Attachment 1a.
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).
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2012 National Study of Long-Term Care Providers (NSLTCP) Residential Care Community Questionnaire |
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Dear Administrator / Executive 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 residential care communities. RTI International has been contracted to carry out the data collection. Please answer all of the questions in reference to the residential care community at the location shown on the pre-printed label below. If your residential care community is part of a multi-facility campus, please only answer for the residential care community portion of the campus. The accuracy of your answers is important to this study. Residential care places are known by many different names. Just a few terms used to refer to these places are assisted living, personal care, and adult care homes, facilities, and communities; adult family and board and care homes; adult foster care; homes for the aged; and housing with service establishments. For this study, we refer to these places and others like them as residential care communities. Nursing homes are excluded. 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.
Angela M. Greene 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:
Please clearly mark your responses in the boxes provided. Examples or
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Written answers should be printed in the space provided. Example
Residential care places are known by many different names. Just a few terms used to refer to these places are assisted living, personal care, and adult care homes, facilities, and communities; adult family and board and care homes; adult foster care; homes for the aged; and housing with service establishments. For this study, we refer to these places and others like them as residential care communities. Nursing homes are excluded.
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Study Eligibility |
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3b. Does this residential care community exclusively serve both persons with mental retardation/a developmental disability and persons with severe mental illness? Yes SKIP TO BOX A No CONTINUE 4. Does this residential care community provide or arrange for a personal care aide, registered nurse (RN), licenses practical nurse (LPN), or the director or assistant director (if they provide personal care or nursing services to residents) to be on-site 24 hours a day, 7 days a week to meet any resident needs that may arise? On-site means they are located in the same building, in an attached building or next door, or on the same campus. Yes CONTINUE No SKIP TO BOX A 5. Does this residential care community offer help with activities of daily living, such as help with bathing, either directly or arranged through an outside vendor? Yes SKIP TO QUESTION 6 No CONTINUE 5a. Does this residential care community offer assistance with the administration of medications, give reminders, or provide central storage of medications? Yes CONTINUE No SKIP TO BOX A
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The answers to the questions below determine if this residential care community meets the study definition for the 2012 National Study of Long-Term Care Providers. Please answer the following question(s) and follow the instructions next to the answer you mark. 1. Is this residential care community currently licensed, registered, listed, certified, or otherwise regulated by the state? Yes CONTINUE No SKIP TO BOX A 2. Does this residential care community have 4 or more licensed, registered, or certified beds? Yes CONTINUE No SKIP TO BOX A 3. Does this residential care community exclusively serve adults with mental retardation or a developmental disability, such as Down's syndrome or autism? Yes SKIP TO BOX A No CONTINUE 3a. Does this residential care community exclusively serve adults with severe mental illness, such as schizophrenia or psychosis? Please do not include Alzheimer’s disease or other dementias. Yes SKIP TO BOX A No CONTINUE |
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6. Does this residential care community offer at least 2 meals a day to residents? Yes CONTINUE No SKIP TO BOX A 7. Is there at least one resident living at this residential care community? Yes SKIP TO QUESTION 8 THIS RESIDENTIAL CARE COMMUNITY IS ELIGIBLE TO PARTICIPATE IN THIS STUDY. No SKIP TO BOX A
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9. Is this residential care community owned by a person, group, or organization that owns or manages two or more residential care communities? This may include a corporate chain. Yes No 10. Is this residential care community owned by any other type of organization? Yes CONTINUE
No, not part of another 10a. For each item (a–f) below, please indicate whether or not this type of organization owns this residential care community.
11. At this residential care community, what is the number of licensed, registered, or certified residential care beds? Include both occupied and unoccupied beds. Number of beds 12. What is the total number of residents currently living at this residential care community? Include respite care residents. Number of residents
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Background InformationPlease consult records and other staff as needed to answer questions. Please provide answers only for the residential care community portion of your campus. |
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8. What is the type of ownership of this residential care community? MARK ONLY ONE ANSWER Private, nonprofit Private, for profit Publicly traded company or limited liability company (LLC) Government—federal, state, county, or local government |
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13. Of the residents currently living in this residential care community, how many are respite care residents? Number of residents OR None 14. Is this residential care community 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 15. During the last 30 days, how many of this residential care community’s residents had some or all of their long-term care services paid by Medicaid? Number of residents OR None 16. 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 residential care community part of a continuing care retirement community? Yes No 17. What is the total number of years this residential care community has been operating as a residential care community at this location? 1 to 4 years 5 to 9 years 10 to 19 years 20 or more years |
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Services Offered Please provide answers only for the residential care community portion of your campus. |
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18. Does this residential care community only serve adults with dementia or Alzheimer’s disease? Yes CONTINUE No SKIP TO QUESTION 18b 18a. Does this residential care community have specially trained staff for residents with dementia or Alzheimer’s disease? Yes SKIP TO QUESTION 19 No SKIP TO QUESTION 19 18b. Does this residential care community have a distinct unit, wing, or floor that is designated as a dementia or Alzheimer’s Special Care Unit? Yes CONTINUE No SKIP TO QUESTION 19 18c. How many licensed beds are in the dementia or Alzheimer’s Special Care Unit? Number of beds 18d. Does this dementia or Alzheimer's Special Care Unit have . . .
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19. For each item (a–k) below, please mark whether or not this residential care community provides the service and, if it does, whether it is provided only by residential care community employees, only by others through arrangement, or by both. Please mark “Not provided” if the residential care community only refers residents to service providers.
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20. For about how many of the current residents does this residential care community manage, supervise, or store medications; administer medications; or provide assistance with self-administration of medications? Number of residents OR None 21. As a part of the admission process, does this residential care community screen residents 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 22. 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 residential care community offers any of these services for residents with this condition.
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23. On a regular basis, does this residential care community create daily schedules based on each resident’s life history, abilities, and interests? Yes No 24. On a regular basis, does this residential care community seek input from residents and their families into…
25. On a regular basis, does this residential care community give residents choices for each of the following?
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Staff ProfilePlease consult records and other staff as needed to answer questions. Please provide answers only for the residential care community portion of your campus. |
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26. For each item (a–d) below, please indicate the number of staff that currently work at this residential care community full-time and part-time. Please include:
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 residential care community employee category and the contract staff category. If this residential care community does not have any staff for a specific category, enter “0” under the number of full-time and part-time staff.
27. Do any activities directors or activities staff work at this residential care community? Include residential care community employees and contract staff. Yes CONTINUE No SKIP TO QUESTION 29 28. On an average shift, how many activities directors or activities staff are on-site providing services? Include residential care community employees and contract staff. Number of activities directors or activities staff OR None |
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Resident ProfilePlease consult records and other staff as needed to answer questions. Please provide answers only for the residential care community portion of your campus. |
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29. Of the residents currently living in this residential care community, how many are in each of the following categories? Count each resident only once. Enter “0” for any categories with no residents.
NOTE: Total should be the same as provided in Question 12. 30. Of the residents currently living in this residential care community, how many are in each of the following categories? Enter “0” for any categories with no residents.
NOTE: Total should be the same as provided in Question 12. |
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31. Of the residents currently living in this residential care community, how many are in each of the following age categories? Enter “0” for any categories with no residents.
NOTE: Total should be the same as provided in Question 12. 32. Of the residents currently living in this residential care community, about how many have been diagnosed with each of the following conditions?
33. Before or upon admission, does this residential care community use a standardized tool to conduct a formal assessment of its residents to identify anyone with a cognitive impairment? Yes CONTINUE No SKIP TO QUESTION 34 |
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33a. Based on this assessment, about how many of the residents currently living in this residential care community have been identified as having a cognitive impairment? Number of residents OR None 34. This next question asks about the number of residents at this residential care community 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 residential care portion of your campus. Of the residents currently living in this residential care community, about how many need any assistance in each of the following activities?
35. Of the residents currently living in this residential care community, about how many use a manual, electric, or motorized wheelchair or scooter? Number of residents OR None
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36. Of the residents currently living in this residential care community, 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 residents CONTINUE None SKIP TO QUESTION 37 36a. Of the residents who were discharged from an overnight hospital stay in the last 90 days, about how many of those residents were re-admitted to the hospital for an overnight stay within 30 days of their hospital discharge? Number of residents OR None 37. Of the residents currently living in this residential care community, about how many were treated in a hospital emergency department in the last 90 days? Number of residents OR None Questions 38–40b refer to the last 12 months. 38. In the last 12 months, about how many residents moved into this residential care community? Count all residents who moved in—including respite care residents, residents who later died, and residents who no longer live here—regardless of the reason. Number of residents OR None 39. In the last 12 months, about how many residents living in this residential care community died? Include respite care residents. Number of residents OR None 40. In the last 12 months, about how many residents, including respite care residents, moved out of this residential care community? Exclude deaths and residents for whom the community is currently holding a bed for the resident. Number of residents CONTINUE None SKIP TO QUESTION 41 |
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40a. Where did each of these residents go immediately after they moved out? Enter “0” for any categories with no residents.
NOTE: Total should be the same as provided in |
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40b. Of the residents who moved out in the last 12 months, about how many left because the cost of care, including housing, meals, and services required to meet their needs, exceeded their ability to pay? Number of residents OR None
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Record KeepingPlease provide answers only for the residential care community portion of your campus. |
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41. An Electronic Health Record is a computerized version of the resident’s health and personal information used in the management of the resident’s health care. Other than for accounting or billing purposes, does this residential care community use Electronic Health Records? Yes No |
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42. For each item (a–s) below, please indicate in Column 1 whether or not this residential care community collects or tracks this information about residents. If this community does collect or track the information, please indicate in Column 2 whether or not this community has the computerized capability to collect or track it.
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42. Cont’d
43. Does this residential care community’s computerized system support electronic health information exchange with each of the following providers?
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Contact Information
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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:
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Your work e-mail address: Your job title:
Thank you for participating in the NSLTCP.
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File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Valerie Garner |
File Modified | 0000-00-00 |
File Created | 2021-01-30 |