DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES QUALITY OF LIFE ASSESSMENT RESIDENT INTERVIEW Facility Name: Resident Name: Provider Number: Resident Identifier: Surveyor Name: Interview Dates/Times: Surveyor Number: Discipline: Instructions: For question 1,if you are meeting with the resident in a location away from the residents room,visit the room before the interview and note anything about the room that you want to discuss. For question 7,review the RAI to determine the ADL capabilities of this resident. Introduce yourself and explain the survey process and the purpose of the interview using the following concepts. It is not necessary to use the exact wording. [Name of facility] is inspected by a team from the [Name of State Survey Agency] periodically to assure that all residents receive good care. While we are here, we make a lot of observations,review the nursing homes records, and talk to residents to help us understand what its like to live in this nursing home. We appreciate your taking the time to talk to us. We ask certain questions because we want to know whether you have a say in decisions affecting your nursing and medical care, your schedule and the services you receive at this facility. We want to know how you feel about your life here and whether the facility has made efforts to accommodate your preferences. If it is all right with you, Id like to meet with you again later. That will give you time to think things over and to provide additional information later. In asking the following questions,it is not necessary to use the exact wording. Howevuse complete questions,er, do not one-word probes. Get the resident to talk about actual situations and examples by using open-ended probes,such as:Can you tell me more about that?or How is that done here?Avoid asking leading questions which suggest a certain response. If a resident gives a response to any question that indicates there may be a concern with facility services,probe to determine if the resident has communicated the problem to facility staff and what their response was. 1. ROOM: (F177,201,207, 242,250,252,256, 257) A good approach for initiating this discussion is to make a comment about something you have noticed about the residents room,for example, I notice that you have a lot of plants in your room. Please tell me about your room and how you feel about it. Did you have a choice about changing rooms? Do you enjoy spending time in your room? Where was your other room? What was it like? Is there enough light for you? Is there anything you would like to change about your Is the room temperature comfortable? room? Have you lived in a different room in the facility? (If yes)Have you talked to the facility about this? (If yes)What was the reason for the room change? How did they respond? Form CMS-806A(07/95) >>>> 2 RESIDENT INTERVIEW 2. ENVIRONMENT: (F252,258) Is there anything that would make this facility moreI realize that being in a nursing home is not like being in comfortable for you? your own home,but do staff here try to make this Is it generally quiet or noisy here? facility seem homelike? What about at night?Weve already talked about your room. How about other Is the facility usually clean and free of bad smells? places you use,like the activities room and dining room? Do they seem homelike to you? 3. PRIVACY: (F164,174) (If no phone in room)Where do you make phone calls?Are you a person who likes to have privacy sometimes? Do you have privacy when you are on the phone?(If theAre you able to have privacy when you want it? resident indicates any problems with privacy, probe forDo staff and other residents respect your privacy? specific examples. Ask if they talked to staff and whatDo you have a private place to meet with visitors? was their response.)4. FOOD:(F365) Have you ever refused to eat something served to you?Tell me about the food here. (If yes)Did the facility offer you something else toDo you have any restrictions on your diet? eat?How does your food taste? (If the resident refused a food and did not get a Are you served foods that you like to eat? substitute)Did you ask for another food? What Are your hot and cold foods served at a temperature was the facilitys response? you like? 5. ACTIVITIES: (F242,248) (If resident does not participate,probe to find out whyHow do you find out about the activities that are going not.) on? Is there some activity that you would like to do that isAre there activities available on the weekends? not available here?Do you participate in activities? (If yes)Which activity would you like to attend? (If yes)What kinds of activities do you participate in? Have you talked to anybody about this? What was (If resident participates)Do you enjoy these activities? the response?Form CMS-806A(07/95) >>>> 3 RESIDENT INTERVIEW 6. STAFF: (F223,241) Has any resident or staff member ever physicallyTell me how you feel about the staff members at this harmed you? facility. Do they treat you with respect? Has any resident or staff member ever taken anythingDo you feel they know something about you as a person? belonging to you without permission?Are they usually willing to take the time to listen when (If yes)Can you tell me who did this? you want to talk about something personal or a Has a staff member ever yelled or sworn at you? problem you are having? (If yes)Please describe what happened.Do they make efforts to resolve your problems? Can you tell me who did this? Did you report this to someone? (If yes)How did they respond? 7. ADLs: (F216,311,312) Do you feel that you get help when you need it?(Tailor this question to what you have observed and what is Do staff encourage you to do as much as you can for noted in the MDS about ADL capabilities of this resi- yourself? dent.) For example:I see that your care plan calls for you to dress with a little help from staff. How is that working for you? 8. DECISIONS: (F154,242, 280) If you are unhappy with something,or if you want toHere at this facility, are you involved in making choices change something about your care or your daily about your daily activities? schedule,how do you let the facility know?Are you involved in making decisions about your nursing Do you feel the staff members listen to your requests care and medical treatment? and respond appropriately?(If not,probe to determine what these choices and decisions If the staff are unable