Home Assessement Report

Home for Life Design
Home Assessment Report

Nicholas Druzinski of Touro University, performed the following occupational therapy home assessment to determine the
safety and current functional status of A. in the home. This report details Connie A.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: 10/1/2015
Patient Information:
Patient Name:
A., Connie
Date of Birth: 1/1/1953
Address:
2414 Pickwick Drive
Gender:
Female
Henderson, NV 89014
Tennant Type:
Owner
Is Veteran:
No
Housing Type:
Apartment/Condo
Has HOA:
Yes
No. Floors:
Lives With:
Self
Special Considerations:
Inaccessible N/A
Areas:
Assistive Electric scooter, walker, cane, and reacher

Devices:
If the client has fallen, did the most recent fall:
Where did the fall occur: N/A
Result in Injury: No
What Room:
Result in Hospitalization: No
Fall Cause Type: N/A
Result in Rehabilitation: No
Fall Cause Comments: N/A
Other Considerations:
Consideration Type
Therapist Note
Has Orthopedic Issues
R TKR
Has Pets
Has two small dogs running at her feet.
Other Concern
Has many throw rugs on the ground increasing risk of fall
Home and Personal Findings:

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:
A Home for Life Design Solution
http://www.homeforlifedesign.com
Page: 1 of 13
Pre-Assessment
Personal Safety
Rating %
Therapist
Accessibility
Rating %
Bathroom, In client's bedroom
80 %
94 %
Bedroom,
90 %
70 %
Dining Space,
80 %
88 %
Entryway,
80 %
50 %
Kitchen,
70 %
100 %
Living/Family Room,
70 %
100 %
Hallway,
90 %
100 %
Outdoor Space,
90 %
83 %
Stairs,
90 %
100 %
Room Assessed
Post-Assessment
Therapist
Personal Safety
Accessibility
Rating %
Rating %
Page: 2 of 13
Home Recommendations Based on Findings:

Pre-Assessment
Bathroom, In client's bedroom
Personal Safety
Rating %
Therapist
Accessibility
Rating %
80.00 %
94.44 %
Post-Assessment
Personal
Safety
Rating %
Therapist
Accessibility
Rating %
Recommended Modifications:
- Shower Seat with Armrests
- Angled Grab Bar
- Grab Bar Right Side of Bathing Entry
- Diagonal Grab Bar
- 18" - Textured
- Wall Mounted Grab Bar
- Remove Shower Doors
- Hand Held Shower
- Anti-Slip Floor Coating
- Add Lighting
- Bench Chair
Pre-Assessment Notes:
Post-Assessment Notes:
Page: 3 of 13
Pre-Assessment
Bedroom,
Personal Safety
Rating %
Therapist
Accessibility
Rating %
90.00 %
70.00 %
Post-Assessment
Personal
Safety
Rating %
Therapist
Accessibility
Rating %
- Add Lighting
Page: 4 of 13
Pre-Assessment
Dining Space,
Personal Safety
Rating %
Therapist
Accessibility
Rating %
80.00 %
87.50 %
Post-Assessment
Personal
Safety
Rating %
Therapist
Accessibility
Rating %
- Add Lighting
- Organize/Declutter Space
- Change Flooring
Page: 5 of 13
Pre-Assessment
Entryway,
Personal Safety
Rating %
Therapist
Accessibility
Rating %
80.00 %
50.00 %
Post-Assessment
Personal
Safety
Rating %
Therapist
Accessibility
Rating %
- Add Visible Steps
- Add Visible Street Numbers
- Add Hand Rails
Page: 6 of 13
Pre-Assessment
Kitchen,
Personal Safety
Rating %
Therapist
Accessibility
Rating %
70.00 %
100.00 %
Post-Assessment
Personal
Safety
Rating %
Therapist
Accessibility
Rating %
- Change Flooring
- Raise Counter Height
- Add Raised Dishwasher
Page: 7 of 13
Pre-Assessment
Living/Family Room,
Personal Safety
Rating %
Therapist
Accessibility
Rating %
70.00 %
100.00 %
Post-Assessment
Personal
Safety
Rating %
Therapist
Accessibility
Rating %
- Organize/Declutter Space
Page: 8 of 13
Pre-Assessment
Hallway,
Personal Safety
Rating %
Therapist
Accessibility
Rating %
90.00 %
100.00 %
Post-Assessment
Personal
Safety
Rating %
Therapist
Accessibility
Rating %
- Add Lighting
Page: 9 of 13
Pre-Assessment
Outdoor Space,
Personal Safety
Rating %
Therapist
Accessibility
Rating %
90.00 %
83.33 %
Post-Assessment
Personal
Safety
Rating %
Therapist
Accessibility
Rating %
- Add Lighting
- Add Hand Rails
- Create Smooth Pavement
- Add Visible Steps
Page: 10 of 13
Pre-Assessment
Stairs,
Personal Safety
Rating %
Therapist
Accessibility
Rating %
90.00 %
100.00 %
Post-Assessment
Personal
Safety
Rating %
Therapist
Accessibility
Rating %
- Add Lighting
- Add Hand Rails
- Add Visible Steps
Page: 11 of 13
Page: 12 of 13
Additional Service Recommendations (e.g. home health, medication management):

Client would benefit from further home modification.
Additional Notes:
Submitted By:
Nicholas Druzinski, , License #

11/10/2015
Page: 13 of 13

Home Assessement Report

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Home for Life Design

Home Assessment Report

Date of Birth: 1/1/1953

2414 Pickwick Drive

Assistive Electric scooter, walker, cane, and reacher

If the client has fallen, did the most recent fall:

Where did the fall occur: N/A

Fall Cause Type: N/A

Fall Cause Comments: N/A

Has Orthopedic Issues

Has two small dogs running at her feet.

Has many throw rugs on the ground increasing risk of fall

Home and Personal Findings:

A Home for Life Design Solution

Bathroom, In client's bedroom

A Home for Life Design Solution

Home Recommendations Based on Findings:

A Home for Life Design Solution

A Home for Life Design Solution

A Home for Life Design Solution

A Home for Life Design Solution

A Home for Life Design Solution

A Home for Life Design Solution

A Home for Life Design Solution

A Home for Life Design Solution

A Home for Life Design Solution

A Home for Life Design Solution

Additional Service Recommendations (e.g. home health, medication management):

Nicholas Druzinski, , License #

A Home for Life Design Solution

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