Form Cms-806b - Quality Of Life Assessment - Group Interview printable pdf download

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

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES

QUALITY OF LIFE ASSESSMENT

GROUP INTERVIEW

Facility Name:

Surveyor Name:

Provider Number:

Surveyor Number:

Interview Dates/Times:

Discipline:

Residents Attending:

Instructions:

Introduce yourself to the group 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 as one part of a

process in which we evaluate the quality of life and quality of care in this facility.

While we are here, we make observations, look over the facility's records, and talk to residents about life in this

facility.

We appreciate you taking the time to talk to us.

We would like to ask you several questions about life in the facility and the interactions of residents and staff.”

1. RULES: (F151, 242, 243)

Tell me about the rules in this facility.

Do you as a group have input into the rules of this

For instance, rules about what time residents go to bed

facility?

at night and get up in the morning?

Does the facility listen to your suggestions?

Are there any other facility rules you would like to

discuss?

2. PRIVACY: (F164, 174)

Can you meet privately with your visitors?

Does the facility make an effort to assure that privacy

Can you make a telephone call without other people

rights are respected for all residents?

overhearing your conversation?

Form CMS-806B (07/95)

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