Form 0920-0943 RCC Provider Questionnaire

Attachment C-2 RCC Provider Questionnaire Items

Form Approved

OMB No. 0920-0943

Exp. Date XX/XX/XXXX

Assurance of Confidentiality - We take your privacy very seriously. All information that relates to or describes identifiable characteristics of individuals, a practice, or an establishment will be used only for statistical purposes. NCHS staff, contractors, and agents will not disclose or release responses in identifiable form without the consent of the individual or establishment in accordance with section 308(d) of the Public Health Service Act (42 U.S.C. 242m(d)) and the Confidential Information Protection and Statistical Efficiency Act of 2002 (CIPSEA, Title 5 of Public Law 107-347). In accordance with CIPSEA, every NCHS employee, contractor, and agent has taken an oath and is subject to a jail term of up to five years, a fine of up to $250,000, or both if he or she willfully discloses ANY identifiable information about you. In addition, NCHS complies with the Federal Cybersecurity Enhancement Act of 2015 (6 U.S.C. §§ 151 & 151 note). This law requires the federal government to protect federal computer networks by using computer security programs to identify cybersecurity risks like hacking, internet attacks, and other security weaknesses. If information sent through government networks triggers a cyber-threat indicator, the information may be intercepted and reviewed for cyber threats by computer network experts working for, or on behalf of, the government.

Public reporting burden of this collection of information is estimated to average 30 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, GA 30333. ATTN: PRA (0920-0943).

Background information

1. 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.” (number of beds)

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

Private, nonprofit

Private, for profit

Publicly traded company or limited liability company (LLC)

Government, federal, state, county, or local

3. 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

4. Is this residential care community located in the same building as, on the grounds of, or immediately adjacent to each of the following settings? MARK YES OR NO IN EACH ROW

	Yes	No
Independent living residences
Hospital
Nursing home or skilled nursing facility
Home health agency
Hospice agency
Adult day services center
A specific unit where subacute or rehabilitation care is provided

IF YES TO ANY OF THE SETTINGS: If this residential care community is associated with another residential care community or is part of a facility or campus that offers multiple levels of care, please answer only for the residential care portion operating at [IF MAIL: the location on the label on the cover of this questionnaire; IF WEB: FILL FACILITY NAME, FACILILTY ADDRESS, LICENSE NUMBER, FACILITY ID, NUMBER OF BEDS].

5. 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

20 or more years

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

Yes

No

7. Does this residential care community only serve adults with Alzheimer’s disease or other dementias?

Yes (SKIP to Q10)

No

8. Does this residential care community have a distinct unit, wing, or floor that is designated as a dementia, Alzheimer’s, or memory care unit?

Yes

No (SKIP to Q10)

9. How many licensed beds are in the dementia, Alzheimer’s, or memory care unit, wing, or floor? If this residential care community is licensed, registered, or certified by apartments or units, 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)

10. When does this residential care community screen each resident with a standardized tool for each of the following? MARK ALL THAT APPLY IN EACH ROW

	At admission	Routinely after admission	When condition changes	Case by case	Do not screen
Alcohol or substance abuse
Anxiety
Cognitive impairment
Depression
Pain
Pressure injury/ulcer risk
Activities of Daily Living (ADLs)
Instrumental Activities of Daily Living (IADLs)

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?

Yes

No

12. Does this residential care community use computerized capabilities to… MARK A RESPONSE IN EACH ROW

	Yes	No	Don’t Know
Record resident demographics
Record clinical notes
Record resident medications and allergies
Record resident problem list
Record individual service plans
View lab results
View imaging reports
Order prescriptions

13. 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
Physician
Pharmacy
Hospital
Behavioral health provider
Skilled nursing facility, nursing home, or inpatient rehabilitation facility
Other long-term care provider

13. For each of the following statements, please indicate how often this is your residential care communities’ current practice. MARK ONE RESPONSE IN EACH ROW

	Rarely	Sometimes	Often	Almost Always	Don’t Know
Residents choose the times they prefer to eat
Residents have access to food in the residential care community at any time
Residents participate in choosing the types of activities that are offered to them
Residents choose when they want to get up in the morning
Residents choose the way they bathe, such as shower, bed bath, or bathtub
Residents choose the time of day they bathe
Residents participate in developing their care plan
Residents participate in deciding which aides are assigned to care for them
Residents with memory problems have special activities designed for them
Residents or their family members are provided with opportunities to express their preferences about end-of-life care

15. Which of the following best describes your residential care community’s policy for residents leaving the building? MARK ONLY ONE ANSWER

1. All residents come and go as they wish without informing staff

2. Residents with known memory or cognitive impairment may not leave the building without an escort, like family, friend, or staff

3. All residents are asked to sign-out when leaving the building or campus

4. Other

15. Which of the following best describes your residential care community’s visitor policy? MARK ONLY ONE ANSWER

1. Residents may have visitors at any time of the day or night, so long as they do not infringe on the rights of other residents

2. Residents are encouraged to limit visitors to specified hours, such as between breakfast and bed-time hours

3. Residents are required to limit visitors to specified hours, such as between breakfast and bed-time hours

Resident Profile

17. 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. [number of residents]

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

a. Male [number of residents]

b. Female [number of residents]

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

a. 17 years or younger [number of residents]

a. 18–44 years [number of residents]

b. 45–54 years [number of residents]

c. 55–64 years [number of residents]

d. 65–74 years [number of residents]

e. 75–84 years [number of residents]

f. 85 years or older [number of residents]

17. 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.

a. With eating, like cutting up food [number of residents]

b. With bathing or showering [number of residents]

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

22. Of the residents currently living in this residential care community, about how many have a private apartment or room? Include residents who have chosen to share an apartment or room, for example couples or family members. [number of residents]

23. In the last 12 months, about how many residents moved out of this residential care community? Exclude deaths and residents for whom the residential care community is currently holding a bed.

[number of residents] If ‘0’ SKIP to Q26

24. Of residents who moved out in the last 12 months, how many of these residents went to each of the following locations immediately after they moved out? Each resident who moved out should be counted only once. Enter “0” for any categories with no residents.

a. Another assisted living or similar residential care community [number of residents]

b. Hospital [number of residents]

c. Nursing home [number of residents]

d. Private residence (house or apartment) [number of residents]

e. Some other place [number of residents]

f. Do not know [number of residents]

25. Of residents who moved out in the last 12 months, how many left because the cost of care, including housing, meals, and services required to meet their needs, exceeded their ability to pay?

[number of residents]

Services Offered

26. For each service listed below . . . MARK ALL THAT APPLY

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
Routine and emergency dental services by a licensed dentist
Hospice services
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, support groups, and referral services
Mental or behavioral health services—target residents' mental, emotional, psychological, or psychiatric well-being, and may include diagnosing, describing, evaluating, and treating mental conditions
Physical, occupational, or speech therapies
Pharmacy services—including filling of or delivery of prescription
Podiatry services
Dietary and nutritional services
Skilled nursing services—must be performed by an RN, LPN, or LVN and are medical in nature
Transportation services for medical or dental appointments
Transportation services for social and recreational activities, or shopping

27. For each specialized service listed below, how does this residential care community provide the service?

MARK ALL THAT APPLY

	Provides the service by paid residential care community employees	Arranges for the service to be provided by outside service providers	Does not provide, arrange, or refer for this service
Management of behavioral symptoms, such as agitation
Pressure injury or wound care
Continence management
Palliative care-treatment of the pain, discomfort, and symptoms of serious illness

28. 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 residential care community typically evaluate each resident’s risk for falling using any fall risk assessment tool?

Yes, as standard practice with every resident

Case by case, depending on each resident

No

29. Fall reduction interventions may include but are not limited to environmental safety measures; medication reconciliation; exercise, gait, or balance training; and resident or family education. Does this residential care community currently use any formal fall reduction interventions?

Yes

No

30. Please indicate how often your residential care community engages in the following practices when a resident is dying or has died. MARK ONE RESPONSE IN EACH ROW

	Rarely	Sometimes	Often	Almost Always	Don’t Know
Discuss a resident’s spiritual needs at care planning conferences when the resident has an acute or chronic terminal illness?
Document in the care plan of a terminally ill resident what is important to the individual at the end of life, such as the presence of family or religious or cultural practices?
Honor the deceased in some public way in this residential care community?
Offer bereavement services to staff and residents?

Staff Profile

31. 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.

l	Number of Full-Time Employees	Number of Part-Time Employees
a. Nurse Practitioners (NPs)
b. Registered nurses (RNs)
c. Licensed practical nurses (LPNs) / licensed vocational nurses (LVNs)
d. Certified nursing assistants, nursing assistants, home health aides, home care aides, personal care aides, personal care assistants, and medication technicians or medication aides
e. Social workers-licensed social workers or persons with a bachelor’s or master’s degree in social work
f. Activities directors and activities staff

If you reported “0” full-time and part-time employees in 31b, c and d, skip to Q33.

32. For each of the following employees…

	Of the number of full-time and part-time employees currently employed in this residential care community, about how many have been employed at this residential care community for more than 1 year?
	Full-Time	Part-Time
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

33. For each of the following employees…

	a. How many employees did this residential care community have as of January 1, 2017?			b. How many full-time and part-time employees left this residential care community between January 1, 2017 and December 31, 2017? This would include both voluntary and involuntary terminations (retired, dismissed, resigned).
	Full-Time		Part-Time	Full-Time	Part-Time
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

The next series of questions asks about aide employees which includes certified nursing assistants, nursing assistants, home health aides, home care aides, personal care aides, personal care assistants, and medication technicians or medication aides. Contract workers are not to be included in your answers.

34. If hired today in this residential care community, what would be the lowest and highest hourly wage that might be offered to an entry-level aide employee? Lowest (dollar amount per hour) Highest (dollar amount per hour)

35. How many hours of training does this residential care community require newly employed aide employees to have prior to providing care to residents? (Number of hours)

36. How many hours of on-going continuing education or in-service training annually does this residential care community provide or arrange for your aide employees? (Number of hours)

37. Does this residential care community offer the following benefits to full-time aide employees? (MARK YES OR NO IN EACH ROW)

	Yes	No
Health insurance for the employee only
Health insurance that includes family coverage
Life insurance
A pension, a 401(k), or a 403(b)
Paid personal time off, vacation time, or sick leave

38. For each of the items below, please indicate how often this occurs at this residential care community…… (MARK ONE RESPONSE IN EACH ROW)

	Rarely	Sometimes	Often	Almost Always	Don’t Know
Aides attend resident care plan meetings
Changes in residents’ care are made as a result of aide input
Aides work with the same residents

39. 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 (SKIP to Q41)

40. 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. Do not include individuals directly employed by the residential care community. 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
Nurse Practitioners (NPs)
Registered nurses (RNs)
Licensed practical nurses (LPNs) / licensed vocational nurses (LVNs)
Certified nursing assistants, nursing assistants, home health aides, home care aides, personal care aides, personal care assistants, and medication technicians or medication aides
Social workers-licensed social workers or persons with a bachelor’s or master’s degree in social work
Activities directors and activities staff

41. Contact Information:

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: Your work telephone number, with extension: Your work e-mail address: Your job title:

Thank you for participating. Please return this questionnaire in the enclosed return envelope.

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