0920-0222 National Study of Long-Term Care Providers 2016 Resident

Form Approved
OMB No. 0920-0222
Exp. Date: 07/31/2018

Attachment 1b: Residential Care Community (RCC) 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 Residential Care Community Questionnaire
Dear Administrator or Executive Director,
The Centers for Disease Control and Prevention conducts the National Study of Long-Term
Care Providers. Please complete this questionnaire about the residential care community at
the location listed below.
•
•
•

If this residential care community is part of a multi-facility campus or has more
than one residential care 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.

(B)
Label here



Residential care places are known by different names in different states. We refer to all of these
places and others like them as residential care communities.
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 services establishments.

Thank you for taking the time to complete this questionnaire.

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1.

5.

Background Information

Is this residential care community currently licensed,
registered, certified, or otherwise regulated by the
State?

Number of residents

Yes

If you answered “0,” skip to question 35 on
page 8.

No

6.

If you answered “No,” skip to question 35 on
page 8.

2.

At this residential care community, what is the
number of licensed, registered, or certified residential
care beds? Include both occupied and unoccupied
beds.

MARK A RESPONSE IN EACH ROW

Yes

b. Registered nurse (RN),
licensed practical nurse
(LPN), or licensed
vocational nurse (LVN)

If you answered fewer than 4 beds, skip to
question 35 on page 8.

c. Director, assistant
director, administrator or
operator (if they provide
personal care or nursing
services to residents)

Does this residential care community only serve
adults with…
MARK YES OR NO IN EACH ROW
No

If you answered “No” to 6a, 6b, and 6c, skip to
question 35 on page 8.

a. an intellectual or developmental
disability?

7.

b. severe mental illness, such as
schizophrenia and psychosis?

Does this residential care community offer…
MARK YES OR NO IN EACH ROW

Do not include Alzheimer’s
disease or other dementias.

Yes

No

a. help with activities of daily living
(ADLs), such as help with
bathing, either directly or
arranged through an outside
vendor?

If you answered “Yes” to either 3a or 3b,
skip to question 35 on page 8.

4.

On an
as-needed
basis
No

a. Personal care aide or
staff caregiver

Number of beds

Yes

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.

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.”

3.

What is the total number of residents currently living at
this residential care community? Please include
residents for whom a bed is being held while in the
hospital. If you have respite care residents, please
include them. If none, enter “0.”

Does this residential care community offer at least
two meals a day to residents?

b. assistance with medications,
such as the administration of
medications, give reminders, or
provide central storage of
medications?

Yes
No

If you answered “No,” skip to question 35 on
page 8.

If you answered “No” to 7a and 7b, skip to
question 35 on page 8.
2

8.

2

What is the type of ownership of this residential
care community?
MARK ONLY ONE ANSWER

14.

Private—nonprofit
Private—for profit
Publicly traded company or limited liability
company (LLC)

Resident Profile

Of the residents currently living in this residential
care community, what is the racial-ethnic
breakdown? Count each resident only once. Enter
“0” for any categories with no residents.
NUMBER OF
RESIDENTS

Government—federal, state, county, or local

9.

a. Hispanic or Latino, of any race

Is this residential care community authorized or
otherwise set up to participate in Medicaid?
Yes

b. American Indian or Alaska
Native, not Hispanic or Latino

No

c. Asian, not Hispanic or Latino

If you answered “No,” skip to question 11.

10.

d. Black, not Hispanic or Latino

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

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

Number of residents

11.

An electronic health record (EHR) 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?

h. Some other category reported in
this residential care community’s
system
i. Not reported (race and ethnicity
unknown)
TOTAL

Yes

NOTE: Total should be the same as the number
of residents provided in question 5.

No

12.

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

15.

MARK YES OR NO IN EACH ROW
Yes

Of the residents currently living in this residential
care community, what is the sex breakdown? Enter
“0” for any categories with no residents.

No

NUMBER OF
RESIDENTS

a. Physician
a. Male

b. Pharmacy
c. Hospital

13.

b. Female

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.

TOTAL

NOTE: Total should be the same as the number
of residents provided in question 5.

Yes
No
3

16.

18.

Of the residents currently living in this residential
care community, what is the age breakdown?
Enter “0” for any categories with no residents.

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.

NUMBER OF
RESIDENTS

NUMBER OF
RESIDENTS

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. 65–74 years
e. Chronic kidney disease
f. 75–84 years
f. COPD (chronic bronchitis or
emphysema)

g. 85 years or older

g. Depression
TOTAL
h. Diabetes

NOTE: Total should be the same as the
number of residents provided in
question 5.

17.

i. Heart disease (for example,
congestive heart failure,
coronary or ischemic heart
disease, heart attack, stroke)

Assistance refers to needing any help or
supervision from another person, or use of
assistive devices.

j. High blood pressure or
hypertension

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.

k. Human immunodeficiency virus
(HIV)/AIDS
l. Intellectual or developmental
disability

NUMBER OF
RESIDENTS

m. Multiple sclerosis

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

n. Obesity

b. With eating, like cutting up
food

o. Osteoporosis

c. With dressing

p. Parkinson’s disease

d. With bathing or showering

q. Severe mental illness, such as
schizophrenia and psychosis

e. With using the bathroom
(toileting)

r. Traumatic brain injury

f. With locomotion or walking—
this includes using a cane,
walker, or wheelchair, or help
from another person

4

19.

23.

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

20.

Advance directives are written documentation and
may include health care proxies, durable power of
attorney, living wills, do not resuscitate (DNR)
orders, or physician or medical orders for lifesustaining treatments (POLST or MOLST).
Does this residential care community provide any
information about advance directives to residents or
their families?

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.”

Yes
No

24.

Number of residents

Does your state require your residential care
community to provide information about advance
directives to residents or their families?

If you answered “0,” skip to question 22.
Yes

21.

No
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? If none, enter “0.”

Do not know

25.

Number of residents

22.

Does this residential care community typically
maintain documentation of residents’ advance
directives or have documentation that an advance
directive exists in resident files?
Yes

Of the residents currently living in this residential
care community, about how many have elected
and are now receiving hospice care? If none, enter
“0.”

No

If you answered “No,” skip to question 27.

26.

Number of residents

Of the current residents, how many have
documentation of an advance directive in their file?
If none, enter “0.”
Number of residents

5

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27.

Services Offered

Does this residential care community only serve adults with dementia or Alzheimer’s disease?
Yes
No

If you answered “Yes,” skip to question 29.

28.

Does this residential care community have a distinct unit, wing, or floor that is designated as a dementia or
Alzheimer’s care unit?
Yes
No

29.

For each service listed below . . . MARK ALL THAT APPLY
This residential care community. . .

Type of Service

Provides the
service by paid
residential care
community
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 residents'
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

6

Arranges for the
service to be
provided by
outside service
providers

Refers residents
or family to
outside service
providers

Does not
provide,
arrange, or
refer for this
service

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30.

Staff Profile

An individual is considered an employee if the residential care community 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
residential care community currently has. Enter “0” for any categories with no employees.
Number of

Number of

Full-Time
Employees

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

31.

Contract or agency staff refers to individuals or organization staff under contract with and working at this
residential care community, but are not directly employed by the residential care community. Does this residential
care community currently have any nursing, aide, social work, or activities contract or agency staff?
Yes
No

If you answered “No,” skip to question 33.

32.

For each staff type below, indicate how many full-time contract or agency staff and part-time contract or
agency staff this residential care community currently has. Enter “0” for any categories with no 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

Number of

Full-Time Contract or
Agency Staff

Part-Time Contract
or Agency Staff

5

The following questions ask for information to help inform
planning for future waves of NSLTCP.

33.

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 residents of residential
care communities use. In order to link data in future
surveys, we would need the information below
about your current residents. 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.

35.

b. Dates of birth

c. Last four digits
of Social
Security
numbers

In which of the following ways do you have Internet
access at work?
MARK ALL THAT APPLY
Desktop or laptop
Smartphone
Tablet/iPad
Other
No Internet access at work

To help NCHS plan for future surveys, please
answer the following questions: For each item
below, in Column 1, indicate whether or not this
residential care community has this information
about its current residents. For each “yes” in
Column 1, in Column 2, indicate whether or not
this residential care community is willing to
provide this information about residents.

a. Full names

Contact Information

36.

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.

Column 1

Column 2

PLEASE PRINT

This
community
has. . .

I would be
willing to
provide . . .

Your full name:

Yes

Yes

No

No

Yes

Yes

No

No

Yes

Yes

No

No

Your work telephone number, with extension:

(

)

Your work e-mail address:

Your job title:
d. Full Social
Security
numbers

34.

Yes

Yes

No

No

Thank you for participating.

Is this residential care community 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