DSHS Form 10-365 Attachment G "Assisted Living Facility Resident Interview" - Washington

What Is DSHS Form 10-365 Attachment G?

This is a legal form that was released by the Washington State Department of Social and Health Services - a government authority operating within Washington. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 2019;
  • The latest edition provided by the Washington State Department of Social and Health Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of DSHS Form 10-365 Attachment G by clicking the link below or browse more documents and templates provided by the Washington State Department of Social and Health Services.

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Download DSHS Form 10-365 Attachment G "Assisted Living Facility Resident Interview" - Washington

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Attachment G
Assisted Living Facility
Resident Interview
ASSISTED LIVING FACILITY NAME
LICENSE NUMBER
INSPECTION DATE
LICENSOR NAME
RESIDENT NAME
RESIDENT NUMBER
ROOM NUMBER
PAY STATUS
Private
State
Brief Review of Negotiated Service Agreement:
The questions in Section B – K 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.
SELECT ONE
Resident Interview
Representative Interview
A. The following are REQUIRED questions and MUST be asked during the interview. Check “Y,” if the answer is yes;
check “N,” if the answer is no and document the interviewee’s response; or check “D” if the interviewee declined to
answer the question.
Y
N
D
Can you make choices about the care and
services you receive here at the facility?
If you have a roommate, were you informed
you would have a roommate? Could you
change roommates if you wanted to?
Do you have an opportunity to participate in
community activities?
Can you choose who visits you and when?
Do they pay attention to what you have to say?
Can you choose to lock your door?
Do you have access to food anytime?
Do you receive services in the community?
INSTRUCTIONS: Your interview must address each category. Check the question asked or write your own question.
If you are concerned about the answers, please investigate further. If resident is not interviewable, modify questions for
Representative interview.
B.
Care and Service Needs
What kind of help do you get from the staff?
Other:
How well does staff meet your needs?
No Concerns
C.
Support of Personal Relationships (if the resident has family or significant others)
Does staff give you time and space to meet / visit with
Other:
friends and family who come to visit?
Are you able to make personal phone calls without
No Concerns
being overheard?
D.
Reasonable House Rules
Tell me about the rules of the facility.
Other:
What have you been told about how long you can stay
No Concerns
up at night or how early or late you can watch TV?
Page 1 of 3
ASSISTED LIVING FACILITY RESIDENT INTERVIEW
DSHS 10-365 (REV. 10/2021)
Attachment G
Assisted Living Facility
Resident Interview
ASSISTED LIVING FACILITY NAME
LICENSE NUMBER
INSPECTION DATE
LICENSOR NAME
RESIDENT NAME
RESIDENT NUMBER
ROOM NUMBER
PAY STATUS
Private
State
Brief Review of Negotiated Service Agreement:
The questions in Section B – K 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.
SELECT ONE
Resident Interview
Representative Interview
A. The following are REQUIRED questions and MUST be asked during the interview. Check “Y,” if the answer is yes;
check “N,” if the answer is no and document the interviewee’s response; or check “D” if the interviewee declined to
answer the question.
Y
N
D
Can you make choices about the care and
services you receive here at the facility?
If you have a roommate, were you informed
you would have a roommate? Could you
change roommates if you wanted to?
Do you have an opportunity to participate in
community activities?
Can you choose who visits you and when?
Do they pay attention to what you have to say?
Can you choose to lock your door?
Do you have access to food anytime?
Do you receive services in the community?
INSTRUCTIONS: Your interview must address each category. Check the question asked or write your own question.
If you are concerned about the answers, please investigate further. If resident is not interviewable, modify questions for
Representative interview.
B.
Care and Service Needs
What kind of help do you get from the staff?
Other:
How well does staff meet your needs?
No Concerns
C.
Support of Personal Relationships (if the resident has family or significant others)
Does staff give you time and space to meet / visit with
Other:
friends and family who come to visit?
Are you able to make personal phone calls without
No Concerns
being overheard?
D.
Reasonable House Rules
Tell me about the rules of the facility.
Other:
What have you been told about how long you can stay
No Concerns
up at night or how early or late you can watch TV?
Page 1 of 3
ASSISTED LIVING FACILITY RESIDENT INTERVIEW
DSHS 10-365 (REV. 10/2021)
E.
Respect of Individuality, Independence, Personal Choice, Dignity
Does the staff here know about your preferences?
Other:
What kinds of things do you make choices about?
No Concerns
How does the staff treat you? Speak to you?
Do you have any concerns about how you are
treated?
F.
Homelike Environment
What is your room like?
Other:
Are you comfortable there?
What personal items were you allowed to bring when
No Concerns
you came here?
Is the temperature here comfortable to you?
G. Response to Concerns
Do you feel like you can tell someone if you don’t like
Other:
it here?
Who would you talk to if you had concerns?
No Concerns
What do you think they would do about it?
H.
Sense of Well-Being and Safety
Do you feel safe here?
Other:
Does anything make you feel uncomfortable here?
No Concerns
I.
Meals / Snacks / Preferences
How is the food here?
Other:
If you can’t eat something or don’t like something,
what kind of replacement does the home offer you?
No Concerns
How often do you get the foods you like to eat?
J.
Activities
What activities are offered to you by the facility?
Other:
What kinds of things did you do for fun and relaxation
before you came here?
No Concerns
Are there activities you would like to do that you are
not offered?
Is there anything you wanted to do and the facility
helped you do it?
K.
Notice
Do you handle your own finances or does someone
Other:
help you with that?
What were you told about paying for your care here
No Concerns
and the facility’s policy about admitting and keeping
residents whose stay is paid for by the state
(Medicaid)?
When and how were you told about this?
Leave a contact number for the resident to be able to contact you / RCS staff in the future.
Page 2 of 3
ASSISTED LIVING FACILITY RESIDENT INTERVIEW
DSHS 10-365 (REV. 10/2021)
NOTE: This form should be used to document any additional information or data that does not fit in the designated space.
NOTES
Page 3 of 3
ASSISTED LIVING FACILITY RESIDENT INTERVIEW
DSHS 10-365 (REV. 10/2021)
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