Home for Life Design™ Home Assessment Report Faith Wilkins of Touro University, performed the following occupational therapy home assessment to determine the safety and current functional status of Chang in the home. This report detalls Mary Chang's 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: 9/7/2015 Patient Information: Patient Name: Address: 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: Yes Result in Hospitalization’ Yes Result in Rehabilitation: No Other Considerations’ Consideration Type Has a History of Falls Has Orthopedic Issues Has Visual Defects Home and Personal gs: Date of Birth Height (in) 60, Weight (Ibs) 100 Is Veteran: No HasHOA: Yes Lives With: Self Assistive SC, walk in shower, scooter (doesnt use often), Devices: FW, 4WW. Where did the fall occur: Inside the Home. What Room: Bathroom Fall Cause Type: Environmental Fall Cause Comments: Fell going into the bathroom. Lost balance and held onto door. Didr't go to hospital right away. ‘Went to hospital s/p hematoma, nausea, swelling shut of eyes Therapist Note Back pain and balance concerns Reported declining vision The following rooms assessed each indicate the Personal Safety Rating given by the patient and the Therapist Accessibility Rating determined by activity analysis during skill performance.Home for Life Design™ Home Assessment Report Faith Wilkins of Touro University, performed the following occupational therapy home assessment to determine the ‘safety and current functional status of Chang in the home. This report details Mary Chang's feeling of safety and measures the accessibilty of important occupations that occur throughout areas of the home. Information was gathered via professional interview with the client andior family, activity analysis, objective measurements and photography. This assessment was performed on: 9/7/2015 Patient Information: Patient Name: Chang, Mary Address: 2030 Woodspring Terrace Henderson, NV 89012 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: Yes Result in Hospitalization: Yes Result in Rehabilitation: No Other Considerations: Consideration Type Has a History of Falls Has Orthopedic Issues Has Visual Defects Home and Personal gs: Date of Birth: 8/11/1932 Gender: Female Height (in) 60, Weight (Ibs) 100 Is Veteran: No HasHOA: Yes Lives With: Self Assistive SC, walk in shower, scooter (doesn't use often), Devices: FW, 4WW. Where did the fall occur: Inside the Home What Room: Bathroom Fall Cause Type: Environmental Fall Cause Comments: Fell going into the bathroom. Lost balance and held onto door. Didn't go to hospital right away. ‘Went to hospital s/p hematoma, nausea, swelling shut of eyes ‘Therapist Note Back pain and balance concerns Reported declining vision The following rooms assessed each indicate the Personal Safety Rating given by the patient and the Therapist Accessibilty Rating determined by activity analysis during skill performance: Betome Life AHome for Life Design™ Solution hitpwmw:nometoritedesign.com Page: 1 of 15Pre-Assessment Room Assessed Pergonal Safty cosiaity Rating % Outdoor spac, 10000% 75.00% Bathroom, Connected to master bedroom 70.00 % 83.33 % Kitchen, 80.00 % 80.00 % Sag ay po A ‘the back of the home- 400.00 % 83.33 % Entryway, Front entry way 100.00 % 100.00 % Becroom, Master 000% 87.80% Using orily Room, Guest living room at front 400.00 % 66.67% Bathroom, Guest 100.00 % 83.33 % Bedroom, Guest bedroom/office 90.00 % 75.00 % Halvay, From bedroom kchen 00.00% 10000% Laundry Room, Leads into gareee 700% 83.33% Laundry Room, Leads into garage 70.00 % 83.33 % Btome Life AHome for Lite Design™ Solution Post-Assessment Personal Safety Rating % itp ww omeforifedesign.com Therapist cer Page: 2 of 15Home Recommendations Based on Findings: Personal Safety Rating Accessibility Rating Outdoor Space, 100.00 % 75.00% Recommended Modificati Pre-Assessment Notes: Front doorway has a raised threshold that could pose a fall risk Post-Assessment Notes: Personal Safety Rating Accessibility Rating Bathroom, Connected to master bedroom 70.00 % 83.33% Recommended Modifications - Grab Bar Right Side of Bathing Entry - Vertical Grab Bar Horizontal Grab Bar - 18" - Textured Wall Mounted Grab Bar - Low Threshold Shower ~ Add Lighting Befome\ Life A Home for Life Design™ Solution htip:itwvrw.homeforlfedesign.com Page: 3 of 15Pre-Assessment Notes: Walk in shower has 4" threshold to get inside; hand held shower head and grab bar inside the shower. Client needed to be reminded not to use the towel racks as grab bars. Client currently sitting at the edge of the tub after the shower which may cause a fall, Recommend a bench inside the bathroom to sit on instead of the tub siding. Door swings into bathroom which may pose a risk if client uses door for support (cause of most recent fall Post-Assessment Notes: ‘Bttome Life AHome for Life Design™ Solution bitp www homeforifedesign.com Page: 4 of 15Brome Life AHome for Life Design™ Solution htpvvwww ometorttedesign.com Page: 5 of 15Biome» Life Home or Life Design™ Solution tr vnw homsoitedesan com Page: 6 of 15Personal Safety Rating Accessibility Rating Kitchen, 80.00 % 80.00 % Recommended Modifications: Pre-Assessment Notes: Commonly used items on easily accessible shelving. Medications on a low shelf that can easily be reached. Microwave on counter is used more than installed microwave because itis easier to reach. All cups and plates are within easy reaching height. No obstructions on the floor. Island in the middle is of a good height and she uses ito cook. She mostly cooks with the stove top and microwave. Some cooking pots and supplies are low and require bending over Post-Assessment Notes: PHtome Life A Home for Life Design™ Solution hitpthww.homeforifedesign.com Page: 7 of 15Personal Safety Rating Accessibility Rating 83.33% 100.00 % Living/Family Room, At the back of the home- most commonly used Recommended Modifications: Pre-Assessment Notes: Area rug under coffee table could pose risk for fal. Limited space between coffee table and ‘couches to maneuver Post-Assessment Notes: itp the homefoifeesign com Page: 8 of 15 BHfome Life A Home for Life Design™ SolutionPersonal Safety Rating Accessibility Rating Entryway, Front entry way 100.00 % 100.00 % Recommended Modifications: Pre-Assessment Notes: Recommend removing small rug in doorway to prevent fall or put non-skid mat under rug Reduce possible clutter from shoes by having a shoe rack by the door Post-Assessment Notes: Bete Life AHome for Life Design™ Solution hitpvhu homeforiedesign com Page: 9 0f 15sonal Safety Rating Accessibility Rating Bedroom, Master 90.00% 87.50% Recommended Modifications: Pre-Assessment Notes: Remove area rug or tape down edges to reduce risk of falls; recommend a hand held light control to use at night if she needs to use the restroom Post-Assessment Notes: Personal Safety Rating Accessibility Rating LivingiFamily Room, Guest living room at front of house 100.00 % 66.67 % Recommended Modifications: - Organize/Declutter Space Pre-Assessment Notes: Client states she never uses he front living room unless she has many guests. She uses the living room closest to the kitchen Post-Assessment Notes Brome Life AHome for Life Design™ Solution ‘nto: ww hameforifedesign.com Page: 10 of 15Personal Safety Rating Accessibility Rating Bathroom, Guest 100.00 % 83.33% Recommended Modifications: Pre-Assessment Notes: Post-Assessment Notes: Brtome Life AHome for Life Design™ Solution itp: nometorifedesign.com Page: 14 of 15Personal Safety Rating Accessibility Rating Bedroom, Guest bedroomioftice 90.00 % 75.00 % Recommended Modifications: - Organize/Declutter Space Pre-Assessment Notes: Rolling chair used for desk could pose a risk for fall; recommend a non-rolling chair or at least a rolling chair with arm rests Post-Assessment Notes: Personal Safety Rating Accessibility Rating Hallway, From bedroom to kitchen 100.00 % 100.00 % Recommended Modifications: Pre-Assessment Notes: Clear hallway with good lighting Post-Assessment Notes: Betome Life AHome for Life Design™ Solution tp:iwerw hometorifedesign.com Page: 12 of 15Personal Safety Rating Accessibility Rating Laundry Room, Leads into garage 70.00 % 83.33 % Recommended Modification: Pre-Assessment Notes: Post-Assessment Notes: ‘RHtome Life Home for Life Design™ Solution tpn. homeforifedesign.com Page: 13 of 15Personal Safety Rating Accessibility Rating Laundry Room, Leads into garage 70.00% 83.33% Recommended Modifications: Pre-Assessment Notes: Post-Assessment Notes: BHtome Life AHome for Life Design™ Solution ito sNew.hometeifedesign.com Page: 14 of 15Additional Service Recommendations (e.g. home health, medication management): Additional Notes: - Client is an 83 y/o woman living alone in a SSH in Henderson, NV. Family ives within a five minute drive from clients home & provides support as needed. Client has a recent history of a fall. PMHx: MI. Clients home has a fairly open floor plan and adequate lighting throughout. Client reports she is satisfied with current home set up and home modifications. Client needed to be reminded to not use towel bar for WB. Client was given instruction on how to adjust handles on 4WW if she desired. Sydney Cormevase, ors H A Git EE ons 7 te ilu meso ( See huss OTS fgg ~ / Faith Wilkins, , License # 9/17/2018 Petome Life AHome for Life Design™ Solution ito. hometoitedesign.com Page: 15 of 15