Family Interview Form Page 4
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8DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
FAMILY INTERVIEW
Is [resident's name] capable of conversing on the phone?
2)
No (skip to #4)
Yes
Can she/he do so without being overheard?
3)
No
Yes
Does the staff speak privately (without being overheard) about your
4)
No
relative’s/friend’s medical or behavioral condition?
Yes
Dignity QP240
E
Do staff treat [resident's name] with respect and dignity?
1)
If No: Tell me some examples about when staff did not treat [resident's name]
No
with respect and dignity. The focus of this question is how well staff interacts
Yes
with the resident.
Interactions with Others QP247
F
Have there been any concerns or problems with a roommate or any other
1)
No (skip to Sufficient Staff)
resident?
Yes
Has the staff addressed the concern(s) to your satisfaction?
2)
No
Yes
Sufficient Staff QP237
G
Is there enough staff available in this facility to make sure that residents get
1)
No
the care and assistance they need without having to wait a long time?
Yes
ADL Assistance QP238
H
Does [resident’s name] receive the assistance with meals that she/he needs?
No
1)
Yes
I don’t know
Does [resident’s name] receive the assistance with dressing and grooming
2)
No
including teeth, dentures, and mouth cleaned (routine oral hygiene) that
Yes
she/he needs?
I don’t know
FORM CMS-20049 (7/2012)
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