2022 Npals Ss B 052522

Supporting Statement B for Paperwork Reduction Act Submission for

Revision

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

OMB No. 0920-0943

Exp. Date: 09/30/2023

May 25, 2022

Manisha Sengupta

Acting Branch Chief, Long-Term Care Statistics Branch

Division of Health Care Statistics

National Center for Health Statistics

Phone: 301.458.4754

Fax: 301.458.4693

Email: [email protected]

TABLE OF CONTENTS

B. Collections of Information Employing Statistical Methods

1. Respondent Universe and Sampling Methods............................................. 3

2. Procedures for the Collection of Information.............................................. 5

3. Methods to Maximize Response Rates and Deal with Nonresponse........... 9

4. Tests of Procedures or Methods to be Undertaken...................................... 13

5. Individuals Consulted on Statistical Aspects and Individual Collecting

and/or Analyzing Data................................................................................... 13

List of Attachments

Attachment A Authorizing Legislation

Attachment B-1 Sixty-day Notice in Federal Register

Attachment B-2 Public Comment

Attachment C-1 RCC Provider Questionnaire

Attachment C-2 ADSC Provider Questionnaire

Attachment C-3 RCC Services User Questionnaire

Attachment C-4 ADSC Services User Questionnaire

Attachment D-1 RCC Question Changes

Attachment D-2 ADSC Question Changes

Attachment E-1 NCHS Letter with FAQs

Attachment E-2 Resident and Participant Data Briefs

Attachment E-3 Letter of Support

Attachment E-4 Confidentiality Brochure

Attachment F Provider Questionnaire letters

Attachment G Prompting Letters and Emails

Attachment H Services User CATI Confirmation and Prep Letters and emails

Attachment I Human Subjects Research Determination

Attachment J EHRs Subject Matter Experts interviews

B. Statistical Methods

1. Respondent Universe and Sampling Methods

The National Post-acute and Long-term Care Study (NPALS), formerly known as the National Study of Long-Term Care Providers or NSLTCP (OMB No. 0920-0943 Exp. Date: 09/30/2023) includes nationally representative surveys of residential care communities (RCCs) and adult day services centers (ADSCs). The primary goal of the survey component of NPALS is to provide a general purpose database on RCCs and ADSCs that researchers and policymakers can use to address a wide variety of questions. As a general purpose survey, it will provide broad descriptive data and does not presuppose any particular typology of communities/centers or residents/participants. The main focus is on RCCs and ADSCs, with the survey gathering as much information about their residents/participants as possible while keeping response burden low and within budget constraints.

While the survey content and the data collection protocol are similar for RCCs and ADSCs, each provider type has its own universe and sampling methods. The remainder of this section discusses the universe definition, sampling frame, and sampling methods for RCCs followed by a corresponding discussion for ADSCs.

RCCs: NCHS will use the same definition for RCC in the 2022 NPALS as was used for defining a residential care community in the 2020 NPALS. As such, the following criteria will be used to determine the universe of RCCs that are eligible for selection in the 2022 NPALS survey:

Places that are licensed, registered, listed, certified, or otherwise regulated by the state to provide room and board with at least two meals a day, around-the-clock on-site supervision, and help with activities of daily living (e.g., bathing, eating, dressing) or health-related services (e.g., medication supervision); serve primarily an adult population; have at least four beds; and are serving at least one resident at the time of the survey.

The eligibility definition encompasses many types of RCCs, including assisted living places that arrange for personal care services from an outside vendor, as in Connecticut and Minnesota. Excluded are nursing facilities; facilities serving exclusively people with intellectual disabilities or developmental disabilities; group homes and residential care facilities serving exclusively people with severe mental illness; and other residential care settings where personal care or health related services are not arranged or provided. Unregulated communities are also excluded.

The sampling frame for the RCC component of the NPALS survey will be constructed from lists of RCCs that are licensed, registered, listed, certified, or otherwise regulated by the state, acquired from the licensing agencies in each of the 50 states and the District of Columbia in 2021 (OMB No. 0920-1030, Exp. Date 04/30/2020). State data on the number of licensed beds for each community and the licensure categories will be used to determine the list of eligible communities. The RCC sampling frame for NPALS will contain all of the state-licensed RCCs that are licensed for four or more beds.

ADSCs: Establishments eligible for the ADSC component of NPALS consist of:

Centers included in the 2022 National Adult Day Services Association’s data base and in operation; were licensed or certified by the State specifically to provide adult day services, or accredited by the Commission on Accreditation of Rehabilitation Facilities (CARF), or authorized or otherwise set up to participate in Medicaid (Medicaid state plan, Medicaid waiver, or Medicaid managed care), or part of a Program of All-Inclusive Care for the Elderly (PACE); and had one or more average daily attendance of participants based on a typical week and one or more participants enrolled at the center at the location at the time of the survey.

The National Adult Day Services Association (NADSA), a professional trade association, is the leading voice of the rapidly growing adult day services industry and the national focal point for ADSCs (www.nadsa.org). According to NADSA, ADSCs provide a coordinated program of services for adults in a community-based group setting. Services are designed to provide social and health services to adults who need supervised care in a safe place outside the home during the day, and to provide respite for caregivers. ADSCs generally operate during normal business hours five days a week. Although each ADSC may differ in terms of features, most ADSCs provide social activities, transportation to/from the ADSC, meals and snacks, assistance with activities of daily living, and therapeutic activities such as exercise and mental interaction.

As we did for previous survey waves, the frames that NCHS will use for the ADSC component of the 2022 NPALS survey will be a comprehensive listing of ADSCs that NCHS will purchase from NADSA. Purchasing these lists from NADSA represents a substantial cost-savings over collecting, cleaning and concatenating licensing lists of ADSCs from each of the 50 states and the District of Columbia. In addition, the NADSA’s list include ADSCs located in states that do not license ADSCs. The 2022 NADSA list will be the most complete listing of ADSCs in the United States that NCHS is aware exists at this time. The approach that NADSA used in creating and maintaining the 2022 frame is inclusive; any program that self-identified as adult day care, adult day services, or adult day health services was included.  ADSCs were included if they offered socialization, nutritional support,  and “hands-on”  assistance with activities of daily living, at a congregate site, which had daytime hours. Hands on assistance could include offering an arm as support to the bathroom.  Frame construction started with an existing NADSA database.  NADSA staff contacted all ADCSs to verify they were still providing adult day care, and updated the contact information.  Several methods were used to identify additional ADSCs.  These included contacting state government offices with oversight of ADSCs to identify ADSCs that met state requirements. Other ADSCs were identified through phone books, the internet, and state adult day services associations not affiliated with NADSA.

Two separate random national samples, one of RCCs and the other of ADSCs, will be drawn from among the universe of these providers on the two respective sector-specific frames.

The 2022 NPALS will involve a two-stage probability-based sampling design. In the first stage, stratified (by Census Region) samples of providers (RCCs and ADSCs) will be selected using systematic random sampling; in addition to explicit stratification by region, the providers will be sorted by bed size categories (RCCS only) and MSA status. The second stage will involve the selection of current residents/participants from these providers. Within each eligible, participating ADSC/RCC, a random sample of two participants/residents will be selected. For the ADSC component, a reserve sample of ADSCs in excess of the base sample will be selected in case projected ineligibility rates among ADSCs were underestimated. The reserve sample will be 100 ADSCs and be released in bundles of 10. These excess samples will not be fielded if targeted numbers of eligible ADSCs are reached using the base sample alone. After removing the base ADSC sample from the frame, a reserve sample of 100 ADSCs will be selected using the same strata as the initial sample. The reserve sample will be arrayed in order of the random numbers assigned to them. Sets of 10 ADSCs will be formed each, in the order of the ADSC assigned random numbers. For each 10 previously sampled ADSC (from either the base or the reserve sample) that are confirmed ineligible or non-respondent, sets of 10 ADSCs will be added to the sample in the order of their formation.

The resident/participant sampling list will be prepared from the sampled RCC’s/ADSC’s resident/participant census as of midnight the day before the date of the services user telephone interview. Collecting individual services user-level data requires that a sample of participants be selected in each participating ADSC and a sample of residents be selected in each participating RCC, which raises challenges for a self-administered mail or web survey. In the absence of an in-person interviewer being present to assist with or perform the sampling routine, the sampling procedure must be simple enough for the busy ADSC or RCC director to be willing and able to follow and not be burdensome. To assess the feasibility of randomly selecting services users without the assistance of an in-person field interviewer, and correctly completing the steps involved in sampling via a telephone protocol, NCHS conducted a feasibility project in 2016 (OMB No. 0920-1030, Exp. Date 04/30/2020). Key findings from the feasibility project included: correct sampling is feasible, respondents received and used show cards when needed for selected survey items, but many respondents were not willing to spend an hour on the telephone for the services user sampling and data collection stage. Results from the feasibility project informed the protocol for the 2018 service user-level data collection and we will continue with the same protocol in 2022. In particular, the protocol in both waves was designed in order to limit the services user data collection telephone interview to a maximum average of 30 minutes (10 minutes for sampling and 20 minutes for collecting data about two residents/participants). In the debriefing questions for the feasibility project, participants said they were not willing to give more than an hour on the phone. To achieve this goal, we sample only two services users per provider and design the provider questionnaire to be 30 minutes for eligible respondents.

Since NPALS is a general-purpose survey, no specific outcomes were used to prepare the sample size and precision requirements, but rather conservative estimates of the subgroup comparison tests were calculated. The sample sizes for ADSCs and RCCs are based on the ability to detect a 7% point difference in residents with 80% statistical power between two groups of ADSCs/RCCs with equal size. These resident groups were defined by various characteristics, such as race, ADLs, and emergency department visits.

All data will be weighted to national estimates using the inverse of selection probabilities. Because the 2022 NPALS uses sample surveys, data analyses must include survey weights, to inflate the sample numbers to national estimates. The weight associated with each sampled provider and each sampled services user is constructed to account for the multistage sampling design. The final weight for each sampled unit (provider or services user) is the product of two components: 1. inverse of the probability of selection and 2. nonresponse adjustment. The first component of the weight for each sampled unit is the inverse of the unit’s selection probability. For the services user, the selection probability is the product of two selection probabilities: the probability of selecting the provider to the sample and the probability of selecting the services user within the sampled provider. The inverse of the product of these probabilities is used for weighting. The second component for calculating the weight is adjustment for nonresponse. This adjustment is made for three types of nonresponse. The first two types are provider level, and the third is services user level. The first type occurs when in-scope providers do not respond to NPALS. In NPALS, the second type occurs when an in-scope provider does not provide the number of current services users within the respective provider. The third type occurs when the provider does not provide information requested in the survey about the sampled services user. Adjustments for unknown eligibility and non-response will be applied to the RCC/ADSC selection weights to obtain unbiased estimates of the number of eligible RCCs and current residents and ADSCs and current participants in the U.S.

In 2012, NSLTCP response rates were 67% for ADSCs and 60% for RCCs; 2014 saw a decline in the response rates to 58% for ADSCs and 54% for RCCs; in 2016, the response rate improved for ADSCs to 62% and decreased slightly for RCCs at 51%; in 2018, the response rate was 50% for ADSCs and 30% for RCCs; in 2020, the response rate declined slightly for ADSCs to 43% and increased for RCCs to 45%. Because we are assuming response rates of less than 90%, non-response bias analysis will be conducted and non-response adjustments will be necessary for the provider and resident/participant analysis weights. The standard errors of the outcome estimates will be computed by NCHS staff using SUDAAN software.

2. Procedures for the Collection of Information

As in 2018, the 2022 survey will be administered by mail, web, and telephone, and data will be collected from samples of 2,090 RCCs and 1,750 ADSCs in the 50 states and the District of Columbia to enable producing national estimates. 2022 data collection includes three components: a 30-minute provider questionnaire for RCC and ADSC directors to complete by mail or web with nonresponse telephone follow-up; a 30-minute services user questionnaire for RCC and ADSC directors to complete by telephone for two services users in each facility; and a 60-minute semi-structured telephone interview with select electronic health records (EHRs) subject matter experts (SMEs).

NPALS includes a series of mailings (Attachments E-I). The first step in data collection is mailout of an advance packet (Attachments E-1 to E-4, I) that contains:

• a cover letter signed by the Director of NCHS (separate versions for RCCs and ADSCs) (Attachment E-1)

• FAQs on the back of the cover letter (separate versions for RCCs and ADSCs) (Attachment E-1)

• Resident/Participant data brief using 2018 data (Attachment E-2)

• an NCHS brochure about confidentiality in surveys (Attachment E-4)

• insert highlighting the web survey completion option (Attachment E-1)

• a letter of support from national provider associations (separate versions for RCCs and ADSCs) (Attachment E-3), and

• an Ethics Review Board (ERB) approval letter (Attachment I).

The cover letter in the advance packet will be personalized with the name of the RCC and ADCS directors. The letter will inform the administrator of the purpose and content of the survey. In addition to explaining the confidentiality of the information provided and the voluntary nature of participation, the letter includes a reference to the legislative authority for the survey and an explanation of how the data will be used. This letter will emphasize that data collected about the RCC or ADSC and its residents/participants will never be linked to their names or other identifying features and that the web survey is administered over a safe and secure network. The cover letter will provide a toll-free number that survey participants/respondents can call with any questions. Anticipated topics include problems logging in and questions about the survey. This toll-free number will be directed to the NPALS help desk.

The cover letter will also include the web survey URL and unique credentials for the director to access the web provider questionnaire. Respondents can answer some questions, exit the questionnaire, and return later to the point where they stopped. The web questionnaire option will remain available until the end of the data collection period. The web link will also provide a pdf version of the questionnaire, so that respondents to the web survey can see all questions prior to completing the survey by web.

On the back of the cover letter are frequently asked questions (FAQ), designed to address what are expected to be the primary concerns of RCC and ADSC directors and staff.

The letters of support were obtained from associations that represent RCCs and ADSCs and include the following organizations:

• RCC provider associations

  • The Center for Excellence in Assisted Living (CEAL)

  • LeadingAge

  • American Seniors Housing Association (ASHA)

  • Argentum

  • National Center for Assisted Living (NCAL)

• ADSC provider associations

  • National Adult Day Services Association (NADSA).

  • LeadingAge

  • National Association of States United for Aging and Disabilities (NASUAD)

Next, we will send two questionnaire packets that will include a hardcopy of the survey questionnaire. Attachments C-1-C-2 and F contain a list of questionnaire items for 2022 and the NCHS letters. We estimate that it will take 30 minutes on average to answer the questionnaire.

Next, NCHS will send the services user confirmation and prep email or letter for the services user computer-assisted telephone interview (CATI) (Attachment H). This email/letter will confirm the date and time of services user CATI questionnaire, and provide instructions for preparing the list of services users.

The services user CATI call (Attachments C-3 and C-4)—another step in study participation for respondents—will involve directors sampling two services users for each facility and answering questions about the selected services users. Directors or their designated staff are the target respondents; residents/participants will not be contacted. These calls are expected to take 30 minutes on average.

Throughout data collection we will send prompting reminder letters/emails (Attachment G).

Later into the field period, NCHS will contact non-responding RCC and ADSC directors to administer the provider CATI questionnaire. The provider CATI questionnaire has the same content as the mail/web versions.

The entire process of completing the provider questionnaire (30 mins) and services user sampling and questionnaires CATI interview (30 mins) is estimated to take on average 60 minutes per eligible respondent.

The 2022 NPALS also includes semi-structured interviews with SMEs about EHRs use among ADSCs and RCCs and available EHRs data for them (Attachment J). The interviews will be conducted with experts in the field. These individuals will be purposively selected. The subject matter experts chosen will represent organizations or agencies that, based on knowledge of the project team, are pertinent to EHRs use in the United States, especially in long-term care settings. Email addresses and phone numbers for subject matter experts will be obtained from the websites of the agencies or organizations or from personal knowledge by project team members. We plan to conduct 20 interviews that will take 60 minutes each.

Training interviewing staff is an important requirement for implementing the NPALS data collection effort. The general training covers standardized contacting and interviewing skills and educates interviewers on the concepts of data confidentiality and data security. This training is available as an interactive web-based self-learning program that interviewers access over the internet. It includes quizzes on each topic covered to assess the interviewers’ understanding of the information.

Prior to project-specific training, all interviewers will be provided an NPALS Telephone Interviewer Manual and will be required to complete a home study exercise using their manual. We have found that requiring the completion of the home study exercise before training helps to familiarize trainees with background information, project terminologies, and job expectations.

Project-specific trainings will be conducted over 2 days immediately before CATI production is scheduled to begin. Trainings will be conducted virtually.

Training materials will include a manual for telephone interviewers, a manual for Quality Control Supervisors, a training agenda, a training guide with PowerPoint presentation, FAQs for answering respondent questions, mock scenarios for averting/converting refusals, mock interview scripts for conducting the NPALS interview and data retrieval calls, and job aids to assist interviewers in their work.

At the end of training, interviewers must be certified for data collection by successfully completing a certification interview. Certification will be conducted by approved project personnel who will evaluate the interviewers’ mastery of the required skills and knowledge for NPALS. The certification process will consist of:

• a brief oral exam covering selected FAQs to ensure that Interviewers are able to answer the most frequently asked questions from survey participants/respondents;

• a full-length mock interview with another trainee under the observation of project staff to demonstrate knowledge of proper interviewing techniques;

• a mock interview with another trainee under the observation of project staff to demonstrate knowledge of retrieval and callback procedures; and

• a short exercise on selecting appropriate event (disposition) codes and working in CATI to demonstrate knowledge of how to work in the data collection systems.

The period of data collection is scheduled to last from August 2022 to February 2023. Field staff will closely monitor RCCs/ADSCs that have not responded to the mail or web surveys. There will be a very strong effort during the first wave of contacts, followed by persistent follow-up. During the CATI portion of the survey protocol, a maximum of six contact attempts (calls) will be made before a case will be considered as a noncontact or refusal. Each sampled case will receive the same field effort needed for contact and response. NCHS will receive weekly production reports from its contractor that will show the contact/response trends at the national and state levels and help to identify problem spots at the earliest stage in the data collection process as is feasible.

After the data have been processed, post-data collection edit checks have been completed, and weights have been developed, NCHS plans to publish public-use data files and create Research Data Center (RDC) restricted data files for the RCC and ADSC versions of the survey. All data will be weighted to national estimates using the inverses of selection probabilities, and adjusting for non-response. Sampling errors are computed using the linearized Taylor series method of approximation as applied in the SUDAAN software package.

3. Methods to Maximize Response Rates and Deal with Nonresponse

NCHS will make every reasonable attempt to encourage completion of NPALS. To maximize response rates, NCHS will use methods similar to those used in previous establishment surveys (e.g., 2012-2020 NSLTCP/NPALS, National Survey of Residential Care Facilities, National Home and Hospice Care Survey, National Nursing Home Survey). To this end, we will use the refusal aversion techniques described below.

Robust mailout materials. NPALS’s advance and questionnaire packets convey the legitimacy of the study and help respondents understand the relevance and importance of the survey. The materials and FAQs are based on those used successfully in previous waves (OMB No. 0920-0943).

Low burden. We estimate that it will take 60 minutes on average to answer the questionnaire items (Attachments C-1-C-4).

Multimode approach. The hardcopy and web modes offer RCCs/ADSCs the flexibility to complete the survey at their convenience. Sessions can be stopped and restarted as needed. The web mode option further reduces burden by giving the respondent only questions that apply to them based on previous responses in the questionnaire, eliminating missing data by requiring all screener items to be answered in order to progress through the instrument, and giving the respondent the option to save or print a copy of their completed web questionnaire for their records.

Web Scheduler. For the first time, we will offer RCCs/ADSCs the flexibility to schedule their appointment for the SU telephone survey.

Industry outreach. NCHS has contacted and will continue outreach efforts to national long-term care provider associations representing the RCC and the ADSC industries to inform them of the survey and ask for their support. NCHS is working with these organizations to share information about the study with their state member affiliates and publicize the study in newsletters.

CATI follow-up. Some sample members will not be persuaded to complete a survey using only mailing or web techniques. Telephone work will be required, and the CATI follow-up is therefore an important part of NPALS’s refusal aversion/conversion program. It is important that the CATI Interviewers be extremely professional, efficient, and convey to respondents the legitimacy and importance of the survey for U.S. LTC policy. Interviewers will be trained how to convey the importance of this work.

Use of Proxies. In 2022, we will use proxies to complete the eligibility questions in situations when it is difficult to reach the director or administrator and there is the risk of a non-complete. We will identify a qualified proxy to complete the eligibility questions—an assistant director, director of nursing, owner, operator, or manager knowledgeable about the services offered and the residents or participants the RCC/ADSC serves. If the RCC/ADSC is eligible, we will include instructions for CATI interviewers to either continue with the interview--if the proxy is qualified to answer the remaining survey questions--or break off and ask the proxy to suggest a good time and the best telephone number to reach the director or administrator so that the CATI interviewer can schedule a soft appointment to call back to complete the questionnaire.

Emailing Respondents. In 2022, we will email respondents that provide an email address. We will email these cases prompting letters (See Attachment G). We expect that emailing respondents in this way will help to increase response rates, particularly for web completion.

Despite efforts to avert refusals, refusals can be expected. CATI staff will be trained so that if they encounter a potential refusal, they will listen to the concerns raised and attempt to address these concerns. When appropriate, CATI staff will provide a few weeks’ cooling off period before they contact RCCs and ADSCs again. CATI staff will provide detailed notes of these exchanges, and discuss the best course of action. In some cases, NCHS staff and/or senior staff at the NCHS contractor organization will be involved.

The overall target response rate for the survey is at least 65 percent. After the field period ends, NCHS will assess nonresponse bias by examining how much the respondents and nonrespondents differed on key relevant variables available from the respective RCC and ADSC frames. These include bed size (for RCCs only), Census geographic region (Northeast, Midwest, South, and West), and MSA status (metropolitan or nonmetropolitan). Because CATI is being used as a follow-up for non-respondents to the mail and web surveys, CATI responders may be considered as a late responder and possibly as non-responder had CATI not been included in the protocol. With that in mind, as another way to examine nonresponse bias, NCHS will also examine whether there are differences between mail/web respondents and CATI respondents in their survey responses.

4. Tests of Procedures or Methods to be Undertaken

The lists of survey question items in 2022 are in Attachments C-1-C-4. The majority of the 2022 NPALS survey question items have been (1) drawn from previously fielded NCHS LTC provider surveys (NNHS, NHHCS, NSRCF or NSLTCP) and (2) evaluated through expert questionnaire appraisal.

Internally NCHS staff, including staff in NCHS’s Collaborating Center for Questionnaire Design and Evaluation Research (formerly known as the QDRL), have reviewed the question lists in the past and provided feedback. The Collaborating Center for Questionnaire Design and Evaluation Research also conducted a record keeping-question alignment project (OMB No. 0920-0222). The purpose of this project was to determine whether there were data quality (measurement and response generation) challenges with the use of aggregate-level services users surveys questions in the NSLTCP, and if there were, how this could inform future study design and questionnaire development through a better understanding of record keeping practices among providers, the tasks involved in using records to calculate answers/responses to aggregate services user questionnaire items, the perception of the burden in looking up the records, and the impact of the perceived burden on data quality. Externally, experts from organizations such as the office of the Assistant Secretary of Planning and Evaluation and Administration for Community Living within DHHS and provider membership associations such as the National Center for Assisted Living, LeadingAge, and the National Adult Day Services Association (NADSA) gave input on the wording of selected new and existing NPALS question items.

Based on the internal and external review, NCHS revised selected NPALS survey question items (Attachments C-1 to C-4 and D-1-D-2). Question item changes included the following types of revisions:

• Wording changes to address problems 2018 or 2020 respondents had understanding the intent of the question or answering the question correctly, or difficulties encountered for other reasons;

• Revising response categories to more closely align with expected analytic groupings and to address respondent queries about response options;

• Revising the number of response categories to decrease respondent burden;

• Adding back in NPALS items that are not asked each wave; and

• Adding new items on topics that reviewers saw as gaps in the substantive areas of NPALS.

5. Individuals Consulted on Statistical Aspects and Individuals Collecting and/or Analyzing Data

The following government employee is responsible for oversight on the design and implementation of this collection:

NCHS

Manisha Sengupta, Ph.D.

Acting Branch Chief, Long-Term Care Statistics Branch

National Center for Health Statistics

3311 Toledo Road, Workstation 3516

Hyattsville, Maryland 20782

Phone: (301) 458-4754

Fax: (301) 458-4350

E-Mail: [email protected]

RTI International is NCHS’ contractor for the implementation of the survey data collection component for NSLTCP. The following RTI person oversees this contract:

Angela M. Greene, M.A.

Project Director

Program on Aging, Disability and Long-Term Care

RTI International

P.O. Box 2194

RTP, NC 27709

(919) 541-6675 (voice)

(919) 990-8454 (fax)

[email protected]

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