BOARDING HOME PRE INSPECTION PREPARATION



|[pic] | Attachment G |

| |Assisted Living Facility |

| |Resident Interview |

|ASSISTED LIVING FACILITY NAME |LICENSE NUMBER |

|      |      |

|INSPECTION DATE |LICENSOR NAME |

|      |      |

|Inspection Type: Initial Full Follow up Monitoring Complaint: Number       |

| |

|RESIDENT NAME |RESIDENT NUMBER |ROOM NUMBER |PAY STATUS |

|      |      |      |Private State |

|Brief Review of Negotiated Service Agreement: |

|      |

|The questions below are intended as a guide and should not prevent the interviewer from asking more questions or obtaining more data if concerns are identified. |

|If you are concerned about the answers, please investigate further. |

|Introductory questions: The interviewer may want to consider one of the following questions as a lead to the interview. |

|Resident Room / Environment |

|Resident: I realize this is not like your own home. How does staff here try to make this place seem homelike? Is there anything that would make this place more |

|comfortable for you? |

|      |

|Resident Room/Environment: Begin discussion by making a comment about something you noticed about the resident’s room, such as plants. Please tell me about your |

|room and how you feel about it. Tell me about the temperature in your room, the lighting. What things do you enjoy about your room? What kinds of things do you |

|enjoy doing in your room? What could the facility do to help you be more comfortable or do things such as reading, crafts, visiting with others when in your room?|

|      |

| Water temperature:       |

|Resident Services |

|Key needs and services met: Observe staff to resident interactions, responsiveness and if meeting resident needs. Review negotiated service agreement. |

|Can you tell me what kind of help you get from staff here? Do you feel that you get help when you need it? Describe how staff acts toward you when they are |

|assisting you. |

|      |

|Health care services: Observe delivery of care. Are you satisfied with the care provided by your physician and caregivers? |

|      |

|Generic personal care items provided if state contract: Do you receive personal care items you need, such as, soap, shampoo, toothbrush, toothpaste, deodorant? |

|      |

|Resident Rights / Quality of Life |

|Personal Choice/Preferences: Do staff know about your preferences? What kinds of things do you make choices about? Do you or your family participate in |

|meetings where staff plans your activities and daily medical and nursing care? |

|      |

|Dignity/Privacy: Are you able to have privacy when you want it? Do staff and other residents respect your privacy? Do you have a private place to meet with |

|visitors? To make phone calls? |

|      |

|Sense of well-being/safety: Do you feel safe here? Describe what helps you feel that you are safe here? Are there things here that make you feel fearful? |

|Observe resident grooming, hygiene, and dress. Has any resident or staff member ever physically harmed you, or taken anything without your permission? Describe |

|the way staff assist you when they are helping you with grooming and self-care. On a scale of 1 to 10 with 1 being gentle and 10 being rough, describe how you |

|feel you are touched and assisted by staff. Is there any staff that treats you very gently? Are there any staff who are rough with you, or take anything without |

|your permission? Is there enough staff to take care of everyone? |

|      |

|Response to concerns: Do you feel you can tell someone if you are unhappy about something or want to change something about your care? Do staff members listen to|

|your requests and respond to your satisfaction? |

|When you are unhappy, who do you talk with knowing that they will listen to you and respond to your concerns? When you bring things to the attention of people, |

|how long does it take for your concerns or problems to be taken care of? Have you ever talked with the ombudsman about any concerns? Do you know how to contact |

|the ombudsman or the state when you are scared or feel your needs are not being met? |

|      |

|Activities: Are there activities going on in the facility? Do you like to participate in activities? What kinds of activities were you involved in before coming|

|to this home? What activities do you enjoy that the facility offers? How often do you participate in activities? What activities would you like to do that is |

|not provided? What activities have you asked the facility to provide? |

|      |

|Meals / Food Services |

|How is the food here? Do you have any restrictions on your diet? How does your food taste? Have you ever refused to eat something served to you? (If yes), did |

|the facility offer you something else to eat? |

|      |

|Are there foods that are important to you from your background / history / culture that you would like to have that you are not now getting? How do you participate|

|in choosing the food, snacks, and alternate choices that are provided? Describe a typical meal services from start to end. When food is delivered to you is it the |

|right temperature? Describe the texture of the food? |

|      |

|Medication Services |

|How do you receive your medications? Do you take your own medication, or does your family or staff assist you? If you take your own medications, how are they |

|stored? |

|      |

|Medicaid Policy |

|Please tell me what the home told you about whether they admit and keep residents whose stay is paid by the state (Medicaid). When were you told about this? |

|      |

|Did the home tell you if they would allow you to stay if you ran out of money, and had to apply to the state for assistance? How did they give you the information,|

|in writing or verbally? |

|      |

|Additional Notes Attachment G |

|      |

|Leave a contact number for the resident to be able to contact you/RCS staff in the future. |

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