Form Cms-806a - Quality Of Life Assessment - Resident Interview printable pdf download

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES

QUALITY OF LIFE ASSESSMENT

RESIDENT INTERVIEW

Facility Name:

Resident Name:

Provider Number:

Resident Identifier:

Surveyor Name:

Interview Dates/Times:

Surveyor Number:

Discipline:

Instructions:

For question 1, if you are meeting with the resident in a location away from the resident's room, visit the room before

the interview and note anything about the room that you want to discuss. For question 7, review the RAI to determine

the ADL capabilities of this resident.

Introduce yourself and explain the survey process and the purpose of the interview using the following concepts. It is not

necessary to use the exact wording.

“[Name of facility] is inspected by a team from the [Name of State Survey Agency] periodically to assure that all

residents receive good care. While we are here, we make a lot of observations, review the nursing home's records,

and talk to residents to help us understand what it's like to live in this nursing home. We appreciate your taking

the time to talk to us.”

“We ask certain questions because we want to know whether you have a say in decisions affecting your nursing

and medical care, your schedule and the services you receive at this facility. We want to know how you feel about

your life here and whether the facility has made efforts to accommodate your preferences.”

“If it is all right with you, I'd like to meet with you again later. That will give you time to think things over and to

provide additional information later.”

In asking the following questions, it is not necessary to use the exact wording. However, do use complete questions, not

one-word probes.

Get the resident to talk about actual situations and examples by using open-ended probes, such as: “Can you tell me

more about that?” or “How is that done here?” Avoid asking leading questions which suggest a certain response.

If a resident gives a response to any question that indicates there may be a concern with facility services, probe to

determine if the resident has communicated the problem to facility staff and what their response was.

1. ROOM: (F177, 201, 207, 242, 250, 252, 256, 257)

A good approach for initiating this discussion is to make a comment about something you have noticed about the

resident's room, for example, “I notice that you have a lot of plants in your room.”

Please tell me about your room and how you feel about it.

Did you have a choice about changing rooms?

Do you enjoy spending time in your room?

Where was your other room? What was it like?

Is there enough light for you?

Is there anything you would like to change about your

Is the room temperature comfortable?

room?

Have you lived in a different room in the facility?

(If yes) Have you talked to the facility about this?

(If yes) What was the reason for the room change?

How did they respond?

Form CMS-806A (07/95)

Form Cms-806a - Quality Of Life Assessment - Resident Interview

Related Articles

Related forms

Related Categories