Family Interview Form Page 5
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8DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
FAMILY INTERVIEW
Does [resident’s name] receive the assistance with toileting that she/he needs?
No
3)
Yes
I don’t know
Oral Health QP245
I
Does [resident’s name] have any chewing or eating problems, or mouth pain?
1)
No
Yes
Does [resident’s name] have any tooth problems, gum problems, mouth sores
2)
No
or denture problems?
Yes
Abuse QP236
J
Have you ever noticed any staff member being rough with, talking in a
1)
No (skip to Personal Property)
demeaning way or yelling at [resident's name] or any other resident?
Yes
Did you report it?
2)
(If "No", ask the relative/friend if he/she knew how to report the concern. If
No (skip to Personal Property)
his/her response is "No", initiate the Abuse care area for the resident and the
Yes
Abuse Prohibition task for the facility.)
Did facility staff act promptly to investigate and correct the situation?
3)
No
Yes
Personal Property QP241
K
Were you encouraged by staff to bring in any personal items?
1)
No
If No: Do you wish to have items brought in?
Yes
N/A, the resident is a short-stay resident
Has [resident's name] had any missing personal items?
2)
No (skip to Building and Environment)
If Yes: What is still missing and how long has it been missing?
Yes
Did you tell staff about the missing item(s)?
3)
No (skip to Building and Environment)
If Yes: Who did you tell about the missing item? If the answer is "Yes," then
Yes
ask question 4.
Has staff told you they are looking for your missing item?
4)
No
If No: Do you know who or which department is supposed to be looking for
Yes
your missing item?
FORM CMS-20049 (7/2012)
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