Form #2 Form #2 Administrator Interview Guide & Facility Information For

ATTACHMENT E:

FACILITY INFORMATION FORM

ADMINSTRATOR INTERVIEW

Collaborative Studies of Long-Term Care

Form Approved
OMB No. 0935-XXXX
Exp. Date XX/XX/20XX

Antibiotic Use

In

Long-Term Care Settings

Facility Information Form

(FAC)

1.06.2010

	Facility ID:
	Master Facility ID:
	Interviewer ID:
	Date:
		M	M	D	D	Y	Y

Developed / adapted for the Collaborative Studies of Long-Term Care

Cecil G. Sheps Center for Health Services Research

University of North Carolina at Chapel Hill

Do not use without permission

Public reporting burden for this collection of information is estimated to average 15 minutes per response, the estimated time required to complete the survey. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-XXXX) AHRQ, 540 Gaither Road, Room # 5036, Rockville, MD 20850.

I. Facility Characteristics
1. Is your facility’s ownership for profit, non-profit, or government?				1	Profit
				2	Non-profit
				3	Government
2a. Is your facility owned or operated in association with a (or another):						No		Yes
		1. continuing care retirement community (CCRC)?				0		1
		2. hospital?..................................................................				0		1
		3. nursing home?.........................................................				0		1
		4. residential care facility?..................				0		1
b. Is it affiliated with a religious organization? ......................................................………..….......						0		1
c. Does the owner of your facility own other facilities? ..................................................................						0		1
3. How many years has this facility been in operation? [Round to nearest whole number. If < one year, record number of months.]			___ ___ Years or ___ ___ Months
					(1) Total		(2) Occupied
4a. How many beds does this facility have overall, and how many are occupied today?					___ ___ ___		___ ___ ___
b. How many licensed residential care beds does this facility have, and how many are occupied today?					___ ___ ___		___ ___ ___
c. How many licensed nursing home beds does this facility have, and how many are occupied today?					___ ___ ___		___ ___ ___

II. Facility Staff
The next questions are about the number of paid employees you have on staff. Please be thinking of the primary position of your staff; even if a paid staff member fulfills more than one role, assign him or her to a single primary classification. [If 4a ≠ 4b on page 2, say]: Since this is a multi-level facility, only include persons who spend at least one-half of their work time in the _____________ [NH] portion of the facility.
PRESENT TIME 1. How many (1) FULL and (2) PART TIME paid staff are there in each of these positions at THE PRESENT TIME, not including contract workers and other persons not paid by the facility? [Ask full and part time for each row before moving onto the next row.]
Staff Classification	Total Number Paid Staff Now
	1. Full Time	2. Part Time
a. Administrative Director or Assistant Director
b. Registered Nurses
c. Licensed Practical Nurses or Licensed Vocational Nurses
d. Certified Nursing Assistants or Personal Care Providers

LAST 6 MONTHS 2. How many (1) FULL and (2) PART TIME paid staff persons left this position in the LAST SIX MONTHS, not including contract workers and other persons not paid by the facility? [Ask full and part time for each row before moving onto the next row.]
Staff Classification	Total Number Paid Staff Last 6 months
	3. Full Time	4. Part Time
a. Administrative Director/Assistant Director
b. Registered Nurses
c. Licensed Practical Nurses or Licensed Vocational Nurses
d. Certified Nursing Assistants or Personal Care Providers

III. Resident Characteristics
For the rest of this interview, when I use the word “facility”, I mean only the nursing home portion of your facility that is participating in this project. [In most cases, it will be the entire facility.] The next few questions ask for numbers of residents within certain categories. Please provide your best estimate of these numbers. It is not necessary for you to review records for this information.
5. How many of all of your current residents are....		Number
a. Resident Age Distribution [Items 1-6 should sum to the total number of residents in the participating portion of the facility]	1. 0 -18 years old	__ ___ ___
	2. 19-64 years old	___ ___ ___
	3. 65-74 years old	___ ___ ___
	4. 75-84 years old	___ ___ ___
	5. 85 - 94 years old	___ ___ ___
	6. 95 years old and over	___ ___ ___
b. Resident Gender	Male	___ ___ ___
c. Resident Racial Background [Items 1-5 should sum to the total number of residents in the participating portion of the facility]	1. American Indian or Alaskan Native	___ ___ ___
	2. Asian or Pacific Islander	___ ___ ___
	3. Black	___ ___ ___
	4. White	___ ___ ___
	5. Other	___ ___ ___
d. Resident Ethnicity	of Hispanic Origin	___ ___ ___
e. Acute care/rehab		___ ___ ___
f. Have a diagnosis of dementia? Diagnoses include: Alzheimer’s Disease (AD); Senile Dementia; Senile Dementia of the Alzheimer’s Type (SDAT); Organic Brain Syndrome (OBS); Cerebral Arteriosclerosis; Multi-Infarct Dementia (MID); Subcortical Dementia; Binswanger’s Disease; Pick’s Disease; Creutzfeldt-Jakob Disease; Lewy Body Disease; Any other diagnosis that includes dementia, such as “Alcoholic Dementia” or “Parkinson’s Disease with Dementia”; and Dementia not otherwise specified.		___ ___ ___
g. Are currently receiving state financial assistance or Medicaid?		___ ___ ___