CMS SOM App. B, Tag G528

The comprehensive

assessment must accurately reflect the patient's status, and must include, at a

minimum, the following information:

(1) The patient’s current health, psychosocial, functional, and cognitive status;

Interpretive Guidelines §484.55(c)(1)

Completion of the comprehensive assessment should provide the HHA with a complete

picture of the patient’s status to assist the HHA in developing the patient’s plan of care.

Assessment of the patient’s current health status includes relevant past medical history as

well as all active health and medical problems.

Assessment of a patient’s psychosocial status and his/her functional capacity within the

community is intended to be a screening of the patient’s relationships, living

environment, impact on the delivery of services and ability to participate in his/her own

care. Assessment of a patient’s functional status includes the patient’s level of ability to

function independently in the home such as activities of daily living.

Assessment of a patient’s cognitive status refers to an evaluation of the degree of his or

her ability to understand, remember, and participate in developing and implementing the

plan of care.