2014 RCC Questions

Attachment B-1: National Study of Long-Term Care Providers----2014 Residential Care Community Questions

OMB No. 0920-0943

Exp. Date 07/31/2015

NOTICE – Public reporting burden of this collection of information is estimated to average 30 minutes per response. 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 (0920-0943).

Assurance of Confidentiality – All information which would permit identification of an 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 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).

Background Information

1. Is this residential care community currently licensed, registered, listed, certified, or otherwise regulated by the state?

Yes No If you answered No, skip to question 30.

2. At this residential care community, what is the number of licensed, registered, or certified residential care beds? Include both occupied and unoccupied beds. If this residential care community is licensed, registered, or certified by apartment or unit, please count the number of single resident apartments or units as one bed each, two bedroom apartments or units as two beds each and so forth.

[Number of beds] If you answered fewer than 4 beds, skip to question 30.

3. Does this residential care community only serve adults with…

a. an intellectual or developmental disability? Yes No

b. severe mental illness? Yes No

Do not include Alzheimer’s disease or other dementias.

If you answered Yes to either 3a or 3b, skip to question 30.

4. Does this residential care community offer at least 2 meals a day to residents?

Yes No If you answered No, skip to question 30.

5. What is the total number of residents currently living at this residential care community? If you have respite care residents please include them. If none, enter “0.”

[Number of residents ] If you answered “0,” skip to question 30.

6. Does this residential care community provide or arrange for any of the following types of staff to be on-site 24 hours a day, 7 days a week to meet any resident needs that may arise? On-site means the staff are located in the same building, in an attached building or next door, or on the same campus.

a. Personal care aide or staff caregiver Yes No

b. Registered Nurse (RN) or Licensed Practical Nurse (LPN) Yes No

c. Director, Assistant Director, Administrator or Operator (if they provide personal care or nursing services to residents) Yes No

If you answered No to 6a, 6b, and 6c, skip to question 30.

7. Does this residential care community offer…

a. help with activities of daily living (ADLs), such as help with bathing, either directly or arranged through an outside vendor? Yes No

b. assistance with medications, such as the administration of medications, give reminders, or provide central storage of medications? Yes No

If you answered No to 7a and 7b, skip to question 30.

8. What is the type of ownership of this residential care community?

Private, nonprofit; Private, for profit; Publicly traded company or limited liability company (LLC); or Government—federal, state, county, or local

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 authorized or otherwise set up to participate in Medicaid?

Yes No If you answered No, skip to question 11.

10a. During the last 30 days, for how many of this residential care community’s residents did Medicaid pay for some or all of their services received at this community? If none, enter “0.”

Number of residents

11. What is the total number of years this residential care community has been operating as a residential care community at this location? MARK ONLY ONE ANSWER

Less than 1 year; 1 to 4 years; 5 to 9 years; 10 to 19 years; or 20 or more years

12. As a part of the admission process, does this residential care community . . .

a. screen residents for depression with a standardized tool or scale? Yes No

b. accept results from depression screenings performed by other health care providers?

Yes No

13. Does this residential care community only serve adults with dementia or Alzheimer’s disease?

Yes No If you answered Yes, skip to question 14.

13a. 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 No If you answered No, skip to question 14.

13b. How many licensed beds are in the dementia or Alzheimer’s Special Care Unit? If this residential care community is licensed, registered, or certified by apartment or unit, please count the number of single resident apartments or units as one bed each, two bedroom apartments or units as two beds each and so forth. If none, enter “0.” Number of beds

14. Does this residential care community offers any disease-specific programs for residents with the following conditions. These programs may include one or more of the following services—education, physical activity, diet/nutrition, medication management, or weight management.

a. Alzheimer’s disease and other dementias Yes No

b. Cardiovascular disease (e.g., heart disease, stroke, high blood pressure) Yes No

c. Depression Yes No

d. Diabetes Yes No

Services Offered

15. For each row, mark if this residential care community provides the service by . . . (MARK ALL THAT APPLY)

• Paid residential care community employees

• Arranging for and paying outside vendors

• Arranging for outside vendors paid by others

• Referral

• NONE OF THESE APPLY/NOT PROVIDED

a. Routine and emergency dental services by a licensed dentist

b. Hospice services

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

d. Mental health services—target residents' mental, emotional, psychological, or psychiatric well-being and include diagnosing, describing, evaluating, and treating mental conditions

e. Any therapeutic services—physical, occupational, or speech

f. Pharmacy services—including filling of and delivery of prescriptions

g. Podiatry services

h. Skilled nursing services—must be performed by an RN or LPN and are medical in nature

i. Transportation services for medical or dental appointments

j. Transportation services for social and recreational activities, or shopping

Staff Profile

16a. What is the maximum number of hours per week that part-time staff can work at this residential care community? hours per week.

16b. What is the minimum number of hours per week that full-time staff can work at this residential care community? hours per week.

17. For each category of staff listed below, please indicate the number of staff that currently work at this residential care community full-time and part-time. Include:

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

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

Enter “0” for any categories with no employees or staff.

Number of Full-Time Staff Number of Part-Time Staff

a. Registered nurses (RNs)

b. Licensed practical nurses (LPNs)/Licensed vocational nurses (LVNs)

c. Certified nursing assistants, nursing assistants, home health aides, home care aides, personal care aides, personal care assistants, and medication technicians or medication aides

d. Social workers—licensed social workers or persons with a bachelor’s or master’s degree in social work

e. Activities directors or activities staff

Resident Profile

18. 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.

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 residential care community’s system

i. Not reported (race and ethnicity unknown)

19. 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.

a. Male

b. Female

20. 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.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 or older

21. Of the residents currently living in this residential care community, about how many have been diagnosed with each of the following conditions? Enter “0” for any categories with no residents.

a. Alzheimer’s disease or other dementias

b. Intellectual/ developmental disability

c. Severe mental illness

d. Depression

e. Cardiovascular disease (e.g., heart disease, stroke, high blood pressure)

f. Diabetes

22. Assistance refers to needing any help or supervision from another person, or use of special equipment. Of the residents currently living in this residential care community, about how many now need any assistance in each of the following activities? Enter “0” for any categories with no residents.

a. With transferring in and out of a bed or chair

b. With eating, like cutting up food

c. With dressing

d. With bathing or showering

e. In using the bathroom (toileting)

f. With walking

23. 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. If none, enter “0.”

Number of residents

24. 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? If none, enter “0.”

Number of residents

25. Of the residents currently living in this community, about how many had any fall in the last 90 days? Include onsite and offsite falls. If none, enter “0.”

Number of residents

26. For about how many of the current residents does this residential care community provide medication-related services, such as storing medications; administering medications; or providing assistance to residents with self-administration of medications? If none, enter “0.”

Number of residents

27. Of the residents who moved out in the last 12 months, did any leave because the cost of care, including housing, meals, and services required to meet their needs, exceeded their ability to pay?

Yes No

Record keeping

28. 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

29. Does this residential care community’s computerized system support electronic health information exchange with each of the following providers? Do not include faxing.

a. Physician Yes No

b. Pharmacy Yes No

c. Hospital Yes No

Contact Information

30. In case we need to reach you, 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.