NSLTP - Adult Day Services Center

Attachment 1b.

Note to reviewers: No changes have been made to the questionnaire since OMB’s approval of OMB# 0902-0943. In addition to the questions presented in the questionnaire below, additional questions probing the respondents’ cognitive processes will be administered, following the methodology laid out in the QDRL Generic IRC, OMB# 0902-0222 (ex 06/30/2015).

2012 National Study of Long-Term Care Providers (NSLTCP) Adult Day Services Center Questionnaire

Dear Director, The Centers for Disease Control and Prevention’s National Center for Health Statistics (NCHS) is conducting the new National Study of Long-Term Care Providers (NSLTCP), which includes a national survey of adult day services centers. RTI International has been contracted to carry out the data collection. Please answer all of the questions in reference to the adult day services center at the location shown on the pre-printed label below. If your center is part of a multi-facility campus, please only answer for the adult day services center portion of the campus. The accuracy of your answers is important to this study. If you need assistance or have any questions while completing this questionnaire, please call 1-800-957-6456 to speak to a member of the NSLTCP project team. Thank you for taking the time to complete this questionnaire. Label here Sincerely, Angela M. Greene RTI International, Survey Contractor to NCHS NOTICE – The Public Health Service Act provides us with the authority to do this research (42 United States Code 242k). All information which would permit identification of any individual, a practice, or an establishment will be held confidential, will be used for statistical purposes only by NCHS staff, contractors, and agents only when required and with necessary controls, and will not be disclosed or released to other persons without the consent of the individual or the establishment in accordance with section 308(d) of the Public Health Service Act (42 USC 242m) and the Confidential Information Protection and Statistical Efficiency Act (PL-107-347). Public reporting burden for this collection of information is estimated to average 1 hour per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. 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 CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0222). OMB #0920-0222; Expiration Date: 06/30/2015

INSTRUCTIONS:

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• Written answers should be printed in the space provided. Example

1

Background Information

Please consult records and other staff as needed to answer questions.

Please provide answers only for the adult day services center portion of your campus.

3a. For each item (a–f) below, please indicate whether or not this type of organization owns this center.

	Yes	No
a. Hospital
b. Nursing home or skilled nursing facility
c. Home health agency
d. Hospice agency
e. Assisted living or similar residential care community (e.g., adult care or personal care residence)
f. Other

4. What is the maximum number of participants allowed at this adult day services center at this location? This may be called the allowable daily capacity and is usually determined by law or by fire code, but may also be a program decision.

Maximum number of participants allowed

5. What is the total number of participants currently enrolled at this center at this location? Include respite care participants.

Number of participants

6. Based on a typical week, what is the approximate average daily attendance at this center at this location? Include respite care participants.

Average daily attendance of participants

1. What is the type of ownership of this adult day services center?

MARK ONLY ONE ANSWER

Private, nonprofit

Private, for profit

Publicly traded company or limited liability company (LLC)

Government—federal, state, county, or local government

2. Is this center owned by a person, group, or organization that owns or manages two or more adult day services centers? This may include a corporate chain.

Yes

No

3. Is this adult day services center owned by any other type of organization?

Yes CONTINUE

No, not part of another
organization SKIP TO QUESTION 4

7. Based on a typical week, how many respite care participants does this center serve?

Number of participants OR None

8. Is this adult day services center certified or otherwise set up to participate in Medicaid, either through the Medicaid State Plan or a home and community-based services waiver program?

Yes

No

9. During the last 30 days, how many of this center’s participants had some or all of their long-term care services paid by Medicaid?

Number of participants OR None

10. Other than from Medicaid, does this adult day services center receive funding from any federal, state, county or city community care agencies? For example, Older American Act Funding, State Unit on Aging, Area Agencies on Aging, or Councils on Aging.

Yes

No

11. Of this center’s revenue from paid participant fees, about what percentage comes from each of the following sources? Your entries should add up to 100%. Enter “0” for any sources that do not apply.

a. Medicaid	%
b. Medicare	%
c. Other government	%
d. Out-of-pocket payment by the participant or family	%
e. Private insurance	%
f. Other source	%
TOTAL	100 %

12. Is this center licensed or certified by the state specifically to provide adult day services?

Yes

No

13. Is this center licensed or certified under some other type of provider? For example, nursing home, rehabilitation center, or hospital.

Yes

No

14. A continuing care retirement community is a community that offers multiple levels of care such as independent living, residential care and skilled nursing care, and provides residents the opportunity to remain in the same community as their needs change. Is this adult day services center part of a continuing care retirement community?

Yes

No

15. What is the total number of years this center has been operating as an adult day services center at this location?

Less than 1 year

1 to 4 years

5 to 9 years

10 to 19 years

_{20 or more years}

2

Services Offered

Please provide answers only for the adult day services center portion of your campus.

16. For each item (a–l) below, please mark whether or not this adult day services center provides the service and, if it does, whether it is provided only by center employees, only by others through arrangement, or by both. Please mark “Not provided” if the center only refers participants to service providers.

a. Routine and emergency dental services by a licensed dentist	Not provided Provided only by center employees Provided only by others through arrangement Provided by both center employees and others through arrangement
b. Hospice services	Not provided Provided only by center employees Provided only by others through arrangement Provided by both center employees and others through arrangement
c. Social work services—provided by licensed social workers or persons with a bachelor’s or master’s degree in social work, and include an array of services such as psychosocial assessment, individual or group counseling, and referral services	Not provided Provided only by center employees Provided only by others through arrangement Provided by both center employees and others through arrangement
d. Any case management services—generally a process of assessment, planning, and facilitation of options and services for an individual	Not provided Provided only by center employees Provided only by others through arrangement Provided by both center employees and others through arrangement
e. Mental health services—target participants' mental, emotional, psychological, or psychiatric well-being and include diagnosing, describing, evaluating, and treating mental conditions	Not provided Provided only by center employees Provided only by others through arrangement Provided by both center employees and others through arrangement
f. Any therapeutic services—physical, occupational, or speech	Not provided Provided only by center employees Provided only by others through arrangement Provided by both center employees and others through arrangement
g. Pharmacy services—including filling of and delivery of prescriptions	Not provided Provided only by center employees Provided only by others through arrangement Provided by both center employees and others through arrangement
h. Podiatry services	Not provided Provided only by center employees Provided only by others through arrangement Provided by both center employees and others through arrangement
Skilled nursing services—must be performed by a registered nurse (RN) or a licensed practical nurse (LPN) and are medical in nature	Not provided Provided only by center employees Provided only by others through arrangement Provided by both center employees and others through arrangement

16. Cont’d

j. Transportation services for medical or dental appointments	Not provided Provided only by center employees Provided only by others through arrangement Provided by both center employees and others through arrangement
k. Transportation services for social and recreational activities, or shopping	Not provided Provided only by center employees Provided only by others through arrangement Provided by both center employees and others through arrangement
l. Daily round trip transportation services to/from this center	Not provided Provided only by center employees Provided only by others through arrangement Provided by both center employees and others through arrangement

17. For about how many of the currently enrolled participants does this center manage, supervise, or store medications; administer medications; or provide assistance with self-administration of medications?

Number of participants OR None

18. As a part of the admission process, does this center screen participants for depression with a standardized tool such as the Geriatric Depression Scale, Beck Depression Inventory, or the Center for Epidemiological Studies-Depression (CES-D) scale?

Yes

No

19. Disease-specific programs may include one or more of the following services—educational programs, physical activity programs, diet/nutrition programs, medication management programs, and weight management programs. For each condition (a–d) below, please indicate whether or not this center offers any of these services for participants with this condition.

	Yes	No
a. Alzheimer’s disease and other dementias
b. Cardiovascular disease (e.g., heart disease, stroke, high blood pressure)
c. Depression
d. Diabetes

20. On a regular basis, does this center create daily schedules based on each participant’s life history, abilities, and interests?

Yes

No

21. On a regular basis, does this center seek input from participants and their families into what personal care services are received by the participant?

Yes

No

22. On a regular basis, does this center give participants choices for each of the following?

MARK YES OR NO IN EACH ROW
	Yes	No
a. Meal times
b. Meal types/menus

3

Staff Profile

Please consult records and other staff as needed to answer questions.

Please provide answers only for the adult day services center portion of your campus.

23. For each item (a–d) below, please indicate the number of center staff that currently work at this adult day services center full-time and part-time. Please include:

• both full-time and part-time center employees (an individual is considered a center employee if the center is required to issue a Form W-2 on their behalf), and

• other individuals or organization staff under contract with and working at this center full-time and part-time.

Please report either the number of full-time and part-time staff OR the number of full-time equivalent (FTE) staff, but not both, for the center employee category and the contract staff category. If this center does not have any staff for a specific category, enter “0” under the number of full-time and part-time staff.

Current Center Staff		Number of Full-Time Staff If none, enter “0”	Number of Part-Time Staff If none, enter “0”		Number of Full-Time Equivalent (FTE) Staff If none, enter “0”
a. RNs	Center employee(s)			OR
	Contract staff			OR
b. LPNs/licensed vocational nurses (LVNs)	Center employee(s)			OR
	Contract staff			OR
c. Certified nursing assistants, nursing assistants, home health aides, home care aides, personal care aides, personal care assistants, and medication technicians or medication aides	Center employee(s)			OR
	Contract staff			OR
d. Social workers—licensed social workers or persons with a bachelor’s or master’s degree in social work	Center employee(s)			OR
	Contract staff			OR

24. Do any activities directors or activities staff work at this adult day services center? Include center employees and contract staff.

Yes CONTINUE

No SKIP TO QUESTION 26

25. On an average shift, how many activities directors or activities staff are on-site providing services? Include center employees and contract staff.

Number of activities directors or activities staff OR None

4

Participant Profile

Please consult records and other staff as needed to answer questions.

Please provide answers only for the adult day services center portion of your campus.

26. Of the participants currently enrolled at this center, how many are in each of the following categories? Count each participant only once. Enter “0” for any categories with no participants.

	NUMBER OF PARTICIPANTS
a. Hispanic or Latino, of any race
b. American Indian or Alaska Native, not Hispanic or Latino
c. Asian, not Hispanic or Latino
d. Black, not Hispanic or Latino
e. Native Hawaiian or Other Pacific Islander, not Hispanic or Latino
f. White, not Hispanic or Latino
g. Two or more races, not Hispanic or Latino
h. Some other category reported in this center’s system
i. Not reported (race and ethnicity unknown)
TOTAL

NOTE: Total should be the same as provided in Question 5.

27. Of the participants currently enrolled at this center, how many are in each of the following categories? Enter “0” for any categories with no participants.

	NUMBER OF PARTICIPANTS
a. Male
b. Female
TOTAL

NOTE: Total should be the same as provided in Question 5.

28. Of the participants currently enrolled at this center, how many are in each of the following age categories? Enter “0” for any categories with no participants.

	NUMBER OF PARTICIPANTS
a. 17 years or younger
b. 18–44 years
c. 45–54 years
d. 55–64 years
e. 65–74 years
f. 75–84 years
g. 85 years and older
TOTAL

NOTE: Total should be the same as provided in Question 5.

29. Of the participants currently enrolled at this center, how many live in each of the following places? Enter “0” for any categories with no participants.

	NUMBER OF PARTICIPANTS
a. An assisted living or similar residential care community (e.g., adult care or personal care residence)
b. A private residence (house or apartment)
c. A nursing home or other institutional setting
d. Some other place
TOTAL

NOTE: Total should be the same as provided in Question 5.

30. Of the participants currently enrolled at this center, about how many have been diagnosed with each of the following conditions?

NUMBER OF PARTICIPANTS
a. Alzheimer’s disease or other dementias		OR	None
b. Developmental disability, such as mental retardation, autism, or Down’s syndrome		OR	None
c. Severe mental illness, such as schizophrenia and psychosis		OR	None
d. Depression		OR	None

31. Before or upon admission, does this center use a standardized tool to conduct a formal assessment of its participants to identify anyone with a cognitive impairment?

Yes CONTINUE

_{No SKIP TO QUESTION 32}

31a. Based on this assessment, about how many of the participants currently enrolled at this center have been identified as having a cognitive impairment?

Number of participants OR None

32. This next question asks about the number of participants at this adult day services center who currently need assistance in activities of daily living (ADLs).

Assistance refers to needing any help or supervision from another person, or use of special equipment. As a reminder, please provide answers only for the adult day services center portion of your campus.

Of the participants currently enrolled at this center, about how many need any assistance in each of the following activities?

NUMBER OF PARTICIPANTS
a. Transferring in and out of bed		OR	None
b. Transferring in and out of a chair		OR	None
c. With eating, like cutting up food		OR	None
d. With dressing		OR	None
e. With bathing or showering		OR	None
f. In using the bathroom (toileting)		OR	None
g. With locomotion or walking—this includes using a cane, walker, or wheelchair and/or help from another person.		OR	None

33. Of the participants currently enrolled at this center, about how many use a manual, electric, or motorized wheelchair or scooter?

Number of participants OR None

34. Of the participants currently enrolled at this center, about how many were discharged from an overnight hospital stay in the last 90 days? Exclude trips to the hospital emergency department that did not result in an overnight hospital stay.

Number of participants CONTINUE

None SKIP TO QUESTION 35

34a. Of the participants who were discharged from an overnight hospital stay in the last 90 days, about how many of those participants were re-admitted to the hospital for an overnight stay within 30 days of their hospital discharge?

Number of participants OR None

35. Of the participants currently enrolled at this center, about how many were treated in a hospital emergency department in the last 90 days?

Number of participants OR None

Questions 36–38b refer to the last 12 months.

36. In the last 12 months, about how many participants were newly enrolled into this center? Count all participants who were newly enrolled—including respite care participants, participants who later died, and participants who are no longer enrolled—regardless of the reason.

Number of participants OR None

37. In the last 12 months, about how many participants died? Include respite care participants.

Number of participants OR None

38. In the last 12 months, about how many participants, including respite care participants, permanently stopped using this adult day services center? Exclude deaths.

Number of participants CONTINUE

None SKIP TO QUESTION 39

38a. Where did each of these participants go immediately after they stopped using the center? Enter “0” for any categories with no participants.

	NUMBER OF PARTICIPANTS
a. Another adult day services center
b. Assisted living or similar residential care community (e.g., adult care or personal care residence)
c. Hospital
d. Nursing home
e. Private residence (house or apartment)
f. Some other place
TOTAL
NOTE: Total should be the same as provided in Question 38.

38b. Of those participants who stopped using this center in the last 12 months, about how many left because the cost of attending the center, including meals and services required to meet their needs, exceeded their ability to pay?

Number of participants OR None

5

Record Keeping

Please provide answers only for the adult day services center portion of your campus.

39. An Electronic Health Record is a computerized version of the participant’s health and personal information used in the management of the participant’s health care. Other than for accounting or billing purposes, does this adult day services center use Electronic Health Records?

Yes

No

40. For each item (a–s) below, please indicate in Column 1 whether or not this adult day services center collects or tracks this information about participants. If this center does collect or track the information, please indicate in Column 2 whether or not this center has the computerized capability to collect or track it.

	Column 1 Does this center collect/track this information?	IF YES IN COLUMN 1	Column 2 Does this center have the computerized capability to collect/track this information?
a. Contact information for the participant’s medical providers	Yes No		Yes No
b. Participant demographics	Yes No		Yes No
c. Functional assessments	Yes No		Yes No
d. Individual service plans	Yes No		Yes No
e. Participant service records (a record of the services being provided to each participant)	Yes No		Yes No
f. Clinical notes, such as medical history and daily progress notes	Yes No		Yes No
g. Participant problem list (medical and behavioral concerns)	Yes No		Yes No
h. Advance directives	Yes No		Yes No
i. Automatic reminders for updating records, scheduling screening tests or guideline based interventions	Yes No		Yes No
j. Lists of medications	Yes No		Yes No
k. Medication administration records	Yes No		Yes No
l. Active medication allergy lists	Yes No		Yes No

40. Cont’d

	Column 1 Does this center collect/track this information?	IF YES IN COLUMN 1	Column 2 Does this center have the computerized capability to collect/track this information?
m. Warning of drug interactions or contraindications	Yes No		Yes No
n. Discharge and transfer summaries	Yes No		Yes No
o. Outside health care visits, including emergency room visits and overnight hospital admissions	Yes No		Yes No
p. Orders for prescriptions	Yes No		Yes No
q. Orders for tests	Yes No		Yes No
r. Viewing laboratory/imaging results (seeing and reading test results)	Yes No		Yes No
s. Public health reporting	Yes No		Yes No

41. Does this adult day services center’s computerized system support electronic health information exchange with each of the following providers?

			MARK YES OR NO IN EACH ROW
		Yes		No
a. Physician
b. Pharmacy

6

Contact Information

We would like to reach you if we have questions about your answers. Please provide your name, telephone number, work e-mail address, and job title. Your contact information will be kept confidential and will not be shared with anyone outside the project team. PLEASE PRINT Your full name: ( ) Your work telephone number, with extension: Your work e-mail address: Your job title: Thank you for participating in the NSLTCP. Please return your completed questionnaire in the postage-paid self-addressed envelope provided to: NSLTCP RTI International Suite 100 Imperial Court Business Park 1000 Parliament Court Durham, NC 27703