| Attachment C-2 NSLTCP 2014 to 2016 ADSC changes | |
| 2016 Change | 2014 Questionnaire Number and Wording |
| DROP | ADSC 8. What is the total number of years this center has been operating as an adult day services center at this location? |
| DROP | ADSC 10. As a part of the admission process, does this adult day services center... a. screen participants for depression with a standardized tool or scale? b. accept results from depression screenings performed by other health care providers? |
| DROP | ADSC 11. Disease-specific programs may include one or more of the following services—education, physical activity, diet/nutrition, medication management, or weight management. Does this adult day services center offer any disease-specific programs for participants with the following conditions? a. Alzheimer’s disease and other dementias b. Cardiovascular disease (e.g., heart disease, stroke, high blood pressure) c. Depression d. Diabetes |
| DROP-select services- a. Routine and emergency dental services by a icensed dentist, g. Podiatry services, j. Transportation services for social and recreational activities, or shopping | ADSC 12. For each row, mark if this adult day services center provides the service by...Paid center employees, Arranging for and paying outside vendors, Arranging for outside vendors paid by others, Referral, NONE OF THESE APPLY / NOT PROVIDED |
| DROP | ADSC 13a. What is the maximum number of hours per week that part-time staff can work at this adult day services center? |
| DROP | ADSC 13b. What is the minimum number of hours per week that full-time staff can work at this adult day services center? |
| DROP | ADSC 23. For about how many of the currently enrolled participants does this adult day services center provide medication-related services, such as storing medications; administering medications; or providing assistance to participants with self administration of medications? |
| DROP | ADSC 24. Of participants who stopped using this adult day services center in the last 12 months, did any leave because the cost of attending the center, including meals and services required to meet their needs, exceeded their ability to pay? |
| REVISE- response categories to better distinguish between paid employees, arranging, referring, and no provision | ADSC 12. For each row, mark if this adult day services center provides the service by...Paid center employees, Arranging for and paying outside vendors, Arranging for outside vendors paid by others, Referral, NONE OF THESE APPLY / NOT PROVIDED |
| REVISE- create separate questions for employees and contract workers, and add a gate question asking if the place has contract workers. | ADSC 14. For each category of staff listed below, please indicate the number of staff that currently work at this adult day services center full-time and part-time. Please include: both full-time and part-time adult day services 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 adult day services center fulltime and part-time. |
| REVISE-- to add more detailed definition of falls | ADSC 22. Of the participants currently enrolled at this center, about how many had any falls in the last 90 days? Include on-site and off-site falls. |
| ADD-revenue sources-c. Older Americans Act d. Veteran’s Administration |
ADSC 12. 9. Of this center’s revenue from paid participant fees, about what percentage comes from each of the following sources? |
| ADD-Dietary or nutritional guidance services | ADSC 12. For each row, mark if this adult day services center provides the service by...Paid center employees, Arranging for and paying outside vendors, Arranging for outside vendors paid by others, Referral, NONE OF THESE APPLY / NOT PROVIDED |
| ADD-conditions--b. Arthritis, c. Asthma, d. Cancer, e. Chronic kidney disease, f. COPD (chronic bronchitis or emphysema), j, High blood pressure or hypertension k. Human immunodeficiency virus (HIV), m. Multiple sclerosis, n. Obesity, o. Osteoporosis, p. Parkinson’s disease, r. Traumatic brain injury |
ADSC 18. Of the participants currently enrolled at this center, about how many have been diagnosed with each of the following conditions? |
| ADD question on participant needs. (2016 ADSC Q5) | NA |
| ADD question assessing specialized centers. (2016 ADSC Q6) | NA |
| ADD question on conditions center specializes in. (2016 ADSC Q7) | NA |
| ADD question on fall screening. (2016 ADSC Q11) | NA |
| ADD question on fall reduction interventions. (2016 ADSC Q12) | NA |
| ADD question on participant living arrangements (2016 ADSC Q22) | NA |
| ADD question on living arrangement of participants living in private residences (2016 ADSC Q23) | NA |
| ADD question on number of participants in hospice (2016 ADSC Q24) | NA |
| ADD question on readmissions (2016 ADSC Q28) | NA |
| ADD question on falls and resulting injuries. (2016 ADSC Q30) | NA |
| ADD question on falls resulting in hospitalizations. (2016 ADSC Q31) | NA |
| ADD question on provision of advance directive information (2016 ADSC Q33) | NA |
| ADD question on state requirements for advance directives (2016 ADSC Q34) | NA |
| ADD question on advance directive record keeping (2016 ADSC Q35) | NA |
| ADD question on number of participants with advance directives in records (2016 ADSC Q36) | NA |
| ADD question on ability and willingness to provide participant personal information in the future (2016 ADSC Q37) | NA |
| ADD question on knowledge of HIPAA coverage (2016 ADSC Q38) | NA |
| ADD question on access to internet at work(2016 ADSC Q39) | NA |
| ADD item soliciting any comments or feedback (2016 ADSC comment sheet) | NA |
| File Type | application/vnd.openxmlformats-officedocument.spreadsheetml.sheet |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |