Free Community Based Residential Facility (CBRF) Resident Satisfaction Evaluation-F-62372 - Wisconsin


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State: Wisconsin
Category: Health Care
Author: Division of Quality Assurance
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Preview Community Based Residential Facility (CBRF) Resident Satisfaction Evaluation-F-62372
DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance F-62372 (Rev. 04/09)

STATE OF WISCONSIN

COMMUNITY BASED RESIDENTIAL FACILITY (CBRF) RESIDENT SATISFACTION EVALUATION
Wisconsin Administrative Code, DHS 83.35(4), requires that within 30 days prior to the annual evaluation, the resident and his/her guardian or agent shall be offered the opportunity to complete a written or oral evaluation of the facility's services, including but not limited to the ability of the facility to identify and meet his/her needs and preferences for care. A facility-developed form may be used if it captures the identical information and is approved by the Department.
Name - Facility

Name - Resident

Date Form Completed

1. All facilities must provide or make available to residents certain services. From the following list, please check the services you receive: Supervision Leisure time activities Family contacts Health monitoring Medication monitoring/supervision Help with personal care Help in communication Assistance in decision-making Information and Referral Activities in the community Transportation Access to medical services Limited nursing services Help with independent living skills Opportunity to socialize with others Transition services

Please list any other services you receive that are not included in the above list:

Are there other services or activities that you feel you need but are NOT provided or arranged by the CBRF? Please list:

2. Overall, I am satisfied with the services provided by this facility. Yes Comments: Somewhat No Don't Know

3. The care I receive is the kind of care I desire. Yes Comments: Somewhat No Don't Know

4. The facility meets my treatment preferences (choice of doctors, pharmacy, etc.) Yes Comments: Somewhat No Don't Know

5. The facility meets my preferences for services (I receive the services I need or want).

F-62372 (Rev. 04/09)

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Yes Comments:

Somewhat

No

Don't Know

6. The facility offers a variety of activities for me to choose from. Yes Somewhat No Don't Know

List activities in which you take part and how often you participate.

6a. List any activities you would like to have but are not available.

7. There appears to be enough staff on duty at all times to meet my needs as well as those of other residents. Yes Comments: Somewhat No Don't Know

8. Staff members appear to know what their responsibilities are. Yes Comments: Somewhat No Don't Know

9. I am treated respectfully at all times. Yes Comments: Somewhat No Don't Know

10. My rights have been explained to me. Yes Comments: Somewhat No Don't Know

11. I feel that my rights are being protected. Yes Comments: Somewhat No Don't Know

12. The food served ... ... is of good quality Comments: ... meets my nutritional needs Yes No Don't Know Yes No Don't Know

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Comments: ... is prepared well Comments: ... tastes good Comments: ... is always enough Comments: ... is of a wide variety Comments: ... hot foods are served hot and cold foods are served cold Comments: 13. My room is comfortable and meets my needs. Yes Comments: Somewhat No Don't Know Yes No Don't Know Yes No Don't Know Yes No Don't Know Yes No Don't Know Yes No Don't Know

14. The furnishings in my room are kept in good repair. Yes Comments: Somewhat No Don't Know

15. My room, as well as the rest of the facility, is kept neat and clean. Yes Comments: Somewhat No Don't Know

16. I feel safe and comfortable here. Yes Comments: Somewhat No Don't Know

17. People respect my privacy. Yes Comments: Somewhat No Don't Know

18. The facility manages my personal funds. Yes No Don't Know

If you answered "Yes," do you have concerns about how the facility is handling your funds?

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19. The facility gives me WRITTEN notices of any changes in fees or services at least 30 days before the change happens. Yes Comments: No Don't Know

20. Do you control and take your own medications? Yes No Don't Know

If you answered "NO," have either you or your doctor signed a paper allowing the facility to control your medications and give them to you? Yes Comments: 21. If the facility assists me with my medications, I receive them ... ... on time Comments: Yes No Don't Know Not Applicable No Don't Know

... in an acceptable manner Comments:

Yes

No

Don't Know

Not Applicable

... as prescribed by my doctor Comments:

Yes

No

Don't Know

Not Applicable

22. Any other comments regarding this facility you would like to make? (Attach extra pages, if needed.)

SIGNATURE - Resident

Date Signed

OTHER PERSON(S) ASSISTING RESIDENT IN COMPLETING THIS EVALUATION
SIGNATURE Guardian / Representative Date Signed

SIGNATURE - CBRF Staff

Date Signed