Form Cms-806b - Quality Of Life Assessment - Group Interview Page 2

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GROUP INTERVIEW
3. ACTIVITIES: (F242, 248)
Activities programs are supposed to meet your interests
Is there anything about the activities program that you
and needs. Do you feel the activities here do that?
would like to talk about?
(If no, probe for specifics.)
Outside of the formal activity programs, are there
Do you participate in the activities here?
opportunities for you to socialize with other residents?
Do you enjoy them?
Are there places you can go when you want to be with
Are there enough help and supplies available so that
other residents?
everyone who wants to can participate?
(If answers are negative) Why do you think that occurs?
Do you as a group have input into the selection of the
activities that are offered?
How does the facility respond to your suggestions?
4. PERSONAL PROPERTY: (F252)
Can residents have their own belongings here if they
Does the facility make efforts to prevent loss, theft, or
choose to do so?
destruction of personal property?
What about their own furniture?
Have any of your belongings ever been missing?
How are your personal belongings treated here?
(If anyone answers yes) Did you talk to a staff member
about this? What was their response?
5. RIGHTS: (F151, 153, 156, 167, 168, 170, 280)
How do residents here find out about their rights —
Do you know how to contact an advocacy agency such
such as voting, making a living will, getting what you
as the ombudsman office?
need here?
Do you know you can look at your medical record?
Are you invited to meetings in which staff plan your
Have any of you asked to see your record? What was
nursing care, medical treatment and activities?
the facility's response?
Do you know that you can see a copy of the facility's
Has anyone from the facility staff talked to you about
latest survey inspection results?
these things?
Where is that report kept here?
Tell me about the mail delivery system here.
Is mail delivery prompt? Does your mail arrive
unopened daily?
6. DIGNITY: (F223, 241)
How do staff members treat the residents here, not just
Do they try to accommodate residents' wishes where
yourselves, but others who can't speak for them-
possible?
selves?
(If answers are negative) Please describe instances in
Do you feel the staff here treat residents with respect
which the facility did not treat you or another
and dignity?
resident with dignity. Did you talk to anyone on the
staff about this? How did they respond?
Form CMS-806B (07/95)
Page 2

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