Form 0920-0943 ADSC Provider Questionnaire

Attachment C-1 ADSC Provider Questionnaire Items

Form Approved

OMB No. 0920-0943

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).

Exp. Date XX/XX/XXXX

Background information

1. 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.” (Maximum number of participants allowed)

2. 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)

Government, federal, state, county, or local

3. 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.

Yes

No

4. Is this adult day services center 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
Assisted living or similar residential care community
A specific unit where subacute or rehabilitation care is provided

IF YES TO ANY OF THE SETTINGS ABOVE: If this adult day services center is associated with another adult day services center or is part of a facility or campus that offers multiple levels of care, please answer only for the adult day services portion at [IF MAIL: the location on the label on the cover of this questionnaire; IF WEB: FILL FACILITY NAME, FACILTY ADDRESS].

5. Which one of the following best describes the participant needs that the services of this center are designed to meet? MARK ONLY ONE ANSWER

ONLY social/recreational needs—NO health/medical needs

PRIMARILY social/recreational needs and SOME health/medical needs

EQUALLY social/recreational and health/medical needs

PRIMARILY health/medical needs and SOME social/recreational needs

ONLY health/medical needs—NO social/recreational needs)

6. Is this a specialized center that serves only participants with particular diagnoses, conditions, or disabilities?

Yes

No (SKIP to Q8)

7. In which of the following diagnoses, conditions, or disabilities does this center specialize? MARK ALL THAT APPLY

__ Alzheimer’s disease or other dementias

__ Human immunodeficiency virus (HIV)/AIDS

__ Intellectual or developmental disabilities

__ Multiple sclerosis, Parkinson’s disease

__ Post-stroke physical or cognitive impairments with a need for rehabilitative therapies

__ Severe mental illness, such as schizophrenia and psychosis

__ Traumatic brain injury

__ Other (please specify)

8. What is the total number of years this center has been operating as an adult day services center 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

8. What days of the week and times of the day is your center typically open?

Open? Time of day center opens Time of day center closes

Monday yes, no If yes ______ am, pm _____ am, pm

Tuesday yes, No If yes ______ am, pm _____ am, pm

Wednesday yes, no If yes ______ am, pm _____ am, pm

Thursday yes, no If yes ______ am, pm _____ am, pm

Friday yes, no If yes ______ am, pm _____ am, pm

Saturday yes, no If yes ______ am, pm _____ am, pm

Sunday yes, no If yes ______ am, pm _____ am, pm

8. 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.

1. Medicaid (include revenue from a Medicaid state plan, (percent)

Medicaid waiver, Medicaid managed care, or California regional center)

2. Medicare (include revenue from a Medicare Advantage managed (percent)

care plan)

3. Older Americans Act/Title III (percent)

4. Veterans Administration (percent)

5. Program of All-Inclusive Care for the Elderly (PACE) (percent)

6. Other federal, state, or local government (percent)

7. Out-of-pocket payment by the participant or family (percent)

8. Private insurance (percent)

9. Other source (percent)

8. When does this adult day services center screen each participant 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)

8. 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?

Yes

No

8. Does this adult day services center use computerized capabilities to… MARK A RESPONSE IN EACH ROW

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

8. Does this adult day services center’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

8. For each of the following statements, please indicate how often this is your adult day services center’s current practice. MARK A RESPONSE IN EACH ROW

	Rarely	Sometimes	Often	Almost Always	Don’t Know
Participants choose the times they prefer to eat
Participants have access to food in the center at any time
Participants participate in choosing the types of activities that are offered to them
Participants participate in developing their care plan
Participants participate in deciding which aides are assigned to care for them
Participants with memory problems have special activities designed for them
Participants or their family members are provided with opportunities to express their preferences about end-of-life care

Participant Profile

8. What is the total number of participants currently enrolled at this adult day services center at this location? If none, enter “0.” [number of participants]

17. Of the participants currently enrolled at this center, what is the sex breakdown? Enter “0” for any categories with no participants.

a. Male [number of participants]

b. Female [number of participants]

18. Of the participants currently enrolled at this center, what is the age breakdown? Enter “0” for any categories with no participants.

a. 17 years or younger [number of participants]

b. 18–44 years [number of participants]

c. 45–54 years [number of participants]

d. 55–64 years [number of participants]

e. 65–74 years [number of participants]

f. 75–84 years [number of participants]

g. 85 years or older [number of participants]

19. 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.

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

b. With bathing or showering [number of participants]

20. During the last 30 days, for how many of the participants currently enrolled at this adult day services center did Medicaid pay 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]

21. In the last 12 months, about how many participants permanently stopped using this adult day services center? Exclude deaths.

[Number of participants] If ‘0’ SKIP TO Q23

22. Of those participants who stopped using this center in the last 12 months, how many left because the cost of attending the center, including meals and services required to meet their needs, exceeded their ability to pay?

[Number of participants]

Services Offered

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

This adult day services center. . .

	Provides the service by paid center employees	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
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 participants' 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
Daily round trip transportation services to or from this center

24. For each specialized service listed below, how does this adult day services center provide the service? MARK ALL THAT APPLY

	Provides the service by paid center 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

25. 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 adult day services center typically evaluate each participant’s risk for falling using any fall risk assessment tool?

Yes, as standard practice with every participant

Case by case, depending on each participant

No

26. 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 adult day services center currently use any formal fall reduction interventions?

Yes

No

27. Please indicate how often your adult day services center engages in the following practices when a participant is dying or has died. (MARK ONE RESPONSE IN EACH ROW)

	Rarely	Sometimes	Often	Almost Always	Don’t Know
Discuss a participant’s spiritual needs at care planning conferences when the participant has an acute or chronic terminal illness
Document in the care plan of a terminally ill participant 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 center
Offer bereavement services to staff and participants

Staff Profile

28. 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. 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 28b, c and d, skip to Q30.

29. For each of the following employees…

Enter “0” for any cells with no employees	Of the number of full-time and part-time employees currently employed in this center that you listed in 28b, c, and d, about how many have been employed at this center 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

30 For each of the following employees…

Enter “0” for any cells with no employees	a. How many employees did this center have as of January 1, 2017?		b. How many full-time and part-time employees left this center 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
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

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.

31. If hired today in this center, 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)

32. How many hours of training does this center require newly employed aide employees to have prior to providing care to participants? (Number of hours)

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

34. Does this center 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

35. For each of the items below, please indicate how often this occurs at this center……

(MARK ONE RESPONSE IN EACH ROW)

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

36. 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 (SKIP to Q38)

37. 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. Do not include individuals directly employed by the center. 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

38. 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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