Form Cms-806c - Quality Of Life Assessment - Family Interview (Page 4 of 4) in pdf

Form Cms-806c - Quality Of Life Assessment - Family Interview Page 4

FAMILY INTERVIEW

5. (For all the items below: If the family member describes any problems, probe for specific information. Ask if they

have talked to staff, and what was the facility's response. If the resident's payment source changed from private

pay or Medicare to Medicaid, inquire if there were any changes in any of the following after the payment source

changed.)

Please share with me your observations, either positive things or concerns, about all of the following items. If you

have no information about these issues that is OK.

Meals and snacks (F242, 310, 365, 366, 367)

Noise level of the facility (F258)

Routines and activities (F242, 245, 248)

Privacy when receiving care (F164)

Visitor policies and hours, privacy for visits when desired

Transfers (F177, 201, 203–207)

(F164, 172)

Security and personal property (F159, 223, 252)

Care by nursing home staff (F241, 309–312)

Cleanliness and odor (F252–254)

6. Did you participate in the admission process?

(If yes) Were you told anything about using Medicare or Medicaid to pay for

’s stay here?

(If yes) What did they tell you?

(If resident's care is being paid by Medicaid) Were you asked to pay for any extras above the Medicaid rate?

(If yes) What were these? Did you have a choice about receiving these services?

When your relative/friend moved here, did the facility ask you to pay out of your savings or your relative's

savings? (F156, 208)

7. Are you the person who would be notified if

’s condition changed. (If yes) Have you been notified when there

have been changes in your relative's condition? Are you involved in

’s care planning? (F157)

8. “Is there anything else that I have not asked that is important to understand about ___________’s everyday life

here?”

When finished: “Thank you for your help. You will be able to examine a copy of the results of this survey in about

___ days.”

Form CMS-806C (07/95)

Form Cms-806c - Quality Of Life Assessment - Family Interview Page 4