode|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of|95
263|4 - With a friend|4 - With a friend|95
264|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|95
265|4-OT|4-OT|95
266|5 - Advocates or facilitates patient's participation in appropriate medical care|5 - Advocates or facilitates patient's participation in appropriate medical care|95
267|5 - At least daily|5 - At least daily|95
268|6 - Bedfast, unable to ambulate or be up in a chair.|6 - Bedfast, unable to ambulate or be up in a chair.|95
269|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|95
270|5 - Disruptive or socially inappropriate behavior|5 - Disruptive or socially inappropriate behavior|95
271|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|95
272|5 - Hypo/Hyperglycemia, diabetes out of control|5 - Hypo/Hyperglycemia, diabetes out of control|95
273|5 - More often than once daily|5 - More often than once daily|95
274|5 - Native Hawaiian or Pacific Islander|5 - Native Hawaiian or Pacific Islander|95
275|5 - None of the above|5 - None of the above|95
276|5 - One to two times per week|5 - One to two times per week|95
277|5 - Other|5 - Other|95
278|5 - Other follow-up|5 - Other follow-up|95
279|5 - Paid help|5 - Paid help|95
280|5 - Patient nonresponsive or unable to speak.|5 - Patient nonresponsive or unable to speak.|95
281|5 - Thoughts of suicide|5 - Thoughts of suicide|95
282|5 - Totally unable to use the telephone.|5 - Totally unable to use the telephone.|95
283|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|95
284|5 - Unable to take in nutrients orally or by tube feeding.|5 - Unable to take in nutrients orally or by tube feeding.|95
285|5 - Unsafe for care at home|5 - Unsafe for care at home|95
286|5 - With paid help (other than home care agency staff)|5 - With paid help (other than home care agency staff)|95
287|5 - Workers' compensation|5 - Workers' compensation|95
288|5 - Wound infection, deteriorating wound status, new lesion/ulcer|5 - Wound infection, deteriorating wound status, new lesion/ulcer|95
289|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|95
290|6 - Delusional, hallucinatory, or paranoid behavior|6 - Delusional, hallucinatory, or paranoid behavior|95
291|6 - Financial agent, power of attorney, or conservator of finance|6 - Financial agent, power of attorney, or conservator of finance|95
292|6 - GI bleeding, obstruction|6 - GI bleeding, obstruction|95
293|6 - Less often than weekly|6 - Less often than weekly|95
294|6 - Memory loss to the extent that supervision required|6 - Memory loss to the extent that supervision required|95
295|6 - None of the above feelings observed or reported|6 - None of the above feelings observed or reported|95
296|6 - Other|6 - Other|95
297|6 - Title programs (e.g., Title III, V, or XX)|6 - Title programs (e.g., Title III, V, or XX)|95
298|6 - Transferred to an inpatient facility - patient not discharged from agency|6 - Transferred to an inpatient facility - patient not discharged from agency|95
299|6 - White|6 - White|95
300|6 - With other than above|6 - With other than above|95
301|7 - Exacerbation of CHF, fluid overload, heart failure|7 - Exacerbation of CHF, fluid overload, heart failure|95
302|7 - Health care agent, conservator of person, or medical power of attorney|7 - Health care agent, conservator of person, or medical power of attorney|95
303|7 - Hypo/Hyperglycemia, diabetes out of control|7 - Hypo/Hyperglycemia, diabetes out of control|95
304|7 - None of the above|7 - None of the above|95
305|7 - None of the above behaviors demonstrated|7 - None of the above behaviors demonstrated|95
306|7 - Other government (e.g., TriCare, VA, etc.)|7 - Other government (e.g., TriCare, VA, etc.)|95
307|7 - Transferred to an inpatient facility - patient discharged from agency|7 - Transferred to an inpatient facility - patient discharged from agency|95
308|8 - Death at home|8 - Death at home|95
309|8 - GI bleeding, obstruction|8 - GI bleeding, obstruction|95
310|8 - Myocardial infarction, stroke|8 - Myocardial infarction, stroke|95
311|8 - Private insurance|8 - Private insurance|95
312|9 - Chemotherapy|9 - Chemotherapy|95
313|9 - Discharge from agency|9 - Discharge from agency|95
314|9 - Other than above reasons|9 - Other than above reasons|95
315|9 - Private HMO/managed care|9 - Private HMO/managed care|95
316|NA - No caregiver|NA - No caregiver|95
317|NA - No equipment of this type used in care.|NA - No equipment of this type used in care.|95
318|NA - No inhalant/mist medications prescribed.|NA - No inhalant/mist medications prescribed.|95
319|NA - No injectable medications prescribed.|NA - No injectable medications prescribed.|95
320|NA - No inpatient facility admission|NA - No inpatient facility admission|95
321|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|95
322|NA - No Medicaid|NA - No Medicaid|95
323|NA - No Medicare|NA - No Medicare|95
324|NA - No observable pressure ulcer or unhealed pressure ulcer|NA - No observable pressure ulcer or unhealed pressure ulcer|95
325|NA - No observable stasis ulcer|NA - No observable stasis ulcer|95
326|NA - No observable surgical wound|NA - No observable surgical wound|95
327|NA - No oral medications prescribed.|NA - No oral medications prescribed.|95
328|NA - Not applicable|NA - Not applicable|95
329|NA - Patient does not have a telephone.|NA - Patient does not have a telephone.|95
330|NA - Patient has ostomy for bowel elimination|NA - Patient has ostomy for bowel elimination|95
331|NA - Patient nonresponsive|NA - Patient nonresponsive|95
332|NA - Patient on prophylactic treatment|NA - Patient on prophylactic treatment|95
333|NA - Patient was not discharged from an inpatient facility [Go to M1017]|NA - Patient was not discharged from an inpatient facility [Go to M1017]|95
334|UK - Other unknown|UK - Other unknown|95
335|UK - Reason unknown|UK - Reason unknown|95
336|UK - Unknown|UK - Unknown|95
337|UK - Unknown or Not Available|UK - Unknown or Not Available|95
341|01 - Early|01 - Early|95
342|02 - Late|02 - Late|95
343|NA - Not Applicable. No case mix group defined for this assessment.|NA - Not Applicable. No case mix group defined for this assessment.|95
344|NA - No case mix group defined by this assessment.|NA - No case mix group defined by this assessment.|95
345|1 - Recent decline in mental, emotional, or behavioral status|1 - Recent decline in mental, emotional, or behavioral status|95
346|2 - Multiple hospitalizations (2 or more) in the past 12 months|2 - Multiple hospitalizations (2 or more) in the past 12 months|95
347|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|95
348|4 - Taking five or more medications|4 - Taking five or more medications|95
349|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|95
350|6 - Other|6 - Other|95
351|7 - None of the above|7 - None of the above|95
352|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond tho|95
353|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable without heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable wi|95
354|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious complications and death.|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious compl|95
355|3 - The patient has serious progressive conditions that could lead to death within a year.|3 - The patient has serious progressive conditions that could lead to death within a year.|95
356|UK - The patient+s situation is unknown or unclear.|UK - The patient+s situation is unknown or unclear.|95
357|1 - Yes [ Go to M1050 ]|1 - Yes [ Go to M1050 ]|95
358|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this influenza season. [ Go to M1050 ]|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this i|95
359|1 - Received from another health care provider (e.g., physician)|1 - Received from another health care provider (e.g., physician)|95
360|2 - Received from your agency previously during this year+s flu season|2 - Received from your agency previously during this year+s flu season|95
361|3 - Offered and declined|3 - Offered and declined|95
362|4 - Assessed and determined to have medical contraindication(s)|4 - Assessed and determined to have medical contraindication(s)|95
363|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|95
364|6 - Inability to obtain vaccine due to declared shortage|6 - Inability to obtain vaccine due to declared shortage|95
365|1 - Yes [ Go to M2005 at TRN; Go to M1230 at DC ]|1 - Yes [ Go to M2005 at TRN; Go to M1230 at DC ]|95
366|1 - Patient has received PPV in the past|1 - Patient has received PPV in the past|95
367|2 - Offered and declined|2 - Offered and declined|95
368|3 - Assessed and determined to have medical contraindication(s)|3 - Assessed and determined to have medical contraindication(s)|95
369|4 - Not indicated; patient does not meet age/condition guidelines for PPV|4 - Not indicated; patient does not meet age/condition guidelines for PPV|95
370|5 - None of the above|5 - None of the above|95
371|0 - Adequate: hears normal conversation without difficulty.|0 - Adequate: hears normal conversation without difficulty.|95
372|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to increase volume or speak distinctly.|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to in|95
373|2 - Severely Impaired: absence of useful hearing.|2 - Severely Impaired: absence of useful hearing.|95
374|UK - Unable to assess hearing.|UK - Unable to assess hearing.|95
375|0 - Understands: clear comprehension without cues or repetitions.|0 - Understands: clear comprehension without cues or repetitions.|95
376|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Requires cues at times to understand.|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Req|95
377|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequently requires cues to understand.|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequentl|95
378|3 - Rarely/Never Understands|3 - Rarely/Never Understands|95
379|UK - Unable to assess understanding.|UK - Unable to assess understanding.|95
380|0 - No standardized assessment conducted|0 - No standardized assessment conducted|95
381|1 - Yes, and it does not indicate severe pain|1 - Yes, and it does not indicate severe pain|95
382|2 - Yes, and it indicates severe pain|2 - Yes, and it indicates severe pain|95
383|0 - Patient has no pain|0 - Patient has no pain|95
384|1 - Patient has pain that does not interfere with activity or movement|1 - Patient has pain that does not interfere with activity or movement|95
385|2 - Less often than daily|2 - Less often than daily|95
386|3 - Daily, but not constantly|3 - Daily, but not constantly|95
387|4 - All of the time|4 - All of the time|95
388|0 - No assessment conducted [ Go to M1306 ]|0 - No assessment conducted [ Go to M1306 ]|95
389|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc., without use of standardized tool|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc.,|95
390|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|95
391|0 - No [ Go to M1322]|0 - No [ Go to M1322]|95
392|0 v Newly epithelialized|0 v Newly epithelialized|95
393|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|95
394|2 - Yes, patient has observable stasis ulcers ONLY|2 - Yes, patient has observable stasis ulcers ONLY|95
395|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable dressing) [Go to M1340]|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable|95
396|0 - No [ Go to M1400 ]|0 - No [ Go to M1400 ]|95
397|1 - Yes, patient has at least one (observable) surgical wound|1 - Yes, patient has at least one (observable) surgical wound|95
398|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1400 ]|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1400 ]|95
399|0 - Patient is not short of breath|0 - Patient is not short of breath|95
400|3 - Continuous Bi-level positive airway pressure|3 - Continuous Bi-level positive airway pressure|95
401|0 - No [ Go to M1732 at TRN; Go to M1600 at DC ]|0 - No [ Go to M1732 at TRN; Go to M1600 at DC ]|95
402|2 - Not assessed [Go to M1732 at TRN; Go to M1600 at DC ]|2 - Not assessed [Go to M1732 at TRN; Go to M1600 at DC ]|95
570|Z - None of the above|Z - None of the above|95
569|E - Orthotics/Prosthetics|E - Orthotics/Prosthetics|95
568|D - Walker|D - Walker|95
567|C - Mechanical lift|C - Mechanical lift|95
566|B - Motorized wheelchair and/or scooter|B - Motorized wheelchair and/or scooter|95
565|A - Manual wheelchair|A - Manual wheelchair|95
564|9 - Not Applicable|9 - Not Applicable|95
563|8 - Unknown|8 - Unknown|95
562|1 - Dependent - A helper completed the activities for the patient.|1 - Dependent - A helper completed the activities for the patient.|95
561|2 - Needed Some Help - Patient needed partial assistance from another person to complete activities.|2 - Needed Some Help - Patient needed partial assistance from another person to complete activities.|95
560|3 - Independent - Patient completed the activities by him/herself, with or without an assistive device, with no assistance from a helper.|3 - Independent - Patient completed the activities by him/herself, with or without an assistive devi|95
559|2 - Two or More|2 - Two or More|95
558|1 - One|1 - One|95
557|0 - None|0 - None|95
556|1 - Yes [Continue to J1900, Number of Falls Since SOC/ROC, whichever is more recent]|1 - Yes [Continue to J1900, Number of Falls Since SOC/ROC, whichever is more recent]|95
555|0 - No [STOP]|0 - No [STOP]|95
554|0 - No [Skip to J1800 Any falls since SOC/ROC, whichever is more recent.]|0 - No [Skip to J1800 Any falls since SOC/ROC, whichever is more recent.]|95
553|2 - Motorized|2 - Motorized|95
552|1 - Manual|1 - Manual|95
551|1 - Yes [Continue to GG0170R, Wheel 50 feet with two turns.]|1 - Yes [Continue to GG0170R, Wheel 50 feet with two turns.]|95
550|0 - No [STOP]|0 - No [Skip GG0170R]|95
549|0 - No [STOP]|0 - No [STOP]|95
548|88 - Not attempted due to medical conditions or safety concerns|88 - Not attempted due to medical conditions or safety concerns|95
547|10 - Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)|10 - Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)|95
546|09 - Not applicable - Not attempted and the patient did not perform this activity prior to the current illness,exacerbation or injury.|09 - Not applicable - Not attempted and the patient did not perform this activity prior to the curre|95
545|07 - Patient refused|07 - Patient refused|95
544|01 - Dependent - Helper does ALL of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity.|01 - Dependent - Helper does ALL of the effort. Patient does none of the effort to complete the acti|95
543|02 - Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.|02 - Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds t|95
542|03 - Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort.|03 - Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or sup|95
541|04 - Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently.|04 - Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/|95
540|05 - Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity.|05 - Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper|95
539|06 - Independent - Patient completes the activity by him/herself with no assistance from a helper.|06 - Independent - Patient completes the activity by him/herself with no assistance from a helper.|95
403|NA - Patient does not have diagnosis of heart failure [Go to M2005 at TRN; Go to M1600 at DC]|NA - Patient does not have diagnosis of heart failure [Go to M2005 at TRN; Go to M1600 at DC]|95
404|0 - No action taken|0 - No action taken|95
405|1 - Patient+s physician (or other primary care practitioner) contacted the same day|1 - Patient+s physician (or other primary care practitioner) contacted the same day|95
406|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|95
407|3 - Implement physician-ordered patient-specific established parameters for treatment|3 - Implement physician-ordered patient-specific established parameters for treatment|95
408|4 - Patient education or other clinical interventions|4 - Patient education or other clinical interventions|95
409|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequency, telehealth, etc.)|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequ|95
410|1 - Occasional stress incontinence|1 - Occasional stress incontinence|95
411|2 - During the night only|2 - During the night only|95
412|3 - During the day only|3 - During the day only|95
413|4 - During the day and night|4 - During the day and night|95
414|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|95
415|0 - Able to manage toileting hygiene and clothing management without assistance.|0 - Able to manage toileting hygiene and clothing management without assistance.|95
416|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implements are laid out for the patient.|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implemen|95
417|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|95
418|3 - Patient depends entirely upon another person to maintain toileting hygiene.|3 - Patient depends entirely upon another person to maintain toileting hygiene.|95
419|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independent|95
420|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface|95
421|0 - No multi-factor falls risk assessment conducted.|0 - No multi-factor falls risk assessment conducted.|95
422|1 - Yes, and it does not indicate a risk for falls.|1 - Yes, and it does not indicate a risk for falls.|95
423|2 - Yes, and it indicates a risk for falls.|2 - Yes, and it indicates a risk for falls.|95
424|0 - Not assessed/reviewed [ Go to M2010 ]|0 - Not assessed/reviewed [ Go to M2010 ]|95
425|1 - No problems found during review [ Go to M2010 ]|1 - No problems found during review [ Go to M2010 ]|95
426|2 - Problems found during review|2 - Problems found during review|95
427|NA - Patient is not taking any medications [ Go to M2040 ]|NA - Patient is not taking any medications [ Go to M2040 ]|95
428|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special precautions associated with all high-risk medications|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special p|95
429|NA - Patient not taking any drugs|NA - Patient not taking any drugs|95
430|2 - Able to take medication(s) at the correct times if given reminders by another person at the appropriate times|2 - Able to take medication(s) at the correct times if given reminders by another person at the appr|95
431|3 - Unable to take medication unless administered by another person.|3 - Unable to take medication unless administered by another person.|95
432|1 - At least daily|1 - At least daily|95
433|2 - Three or more times per week|2 - Three or more times per week|95
434|3 - One to two times per week|3 - One to two times per week|95
435|4 - Received, but less often than weekly|4 - Received, but less often than weekly|95
436|5 - No assistance received|5 - No assistance received|95
437|0 - No [Go to M2401]|0 - No [Go to M2401]|95
438|1 - Yes, used hospital emergency department WITHOUT hospital admission|1 - Yes, used hospital emergency department WITHOUT hospital admission|95
439|2 - Yes, used hospital emergency department WITH hospital admission|2 - Yes, used hospital emergency department WITH hospital admission|95
440|UK - Unknown [Go to M2401]|UK - Unknown [Go to M2401]|95
441|2 - Injury caused by fall|2 - Injury caused by fall|95
442|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|95
443|4 - Other respiratory problem|4 - Other respiratory problem|95
444|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|95
445|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|95
446|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|95
447|8 - Other heart disease|8 - Other heart disease|95
448|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|95
449|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|95
450|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|95
451|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|95
452|13 - Urinary tract infection|13 - Urinary tract infection|95
453|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|95
454|15 - Wound infection or deterioration|15 - Wound infection or deterioration|95
455|16 - Uncontrolled pain|16 - Uncontrolled pain|95
456|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|95
457|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|95
458|19 - Other than above reasons|19 - Other than above reasons|95
459|2 - Patient remained in the community (with formal assistive services)|2 - Patient remained in the community (with formal assistive services)|95
460|3 - Patient transferred to a noninstitutional hospice|3 - Patient transferred to a noninstitutional hospice|95
461|4 - Unknown because patient moved to a geographic location not served by this agency|4 - Unknown because patient moved to a geographic location not served by this agency|95
462|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|95
463|4 - Other respiratory problem|4 - Other respiratory problem|95
464|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|95
465|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|95
466|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|95
467|8 - Other heart disease|8 - Other heart disease|95
468|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|95
469|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|95
470|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|95
471|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|95
472|13 - Urinary tract infection|13 - Urinary tract infection|95
473|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|95
474|15 - Wound infection or deterioration|15 - Wound infection or deterioration|95
475|16 - Uncontrolled pain|16 - Uncontrolled pain|95
476|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|95
477|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|95
478|19 - Scheduled treatment or procedure|19 - Scheduled treatment or procedure|95
479|20 - Other than above reasons|20 - Other than above reasons|95
480|UK - Reason unknown [Go to M0903]|UK - Reason unknown [Go to M0903]|95
482|01 - Patient lives alone around the clock|01 - Patient lives alone around the clock|95
483|02 - Patient lives alone regular daytime|02 - Patient lives alone regular daytime|95
484|03 - Patient lives alone regular nighttime|03 - Patient lives alone regular nighttime|95
485|04 - Patient lives alone occassional/short term assistance|04 - Patient lives alone occassional/short term assistance|95
486|05 - Patient lives alone no assisstance available|05 - Patient lives alone no assisstance available|95
487|06 - Patient lives with other person(s) in the home around the clock|06 - Patient lives with other person(s) in the home around the clock|95
488|07 - Patient lives with other person(s) in the home regular daytime|07 - Patient lives with other person(s) in the home regular daytime|95
489|08 - Patient lives with other person(s) in the home regular nighttime|08 - Patient lives with other person(s) in the home regular nighttime|95
490|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|95
491|10 - Patient lives with other person(s) in the home no assistance available|10 - Patient lives with other person(s) in the home no assistance available|95
492|1 - Was present at the most recent SOC/ROC assessment|1 - Was present at the most recent SOC/ROC assessment|95
493|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|95
494|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|95
495|0 - Newly epithelialized|0 - Newly epithelialized|95
496|0 - No [ Go to M1340 ]|0 - No [ Go to M1340 ]|95
498|0 - Independent|0 - Independent|95
499|1 - Needed Some Help|1 - Needed Some Help|95
500|2 - Dependent|2 - Dependent|95
502|0 - No assistance needed in this area|0 - No assistance needed in this area|95
503|1 - Caregiver(s) currently provide assistance|1 - Caregiver(s) currently provide assistance|95
504|2 - Caregiver(s) need training/ supportive services to provide assistance|2 - Caregiver(s) need training/ supportive services to provide assistance|95
505|3 - Caregiver(s) not likely to provide assistance|3 - Caregiver(s) not likely to provide assistance|95
506|4 - Unclear if Caregiver(s) will provide assistance|4 - Unclear if Caregiver(s) will provide assistance|95
507|5 - Assistance needed, but no Caregiver(s) available|5 - Assistance needed, but no Caregiver(s) available|95
508|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will use standardized clinical guidelines accessible for all care providers to reference|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will|95
510|NA - Patient is not assessed to be at risk for falls|NA - Patient is not assessed to be at risk for falls|95
511|NA - Patient has no diagnosis or symptoms of depression|NA - Patient has no diagnosis or symptoms of depression|95
512|NA - No pain identified|NA - No pain identified|95
513|NA - Patient is not assessed to be at risk for pressure ulcers|NA - Patient is not assessed to be at risk for pressure ulcers|95
514|NA - Patient has no pressure ulcers with need for moist wound healing|NA - Patient has no pressure ulcers with need for moist wound healing|95
515|1 - Long-term nursing facility (NF)|1 - Long-term nursing facility (NF)|95
516|2 - Skilled nursing facility (SNF / TCU)|2 - Skilled nursing facility (SNF / TCU)|95
517|3 - Short stay acute hospital (IPP S)|3 - Short stay acute hospital (IPP S)|95
518|4 - Long-term care hospital (LTCH)|4 - Long-term care hospital (LTCH)|95
519|5 - Inpatient rehabilitation hospital or unit (IRF)|5 - Inpatient rehabilitation hospital or unit (IRF)|95
520|6 - Psychiatric hospital or unit|6 - Psychiatric hospital or unit|95
521|7 - Other|7 - Other|95
522|NA - Patient was not discharged from an inpatient facility [Go to M1017]|NA - Patient was not discharged from an inpatient facility [Go to M1017]|95
523|6 - Unable to participate effectively in bathing and is bathed totally by another person|6 - Unable to participate effectively in bathing and is bathed totally by another person|95
524|4 - Chairfast, unable to ambulate but is able to wheel self independently.|4 - Chairfast, unable to ambulate but is able to wheel self independently.|95
525|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask patient: "Over the last two weeks, how often have you been bothered by any of the following problems")   *Copyright+ Pfizer Inc. All rights reserved. Reproduced with permission.|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask|95
526|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluation for depression.|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluat|95
527|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet criteria for further evaluation for depression.|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet|95
528|0 - Not at all  0 - 1 day|0 - Not at all  0 - 1 day|95
529|1 - Several days  2 - 6 days|1 - Several days  2 - 6 days|95
530|2 - More than half of the days  7 - 11 days|2 - More than half of the days  7 - 11 days|95
531|3 - Nearly every day  12 - 14 days|3 - Nearly every day  12 - 14 days|95
532|NA - N/A  Unable to respond|NA - N/A  Unable to respond|95
533|2 - Able to take medication(s) at the correct times if given reminders by another person based on the frequency of the injection|2 - Able to take medication(s) at the correct times if given reminders by another person based on th|95
534|3 - Unable to take injectable medication unless administered by another person.|3 - Unable to take injectable medication unless administered by another person.|95
536|UK - Inpatient Discharge Date Unknown|UK - Inpatient Discharge Date Unknown|95
537|NA - Inpatient stay within last 14 days Not Applicable|NA - Inpatient stay within last 14 days Not Applicable|95
2|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; OR (b) Is physically, cognitively, and mentally able to prepare light meals on a regular basis but has not routinely performed light meal preparation in the past (i.e., prior to this home care admission).|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; O|96
3|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and mentally able to perform all housekeeping tasks .|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and menta|96
4|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and mentally able to do laundry and access facilities.|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and menta|96
5|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying packages OR b) Physically, cognitively, and mentally able to take care of shopping, but has not done shopping in the past (i.e., prior to this home care admission).|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying|96
6|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|96
7|0 - Able to dial numbers and answer calls appropriately and as desired.|0 - Able to dial numbers and answer calls appropriately and as desired.|96
8|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body without assistance.|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body|96
9|0 - Able to get to and from the toilet and transfer independently with or without a device.|0 - Able to get to and from the toilet and transfer independently with or without a device.|96
10|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|96
11|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible public bus.|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible p|96
12|0 - Able to independently feed self.|0 - Able to independently feed self.|96
13|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|96
14|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct times.|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct ti|96
15|0 - Able to independently transfer.|0 - Able to independently transfer.|96
16|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without rail|96
17|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings|96
18|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|96
19|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions independently.|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions indep|96
20|0 - Asymptomatic, no treatment needed at this time|0 - Asymptomatic, no treatment needed at this time|96
21|0 - Caregiver manages all tasks related to equipment completely independently.|0 - Caregiver manages all tasks related to equipment completely independently.|96
22|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations with no observable impairment.|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations w|96
23|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|96
24|0 - Life expectancy is greater than 6 months|0 - Life expectancy is greater than 6 months|96
25|0 - Never|0 - Never|96
26|0 - Patient is not short of breath|0 - Patient is not short of breath|96
27|0 - No|0 - No|96
28|0 - No emergent care services|0 - No emergent care services|96
29|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [Goto 1620]|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [Goto 1620]|96
30|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and extended or abstract conversation.|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and exte|96
31|0 - No one person|0 - No one person|96
32|0 - None of the time|0 - None of the time|96
33|0 - None, no charge for current services|0 - None, no charge for current services|96
34|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|96
35|0 - Patient does NOT have an ostomy for bowel elimination.|0 - Patient does NOT have an ostomy for bowel elimination.|96
36|0 - Patient has no pain|0 - Patient has no pain|96
37|0 - Patient manages all tasks related to equipment completely independently.|0 - Patient manages all tasks related to equipment completely independently.|96
38|0 - Poor:  little or no recovery is expected and/or further decline is imminent|0 - Poor:  little or no recovery is expected and/or further decline is imminent|96
39|0 - Timed-voiding defers incontinence|0 - Timed-voiding defers incontinence|96
40|0 - Very rarely or never has bowel incontinence|0 - Very rarely or never has bowel incontinence|96
41|0 - Zero|0 - Zero|96
42|00 - No|00 - No|96
43|01 - Yes|01 - Yes|96
44|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or mental limitations, needs assistance with heavy laundry.|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or|96
45|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the patient.|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the|96
46|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|96
47|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or supervision from another person OR c) a liquid, pureed or ground meat diet.|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or su|96
48|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|96
49|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|96
50|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independently.|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independe|96
51|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only when assisted or accompanied by another person.|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only w|96
52|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepa|96
53|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance by another person OR b) given daily reminders.|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance b|96
54|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advan|96
55|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advan|96
56|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for the deaf) and call essential numbers.|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for t|96
57|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|96
58|1 - American Indian or Alaska Native|1 - American Indian or Alaska Native|96
59|1 - Depressed mood (e.g., feeling sad, tearful)|1 - Depressed mood (e.g., feeling sad, tearful)|96
60|1 - During the night only|1 - During the night only|96
61|1 - Fully granulating|1 - Fully granulating|96
62|1 - Good/Fair:  partial to full recovery is expected|1 - Good/Fair:  partial to full recovery is expected|96
63|1 - Good:  marked improvement in functional status is expected|1 - Good:  marked improvement in functional status is expected|96
64|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|96
65|1 - Smoking|1 - Smoking|96
66|1 - Hospital|1 - Hospital|96
67|1 - Hospital emergency room (includes 23-hour holding)|1 - Hospital emergency room (includes 23-hour holding)|96
68|1 - Hospitalization for EMERGENT (unscheduled) care|1 - Hospitalization for EMERGENT (unscheduled) care|96
69|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepared solutions), patient is able to manage all other aspects of equipment.|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepar|96
70|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|96
71|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|96
72|1 - In new or complex situations only|1 - In new or complex situations only|96
73|1 - Intravenous or infusion therapy (excludes TPN)|1 - Intravenous or infusion therapy (excludes TPN)|96
74|1 - Less often than daily|1 - Less often than daily|96
75|1 - Less than once a month|1 - Less than once a month|96
76|1 - Less than once weekly|1 - Less than once weekly|96
77|1 - Life expectancy is 6 months or fewer|1 - Life expectancy is 6 months or fewer|96
78|1 - Lives alone|1 - Lives alone|96
79|1 - Male|1 - Male|96
80|1 - Medicare (traditional fee-for-service)|1 - Medicare (traditional fee-for-service)|96
81|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of past 24 hours, significant memory loss so that supervision is required|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of pas|96
82|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors in word choice, grammar or speech intelligibility, needs minimal prompting or assistance).|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors i|96
83|1 - No assistance or services received|1 - No assistance or services received|96
84|1 - One|1 - One|96
85|1 - Oxygen (intermittent or continuous)|1 - Oxygen (intermittent or continuous)|96
86|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, and the surrounding layout, can count fingers at arm's length.|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, a|96
87|1 - Patient is incontinent|1 - Patient is incontinent|96
88|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|96
89|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical or treatment regimen.|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical|96
90|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient/couple/significant other)|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient|96
91|1 - Relatives, friends, or neighbors living outside the home|1 - Relatives, friends, or neighbors living outside the home|96
92|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions.|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions|96
93|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independentl|96
94|1 - Several times during day and night|1 - Several times during day and night|96
95|1 - Spouse or significant other|1 - Spouse or significant other|96
96|1 - Stage 1|1 - Stage 1|96
97|1 - Start of care - further visits planned|1 - Start of care - further visits planned|96
98|1 - Symptoms well controlled with current therapy|1 - Symptoms well controlled with current therapy|96
99|1 - Therapy services|1 - Therapy services|96
100|1 - Able to transfer with minimal human assistance or with use of an assistive device.|1 - Able to transfer with minimal human assistance or with use of an assistive device.|96
101|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitations.|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitatio|96
102|1 - Urinary incontinence|1 - Urinary incontinence|96
103|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and transfer.|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and|96
104|1 - When walking more than 20 feet, climbing stairs|1 - When walking more than 20 feet, climbing stairs|96
105|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary conversation. May need occasional repetition, extra time, or louder voice.|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary c|96
106|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting in and out of tub/shower|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting|96
107|1 - Yes|1 - Yes|96
108|1-RN|1-RN|96
109|10 - Discharge from agency - no visits completed after start/resumption of care assessment|10 - Discharge from agency - no visits completed after start/resumption of care assessment|96
110|10 - Scheduled surgical procedure|10 - Scheduled surgical procedure|96
111|10 - Self-pay|10 - Self-pay|96
112|11 - Other|11 - Other|96
113|11 - Urinary tract infection|11 - Urinary tract infection|96
114|12 - IV catheter-related infection|12 - IV catheter-related infection|96
115|13 - Deep vein thrombosis, pulmonary embolus|13 - Deep vein thrombosis, pulmonary embolus|96
116|14 - Uncontrolled pain|14 - Uncontrolled pain|96
117|15 - Psychotic episode|15 - Psychotic episode|96
118|16 - Other than above reasons|16 - Other than above reasons|96
119|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing calls.|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing|96
120|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another person.|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another pers|96
121|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface a|96
122|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for intermittent supervision or encouragement or reminders, OR (b) to get in and out of the shower or tub, OR (c) for washing difficult to reach areas.|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for inter|96
123|2 - Asian|2 - Asian|96
124|2 - Caregiver requires considerable assistance from another person to manage equipment, but independently completes significant portions of task.|2 - Caregiver requires considerable assistance from another person to manage equipment, but independ|96
125|2 - Daily, but not constantly|2 - Daily, but not constantly|96
126|2 - Daughter or son|2 - Daughter or son|96
127|2 - Doctor's office emergency visit/house call|2 - Doctor's office emergency visit/house call|96
128|2 - During the day and night|2 - During the day and night|96
129|2 - Early/partial granulation|2 - Early/partial granulation|96
130|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors in word choice, organization or speech intelligibility). Speaks in phrases or short sentences.|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors|96
131|2 - Family member's residence|2 - Family member's residence|96
132|2 - Female|2 - Female|96
133|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conversation, needs frequent prompting or assistance.|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conver|96
134|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|96
135|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|96
136|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately stop activities, jeopardizes safety through actions|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately st|96
137|2 - Indwelling/suprapubic catheter|2 - Indwelling/suprapubic catheter|96
138|2 - Injury caused by fall|2 - Injury caused by fall|96
139|2 - Medicare (HMO/managed care/Advantage plan)|2 - Medicare (HMO/managed care/Advantage plan)|96
140|2 - Nausea, dehydration, malnutrition, constipation, impaction|2 - Nausea, dehydration, malnutrition, constipation, impaction|96
141|2 - Obesity|2 - Obesity|96
142|2 - On awakening or at night only|2 - On awakening or at night only|96
143|2 - Once a month|2 - Once a month|96
144|2 - One to three times weekly|2 - One to three times weekly|96
145|2 - Parenteral nutrition (TPN or lipids)|2 - Parenteral nutrition (TPN or lipids)|96
146|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic) [ Go to M1620]|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic) [ Go|96
147|2 - Patient requires considerable assistance from another person to manage equipment, but independently completes portions of the task.|2 - Patient requires considerable assistance from another person to manage equipment, but independen|96
148|2 - Patient transferred to a noninstitutional hospice|2 - Patient transferred to a noninstitutional hospice|96
149|2 - Person residing in the home (EXCLUDING paid help)|2 - Person residing in the home (EXCLUDING paid help)|96
150|2 - Rehabilitation facility|2 - Rehabilitation facility|96
151|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifting of attention) or consistently requires low stimulus environment due to distractibility.|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifti|96
152|2 - Respite care|2 - Respite care|96
153|2 - Sense of failure or self reproach|2 - Sense of failure or self reproach|96
154|2 - Several times during day|2 - Several times during day|96
155|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonresponsive.|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonrespons|96
156|2 - Someone must assist the patient to groom self.|2 - Someone must assist the patient to groom self.|96
157|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|96
158|2 - Someone must help the patient put on upper body clothing.|2 - Someone must help the patient put on upper body clothing.|96
159|2 - Stage 2|2 - Stage 2|96
160|2 - Start of care - no further visits planned|2 - Start of care - no further visits planned|96
161|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitoring|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitori|96
162|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment regimen.|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment re|96
163|2 - Two|2 - Two|96
164|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistance due to cognitive or mental limitation.|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistanc|96
165|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|96
166|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assistance).|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assis|96
167|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home delivery.|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home deli|96
168|2 - Unable to prepare any light meals or reheat any delivered meals.|2 - Unable to prepare any light meals or reheat any delivered meals.|96
169|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|96
170|2 - UNABLE to take injectable medications unless administered by someone else.|2 - UNABLE to take injectable medications unless administered by someone else.|96
171|2 - UNABLE to take medication unless administered by someone else.|2 - UNABLE to take medication unless administered by someone else.|96
172|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|96
173|2 - Ventilator (continually or at night)|2 - Ventilator (continually or at night)|96
174|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less than 20 feet)|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less th|96
175|2 - With spouse or significant other|2 - With spouse or significant other|96
176|2 - Yes, assistance or services provided by family or friends|2 - Yes, assistance or services provided by family or friends|96
177|2-PT|2-PT|96
178|3 - Able to answer the telephone only some of the time or is able to carry on only a limited conversation.|3 - Able to answer the telephone only some of the time or is able to carry on only a limited convers|96
179|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube or gastrostomy.|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube|96
180|3 - Alcohol dependency|3 - Alcohol dependency|96
181|3 - All of the time|3 - All of the time|96
182|3 - Black or African-American|3 - Black or African-American|96
183|3 - Boarding home or rented room|3 - Boarding home or rented room|96
184|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment, clean/store/dispose of equipment or supplies).|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment,|96
185|3 -Able to walk only with the supervision or assistance of another person at all times.|3 -Able to walk only with the supervision or assistance of another person at all times.|96
186|3 - Continuous / Bi-level positive airway pressure|3 - Continuous / Bi-level positive airway pressure|96
187|3 - During the day and evening, but not constantly|3 - During the day and evening, but not constantly|96
188|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the alimentary canal)|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the|96
189|3 - Environmental support (e.g., housing, home maintenance)|3 - Environmental support (e.g., housing, home maintenance)|96
190|3 - Four to six times weekly|3 - Four to six times weekly|96
191|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessing by listener.  Speech limited to single words or short phrases.|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessin|96
192|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires multiple repetitions, restatements, demonstrations, additional time.|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires m|96
193|3 - Hopelessness|3 - Hopelessness|96
194|3 - Hospice care|3 - Hospice care|96
195|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|96
196|3 - Injury caused by fall or accident at home|3 - Injury caused by fall or accident at home|96
197|3 - Intractable pain|3 - Intractable pain|96
198|3 - Medicaid (traditional fee-for-service)|3 - Medicaid (traditional fee-for-service)|96
199|3 - Needs someone to do all shopping and errands.|3 - Needs someone to do all shopping and errands.|96
200|3 - Not healing|3 - Not healing|96
201|3 - Nursing home|3 - Nursing home|96
202|3 - Once daily|3 - Once daily|96
203|3 - Other family member|3 - Other family member|96
204|3 - Outpatient department/clinic emergency (includes urgicenter sites)|3 - Outpatient department/clinic emergency (includes urgicenter sites)|96
205|3 - Paid help|3 - Paid help|96
206|3 - Able to participate in bathing self in shower or tub, but requires presence of another person throughout the bath for assistance or supervision.|3 - Able to participate in bathing self in shower or tub, but requires presence of another person th|96
207|3 - Patient depends entirely upon another person to dress lower body.|3 - Patient depends entirely upon another person to dress lower body.|96
208|3 - Patient depends entirely upon another person to dress the upper body.|3 - Patient depends entirely upon another person to dress the upper body.|96
209|3 - Patient depends entirely upon someone else for grooming needs.|3 - Patient depends entirely upon someone else for grooming needs.|96
210|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone else to manage the equipment.|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone|96
211|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable to shift attention and recall directions more than half the time.|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable|96
212|3 - Respiratory problems (SOB, infection, obstruction)|3 - Respiratory problems (SOB, infection, obstruction)|96
213|3 - Resumption of care (after inpatient stay)|3 - Resumption of care (after inpatient stay)|96
214|3 - Several times each month|3 - Several times each month|96
215|3 - Skilled Nursing Facility|3 - Skilled Nursing Facility|96
216|3 - Stage 3|3 - Stage 3|96
217|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|96
218|3 - Three|3 - Three|96
219|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person throughout the process.|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person through|96
220|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal independently.|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal indep|96
221|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person.|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person|96
222|3 - Unknown because patient moved to a geographic location not served by this agency|3 - Unknown because patient moved to a geographic location not served by this agency|96
223|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|96
224|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|96
225|3 - With other family member|3 - With other family member|96
226|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home health services, homemaker assistance, transportation assistance, assisted living, board and care)|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home h|96
227|3-SLP/ST|3-SLP/ST|96
228|4 - At rest (during day or night)|4 - At rest (during day or night)|96
229|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|96
230|4 - Board and care or assisted living facility|4 - Board and care or assisted living facility|96
231|4 - Caregiver is completely dependent on someone else to manage all equipment.|4 - Caregiver is completely dependent on someone else to manage all equipment.|96
232|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|96
233|4 - Constantly|4 - Constantly|96
234|4 - Drug dependency|4 - Drug dependency|96
235|4 - Four or more|4 - Four or more|96
236|4 - Friend or neighbor or community or church member|4 - Friend or neighbor or community or church member|96
237|4 - Hispanic or Latino|4 - Hispanic or Latino|96
238|4 - Hospice|4 - Hospice|96
239|4 - Impaired decision-making|4 - Impaired decision-making|96
240|4 - Is totally dependent in toileting.|4 - Is totally dependent in toileting.|96
241|4 - Medicaid (HMO/managed care)|4 - Medicaid (HMO/managed care)|96
242|4 - None of the above|4 - None of the above|96
243|4 - Nursing home|4 - Nursing home|96
244|4 - On a daily basis|4 - On a daily basis|96
245|4 - Patient is completely dependent on someone else to manage all equipment.|4 - Patient is completely dependent on someone else to manage all equipment.|96
246|4 - Permanent placement|4 - Permanent placement|96
247|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, punches, dangerous maneuvers w/ wheelchair or other objects)|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, pu|96
248|4 - Psychosocial support (e.g., socialization, companionship, recreation)|4 - Psychosocial support (e.g., socialization, companionship, recreation)|96
249|4 - Recertification (follow-up) reassessment|4 - Recertification (follow-up) reassessment|96
250|4 - Recurrent thoughts of death|4 - Recurrent thoughts of death|96
251|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruction)|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruc|96
252|4 - Several times a week|4 - Several times a week|96
253|4 - Stage 4|4 - Stage 4|96
254|4 - Symptoms poorly controlled, history of rehospitalizations|4 - Symptoms poorly controlled, history of rehospitalizations|96
255|4 - Three or more times per week|4 - Three or more times per week|96
256|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetative state, or delirium.|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetati|96
257|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|96
258|4 - Unable to effectively participate in any housekeeping tasks.|4 - Unable to effectively participate in any housekeeping tasks.|96
259|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or unresponsive (e.g., speech is nonsensical or unintelligible).|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or u|96
260|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonresponsive.|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonr|96
261|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostomy.|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostom|96
262|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of devices at the sink, in chair, or on commode|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of|96
263|4 - With a friend|4 - With a friend|96
264|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|96
265|4-OT|4-OT|96
266|5 - Advocates or facilitates patient's participation in appropriate medical care|5 - Advocates or facilitates patient's participation in appropriate medical care|96
267|5 - At least daily|5 - At least daily|96
268|6 - Bedfast, unable to ambulate or be up in a chair.|6 - Bedfast, unable to ambulate or be up in a chair.|96
269|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|96
270|5 - Disruptive or socially inappropriate behavior|5 - Disruptive or socially inappropriate behavior|96
271|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|96
272|5 - Hypo/Hyperglycemia, diabetes out of control|5 - Hypo/Hyperglycemia, diabetes out of control|96
273|5 - More often than once daily|5 - More often than once daily|96
274|5 - Native Hawaiian or Pacific Islander|5 - Native Hawaiian or Pacific Islander|96
275|5 - None of the above|5 - None of the above|96
276|5 - One to two times per week|5 - One to two times per week|96
277|5 - Other|5 - Other|96
278|5 - Other follow-up|5 - Other follow-up|96
279|5 - Paid help|5 - Paid help|96
280|5 - Patient nonresponsive or unable to speak.|5 - Patient nonresponsive or unable to speak.|96
281|5 - Thoughts of suicide|5 - Thoughts of suicide|96
282|5 - Totally unable to use the telephone.|5 - Totally unable to use the telephone.|96
283|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|96
284|5 - Unable to take in nutrients orally or by tube feeding.|5 - Unable to take in nutrients orally or by tube feeding.|96
285|5 - Unsafe for care at home|5 - Unsafe for care at home|96
286|5 - With paid help (other than home care agency staff)|5 - With paid help (other than home care agency staff)|96
287|5 - Workers' compensation|5 - Workers' compensation|96
288|5 - Wound infection, deteriorating wound status, new lesion/ulcer|5 - Wound infection, deteriorating wound status, new lesion/ulcer|96
289|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|96
290|6 - Delusional, hallucinatory, or paranoid behavior|6 - Delusional, hallucinatory, or paranoid behavior|96
291|6 - Financial agent, power of attorney, or conservator of finance|6 - Financial agent, power of attorney, or conservator of finance|96
292|6 - GI bleeding, obstruction|6 - GI bleeding, obstruction|96
293|6 - Less often than weekly|6 - Less often than weekly|96
294|6 - Memory loss to the extent that supervision required|6 - Memory loss to the extent that supervision required|96
295|6 - None of the above feelings observed or reported|6 - None of the above feelings observed or reported|96
296|6 - Other|6 - Other|96
297|6 - Title programs (e.g., Title III, V, or XX)|6 - Title programs (e.g., Title III, V, or XX)|96
298|6 - Transferred to an inpatient facility - patient not discharged from agency|6 - Transferred to an inpatient facility - patient not discharged from agency|96
299|6 - White|6 - White|96
300|6 - With other than above|6 - With other than above|96
301|7 - Exacerbation of CHF, fluid overload, heart failure|7 - Exacerbation of CHF, fluid overload, heart failure|96
302|7 - Health care agent, conservator of person, or medical power of attorney|7 - Health care agent, conservator of person, or medical power of attorney|96
303|7 - Hypo/Hyperglycemia, diabetes out of control|7 - Hypo/Hyperglycemia, diabetes out of control|96
304|7 - None of the above|7 - None of the above|96
305|7 - None of the above behaviors demonstrated|7 - None of the above behaviors demonstrated|96
306|7 - Other government (e.g., TriCare, VA, etc.)|7 - Other government (e.g., TriCare, VA, etc.)|96
307|7 - Transferred to an inpatient facility - patient discharged from agency|7 - Transferred to an inpatient facility - patient discharged from agency|96
308|8 - Death at home|8 - Death at home|96
309|8 - GI bleeding, obstruction|8 - GI bleeding, obstruction|96
310|8 - Myocardial infarction, stroke|8 - Myocardial infarction, stroke|96
311|8 - Private insurance|8 - Private insurance|96
312|9 - Chemotherapy|9 - Chemotherapy|96
313|9 - Discharge from agency|9 - Discharge from agency|96
314|9 - Other than above reasons|9 - Other than above reasons|96
315|9 - Private HMO/managed care|9 - Private HMO/managed care|96
316|NA - No caregiver|NA - No caregiver|96
317|NA - No equipment of this type used in care.|NA - No equipment of this type used in care.|96
318|NA - No inhalant/mist medications prescribed.|NA - No inhalant/mist medications prescribed.|96
319|NA - No injectable medications prescribed.|NA - No injectable medications prescribed.|96
320|NA - No inpatient facility admission|NA - No inpatient facility admission|96
321|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|96
322|NA - No Medicaid|NA - No Medicaid|96
323|NA - No Medicare|NA - No Medicare|96
324|NA - No observable pressure ulcer or unhealed pressure ulcer|NA - No observable pressure ulcer or unhealed pressure ulcer|96
325|NA - No observable stasis ulcer|NA - No observable stasis ulcer|96
326|NA - No observable surgical wound|NA - No observable surgical wound|96
327|NA - No oral medications prescribed.|NA - No oral medications prescribed.|96
328|NA - Not applicable|NA - Not applicable|96
329|NA - Patient does not have a telephone.|NA - Patient does not have a telephone.|96
330|NA - Patient has ostomy for bowel elimination|NA - Patient has ostomy for bowel elimination|96
331|NA - Patient nonresponsive|NA - Patient nonresponsive|96
332|NA - Patient on prophylactic treatment|NA - Patient on prophylactic treatment|96
333|NA - Patient was not discharged from an inpatient facility [Go to M1017]|NA - Patient was not discharged from an inpatient facility [Go to M1017]|96
334|UK - Other unknown|UK - Other unknown|96
335|UK - Reason unknown|UK - Reason unknown|96
336|UK - Unknown|UK - Unknown|96
337|UK - Unknown or Not Available|UK - Unknown or Not Available|96
341|01 - Early|01 - Early|96
342|02 - Late|02 - Late|96
343|NA - Not Applicable. No case mix group defined for this assessment.|NA - Not Applicable. No case mix group defined for this assessment.|96
344|NA - No case mix group defined by this assessment.|NA - No case mix group defined by this assessment.|96
345|1 - Recent decline in mental, emotional, or behavioral status|1 - Recent decline in mental, emotional, or behavioral status|96
346|2 - Multiple hospitalizations (2 or more) in the past 12 months|2 - Multiple hospitalizations (2 or more) in the past 12 months|96
347|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|96
348|4 - Taking five or more medications|4 - Taking five or more medications|96
349|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|96
350|6 - Other|6 - Other|96
351|7 - None of the above|7 - None of the above|96
352|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond tho|96
353|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable without heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable wi|96
354|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious complications and death.|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious compl|96
355|3 - The patient has serious progressive conditions that could lead to death within a year.|3 - The patient has serious progressive conditions that could lead to death within a year.|96
356|UK - The patient+s situation is unknown or unclear.|UK - The patient+s situation is unknown or unclear.|96
357|0 - No [ Go to M1051 ]|0 - No [ Go to M1051 ]|96
358|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this influenza season. [ Go to M1050 ]|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this i|96
359|1 - Received from another health care provider (e.g., physician)|1 - Received from another health care provider (e.g., physician)|96
360|2 - Received from your agency previously during this year+s flu season|2 - Received from your agency previously during this year+s flu season|96
361|3 - Offered and declined|3 - Offered and declined|96
362|4 - Assessed and determined to have medical contraindication(s)|4 - Assessed and determined to have medical contraindication(s)|96
363|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|96
364|6 - Inability to obtain vaccine due to declared shortage|6 - Inability to obtain vaccine due to declared shortage|96
365|1 - Yes [ Go to M2005 at TRN; Go to M1230 at DC ]|1 - Yes [ Go to M2005 at TRN; Go to M1230 at DC ]|96
366|1 - Patient has received PPV in the past|1 - Patient has received PPV in the past|96
367|2 - Offered and declined|2 - Offered and declined|96
368|3 - Assessed and determined to have medical contraindication(s)|3 - Assessed and determined to have medical contraindication(s)|96
369|4 - Not indicated; patient does not meet age/condition guidelines for PPV|4 - Not indicated; patient does not meet age/condition guidelines for PPV|96
370|5 - None of the above|5 - None of the above|96
371|0 - Adequate: hears normal conversation without difficulty.|0 - Adequate: hears normal conversation without difficulty.|96
372|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to increase volume or speak distinctly.|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to in|96
373|2 - Severely Impaired: absence of useful hearing.|2 - Severely Impaired: absence of useful hearing.|96
374|UK - Unable to assess hearing.|UK - Unable to assess hearing.|96
375|0 - Understands: clear comprehension without cues or repetitions.|0 - Understands: clear comprehension without cues or repetitions.|96
376|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Requires cues at times to understand.|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Req|96
377|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequently requires cues to understand.|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequentl|96
378|3 - Rarely/Never Understands|3 - Rarely/Never Understands|96
379|UK - Unable to assess understanding.|UK - Unable to assess understanding.|96
380|0 - No standardized assessment conducted|0 - No standardized assessment conducted|96
381|1 - Yes, and it does not indicate severe pain|1 - Yes, and it does not indicate severe pain|96
382|2 - Yes, and it indicates severe pain|2 - Yes, and it indicates severe pain|96
383|0 - Patient has no pain|0 - Patient has no pain|96
384|1 - Patient has pain that does not interfere with activity or movement|1 - Patient has pain that does not interfere with activity or movement|96
385|2 - Less often than daily|2 - Less often than daily|96
386|3 - Daily, but not constantly|3 - Daily, but not constantly|96
387|4 - All of the time|4 - All of the time|96
388|0 - No assessment conducted [ Go to M1306 ]|0 - No assessment conducted [ Go to M1306 ]|96
389|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc., without use of standardized tool|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc.,|96
390|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|96
391|0 - No [ Go to M1322]|0 - No [ Go to M1322]|96
392|0 v Newly epithelialized|0 v Newly epithelialized|96
393|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|96
394|2 - Yes, patient has observable stasis ulcers ONLY|2 - Yes, patient has observable stasis ulcers ONLY|96
395|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable dressing) [Go to M1340]|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable|96
396|0 - No [ Go to M1350 ]|0 - No [ Go to M1350 ]|96
397|1 - Yes, patient has at least one (observable) surgical wound|1 - Yes, patient has at least one (observable) surgical wound|96
398|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1350 ]|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1350 ]|96
399|0 - Patient is not short of breath|0 - Patient is not short of breath|96
400|3 - Continuous Bi-level positive airway pressure|3 - Continuous Bi-level positive airway pressure|96
401|0 - No [ Go to M2005 at TRN; Go to M1600 at DC ]|0 - No [ Go to M2005 at TRN; Go to M1600 at DC ]|96
402|2 - Not assessed [Go to M2005 at TRN; Go to M1600 at DC ]|2 - Not assessed [Go to M2005 at TRN; Go to M1600 at DC ]|96
403|NA - Patient does not have diagnosis of heart failure [Go to M2005 at TRN; Go to M1600 at DC]|NA - Patient does not have diagnosis of heart failure [Go to M2005 at TRN; Go to M1600 at DC]|96
404|0 - No action taken|0 - No action taken|96
405|1 - Patient+s physician (or other primary care practitioner) contacted the same day|1 - Patient+s physician (or other primary care practitioner) contacted the same day|96
406|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|96
407|3 - Implement physician-ordered patient-specific established parameters for treatment|3 - Implement physician-ordered patient-specific established parameters for treatment|96
408|4 - Patient education or other clinical interventions|4 - Patient education or other clinical interventions|96
409|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequency, telehealth, etc.)|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequ|96
410|1 - Occasional stress incontinence|1 - Occasional stress incontinence|96
411|2 - During the night only|2 - During the night only|96
412|3 - During the day only|3 - During the day only|96
413|4 - During the day and night|4 - During the day and night|96
414|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|96
415|0 - Able to manage toileting hygiene and clothing management without assistance.|0 - Able to manage toileting hygiene and clothing management without assistance.|96
416|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implements are laid out for the patient.|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implemen|96
417|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|96
418|3 - Patient depends entirely upon another person to maintain toileting hygiene.|3 - Patient depends entirely upon another person to maintain toileting hygiene.|96
419|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independent|96
420|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface|96
421|0 - No multi-factor falls risk assessment conducted.|0 - No multi-factor falls risk assessment conducted.|96
422|1 - Yes, and it does not indicate a risk for falls.|1 - Yes, and it does not indicate a risk for falls.|96
423|2 - Yes, and it indicates a risk for falls.|2 - Yes, and it indicates a risk for falls.|96
424|0 - Not assessed/reviewed [ Go to M2010 ]|0 - Not assessed/reviewed [ Go to M2010 ]|96
425|1 - No problems found during review [ Go to M2010 ]|1 - No problems found during review [ Go to M2010 ]|96
426|2 - Problems found during review|2 - Problems found during review|96
427|NA - Patient is not taking any medications [ Go to M2040 ]|NA - Patient is not taking any medications [ Go to M2040 ]|96
428|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special precautions associated with all high-risk medications|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special p|96
429|NA - Patient not taking any drugs|NA - Patient not taking any drugs|96
430|2 - Able to take medication(s) at the correct times if given reminders by another person at the appropriate times|2 - Able to take medication(s) at the correct times if given reminders by another person at the appr|96
431|3 - Unable to take medication unless administered by another person.|3 - Unable to take medication unless administered by another person.|96
432|1 - At least daily|1 - At least daily|96
433|2 - Three or more times per week|2 - Three or more times per week|96
434|3 - One to two times per week|3 - One to two times per week|96
435|4 - Received, but less often than weekly|4 - Received, but less often than weekly|96
436|5 - No assistance received|5 - No assistance received|96
437|0 - No [Go to M2401]|0 - No [Go to M2401]|96
438|1 - Yes, used hospital emergency department WITHOUT hospital admission|1 - Yes, used hospital emergency department WITHOUT hospital admission|96
439|2 - Yes, used hospital emergency department WITH hospital admission|2 - Yes, used hospital emergency department WITH hospital admission|96
440|UK - Unknown [Go to M2401]|UK - Unknown [Go to M2401]|96
441|2 - Injury caused by fall|2 - Injury caused by fall|96
442|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|96
443|4 - Other respiratory problem|4 - Other respiratory problem|96
444|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|96
445|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|96
446|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|96
447|8 - Other heart disease|8 - Other heart disease|96
448|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|96
449|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|96
450|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|96
451|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|96
452|13 - Urinary tract infection|13 - Urinary tract infection|96
453|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|96
454|15 - Wound infection or deterioration|15 - Wound infection or deterioration|96
455|16 - Uncontrolled pain|16 - Uncontrolled pain|96
456|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|96
457|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|96
458|19 - Other than above reasons|19 - Other than above reasons|96
459|2 - Patient remained in the community (with formal assistive services)|2 - Patient remained in the community (with formal assistive services)|96
460|3 - Patient transferred to a noninstitutional hospice|3 - Patient transferred to a noninstitutional hospice|96
461|4 - Unknown because patient moved to a geographic location not served by this agency|4 - Unknown because patient moved to a geographic location not served by this agency|96
462|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|96
463|4 - Other respiratory problem|4 - Other respiratory problem|96
464|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|96
465|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|96
466|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|96
467|8 - Other heart disease|8 - Other heart disease|96
468|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|96
469|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|96
470|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|96
471|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|96
472|13 - Urinary tract infection|13 - Urinary tract infection|96
473|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|96
474|15 - Wound infection or deterioration|15 - Wound infection or deterioration|96
475|16 - Uncontrolled pain|16 - Uncontrolled pain|96
476|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|96
477|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|96
478|19 - Scheduled treatment or procedure|19 - Scheduled treatment or procedure|96
479|20 - Other than above reasons|20 - Other than above reasons|96
480|UK - Reason unknown [Go to M0903]|UK - Reason unknown [Go to M0903]|96
482|01 - Patient lives alone around the clock|01 - Patient lives alone around the clock|96
483|02 - Patient lives alone regular daytime|02 - Patient lives alone regular daytime|96
484|03 - Patient lives alone regular nighttime|03 - Patient lives alone regular nighttime|96
485|04 - Patient lives alone occassional/short term assistance|04 - Patient lives alone occassional/short term assistance|96
486|05 - Patient lives alone no assisstance available|05 - Patient lives alone no assisstance available|96
487|06 - Patient lives with other person(s) in the home around the clock|06 - Patient lives with other person(s) in the home around the clock|96
488|07 - Patient lives with other person(s) in the home regular daytime|07 - Patient lives with other person(s) in the home regular daytime|96
489|08 - Patient lives with other person(s) in the home regular nighttime|08 - Patient lives with other person(s) in the home regular nighttime|96
490|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|96
491|10 - Patient lives with other person(s) in the home no assistance available|10 - Patient lives with other person(s) in the home no assistance available|96
492|1 - Was present at the most recent SOC/ROC assessment|1 - Was present at the most recent SOC/ROC assessment|96
493|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|96
494|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|96
495|0 - Newly epithelialized|0 - Newly epithelialized|96
496|0 - No [ Go to M1340 ]|0 - No [ Go to M1340 ]|96
498|0 - Independent|0 - Independent|96
499|1 - Needed Some Help|1 - Needed Some Help|96
500|2 - Dependent|2 - Dependent|96
502|0 - No assistance needed in this area|0 - No assistance needed in this area|96
503|1 - Caregiver(s) currently provide assistance|1 - Caregiver(s) currently provide assistance|96
504|2 - Caregiver(s) need training/ supportive services to provide assistance|2 - Caregiver(s) need training/ supportive services to provide assistance|96
505|3 - Caregiver(s) not likely to provide assistance|3 - Caregiver(s) not likely to provide assistance|96
506|4 - Unclear if Caregiver(s) will provide assistance|4 - Unclear if Caregiver(s) will provide assistance|96
507|5 - Assistance needed, but no Caregiver(s) available|5 - Assistance needed, but no Caregiver(s) available|96
508|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will use standardized clinical guidelines accessible for all care providers to reference|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will|96
510|NA - Patient is not assessed to be at risk for falls|NA - Patient is not assessed to be at risk for falls|96
511|NA - Patient has no diagnosis or symptoms of depression|NA - Patient has no diagnosis or symptoms of depression|96
512|NA - No pain identified|NA - No pain identified|96
513|NA - Patient is not assessed to be at risk for pressure ulcers|NA - Patient is not assessed to be at risk for pressure ulcers|96
514|NA - Patient has no pressure ulcers with need for moist wound healing|NA - Patient has no pressure ulcers with need for moist wound healing|96
515|1 - Long-term nursing facility (NF)|1 - Long-term nursing facility (NF)|96
516|2 - Skilled nursing facility (SNF / TCU)|2 - Skilled nursing facility (SNF / TCU)|96
517|3 - Short stay acute hospital (IPP S)|3 - Short stay acute hospital (IPP S)|96
518|4 - Long-term care hospital (LTCH)|4 - Long-term care hospital (LTCH)|96
519|5 - Inpatient rehabilitation hospital or unit (IRF)|5 - Inpatient rehabilitation hospital or unit (IRF)|96
520|6 - Psychiatric hospital or unit|6 - Psychiatric hospital or unit|96
521|7 - Other|7 - Other|96
522|NA - Patient was not discharged from an inpatient facility [Go to M1017]|NA - Patient was not discharged from an inpatient facility [Go to M1017]|96
523|6 - Unable to participate effectively in bathing and is bathed totally by another person|6 - Unable to participate effectively in bathing and is bathed totally by another person|96
524|4 - Chairfast, unable to ambulate but is able to wheel self independently.|4 - Chairfast, unable to ambulate but is able to wheel self independently.|96
525|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask patient: "Over the last two weeks, how often have you been bothered by any of the following problems")|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask|96
526|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluation for depression.|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluat|96
527|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet criteria for further evaluation for depression.|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet|96
528|0 - Not at all  0 - 1 day|0 - Not at all  0 - 1 day|96
529|1 - Several days  2 - 6 days|1 - Several days  2 - 6 days|96
530|2 - More than half of the days  7 - 11 days|2 - More than half of the days  7 - 11 days|96
531|3 - Nearly every day  12 - 14 days|3 - Nearly every day  12 - 14 days|96
532|NA - N/A  Unable to respond|NA - N/A  Unable to respond|96
533|2 - Able to take medication(s) at the correct times if given reminders by another person based on the frequency of the injection|2 - Able to take medication(s) at the correct times if given reminders by another person based on th|96
534|3 - Unable to take injectable medication unless administered by another person.|3 - Unable to take injectable medication unless administered by another person.|96
547|NA - There were no potential clinically significant medication issues identified since SOC/ROC or patient is not taking any medications|NA -  There were no potential clinically significant medication issues identified since SOC/ROC |96
552|1 - Hospital|1 - Hospital [ Go to M2430 ]|96
553|2 - Rehabilitation facility |2 - Rehabilitation facility [ Go to M0903 ]|96
554|3 - Nursing home|3 - Nursing home [ Go to M2440 ]|96
555|4 - Hospice|4 - Hospice [ Go to M0903 ]|96
557|NA - Patient is not diabetic or is bilateral amputee|NA - Patient is not diabetic or is bilateral amputee|96
558|NA - Every standardized,validated multifactor fall risk assessment conducted at or since the most recent SOC/ROC assessment indicates the patient has no risk for falls.|NA - Every standardized,validated multifactor fall risk assessment condition|96
559|NA - Patient has no diagnosis of depression AND every standardized, validated depression screening conducted at or since the most recent SOC/ROC assessment indicates the patient has: 1) no symptoms of depression; or 2) has some symptoms of depression but does not meet criteria for further evaluation of depression based on screening tool used.|NA - Patient has no diagnosis of depression AND every standardized, validated |96
560|NA - Every standardized, validated pain assessment conducted at or since the most recent SOC/ROC assessment indicates the patient has no pain.|NA - Every standardized, validated pain assessment conducted at or since the most|96
561|NA - Every standardized, validated pressure ulcer risk assessment conducted at or since the most recent SOC/ROC assessment indicates the patient is not at risk of developing pressure ulcers.|NA - Every standardized, validated pressure ulcer risk assessment conducted|96
562|NA - Dressings that support the principles of moist wound healing not indicated for this patient's pressure ulcers OR patient has no pressure ulcers with need for moist wound healing|NA - Dressings that support the principles of moist wound healing not indicated for this patient's p|96
620|1 - Yes; received from your agency during this episode of care (SOC/ROC to Transfer/Discharge)|1 - Yes; received from your agency during this episode of care (SOC/ROC to Transfer/Discharge)|96
621|2 - Yes; received from your agency during a prior episode of care (SOC/ROC to Transfer/Discharge)|2 - Yes; received from your agency during a prior episode of care (SOC/ROC to Transfer/Discharge)|96
622|3 - Yes; received from another health care provider (for example physician pharmacist)|3 - Yes; received from another health care provider (for example physician pharmacist)|96
623|4 - No; patient offered and declined |4 - No; patient offered and declined |96
624|5 - No; patient assessed and determined to have medical contraindication(s)|5 - No; patient assessed and determined to have medical contraindication(s)|96
625|6 - No; not indicated - patient does not meet age/condition guidelines for influenza vaccine|6 - No; not indicated - patient does not meet age/condition guidelines for influenza vaccine|96
626|7 - No; inability to obtain vaccine due to declared shortage |7 - No; inability to obtain vaccine due to declared shortage |96
627|8 - No; patient did not receive the vaccine due to reasons other than those listed in responses 4 v 7. |8 - No; patient did not receive the vaccine due to reasons other than those listed in responses 4v7.|96
628|1 - Offered and declined|1 - Offered and declined|96
629|2 - Assessed and determined to have medical contraindication(s) |2 - Assessed and determined to have medical contraindication(s) |96
630|3 - Not indicated; patient does not meet age/condition guidelines for Pneumococcal Vaccine|3 - Not indicated; patient does not meet age/condition guidelines for Pneumococcal Vaccine|96
631|4 - None of the above|4 - None of the above|96
653|0 - No [STOP]|0 - No [STOP]|96
654|1 - Yes |1 - Yes|96
655|0 - None|0 - None|96
656|1 - One|1 - One|96
657|2 - Two or More|2 - Two or More|96
653|0 - No [STOP]|0 - No [STOP]|97
654|1 - Yes |1 - Yes|97
655|0 - None|0 - None|97
656|1 - One|1 - One|97
657|2 - Two or More|2 - Two or More|97
2|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; OR (b) Is physically, cognitively, and mentally able to prepare light meals on a regular basis but has not routinely performed light meal preparation in the past (i.e., prior to this home care admission).|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; O|97
3|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and mentally able to perform all housekeeping tasks .|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and menta|97
4|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and mentally able to do laundry and access facilities.|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and menta|97
5|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying packages OR b) Physically, cognitively, and mentally able to take care of shopping, but has not done shopping in the past (i.e., prior to this home care admission).|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying|97
6|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|97
7|0 - Able to dial numbers and answer calls appropriately and as desired.|0 - Able to dial numbers and answer calls appropriately and as desired.|97
8|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body without assistance.|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body|97
9|0 - Able to get to and from the toilet and transfer independently with or without a device.|0 - Able to get to and from the toilet and transfer independently with or without a device.|97
10|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|97
11|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible public bus.|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible p|97
12|0 - Able to independently feed self.|0 - Able to independently feed self.|97
13|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|97
14|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct times.|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct ti|97
15|0 - Able to independently transfer.|0 - Able to independently transfer.|97
16|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without rail|97
17|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings|97
18|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|97
19|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions independently.|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions indep|97
20|0 - Asymptomatic, no treatment needed at this time|0 - Asymptomatic, no treatment needed at this time|97
21|0 - Caregiver manages all tasks related to equipment completely independently.|0 - Caregiver manages all tasks related to equipment completely independently.|97
22|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations with no observable impairment.|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations w|97
23|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|97
24|0 - Life expectancy is greater than 6 months|0 - Life expectancy is greater than 6 months|97
25|0 - Never|0 - Never|97
26|0 - Patient is not short of breath|0 - Patient is not short of breath|97
27|0 - No|0 - No|97
28|0 - No emergent care services|0 - No emergent care services|97
29|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [Goto 1620]|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [Goto 1620]|97
30|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and extended or abstract conversation.|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and exte|97
31|0 - No one person|0 - No one person|97
32|0 - None of the time|0 - None of the time|97
33|0 - None, no charge for current services|0 - None, no charge for current services|97
34|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|97
35|0 - Patient does NOT have an ostomy for bowel elimination.|0 - Patient does NOT have an ostomy for bowel elimination.|97
36|0 - Patient has no pain|0 - Patient has no pain|97
37|0 - Patient manages all tasks related to equipment completely independently.|0 - Patient manages all tasks related to equipment completely independently.|97
38|0 - Poor:  little or no recovery is expected and/or further decline is imminent|0 - Poor:  little or no recovery is expected and/or further decline is imminent|97
39|0 - Timed-voiding defers incontinence|0 - Timed-voiding defers incontinence|97
40|0 - Very rarely or never has bowel incontinence|0 - Very rarely or never has bowel incontinence|97
41|0 - Zero|0 - Zero|97
42|00 - No|00 - No|97
43|01 - Yes|01 - Yes|97
44|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or mental limitations, needs assistance with heavy laundry.|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or|97
45|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the patient.|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the|97
46|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|97
47|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or supervision from another person OR c) a liquid, pureed or ground meat diet.|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or su|97
48|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|97
49|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|97
50|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independently.|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independe|97
51|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only when assisted or accompanied by another person.|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only w|97
52|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepa|97
53|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance by another person OR b) given daily reminders.|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance b|97
54|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advan|97
55|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advan|97
56|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for the deaf) and call essential numbers.|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for t|97
57|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|97
58|1 - American Indian or Alaska Native|1 - American Indian or Alaska Native|97
59|1 - Depressed mood (e.g., feeling sad, tearful)|1 - Depressed mood (e.g., feeling sad, tearful)|97
60|1 - During the night only|1 - During the night only|97
61|1 - Fully granulating|1 - Fully granulating|97
62|1 - Good/Fair:  partial to full recovery is expected|1 - Good/Fair:  partial to full recovery is expected|97
63|1 - Good:  marked improvement in functional status is expected|1 - Good:  marked improvement in functional status is expected|97
64|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|97
65|1 - Smoking|1 - Smoking|97
66|1 - Hospital|1 - Hospital|97
67|1 - Hospital emergency room (includes 23-hour holding)|1 - Hospital emergency room (includes 23-hour holding)|97
68|1 - Hospitalization for EMERGENT (unscheduled) care|1 - Hospitalization for EMERGENT (unscheduled) care|97
69|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepared solutions), patient is able to manage all other aspects of equipment.|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepar|97
70|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|97
71|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|97
72|1 - In new or complex situations only|1 - In new or complex situations only|97
73|1 - Intravenous or infusion therapy (excludes TPN)|1 - Intravenous or infusion therapy (excludes TPN)|97
74|1 - Less often than daily|1 - Less often than daily|97
75|1 - Less than once a month|1 - Less than once a month|97
76|1 - Less than once weekly|1 - Less than once weekly|97
77|1 - Life expectancy is 6 months or fewer|1 - Life expectancy is 6 months or fewer|97
78|1 - Lives alone|1 - Lives alone|97
79|1 - Male|1 - Male|97
80|1 - Medicare (traditional fee-for-service)|1 - Medicare (traditional fee-for-service)|97
81|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of past 24 hours, significant memory loss so that supervision is required|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of pas|97
82|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors in word choice, grammar or speech intelligibility, needs minimal prompting or assistance).|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors i|97
83|1 - No assistance or services received|1 - No assistance or services received|97
84|1 - One|1 - One|97
85|1 - Oxygen (intermittent or continuous)|1 - Oxygen (intermittent or continuous)|97
86|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, and the surrounding layout, can count fingers at arm's length.|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, a|97
87|1 - Patient is incontinent|1 - Patient is incontinent|97
88|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|97
89|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical or treatment regimen.|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical|97
90|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient/couple/significant other)|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient|97
91|1 - Relatives, friends, or neighbors living outside the home|1 - Relatives, friends, or neighbors living outside the home|97
92|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions.|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions|97
93|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independentl|97
94|1 - Several times during day and night|1 - Several times during day and night|97
95|1 - Spouse or significant other|1 - Spouse or significant other|97
96|1 - Stage 1|1 - Stage 1|97
97|1 - Start of care - further visits planned|1 - Start of care - further visits planned|97
98|1 - Symptoms well controlled with current therapy|1 - Symptoms well controlled with current therapy|97
99|1 - Therapy services|1 - Therapy services|97
100|1 - Able to transfer with minimal human assistance or with use of an assistive device.|1 - Able to transfer with minimal human assistance or with use of an assistive device.|97
101|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitations.|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitatio|97
102|1 - Urinary incontinence|1 - Urinary incontinence|97
103|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and transfer.|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and|97
104|1 - When walking more than 20 feet, climbing stairs|1 - When walking more than 20 feet, climbing stairs|97
105|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary conversation. May need occasional repetition, extra time, or louder voice.|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary c|97
106|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting in and out of tub/shower|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting|97
107|1 - Yes|1 - Yes|97
108|1-RN|1-RN|97
109|10 - Discharge from agency - no visits completed after start/resumption of care assessment|10 - Discharge from agency - no visits completed after start/resumption of care assessment|97
110|10 - Scheduled surgical procedure|10 - Scheduled surgical procedure|97
111|10 - Self-pay|10 - Self-pay|97
112|11 - Other|11 - Other|97
113|11 - Urinary tract infection|11 - Urinary tract infection|97
114|12 - IV catheter-related infection|12 - IV catheter-related infection|97
115|13 - Deep vein thrombosis, pulmonary embolus|13 - Deep vein thrombosis, pulmonary embolus|97
116|14 - Uncontrolled pain|14 - Uncontrolled pain|97
117|15 - Psychotic episode|15 - Psychotic episode|97
118|16 - Other than above reasons|16 - Other than above reasons|97
119|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing calls.|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing|97
120|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another person.|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another pers|97
121|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface a|97
122|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for intermittent supervision or encouragement or reminders, OR (b) to get in and out of the shower or tub, OR (c) for washing difficult to reach areas.|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for inter|97
123|2 - Asian|2 - Asian|97
124|2 - Caregiver requires considerable assistance from another person to manage equipment, but independently completes significant portions of task.|2 - Caregiver requires considerable assistance from another person to manage equipment, but independ|97
125|2 - Daily, but not constantly|2 - Daily, but not constantly|97
126|2 - Daughter or son|2 - Daughter or son|97
127|2 - Doctor's office emergency visit/house call|2 - Doctor's office emergency visit/house call|97
128|2 - During the day and night|2 - During the day and night|97
129|2 - Early/partial granulation|2 - Early/partial granulation|97
130|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors in word choice, organization or speech intelligibility). Speaks in phrases or short sentences.|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors|97
131|2 - Family member's residence|2 - Family member's residence|97
132|2 - Female|2 - Female|97
133|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conversation, needs frequent prompting or assistance.|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conver|97
134|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|97
135|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|97
136|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately stop activities, jeopardizes safety through actions|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately st|97
137|2 - Indwelling/suprapubic catheter|2 - Indwelling/suprapubic catheter|97
138|2 - Injury caused by fall|2 - Injury caused by fall|97
139|2 - Medicare (HMO/managed care/Advantage plan)|2 - Medicare (HMO/managed care/Advantage plan)|97
140|2 - Nausea, dehydration, malnutrition, constipation, impaction|2 - Nausea, dehydration, malnutrition, constipation, impaction|97
141|2 - Obesity|2 - Obesity|97
142|2 - On awakening or at night only|2 - On awakening or at night only|97
143|2 - Once a month|2 - Once a month|97
144|2 - One to three times weekly|2 - One to three times weekly|97
145|2 - Parenteral nutrition (TPN or lipids)|2 - Parenteral nutrition (TPN or lipids)|97
146|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic) [ Go to M1620]|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic) [ Go|97
147|2 - Patient requires considerable assistance from another person to manage equipment, but independently completes portions of the task.|2 - Patient requires considerable assistance from another person to manage equipment, but independen|97
148|2 - Patient transferred to a noninstitutional hospice|2 - Patient transferred to a noninstitutional hospice|97
149|2 - Person residing in the home (EXCLUDING paid help)|2 - Person residing in the home (EXCLUDING paid help)|97
150|2 - Rehabilitation facility|2 - Rehabilitation facility|97
151|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifting of attention) or consistently requires low stimulus environment due to distractibility.|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifti|97
152|2 - Respite care|2 - Respite care|97
153|2 - Sense of failure or self reproach|2 - Sense of failure or self reproach|97
154|2 - Several times during day|2 - Several times during day|97
155|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonresponsive.|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonrespons|97
156|2 - Someone must assist the patient to groom self.|2 - Someone must assist the patient to groom self.|97
157|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|97
158|2 - Someone must help the patient put on upper body clothing.|2 - Someone must help the patient put on upper body clothing.|97
159|2 - Stage 2|2 - Stage 2|97
160|2 - Start of care - no further visits planned|2 - Start of care - no further visits planned|97
161|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitoring|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitori|97
162|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment regimen.|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment re|97
163|2 - Two|2 - Two|97
164|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistance due to cognitive or mental limitation.|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistanc|97
165|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|97
166|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assistance).|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assis|97
167|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home delivery.|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home deli|97
168|2 - Unable to prepare any light meals or reheat any delivered meals.|2 - Unable to prepare any light meals or reheat any delivered meals.|97
169|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|97
170|2 - UNABLE to take injectable medications unless administered by someone else.|2 - UNABLE to take injectable medications unless administered by someone else.|97
171|2 - UNABLE to take medication unless administered by someone else.|2 - UNABLE to take medication unless administered by someone else.|97
172|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|97
173|2 - Ventilator (continually or at night)|2 - Ventilator (continually or at night)|97
174|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less than 20 feet)|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less th|97
175|2 - With spouse or significant other|2 - With spouse or significant other|97
176|2 - Yes, assistance or services provided by family or friends|2 - Yes, assistance or services provided by family or friends|97
177|2-PT|2-PT|97
178|3 - Able to answer the telephone only some of the time or is able to carry on only a limited conversation.|3 - Able to answer the telephone only some of the time or is able to carry on only a limited convers|97
179|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube or gastrostomy.|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube|97
180|3 - Alcohol dependency|3 - Alcohol dependency|97
181|3 - All of the time|3 - All of the time|97
182|3 - Black or African-American|3 - Black or African-American|97
183|3 - Boarding home or rented room|3 - Boarding home or rented room|97
184|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment, clean/store/dispose of equipment or supplies).|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment,|97
185|3 -Able to walk only with the supervision or assistance of another person at all times.|3 -Able to walk only with the supervision or assistance of another person at all times.|97
186|3 - Continuous / Bi-level positive airway pressure|3 - Continuous / Bi-level positive airway pressure|97
187|3 - During the day and evening, but not constantly|3 - During the day and evening, but not constantly|97
188|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the alimentary canal)|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the|97
189|3 - Environmental support (e.g., housing, home maintenance)|3 - Environmental support (e.g., housing, home maintenance)|97
190|3 - Four to six times weekly|3 - Four to six times weekly|97
191|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessing by listener.  Speech limited to single words or short phrases.|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessin|97
192|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires multiple repetitions, restatements, demonstrations, additional time.|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires m|97
193|3 - Hopelessness|3 - Hopelessness|97
194|3 - Hospice care|3 - Hospice care|97
195|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|97
196|3 - Injury caused by fall or accident at home|3 - Injury caused by fall or accident at home|97
197|3 - Intractable pain|3 - Intractable pain|97
198|3 - Medicaid (traditional fee-for-service)|3 - Medicaid (traditional fee-for-service)|97
199|3 - Needs someone to do all shopping and errands.|3 - Needs someone to do all shopping and errands.|97
200|3 - Not healing|3 - Not healing|97
201|3 - Nursing home|3 - Nursing home|97
202|3 - Once daily|3 - Once daily|97
203|3 - Other family member|3 - Other family member|97
204|3 - Outpatient department/clinic emergency (includes urgicenter sites)|3 - Outpatient department/clinic emergency (includes urgicenter sites)|97
205|3 - Paid help|3 - Paid help|97
206|3 - Able to participate in bathing self in shower or tub, but requires presence of another person throughout the bath for assistance or supervision.|3 - Able to participate in bathing self in shower or tub, but requires presence of another person th|97
207|3 - Patient depends entirely upon another person to dress lower body.|3 - Patient depends entirely upon another person to dress lower body.|97
208|3 - Patient depends entirely upon another person to dress the upper body.|3 - Patient depends entirely upon another person to dress the upper body.|97
209|3 - Patient depends entirely upon someone else for grooming needs.|3 - Patient depends entirely upon someone else for grooming needs.|97
210|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone else to manage the equipment.|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone|97
211|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable to shift attention and recall directions more than half the time.|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable|97
212|3 - Respiratory problems (SOB, infection, obstruction)|3 - Respiratory problems (SOB, infection, obstruction)|97
213|3 - Resumption of care (after inpatient stay)|3 - Resumption of care (after inpatient stay)|97
214|3 - Several times each month|3 - Several times each month|97
215|3 - Skilled Nursing Facility|3 - Skilled Nursing Facility|97
216|3 - Stage 3|3 - Stage 3|97
217|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|97
218|3 - Three|3 - Three|97
219|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person throughout the process.|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person through|97
220|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal independently.|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal indep|97
221|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person.|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person|97
222|3 - Unknown because patient moved to a geographic location not served by this agency|3 - Unknown because patient moved to a geographic location not served by this agency|97
223|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|97
224|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|97
225|3 - With other family member|3 - With other family member|97
226|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home health services, homemaker assistance, transportation assistance, assisted living, board and care)|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home h|97
227|3-SLP/ST|3-SLP/ST|97
228|4 - At rest (during day or night)|4 - At rest (during day or night)|97
229|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|97
230|4 - Board and care or assisted living facility|4 - Board and care or assisted living facility|97
231|4 - Caregiver is completely dependent on someone else to manage all equipment.|4 - Caregiver is completely dependent on someone else to manage all equipment.|97
232|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|97
233|4 - Constantly|4 - Constantly|97
234|4 - Drug dependency|4 - Drug dependency|97
235|4 - Four or more|4 - Four or more|97
236|4 - Friend or neighbor or community or church member|4 - Friend or neighbor or community or church member|97
237|4 - Hispanic or Latino|4 - Hispanic or Latino|97
238|4 - Hospice|4 - Hospice|97
239|4 - Impaired decision-making|4 - Impaired decision-making|97
240|4 - Is totally dependent in toileting.|4 - Is totally dependent in toileting.|97
241|4 - Medicaid (HMO/managed care)|4 - Medicaid (HMO/managed care)|97
242|4 - None of the above|4 - None of the above|97
243|4 - Nursing home|4 - Nursing home|97
244|4 - On a daily basis|4 - On a daily basis|97
245|4 - Patient is completely dependent on someone else to manage all equipment.|4 - Patient is completely dependent on someone else to manage all equipment.|97
246|4 - Permanent placement|4 - Permanent placement|97
247|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, punches, dangerous maneuvers w/ wheelchair or other objects)|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, pu|97
248|4 - Psychosocial support (e.g., socialization, companionship, recreation)|4 - Psychosocial support (e.g., socialization, companionship, recreation)|97
249|4 - Recertification (follow-up) reassessment|4 - Recertification (follow-up) reassessment|97
250|4 - Recurrent thoughts of death|4 - Recurrent thoughts of death|97
251|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruction)|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruc|97
252|4 - Several times a week|4 - Several times a week|97
253|4 - Stage 4|4 - Stage 4|97
254|4 - Symptoms poorly controlled, history of rehospitalizations|4 - Symptoms poorly controlled, history of rehospitalizations|97
255|4 - Three or more times per week|4 - Three or more times per week|97
256|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetative state, or delirium.|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetati|97
257|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|97
258|4 - Unable to effectively participate in any housekeeping tasks.|4 - Unable to effectively participate in any housekeeping tasks.|97
259|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or unresponsive (e.g., speech is nonsensical or unintelligible).|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or u|97
260|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonresponsive.|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonr|97
261|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostomy.|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostom|97
262|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of devices at the sink, in chair, or on commode|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of|97
263|4 - With a friend|4 - With a friend|97
264|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|97
265|4-OT|4-OT|97
266|5 - Advocates or facilitates patient's participation in appropriate medical care|5 - Advocates or facilitates patient's participation in appropriate medical care|97
267|5 - At least daily|5 - At least daily|97
268|6 - Bedfast, unable to ambulate or be up in a chair.|6 - Bedfast, unable to ambulate or be up in a chair.|97
269|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|97
270|5 - Disruptive or socially inappropriate behavior|5 - Disruptive or socially inappropriate behavior|97
271|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|97
272|5 - Hypo/Hyperglycemia, diabetes out of control|5 - Hypo/Hyperglycemia, diabetes out of control|97
273|5 - More often than once daily|5 - More often than once daily|97
274|5 - Native Hawaiian or Pacific Islander|5 - Native Hawaiian or Pacific Islander|97
275|5 - None of the above|5 - None of the above|97
276|5 - One to two times per week|5 - One to two times per week|97
277|5 - Other|5 - Other|97
278|5 - Other follow-up|5 - Other follow-up|97
279|5 - Paid help|5 - Paid help|97
280|5 - Patient nonresponsive or unable to speak.|5 - Patient nonresponsive or unable to speak.|97
281|5 - Thoughts of suicide|5 - Thoughts of suicide|97
282|5 - Totally unable to use the telephone.|5 - Totally unable to use the telephone.|97
283|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|97
284|5 - Unable to take in nutrients orally or by tube feeding.|5 - Unable to take in nutrients orally or by tube feeding.|97
285|5 - Unsafe for care at home|5 - Unsafe for care at home|97
286|5 - With paid help (other than home care agency staff)|5 - With paid help (other than home care agency staff)|97
287|5 - Workers' compensation|5 - Workers' compensation|97
288|5 - Wound infection, deteriorating wound status, new lesion/ulcer|5 - Wound infection, deteriorating wound status, new lesion/ulcer|97
289|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|97
290|6 - Delusional, hallucinatory, or paranoid behavior|6 - Delusional, hallucinatory, or paranoid behavior|97
291|6 - Financial agent, power of attorney, or conservator of finance|6 - Financial agent, power of attorney, or conservator of finance|97
292|6 - GI bleeding, obstruction|6 - GI bleeding, obstruction|97
293|6 - Less often than weekly|6 - Less often than weekly|97
294|6 - Memory loss to the extent that supervision required|6 - Memory loss to the extent that supervision required|97
295|6 - None of the above feelings observed or reported|6 - None of the above feelings observed or reported|97
296|6 - Other|6 - Other|97
297|6 - Title programs (e.g., Title III, V, or XX)|6 - Title programs (e.g., Title III, V, or XX)|97
298|6 - Transferred to an inpatient facility - patient not discharged from agency|6 - Transferred to an inpatient facility - patient not discharged from agency|97
299|6 - White|6 - White|97
300|6 - With other than above|6 - With other than above|97
301|7 - Exacerbation of CHF, fluid overload, heart failure|7 - Exacerbation of CHF, fluid overload, heart failure|97
302|7 - Health care agent, conservator of person, or medical power of attorney|7 - Health care agent, conservator of person, or medical power of attorney|97
303|7 - Hypo/Hyperglycemia, diabetes out of control|7 - Hypo/Hyperglycemia, diabetes out of control|97
304|7 - None of the above|7 - None of the above|97
305|7 - None of the above behaviors demonstrated|7 - None of the above behaviors demonstrated|97
306|7 - Other government (e.g., TriCare, VA, etc.)|7 - Other government (e.g., TriCare, VA, etc.)|97
307|7 - Transferred to an inpatient facility - patient discharged from agency|7 - Transferred to an inpatient facility - patient discharged from agency|97
308|8 - Death at home|8 - Death at home|97
309|8 - GI bleeding, obstruction|8 - GI bleeding, obstruction|97
310|8 - Myocardial infarction, stroke|8 - Myocardial infarction, stroke|97
311|8 - Private insurance|8 - Private insurance|97
312|9 - Chemotherapy|9 - Chemotherapy|97
313|9 - Discharge from agency|9 - Discharge from agency|97
314|9 - Other than above reasons|9 - Other than above reasons|97
315|9 - Private HMO/managed care|9 - Private HMO/managed care|97
316|NA - No caregiver|NA - No caregiver|97
317|NA - No equipment of this type used in care.|NA - No equipment of this type used in care.|97
318|NA - No inhalant/mist medications prescribed.|NA - No inhalant/mist medications prescribed.|97
319|NA - No injectable medications prescribed.|NA - No injectable medications prescribed.|97
320|NA - No inpatient facility admission|NA - No inpatient facility admission|97
321|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|97
322|NA - No Medicaid|NA - No Medicaid|97
323|NA - No Medicare|NA - No Medicare|97
324|NA - No observable pressure ulcer or unhealed pressure ulcer|NA - No observable pressure ulcer or unhealed pressure ulcer|97
325|NA - No observable stasis ulcer|NA - No observable stasis ulcer|97
326|NA - No observable surgical wound|NA - No observable surgical wound|97
327|NA - No oral medications prescribed.|NA - No oral medications prescribed.|97
328|NA - Not applicable|NA - Not applicable|97
329|NA - Patient does not have a telephone.|NA - Patient does not have a telephone.|97
330|NA - Patient has ostomy for bowel elimination|NA - Patient has ostomy for bowel elimination|97
331|NA - Patient nonresponsive|NA - Patient nonresponsive|97
332|NA - Patient on prophylactic treatment|NA - Patient on prophylactic treatment|97
333|NA - Patient was not discharged from an inpatient facility [Go to M1017]|NA - Patient was not discharged from an inpatient facility [Go to M1017]|97
334|UK - Other unknown|UK - Other unknown|97
335|UK - Reason unknown|UK - Reason unknown|97
336|UK - Unknown|UK - Unknown|97
337|UK - Unknown or Not Available|UK - Unknown or Not Available|97
341|01 - Early|01 - Early|97
342|02 - Late|02 - Late|97
343|NA - Not Applicable. No case mix group defined for this assessment.|NA - Not Applicable. No case mix group defined for this assessment.|97
344|NA - No case mix group defined by this assessment.|NA - No case mix group defined by this assessment.|97
345|1 - Recent decline in mental, emotional, or behavioral status|1 - Recent decline in mental, emotional, or behavioral status|97
346|2 - Multiple hospitalizations (2 or more) in the past 12 months|2 - Multiple hospitalizations (2 or more) in the past 12 months|97
347|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|97
348|4 - Taking five or more medications|4 - Taking five or more medications|97
349|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|97
350|6 - Other|6 - Other|97
351|7 - None of the above|7 - None of the above|97
352|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond tho|97
353|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable without heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable wi|97
354|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious complications and death.|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious compl|97
355|3 - The patient has serious progressive conditions that could lead to death within a year.|3 - The patient has serious progressive conditions that could lead to death within a year.|97
356|UK - The patient+s situation is unknown or unclear.|UK - The patient+s situation is unknown or unclear.|97
357|0 - No [ Go to M1051 ]|0 - No [ Go to M1051 ]|97
358|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this influenza season. [ Go to M1050 ]|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this i|97
359|1 - Received from another health care provider (e.g., physician)|1 - Received from another health care provider (e.g., physician)|97
360|2 - Received from your agency previously during this year+s flu season|2 - Received from your agency previously during this year+s flu season|97
361|3 - Offered and declined|3 - Offered and declined|97
362|4 - Assessed and determined to have medical contraindication(s)|4 - Assessed and determined to have medical contraindication(s)|97
363|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|97
364|6 - Inability to obtain vaccine due to declared shortage|6 - Inability to obtain vaccine due to declared shortage|97
365|1 - Yes [ Go to M2005 at TRN; Go to M1230 at DC ]|1 - Yes [ Go to M2005 at TRN; Go to M1230 at DC ]|97
366|1 - Patient has received PPV in the past|1 - Patient has received PPV in the past|97
367|2 - Offered and declined|2 - Offered and declined|97
368|3 - Assessed and determined to have medical contraindication(s)|3 - Assessed and determined to have medical contraindication(s)|97
369|4 - Not indicated; patient does not meet age/condition guidelines for PPV|4 - Not indicated; patient does not meet age/condition guidelines for PPV|97
370|5 - None of the above|5 - None of the above|97
371|0 - Adequate: hears normal conversation without difficulty.|0 - Adequate: hears normal conversation without difficulty.|97
372|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to increase volume or speak distinctly.|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to in|97
373|2 - Severely Impaired: absence of useful hearing.|2 - Severely Impaired: absence of useful hearing.|97
374|UK - Unable to assess hearing.|UK - Unable to assess hearing.|97
375|0 - Understands: clear comprehension without cues or repetitions.|0 - Understands: clear comprehension without cues or repetitions.|97
376|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Requires cues at times to understand.|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Req|97
377|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequently requires cues to understand.|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequentl|97
378|3 - Rarely/Never Understands|3 - Rarely/Never Understands|97
379|UK - Unable to assess understanding.|UK - Unable to assess understanding.|97
380|0 - No standardized assessment conducted|0 - No standardized assessment conducted|97
381|1 - Yes, and it does not indicate severe pain|1 - Yes, and it does not indicate severe pain|97
382|2 - Yes, and it indicates severe pain|2 - Yes, and it indicates severe pain|97
383|0 - Patient has no pain|0 - Patient has no pain|97
384|1 - Patient has pain that does not interfere with activity or movement|1 - Patient has pain that does not interfere with activity or movement|97
385|2 - Less often than daily|2 - Less often than daily|97
386|3 - Daily, but not constantly|3 - Daily, but not constantly|97
387|4 - All of the time|4 - All of the time|97
388|0 - No assessment conducted [ Go to M1306 ]|0 - No assessment conducted [ Go to M1306 ]|97
389|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc., without use of standardized tool|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc.,|97
390|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|97
391|0 - No [ Go to M1322]|0 - No [ Go to M1322]|97
392|0 v Newly epithelialized|0 v Newly epithelialized|97
393|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|97
394|2 - Yes, patient has observable stasis ulcers ONLY|2 - Yes, patient has observable stasis ulcers ONLY|97
395|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable dressing) [Go to M1340]|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable|97
396|0 - No [ Go to M1350 ]|0 - No [ Go to M1350 ]|97
397|1 - Yes, patient has at least one (observable) surgical wound|1 - Yes, patient has at least one (observable) surgical wound|97
398|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1350 ]|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1350 ]|97
399|0 - Patient is not short of breath|0 - Patient is not short of breath|97
400|3 - Continuous Bi-level positive airway pressure|3 - Continuous Bi-level positive airway pressure|97
401|0 - No [ Go to M2005 at TRN; Go to M1600 at DC ]|0 - No [ Go to M2005 at TRN; Go to M1600 at DC ]|97
402|2 - Not assessed [Go to M2005 at TRN; Go to M1600 at DC ]|2 - Not assessed [Go to M2005 at TRN; Go to M1600 at DC ]|97
403|NA - Patient does not have diagnosis of heart failure [Go to M2005 at TRN; Go to M1600 at DC]|NA - Patient does not have diagnosis of heart failure [Go to M2005 at TRN; Go to M1600 at DC]|97
404|0 - No action taken|0 - No action taken|97
405|1 - Patient+s physician (or other primary care practitioner) contacted the same day|1 - Patient+s physician (or other primary care practitioner) contacted the same day|97
406|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|97
407|3 - Implement physician-ordered patient-specific established parameters for treatment|3 - Implement physician-ordered patient-specific established parameters for treatment|97
408|4 - Patient education or other clinical interventions|4 - Patient education or other clinical interventions|97
409|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequency, telehealth, etc.)|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequ|97
410|1 - Occasional stress incontinence|1 - Occasional stress incontinence|97
411|2 - During the night only|2 - During the night only|97
412|3 - During the day only|3 - During the day only|97
413|4 - During the day and night|4 - During the day and night|97
414|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|97
415|0 - Able to manage toileting hygiene and clothing management without assistance.|0 - Able to manage toileting hygiene and clothing management without assistance.|97
416|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implements are laid out for the patient.|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implemen|97
417|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|97
418|3 - Patient depends entirely upon another person to maintain toileting hygiene.|3 - Patient depends entirely upon another person to maintain toileting hygiene.|97
419|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independent|97
420|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface|97
421|0 - No multi-factor falls risk assessment conducted.|0 - No multi-factor falls risk assessment conducted.|97
422|1 - Yes, and it does not indicate a risk for falls.|1 - Yes, and it does not indicate a risk for falls.|97
423|2 - Yes, and it indicates a risk for falls.|2 - Yes, and it indicates a risk for falls.|97
424|0 - Not assessed/reviewed [ Go to M2010 ]|0 - Not assessed/reviewed [ Go to M2010 ]|97
425|1 - No problems found during review [ Go to M2010 ]|1 - No problems found during review [ Go to M2010 ]|97
426|2 - Problems found during review|2 - Problems found during review|97
427|NA - Patient is not taking any medications [ Go to M2040 ]|NA - Patient is not taking any medications [ Go to M2040 ]|97
428|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special precautions associated with all high-risk medications|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special p|97
429|NA - Patient not taking any drugs|NA - Patient not taking any drugs|97
430|2 - Able to take medication(s) at the correct times if given reminders by another person at the appropriate times|2 - Able to take medication(s) at the correct times if given reminders by another person at the appr|97
431|3 - Unable to take medication unless administered by another person.|3 - Unable to take medication unless administered by another person.|97
432|1 - At least daily|1 - At least daily|97
433|2 - Three or more times per week|2 - Three or more times per week|97
434|3 - One to two times per week|3 - One to two times per week|97
435|4 - Received, but less often than weekly|4 - Received, but less often than weekly|97
436|5 - No assistance received|5 - No assistance received|97
437|0 - No [Go to M2401]|0 - No [Go to M2401]|97
438|1 - Yes, used hospital emergency department WITHOUT hospital admission|1 - Yes, used hospital emergency department WITHOUT hospital admission|97
439|2 - Yes, used hospital emergency department WITH hospital admission|2 - Yes, used hospital emergency department WITH hospital admission|97
440|UK - Unknown [Go to M2401]|UK - Unknown [Go to M2401]|97
441|2 - Injury caused by fall|2 - Injury caused by fall|97
442|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|97
443|4 - Other respiratory problem|4 - Other respiratory problem|97
444|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|97
445|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|97
446|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|97
447|8 - Other heart disease|8 - Other heart disease|97
448|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|97
449|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|97
450|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|97
451|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|97
452|13 - Urinary tract infection|13 - Urinary tract infection|97
453|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|97
454|15 - Wound infection or deterioration|15 - Wound infection or deterioration|97
455|16 - Uncontrolled pain|16 - Uncontrolled pain|97
456|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|97
457|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|97
458|19 - Other than above reasons|19 - Other than above reasons|97
459|2 - Patient remained in the community (with formal assistive services)|2 - Patient remained in the community (with formal assistive services)|97
460|3 - Patient transferred to a noninstitutional hospice|3 - Patient transferred to a noninstitutional hospice|97
461|4 - Unknown because patient moved to a geographic location not served by this agency|4 - Unknown because patient moved to a geographic location not served by this agency|97
462|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|97
463|4 - Other respiratory problem|4 - Other respiratory problem|97
464|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|97
465|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|97
466|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|97
467|8 - Other heart disease|8 - Other heart disease|97
468|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|97
469|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|97
470|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|97
471|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|97
472|13 - Urinary tract infection|13 - Urinary tract infection|97
473|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|97
474|15 - Wound infection or deterioration|15 - Wound infection or deterioration|97
475|16 - Uncontrolled pain|16 - Uncontrolled pain|97
476|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|97
477|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|97
478|19 - Scheduled treatment or procedure|19 - Scheduled treatment or procedure|97
479|20 - Other than above reasons|20 - Other than above reasons|97
480|UK - Reason unknown [Go to M0903]|UK - Reason unknown [Go to M0903]|97
482|01 - Patient lives alone around the clock|01 - Patient lives alone around the clock|97
483|02 - Patient lives alone regular daytime|02 - Patient lives alone regular daytime|97
484|03 - Patient lives alone regular nighttime|03 - Patient lives alone regular nighttime|97
485|04 - Patient lives alone occassional/short term assistance|04 - Patient lives alone occassional/short term assistance|97
486|05 - Patient lives alone no assisstance available|05 - Patient lives alone no assisstance available|97
487|06 - Patient lives with other person(s) in the home around the clock|06 - Patient lives with other person(s) in the home around the clock|97
488|07 - Patient lives with other person(s) in the home regular daytime|07 - Patient lives with other person(s) in the home regular daytime|97
489|08 - Patient lives with other person(s) in the home regular nighttime|08 - Patient lives with other person(s) in the home regular nighttime|97
490|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|97
491|10 - Patient lives with other person(s) in the home no assistance available|10 - Patient lives with other person(s) in the home no assistance available|97
492|1 - Was present at the most recent SOC/ROC assessment|1 - Was present at the most recent SOC/ROC assessment|97
493|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|97
494|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|97
495|0 - Newly epithelialized|0 - Newly epithelialized|97
496|0 - No [ Go to M1340 ]|0 - No [ Go to M1340 ]|97
498|0 - Independent|0 - Independent|97
499|1 - Needed Some Help|1 - Needed Some Help|97
500|2 - Dependent|2 - Dependent|97
502|0 - No assistance needed in this area|0 - No assistance needed in this area|97
503|1 - Caregiver(s) currently provide assistance|1 - Caregiver(s) currently provide assistance|97
504|2 - Caregiver(s) need training/ supportive services to provide assistance|2 - Caregiver(s) need training/ supportive services to provide assistance|97
505|3 - Caregiver(s) not likely to provide assistance|3 - Caregiver(s) not likely to provide assistance|97
506|4 - Unclear if Caregiver(s) will provide assistance|4 - Unclear if Caregiver(s) will provide assistance|97
507|5 - Assistance needed, but no Caregiver(s) available|5 - Assistance needed, but no Caregiver(s) available|97
508|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will use standardized clinical guidelines accessible for all care providers to reference|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will|97
510|NA - Patient is not assessed to be at risk for falls|NA - Patient is not assessed to be at risk for falls|97
511|NA - Patient has no diagnosis or symptoms of depression|NA - Patient has no diagnosis or symptoms of depression|97
512|NA - No pain identified|NA - No pain identified|97
513|NA - Patient is not assessed to be at risk for pressure ulcers|NA - Patient is not assessed to be at risk for pressure ulcers|97
514|NA - Patient has no pressure ulcers with need for moist wound healing|NA - Patient has no pressure ulcers with need for moist wound healing|97
515|1 - Long-term nursing facility (NF)|1 - Long-term nursing facility (NF)|97
516|2 - Skilled nursing facility (SNF / TCU)|2 - Skilled nursing facility (SNF / TCU)|97
517|3 - Short stay acute hospital (IPP S)|3 - Short stay acute hospital (IPP S)|97
518|4 - Long-term care hospital (LTCH)|4 - Long-term care hospital (LTCH)|97
519|5 - Inpatient rehabilitation hospital or unit (IRF)|5 - Inpatient rehabilitation hospital or unit (IRF)|97
520|6 - Psychiatric hospital or unit|6 - Psychiatric hospital or unit|97
521|7 - Other|7 - Other|97
522|NA - Patient was not discharged from an inpatient facility [Go to M1017]|NA - Patient was not discharged from an inpatient facility [Go to M1017]|97
523|6 - Unable to participate effectively in bathing and is bathed totally by another person|6 - Unable to participate effectively in bathing and is bathed totally by another person|97
524|4 - Chairfast, unable to ambulate but is able to wheel self independently.|4 - Chairfast, unable to ambulate but is able to wheel self independently.|97
525|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask patient: "Over the last two weeks, how often have you been bothered by any of the following problems")|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask|97
526|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluation for depression.|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluat|97
527|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet criteria for further evaluation for depression.|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet|97
528|0 - Not at all  0 - 1 day|0 - Not at all  0 - 1 day|97
529|1 - Several days  2 - 6 days|1 - Several days  2 - 6 days|97
530|2 - More than half of the days  7 - 11 days|2 - More than half of the days  7 - 11 days|97
531|3 - Nearly every day  12 - 14 days|3 - Nearly every day  12 - 14 days|97
532|NA - N/A  Unable to respond|NA - N/A  Unable to respond|97
533|2 - Able to take medication(s) at the correct times if given reminders by another person based on the frequency of the injection|2 - Able to take medication(s) at the correct times if given reminders by another person based on th|97
534|3 - Unable to take injectable medication unless administered by another person.|3 - Unable to take injectable medication unless administered by another person.|97
547|NA - There were no potential clinically significant medication issues identified since SOC/ROC or patient is not taking any medications|NA v There were no potential clinically significant medication issues identified since SOC/ROC |97
552|1 - Hospital|1 - Hospital [ Go to M2430 ]|97
553|2 - Rehabilitation facility |2 - Rehabilitation facility [ Go to M0903 ]|97
554|3 - Nursing home|3 - Nursing home [ Go to M2440 ]|97
555|4 - Hospice|4 - Hospice [ Go to M0903 ]|97
564|NA - Patient is not diabetic or is bilateral amputee|NA - Patient is not diabetic or is bilateral amputee|97
565|NA - Every standardized,validated multifactor fall risk assessment conducted at or since the most recent SOC/ROC assessment indicates the patient has no risk for falls.|NA - Every standardized,validated multifactor fall risk assessment condition|97
566|NA - Patient has no diagnosis of depression AND every standardized, validated depression screening conducted at or since the most recent SOC/ROC assessment indicates the patient has: 1) no symptoms of depression; or 2) has some symptoms of depression but does not meet criteria for further evaluation of depression based on screening tool used.|NA - Patient has no diagnosis of depression AND every standardized, validated |97
567|NA - Every standardized, validated pain assessment conducted at or since the most recent SOC/ROC assessment indicates the patient has no pain.|NA - Every standardized, validated pain assessment conducted at or since the most|97
568|NA - Every standardized, validated pressure ulcer risk assessment conducted at or since the most recent SOC/ROC assessment indicates the patient is not at risk of developing pressure ulcers.|NA - Every standardized, validated pressure ulcer risk assessment conducted|97
569|NA - Dressings that support the principles of moist wound healing not indicated for this patient's pressure ulcers OR patient has no pressure ulcers with need for moist wound healing|NA - Dressings that support the principles of moist wound healing not indicated for this patient's p|97
620|1 - Yes; received from your agency during this episode of care (SOC/ROC to Transfer/Discharge)|1 - Yes; received from your agency during this episode of care (SOC/ROC to Transfer/Discharge)|97
621|2 - Yes; received from your agency during a prior episode of care (SOC/ROC to Transfer/Discharge)|2 - Yes; received from your agency during a prior episode of care (SOC/ROC to Transfer/Discharge)|97
622|3 - Yes; received from another health care provider (for example physician pharmacist)|3 - Yes; received from another health care provider (for example physician pharmacist)|97
623|4 - No; patient offered and declined |4 - No; patient offered and declined |97
624|5 - No; patient assessed and determined to have medical contraindication(s)|5 - No; patient assessed and determined to have medical contraindication(s)|97
625|6 - No; not indicated - patient does not meet age/condition guidelines for influenza vaccine|6 - No; not indicated - patient does not meet age/condition guidelines for influenza vaccine|97
626|7 - No; inability to obtain vaccine due to declared shortage |7 - No; inability to obtain vaccine due to declared shortage |97
627|8 - No; patient did not receive the vaccine due to reasons other than those listed in responses 4 v 7. |8 - No; patient did not receive the vaccine due to reasons other than those listed in responses 4v7.|97
628|1 - Offered and declined|1 - Offered and declined|97
629|2 - Assessed and determined to have medical contraindication(s) |2 - Assessed and determined to have medical contraindication(s) |97
630|3 - Not indicated; patient does not meet age/condition guidelines for Pneumococcal Vaccine|3 - Not indicated; patient does not meet age/condition guidelines for Pneumococcal Vaccine|97
631|4 - None of the above|4 - None of the above|97
47|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or supervision from another person OR c) a liquid, pureed or ground meat diet.|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or su|98
2|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; OR (b) Is physically, cognitively, and mentally able to prepare light meals on a regular basis but has not routinely performed light meal preparation in the past (i.e., prior to this home care admission).|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; O|98
3|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and mentally able to perform all housekeeping tasks .|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and menta|98
4|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and mentally able to do laundry and access facilities.|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and menta|98
5|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying packages OR b) Physically, cognitively, and mentally able to take care of shopping, but has not done shopping in the past (i.e., prior to this home care admission).|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying|98
6|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|98
7|0 - Able to dial numbers and answer calls appropriately and as desired.|0 - Able to dial numbers and answer calls appropriately and as desired.|98
8|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body without assistance.|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body|98
9|0 - Able to get to and from the toilet and transfer independently with or without a device.|0 - Able to get to and from the toilet and transfer independently with or without a device.|98
10|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|98
11|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible public bus.|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible p|98
12|0 - Able to independently feed self.|0 - Able to independently feed self.|98
13|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|98
14|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct times.|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct ti|98
15|0 - Able to independently transfer.|0 - Able to independently transfer.|98
16|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without rail|98
17|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings|98
18|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|98
19|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions independently.|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions indep|98
20|0 - Asymptomatic, no treatment needed at this time|0 - Asymptomatic, no treatment needed at this time|98
21|0 - Caregiver manages all tasks related to equipment completely independently.|0 - Caregiver manages all tasks related to equipment completely independently.|98
22|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations with no observable impairment.|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations w|98
23|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|98
24|0 - Life expectancy is greater than 6 months|0 - Life expectancy is greater than 6 months|98
25|0 - Never|0 - Never|98
26|0 - Patient is not short of breath|0 - Patient is not short of breath|98
27|0 - No|0 - No|98
28|0 - No emergent care services|0 - No emergent care services|98
29|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [Goto 1620]|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [Goto 1620]|98
30|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and extended or abstract conversation.|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and exte|98
31|0 - No one person|0 - No one person|98
32|0 - None of the time|0 - None of the time|98
33|0 - None, no charge for current services|0 - None, no charge for current services|98
34|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|98
35|0 - Patient does NOT have an ostomy for bowel elimination.|0 - Patient does NOT have an ostomy for bowel elimination.|98
36|0 - Patient has no pain|0 - Patient has no pain|98
37|0 - Patient manages all tasks related to equipment completely independently.|0 - Patient manages all tasks related to equipment completely independently.|98
38|0 - Poor:  little or no recovery is expected and/or further decline is imminent|0 - Poor:  little or no recovery is expected and/or further decline is imminent|98
39|0 - Timed-voiding defers incontinence|0 - Timed-voiding defers incontinence|98
40|0 - Very rarely or never has bowel incontinence|0 - Very rarely or never has bowel incontinence|98
41|0 - Zero|0 - Zero|98
42|00 - No|00 - No|98
43|01 - Yes|01 - Yes|98
44|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or mental limitations, needs assistance with heavy laundry.|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or|98
45|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the patient.|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the|98
46|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|98
48|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|98
49|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|98
50|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independently.|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independe|98
51|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only when assisted or accompanied by another person.|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only w|98
52|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepa|98
53|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance by another person OR b) given daily reminders.|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance b|98
54|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advan|98
55|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advan|98
56|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for the deaf) and call essential numbers.|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for t|98
57|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|98
58|1 - American Indian or Alaska Native|1 - American Indian or Alaska Native|98
59|1 - Depressed mood (e.g., feeling sad, tearful)|1 - Depressed mood (e.g., feeling sad, tearful)|98
60|1 - During the night only|1 - During the night only|98
61|1 - Fully granulating|1 - Fully granulating|98
62|1 - Good/Fair:  partial to full recovery is expected|1 - Good/Fair:  partial to full recovery is expected|98
63|1 - Good:  marked improvement in functional status is expected|1 - Good:  marked improvement in functional status is expected|98
64|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|98
65|1 - Smoking|1 - Smoking|98
66|1 - Hospital|1 - Hospital|98
67|1 - Hospital emergency room (includes 23-hour holding)|1 - Hospital emergency room (includes 23-hour holding)|98
68|1 - Hospitalization for EMERGENT (unscheduled) care|1 - Hospitalization for EMERGENT (unscheduled) care|98
69|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepared solutions), patient is able to manage all other aspects of equipment.|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepar|98
70|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|98
71|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|98
72|1 - In new or complex situations only|1 - In new or complex situations only|98
73|1 - Intravenous or infusion therapy (excludes TPN)|1 - Intravenous or infusion therapy (excludes TPN)|98
74|1 - Less often than daily|1 - Less often than daily|98
75|1 - Less than once a month|1 - Less than once a month|98
76|1 - Less than once weekly|1 - Less than once weekly|98
77|1 - Life expectancy is 6 months or fewer|1 - Life expectancy is 6 months or fewer|98
78|1 - Lives alone|1 - Lives alone|98
79|1 - Male|1 - Male|98
80|1 - Medicare (traditional fee-for-service)|1 - Medicare (traditional fee-for-service)|98
81|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of past 24 hours, significant memory loss so that supervision is required|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of pas|98
82|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors in word choice, grammar or speech intelligibility, needs minimal prompting or assistance).|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors i|98
83|1 - No assistance or services received|1 - No assistance or services received|98
84|1 - One|1 - One|98
85|1 - Oxygen (intermittent or continuous)|1 - Oxygen (intermittent or continuous)|98
86|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, and the surrounding layout, can count fingers at arm's length.|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, a|98
87|1 - Patient is incontinent|1 - Patient is incontinent|98
88|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|98
89|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical or treatment regimen.|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical|98
90|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient/couple/significant other)|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient|98
91|1 - Relatives, friends, or neighbors living outside the home|1 - Relatives, friends, or neighbors living outside the home|98
92|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions.|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions|98
93|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independentl|98
94|1 - Several times during day and night|1 - Several times during day and night|98
95|1 - Spouse or significant other|1 - Spouse or significant other|98
96|1 - Stage 1|1 - Stage 1|98
97|1 - Start of care - further visits planned|1 - Start of care - further visits planned|98
98|1 - Symptoms well controlled with current therapy|1 - Symptoms well controlled with current therapy|98
99|1 - Therapy services|1 - Therapy services|98
100|1 - Able to transfer with minimal human assistance or with use of an assistive device.|1 - Able to transfer with minimal human assistance or with use of an assistive device.|98
101|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitations.|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitatio|98
102|1 - Urinary incontinence|1 - Urinary incontinence|98
103|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and transfer.|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and|98
104|1 - When walking more than 20 feet, climbing stairs|1 - When walking more than 20 feet, climbing stairs|98
105|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary conversation. May need occasional repetition, extra time, or louder voice.|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary c|98
106|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting in and out of tub/shower|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting|98
107|1 - Yes|1 - Yes|98
108|1-RN|1-RN|98
109|10 - Discharge from agency - no visits completed after start/resumption of care assessment|10 - Discharge from agency - no visits completed after start/resumption of care assessment|98
110|10 - Scheduled surgical procedure|10 - Scheduled surgical procedure|98
111|10 - Self-pay|10 - Self-pay|98
112|11 - Other|11 - Other|98
113|11 - Urinary tract infection|11 - Urinary tract infection|98
114|12 - IV catheter-related infection|12 - IV catheter-related infection|98
115|13 - Deep vein thrombosis, pulmonary embolus|13 - Deep vein thrombosis, pulmonary embolus|98
116|14 - Uncontrolled pain|14 - Uncontrolled pain|98
117|15 - Psychotic episode|15 - Psychotic episode|98
118|16 - Other than above reasons|16 - Other than above reasons|98
119|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing calls.|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing|98
120|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another person.|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another pers|98
121|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface a|98
122|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for intermittent supervision or encouragement or reminders, OR (b) to get in and out of the shower or tub, OR (c) for washing difficult to reach areas.|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for inter|98
123|2 - Asian|2 - Asian|98
124|2 - Caregiver requires considerable assistance from another person to manage equipment, but independently completes significant portions of task.|2 - Caregiver requires considerable assistance from another person to manage equipment, but independ|98
125|2 - Daily, but not constantly|2 - Daily, but not constantly|98
126|2 - Daughter or son|2 - Daughter or son|98
127|2 - Doctor's office emergency visit/house call|2 - Doctor's office emergency visit/house call|98
128|2 - During the day and night|2 - During the day and night|98
129|2 - Early/partial granulation|2 - Early/partial granulation|98
130|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors in word choice, organization or speech intelligibility). Speaks in phrases or short sentences.|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors|98
131|2 - Family member's residence|2 - Family member's residence|98
132|2 - Female|2 - Female|98
133|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conversation, needs frequent prompting or assistance.|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conver|98
134|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|98
135|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|98
136|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately stop activities, jeopardizes safety through actions|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately st|98
137|2 - Indwelling/suprapubic catheter|2 - Indwelling/suprapubic catheter|98
138|2 - Injury caused by fall or accident at home|2 - Injury caused by fall or accident at home|98
139|2 - Medicare (HMO/managed care/Advantage plan)|2 - Medicare (HMO/managed care/Advantage plan)|98
140|2 - Nausea, dehydration, malnutrition, constipation, impaction|2 - Nausea, dehydration, malnutrition, constipation, impaction|98
141|2 - Obesity|2 - Obesity|98
142|2 - On awakening or at night only|2 - On awakening or at night only|98
143|2 - Once a month|2 - Once a month|98
144|2 - One to three times weekly|2 - One to three times weekly|98
145|2 - Parenteral nutrition (TPN or lipids)|2 - Parenteral nutrition (TPN or lipids)|98
146|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic) [ Go to M1620]|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic) [ Go|98
147|2 - Patient requires considerable assistance from another person to manage equipment, but independently completes portions of the task.|2 - Patient requires considerable assistance from another person to manage equipment, but independen|98
148|2 - Patient transferred to a noninstitutional hospice|2 - Patient transferred to a noninstitutional hospice|98
149|2 - Person residing in the home (EXCLUDING paid help)|2 - Person residing in the home (EXCLUDING paid help)|98
150|2 - Rehabilitation facility|2 - Rehabilitation facility|98
151|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifting of attention) or consistently requires low stimulus environment due to distractibility.|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifti|98
152|2 - Respite care|2 - Respite care|98
153|2 - Sense of failure or self reproach|2 - Sense of failure or self reproach|98
154|2 - Several times during day|2 - Several times during day|98
155|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonresponsive.|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonrespons|98
156|2 - Someone must assist the patient to groom self.|2 - Someone must assist the patient to groom self.|98
157|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|98
158|2 - Someone must help the patient put on upper body clothing.|2 - Someone must help the patient put on upper body clothing.|98
159|2 - Stage 2|2 - Stage 2|98
160|2 - Start of care - no further visits planned|2 - Start of care - no further visits planned|98
161|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitoring|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitori|98
162|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment regimen.|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment re|98
163|2 - Two|2 - Two|98
164|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistance due to cognitive or mental limitation.|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistanc|98
165|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|98
166|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assistance).|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assis|98
167|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home delivery.|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home deli|98
168|2 - Unable to prepare any light meals or reheat any delivered meals.|2 - Unable to prepare any light meals or reheat any delivered meals.|98
169|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|98
170|2 - UNABLE to take injectable medications unless administered by someone else.|2 - UNABLE to take injectable medications unless administered by someone else.|98
171|2 - UNABLE to take medication unless administered by someone else.|2 - UNABLE to take medication unless administered by someone else.|98
172|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|98
173|2 - Ventilator (continually or at night)|2 - Ventilator (continually or at night)|98
174|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less than 20 feet)|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less th|98
175|2 - With spouse or significant other|2 - With spouse or significant other|98
176|2 - Yes, assistance or services provided by family or friends|2 - Yes, assistance or services provided by family or friends|98
177|2-PT|2-PT|98
178|3 - Able to answer the telephone only some of the time or is able to carry on only a limited conversation.|3 - Able to answer the telephone only some of the time or is able to carry on only a limited convers|98
179|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube or gastrostomy.|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube|98
180|3 - Alcohol dependency|3 - Alcohol dependency|98
181|3 - All of the time|3 - All of the time|98
182|3 - Black or African-American|3 - Black or African-American|98
183|3 - Boarding home or rented room|3 - Boarding home or rented room|98
184|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment, clean/store/dispose of equipment or supplies).|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment,|98
185|3 -Able to walk only with the supervision or assistance of another person at all times.|3 -Able to walk only with the supervision or assistance of another person at all times.|98
186|3 - Continuous / Bi-level positive airway pressure|3 - Continuous / Bi-level positive airway pressure|98
187|3 - During the day and evening, but not constantly|3 - During the day and evening, but not constantly|98
188|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the alimentary canal)|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the|98
189|3 - Environmental support (e.g., housing, home maintenance)|3 - Environmental support (e.g., housing, home maintenance)|98
190|3 - Four to six times weekly|3 - Four to six times weekly|98
191|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessing by listener.  Speech limited to single words or short phrases.|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessin|98
192|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires multiple repetitions, restatements, demonstrations, additional time.|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires m|98
193|3 - Hopelessness|3 - Hopelessness|98
194|3 - Hospice care|3 - Hospice care|98
195|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|98
196|3 - Injury caused by fall or accident at home|3 - Injury caused by fall or accident at home|98
197|3 - Intractable pain|3 - Intractable pain|98
198|3 - Medicaid (traditional fee-for-service)|3 - Medicaid (traditional fee-for-service)|98
199|3 - Needs someone to do all shopping and errands.|3 - Needs someone to do all shopping and errands.|98
200|3 - Not healing|3 - Not healing|98
201|3 - Nursing home|3 - Nursing home|98
202|3 - Once daily|3 - Once daily|98
203|3 - Other family member|3 - Other family member|98
204|3 - Outpatient department/clinic emergency (includes urgicenter sites)|3 - Outpatient department/clinic emergency (includes urgicenter sites)|98
205|3 - Paid help|3 - Paid help|98
206|3 - Able to participate in bathing self in shower or tub, but requires presence of another person throughout the bath for assistance or supervision.|3 - Able to participate in bathing self in shower or tub, but requires presence of another person th|98
207|3 - Patient depends entirely upon another person to dress lower body.|3 - Patient depends entirely upon another person to dress lower body.|98
208|3 - Patient depends entirely upon another person to dress the upper body.|3 - Patient depends entirely upon another person to dress the upper body.|98
209|3 - Patient depends entirely upon someone else for grooming needs.|3 - Patient depends entirely upon someone else for grooming needs.|98
210|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone else to manage the equipment.|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone|98
211|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable to shift attention and recall directions more than half the time.|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable|98
212|3 - Respiratory problems (SOB, infection, obstruction)|3 - Respiratory problems (SOB, infection, obstruction)|98
213|3 - Resumption of care (after inpatient stay)|3 - Resumption of care (after inpatient stay)|98
214|3 - Several times each month|3 - Several times each month|98
215|3 - Skilled Nursing Facility|3 - Skilled Nursing Facility|98
216|3 - Stage 3|3 - Stage 3|98
217|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|98
218|3 - Three|3 - Three|98
219|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person throughout the process.|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person through|98
220|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal independently.|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal indep|98
221|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person.|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person|98
222|3 - Unknown because patient moved to a geographic location not served by this agency|3 - Unknown because patient moved to a geographic location not served by this agency|98
223|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|98
224|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|98
225|3 - With other family member|3 - With other family member|98
226|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home health services, homemaker assistance, transportation assistance, assisted living, board and care)|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home h|98
227|3-SLP/ST|3-SLP/ST|98
228|4 - At rest (during day or night)|4 - At rest (during day or night)|98
229|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|98
230|4 - Board and care or assisted living facility|4 - Board and care or assisted living facility|98
231|4 - Caregiver is completely dependent on someone else to manage all equipment.|4 - Caregiver is completely dependent on someone else to manage all equipment.|98
232|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|98
233|4 - Constantly|4 - Constantly|98
234|4 - Drug dependency|4 - Drug dependency|98
235|4 - Four or more|4 - Four or more|98
236|4 - Friend or neighbor or community or church member|4 - Friend or neighbor or community or church member|98
237|4 - Hispanic or Latino|4 - Hispanic or Latino|98
238|4 - Hospice|4 - Hospice|98
239|4 - Impaired decision-making|4 - Impaired decision-making|98
240|4 - Is totally dependent in toileting.|4 - Is totally dependent in toileting.|98
241|4 - Medicaid (HMO/managed care)|4 - Medicaid (HMO/managed care)|98
242|4 - None of the above|4 - None of the above|98
243|4 - Nursing home|4 - Nursing home|98
244|4 - On a daily basis|4 - On a daily basis|98
245|4 - Patient is completely dependent on someone else to manage all equipment.|4 - Patient is completely dependent on someone else to manage all equipment.|98
246|4 - Permanent placement|4 - Permanent placement|98
247|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, punches, dangerous maneuvers w/ wheelchair or other objects)|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, pu|98
248|4 - Psychosocial support (e.g., socialization, companionship, recreation)|4 - Psychosocial support (e.g., socialization, companionship, recreation)|98
249|4 - Recertification (follow-up) reassessment|4 - Recertification (follow-up) reassessment|98
250|4 - Recurrent thoughts of death|4 - Recurrent thoughts of death|98
251|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruction)|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruc|98
252|4 - Several times a week|4 - Several times a week|98
253|4 - Stage 4|4 - Stage 4|98
254|4 - Symptoms poorly controlled, history of rehospitalizations|4 - Symptoms poorly controlled, history of rehospitalizations|98
255|4 - Three or more times per week|4 - Three or more times per week|98
256|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetative state, or delirium.|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetati|98
257|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|98
258|4 - Unable to effectively participate in any housekeeping tasks.|4 - Unable to effectively participate in any housekeeping tasks.|98
259|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or unresponsive (e.g., speech is nonsensical or unintelligible).|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or u|98
260|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonresponsive.|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonr|98
261|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostomy.|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostom|98
262|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of devices at the sink, in chair, or on commode|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of|98
263|4 - With a friend|4 - With a friend|98
264|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|98
265|4-OT|4-OT|98
266|5 - Advocates or facilitates patient's participation in appropriate medical care|5 - Advocates or facilitates patient's participation in appropriate medical care|98
267|5 - At least daily|5 - At least daily|98
268|6 - Bedfast, unable to ambulate or be up in a chair.|6 - Bedfast, unable to ambulate or be up in a chair.|98
269|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|98
270|5 - Disruptive or socially inappropriate behavior|5 - Disruptive or socially inappropriate behavior|98
271|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|98
272|5 - Hypo/Hyperglycemia, diabetes out of control|5 - Hypo/Hyperglycemia, diabetes out of control|98
273|5 - More often than once daily|5 - More often than once daily|98
274|5 - Native Hawaiian or Pacific Islander|5 - Native Hawaiian or Pacific Islander|98
275|5 - None of the above|5 - None of the above|98
276|5 - One to two times per week|5 - One to two times per week|98
277|5 - Other|5 - Other|98
278|5 - Other follow-up|5 - Other follow-up|98
279|5 - Paid help|5 - Paid help|98
280|5 - Patient nonresponsive or unable to speak.|5 - Patient nonresponsive or unable to speak.|98
281|5 - Thoughts of suicide|5 - Thoughts of suicide|98
282|5 - Totally unable to use the telephone.|5 - Totally unable to use the telephone.|98
283|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|98
284|5 - Unable to take in nutrients orally or by tube feeding.|5 - Unable to take in nutrients orally or by tube feeding.|98
285|5 - Unsafe for care at home|5 - Unsafe for care at home|98
286|5 - With paid help (other than home care agency staff)|5 - With paid help (other than home care agency staff)|98
287|5 - Workers' compensation|5 - Workers' compensation|98
288|5 - Wound infection, deteriorating wound status, new lesion/ulcer|5 - Wound infection, deteriorating wound status, new lesion/ulcer|98
289|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|98
290|6 - Delusional, hallucinatory, or paranoid behavior|6 - Delusional, hallucinatory, or paranoid behavior|98
291|6 - Financial agent, power of attorney, or conservator of finance|6 - Financial agent, power of attorney, or conservator of finance|98
292|6 - GI bleeding, obstruction|6 - GI bleeding, obstruction|98
293|6 - Less often than weekly|6 - Less often than weekly|98
294|6 - Memory loss to the extent that supervision required|6 - Memory loss to the extent that supervision required|98
295|6 - None of the above feelings observed or reported|6 - None of the above feelings observed or reported|98
296|6 - Other|6 - Other|98
297|6 - Title programs (e.g., Title III, V, or XX)|6 - Title programs (e.g., Title III, V, or XX)|98
298|6 - Transferred to an inpatient facility - patient not discharged from agency|6 - Transferred to an inpatient facility - patient not discharged from agency|98
299|6 - White|6 - White|98
300|6 - With other than above|6 - With other than above|98
301|7 - Exacerbation of CHF, fluid overload, heart failure|7 - Exacerbation of CHF, fluid overload, heart failure|98
302|7 - Health care agent, conservator of person, or medical power of attorney|7 - Health care agent, conservator of person, or medical power of attorney|98
303|7 - Hypo/Hyperglycemia, diabetes out of control|7 - Hypo/Hyperglycemia, diabetes out of control|98
304|7 - None of the above|7 - None of the above|98
305|7 - None of the above behaviors demonstrated|7 - None of the above behaviors demonstrated|98
306|7 - Other government (e.g., TriCare, VA, etc.)|7 - Other government (e.g., TriCare, VA, etc.)|98
307|7 - Transferred to an inpatient facility - patient discharged from agency|7 - Transferred to an inpatient facility - patient discharged from agency|98
308|8 - Death at home|8 - Death at home|98
309|8 - GI bleeding, obstruction|8 - GI bleeding, obstruction|98
310|8 - Myocardial infarction, stroke|8 - Myocardial infarction, stroke|98
311|8 - Private insurance|8 - Private insurance|98
312|9 - Chemotherapy|9 - Chemotherapy|98
313|9 - Discharge from agency|9 - Discharge from agency|98
314|9 - Other than above reasons|9 - Other than above reasons|98
315|9 - Private HMO/managed care|9 - Private HMO/managed care|98
316|NA - No caregiver|NA - No caregiver|98
317|NA - No equipment of this type used in care.|NA - No equipment of this type used in care.|98
318|NA - No inhalant/mist medications prescribed.|NA - No inhalant/mist medications prescribed.|98
319|NA - No injectable medications prescribed.|NA - No injectable medications prescribed.|98
320|NA - No inpatient facility admission|NA - No inpatient facility admission|98
321|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|98
322|NA - No Medicaid|NA - No Medicaid|98
323|NA - No Medicare|NA - No Medicare|98
324|NA - No observable pressure ulcer or unhealed pressure ulcer|NA - No observable pressure ulcer or unhealed pressure ulcer|98
325|NA - No observable stasis ulcer|NA - No observable stasis ulcer|98
326|NA - No observable surgical wound|NA - No observable surgical wound|98
327|NA - No oral medications prescribed.|NA - No oral medications prescribed.|98
328|NA - Not applicable|NA - Not applicable|98
329|NA - Patient does not have a telephone.|NA - Patient does not have a telephone.|98
330|NA - Patient has ostomy for bowel elimination|NA - Patient has ostomy for bowel elimination|98
331|NA - Patient nonresponsive|NA - Patient nonresponsive|98
332|NA - Patient on prophylactic treatment|NA - Patient on prophylactic treatment|98
333|NA - Patient was not discharged from an inpatient facility [Go to M1017]|NA - Patient was not discharged from an inpatient facility [Go to M1017]|98
334|UK - Other unknown|UK - Other unknown|98
335|UK - Reason unknown|UK - Reason unknown|98
336|UK - Unknown|UK - Unknown|98
337|UK - Unknown or Not Available|UK - Unknown or Not Available|98
341|01 - Early|01 - Early|98
342|02 - Late|02 - Late|98
343|NA - Not Applicable. No case mix group defined for this assessment.|NA - Not Applicable. No case mix group defined for this assessment.|98
344|NA - No case mix group defined by this assessment.|NA - No case mix group defined by this assessment.|98
345|1 - Recent decline in mental, emotional, or behavioral status|1 - Recent decline in mental, emotional, or behavioral status|98
346|2 - Multiple hospitalizations (2 or more) in the past 12 months|2 - Multiple hospitalizations (2 or more) in the past 12 months|98
347|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|98
348|4 - Taking five or more medications|4 - Taking five or more medications|98
349|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|98
350|6 - Other|6 - Other|98
351|7 - None of the above|7 - None of the above|98
352|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond tho|98
353|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable without heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable wi|98
354|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious complications and death.|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious compl|98
355|3 - The patient has serious progressive conditions that could lead to death within a year.|3 - The patient has serious progressive conditions that could lead to death within a year.|98
356|UK - The patient+s situation is unknown or unclear.|UK - The patient+s situation is unknown or unclear.|98
357|1 - Yes [ Go to M1050 ]|1 - Yes [ Go to M1050 ]|98
358|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this influenza season. [ Go to M1050 ]|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this i|98
359|1 - Received from another health care provider (e.g., physician)|1 - Received from another health care provider (e.g., physician)|98
360|2 - Received from your agency previously during this year+s flu season|2 - Received from your agency previously during this year+s flu season|98
361|3 - Offered and declined|3 - Offered and declined|98
362|4 - Assessed and determined to have medical contraindication(s)|4 - Assessed and determined to have medical contraindication(s)|98
363|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|98
364|6 - Inability to obtain vaccine due to declared shortage|6 - Inability to obtain vaccine due to declared shortage|98
365|1 - Yes [ Go to M2005 at TRN; Go to M1230 at DC ]|1 - Yes [ Go to M2005 at TRN; Go to M1230 at DC ]|98
366|1 - Patient has received PPV in the past|1 - Patient has received PPV in the past|98
367|2 - Offered and declined|2 - Offered and declined|98
368|3 - Assessed and determined to have medical contraindication(s)|3 - Assessed and determined to have medical contraindication(s)|98
369|4 - Not indicated; patient does not meet age/condition guidelines for PPV|4 - Not indicated; patient does not meet age/condition guidelines for PPV|98
370|5 - None of the above|5 - None of the above|98
371|0 - Adequate: hears normal conversation without difficulty.|0 - Adequate: hears normal conversation without difficulty.|98
372|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to increase volume or speak distinctly.|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to in|98
373|2 - Severely Impaired: absence of useful hearing.|2 - Severely Impaired: absence of useful hearing.|98
374|UK - Unable to assess hearing.|UK - Unable to assess hearing.|98
375|0 - Understands: clear comprehension without cues or repetitions.|0 - Understands: clear comprehension without cues or repetitions.|98
376|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Requires cues at times to understand.|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Req|98
377|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequently requires cues to understand.|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequentl|98
378|3 - Rarely/Never Understands|3 - Rarely/Never Understands|98
379|UK - Unable to assess understanding.|UK - Unable to assess understanding.|98
380|0 - No standardized assessment conducted|0 - No standardized assessment conducted|98
381|1 - Yes, and it does not indicate severe pain|1 - Yes, and it does not indicate severe pain|98
382|2 - Yes, and it indicates severe pain|2 - Yes, and it indicates severe pain|98
383|0 - Patient has no pain|0 - Patient has no pain|98
384|1 - Patient has pain that does not interfere with activity or movement|1 - Patient has pain that does not interfere with activity or movement|98
385|2 - Less often than daily|2 - Less often than daily|98
386|3 - Daily, but not constantly|3 - Daily, but not constantly|98
387|4 - All of the time|4 - All of the time|98
388|0 - No assessment conducted [ Go to M1306 ]|0 - No assessment conducted [ Go to M1306 ]|98
389|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc., without use of standardized tool|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc.,|98
390|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|98
391|0 - No [ Go to M1322]|0 - No [ Go to M1322]|98
392|0 v Newly epithelialized|0 v Newly epithelialized|98
393|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|98
394|2 - Yes, patient has observable stasis ulcers ONLY|2 - Yes, patient has observable stasis ulcers ONLY|98
395|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable dressing) [Go to M1340]|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable|98
396|0 - No [ Go to M1350 ]|0 - No [ Go to M1350 ]|98
397|1 - Yes, patient has at least one (observable) surgical wound|1 - Yes, patient has at least one (observable) surgical wound|98
398|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1350 ]|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1350 ]|98
399|0 - Patient is not short of breath|0 - Patient is not short of breath|98
400|3 - Continuous Bi-level positive airway pressure|3 - Continuous Bi-level positive airway pressure|98
401|0 - No [ Go to M2005 at TRN; Go to M1600 at DC ]|0 - No [ Go to M2005 at TRN; Go to M1600 at DC ]|98
402|2 - Not assessed [Go to M2005 at TRN; Go to M1600 at DC ]|2 - Not assessed [Go to M2005 at TRN; Go to M1600 at DC ]|98
403|NA - Patient does not have diagnosis of heart failure [Go to M2005 at TRN; Go to M1600 at DC]|NA - Patient does not have diagnosis of heart failure [Go to M2005 at TRN; Go to M1600 at DC]|98
404|0 - No action taken|0 - No action taken|98
405|1 - Patient+s physician (or other primary care practitioner) contacted the same day|1 - Patient+s physician (or other primary care practitioner) contacted the same day|98
406|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|98
407|3 - Implement physician-ordered patient-specific established parameters for treatment|3 - Implement physician-ordered patient-specific established parameters for treatment|98
408|4 - Patient education or other clinical interventions|4 - Patient education or other clinical interventions|98
409|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequency, telehealth, etc.)|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequ|98
410|1 - Occasional stress incontinence|1 - Occasional stress incontinence|98
411|2 - During the night only|2 - During the night only|98
412|3 - During the day only|3 - During the day only|98
413|4 - During the day and night|4 - During the day and night|98
414|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|98
415|0 - Able to manage toileting hygiene and clothing management without assistance.|0 - Able to manage toileting hygiene and clothing management without assistance.|98
416|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implements are laid out for the patient.|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implemen|98
417|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|98
418|3 - Patient depends entirely upon another person to maintain toileting hygiene.|3 - Patient depends entirely upon another person to maintain toileting hygiene.|98
419|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independent|98
420|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface|98
421|0 - No multi-factor falls risk assessment conducted.|0 - No multi-factor falls risk assessment conducted.|98
422|1 - Yes, and it does not indicate a risk for falls.|1 - Yes, and it does not indicate a risk for falls.|98
423|2 - Yes, and it indicates a risk for falls.|2 - Yes, and it indicates a risk for falls.|98
424|0 - Not assessed/reviewed [ Go to M2010 ]|0 - Not assessed/reviewed [ Go to M2010 ]|98
425|1 - No problems found during review [ Go to M2010 ]|1 - No problems found during review [ Go to M2010 ]|98
426|2 - Problems found during review|2 - Problems found during review|98
427|NA - Patient is not taking any medications [ Go to M2040 ]|NA - Patient is not taking any medications [ Go to M2040 ]|98
428|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special precautions associated with all high-risk medications|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special p|98
429|NA - Patient not taking any drugs|NA - Patient not taking any drugs|98
430|2 - Able to take medication(s) at the correct times if given reminders by another person at the appropriate times|2 - Able to take medication(s) at the correct times if given reminders by another person at the appr|98
431|3 - Unable to take medication unless administered by another person.|3 - Unable to take medication unless administered by another person.|98
432|1 - At least daily|1 - At least daily|98
433|2 - Three or more times per week|2 - Three or more times per week|98
434|3 - One to two times per week|3 - One to two times per week|98
435|4 - Received, but less often than weekly|4 - Received, but less often than weekly|98
436|5 - No assistance received|5 - No assistance received|98
437|0 - No [Go to M2401]|0 - No [Go to M2401]|98
438|1 - Yes, used hospital emergency department WITHOUT hospital admission|1 - Yes, used hospital emergency department WITHOUT hospital admission|98
439|2 - Yes, used hospital emergency department WITH hospital admission|2 - Yes, used hospital emergency department WITH hospital admission|98
440|UK - Unknown [Go to M2401]|UK - Unknown [Go to M2401]|98
441|2 - Injury caused by fall|2 - Injury caused by fall|98
442|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|98
443|4 - Other respiratory problem|4 - Other respiratory problem|98
444|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|98
445|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|98
446|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|98
447|8 - Other heart disease|8 - Other heart disease|98
448|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|98
449|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|98
450|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|98
451|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|98
452|13 - Urinary tract infection|13 - Urinary tract infection|98
453|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|98
454|15 - Wound infection or deterioration|15 - Wound infection or deterioration|98
455|16 - Uncontrolled pain|16 - Uncontrolled pain|98
456|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|98
457|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|98
458|19 - Other than above reasons|19 - Other than above reasons|98
459|2 - Patient remained in the community (with formal assistive services)|2 - Patient remained in the community (with formal assistive services)|98
460|3 - Patient transferred to a noninstitutional hospice|3 - Patient transferred to a noninstitutional hospice|98
461|4 - Unknown because patient moved to a geographic location not served by this agency|4 - Unknown because patient moved to a geographic location not served by this agency|98
462|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|98
463|4 - Other respiratory problem|4 - Other respiratory problem|98
464|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|98
465|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|98
466|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|98
467|8 - Other heart disease|8 - Other heart disease|98
468|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|98
469|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|98
470|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|98
471|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|98
472|13 - Urinary tract infection|13 - Urinary tract infection|98
473|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|98
474|15 - Wound infection or deterioration|15 - Wound infection or deterioration|98
475|16 - Uncontrolled pain|16 - Uncontrolled pain|98
476|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|98
477|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|98
478|19 - Scheduled treatment or procedure|19 - Scheduled treatment or procedure|98
479|20 - Other than above reasons|20 - Other than above reasons|98
480|UK - Reason unknown [Go to M0903]|UK - Reason unknown [Go to M0903]|98
482|01 - Patient lives alone around the clock|01 - Patient lives alone around the clock|98
483|02 - Patient lives alone regular daytime|02 - Patient lives alone regular daytime|98
484|03 - Patient lives alone regular nighttime|03 - Patient lives alone regular nighttime|98
485|04 - Patient lives alone occassional/short term assistance|04 - Patient lives alone occassional/short term assistance|98
486|05 - Patient lives alone no assisstance available|05 - Patient lives alone no assisstance available|98
487|06 - Patient lives with other person(s) in the home around the clock|06 - Patient lives with other person(s) in the home around the clock|98
488|07 - Patient lives with other person(s) in the home regular daytime|07 - Patient lives with other person(s) in the home regular daytime|98
489|08 - Patient lives with other person(s) in the home regular nighttime|08 - Patient lives with other person(s) in the home regular nighttime|98
490|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|98
491|10 - Patient lives with other person(s) in the home no assistance available|10 - Patient lives with other person(s) in the home no assistance available|98
492|1 - Was present at the most recent SOC/ROC assessment|1 - Was present at the most recent SOC/ROC assessment|98
493|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|98
494|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|98
495|0 - Newly epithelialized|0 - Newly epithelialized|98
496|0 - No [ Go to M1340 ]|0 - No [ Go to M1340 ]|98
498|0 - Independent|0 - Independent|98
499|1 - Needed Some Help|1 - Needed Some Help|98
500|2 - Dependent|2 - Dependent|98
502|0 - No assistance needed in this area|0 - No assistance needed in this area|98
503|1 - Caregiver(s) currently provide assistance|1 - Caregiver(s) currently provide assistance|98
504|2 - Caregiver(s) need training/ supportive services to provide assistance|2 - Caregiver(s) need training/ supportive services to provide assistance|98
505|3 - Caregiver(s) not likely to provide assistance|3 - Caregiver(s) not likely to provide assistance|98
506|4 - Unclear if Caregiver(s) will provide assistance|4 - Unclear if Caregiver(s) will provide assistance|98
507|5 - Assistance needed, but no Caregiver(s) available|5 - Assistance needed, but no Caregiver(s) available|98
508|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will use standardized clinical guidelines accessible for all care providers to reference|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will|98
510|NA - Patient is not assessed to be at risk for falls|NA - Patient is not assessed to be at risk for falls|98
511|NA - Patient has no diagnosis or symptoms of depression|NA - Patient has no diagnosis or symptoms of depression|98
512|NA - No pain identified|NA - No pain identified|98
513|NA - Patient is not assessed to be at risk for pressure ulcers|NA - Patient is not assessed to be at risk for pressure ulcers|98
514|NA - Patient has no pressure ulcers with need for moist wound healing|NA - Patient has no pressure ulcers with need for moist wound healing|98
515|1 - Long-term nursing facility (NF)|1 - Long-term nursing facility (NF)|98
516|2 - Skilled nursing facility (SNF / TCU)|2 - Skilled nursing facility (SNF / TCU)|98
517|3 - Short stay acute hospital (IPP S)|3 - Short stay acute hospital (IPP S)|98
518|4 - Long-term care hospital (LTCH)|4 - Long-term care hospital (LTCH)|98
519|5 - Inpatient rehabilitation hospital or unit (IRF)|5 - Inpatient rehabilitation hospital or unit (IRF)|98
520|6 - Psychiatric hospital or unit|6 - Psychiatric hospital or unit|98
521|7 - Other|7 - Other|98
522|NA - Patient was not discharged from an inpatient facility [Go to M1017]|NA - Patient was not discharged from an inpatient facility [Go to M1017]|98
523|6 - Unable to participate effectively in bathing and is bathed totally by another person|6 - Unable to participate effectively in bathing and is bathed totally by another person|98
524|4 - Chairfast, unable to ambulate but is able to wheel self independently.|4 - Chairfast, unable to ambulate but is able to wheel self independently.|98
525|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask patient: "Over the last two weeks, how often have you been bothered by any of the following problems")|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask|98
526|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluation for depression.|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluat|98
527|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet criteria for further evaluation for depression.|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet|98
528|0 - Not at all  0 - 1 day|0 - Not at all  0 - 1 day|98
529|1 - Several days  2 - 6 days|1 - Several days  2 - 6 days|98
530|2 - More than half of the days  7 - 11 days|2 - More than half of the days  7 - 11 days|98
531|3 - Nearly every day  12 - 14 days|3 - Nearly every day  12 - 14 days|98
532|NA - N/A  Unable to respond|NA - N/A  Unable to respond|98
533|2 - Able to take medication(s) at the correct times if given reminders by another person based on the frequency of the injection|2 - Able to take medication(s) at the correct times if given reminders by another person based on th|98
534|3 - Unable to take injectable medication unless administered by another person.|3 - Unable to take injectable medication unless administered by another person.|98
547|NA - There were no potential clinically significant medication issues identified since SOC/ROC or patient is not taking any medications|NA v There were no potential clinically significant medication issues identified since SOC/ROC |98
552|1 - Hospital|1 - Hospital [ Go to M2430 ]|98
553|2 - Rehabilitation facility|2 - Rehabilitation facility [ Go to M0903 ]|98
554|3 - Nursing home|3 - Nursing home [ Go to M2440 ]|98
555|4 - Hospice|4 - Hospice [ Go to M0903 ]|98
653|0 - No [STOP]|0 - No [STOP]|98
654|1 - Yes |1 - Yes|98
655|0 - None|0 - None|98
656|1 - One|1 - One|98
657|2 - Two or More|2 - Two or More|98
660|1 - Dependent - A helper completed the activities for the patient.|1 - Dependent - A helper completed the activities for the patient.|99
659|2 - Needed Some Help - Patient needed partial assistance from another person to complete activities.|2 - Needed Some Help - Patient needed partial assistance from another person to complete activities.|99
657|2 - Two or More|2 - Two or More|99
658|3 - Independent - Patient completed the activities by him/herself, with or without an assistive device, with no assistance from a helper.|3 - Independent - Patient completed the activities by him/herself, with or without an assistive devi|99
653|0 - No [STOP]|0 - No [STOP]|99
654|1 - Yes |1 - Yes|99
655|0 - None|0 - None|99
656|1 - One|1 - One|99
661|8 - Unknown|8 - Unknown|99
662|9 - Not Applicable|9 - Not Applicable|99
663|A - Manual wheelchair|A - Manual wheelchair|99
664|B - Motorized wheelchair and/or scooter|B - Motorized wheelchair and/or scooter|99
665|C - Mechanical lift|C - Mechanical lift|99
666|D - Walker|D - Walker|99
667|E - Orthotics/Prosthetics|E - Orthotics/Prosthetics|99
668|Z - None of the above|Z - None of the above|99
637|06 - Independent - Patient completes the activity by him/herself with no assistance from a helper.|06 - Independent - Patient completes the activity by him/herself with no assistance from a helper.|99
638|05 - Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper assists only prior to or following the activity.|05 - Setup or clean-up assistance - Helper sets up or cleans up; patient completes activity. Helper|99
639|04 - Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as patient completes activity. Assistance may be provided throughout the activity or intermittently.|04 - Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/|99
640|03 - Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or supports trunk or limbs, but provides less than half the effort.|03 - Partial/moderate assistance - Helper does LESS THAN HALF the effort. Helper lifts, holds or sup|99
641|02 - Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.|02 - Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds t|99
642|01 - Dependent - Helper does ALL of the effort. Patient does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the patient to complete the activity.|01 - Dependent - Helper does ALL of the effort. Patient does none of the effort to complete the acti|99
643|07 - Patient refused|07 - Patient refused|99
644|09 - Not applicable - Not attempted and the patient did not perform this activity prior to the current illness,exacerbation or injury.|09 - Not applicable - Not attempted and the patient did not perform this activity prior to the curre|99
645|10 - Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)|10 - Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)|99
646|88 - Not attempted due to medical conditions or safety concerns|88 - Not attempted due to medical conditions or safety concerns|99
647|0 - No [Skip GG0170R, GG0170RR, GG0170S, and GG0170SS]|0 - No [Skip GG0170R, GG0170RR1, GG0170S, and GG0170SS1.]|99
648|0 - No [Skip GG0170R]|0 - No [Skip GG0170R]|99
649|1 - Yes |1 - Yes [Continue to GG0170R, Wheel 50 feet with two turns.]|99
650|1 - Manual|1 - Manual|99
651|2 - Motorized|2 - Motorized|99
652|0 - No [Skip to J1800 Any falls since SOC/ROC, whichever is more recent.]|0 - No [Skip to J1800 Any falls since SOC/ROC, whichever is more recent.]|99
47|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or supervision from another person OR c) a liquid, pureed or ground meat diet.|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or su|99
2|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; OR (b) Is physically, cognitively, and mentally able to prepare light meals on a regular basis but has not routinely performed light meal preparation in the past (i.e., prior to this home care admission).|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; O|99
3|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and mentally able to perform all housekeeping tasks .|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and menta|99
4|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and mentally able to do laundry and access facilities.|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and menta|99
5|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying packages OR b) Physically, cognitively, and mentally able to take care of shopping, but has not done shopping in the past (i.e., prior to this home care admission).|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying|99
6|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|99
7|0 - Able to dial numbers and answer calls appropriately and as desired.|0 - Able to dial numbers and answer calls appropriately and as desired.|99
8|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body without assistance.|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body|99
9|0 - Able to get to and from the toilet and transfer independently with or without a device.|0 - Able to get to and from the toilet and transfer independently with or without a device.|99
10|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|99
11|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible public bus.|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible p|99
12|0 - Able to independently feed self.|0 - Able to independently feed self.|99
13|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|99
14|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct times.|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct ti|99
15|0 - Able to independently transfer.|0 - Able to independently transfer.|99
16|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without rail|99
17|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings|99
18|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|99
19|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions independently.|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions indep|99
20|0 - Asymptomatic, no treatment needed at this time|0 - Asymptomatic, no treatment needed at this time|99
21|0 - Caregiver manages all tasks related to equipment completely independently.|0 - Caregiver manages all tasks related to equipment completely independently.|99
22|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations with no observable impairment.|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations w|99
23|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|99
24|0 - Life expectancy is greater than 6 months|0 - Life expectancy is greater than 6 months|99
25|0 - Never|0 - Never|99
26|0 - Patient is not short of breath|0 - Patient is not short of breath|99
27|0 - No|0 - No|99
28|0 - No emergent care services|0 - No emergent care services|99
29|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [Goto M1620]|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [Goto M1620]|99
30|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and extended or abstract conversation.|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and exte|99
31|0 - No one person|0 - No one person|99
32|0 - None of the time|0 - None of the time|99
33|0 - None, no charge for current services|0 - None, no charge for current services|99
34|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|99
35|0 - Patient does NOT have an ostomy for bowel elimination.|0 - Patient does NOT have an ostomy for bowel elimination.|99
36|0 - Patient has no pain|0 - Patient has no pain|99
37|0 - Patient manages all tasks related to equipment completely independently.|0 - Patient manages all tasks related to equipment completely independently.|99
38|0 - Poor:  little or no recovery is expected and/or further decline is imminent|0 - Poor:  little or no recovery is expected and/or further decline is imminent|99
39|0 - Timed-voiding defers incontinence|0 - Timed-voiding defers incontinence|99
40|0 - Very rarely or never has bowel incontinence|0 - Very rarely or never has bowel incontinence|99
41|0 - Zero|0 - Zero|99
42|00 - No|00 - No|99
43|01 - Yes|01 - Yes|99
44|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or mental limitations, needs assistance with heavy laundry.|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or|99
45|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the patient.|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the|99
46|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|99
48|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|99
49|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|99
50|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independently.|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independe|99
51|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only when assisted or accompanied by another person.|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only w|99
52|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepa|99
53|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance by another person OR b) given daily reminders.|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance b|99
54|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advan|99
55|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advan|99
56|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for the deaf) and call essential numbers.|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for t|99
57|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|99
58|1 - American Indian or Alaska Native|1 - American Indian or Alaska Native|99
59|1 - Depressed mood (e.g., feeling sad, tearful)|1 - Depressed mood (e.g., feeling sad, tearful)|99
60|1 - During the night only|1 - During the night only|99
61|1 - Fully granulating|1 - Fully granulating|99
62|1 - Good/Fair:  partial to full recovery is expected|1 - Good/Fair:  partial to full recovery is expected|99
63|1 - Good:  marked improvement in functional status is expected|1 - Good:  marked improvement in functional status is expected|99
64|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|99
65|1 - Smoking|1 - Smoking|99
66|1 - Hospital|1 - Hospital [ Go to M2430 ]|99
67|1 - Hospital emergency room (includes 23-hour holding)|1 - Hospital emergency room (includes 23-hour holding)|99
68|1 - Hospitalization for EMERGENT (unscheduled) care|1 - Hospitalization for EMERGENT (unscheduled) care|99
69|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepared solutions), patient is able to manage all other aspects of equipment.|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepar|99
70|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|99
71|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|99
72|1 - In new or complex situations only|1 - In new or complex situations only|99
73|1 - Intravenous or infusion therapy (excludes TPN)|1 - Intravenous or infusion therapy (excludes TPN)|99
74|1 - Less often than daily|1 - Less often than daily|99
75|1 - Less than once a month|1 - Less than once a month|99
76|1 - Less than once weekly|1 - Less than once weekly|99
77|1 - Life expectancy is 6 months or fewer|1 - Life expectancy is 6 months or fewer|99
78|1 - Lives alone|1 - Lives alone|99
79|1 - Male|1 - Male|99
80|1 - Medicare (traditional fee-for-service)|1 - Medicare (traditional fee-for-service)|99
81|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of past 24 hours, significant memory loss so that supervision is required|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of pas|99
82|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors in word choice, grammar or speech intelligibility, needs minimal prompting or assistance).|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors i|99
83|1 - No assistance or services received|1 - No assistance or services received|99
84|1 - One|1 - One|99
85|1 - Oxygen (intermittent or continuous)|1 - Oxygen (intermittent or continuous)|99
86|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, and the surrounding layout, can count fingers at arm's length.|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, a|99
87|1 - Patient is incontinent|1 - Patient is incontinent|99
88|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|99
89|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical or treatment regimen.|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical|99
90|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient/couple/significant other)|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient|99
91|1 - Relatives, friends, or neighbors living outside the home|1 - Relatives, friends, or neighbors living outside the home|99
92|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions.|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions|99
93|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independentl|99
94|1 - Several times during day and night|1 - Several times during day and night|99
95|1 - Spouse or significant other|1 - Spouse or significant other|99
96|1 - Stage 1|1 - Stage 1|99
97|1 - Start of care - further visits planned|1 - Start of care - further visits planned|99
98|1 - Symptoms well controlled with current therapy|1 - Symptoms well controlled with current therapy|99
99|1 - Therapy services|1 - Therapy services|99
100|1 - Able to transfer with minimal human assistance or with use of an assistive device.|1 - Able to transfer with minimal human assistance or with use of an assistive device.|99
101|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitations.|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitatio|99
102|1 - Urinary incontinence|1 - Urinary incontinence|99
103|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and transfer.|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and|99
104|1 - When walking more than 20 feet, climbing stairs|1 - When walking more than 20 feet, climbing stairs|99
105|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary conversation. May need occasional repetition, extra time, or louder voice.|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary c|99
106|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting in and out of tub/shower|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting|99
107|1 - Yes|1 - Yes|99
108|1-RN|1-RN|99
109|10 - Discharge from agency - no visits completed after start/resumption of care assessment|10 - Discharge from agency - no visits completed after start/resumption of care assessment|99
110|10 - Scheduled surgical procedure|10 - Scheduled surgical procedure|99
111|10 - Self-pay|10 - Self-pay|99
112|11 - Other|11 - Other|99
113|11 - Urinary tract infection|11 - Urinary tract infection|99
114|12 - IV catheter-related infection|12 - IV catheter-related infection|99
115|13 - Deep vein thrombosis, pulmonary embolus|13 - Deep vein thrombosis, pulmonary embolus|99
116|14 - Uncontrolled pain|14 - Uncontrolled pain|99
117|15 - Psychotic episode|15 - Psychotic episode|99
118|16 - Other than above reasons|16 - Other than above reasons|99
119|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing calls.|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing|99
120|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another person.|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another pers|99
121|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface a|99
122|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for intermittent supervision or encouragement or reminders, OR (b) to get in and out of the shower or tub, OR (c) for washing difficult to reach areas.|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for inter|99
123|2 - Asian|2 - Asian|99
124|2 - Caregiver requires considerable assistance from another person to manage equipment, but independently completes significant portions of task.|2 - Caregiver requires considerable assistance from another person to manage equipment, but independ|99
125|2 - Daily, but not constantly|2 - Daily, but not constantly|99
126|2 - Daughter or son|2 - Daughter or son|99
127|2 - Doctor's office emergency visit/house call|2 - Doctor's office emergency visit/house call|99
128|2 - During the day and night|2 - During the day and night|99
129|2 - Early/partial granulation|2 - Early/partial granulation|99
130|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors in word choice, organization or speech intelligibility). Speaks in phrases or short sentences.|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors|99
131|2 - Family member's residence|2 - Family member's residence|99
132|2 - Female|2 - Female|99
133|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conversation, needs frequent prompting or assistance.|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conver|99
134|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|99
135|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|99
136|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately stop activities, jeopardizes safety through actions|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately st|99
137|2 - Indwelling/suprapubic catheter|2 - Indwelling/suprapubic catheter|99
138|2 - Injury caused by fall or accident at home|2 - Injury caused by fall or accident at home|99
139|2 - Medicare (HMO/managed care/Advantage plan)|2 - Medicare (HMO/managed care/Advantage plan)|99
140|2 - Nausea, dehydration, malnutrition, constipation, impaction|2 - Nausea, dehydration, malnutrition, constipation, impaction|99
141|2 - Obesity|2 - Obesity|99
142|2 - On awakening or at night only|2 - On awakening or at night only|99
143|2 - Once a month|2 - Once a month|99
144|2 - One to three times weekly|2 - One to three times weekly|99
145|2 - Parenteral nutrition (TPN or lipids)|2 - Parenteral nutrition (TPN or lipids)|99
146|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic) [ Go to M1620 ]|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic) [ Go|99
147|2 - Patient requires considerable assistance from another person to manage equipment, but independently completes portions of the task.|2 - Patient requires considerable assistance from another person to manage equipment, but independen|99
148|2 - Patient transferred to a noninstitutional hospice|2 - Patient transferred to a noninstitutional hospice|99
149|2 - Person residing in the home (EXCLUDING paid help)|2 - Person residing in the home (EXCLUDING paid help)|99
150|2 - Rehabilitation facility|2 - Rehabilitation facility [ Go to M0906 ]|99
151|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifting of attention) or consistently requires low stimulus environment due to distractibility.|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifti|99
152|2 - Respite care|2 - Respite care|99
153|2 - Sense of failure or self reproach|2 - Sense of failure or self reproach|99
154|2 - Several times during day|2 - Several times during day|99
155|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonresponsive.|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonrespons|99
156|2 - Someone must assist the patient to groom self.|2 - Someone must assist the patient to groom self.|99
157|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|99
158|2 - Someone must help the patient put on upper body clothing.|2 - Someone must help the patient put on upper body clothing.|99
159|2 - Stage 2|2 - Stage 2|99
160|2 - Start of care - no further visits planned|2 - Start of care - no further visits planned|99
161|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitoring|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitori|99
162|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment regimen.|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment re|99
163|2 - Two|2 - Two|99
164|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistance due to cognitive or mental limitation.|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistanc|99
165|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|99
166|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assistance).|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assis|99
167|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home delivery.|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home deli|99
168|2 - Unable to prepare any light meals or reheat any delivered meals.|2 - Unable to prepare any light meals or reheat any delivered meals.|99
169|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|99
170|2 - UNABLE to take injectable medications unless administered by someone else.|2 - UNABLE to take injectable medications unless administered by someone else.|99
171|2 - UNABLE to take medication unless administered by someone else.|2 - UNABLE to take medication unless administered by someone else.|99
172|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|99
173|2 - Ventilator (continually or at night)|2 - Ventilator (continually or at night)|99
174|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less than 20 feet)|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less th|99
175|2 - With spouse or significant other|2 - With spouse or significant other|99
176|2 - Yes, assistance or services provided by family or friends|2 - Yes, assistance or services provided by family or friends|99
177|2-PT|2-PT|99
178|3 - Able to answer the telephone only some of the time or is able to carry on only a limited conversation.|3 - Able to answer the telephone only some of the time or is able to carry on only a limited convers|99
179|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube or gastrostomy.|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube|99
180|3 - Alcohol dependency|3 - Alcohol dependency|99
181|3 - All of the time|3 - All of the time|99
182|3 - Black or African-American|3 - Black or African-American|99
183|3 - Boarding home or rented room|3 - Boarding home or rented room|99
184|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment, clean/store/dispose of equipment or supplies).|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment,|99
185|3 -Able to walk only with the supervision or assistance of another person at all times.|3 -Able to walk only with the supervision or assistance of another person at all times.|99
186|3 - Continuous / Bi-level positive airway pressure|3 - Continuous / Bi-level positive airway pressure|99
187|3 - During the day and evening, but not constantly|3 - During the day and evening, but not constantly|99
188|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the alimentary canal)|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the|99
189|3 - Environmental support (e.g., housing, home maintenance)|3 - Environmental support (e.g., housing, home maintenance)|99
190|3 - Four to six times weekly|3 - Four to six times weekly|99
191|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessing by listener.  Speech limited to single words or short phrases.|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessin|99
192|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires multiple repetitions, restatements, demonstrations, additional time.|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires m|99
193|3 - Hopelessness|3 - Hopelessness|99
194|3 - Hospice care|3 - Hospice care|99
195|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|99
196|3 - Injury caused by fall or accident at home|3 - Injury caused by fall or accident at home|99
197|3 - Intractable pain|3 - Intractable pain|99
198|3 - Medicaid (traditional fee-for-service)|3 - Medicaid (traditional fee-for-service)|99
199|3 - Needs someone to do all shopping and errands.|3 - Needs someone to do all shopping and errands.|99
200|3 - Not healing|3 - Not healing|99
201|3 - Nursing home|3 - Nursing home [ Go to M2440 ]|99
202|3 - Once daily|3 - Once daily|99
203|3 - Other family member|3 - Other family member|99
204|3 - Outpatient department/clinic emergency (includes urgicenter sites)|3 - Outpatient department/clinic emergency (includes urgicenter sites)|99
205|3 - Paid help|3 - Paid help|99
206|3 - Able to participate in bathing self in shower or tub, but requires presence of another person throughout the bath for assistance or supervision.|3 - Able to participate in bathing self in shower or tub, but requires presence of another person th|99
207|3 - Patient depends entirely upon another person to dress lower body.|3 - Patient depends entirely upon another person to dress lower body.|99
208|3 - Patient depends entirely upon another person to dress the upper body.|3 - Patient depends entirely upon another person to dress the upper body.|99
209|3 - Patient depends entirely upon someone else for grooming needs.|3 - Patient depends entirely upon someone else for grooming needs.|99
210|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone else to manage the equipment.|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone|99
211|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable to shift attention and recall directions more than half the time.|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable|99
212|3 - Respiratory problems (SOB, infection, obstruction)|3 - Respiratory problems (SOB, infection, obstruction)|99
213|3 - Resumption of care (after inpatient stay)|3 - Resumption of care (after inpatient stay)|99
214|3 - Several times each month|3 - Several times each month|99
215|3 - Skilled Nursing Facility|3 - Skilled Nursing Facility|99
216|3 - Stage 3|3 - Stage 3|99
217|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|99
218|3 - Three|3 - Three|99
219|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person throughout the process.|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person through|99
220|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal independently.|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal indep|99
221|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person.|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person|99
222|3 - Unknown because patient moved to a geographic location not served by this agency|3 - Unknown because patient moved to a geographic location not served by this agency|99
223|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|99
224|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|99
225|3 - With other family member|3 - With other family member|99
226|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home health services, homemaker assistance, transportation assistance, assisted living, board and care)|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home h|99
227|3-SLP/ST|3-SLP/ST|99
228|4 - At rest (during day or night)|4 - At rest (during day or night)|99
229|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|99
230|4 - Board and care or assisted living facility|4 - Board and care or assisted living facility|99
231|4 - Caregiver is completely dependent on someone else to manage all equipment.|4 - Caregiver is completely dependent on someone else to manage all equipment.|99
232|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|99
233|4 - Constantly|4 - Constantly|99
234|4 - Drug dependency|4 - Drug dependency|99
235|4 - Four or more|4 - Four or more|99
236|4 - Friend or neighbor or community or church member|4 - Friend or neighbor or community or church member|99
237|4 - Hispanic or Latino|4 - Hispanic or Latino|99
238|4 - Hospice|4 - Hospice [ Go to M0906 ]|99
239|4 - Impaired decision-making|4 - Impaired decision-making|99
240|4 - Is totally dependent in toileting.|4 - Is totally dependent in toileting.|99
241|4 - Medicaid (HMO/managed care)|4 - Medicaid (HMO/managed care)|99
242|4 - None of the above|4 - None of the above|99
243|4 - Nursing home|4 - Nursing home|99
244|4 - On a daily basis|4 - On a daily basis|99
245|4 - Patient is completely dependent on someone else to manage all equipment.|4 - Patient is completely dependent on someone else to manage all equipment.|99
246|4 - Permanent placement|4 - Permanent placement|99
247|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, punches, dangerous maneuvers w/ wheelchair or other objects)|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, pu|99
248|4 - Psychosocial support (e.g., socialization, companionship, recreation)|4 - Psychosocial support (e.g., socialization, companionship, recreation)|99
249|4 - Recertification (follow-up) reassessment|4 - Recertification (follow-up) reassessment|99
250|4 - Recurrent thoughts of death|4 - Recurrent thoughts of death|99
251|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruction)|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruc|99
252|4 - Several times a week|4 - Several times a week|99
253|4 - Stage 4|4 - Stage 4|99
254|4 - Symptoms poorly controlled, history of re-hospitalizations|4 - Symptoms poorly controlled, history of re-hospitalizations|99
255|4 - Three or more times per week|4 - Three or more times per week|99
256|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetative state, or delirium.|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetati|99
257|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|99
258|4 - Unable to effectively participate in any housekeeping tasks.|4 - Unable to effectively participate in any housekeeping tasks.|99
259|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or unresponsive (e.g., speech is nonsensical or unintelligible).|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or u|99
260|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonresponsive.|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonr|99
261|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostomy.|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostom|99
262|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of devices at the sink, in chair, or on commode|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of|99
263|4 - With a friend|4 - With a friend|99
264|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|99
265|4-OT|4-OT|99
266|5 - Advocates or facilitates patient's participation in appropriate medical care|5 - Advocates or facilitates patient's participation in appropriate medical care|99
267|5 - At least daily|5 - At least daily|99
268|6 - Bedfast, unable to ambulate or be up in a chair.|6 - Bedfast, unable to ambulate or be up in a chair.|99
269|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|99
270|5 - Disruptive or socially inappropriate behavior|5 - Disruptive or socially inappropriate behavior|99
271|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|99
272|5 - Hypo/Hyperglycemia, diabetes out of control|5 - Hypo/Hyperglycemia, diabetes out of control|99
273|5 - More often than once daily|5 - More often than once daily|99
274|5 - Native Hawaiian or Pacific Islander|5 - Native Hawaiian or Pacific Islander|99
275|5 - None of the above|5 - None of the above|99
276|5 - One to two times per week|5 - One to two times per week|99
277|5 - Other|5 - Other|99
278|5 - Other follow-up|5 - Other follow-up|99
279|5 - Paid help|5 - Paid help|99
280|5 - Patient nonresponsive or unable to speak.|5 - Patient nonresponsive or unable to speak.|99
281|5 - Thoughts of suicide|5 - Thoughts of suicide|99
282|5 - Totally unable to use the telephone.|5 - Totally unable to use the telephone.|99
283|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|99
284|5 - Unable to take in nutrients orally or by tube feeding.|5 - Unable to take in nutrients orally or by tube feeding.|99
285|5 - Unsafe for care at home|5 - Unsafe for care at home|99
286|5 - With paid help (other than home care agency staff)|5 - With paid help (other than home care agency staff)|99
287|5 - Workers' compensation|5 - Workers' compensation|99
288|5 - Wound infection, deteriorating wound status, new lesion/ulcer|5 - Wound infection, deteriorating wound status, new lesion/ulcer|99
289|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|99
290|6 - Delusional, hallucinatory, or paranoid behavior|6 - Delusional, hallucinatory, or paranoid behavior|99
291|6 - Financial agent, power of attorney, or conservator of finance|6 - Financial agent, power of attorney, or conservator of finance|99
292|6 - GI bleeding, obstruction|6 - GI bleeding, obstruction|99
293|6 - Less often than weekly|6 - Less often than weekly|99
294|6 - Memory loss to the extent that supervision required|6 - Memory loss to the extent that supervision required|99
295|6 - None of the above feelings observed or reported|6 - None of the above feelings observed or reported|99
296|6 - Other|6 - Other|99
297|6 - Title programs (e.g., Title III, V, or XX)|6 - Title programs (e.g., Title III, V, or XX)|99
298|6 - Transferred to an inpatient facility - patient not discharged from agency|6 - Transferred to an inpatient facility - patient not discharged from agency|99
299|6 - White|6 - White|99
300|6 - With other than above|6 - With other than above|99
301|7 - Exacerbation of CHF, fluid overload, heart failure|7 - Exacerbation of CHF, fluid overload, heart failure|99
302|7 - Health care agent, conservator of person, or medical power of attorney|7 - Health care agent, conservator of person, or medical power of attorney|99
303|7 - Hypo/Hyperglycemia, diabetes out of control|7 - Hypo/Hyperglycemia, diabetes out of control|99
304|7 - None of the above|7 - None of the above|99
305|7 - None of the above behaviors demonstrated|7 - None of the above behaviors demonstrated|99
306|7 - Other government (e.g., TriCare, VA, etc.)|7 - Other government (e.g., TriCare, VA, etc.)|99
307|7 - Transferred to an inpatient facility - patient discharged from agency|7 - Transferred to an inpatient facility - patient discharged from agency|99
308|8 - Death at home|8 - Death at home|99
309|8 - GI bleeding, obstruction|8 - GI bleeding, obstruction|99
310|8 - Myocardial infarction, stroke|8 - Myocardial infarction, stroke|99
311|8 - Private insurance|8 - Private insurance|99
312|9 - Chemotherapy|9 - Chemotherapy|99
313|9 - Discharge from agency|9 - Discharge from agency|99
314|9 - Other than above reasons|9 - Other than above reasons|99
315|9 - Private HMO/managed care|9 - Private HMO/managed care|99
316|NA - No caregiver|NA - No caregiver|99
317|NA - No equipment of this type used in care.|NA - No equipment of this type used in care.|99
318|NA - No inhalant/mist medications prescribed.|NA - No inhalant/mist medications prescribed.|99
319|NA - No injectable medications prescribed.|NA - No injectable medications prescribed.|99
320|NA - No inpatient facility admission|NA - No inpatient facility admission|99
321|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|99
322|NA - No Medicaid|NA - No Medicaid|99
323|NA - No Medicare|NA - No Medicare|99
324|NA - No observable pressure ulcer|NA - No observable pressure ulcer|99
325|NA - No observable stasis ulcer|NA - No observable stasis ulcer|99
326|NA - No observable surgical wound|NA - No observable surgical wound|99
327|NA - No oral medications prescribed.|NA - No oral medications prescribed.|99
328|NA - Not applicable|NA - Not applicable|99
329|NA - Patient does not have a telephone.|NA - Patient does not have a telephone.|99
330|NA - Patient has ostomy for bowel elimination|NA - Patient has ostomy for bowel elimination|99
331|NA - Patient nonresponsive|NA - Patient nonresponsive|99
332|NA - Patient on prophylactic treatment|NA - Patient on prophylactic treatment|99
333|NA - Patient was not discharged from an inpatient facility [Go to M1017]|NA - Patient was not discharged from an inpatient facility [Go to M1017]|99
334|UK - Other unknown|UK - Other unknown|99
335|UK - Reason unknown|UK - Reason unknown|99
336|UK - Unknown|UK - Unknown|99
337|UK - Unknown or Not Available|UK - Unknown or Not Available|99
341|01 - Early|01 - Early|99
342|02 - Late|02 - Late|99
343|NA - Not Applicable. No case mix group defined for this assessment.|NA - Not Applicable. No case mix group defined for this assessment.|99
344|NA - No case mix group defined by this assessment.|NA - No case mix group defined by this assessment.|99
345|1 - Recent decline in mental, emotional, or behavioral status|1 - Recent decline in mental, emotional, or behavioral status|99
346|2 - Multiple hospitalizations (2 or more) in the past 12 months|2 - Multiple hospitalizations (2 or more) in the past 12 months|99
347|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|99
348|4 - Taking five or more medications|4 - Taking five or more medications|99
349|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|99
350|6 - Other|6 - Other|99
351|7 - None of the above|7 - None of the above|99
352|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond tho|99
353|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable without heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable wi|99
354|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious complications and death.|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious compl|99
355|3 - The patient has serious progressive conditions that could lead to death within a year.|3 - The patient has serious progressive conditions that could lead to death within a year.|99
356|UK - The patient+s situation is unknown or unclear.|UK - The patient+s situation is unknown or unclear.|99
357|0 - No [ Go to M1051 ]|0 - No [ Go to M1051 ]|99
358|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this influenza season. [ Go to M1050 ]|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this i|99
359|1 - Received from another health care provider (e.g., physician)|1 - Received from another health care provider (e.g., physician)|99
360|2 - Received from your agency previously during this year+s flu season|2 - Received from your agency previously during this year+s flu season|99
361|3 - Offered and declined|3 - Offered and declined|99
362|4 - Assessed and determined to have medical contraindication(s)|4 - Assessed and determined to have medical contraindication(s)|99
363|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|99
364|6 - Inability to obtain vaccine due to declared shortage|6 - Inability to obtain vaccine due to declared shortage|99
365|1 - Yes [ Go to M2005 at TRN; Go to M1230 at DC ]|1 - Yes [ Go to M2005 at TRN; Go to M1230 at DC ]|99
366|1 - Patient has received PPV in the past|1 - Patient has received PPV in the past|99
367|2 - Offered and declined|2 - Offered and declined|99
368|3 - Assessed and determined to have medical contraindication(s)|3 - Assessed and determined to have medical contraindication(s)|99
369|4 - Not indicated; patient does not meet age/condition guidelines for PPV|4 - Not indicated; patient does not meet age/condition guidelines for PPV|99
370|5 - None of the above|5 - None of the above|99
371|0 - Adequate: hears normal conversation without difficulty.|0 - Adequate: hears normal conversation without difficulty.|99
372|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to increase volume or speak distinctly.|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to in|99
373|2 - Severely Impaired: absence of useful hearing.|2 - Severely Impaired: absence of useful hearing.|99
374|UK - Unable to assess hearing.|UK - Unable to assess hearing.|99
375|0 - Understands: clear comprehension without cues or repetitions.|0 - Understands: clear comprehension without cues or repetitions.|99
376|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Requires cues at times to understand.|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Req|99
377|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequently requires cues to understand.|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequentl|99
378|3 - Rarely/Never Understands|3 - Rarely/Never Understands|99
379|UK - Unable to assess understanding.|UK - Unable to assess understanding.|99
380|0 - No standardized assessment conducted|0 - No standardized assessment conducted|99
381|1 - Yes, and it does not indicate severe pain|1 - Yes, and it does not indicate severe pain|99
382|2 - Yes, and it indicates severe pain|2 - Yes, and it indicates severe pain|99
383|0 - Patient has no pain|0 - Patient has no pain|99
384|1 - Patient has pain that does not interfere with activity or movement|1 - Patient has pain that does not interfere with activity or movement|99
385|2 - Less often than daily|2 - Less often than daily|99
386|3 - Daily, but not constantly|3 - Daily, but not constantly|99
387|4 - All of the time|4 - All of the time|99
388|0 - No assessment conducted [ Go to M1306 ]|0 - No assessment conducted [ Go to M1306 ]|99
389|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc., without use of standardized tool|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc.,|99
390|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|99
391|0 - No [ Go to M1322]|0 - No [ Go to M1322]|99
392|0 v Newly epithelialized|0 v Newly epithelialized|99
393|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|99
394|2 - Yes, patient has observable stasis ulcers ONLY|2 - Yes, patient has observable stasis ulcers ONLY|99
395|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable dressing) [Go to M1340]|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable|99
396|0 - No [ Go to M1400 ]|0 - No [ Go to M1400 ]|99
397|1 - Yes, patient has at least one (observable) surgical wound|1 - Yes, patient has at least one (observable) surgical wound|99
398|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1400 ]|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1400 ]|99
399|0 - Patient is not short of breath|0 - Patient is not short of breath|99
400|3 - Continuous Bi-level positive airway pressure|3 - Continuous Bi-level positive airway pressure|99
401|0 - No [ Go to M2005 at TRN; Go to M1600 at DC ]|0 - No [ Go to M2005 at TRN; Go to M1600 at DC ]|99
402|2 - Not assessed [Go to M2005 at TRN; Go to M1600 at DC ]|2 - Not assessed [Go to M1732 at TRN; Go to M1600 at DC ]|99
403|NA - Patient does not have diagnosis of heart failure [Go to M2005 at TRN; Go to M1600 at DC]|NA - Patient does not have diagnosis of heart failure [Go to M2005 at TRN; Go to M1600 at DC]|99
404|0 - No action taken|0 - No action taken|99
405|1 - Patient+s physician (or other primary care practitioner) contacted the same day|1 - Patient+s physician (or other primary care practitioner) contacted the same day|99
406|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|99
407|3 - Implement physician-ordered patient-specific established parameters for treatment|3 - Implement physician-ordered patient-specific established parameters for treatment|99
408|4 - Patient education or other clinical interventions|4 - Patient education or other clinical interventions|99
409|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequency, telehealth, etc.)|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequ|99
410|1 - Occasional stress incontinence|1 - Occasional stress incontinence|99
411|2 - During the night only|2 - During the night only|99
412|3 - During the day only|3 - During the day only|99
413|4 - During the day and night|4 - During the day and night|99
414|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|99
415|0 - Able to manage toileting hygiene and clothing management without assistance.|0 - Able to manage toileting hygiene and clothing management without assistance.|99
416|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implements are laid out for the patient.|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implemen|99
417|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|99
418|3 - Patient depends entirely upon another person to maintain toileting hygiene.|3 - Patient depends entirely upon another person to maintain toileting hygiene.|99
419|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independent|99
420|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface|99
421|0 - No multi-factor falls risk assessment conducted.|0 - No multi-factor falls risk assessment conducted.|99
422|1 - Yes, and it does not indicate a risk for falls.|1 - Yes, and it does not indicate a risk for falls.|99
423|2 - Yes, and it indicates a risk for falls.|2 - Yes, and it indicates a risk for falls.|99
424|0 - Not assessed/reviewed [ Go to M2010 ]|0 - Not assessed/reviewed [ Go to M2010 ]|99
425|1 - No problems found during review [ Go to M2010 ]|1 - No problems found during review [ Go to M2010 ]|99
426|2 - Problems found during review|2 - Problems found during review|99
427|NA - Patient is not taking any medications [ Go to M2040 ]|NA - Patient is not taking any medications [ Go to M2040 ]|99
428|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special precautions associated with all high-risk medications|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special p|99
429|NA - Patient not taking any drugs|NA - Patient not taking any drugs|99
430|2 - Able to take medication(s) at the correct times if given reminders by another person at the appropriate times|2 - Able to take medication(s) at the correct times if given reminders by another person at the appr|99
431|3 - Unable to take medication unless administered by another person.|3 - Unable to take medication unless administered by another person.|99
432|1 - At least daily|1 - At least daily|99
433|2 - Three or more times per week|2 - Three or more times per week|99
434|3 - One to two times per week|3 - One to two times per week|99
435|4 - Received, but less often than weekly|4 - Received, but less often than weekly|99
436|5 - No assistance received|5 - No assistance received|99
437|0 - No [Go to M2401]|0 - No [Go to M2401]|99
438|1 - Yes, used hospital emergency department WITHOUT hospital admission|1 - Yes, used hospital emergency department WITHOUT hospital admission|99
439|2 - Yes, used hospital emergency department WITH hospital admission|2 - Yes, used hospital emergency department WITH hospital admission|99
440|UK - Unknown [Go to M2401]|UK - Unknown [Go to M2401]|99
441|2 - Injury caused by fall|2 - Injury caused by fall|99
442|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|99
443|4 - Other respiratory problem|4 - Other respiratory problem|99
444|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|99
445|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|99
446|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|99
447|8 - Other heart disease|8 - Other heart disease|99
448|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|99
449|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|99
450|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|99
451|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|99
452|13 - Urinary tract infection|13 - Urinary tract infection|99
453|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|99
454|15 - Wound infection or deterioration|15 - Wound infection or deterioration|99
455|16 - Uncontrolled pain|16 - Uncontrolled pain|99
456|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|99
457|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|99
458|19 - Other than above reasons|19 - Other than above reasons|99
459|2 - Patient remained in the community (with formal assistive services)|2 - Patient remained in the community (with formal assistive services)|99
460|3 - Patient transferred to a noninstitutional hospice|3 - Patient transferred to a noninstitutional hospice|99
461|4 - Unknown because patient moved to a geographic location not served by this agency|4 - Unknown because patient moved to a geographic location not served by this agency|99
462|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|99
463|4 - Other respiratory problem|4 - Other respiratory problem|99
464|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|99
465|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|99
466|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|99
467|8 - Other heart disease|8 - Other heart disease|99
468|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|99
469|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|99
470|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|99
471|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|99
472|13 - Urinary tract infection|13 - Urinary tract infection|99
473|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|99
474|15 - Wound infection or deterioration|15 - Wound infection or deterioration|99
475|16 - Uncontrolled pain|16 - Uncontrolled pain|99
476|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|99
477|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|99
478|19 - Scheduled treatment or procedure|19 - Scheduled treatment or procedure|99
479|20 - Other than above reasons|20 - Other than above reasons|99
480|UK - Reason unknown [Go to M0903]|UK - Reason unknown [Go to M0903]|99
482|01 - Patient lives alone around the clock|01 - Patient lives alone around the clock|99
483|02 - Patient lives alone regular daytime|02 - Patient lives alone regular daytime|99
484|03 - Patient lives alone regular nighttime|03 - Patient lives alone regular nighttime|99
485|04 - Patient lives alone occassional/short term assistance|04 - Patient lives alone occassional/short term assistance|99
486|05 - Patient lives alone no assisstance available|05 - Patient lives alone no assisstance available|99
487|06 - Patient lives with other person(s) in the home around the clock|06 - Patient lives with other person(s) in the home around the clock|99
488|07 - Patient lives with other person(s) in the home regular daytime|07 - Patient lives with other person(s) in the home regular daytime|99
489|08 - Patient lives with other person(s) in the home regular nighttime|08 - Patient lives with other person(s) in the home regular nighttime|99
490|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|99
491|10 - Patient lives with other person(s) in the home no assistance available|10 - Patient lives with other person(s) in the home no assistance available|99
492|1 - Was present at the most recent SOC/ROC assessment [Goto M1311A1]|1 - Was present at the most recent SOC/ROC assessment [Goto M1311A1]|99
493|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|99
494|NA - No non-epithelialized Stage II pressure ulcers are present at discharge [Goto M1311A1]|NA - No non-epithelialized Stage II pressure ulcers are present at discharge [Goto M1311A1]|99
495|0 - Newly epithelialized|0 - Newly epithelialized|99
496|0 - No [ Go to M1340 ]|0 - No [ Go to M1340 ]|99
498|0 - Independent|0 - Independent|99
499|1 - Needed Some Help|1 - Needed Some Help|99
500|2 - Dependent|2 - Dependent|99
502|0 - No assistance needed in this area|0 - No assistance needed in this area|99
503|1 - Caregiver(s) currently provide assistance|1 - Caregiver(s) currently provide assistance|99
504|2 - Caregiver(s) need training/ supportive services to provide assistance|2 - Caregiver(s) need training/ supportive services to provide assistance|99
505|3 - Caregiver(s) not likely to provide assistance|3 - Caregiver(s) not likely to provide assistance|99
506|4 - Unclear if Caregiver(s) will provide assistance|4 - Unclear if Caregiver(s) will provide assistance|99
507|5 - Assistance needed, but no Caregiver(s) available|5 - Assistance needed, but no Caregiver(s) available|99
508|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will use standardized clinical guidelines accessible for all care providers to reference|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will|99
510|NA - Patient is not assessed to be at risk for falls|NA - Patient is not assessed to be at risk for falls|99
511|NA - Patient has no diagnosis or symptoms of depression|NA - Patient has no diagnosis or symptoms of depression|99
512|NA - No pain identified|NA - No pain identified|99
513|NA - Patient is not assessed to be at risk for pressure ulcers|NA - Patient is not assessed to be at risk for pressure ulcers|99
514|NA - Patient has no pressure ulcers with need for moist wound healing|NA - Patient has no pressure ulcers with need for moist wound healing|99
515|1 - Long-term nursing facility (NF)|1 - Long-term nursing facility (NF)|99
516|2 - Skilled nursing facility (SNF / TCU)|2 - Skilled nursing facility (SNF / TCU)|99
517|3 - Short stay acute hospital (IPP S)|3 - Short stay acute hospital (IPP S)|99
518|4 - Long-term care hospital (LTCH)|4 - Long-term care hospital (LTCH)|99
519|5 - Inpatient rehabilitation hospital or unit (IRF)|5 - Inpatient rehabilitation hospital or unit (IRF)|99
520|6 - Psychiatric hospital or unit|6 - Psychiatric hospital or unit|99
521|7 - Other|7 - Other|99
522|NA - Patient was not discharged from an inpatient facility [Go to M1017]|NA - Patient was not discharged from an inpatient facility [Go to M1017]|99
523|6 - Unable to participate effectively in bathing and is bathed totally by another person|6 - Unable to participate effectively in bathing and is bathed totally by another person|99
524|4 - Chairfast, unable to ambulate but is able to wheel self independently.|4 - Chairfast, unable to ambulate but is able to wheel self independently.|99
525|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask patient: "Over the last two weeks, how often have you been bothered by any of the following problems")  *Copyright+ Pfizer Inc. All rights reserved. Reproduced with permission.|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask|99
526|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluation for depression.|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluat|99
527|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet criteria for further evaluation for depression.|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet|99
528|0 - Not at all  0 - 1 day|0 - Not at all  0 - 1 day|99
529|1 - Several days  2 - 6 days|1 - Several days  2 - 6 days|99
530|2 - More than half of the days  7 - 11 days|2 - More than half of the days  7 - 11 days|99
531|3 - Nearly every day  12 - 14 days|3 - Nearly every day  12 - 14 days|99
532|NA - N/A  Unable to respond|NA - N/A  Unable to respond|99
533|2 - Able to take medication(s) at the correct times if given reminders by another person based on the frequency of the injection|2 - Able to take medication(s) at the correct times if given reminders by another person based on th|99
534|3 - Unable to take injectable medication unless administered by another person.|3 - Unable to take injectable medication unless administered by another person.|99
570|NA - No observable pressure ulcer or unhealed pressure ulcer|NA - No observable pressure ulcer or unhealed pressure ulcer|99
571|NA - There were no potential clinically significant medication issues identified since SOC/ROC or patient is not taking any medications|NA - There were no potential clinically significant medication issues identified sinc|99
572|NA - Patient is not diabetic or is bilateral amputee|NA - Patient is not diabetic or is bilateral amputee|99
573|NA - Every standardized,validated multifactor fall risk assessment conducted at or since the most recent SOC/ROC assessment indicates the patient has no risk for falls.|NA - Every standardized,validated multifactor fall risk assessment condition|99
574|NA - Patient has no diagnosis of depression AND every standardized, validated depression screening conducted at or since the most recent SOC/ROC assessment indicates the patient has: 1) no symptoms of depression; or 2) has some symptoms of depression but does not meet criteria for further evaluation of depression based on screening tool used.|NA - Patient has no diagnosis of depression AND every standardized, validated |99
575|NA - Every standardized, validated pain assessment conducted at or since the most recent SOC/ROC assessment indicates the patient has no pain.|NA - Every standardized, validated pain assessment conducted at or since the most|99
576|NA - Every standardized, validated pressure ulcer risk assessment conducted at or since the most recent SOC/ROC assessment indicates the patient is not at risk of developing pressure ulcers.|NA - Every standardized, validated pressure ulcer risk assessment conducted|99
577|NA - Dressings that support the principles of moist wound healing not indicated for this patient's pressure ulcers OR patient has no pressure ulcers with need for moist wound healing|NA - Dressings that support the principles of moist wound healing not indicated for this patient's p|99
578|1 - Patient remained in the community (without formal assistive services)|1 - Patient remained in the community (without formal assistive services)|99
579|2 - Patient remained in the community (with formal assistive services)|2 - Patient remained in the community (with formal assistive services)|99
580|3 - Patient transferred to a non-institutional hospice|3 - Patient transferred to a non-institutional hospice|99
581|4 - Unknown because patient moved to a geographic location not served by this agency|4 - Unknown because patient moved to a geographic location not served by this agency|99
620|1 - Yes; received from your agency during this episode of care (SOC/ROC to Transfer/Discharge)|1 - Yes; received from your agency during this episode of care (SOC/ROC to Transfer/Discharge)|99
621|2 - Yes; received from your agency during a prior episode of care (SOC/ROC to Transfer/Discharge)|2 - Yes; received from your agency during a prior episode of care (SOC/ROC to Transfer/Discharge)|99
622|3 - Yes; received from another health care provider (for example physician pharmacist)|3 - Yes; received from another health care provider (for example physician pharmacist)|99
623|4 - No; patient offered and declined |4 - No; patient offered and declined |99
624|5 - No; patient assessed and determined to have medical contraindication(s)|5 - No; patient assessed and determined to have medical contraindication(s)|99
625|6 - No; not indicated - patient does not meet age/condition guidelines for influenza vaccine|6 - No; not indicated - patient does not meet age/condition guidelines for influenza vaccine|99
626|7 - No; inability to obtain vaccine due to declared shortage |7 - No; inability to obtain vaccine due to declared shortage |99
627|8 - No; patient did not receive the vaccine due to reasons other than those listed in responses 4 v 7. |8 - No; patient did not receive the vaccine due to reasons other than those listed in responses 4v7.|99
628|1 - Offered and declined|1 - Offered and declined|99
629|2 - Assessed and determined to have medical contraindication(s) |2 - Assessed and determined to have medical contraindication(s) |99
630|3 - Not indicated; patient does not meet age/condition guidelines for Pneumococcal Vaccine|3 - Not indicated; patient does not meet age/condition guidelines for Pneumococcal Vaccine|99
631|4 - None of the above|4 - None of the above|99
632|0 - No assistance needed v patient is independent or does not have needs in this area|0 - No assistance needed v patient is independent or does not have needs in this area|99
633|1 - Non-agency caregiver(s) currently provide assistance |1 - Non-agency caregiver(s) currently provide assistance |99
634|2 - Non-agency caregiver(s) need training/ supportive services to provide assistance|2 - Non-agency caregiver(s) need training/ supportive services to provide assistance|99
635|3 - Non-agency caregiver(s) are not likely to provide assistance OR it is unclear if they will provide assistance|3 - Non-agency caregiver(s) are not likely to provide assistance OR unclear if will provide asst|99
636|4 - Assistance needed but no non-agency caregiver(s) available|4 - Assistance needed but no non-agency caregiver(s) available|99
2|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; OR (b) Is physically, cognitively, and mentally able to prepare light meals on a regular basis but has not routinely performed light meal preparation in the past (i.e., prior to this home care admission).|0 - (a) Able to independently plan and prepare all light meals for self or reheat delivered meals; O|999
3|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and mentally able to perform all housekeeping tasks .|0 - a) Able to independently perform all housekeeping tasks OR b) Physically, cognitively, and menta|999
4|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and mentally able to do laundry and access facilities.|0 - a) Able to independently take care of all laundry tasks OR b) Physically, cognitively, and menta|999
5|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying packages OR b) Physically, cognitively, and mentally able to take care of shopping, but has not done shopping in the past (i.e., prior to this home care admission).|0 - a) Able to plan for shopping needs and independently perform shopping tasks, including carrying|999
6|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|0 - Able to bathe self in SHOWER OR TUB independently, including getting in and out of tub/shower|999
7|0 - Able to dial numbers and answer calls appropriately and as desired.|0 - Able to dial numbers and answer calls appropriately and as desired.|999
8|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body without assistance.|0 - Able to get clothes out of closets and drawers, put them on and remove them from the upper body|999
9|0 - Able to get to and from the toilet and transfer independently with or without a device.|0 - Able to get to and from the toilet and transfer independently with or without a device.|999
10|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|0 - Able to groom self unaided, with or without the use of assistive devices or adapted methods.|999
11|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible public bus.|0 - Able to independently drive a regular or adapted car, OR uses a regular or handicap-accessible p|999
12|0 - Able to independently feed self.|0 - Able to independently feed self.|999
13|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|0 - Able to independently take the correct medication(s) and proper dosage(s) at the correct times|999
14|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct times.|0 - Able to independently take the correct oral medication(s) and proper dosage(s) at the correct ti|999
15|0 - Able to independently transfer.|0 - Able to independently transfer.|999
16|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even and uneven surfaces and negotiate stairs with or without rail|999
17|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings (i.e., needs no human assistance or assistive device).|0 - Able to independently walk on even or uneven surfaces and climb stairs with or without railings|999
18|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|0 - Able to obtain, put on, and remove clothing and shoes without assistance.|999
19|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions independently.|0 - Alert/oriented, able to focus and shift attention, comprehends and recalls task directions indep|999
20|0 - Asymptomatic, no treatment needed at this time|0 - Asymptomatic, no treatment needed at this time|999
21|0 - Caregiver manages all tasks related to equipment completely independently.|0 - Caregiver manages all tasks related to equipment completely independently.|999
22|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations with no observable impairment.|0 - Expresses complex ideas, feelings, and needs clearly, completely, and easily in all situations w|999
23|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|0 - Guarded:  minimal improvement in functional status is expected, decline is possible|999
24|0 - Life expectancy is greater than 6 months|0 - Life expectancy is greater than 6 months|999
25|0 - Never|0 - Never|999
26|0 - Patient is not short of breath|0 - Patient is not short of breath|999
27|0 - No|0 - No|999
28|0 - No emergent care services|0 - No emergent care services|999
29|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [ Go to M1620 ]|0 - No incontinence or catheter (includes anuria or ostomy for urinary drainage) [ Go to M1620 ]|999
30|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and extended or abstract conversation.|0 - No observable impairment.  Able to hear and understand complex or detailed instructions and exte|999
31|0 - No one person|0 - No one person|999
32|0 - None of the time|0 - None of the time|999
33|0 - None, no charge for current services|0 - None, no charge for current services|999
34|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|0 - Normal vision:  sees adequately in most situations, can see medication labels, newsprint.|999
35|0 - Patient does NOT have an ostomy for bowel elimination.|0 - Patient does NOT have an ostomy for bowel elimination.|999
36|0 - Patient has no pain|0 - Patient has no pain|999
37|0 - Patient manages all tasks related to equipment completely independently.|0 - Patient manages all tasks related to equipment completely independently.|999
38|0 - Poor:  little or no recovery is expected and/or further decline is imminent|0 - Poor:  little or no recovery is expected and/or further decline is imminent|999
39|0 - Timed-voiding defers incontinence|0 - Timed-voiding defers incontinence|999
40|0 - Very rarely or never has bowel incontinence|0 - Very rarely or never has bowel incontinence|999
41|0 - Zero|0 - Zero|999
42|00 - No|00 - No|999
43|01 - Yes|01 - Yes|999
44|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or mental limitations, needs assistance with heavy laundry.|1 - Able to do only light laundry, (minor hand wash or light loads).  Due to physical, cognitive, or|999
45|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the patient.|1 - Able to dress lower body without assistance if clothing and shoes are laid out or handed to the|999
46|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|1 - Able to dress upper body without assistance if clothing is laid out or handed to the patient.|999
47|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or supervision from another person OR c) a liquid, pureed or ground meat diet.|1 - Able to feed self independently but requires: a) meal set-up OR b) intermittent assistance or su|999
48|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|999
49|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping and carry small packages, but needs someone to do occasional major shopping, OR (b) UNABLE to go shopping alone, but can go with someone to assist.|1 - Able to go shopping, but needs some assistance: (a) By self is able to do only light shopping an|999
50|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independently.|1 - Able to perform only LIGHT housekeeping (e.g., dusting, wiping kitchen counters) tasks independe|999
51|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only when assisted or accompanied by another person.|1 - Able to ride in car only when driven by another person OR able to use bus or handicap van only w|999
52|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take injectable medication(s) at the correct times if: (a) individual syringes are prepa|999
53|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance by another person OR b) given daily reminders.|1 - Able to take medication at the correct times if: a) individual dosages are prepared in advance b|999
54|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if, (a) individual dosages are prepared in advan|999
55|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advance by another person; OR (b) another person develops a drug diary or chart.|1 - Able to take medication(s) at the correct times if: (a) individual dosages are prepared in advan|999
56|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for the deaf) and call essential numbers.|1 - Able to use a specially adapted telephone (i.e., large numbers on the dial, teletype phone for t|999
57|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|1 - ADL assistance (e.g., bathing, dressing, toileting, bowel/bladder, eating/feeding)|999
58|1 - American Indian or Alaska Native|1 - American Indian or Alaska Native|999
59|1 - Depressed mood (e.g., feeling sad, tearful)|1 - Depressed mood (e.g., feeling sad, tearful)|999
60|1 - During the night only|1 - During the night only|999
61|1 - Fully granulating|1 - Fully granulating|999
62|1 - Good/Fair:  partial to full recovery is expected|1 - Good/Fair:  partial to full recovery is expected|999
63|1 - Good:  marked improvement in functional status is expected|1 - Good:  marked improvement in functional status is expected|999
64|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|1 - Grooming utensils must be placed within reach before able to complete grooming activities.|999
65|1 - Smoking|1 - Smoking|999
66|1 - Hospital|1 - Hospital|999
67|1 - Hospital emergency room (includes 23-hour holding)|1 - Hospital emergency room (includes 23-hour holding)|999
68|1 - Hospitalization for EMERGENT (unscheduled) care|1 - Hospitalization for EMERGENT (unscheduled) care|999
69|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepared solutions), patient is able to manage all other aspects of equipment.|1 - If someone else sets up equipment (i.e. fills portable oxygen tank, provides patient with prepar|999
70|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|1 - If someone else sets up equipment, caregiver is able to manage all other aspects.|999
71|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|1 - Improper medication administration, medication side effects, toxicity, anaphylaxis|999
72|1 - In new or complex situations only|1 - In new or complex situations only|999
73|1 - Intravenous or infusion therapy (excludes TPN)|1 - Intravenous or infusion therapy (excludes TPN)|999
74|1 - Less often than daily|1 - Less often than daily|999
75|1 - Less than once a month|1 - Less than once a month|999
76|1 - Less than once weekly|1 - Less than once weekly|999
77|1 - Life expectancy is 6 months or fewer|1 - Life expectancy is 6 months or fewer|999
78|1 - Lives alone|1 - Lives alone|999
79|1 - Male|1 - Male|999
80|1 - Medicare (traditional fee-for-service)|1 - Medicare (traditional fee-for-service)|999
81|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of past 24 hours, significant memory loss so that supervision is required|1 - Memory deficit:  failure to recognize familiar persons/places, inability to recall events of pas|999
82|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors in word choice, grammar or speech intelligibility, needs minimal prompting or assistance).|1 - Minimal difficulty in expressing ideas and needs (may take extra time, makes occasional errors i|999
83|1 - No assistance or services received|1 - No assistance or services received|999
84|1 - One|1 - One|999
85|1 - Oxygen (intermittent or continuous)|1 - Oxygen (intermittent or continuous)|999
86|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, and the surrounding layout, can count fingers at arm's length.|1 - Partially impaired:  cannot see medication labels or newsprint, but CAN see obstacles in path, a|999
87|1 - Patient is incontinent|1 - Patient is incontinent|999
88|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|1 - Patient remained in the community (not in hospital, nursing home, or rehab facility)|999
89|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical or treatment regimen.|1 - Patient's ostomy was NOT related to an inpatient stay and did NOT necessitate change in medical|999
90|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient/couple/significant other)|1 - Patient's owned or rented residence (house, apartment, or mobile home owned or rented by patient|999
91|1 - Relatives, friends, or neighbors living outside the home|1 - Relatives, friends, or neighbors living outside the home|999
92|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions.|1 - Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar conditions|999
93|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 -With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independentl|999
94|1 - Several times during day and night|1 - Several times during day and night|999
95|1 - Spouse or significant other|1 - Spouse or significant other|999
96|1 - Stage 1|1 - Stage 1|999
97|1 - Start of care - further visits planned|1 - Start of care - further visits planned|999
98|1 - Symptoms well controlled with current therapy|1 - Symptoms well controlled with current therapy|999
99|1 - Therapy services|1 - Therapy services|999
100|1 - Able to transfer with minimal human assistance or with use of an assistive device.|1 - Able to transfer with minimal human assistance or with use of an assistive device.|999
101|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitations.|1 - UNABLE to prepare light meals on a regular basis due to physical, cognitive, or mental limitatio|999
102|1 - Urinary incontinence|1 - Urinary incontinence|999
103|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and transfer.|1 - When reminded, assisted, or supervised by another person, able to get to and from the toilet and|999
104|1 - When walking more than 20 feet, climbing stairs|1 - When walking more than 20 feet, climbing stairs|999
105|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary conversation. May need occasional repetition, extra time, or louder voice.|1 - With minimal difficulty, able to hear and understand most multi-step instructions and ordinary c|999
106|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting in and out of tub/shower|1 - With the use of devices, is able to bathe self in shower or tub independently, including getting|999
107|1 - Yes|1 - Yes|999
108|1-RN|1-RN|999
109|10 - Discharge from agency - no visits completed after start/resumption of care assessment|10 - Discharge from agency - no visits completed after start/resumption of care assessment|999
110|10 - Scheduled surgical procedure|10 - Scheduled surgical procedure|999
111|10 - Self-pay|10 - Self-pay|999
112|11 - Other|11 - Other|999
113|11 - Urinary tract infection|11 - Urinary tract infection|999
114|12 - IV catheter-related infection|12 - IV catheter-related infection|999
115|13 - Deep vein thrombosis, pulmonary embolus|13 - Deep vein thrombosis, pulmonary embolus|999
116|14 - Uncontrolled pain|14 - Uncontrolled pain|999
117|15 - Psychotic episode|15 - Psychotic episode|999
118|16 - Other than above reasons|16 - Other than above reasons|999
119|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing calls.|2 - Able to answer the telephone and carry on a normal conversation but has difficulty with placing|999
120|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another person.|2 - Able to perform housekeeping tasks with intermittent assistance or supervision from another pers|999
121|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 -Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface a|999
122|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for intermittent supervision or encouragement or reminders, OR (b) to get in and out of the shower or tub, OR (c) for washing difficult to reach areas.|2 - Able to bathe in shower or tub with the intermittent assistance of another person: (a) for inter|999
123|2 - Asian|2 - Asian|999
124|2 - Caregiver requires considerable assistance from another person to manage equipment, but independently completes significant portions of task.|2 - Caregiver requires considerable assistance from another person to manage equipment, but independ|999
125|2 - Daily, but not constantly|2 - Daily, but not constantly|999
126|2 - Daughter or son|2 - Daughter or son|999
127|2 - Doctor's office emergency visit/house call|2 - Doctor's office emergency visit/house call|999
128|2 - During the day and night|2 - During the day and night|999
129|2 - Early/partial granulation|2 - Early/partial granulation|999
130|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors in word choice, organization or speech intelligibility). Speaks in phrases or short sentences.|2 - Expresses simple ideas or needs with moderate difficulty (needs prompting or assistance, errors|999
131|2 - Family member's residence|2 - Family member's residence|999
132|2 - Female|2 - Female|999
133|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conversation, needs frequent prompting or assistance.|2 - Has moderate difficulty hearing and understanding simple, one-step instructions and brief conver|999
134|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|2 - Hospitalization for URGENT (scheduled within 24 hours of admisson) care|999
135|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|2 - IADL assistance (e.g., meds, meals, housekeeping, laundry, telephone, shopping, finances)|999
136|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately stop activities, jeopardizes safety through actions|2 - Impaired decision-making:  failure to perform usual ADLs or IADLs, inability to appropriately st|999
137|2 - Indwelling/suprapubic catheter|2 - Indwelling/suprapubic catheter|999
138|2 - Injury caused by fall or accident at home|2 - Injury caused by fall or accident at home|999
139|2 - Medicare (HMO/managed care/Advantage plan)|2 - Medicare (HMO/managed care/Advantage plan)|999
140|2 - Nausea, dehydration, malnutrition, constipation, impaction|2 - Nausea, dehydration, malnutrition, constipation, impaction|999
141|2 - Obesity|2 - Obesity|999
142|2 - On awakening or at night only|2 - On awakening or at night only|999
143|2 - Once a month|2 - Once a month|999
144|2 - One to three times weekly|2 - One to three times weekly|999
145|2 - Parenteral nutrition (TPN or lipids)|2 - Parenteral nutrition (TPN or lipids)|999
146|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic)  [ Go to M1620 ]|2 - Patient requires a urinary catheter (i.e., external, indwelling, intermittent, suprapubic)  [ Go|999
147|2 - Patient requires considerable assistance from another person to manage equipment, but independently completes portions of the task.|2 - Patient requires considerable assistance from another person to manage equipment, but independen|999
148|2 - Patient transferred to a noninstitutional hospice|2 - Patient transferred to a noninstitutional hospice|999
149|2 - Person residing in the home (EXCLUDING paid help)|2 - Person residing in the home (EXCLUDING paid help)|999
150|2 - Rehabilitation facility|2 - Rehabilitation facility|999
151|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifting of attention) or consistently requires low stimulus environment due to distractibility.|2 - Requires assistance and some direction in specific situations (eg, on all tasks involving shifti|999
152|2 - Respite care|2 - Respite care|999
153|2 - Sense of failure or self reproach|2 - Sense of failure or self reproach|999
154|2 - Several times during day|2 - Several times during day|999
155|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonresponsive.|2 - Severely impaired:  cannot locate objects without hearing or touching them OR patient nonrespons|999
156|2 - Someone must assist the patient to groom self.|2 - Someone must assist the patient to groom self.|999
157|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|2 - Someone must help the patient put on undergarments, slacks, socks or nylons, and shoes.|999
158|2 - Someone must help the patient put on upper body clothing.|2 - Someone must help the patient put on upper body clothing.|999
159|2 - Stage 2|2 - Stage 2|999
160|2 - Start of care - no further visits planned|2 - Start of care - no further visits planned|999
161|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitoring|2 - Symptoms controlled with difficulty, affecting daily functioning; patient needs ongoing monitori|999
162|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment regimen.|2 - The ostomy WAS related to an inpatient stay or DID necessitate change in medical or treatment re|999
163|2 - Two|2 - Two|999
164|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistance due to cognitive or mental limitation.|2 - UNABLE to do any laundry due to physical limitation or needs continual supervision and assistanc|999
165|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|2 - UNABLE to feed self and must be assisted or supervised throughout the meal/snack.|999
166|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assistance).|2 - UNABLE to get to and from the toilet but is able to use a bedside commode (with or without assis|999
167|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home delivery.|2 - UNABLE to go shopping, but is able to identify items needed, place orders, and arrange home deli|999
168|2 - Unable to prepare any light meals or reheat any delivered meals.|2 - Unable to prepare any light meals or reheat any delivered meals.|999
169|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|2 - UNABLE to ride in a car, taxi, bus, or van, and requires transportation by ambulance.|999
170|2 - UNABLE to take injectable medications unless administered by someone else.|2 - UNABLE to take injectable medications unless administered by someone else.|999
171|2 - UNABLE to take medication unless administered by someone else.|2 - UNABLE to take medication unless administered by someone else.|999
172|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|2 - Able to bear weight and pivot during the transfer process but unable to transfer self.|999
173|2 - Ventilator (continually or at night)|2 - Ventilator (continually or at night)|999
174|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less than 20 feet)|2 - With moderate exertion (e.g., while dressing, using commode or bedpan, walking distances less th|999
175|2 - With spouse or significant other|2 - With spouse or significant other|999
176|2 - Yes, assistance or services provided by family or friends|2 - Yes, assistance or services provided by family or friends|999
177|2-PT|2-PT|999
178|3 - Able to answer the telephone only some of the time or is able to carry on only a limited conversation.|3 - Able to answer the telephone only some of the time or is able to carry on only a limited convers|999
179|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube or gastrostomy.|3 - Able to take in nutrients orally AND receives supplemental nutrients through a nasogastric tube|999
180|3 - Alcohol dependency|3 - Alcohol dependency|999
181|3 - All of the time|3 - All of the time|999
182|3 - Black or African-American|3 - Black or African-American|999
183|3 - Boarding home or rented room|3 - Boarding home or rented room|999
184|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment, clean/store/dispose of equipment or supplies).|3 - Caregiver is only able to complete small portions of task (e.g., administer nebulizer treatment,|999
185|3 -Able to walk only with the supervision or assistance of another person at all times.|3 -Able to walk only with the supervision or assistance of another person at all times.|999
186|3 - Continuous / Bi-level positive airway pressure|3 - Continuous / Bi-level positive airway pressure|999
187|3 - During the day and evening, but not constantly|3 - During the day and evening, but not constantly|999
188|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the alimentary canal)|3 - Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the|999
189|3 - Environmental support (e.g., housing, home maintenance)|3 - Environmental support (e.g., housing, home maintenance)|999
190|3 - Four to six times weekly|3 - Four to six times weekly|999
191|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessing by listener.  Speech limited to single words or short phrases.|3 - Has severe difficulty expressing basic ideas or needs and requires maximal assistance or guessin|999
192|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires multiple repetitions, restatements, demonstrations, additional time.|3 - Has severe difficulty hearing and understanding simple greetings and short comments.  Requires m|999
193|3 - Hopelessness|3 - Hopelessness|999
194|3 - Hospice care|3 - Hospice care|999
195|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|3 - Hospitalization for ELECTIVE (scheduled more than 24 hours before admission) care|999
196|3 - Injury caused by fall or accident at home|3 - Injury caused by fall or accident at home|999
197|3 - Intractable pain|3 - Intractable pain|999
198|3 - Medicaid (traditional fee-for-service)|3 - Medicaid (traditional fee-for-service)|999
199|3 - Needs someone to do all shopping and errands.|3 - Needs someone to do all shopping and errands.|999
200|3 - Not healing|3 - Not healing|999
201|3 - Nursing home|3 - Nursing home|999
202|3 - Once daily|3 - Once daily|999
203|3 - Other family member|3 - Other family member|999
204|3 - Outpatient department/clinic emergency (includes urgicenter sites)|3 - Outpatient department/clinic emergency (includes urgicenter sites)|999
205|3 - Paid help|3 - Paid help|999
206|3 - Able to participate in bathing self in shower or tub, but requires presence of another person throughout the bath for assistance or supervision.|3 - Able to participate in bathing self in shower or tub, but requires presence of another person th|999
207|3 - Patient depends entirely upon another person to dress lower body.|3 - Patient depends entirely upon another person to dress lower body.|999
208|3 - Patient depends entirely upon another person to dress the upper body.|3 - Patient depends entirely upon another person to dress the upper body.|999
209|3 - Patient depends entirely upon someone else for grooming needs.|3 - Patient depends entirely upon someone else for grooming needs.|999
210|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone else to manage the equipment.|3 - Patient is only able to monitor equipment (e.g., liter flow, fluid in bag) and must call someone|999
211|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable to shift attention and recall directions more than half the time.|3 - Requires considerable assistance in routine situations.  Is not alert and oriented or is unable|999
212|3 - Respiratory problems (SOB, infection, obstruction)|3 - Respiratory problems (SOB, infection, obstruction)|999
213|3 - Resumption of care (after inpatient stay)|3 - Resumption of care (after inpatient stay)|999
214|3 - Several times each month|3 - Several times each month|999
215|3 - Skilled Nursing Facility|3 - Skilled Nursing Facility|999
216|3 - Stage 3|3 - Stage 3|999
217|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|3 - Symptoms poorly controlled, patient needs frequent adjustment in treatment and dose monitoring|999
218|3 - Three|3 - Three|999
219|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person throughout the process.|3 - UNABLE to consistently perform any  housekeeping tasks unless assisted by another person through|999
220|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal independently.|3 - UNABLE to get to and from the toilet or bedside commode but is able to use a bedpan/urinal indep|999
221|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person.|3 - Unable to transfer self and is UNABLE to bear weight or pivot when transferred by another person|999
222|3 - Unknown because patient moved to a geographic location not served by this agency|3 - Unknown because patient moved to a geographic location not served by this agency|999
223|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|3 - Verbal disruption:  yelling, threatening, excessive profanity, sexual references, etc.|999
224|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|3 - With minimal exertion (e.g., while eating, talking, or performing other ADLs) or with agitation|999
225|3 - With other family member|3 - With other family member|999
226|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home health services, homemaker assistance, transportation assistance, assisted living, board and care)|3 - Yes, assistance or services provided by other community resources (e.g., meals-on-wheels, home h|999
227|3-SLP/ST|3-SLP/ST|999
228|4 - At rest (during day or night)|4 - At rest (during day or night)|999
229|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|4 - Bedfast, unable to transfer but is able to turn and position self in bed.|999
230|4 - Board and care or assisted living facility|4 - Board and care or assisted living facility|999
231|4 - Caregiver is completely dependent on someone else to manage all equipment.|4 - Caregiver is completely dependent on someone else to manage all equipment.|999
232|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|5 - Chairfast, unable to ambulate and is UNABLE to wheel self.|999
233|4 - Constantly|4 - Constantly|999
234|4 - Drug dependency|4 - Drug dependency|999
235|4 - Four or more|4 - Four or more|999
236|4 - Friend or neighbor or community or church member|4 - Friend or neighbor or community or church member|999
237|4 - Hispanic or Latino|4 - Hispanic or Latino|999
238|4 - Hospice|4 - Hospice|999
239|4 - Impaired decision-making|4 - Impaired decision-making|999
240|4 - Is totally dependent in toileting.|4 - Is totally dependent in toileting.|999
241|4 - Medicaid (HMO/managed care)|4 - Medicaid (HMO/managed care)|999
242|4 - None of the above|4 - None of the above|999
243|4 - Nursing home|4 - Nursing home|999
244|4 - On a daily basis|4 - On a daily basis|999
245|4 - Patient is completely dependent on someone else to manage all equipment.|4 - Patient is completely dependent on someone else to manage all equipment.|999
246|4 - Permanent placement|4 - Permanent placement|999
247|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, punches, dangerous maneuvers w/ wheelchair or other objects)|4 - Physical aggression: aggressive or combative to self/others (e.g., hits self, throws objects, pu|999
248|4 - Psychosocial support (e.g., socialization, companionship, recreation)|4 - Psychosocial support (e.g., socialization, companionship, recreation)|999
249|4 - Recertification (follow-up) reassessment|4 - Recertification (follow-up) reassessment|999
250|4 - Recurrent thoughts of death|4 - Recurrent thoughts of death|999
251|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruction)|4 - Respiratory problems (e.g., shortness of breath, respiratory infection, tracheobronchial obstruc|999
252|4 - Several times a week|4 - Several times a week|999
253|4 - Stage 4|4 - Stage 4|999
254|4 - Symptoms poorly controlled, history of re-hospitalizations|4 - Symptoms poorly controlled, history of re-hospitalizations|999
255|4 - Three or more times per week|4 - Three or more times per week|999
256|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetative state, or delirium.|4 - Totally dependent due to disturbances such as constant disorientation, coma, persistent vegetati|999
257|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|4 - UNABLE to answer the telephone at all but can listen if assisted with equipment.|999
258|4 - Unable to effectively participate in any housekeeping tasks.|4 - Unable to effectively participate in any housekeeping tasks.|999
259|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or unresponsive (e.g., speech is nonsensical or unintelligible).|4 - UNABLE to express basic needs even with maximal prompting or assistance but is not comatose or u|999
260|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonresponsive.|4 - UNABLE to hear and understand familiar words or common expressions consistently, OR patient nonr|999
261|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostomy.|4 - UNABLE to take in nutrients orally and is fed nutrients through a nasogastric tube or gastrostom|999
262|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of devices at the sink, in chair, or on commode|4 - Unable to use the shower or tub, but able to bathe self independently with or without the use of|999
263|4 - With a friend|4 - With a friend|999
264|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|4 - Wound or tube site infection, deteriorating wound status, new lesion/ulcer|999
265|4-OT|4-OT|999
266|5 - Advocates or facilitates patient's participation in appropriate medical care|5 - Advocates or facilitates patient's participation in appropriate medical care|999
267|5 - At least daily|5 - At least daily|999
268|6 - Bedfast, unable to ambulate or be up in a chair.|6 - Bedfast, unable to ambulate or be up in a chair.|999
269|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|5 - Bedfast, unable to transfer and is UNABLE to turn and position self.|999
270|5 - Disruptive or socially inappropriate behavior|5 - Disruptive or socially inappropriate behavior|999
271|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|5 - Disruptive, infantile, or socially inappropriate behavior (EXCLUDES verbal actions)|999
272|5 - Hypo/Hyperglycemia, diabetes out of control|5 - Hypo/Hyperglycemia, diabetes out of control|999
273|5 - More often than once daily|5 - More often than once daily|999
274|5 - Native Hawaiian or Pacific Islander|5 - Native Hawaiian or Pacific Islander|999
275|5 - None of the above|5 - None of the above|999
276|5 - One to two times per week|5 - One to two times per week|999
277|5 - Other|5 - Other|999
278|5 - Other follow-up|5 - Other follow-up|999
279|5 - Paid help|5 - Paid help|999
280|5 - Patient nonresponsive or unable to speak.|5 - Patient nonresponsive or unable to speak.|999
281|5 - Thoughts of suicide|5 - Thoughts of suicide|999
282|5 - Totally unable to use the telephone.|5 - Totally unable to use the telephone.|999
283|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|999
284|5 - Unable to take in nutrients orally or by tube feeding.|5 - Unable to take in nutrients orally or by tube feeding.|999
285|5 - Unsafe for care at home|5 - Unsafe for care at home|999
286|5 - With paid help (other than home care agency staff)|5 - With paid help (other than home care agency staff)|999
287|5 - Workers' compensation|5 - Workers' compensation|999
288|5 - Wound infection, deteriorating wound status, new lesion/ulcer|5 - Wound infection, deteriorating wound status, new lesion/ulcer|999
289|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|6 - Cardiac problems (e.g., fluid overload, exacerbation of CHF, chest pain)|999
290|6 - Delusional, hallucinatory, or paranoid behavior|6 - Delusional, hallucinatory, or paranoid behavior|999
291|6 - Financial agent, power of attorney, or conservator of finance|6 - Financial agent, power of attorney, or conservator of finance|999
292|6 - GI bleeding, obstruction|6 - GI bleeding, obstruction|999
293|6 - Less often than weekly|6 - Less often than weekly|999
294|6 - Memory loss to the extent that supervision required|6 - Memory loss to the extent that supervision required|999
295|6 - None of the above feelings observed or reported|6 - None of the above feelings observed or reported|999
296|6 - Other|6 - Other|999
297|6 - Title programs (e.g., Title III, V, or XX)|6 - Title programs (e.g., Title III, V, or XX)|999
298|6 - Transferred to an inpatient facility - patient not discharged from agency|6 - Transferred to an inpatient facility - patient not discharged from agency|999
299|6 - White|6 - White|999
300|6 - With other than above|6 - With other than above|999
301|7 - Exacerbation of CHF, fluid overload, heart failure|7 - Exacerbation of CHF, fluid overload, heart failure|999
302|7 - Health care agent, conservator of person, or medical power of attorney|7 - Health care agent, conservator of person, or medical power of attorney|999
303|7 - Hypo/Hyperglycemia, diabetes out of control|7 - Hypo/Hyperglycemia, diabetes out of control|999
304|7 - None of the above|7 - None of the above|999
305|7 - None of the above behaviors demonstrated|7 - None of the above behaviors demonstrated|999
306|7 - Other government (e.g., TriCare, VA, etc.)|7 - Other government (e.g., TriCare, VA, etc.)|999
307|7 - Transferred to an inpatient facility - patient discharged from agency|7 - Transferred to an inpatient facility - patient discharged from agency|999
308|8 - Death at home|8 - Death at home|999
309|8 - GI bleeding, obstruction|8 - GI bleeding, obstruction|999
310|8 - Myocardial infarction, stroke|8 - Myocardial infarction, stroke|999
311|8 - Private insurance|8 - Private insurance|999
312|9 - Chemotherapy|9 - Chemotherapy|999
313|9 - Discharge from agency|9 - Discharge from agency|999
314|9 - Other than above reasons|9 - Other than above reasons|999
315|9 - Private HMO/managed care|9 - Private HMO/managed care|999
316|NA - No caregiver|NA - No caregiver|999
317|NA - No equipment of this type used in care.|NA - No equipment of this type used in care.|999
318|NA - No inhalant/mist medications prescribed.|NA - No inhalant/mist medications prescribed.|999
319|NA - No injectable medications prescribed.|NA - No injectable medications prescribed.|999
320|NA - No inpatient facility admission|NA - No inpatient facility admission|999
321|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|NA - No inpatient facility discharge AND no change in medical or treatment regimen in past 14 days|999
322|NA - No Medicaid|NA - No Medicaid|999
323|NA - No Medicare|NA - No Medicare|999
324|NA - No observable pressure ulcer|NA - No observable pressure ulcer|999
325|NA - No observable stasis ulcer|NA - No observable stasis ulcer|999
326|NA - No observable surgical wound|NA - No observable surgical wound|999
327|NA - No oral medications prescribed.|NA - No oral medications prescribed.|999
328|NA - Not applicable|NA - Not applicable|999
329|NA - Patient does not have a telephone.|NA - Patient does not have a telephone.|999
330|NA - Patient has ostomy for bowel elimination|NA - Patient has ostomy for bowel elimination|999
331|NA - Patient nonresponsive|NA - Patient nonresponsive|999
332|NA - Patient on prophylactic treatment|NA - Patient on prophylactic treatment|999
333|NA - Patient was not discharged from an inpatient facility [Go to M1017]|NA - Patient was not discharged from an inpatient facility [Go to M1017]|999
334|UK - Other unknown|UK - Other unknown|999
335|UK - Reason unknown|UK - Reason unknown|999
336|UK - Unknown|UK - Unknown|999
337|UK - Unknown or Not Available|UK - Unknown or Not Available|999
341|01 - Early|01 - Early|999
342|02 - Late|02 - Late|999
343|NA - Not Applicable. No case mix group defined for this assessment.|NA - Not Applicable. No case mix group defined for this assessment.|999
344|NA - No case mix group defined by this assessment.|NA - No case mix group defined by this assessment.|999
345|1 - Recent decline in mental, emotional, or behavioral status|1 - Recent decline in mental, emotional, or behavioral status|999
346|2 - Multiple hospitalizations (2 or more) in the past 12 months|2 - Multiple hospitalizations (2 or more) in the past 12 months|999
347|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|3 - History of falls (2 or more falls - or any fall with an injury - in the past year)|999
348|4 - Taking five or more medications|4 - Taking five or more medications|999
349|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|5 - Frailty indicators, e.g., weight loss, self-reported exhaustion|999
350|6 - Other|6 - Other|999
351|7 - None of the above|7 - None of the above|999
352|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|0 - The patient is stable with no heightened risk(s) for serious complications and death (beyond tho|999
353|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable without heightened risk(s) for serious complications and death (beyond those typical of the patient+s age).|1 - The patient is temporarily facing high health risk(s) but is likely to return to being stable wi|999
354|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious complications and death.|2 - The patient is likely to remain in fragile health and have ongoing high risk(s) of serious compl|999
355|3 - The patient has serious progressive conditions that could lead to death within a year.|3 - The patient has serious progressive conditions that could lead to death within a year.|999
356|UK - The patient+s situation is unknown or unclear.|UK - The patient+s situation is unknown or unclear.|999
357|1 - Yes [ Go to M1050 ]|1 - Yes [ Go to M1050 ]|999
358|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this influenza season. [ Go to M1050 ]|NA - Does not apply because entire episode of care (SOC/ROC to Transfer/Discharge) is outside this i|999
359|1 - Received from another health care provider (e.g., physician)|1 - Received from another health care provider (e.g., physician)|999
360|2 - Received from your agency previously during this year+s flu season|2 - Received from your agency previously during this year+s flu season|999
361|3 - Offered and declined|3 - Offered and declined|999
362|4 - Assessed and determined to have medical contraindication(s)|4 - Assessed and determined to have medical contraindication(s)|999
363|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|5 - Not indicated; patient does not meet age/ condition guidelines for influenza vaccine|999
364|6 - Inability to obtain vaccine due to declared shortage|6 - Inability to obtain vaccine due to declared shortage|999
365|1 - Yes [ Go to M2005 at TRN; Go to M1230 at DC ]|1 - Yes [ Go to M2005 at TRN; Go to M1230 at DC ]|999
366|1 - Patient has received PPV in the past|1 - Patient has received PPV in the past|999
367|2 - Offered and declined|2 - Offered and declined|999
368|3 - Assessed and determined to have medical contraindication(s)|3 - Assessed and determined to have medical contraindication(s)|999
369|4 - Not indicated; patient does not meet age/condition guidelines for PPV|4 - Not indicated; patient does not meet age/condition guidelines for PPV|999
370|5 - None of the above|5 - None of the above|999
371|0 - Adequate: hears normal conversation without difficulty.|0 - Adequate: hears normal conversation without difficulty.|999
372|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to increase volume or speak distinctly.|1 - Mildly to Moderately Impaired: difficulty hearing in some environments or speaker may need to in|999
373|2 - Severely Impaired: absence of useful hearing.|2 - Severely Impaired: absence of useful hearing.|999
374|UK - Unable to assess hearing.|UK - Unable to assess hearing.|999
375|0 - Understands: clear comprehension without cues or repetitions.|0 - Understands: clear comprehension without cues or repetitions.|999
376|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Requires cues at times to understand.|1 - Usually Understands: understands most conversations, but misses some part/intent of message. Req|999
377|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequently requires cues to understand.|2 - Sometimes Understands: understands only basic conversations or simple, direct phrases. Frequentl|999
378|3 - Rarely/Never Understands|3 - Rarely/Never Understands|999
379|UK - Unable to assess understanding.|UK - Unable to assess understanding.|999
380|0 - No standardized assessment conducted|0 - No standardized assessment conducted|999
381|1 - Yes, and it does not indicate severe pain|1 - Yes, and it does not indicate severe pain|999
382|2 - Yes, and it indicates severe pain|2 - Yes, and it indicates severe pain|999
383|0 - Patient has no pain|0 - Patient has no pain|999
384|1 - Patient has pain that does not interfere with activity or movement|1 - Patient has pain that does not interfere with activity or movement|999
385|2 - Less often than daily|2 - Less often than daily|999
386|3 - Daily, but not constantly|3 - Daily, but not constantly|999
387|4 - All of the time|4 - All of the time|999
388|0 - No assessment conducted [ Go to M1306 ]|0 - No assessment conducted [ Go to M1306 ]|999
389|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc., without use of standardized tool|1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc.,|999
390|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|2 - Yes, using a standardized tool, e.g., Braden, Norton, other|999
391|0 - No [ Go to M1322]|0 - No [ Go to M1322]|999
392|0 v Newly epithelialized|0 v Newly epithelialized|999
393|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|1 - Yes, patient has BOTH observable and unobservable stasis ulcers|999
394|2 - Yes, patient has observable stasis ulcers ONLY|2 - Yes, patient has observable stasis ulcers ONLY|999
395|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable dressing) [Go to M1340]|3 - Yes, patient has unobservable stasis ulcers ONLY (known but not observable due to non-removable|999
396|0 - No [ Go to M1350 ]|0 - No [ Go to M1350 ]|999
397|1 - Yes, patient has at least one (observable) surgical wound|1 - Yes, patient has at least one (observable) surgical wound|999
398|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1350 ]|2 - Surgical wound known but not observable due to non-removable dressing  [ Go to M1350 ]|999
399|0 - Patient is not short of breath|0 - Patient is not short of breath|999
400|3 - Continuous Bi-level positive airway pressure|3 - Continuous Bi-level positive airway pressure|999
401|0 - No [ Go to M1732 at TRN; Go to M1600 at DC ]|0 - No [ Go to M1732 at TRN; Go to M1600 at DC ]|999
402|2 - Not assessed [Go to M1732 at TRN; Go to M1600 at DC ]|2 - Not assessed [Go to M1732 at TRN; Go to M1600 at DC ]|999
403|NA - Patient does not have diagnosis of heart failure [Go to M2004 at TRN; Go to M1600 at DC]|NA - Patient does not have diagnosis of heart failure [Go to M2004 at TRN; Go to M1600 at DC]|999
404|0 - No action taken|0 - No action taken|999
405|1 - Patient+s physician (or other primary care practitioner) contacted the same day|1 - Patient+s physician (or other primary care practitioner) contacted the same day|999
406|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)|999
407|3 - Implement physician-ordered patient-specific established parameters for treatment|3 - Implement physician-ordered patient-specific established parameters for treatment|999
408|4 - Patient education or other clinical interventions|4 - Patient education or other clinical interventions|999
409|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequency, telehealth, etc.)|5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequ|999
410|1 - Occasional stress incontinence|1 - Occasional stress incontinence|999
411|2 - During the night only|2 - During the night only|999
412|3 - During the day only|3 - During the day only|999
413|4 - During the day and night|4 - During the day and night|999
414|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in bedside chair, or on commode, with the assistance or supervision of another person throughout the bath.|5 - Unable to use the shower or tub, but able to participate in bathing self in bed, at the sink, in|999
415|0 - Able to manage toileting hygiene and clothing management without assistance.|0 - Able to manage toileting hygiene and clothing management without assistance.|999
416|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implements are laid out for the patient.|1 - Able to manage toileting hygiene and clothing management without assistance if supplies/implemen|999
417|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|2 - Someone must help the patient to maintain toileting hygiene and/or adjust clothing.|999
418|3 - Patient depends entirely upon another person to maintain toileting hygiene.|3 - Patient depends entirely upon another person to maintain toileting hygiene.|999
419|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independently walk on even and uneven surfaces and negotiate stairs with or without railings.|1 - With the use of a one-handed device (e.g. cane, single crutch, hemi-walker), able to independent|999
420|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface and/or requires human supervision or assistance to negotiate stairs or steps or uneven surfaces.|2 - Requires use of a two-handed device (e.g., walker or crutches) to walk alone on a level surface|999
421|0 - No multi-factor falls risk assessment conducted.|0 - No multi-factor falls risk assessment conducted.|999
422|1 - Yes, and it does not indicate a risk for falls.|1 - Yes, and it does not indicate a risk for falls.|999
423|2 - Yes, and it indicates a risk for falls.|2 - Yes, and it indicates a risk for falls.|999
424|0 - Not assessed/reviewed [ Go to M2010 ]|0 - Not assessed/reviewed [ Go to M2010 ]|999
425|1 - No problems found during review [ Go to M2010 ]|1 - No problems found during review [ Go to M2010 ]|999
426|2 - Problems found during review|2 - Problems found during review|999
427|NA - Patient is not taking any medications [ Go to M2040 ]|NA - Patient is not taking any medications [ Go to M2040 ]|999
428|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special precautions associated with all high-risk medications|NA - Patient not taking any high risk drugs OR patient/caregiver fully knowledgeable about special p|999
429|NA - Patient not taking any drugs|NA - Patient not taking any drugs|999
430|2 - Able to take medication(s) at the correct times if given reminders by another person at the appropriate times|2 - Able to take medication(s) at the correct times if given reminders by another person at the appr|999
431|3 - Unable to take medication unless administered by another person.|3 - Unable to take medication unless administered by another person.|999
432|1 - At least daily|1 - At least daily|999
433|2 - Three or more times per week|2 - Three or more times per week|999
434|3 - One to two times per week|3 - One to two times per week|999
435|4 - Received, but less often than weekly|4 - Received, but less often than weekly|999
436|5 - No assistance received|5 - No assistance received|999
437|0 - No [Go to M2400]|0 - No [Go to M2400]|999
438|1 - Yes, used hospital emergency department WITHOUT hospital admission|1 - Yes, used hospital emergency department WITHOUT hospital admission|999
439|2 - Yes, used hospital emergency department WITH hospital admission|2 - Yes, used hospital emergency department WITH hospital admission|999
440|UK - Unknown [Go to M2400]|UK - Unknown [Go to M2400]|999
441|2 - Injury caused by fall|2 - Injury caused by fall|999
442|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|999
443|4 - Other respiratory problem|4 - Other respiratory problem|999
444|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|999
445|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|999
446|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|999
447|8 - Other heart disease|8 - Other heart disease|999
448|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|999
449|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|999
450|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|999
451|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|999
452|13 - Urinary tract infection|13 - Urinary tract infection|999
453|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|999
454|15 - Wound infection or deterioration|15 - Wound infection or deterioration|999
455|16 - Uncontrolled pain|16 - Uncontrolled pain|999
456|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|999
457|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|999
458|19 - Other than above reasons|19 - Other than above reasons|999
459|2 - Patient remained in the community (with formal assistive services)|2 - Patient remained in the community (with formal assistive services)|999
460|3 - Patient transferred to a noninstitutional hospice|3 - Patient transferred to a noninstitutional hospice|999
461|4 - Unknown because patient moved to a geographic location not served by this agency|4 - Unknown because patient moved to a geographic location not served by this agency|999
462|3 - Respiratory infection (e.g. pneumonia, bronchitis)|3 - Respiratory infection (e.g. pneumonia, bronchitis)|999
463|4 - Other respiratory problem|4 - Other respiratory problem|999
464|5 - Heart failure (e.g., fluid overload)|5 - Heart failure (e.g., fluid overload)|999
465|6 - Cardiac dysrhythmia (irregular heartbeat)|6 - Cardiac dysrhythmia (irregular heartbeat)|999
466|7 - Myocardial infarction or chest pain|7 - Myocardial infarction or chest pain|999
467|8 - Other heart disease|8 - Other heart disease|999
468|9 - Stroke (CVA) or TIA|9 - Stroke (CVA) or TIA|999
469|10 - Hypo/Hyperglycemia, diabetes out of control|10 - Hypo/Hyperglycemia, diabetes out of control|999
470|11 - GI bleeding, obstruction, constipation, impaction|11 - GI bleeding, obstruction, constipation, impaction|999
471|12 - Dehydration, malnutrition|12 - Dehydration, malnutrition|999
472|13 - Urinary tract infection|13 - Urinary tract infection|999
473|14 - IV catheter-related infection or complication|14 - IV catheter-related infection or complication|999
474|15 - Wound infection or deterioration|15 - Wound infection or deterioration|999
475|16 - Uncontrolled pain|16 - Uncontrolled pain|999
476|17 - Acute mental/behavioral health problem|17 - Acute mental/behavioral health problem|999
477|18 - Deep vein thrombosis, pulmonary embolus|18 - Deep vein thrombosis, pulmonary embolus|999
478|19 - Scheduled treatment or procedure|19 - Scheduled treatment or procedure|999
479|20 - Other than above reasons|20 - Other than above reasons|999
480|UK - Reason unknown [Go to M0903]|UK - Reason unknown [Go to M0903]|999
482|01 - Patient lives alone around the clock|01 - Patient lives alone around the clock|999
483|02 - Patient lives alone regular daytime|02 - Patient lives alone regular daytime|999
484|03 - Patient lives alone regular nighttime|03 - Patient lives alone regular nighttime|999
485|04 - Patient lives alone occassional/short term assistance|04 - Patient lives alone occassional/short term assistance|999
486|05 - Patient lives alone no assisstance available|05 - Patient lives alone no assisstance available|999
487|06 - Patient lives with other person(s) in the home around the clock|06 - Patient lives with other person(s) in the home around the clock|999
488|07 - Patient lives with other person(s) in the home regular daytime|07 - Patient lives with other person(s) in the home regular daytime|999
489|08 - Patient lives with other person(s) in the home regular nighttime|08 - Patient lives with other person(s) in the home regular nighttime|999
490|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|09 - Patient lives with other person(s) in the home ocassional/short term assisstance|999
491|10 - Patient lives with other person(s) in the home no assistance available|10 - Patient lives with other person(s) in the home no assistance available|999
492|1 - Was present at the most recent SOC/ROC assessment|1 - Was present at the most recent SOC/ROC assessment|999
493|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified|999
494|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|NA - No non-epithelialized Stage II pressure ulcers are present at discharge|999
495|0 - Newly epithelialized|0 - Newly epithelialized|999
496|0 - No [ Go to M1340 ]|0 - No [ Go to M1340 ]|999
498|0 - Independent|0 - Independent|999
499|1 - Needed Some Help|1 - Needed Some Help|999
500|2 - Dependent|2 - Dependent|999
502|0 - No assistance needed in this area|0 - No assistance needed in this area|999
503|1 - Caregiver(s) currently provide assistance|1 - Caregiver(s) currently provide assistance|999
504|2 - Caregiver(s) need training/ supportive services to provide assistance|2 - Caregiver(s) need training/ supportive services to provide assistance|999
505|3 - Caregiver(s) not likely to provide assistance|3 - Caregiver(s) not likely to provide assistance|999
506|4 - Unclear if Caregiver(s) will provide assistance|4 - Unclear if Caregiver(s) will provide assistance|999
507|5 - Assistance needed, but no Caregiver(s) available|5 - Assistance needed, but no Caregiver(s) available|999
508|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will use standardized clinical guidelines accessible for all care providers to reference|NA - Physician has chosen not to establish patient-specific parameters for this patient. Agency will|999
509|NA - Patient is not diabetic or is bilateral amputee|NA - Patient is not diabetic or is bilateral amputee|999
510|NA - Patient is not assessed to be at risk for falls|NA - Patient is not assessed to be at risk for falls|999
511|NA - Patient has no diagnosis or symptoms of depression|NA - Patient has no diagnosis or symptoms of depression|999
512|NA - No pain identified|NA - No pain identified|999
513|NA - Patient is not assessed to be at risk for pressure ulcers|NA - Patient is not assessed to be at risk for pressure ulcers|999
514|NA - Patient has no pressure ulcers with need for moist wound healing|NA - Patient has no pressure ulcers with need for moist wound healing|999
515|1 - Long-term nursing facility (NF)|1 - Long-term nursing facility (NF)|999
516|2 - Skilled nursing facility (SNF / TCU)|2 - Skilled nursing facility (SNF / TCU)|999
517|3 - Short stay acute hospital (IPP S)|3 - Short stay acute hospital (IPP S)|999
518|4 - Long-term care hospital (LTCH)|4 - Long-term care hospital (LTCH)|999
519|5 - Inpatient rehabilitation hospital or unit (IRF)|5 - Inpatient rehabilitation hospital or unit (IRF)|999
520|6 - Psychiatric hospital or unit|6 - Psychiatric hospital or unit|999
521|7 - Other|7 - Other|999
522|NA - Patient was not discharged from an inpatient facility [Go to M1017]|NA - Patient was not discharged from an inpatient facility [Go to M1017]|999
523|6 - Unable to participate effectively in bathing and is bathed totally by another person|6 - Unable to participate effectively in bathing and is bathed totally by another person|999
524|4 - Chairfast, unable to ambulate but is able to wheel self independently.|4 - Chairfast, unable to ambulate but is able to wheel self independently.|999
525|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask patient: "Over the last two weeks, how often have you been bothered by any of the following problems")  *Copyright+ Pfizer Inc. All rights reserved. Reproduced with permission.|1 - Yes, patient was screened using the PHQ-2+* scale. (Instructions for this two-question tool: Ask|999
526|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluation for depression.|2 - Yes, with a different standardized assessment-and the patient meets criteria for further evaluat|999
527|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet criteria for further evaluation for depression.|3 - Yes, patient was screened with a different standardized assessment-and the patient does not meet|999
528|0 - Not at all  0 - 1 day|0 - Not at all  0 - 1 day|999
529|1 - Several days  2 - 6 days|1 - Several days  2 - 6 days|999
530|2 - More than half of the days  7 - 11 days|2 - More than half of the days  7 - 11 days|999
531|3 - Nearly every day  12 - 14 days|3 - Nearly every day  12 - 14 days|999
532|NA - N/A  Unable to respond|NA - N/A  Unable to respond|999
533|2 - Able to take medication(s) at the correct times if given reminders by another person based on the frequency of the injection|2 - Able to take medication(s) at the correct times if given reminders by another person based on th|999
534|3 - Unable to take injectable medication unless administered by another person.|3 - Unable to take injectable medication unless administered by another person.|999
535|11 - Patient lives in congregate situation (e.g., assisted living) around the clock|11 - Patient lives in congregate situation (e.g., assisted living) around the clock|999
536|12 - Patient lives in congregate situation (e.g., assisted living) regular daytime|12 - Patient lives in congregate situation (e.g., assisted living) regular daytime|999
537|13 - Patient lives in congregate situation (e.g., assisted living) regular nighttime|13 - Patient lives in congregate situation (e.g., assisted living) regular nighttime|999
538|14 - Patient lives in congregate situation (e.g., assisted living) occasional / short-term assistance|14 - Patient lives in congregate situation (e.g., assisted living) occasional / short-term assistanc|999
539|15 - Patient lives in congregate situation (e.g., assisted living) no assistance available|15 - Patient lives in congregate situation (e.g., assisted living) no assistance available|999
545|NA - No observable pressure ulcer or unhealed pressure ulcer|NA - No observable pressure ulcer or unhealed pressure ulcer|999
582|NA - No specific SOC date ordered by physician|NA - No specific SOC date ordered by physician|999
585|UK - Inpatient Discharge Date Unknown|UK - Inpatient Discharge Date Unknown|999
586|1.Poor|1.Poor|999
587|3.Fair|3.Fair|999
588|4.Good|4.Good|999
589|Yes|Yes|999
590|No|No|999
591|2.Guarded|2.Guarded|999
592|5.Excellent|5.Excellent|999
593|1.Amputation|1.Amputation|999
594|2.Bowel/Bladder Incontinence|2.Bowel/Bladder Incontinence|999
595|3.Contracture|3.Contracture|999
596|4.Hearing|4.Hearing|999
597|5.Paralysis|5.Paralysis|999
598|6.Endurance|6.Endurance|999
599|7.Ambulation|7.Ambulation|999
600|8.Speech|8.Speech|999
601|9.Legally Blind|9.Legally Blind|999
602|10.Dyspnea with minimal exertion|10.Dyspnea with minimal exertion|999
603|11.Other (specify)|11.Other (specify)|999
604|1.Oriented|1.Oriented|999
605|2.Comatose|2.Comatose|999
606|3.Forgetful|3.Forgetful|999
607|4.Depressed|4.Depressed|999
608|5.Disoriented|5.Disoriented|999
609|6.Lethargic|6.Lethargic|999
610|7.Agitated|7.Agitated|999
611|8.Other (specify)|8.Other (specify)|999
612|1.Complete Bedrest|1.Complete Bedrest|999
613|2.Bedrest BRP|2.Bedrest BRP|999
614|3.Up As Tolerated|3.Up As Tolerated|999
615|4.Xfer Bed/Chair|4.Xfer Bed/Chair|999
616|5.Excercise Prescribed|5.Excercise Prescribed|999
617|6.Partial Weight Bearing|6.Partial Weight Bearing|999
618|7.Independent|7.Independent|999
619|8.Crutches|8.Crutches|999
620|9.Cane|9.Cane|999
621|A.Wheelchair|A.Wheelchair|999
622|B.Walker|B.Walker|999
623|C.No Restrictions|C.No Restrictions|999
624|D.Other (specify)|D.Other (specify)|999
1|1 - Hospice in patient's home/residence|1 - Hospice in patient's home/residence|10001
2|2 - Hospice in Assisted Living facility|2 - Hospice in Assisted Living facility|10001
3|3 - Hospice provided in Nursing Long Term Care (LTC) or Non-Skilled Nursing Facility (NF)|3 - Hospice provided in Nursing Long Term Care (LTC) or Non-Skilled Nursing Facility (NF)|10001
4|4 - Hospice provided in a Skilled Nursing Facility (SNF)|4 - Hospice provided in a Skilled Nursing Facility (SNF)|10001
5|5 - Hospice provided in Inpatient Hospital|5 - Hospice provided in Inpatient Hospital|10001
6|6 - Hospice provieded in Inpatient Hospice Facility|6 - Hospice provieded in Inpatient Hospice Facility|10001
7|7 - Hospice provided in Long Term Care Hospital (LTCH)|7 - Hospice provided in Long Term Care Hospital (LTCH)|10001
8|8  - Hospice in Inpatient Psychiatric Facility|8  - Hospice in Inpatient Psychiatric Facility|10001
9|9 - Hospice provided in a place not otherwise specified (NOS)|9 - Hospice provided in a place not otherwise specified (NOS)|10001
10|10 - Hospice home care provided in a hospice facility|10 - Hospice home care provided in a hospice facility|10001
11|1- Admission|1 - Admission|10001
12|9 - Discharge|9 - Discharge|10001
13|1 - Male|1 - Male|10001
14|2 - Female|2 - Female|10001
15|American Indian or Alaska Native|American Indian or Alaska Native|10001
16|Asian|Asian|10001
17|Black or African American|Black or African American|10001
18|Hispanic or Latino|Hispanic or Latino|10001
19|Native Hawaiian/Pacific Islander|Native Hawaiian/Pacific Islander|10001
20|White|White|10001
21|Community residential setting (e.g., private home/apt., board/care, assisted living, group home, adult foster care)|Community residential setting|10001
22|Long-term care facility|Long-term care facility|10001
23|Skilled Nursing Facility (SNF)|Skilled Nursing Facility (SNF)|10001
24|Hospital emergency department|Hospital emergency department|10001
25|Short-stay acute hospital (IPPS)|Short-stay acute hospital (IPPS)|10001
26|Long-0term care hospital (LTCH)|Long-0term care hospital (LTCH)|10001
27|Inpatient rehabilitation hospital or unit (IRF)|Inpatient rehabilitation hospital or unit (IRF)|10001
28|Psychiatric hospital or unit|Psychiatric hospital or unit|10001
29|ID/DD Facility|ID/DD Facility|10001
30|Hospice|Hospice|10001
31|None of the Above|None of the Above|10001
32|0 - No|0 - No|10001
33|1 - Yes, and discussion occurred|1 - Yes, and discussion occurred|10001
34|2 - Yes, but the patient/responsible party refused to discuss|2 - Yes, but the patient/responsible party refused to discuss|10001
35|Cancer|Cancer|10001
36|Dementia/Alzheimer's|Dementia/Alzheimer's|10001
37|1 - Yes|1 - Yes|10001
38|1 - Numeric|1 - Numeric|10001
39|2 - Verbal descriptor|2 - Verbal descriptor|10001
40|3 - Patient visual|3 - Patient visual|10001
41|4 - Staff observation|4 - Staff observation|10001
42|9 - No standardized tool used|9 - No standardized tool used|10001
43|0 - None|0 - None|10001
44|1 - Mild|1 - Mild|10001
45|2 - Moderate|2 - Moderate|10001
46|3 - Severe|3 - Severe|10001
47|9 - Pain Not rated|9 - Pain Not Rated|10001
48|Location|Location|10001
49|Severity|Severity|10001
50|Character|Character|10001
51|Duration|Duration|10001
52|Frequency|Frequency|10001
53|What Relieves/Worsens|What Relieves/Worsens|10001
54|Effect Function/Quality of Life|Effect Function/Quality of Life|10001
55|None of the Above|None of the Above|10001
56|No, Patient Declined Treatments Offered|No, Patient Declined Treatments Offered|10001
57|Opiods|Opiods|10001
58|Other Med|Other Med|10001
59|Oxygen|Oxygen|10001
60|Non-Med|Non-Med|10001
61|No, but there is documentation of why a bowel regimen was not initiated or continued|No, but there is documentation of why a bowel regimen was not initiated or continued|10001
11|1- Admission|1 - Admission|10002
12|9 - Discharge|9 - Discharge|10002
13|1 - Male|1 - Male|10002
14|2 - Female|2 - Female|10002
15|1- Expired|1- Expired|10002
16|2 - Revoked|2 - Revoked|10002
17|3 - No longer terminally ill|3 - No longer terminally ill|10002
18|4 - Moved out of hospice service area|4 - Moved out of hospice service area|10002
19|5 - Transferred to another hospice|5 - Transferred to another hospice|10002
20|6 - Discharged for cause|6 - Discharged for cause|10002
1|1 - Hospice in patient's home/residence|1 - Hospice in patient's home/residence|10011
2|2 - Hospice in Assisted Living facility|2 - Hospice in Assisted Living facility|10011
3|3 - Hospice provided in Nursing Long Term Care (LTC) or Non-Skilled Nursing Facility (NF)|3 - Hospice provided in Nursing Long Term Care (LTC) or Non-Skilled Nursing Facility (NF)|10011
4|4 - Hospice provided in a Skilled Nursing Facility (SNF)|4 - Hospice provided in a Skilled Nursing Facility (SNF)|10011
5|5 - Hospice provided in Inpatient Hospital|5 - Hospice provided in Inpatient Hospital|10011
6|6 - Hospice provieded in Inpatient Hospice Facility|6 - Hospice provieded in Inpatient Hospice Facility|10011
7|7 - Hospice provided in Long Term Care Hospital (LTCH)|7 - Hospice provided in Long Term Care Hospital (LTCH)|10011
8|8  - Hospice in Inpatient Psychiatric Facility|8  - Hospice in Inpatient Psychiatric Facility|10011
9|9 - Hospice provided in a place not otherwise specified (NOS)|9 - Hospice provided in a place not otherwise specified (NOS)|10011
10|10 - Hospice home care provided in a hospice facility|10 - Hospice home care provided in a hospice facility|10011
11|1- Admission|1 - Admission|10011
12|9 - Discharge|9 - Discharge|10011
13|1 - Male|1 - Male|10011
14|2 - Female|2 - Female|10011
15|American Indian or Alaska Native|American Indian or Alaska Native|10011
16|Asian|Asian|10011
17|Black or African American|Black or African American|10011
18|Hispanic or Latino|Hispanic or Latino|10011
19|Native Hawaiian/Pacific Islander|Native Hawaiian/Pacific Islander|10011
20|White|White|10011
21|Community residential setting (e.g., private home/apt., board/care, assisted living, group home, adult foster care)|Community residential setting|10011
22|Long-term care facility|Long-term care facility|10011
23|Skilled Nursing Facility (SNF)|Skilled Nursing Facility (SNF)|10011
24|Hospital emergency department|Hospital emergency department|10011
25|Short-stay acute hospital (IPPS)|Short-stay acute hospital (IPPS)|10011
26|Long-0term care hospital (LTCH)|Long-0term care hospital (LTCH)|10011
27|Inpatient rehabilitation hospital or unit (IRF)|Inpatient rehabilitation hospital or unit (IRF)|10011
28|Psychiatric hospital or unit|Psychiatric hospital or unit|10011
29|ID/DD Facility|ID/DD Facility|10011
30|Hospice|Hospice|10011
31|None of the Above|None of the Above|10011
32|0 - No|0 - No|10011
33|1 - Yes, and discussion occurred|1 - Yes, and discussion occurred|10011
34|2 - Yes, but the patient/responsible party refused to discuss|2 - Yes, but the patient/responsible party refused to discuss|10011
35|Cancer|Cancer|10011
36|Dementia/Alzheimer's|Dementia/Alzheimer's|10011
37|1 - Yes|1 - Yes|10011
38|1 - Numeric|1 - Numeric|10011
39|2 - Verbal descriptor|2 - Verbal descriptor|10011
40|3 - Patient visual|3 - Patient visual|10011
41|4 - Staff observation|4 - Staff observation|10011
42|9 - No standardized tool used|9 - No standardized tool used|10011
43|0 - None|0 - None|10011
44|1 - Mild|1 - Mild|10011
45|2 - Moderate|2 - Moderate|10011
46|3 - Severe|3 - Severe|10011
47|9 - Pain Not rated|9 - Pain Not Rated|10011
48|Location|Location|10011
49|Severity|Severity|10011
50|Character|Character|10011
51|Duration|Duration|10011
52|Frequency|Frequency|10011
53|What Relieves/Worsens|What Relieves/Worsens|10011
54|Effect Function/Quality of Life|Effect Function/Quality of Life|10011
55|None of the Above|None of the Above|10011
56|No, Patient Declined Treatments Offered|No, Patient Declined Treatments Offered|10011
57|Opiods|Opiods|10011
58|Other Medication|Other Medication|10011
59|Oxygen|Oxygen|10011
60|Non-Medication|Non-Medication|10011
61|No, but there is documentation of why a bowel regimen was not initiated or continued|No, but there is documentation of why a bowel regimen was not initiated or continued|10011
62|A. Medicare (traditional fee-for-service)|A. Medicare (traditional fee-for-service)|10011
63|B. Medicare (managed care/Part C/Medicare Advantage)|B. Medicare (managed care/Part C/Medicare Advantage)|10011
64|C. Medicaid (traditional fee-for-service)|C. Medicaid (traditional fee-for-service)|10011
65|D. Medicaid (managed care)|D. Medicaid (managed care)|10011
66|G. Other government (e.g., TRICARE, VA, etc.)|G. Other government (e.g., TRICARE, VA, etc.)|10011
67|H. Private Insurance/Medigap|H. Private Insurance/Medigap|10011
68|I. Private managed care|I. Private managed care|10011
69|J. Self-pay|J. Self-pay|10011
70|K. No payor source|K. No payor source|10011
71|X. Unknown|X. Unknown|10011
72|Y. Other|Y. Other|10011
73|0 - No, Skip to J2030.|0 - No, Skip to J2030|10011
74|0 - No, Skip to F2100|0 - N0, Skip to J2100|10011
11|1- Admission|1 - Admission|10012
12|9 - Discharge|9 - Discharge|10012
13|1 - Male|1 - Male|10012
14|2 - Female|2 - Female|10012
15|1- Expired|1- Expired|10012
16|2 - Revoked|2 - Revoked|10012
17|3 - No longer terminally ill|3 - No longer terminally ill|10012
18|4 - Moved out of hospice service area|4 - Moved out of hospice service area|10012
19|5 - Transferred to another hospice|5 - Transferred to another hospice|10012
20|6 - Discharged for cause|6 - Discharged for cause|10012
21|1 - Yes (Skip to Z0400)|1 - Yes (Skip to Z0400)|10012
22|0 - No|0 - No|10012
1|1 - Hospice in patient's home/residence|1 - Hospice in patient's home/residence|10021
2|2 - Hospice in Assisted Living facility|2 - Hospice in Assisted Living facility|10021
3|3 - Hospice provided in Nursing Long Term Care (LTC) or Non-Skilled Nursing Facility (NF)|3 - Hospice provided in Nursing Long Term Care (LTC) or Non-Skilled Nursing Facility (NF)|10021
4|4 - Hospice provided in a Skilled Nursing Facility (SNF)|4 - Hospice provided in a Skilled Nursing Facility (SNF)|10021
5|5 - Hospice provided in Inpatient Hospital|5 - Hospice provided in Inpatient Hospital|10021
6|6 - Hospice provieded in Inpatient Hospice Facility|6 - Hospice provieded in Inpatient Hospice Facility|10021
7|7 - Hospice provided in Long Term Care Hospital (LTCH)|7 - Hospice provided in Long Term Care Hospital (LTCH)|10021
8|8  - Hospice in Inpatient Psychiatric Facility|8  - Hospice in Inpatient Psychiatric Facility|10021
9|9 - Hospice provided in a place not otherwise specified (NOS)|9 - Hospice provided in a place not otherwise specified (NOS)|10021
10|10 - Hospice home care provided in a hospice facility|10 - Hospice home care provided in a hospice facility|10021
11|1- Admission|1 - Admission|10021
12|9 - Discharge|9 - Discharge|10021
13|1 - Male|1 - Male|10021
14|2 - Female|2 - Female|10021
15|American Indian or Alaska Native|American Indian or Alaska Native|10021
16|Asian|Asian|10021
17|Black or African American|Black or African American|10021
18|Hispanic or Latino|Hispanic or Latino|10021
19|Native Hawaiian/Pacific Islander|Native Hawaiian/Pacific Islander|10021
20|White|White|10021
21|Community residential setting (e.g., private home/apt., board/care, assisted living, group home, adult foster care)|Community residential setting|10021
22|Long-term care facility|Long-term care facility|10021
23|Skilled Nursing Facility (SNF)|Skilled Nursing Facility (SNF)|10021
24|Hospital emergency department|Hospital emergency department|10021
25|Short-stay acute hospital (IPPS)|Short-stay acute hospital (IPPS)|10021
26|Long-0term care hospital (LTCH)|Long-0term care hospital (LTCH)|10021
27|Inpatient rehabilitation hospital or unit (IRF)|Inpatient rehabilitation hospital or unit (IRF)|10021
28|Psychiatric hospital or unit|Psychiatric hospital or unit|10021
29|ID/DD Facility|ID/DD Facility|10021
30|Hospice|Hospice|10021
31|None of the Above|None of the Above|10021
32|0 - No|0 - No|10021
33|1 - Yes, and discussion occurred|1 - Yes, and discussion occurred|10021
34|2 - Yes, but the patient/responsible party refused to discuss|2 - Yes, but the patient/responsible party refused to discuss|10021
35|Cancer|Cancer|10021
36|Dementia/Alzheimer's|Dementia/Alzheimer's|10021
37|1 - Yes|1 - Yes|10021
38|1 - Numeric|1 - Numeric|10021
39|2 - Verbal descriptor|2 - Verbal descriptor|10021
40|3 - Patient visual|3 - Patient visual|10021
41|4 - Staff observation|4 - Staff observation|10021
42|9 - No standardized tool used|9 - No standardized tool used|10021
43|0 - None|0 - None|10021
44|1 - Mild|1 - Mild|10021
45|2 - Moderate|2 - Moderate|10021
46|3 - Severe|3 - Severe|10021
47|9 - Pain Not rated|9 - Pain Not Rated|10021
48|Location|Location|10021
49|Severity|Severity|10021
50|Character|Character|10021
51|Duration|Duration|10021
52|Frequency|Frequency|10021
53|What Relieves/Worsens|What Relieves/Worsens|10021
54|Effect Function/Quality of Life|Effect Function/Quality of Life|10021
55|None of the Above|None of the Above|10021
56|No, Patient Declined Treatments Offered|No, Patient Declined Treatments Offered|10021
57|Opiods|Opiods|10021
58|Other Medication|Other Medication|10021
59|Oxygen|Oxygen|10021
60|Non-Medication|Non-Medication|10021
61|No, but there is documentation of why a bowel regimen was not initiated or continued|No, but there is documentation of why a bowel regimen was not initiated or continued|10021
62|A. Medicare (traditional fee-for-service)|A. Medicare (traditional fee-for-service)|10021
63|B. Medicare (managed care/Part C/Medicare Advantage)|B. Medicare (managed care/Part C/Medicare Advantage)|10021
64|C. Medicaid (traditional fee-for-service)|C. Medicaid (traditional fee-for-service)|10021
65|D. Medicaid (managed care)|D. Medicaid (managed care)|10021
66|G. Other government (e.g., TRICARE, VA, etc.)|G. Other government (e.g., TRICARE, VA, etc.)|10021
67|H. Private Insurance/Medigap|H. Private Insurance/Medigap|10021
68|I. Private managed care|I. Private managed care|10021
69|J. Self-pay|J. Self-pay|10021
70|K. No payor source|K. No payor source|10021
71|X. Unknown|X. Unknown|10021
72|Y. Other|Y. Other|10021
73|0 - No, Skip to J2030.|0 - No, Skip to J2030|10021
74|0 - No, Skip to F2100|0 - N0, Skip to J2100|10021
11|1- Admission|1 - Admission|10022
12|9 - Discharge|9 - Discharge|10022
13|1 - Male|1 - Male|10022
14|2 - Female|2 - Female|10022
15|1- Expired|1- Expired|10022
16|2 - Revoked|2 - Revoked|10022
17|3 - No longer terminally ill|3 - No longer terminally ill|10022
18|4 - Moved out of hospice service area|4 - Moved out of hospice service area|10022
19|5 - Transferred to another hospice|5 - Transferred to another hospice|10022
20|6 - Discharged for cause|6 - Discharged for cause|10022
21|1 - Yes (Skip to Z0400)|1 - Yes (Skip to Z0400)|10022
22|0 - No|0 - No|10022
