National Study of Long Term Care Provider --2016 Residen

Data Collection for the Residential Care Community and Adult Day Services Center Components of the National Study of Long-term Care Providers

Att D-2 _2016 RCC Questions-Version B_031816

2016 Residential Care Community Questions-Version B

OMB: 0920-0943

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Attachment D-2:

National Study of Long-Term Care Providers----2016 Residential Care Community Questions-Version B

Form Approved

OMB No. 0920-0943

Exp. Date XX/XX/XXXX

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, certified, or otherwise regulated by the State?

Shape1 Yes

Shape2 No

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


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. If none, enter “0.”

Shape3 Number of beds

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



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

MARK YES OR NO IN EACH ROW


Yes

No

  1. an intellectual or developmental disability?

Shape4

Shape5

  1. severe mental illness?

Do not include Alzheimer’s disease or other dementias.

Shape6

Shape7

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

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

Shape8 Yes

Shape9 No

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

5. What is the total number of residents currently living in 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.”

Shape10 Number of residents

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

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.


MARK A RESPONSE IN EACH ROW


Yes

On an as needed basis

No

a. Personal care aide or staff caregiver

Shape11

Shape12

Shape13

b. Registered Nurse (RN), Licensed Practical Nurse (LPN), or Licensed Vocational Nurse (LVN)

Shape14

Shape15

Shape16

c. Director, Assistant Director, Administrator or Operator (if they provide personal care or nursing services to residents)

Shape17

Shape18

Shape19

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

7. Does this residential care community offer…

MARK YES OR NO IN EACH ROW


Yes

No

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

Shape20

Shape21

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

Shape22

Shape23

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

















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

MARK ONLY ONE ANSWER

Shape24 Private, nonprofit

Shape25 Private, for profit

Shape26 Publicly traded company or limited liability company (LLC)

Shape27 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.

Shape28 Yes

Shape29 No



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

Shape30 Yes

Shape31 No

If you answered ‘No,” skip to question 12.



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


Shape32 Number of residents

12. Does this residential care community only serve adults with dementia or Alzheimer’s disease? (Version B)

Shape33 Yes

Shape34 No

If you answered “Yes,” skip to question 14.

13. Does this residential care community have a distinct unit, wing, or floor that is designated as a dementia or Alzheimer’s care unit? (Version B)

Shape35 Yes

Shape36 No



Services Offered

14. For each service listed below, MARK ALL THAT APPLY.

Type of Service

This residential care community…

Provides the service by paid residential care community employees

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

a. Hospice services

Shape37

Shape38

Shape39

Shape40

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, or referral services

Shape41

Shape42

Shape43

Shape44

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

Shape45

Shape46

Shape47

Shape48

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

Shape49

Shape50

Shape51

Shape52

e. Pharmacy services—including filling of or delivery of prescriptions

Shape53

Shape54

Shape55

Shape56

f. Dietary and nutritional services

Shape57

Shape58

Shape59

Shape60

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

Shape61

Shape62

Shape63

Shape64

h. Transportation services for medical or dental appointments

Shape65

Shape66

Shape67

Shape68





Staff Profile

15. An individual is considered an employee if the residential care community is required to issue a Form W-2 federal tax form on their behalf. For each staff type below, indicate whether or not this residential care community currently has any full-time employees or part-time employees. Enter “0” for any categories with no employees.


Number of Full-Time Employees


Number of Part-Time Employees

a. Registered nurses (RNs)

Shape69


Shape70

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

Shape71


Shape72

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

Shape73


Shape74

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

Shape75


Shape76

e. Activities directors or activities staff

Shape77


Shape78



16. Contract or agency staff refer 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 have any nursing, aide, social work, or activities contract or agency staff?

Shape79 Yes

Shape80 No

If you answered ‘No,” skip to question 18.



17. For each staff type below, indicate whether or not this residential care community currently has any full-time contract or agency staff or part-time contract or agency staff. Enter “0” for any categories with no contract or agency staff.


Number of Full-Time contract or agency staff


Number of Part-Time contract or agency staff

a. Registered nurses (RNs)

Shape81


Shape82

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

Shape83


Shape84

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

Shape85


Shape86

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

Shape87


Shape88

e. Activities directors or activities staff

Shape89


Shape90

Resident Profile

18. 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

a. Hispanic or Latino, of any race

Shape91

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

Shape92

c. Asian, not Hispanic or Latino

Shape93

d. Black, not Hispanic or Latino

Shape94

e. Native Hawaiian or Other Pacific Islander, not Hispanic or Latino

Shape95

f. White, not Hispanic or Latino

Shape96

g. Two or more races, not Hispanic or Latino

Shape97

h. Some other category reported in this residential care community’s system

Shape98

i. Not reported (race and ethnicity unknown)

Shape99

TOTAL

Shape100

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

19. Of the residents currently living in this residential care community, what is the sex breakdown?

Enter “0” for any categories with no residents.


NUMBER OF RESIDENTS

a. Male

Shape101

b. Female

Shape102

TOTAL

Shape103

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









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


NUMBER OF RESIDENTS

a. 17 years or younger

Shape104

b. 1844 years

Shape105

c. 4554 years

Shape106

d. 5564 years

Shape107

e. 6574 years

Shape108

f. 7584 years

Shape109

g. 85 years or older

Shape110

TOTAL

Shape111

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

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.


NUMBER OF RESIDENTS


NUMBER OF RESIDENTS


a. Alzheimer’s disease or other dementias

Shape112

j. High blood pressure or hypertension

Shape113

b. Arthritis

Shape114

k. Human immunodeficiency virus (HIV)

Shape115

c. Asthma

Shape116

l. Intellectual or developmental disability

Shape117

d. Cancer

Shape118

m. Multiple sclerosis

Shape119

e. Chronic kidney disease

Shape120

n. Obesity


o. Osteoporosis


Shape121

Shape122

f. COPD (chronic bronchitis or emphysema)

Shape123

p. Parkinson’s disease

Shape124

g. Depression

Shape125

q. Severe mental illness, such as

schizophrenia and psychosis

Shape126

h. Diabetes



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

Shape127

Shape128

r. Traumatic brain injury

Shape129



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

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.


NUMBER OF RESIDENTS

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

b. With eating, like cutting up food

Shape130

c. With dressing

Shape131

d. With bathing or showering

Shape132

e. With using the bathroom (toileting)

Shape133

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

Shape134

23. 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.” (Version B)

Shape135 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.”

Shape136 Number of residents

25. 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.”

Shape137 Number of residents



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

26. 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.”



Shape138 Number of residents



Record keeping

27. 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?

Shape139 Yes

Shape140 No

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

MARK YES OR NO IN EACH ROW


Yes

No


a. Physician

Shape141

Shape142


b. Pharmacy

Shape143

Shape144


c. Hospital

Shape145

Shape146




29. 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 life sustaining treatments (POLST or MOLST).



Does this residential care community provide any information about advance directives to residents and/or their families? (Version B)

Shape147 Yes

Shape148 No

30. Does your state require your residential care community to provide information to residents or their families about advance directives? (Version B)

Shape149 Yes

Shape150 No

Shape151 Do not know



31. Does this residential care community typically maintain documentation of residents’ advance directives or have documentation that an advance directive exists in resident files? (Version B)

Shape152 Yes

Shape153 No

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



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

Shape154 Number of residents





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 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. 

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.


Column 1

This community has…

Column 2

I would be willing to provide…

a. Full names

Shape156 Shape155 Shape157 Yes

Shape158 No

Shape159 Yes

Shape160 No

b. Dates of birth

Shape161 Shape162 Yes

Shape163 No

Shape164 Yes

Shape165 No

c. Last four digits of Social Security numbers

Shape166 Shape167 Yes

Shape168 No

Shape169 Yes

Shape170 No

d. Full Social Security numbers

Shape171 Shape172 Yes

Shape173 No

Shape174 Yes

Shape175 No



34. Is this residential care community a Health Insurance Portability and Accountability Act (HIPAA)-covered entity?

Shape176 Yes

Shape177 No

Shape178 Do not know

Contact Information

35. In which of the following ways do you have internet access at work?

SELECT ALL THAT APPLY

 Shape179 Desktop or Laptop

Shape180 Smartphone

Shape181 Tablet/iPad

Shape182 Other

Shape183 No internet access at work







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.

PLEASE PRINT

Your full name:

Shape184

Your work telephone number, with extension:

( )

Shape185

Your work e-mail address:

Shape186

Your job title:

Shape187





2016 National Study of

Long-Term Care Providers



Please tell us about your experience participating in this study



If you have additional comments, concerns, or suggestions for improving our survey, please let us know! You can write your comments in the box below and submit them with your completed questionnaire in the enclosed postage-paid return envelope.

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Thank you for your participation and feedback.



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