Form Cms-806c - Quality Of Life Assessment - Family Interview printable pdf download

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES

QUALITY OF LIFE ASSESSMENT

FAMILY INTERVIEW

Facility Name: _________________________________

Resident Name:___________________________________

Provider Number: ______________________________

Resident Identifier:________________________________

Surveyor Name: ________________________________

Person Interviewed: _______________________________

Surveyor Number: ________ Discipline: __________

Relationship to Resident:___________________________

Method of Contact: In person

Phone

Interview Dates/Times: ____________________________

Instructions:

This interview is intended to be conducted with a person (family, friend or guardian) who is the one acting on behalf of the

resident and authorizing care. Prior to the interview, complete as many questions as you can through review of the resident

assessment, care plan and any activities or social service assessment.

Adapt these questions and probes as necessary to make them applicable to 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

residents receive quality care. While we are here, we make observations, review the nursing home’s records, and

talk to residents and family members or friends who can 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 these questions because we want to know about your opportunity for involvement in decision about

_______ ‘s care and schedule, your views on services he/she receives here, and in general, what you think of the

facility. We want to know if the facility has obtained information about _______’s past and current preferences in

order to provide the highest quality of care. We also want to find out about the admission process and what the

facility discussed with you about costs and payment for ______’s stay here.

Question 1 below screens the family member to see if she/he knows the resident well enough to complete the rest of the

interview. Based on answers to question 1, decide whether you can complete the interview, complete it partially if the

family member knows some things, or conclude the interview. If you decide you must conclude this interview, ask a

general question that lets the family member say what they wish to say about the facility such as: “Is there anything you

would like to tell me about this facility and how your relative is treated?”.

1. (Ask about the nature and extent of the relationship between interviewee and resident both prior to and during nursing

home residence):

With whom did your relative/friend live before coming to the nursing home? (If the resident did not live with this

person) About how often did you see her/him?

How often do the resident and you see each other now?

Are you familiar with _________’s preferences and daily routines when he/she was more independent and

more able to make choices and express preferences? (If the resident has had a lifelong disability, ask about choice

and preferences prior to moving to this facility. Adapt question 2 and 3 also.)

Form CMS-806C (07/95)

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

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