National Study of Long Term Care Provider --2016 Residen

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?

Yes

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.”

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
an intellectual or developmental disability?
severe mental illness? Do not include Alzheimer’s disease or other dementias.

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?

Yes

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.”

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
b. Registered Nurse (RN), Licensed Practical Nurse (LPN), or Licensed Vocational Nurse (LVN)
c. Director, Assistant Director, Administrator or Operator (if they provide personal care or nursing services to residents)

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
help with activities of daily living (ADLs), such as help with bathing, either directly or arranged through an outside vendor?
assistance with medications, such as the administration of medications, give reminders, or provide central storage of medications?

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

Private, nonprofit

Private, for profit

Publicly traded company or limited liability company (LLC)

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.

Yes

No

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

Yes

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.”

Number of residents

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

Yes

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)

Yes

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

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)
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

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?

Yes

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)
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

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
b. American Indian or Alaska Native, not Hispanic or Latino
c. Asian, not Hispanic or Latino
d. Black, not Hispanic or Latino
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
h. Some other category reported in this residential care community’s system
i. Not reported (race and ethnicity unknown)
TOTAL

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
b. Female
TOTAL

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
b. 18–44 years
c. 45–54 years
d. 55–64 years
e. 65–74 years
f. 75–84 years
g. 85 years or older
TOTAL

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		j. High blood pressure or hypertension
b. Arthritis		k. Human immunodeficiency virus (HIV)
c. Asthma		l. Intellectual or developmental disability
d. Cancer		m. Multiple sclerosis
e. Chronic kidney disease		n. Obesity o. Osteoporosis
f. COPD (chronic bronchitis or emphysema)		p. Parkinson’s disease
g. Depression		q. Severe mental illness, such as schizophrenia and psychosis
h. Diabetes i. Heart disease (for example, congestive heart failure, coronary or ischemic heart disease, heart attack, stroke)		r. Traumatic brain injury

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
c. With dressing
d. With bathing or showering
e. With using the bathroom (toileting)
f. With locomotion or walking- this includes using a cane, walker, or wheelchair and/or help from another person.

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)

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.”

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.”

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.”

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?

Yes

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
b. Pharmacy
c. Hospital

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)

Yes

No

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

Yes

No

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)

Yes

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)

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	Yes No	Yes No
b. Dates of birth	Yes No	Yes No
c. Last four digits of Social Security numbers	Yes No	Yes No
d. Full Social Security numbers	Yes No	Yes No

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

Yes

No

Do not know

Contact Information

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

SELECT ALL THAT APPLY

  Desktop or Laptop

Smartphone

Tablet/iPad

Other

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:

Your work telephone number, with extension:

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Your work e-mail address:

Your job title:

2016 National Study of

Long-Term Care Providers

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