Family Interview Form printable pdf download

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES

FAMILY INTERVIEW

Facility Name:

Facility ID:

Date:

Surveyor Name:

Resident Name:

Resident ID:

Admit Date:

Resident Room:

Contact Method:  In Person

Relationship to

 By Phone

Person Interviewed:

Resident:

The survey team will interview three (3) family members in each facility during Stage 1 of the survey process. This interview will be

conducted with a person (family, friend or guardian) who knows the resident well and visits the facility often enough to provide

information about service provided. Adjust the questions and probes as necessary to make them applicable to this resident and the

individual being interviewed. If an interviewee is not appropriate for an interview or two attempts to reach the family member/friend

have been unsuccessful, select another sample resident from the sample of non-interviewable Census Sample residents. Do not move

outside the Census Sample. Exhaust all possible sample residents form the sample of non-interviewable Census Sample residents

either by onsite contact or telephone. Select family members of residents from various units in the facility when possible.

Instructions:

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

the exact wording. At all times, be cognizant of resident confidentiality.

“[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 with us.

We ask these questions because we want to know about [resident’s name] prior lifestyle and discuss with you

whether her/his past preferences are still applicable and if the facility accommodates them. We want to know

about your opportunity for involvement in decisions about [resident’s name] care and schedule. We also want to

know your views on services she/he receives here, and in general, what you think of the facility.”

The following questions are asked to determine the family member’s awareness and satisfaction with certain aspects of facility life

and care for the resident. The surveyor should probe more deeply, using the suggested probes, whenever there is a negative response

to determine the exact nature of the concern.

FORM CMS-20049 (7/2012)

Family Interview Form