Family Interview Form Page 6
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8DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
FAMILY INTERVIEW
Building and Environment QP248
L
Is this a comfortable building in which to live? (Comfortable includes
1)
No
appropriate temperature, lighting, and noise levels.)
Yes
Is the facility clean?
2)
No
Yes
Exercise of Rights QP251
M
Has your relative/friend been moved to a different room within the past
1)
No (skip to #3)
several months?
Yes
Did you receive notice of explanation before the move?
2)
No
Yes
N/A, person being interviewed is not the
person who gets the notice
Has your relative/friend been discharged to a hospital within the past several
3)
No (skip to Costs and Personal Funds)
months?
Yes
Were you notified of the facility policy permitting her/him to return?
4)
No
Yes
N/A, person being interviewed is not the
person who gets the notice
Costs and Personal Funds QP121a QP121b
N
Are you the resident’s representative for financial decisions?
1)
No (skip to #5)
Yes
Does the facility manage the resident’s personal funds (funds for beauty shop,
No (skip to #5)
2)
smoking materials, cosmetics, etc.)?
Yes
N/A, person being interviewed does not
have knowledge of the resident's personal
funds
FORM CMS-20049 (7/2012)
6
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