Family Interview Form Page 3
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8DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
FAMILY INTERVIEW
Screening
A
Was a family interview conducted for this resident?
1)
No
Yes
Choices QP244
B
Does [resident's name] get up in the morning according to his/her previous
1)
routine?
No
If No: What time do staff get the resident up? What time did the resident used
Yes
to get up?
Does [resident's name] go to bed according to his/her previous routine?
2)
No
If No: What time does [resident's name] go to bed? What time did he/she used to
Yes
go to bed?
Does [resident's name] receive the same number of baths or showers in a week
3)
based on past preferences?
No
If No: How many times a week does [resident's name] get a bath or shower?
Yes
How many times a week would [resident's name] prefer to bathe?
Is [resident's name] bathed according to his/her past preferences?
4)
No
If No: What type of bathing is [resident's name] receiving? What would
Yes
[resident's name] prefer to receive?
Can you visit anytime during the day or nighttime?
5)
No
If No: What are the visiting restrictions?
Yes
Activities QP239
C
Does staff encourage [resident's name] to attend activities and provide
1)
No
assistance to attend them?
Yes
Privacy QP243
D
Can you meet privately with your relative/friend?
1)
No
Yes
FORM CMS-20049 (7/2012)
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