Home for Life Design™ Home Assessment Report Ecith Feld of Touro University, performed the following occupational therapy home assessment to determine the safety and current functional status of Pinocci in the home. This report detail feeling of safety and measures the accessibility of important occupations that occur throughout areas of the home. Information was gathered via professional interview with the client and/or family, activity analysis, objective measurements and photography, This assessment was performed on: 9/12/2015 Patient Information: Patient Nano: Address: Ee, TS Tennant Type: Owner Housing Type: Single Family No. Floors: 1 Special Considerations: Inaccessible Areas: Ifthe client has fallen, did the most recent fall Result in Injury: No Result in Hospitalization: Yes Result in Rehabilitation: Yes Other Considerations: Consideration Type Has a History of Falls Other Concern Home and Personal Findings: Date of Birth: ‘TB Gender 7 Is Veteran: No Has HOA: Yes Lives With: Self Assistive Four Wheel Walker, Reacher, Arm Bike, Raised Devices: Toilet Seat, Grab Bars in Master Bathroom, Shower Chair, and Hospital Bed. Where did the fall occur: Inside the Home What Room: Kitchen Fall Cause Type: Environmental Fall Cause Comments: Family members found client in the home and called 911, Client accidentally turned on and off the dishwasher attempting to got up. Paramedics arrived and took clients temperature and it was reported to be a 103 degrees. Client was wearing a life alert necklace but failed to use it because she said she had forgotten that she was wearing it Client taken to hospital and diagnosed with pneumonia, ‘Therapist Note Occurred in the kitchen. Lives alone. Giient’s family lives close by but may not always be accessible. The following rooms assessed each indicate the Personal Safely Rating given by the patient and the Therapist Accessibility Rating determined by activity analysis during skill performance time Life Home for Lite Design™ Solution Page: 1 of 7Pre-Assessment Post-Assessment Room Assessed Pergonal Ste) accessny Pe%ONA Sey gece tating tating Bathroom, Fist for -Master Betoom 100.0% 10000% Becoom, Fst oor MastorBoeroom 10.00% 10000% Kitchen, Fist fer 10.00% 60.00% Ding Space, Fst oor 100.0% —#000% LivinglFemily Room, Fst oor 40.00% 68.67% Brome Life AHome for Life Design™ Solution iv. ometorifadesign.com Page: 2 of 7Home Recommendations Based on Findings: Personal Safety Rating Accessibility Rating Bathroom, First floor - Master Bathroom 100.00 % 100,00 % Recommended Modifications: - Grab Bar Opposite Side of Bathing Entry = Horizontal Grab Bar = 18" - Textured Personal Safety Rating Accessibility Rating Bedroom, First floor - Master Bedroom 100.00 9 100.00 % Recommended Modifications: Beteme Life Home tor Life Design™ Solution ty Page: 3 of 7Personal Safety Rating Accessibility Rating Kitchen, First floor 100.00 % 60.00 % Recommended Modifications: $e-loma.». Life. Kom or Ute Design™ Sohtion : m Page: 4 of?Personal Safety Rating Dining Space, 100.00 % Recommended Modifications: Personal Safety Rating Accessil Living/Family Room, First floor 100.00 % 66.67 % Recommended Modifications: tome Life A Home for Life Design™ Solution hitp:tiwakometoritedesl Page: 5 of 7Bete Life AHome tor Design™ Solution nt sx homeforforosign com Page: 6 of 7Additional Service Recommendations (e.g. home health, medication management): Increasing mobility within the home by removing bartiers such as rugs, dressericabinet in kitchen, and threshold bumps in between rooms. Additional Notes: Client reports feeling very safe in her home. Her family lives within 2 miles of her home, so they are close by if needed, She receives car services 1-2 times a week to assist her with errands autside the home. The client also receives ":Meals on Wheels" so she does not have to prepare meals in the kitchen. She has a life alert system around her neck, which she said she would make sure to utilize if another fall were to occur. Client was very upbeat and had a great sense of humor. She loves her home and hopes to stay there and live as independentty as possible, She has not been able to leave her home since her fall, so she is hoping to also be able to get outside more within the coming weeks. ‘Submitted By: Edith Feld, , License # 9/17/2015 Brteme Life K Home for Life Design™ Solution toto com Page: 7 of 7