Download:
pdf |
pdfForm Approved
OMB No. 0920-0222
Exp. Date 07/31/2018
Attachment 1a: Adult Day Services Center (ADSC) Questionnaire to be Evaluated
CDC estimates the average public reporting burden for this collection of information as 60 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and
maintaining the data/information 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 Information
Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0222)
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(d)) and the Confidential Information Protection and Statistical Efficiency Act (PL-107-347).
National Study of Long-Term Care
Providers
2016 Adult Day Services Center Questionnaire
Dear Director,
The Centers for Disease Control and Prevention conducts the National Study of Long-Term
Care Providers. Please complete this questionnaire about the adult day services center at
the location listed below.
•
•
•
If this adult day services center is part of a multi-facility campus or has more than
one adult day license, answer only for the place listed below.
Please consult records and other staff as needed to answer questions.
If you need assistance or have questions, go to http://www.cdc.gov/nchs/nsltcp.htm or
call 1-866-245-8078.
(A)
Label here
Thank you for taking the time to complete this questionnaire.
1
1.
6.
Background Information
MARK ONLY ONE ANSWER
Is this adult day services center …
ONLY social/recreational needs—NO
health/medical needs
MARK YES OR NO IN EACH ROW
Yes
No
PRIMARILY social/recreational needs and SOME
health/medical needs
a. licensed or certified by your State
specifically to provide adult day
services, or accredited by the
Commission on Accreditation of
Rehabilitation Facilities (CARF)?
b. authorized or otherwise set up to
participate in Medicaid (Medicaid
state plan, Medicaid waiver, or
Medicaid managed care) or part of
a Program of All-Inclusive Care for
the Elderly (PACE)?
EQUALLY social/recreational and health/medical
needs
PRIMARILY health/medical needs and SOME
social/recreational needs
ONLY health/medical needs—NO
social/recreational needs
7.
If you answered “No” to both 1a and 1b, skip
to question 36 on page 8.
2.
Is this a specialized center that serves only
participants with a particular diagnosis, condition, or
disability?
Yes
Based on a typical week, what is the approximate
average daily attendance at this adult day services
center at this location? If none, enter “0.”
No
If you answered “No,” skip to question 9.
8.
Average daily attendance of participants
If you answered “0,” skip to question 36 on
page 8.
3.
Which one of the following best describes the
participant needs that the services of this center are
designed to meet?
In which of the following diagnoses, conditions, or
disabilities does this center specialize?
MARK ALL THAT APPLY
Alzheimer’s disease or other dementias
What is the total number of participants currently
enrolled at this adult day services center at this
location? If none, enter “0.”
Human immunodeficiency virus (HIV)/AIDS
Intellectual or developmental disabilities
Multiple sclerosis
Number of participants
Parkinson’s disease
If you answered “0,” skip to question 36 on
page 8.
4.
Post-stroke physical or cognitive impairments with
a need for rehabilitative therapies
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. If none, enter “0.”
Severe mental illness, such as schizophrenia and
psychosis
Traumatic brain injury
Other (please specify)
9.
Maximum number of participants allowed
5.
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.
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)
Yes
No
Government—federal, state, county, or local
2
10.
2
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 (include revenue
from a Medicaid state plan,
Medicaid waiver, Medicaid
managed care, or California
regional center)
13.
%
Participant Profile
Of the participants currently enrolled at this center,
what is the racial-ethnic breakdown? Count each
participant only once. Enter “0” for any categories
with no participants.
NUMBER OF
PARTICIPANTS
b. Medicare
%
a. Hispanic or Latino, of any race
c. Older Americans Act
%
b. American Indian or Alaska
Native, not Hispanic or Latino
d. Veterans Administration
%
e. Other federal, state, or local
government
%
c. Asian, not Hispanic or Latino
d. Black, not Hispanic or Latino
e. Native Hawaiian or other Pacific
Islander, not Hispanic or Latino
f. Out-of-pocket payment by the
participant or family
%
f. White, not Hispanic or Latino
g. Private insurance
h. Other source
TOTAL
100
%
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)
NOTE: Your entries should add up to 100%.
TOTAL
11.
An electronic health record (EHR) 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?
NOTE: Total should be the same as the number
of participants provided in question 3.
14.
Yes
Of the participants currently enrolled at this center,
what is the sex breakdown? Enter “0” for any
categories with no participants.
NUMBER OF
PARTICIPANTS
No
12.
Does this adult day services center’s computerized
system support electronic health information
exchange with each of the following providers? Do
not include faxing.
a. Male
b. Female
MARK YES OR NO IN EACH ROW
Yes
TOTAL
No
NOTE: Total should be the same as the number
of participants provided in question 3.
a. Physician
b. Pharmacy
c. Hospital
3
15.
17.
Of the participants currently enrolled at this center,
what is the age breakdown? Enter “0” for any
categories with no participants.
NUMBER OF
PARTICIPANTS
Of the participants currently enrolled at this center,
about how many have been diagnosed with each of
the following conditions? Enter “0” for any
categories with no participants.
NUMBER OF
PARTICIPANTS
a. 17 years or younger
a. Alzheimer’s disease or other
dementias
b. 18–44 years
b. Arthritis
c. 45–54 years
c. Asthma
d. 55–64 years
d. Cancer
e. Chronic kidney disease
e. 65–74 years
f. COPD (chronic bronchitis or
emphysema)
f. 75–84 years
g. Depression
g. 85 years or older
h. Diabetes
TOTAL
i. Heart disease (for example,
congestive heart failure,
coronary or ischemic heart
disease, heart attack, stroke)
j. High blood pressure or
hypertension
k. Human immunodeficiency
virus (HIV)/AIDS
l. Intellectual or developmental
disability
NOTE: Total should be the same as the number
of participants provided in question 3.
16.
Assistance refers to needing any help or
supervision from another person, or use of
assistive devices.
Of the participants currently enrolled at this center,
about how many now need any assistance at
their usual residence or this center in each of
the following activities? Enter “0” for any
categories with no participants.
m. Multiple sclerosis
n. Obesity
NUMBER OF
PARTICIPANTS
o. Osteoporosis
a. With transferring in and out
of a chair
p. Parkinson’s disease
b. With eating, like cutting up
food
q. Severe mental illness, such as
schizophrenia and psychosis
c. With dressing
r. Traumatic brain injury
18.
d. With bathing or showering
e. With using the bathroom
(toileting)
f. With locomotion or walking—
this includes using a cane,
walker, or wheelchair, or help
from another person
During the last 30 days, for how many of the
participants currently enrolled at this adult day
services center did Medicaid pay for some or all of
their services received at this center? Please include
any participants that received funding from a
Medicaid state plan, Medicaid waiver, Medicaid
managed care, or California regional center.
If none, enter “0.”
Number of participants
4
19.
24.
Of the participants currently enrolled at this center,
about how many were treated in a hospital
emergency department in the last 90 days?
If none, enter “0.”
Number of participants
20.
a. Alone
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. If none, enter “0.”
b. With relative (such as a spouse,
partner, adult child including son
or daughter-in-law, parent, or
other relative)
c. With non-relative(s)
25.
Number of participants
If you answered “0,” skip to question 22.
21.
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? If none, enter “0.”
Number of participants
22.
As best you know, about how many of your current
participants had a fall in the last 90 days? Please
include falls that occurred in your center or off-site,
whether or not the participant was injured, and
whether or not anyone saw the participant fall or
caught them. Please just count one fall per
participant who fell, even if the participant fell more
than one time. If one of your participants fell during
the last 90 days, but is currently in the hospital or
rehabilitation facility, please include that person in
your count. If no participants had a fall, enter “0.”
Number of participants
Of the participants currently enrolled at this center,
about how many have elected and are now
receiving hospice care? If none, enter “0.”
If you answered “0,” skip to question 28.
26.
Number of participants
23.
Of the participants currently enrolled at this center
who live in a private residence, how many live
with the following people? Assign each participant to
only one category. Enter “0” for any categories
with no participants.
NUMBER OF
PARTICIPANTS
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. Private residence (house or
apartment)
As best you know, about how many of the
participants who fell in the last 90 days are in
each of the following categories? If a participant had
more than one fall in the last 90 days, count only
their most serious fall. Enter “0” for any
categories with no participants.
NUMBER OF
PARTICIPANTS
a. Had a fall resulting in some
kind of injury, such as a broken
bone (for example, wrist, arm,
ankle); hip fracture; or head injury
b. Had a fall that did not result in
some kind of injury
b. Assisted living or similar
residential care community
NOTE: Total of 26a and 26b should be the same
as the number provided in question 25.
c. Nursing home or other
institutional setting
27.
d. Some other place
If you answered “0” to 23a, skip to
question 25.
As best you know, of the participants who fell in
the last 90 days, about how many went to a
hospital emergency department or were
hospitalized as a result of the fall? Include hospital
admissions and observation stays. If a participant
had more than one fall in the last 90 days, count only
their most serious fall. If none, enter “0.”
Number of participants
5
3
28.
Services Offered
Fall risk assessment tools often address gait, mobility, strength, balance, cognition, vision, medications, and
environmental factors. Examples of tools include but are not limited to CDC’s Stopping Elderly Accidents, Deaths &
Injuries or STEADI; Timed Up and Go or TUG test; 30-second chair stand test; and 4-stage balance test. Does this
center typically evaluate each participant’s risk for falling using any fall risk assessment tool?
Yes, as a standard practice with every participant
Case by case, depending on each participant
No
29.
Fall reduction interventions may include but are not limited to environmental safety measures; medication
reconciliation; exercise, gait, or balance training; and participant or family education. Does this center currently use
any formal fall reduction interventions?
Yes
No
30.
For each service listed below . . . MARK ALL THAT APPLY
This adult day services center. . .
Type of Service
Provides the
service by paid
center
employees
a. Hospice services
b. Social work services—provided by licensed
social workers or persons with a bachelor’s or
master’s degree in social work, and may include
an array of services such as psychosocial
assessment, individual or group counseling,
and referral services
c. Mental health services—target participants'
mental, emotional, psychological, or psychiatric
well-being, and may include diagnosing,
describing, evaluating, and treating mental
conditions
d. Any therapeutic services—physical,
occupational, or speech
e. Pharmacy services—including filling of or
delivery of prescriptions
f. Dietary and nutritional services
g. Skilled nursing services—must be performed
by an RN or LPN and are medical in nature
h. Transportation services for medical or dental
appointments
i.
Daily round trip transportation services to or
from this center
6
Arranges for the
service to be
provided by outside
service providers
Refers
participants or
family to
outside service
providers
Does not
provide,
arrange, or
refer for this
service
4
31.
Staff Profile
An individual is considered an employee if the center is required to issue a W-2 federal tax form on their behalf. For
each staff type below, indicate how many full-time employees and part-time employees this center currently has.
Enter “0” for any categories with no employees.
Number of
Full-Time
Employees
Number of
Part-Time
Employees
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
32.
Contract or agency staff refers to individuals or organization staff under contract with and working at this center,
but are not directly employed by the center. Does this center currently have any nursing, aide, social work, or
activities contract or agency staff?
Yes
No
If you answered “No,” skip to question 34.
33.
For each staff type below, indicate how many full-time contract or agency staff and part-time contract or
agency staff this center currently has. Enter “0” for any categories with no contract or agency staff.
Number of
Full-Time Contract
or Agency 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
7
Number of
Part-Time Contract
or Agency Staff
5
The following questions ask for information to help inform
planning for future waves of NSLTCP.
34.
The National Center for Health Statistics (NCHS)
links person-level survey data with health records
from other data sources, such as Medicare or
Medicaid data. Linking allows NCHS to better
understand the services participants of centers
use. In order to link data in future surveys, we
would need the information below about your
current participants. We would use this information
for research purposes only. Federal laws authorize
NCHS to ask for this information and require us to
keep it strictly private.
36.
Contact Information
In which of the following ways do you have Internet
access at work?
MARK ALL THAT APPLY
Desktop or laptop
Smartphone
Tablet/iPad
Other
To help NCHS plan for future surveys, please
answer the following questions: For each item
below, in Column 1, indicate whether or not this
center has this information about its current
participants. For each “yes” in Column 1, in
Column 2, indicate whether or not this center is
willing to provide this information about
participants.
No Internet access at work
37.
Column 2
Column 1
This center
has. . .
I would be
willing to
provide . . .
Yes
Yes
No
No
Yes
Yes
No
No
Yes
Yes
No
No
We would like to keep your name, telephone
number, work e-mail address, and job title for
possible future contact related to participation in
current and future NSLTCP waves. Your contact
information will be kept confidential and will not be
shared with anyone outside this project team.
PLEASE PRINT
Your full name:
a. Full names
Your work telephone number, with extension:
b. Dates of birth
c. Last four digits
of Social
Security
numbers
d. Full Social
Security
numbers
35.
(
)
Your work e-mail address:
Your job title:
Yes
Yes
No
No
Thank you for participating.
Is this adult day services center a Health Insurance
Portability and Accountability Act (HIPAA)–
covered entity?
Please return this questionnaire in the
enclosed return envelope.
Yes
NSLTCP
RTI International
Attn: Data Capture
5265 Capital Boulevard
Raleigh, NC 27690-1653
No
Do not know
8
| File Type | application/pdf |
| Author | Valerie Garner |
| File Modified | 2018-05-14 |
| File Created | 2016-06-16 |