NPALS 2022 Residential Care Community Questionnaire

Form Approved OMB No. 0920-0943 Exp. Date: XX/XX/XXXX

National Post-Acute and Long-Term Care Study

2022 Residential Care Community Questionnaire

The Centers for Disease Control and Prevention conducts the National Post-Acute and Long-Term Care Study (NPALS). Please complete this questionnaire about the residential care community at the location listed below.

• Due to the COVID-19 pandemic, we understand services at this residential care community may be temporarily or permanently suspended, reduced, or offered through alternative methods. Although some questions may be difficult to answer at this time, please complete the survey to the best of your ability.

• 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 community portion operating at the location listed below.

• Please consult records and other staff as needed to answer questions.

• If you need assistance or have questions, go to https://www.cdc.gov/nchs/npals/index.htm or call

1-XXX-XXX-XXXX.

• Thank you for taking the time to complete this questionnaire.

CASE ID

DIRECTOR’S NAME

FACILITY NAME, LICENSE NUMBER

FACILITY PHYSICAL STREET ADDRESS



CITY, ST, ZIP

Residential care places are known by different names in different states. We refer to all of these places and others like them as residential care communities. Just a few terms used to refer to these places are assisted living, personal care, and adult care homes, facilities, and communities; adult family and board and care homes; adult foster care; homes for the aged; and housing with services establishments.

We would like to keep your name, telephone number, work e-mail address, and job title for possible contact related to participation in current and future NPALS waves. Your contact information will be kept confidential and will not be shared with anyone outside this project team. PLEASE PRINT

Your name	First Name						Last Name
Your work telephone number, with extension			—		—			Ext.
Your work e-mail address
Your job title

Notice – CDC estimates the average public reporting burden for this collection of information as 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, MS D-74, Atlanta, GA 30333; ATTN: PRA (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 2018 (CIPSEA Pub. L. No. 115-435, 132 Stat. 5529 § 302). 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 to the above cited laws, NCHS

complies with the Federal Cybersecurity Enhancement Act of 2015 (6 U.S.C. §§ 151 and 151 note) which protects Federal information systems from

cybersecurity risks by screening their networks.

1. 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

2. Is this residential care community currently licensed, registered, certified, or otherwise regulated by the State?

	Yes
	No  Skip to question 41

3. 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 41

4. What is the total number of residents currently living in this residential care community? 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 41

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

	Yes
	No  Skip to question 41

6. 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 both 6a and 6b, skip to question 41

7. Is this residential care community permitted, licensed or regulated to only serve adults with an intellectual or developmental disability, severe mental illness, or both? Do not include Alzheimer’s disease or other dementias.

MARK ONLY ONE ANSWER

	 Skip to question 41 Yes, permitted, licensed, or regulated to serve only persons with intellectual or developmental disability
	Yes, permitted, licensed, or regulated to serve only persons with severe mental illness
	Yes, permitted, licensed, or regulated to serve only persons with intellectual or developmental disability and severe mental illness
	No, none of the above

8. Does this residential care community provide or arrange for any of the following types of staff 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 ONE RESPONSE IN EACH ROW

	Yes, staff are on-site 24/7	Yes, staff are available as needed or on call 24/7	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 8a, 8b, and 8c, skip to question 41

Background Information

9. Of the residents currently living in this residential care community, about how many have been diagnosed with dementia or Alzheimer’s disease?

If none, enter “0.”

Number of residents

10. Does this residential care community only serve adults with dementia or Alzheimer’s disease?

	Yes  Skip to question 13
	No

11. 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 question 14

12. 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

13. Does this residential care community or the dementia, Alzheimer's, or memory care unit, wing, or floor have each of the following? MARK YES OR NO IN EACH ROW

	Yes	No
a. High staff-to-resident ratios
b. Staff specially trained in dementia care
Dementia-specific activities or programming
Locked exit doors
Doors with alarms
Doors with key pads/electronic keys
Security cameras in common areas
Personal monitoring devices for residents who wander
An enclosed courtyard

14. 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

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

	Yes
	No  Skip to question 17

16. 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

17. 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  Skip to question 21

18. What is the name of your Electronic Health Records system?
MARK ALL THAT APPLY. IF OTHER IS CHECKED, PLEASE SPECIFY THE NAME.

	American HealthTech
	CADCARE (RTZ Systems)
	Eldermark
	MatrixCare
	PointClickCare
	Storricare
	WellSky (formerly ADS data systems)
	Yardi
	Other (please specify)
	Don’t know

19. Does this residential care community use Electronic Health Records for each of the following?

MARK YES OR NO IN EACH ROW

	Yes	No
a. Record resident demographics
b. Record clinical notes
c. Record resident medications and allergies
d. Record resident problem list
e. Record individual service plans
f. View lab results
g. View imaging results
h. Order prescriptions

20. Does this residential care community’s Electronic Health Records 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
d. Skilled nursing facility, nursing home, or inpatient rehabilitation facility
e. Other long term care provider

21. In the last 12 months, did this residential care community use any of the following types of telehealth tools to assess, diagnose, monitor, or treat residents? MARK YES, NO, OR DON’T KNOW IN EACH ROW

	Yes	No	Don’t Know
a. Telephone audio
b. Videoconference software with audio (e.g., Zoom, Webex, FaceTime)

22. In the last 12 months, did this residential care community have any of the following challenges in implementing or using telehealth? MARK YES, NO, DON’T KNOW, OR NOT APPLICABLE IN EACH ROW

	Yes	No	Don’t Know	Not Applicable
a. Limited internet access and/or speed issues
b. Tools not easy to use or did not meet your needs
c. Not appropriate for serving your residents
d. Limitations in access to technology (e.g., smartphone, computer, tablet, Internet)
e. Residents’ difficulty using technology/telehealth platform
f. Staff difficulty using technology/telehealth platform
g. Reimbursement or cost issues associated with devices or telehealth platform
h. Limited staff available to provide telehealth services

23. Does this residential care community have the following infection control policies and practices?

MARK YES OR NO IN EACH ROW

	Yes	No
a. Have a written Emergency Operations Plan that is specific to or includes pandemic response
b. Have a designated staff member or consultant responsible for coordinating the infection control program
c. Offer annual influenza vaccination to residents
d. Offer annual influenza vaccination to all employees or contract staff
e. Offer COVID-19 vaccination to residents
f. Offer COVID-19 vaccination to all employees or contract staff

Services Offered

24. Services currently offered by this residential care community can include services offered at this physical location or virtually (online or by telephone). For each service listed below… MARK ALL THAT APPLY IN EACH ROW

This residential care community...	Provides the service by paid residential care community employees or 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. Palliative care services—treatment of the pain, discomfort, and symptoms of serious illness
c. 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
d. Mental or behavioral health services—target residents’ mental, emotional, psychological, or psychiatric well-being and may include diagnosing, describing, evaluating, and treating mental conditions
e. Therapy services—physical, occupational, or speech therapies
f. Pharmacy services—including filling of or delivery of prescriptions
g. Dietary and nutritional services
h. Skilled nursing services—must be performed by an RN, LPN or LVN and are medical in nature
i. Transportation services for medical or dental appointments
j. Routine and emergency dental services by a licensed dentist

25. 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

	Routinely at or after admission	Routinely when condition changes	Case by case	Does not screen
a. Cognitive impairment
b. Fall risk

26. The Long-Term Care Ombudsman Program is an advocacy program that serves people living in long-term care facilities. The program works to resolve resident problems, and provides information to residents, their families and facility staff about resident rights, care and quality of life. During the last 12 months, how often did a Long-Term Care Ombudsman Program representative assist or visit this residential care community?

MARK ONLY ONE ANSWER

	At least once every three months
	Less than once every three months
	A representative assisted or visited, but unsure how often
	 Skip to question 28 A representative did not assist or visit in the last 12 months
	Don’t know if a representative assisted or visited in the last 12 months

27. During the last 12 months, what did the representative do for this residential care community? MARK YES OR NO IN EACH ROW

	Yes	No
Visited residents in-person
Contacted or interacted with residents remotely
Responded to resident complaints
Worked with resident or family councils—including attending meetings
Responded to staff requests for help with resident issues or resident advocacy
Provided information or education to staff on resident issues, such as resident rights, care or services
Recommended processes to improve resident rights, care or quality of life
Other

Resident Profile

28. 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. Under 65 years
b. 65–74 years
c. 75–84 years
d. 85 years or older
TOTAL

NOTE: Total should be the same as the number of residents provided in question 4.

29. Of the residents currently living in this residential care community, what is the racial-ethnic breakdown? Count each resident only once. If a non-Hispanic resident falls under more than one category, please include them in the “Two or more races” category.

Enter “0” for any categories with no residents.

	Number of Residents
a. Hispanic or Latino, of any race
b. Two or more races, not Hispanic or Latino
c. American Indian or Alaska Native, not Hispanic or Latino
d. Asian, not Hispanic or Latino
e. Black, not Hispanic or Latino
f. Native Hawaiian or Other Pacific Islander, not Hispanic or Latino
g. White, 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 4.

30. In the last 12 months, how many coronavirus disease (COVID-19) cases did this residential care community have among residents? Enter “0” if none.

Number of residents

 If you answered “0”, skip to question 32

31. Of the COVID-19 cases in your residential care community in the last 12 months, how many cases resulted in each of the following? Enter “0” if none or select don’t know if you do not know the number.

	Number of COVID-19 Cases	Don’t Know
a. Hospitalization
b. Death

Staff Profile

32. 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 how many full-time employees and part-time employees this community currently has. Include employees who work at this physical location or virtually (on-line or by telephone). 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

33. 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 community. Does this community have any nursing, aide, social work, or activities contract or agency staff? Include contract staff who work at this physical location or virtually (on-line or by telephone).

	Yes
	No Skip to question 35

34. 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 this 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
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

35. In the last 12 months, how many coronavirus disease (COVID-19) cases did this residential care community have among employees or contract staff? Enter “0” if none.

Number of COVID-19 cases

 If you answered “0”, skip to question 37

36. Of the COVID-19 cases in your residential care community in the last 12 months, how many cases resulted in each of the following? Enter “0” if none or select don’t know if you do not know the number.

	Number of COVID-19 Cases	Don’t Know
a. Hospitalization
b. Death

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.

37. How many hours of training does this residential care community require aide employees to have for each of the following? If none, enter “0”.

	Number of hours
a. Prior to providing care to residents
b. On-going continuing education or annual in-service training

38. Does this residential care community offer the following benefits to full-time aide employees?

MARK YES OR NO IN EACH ROW

	Yes	No
a. Health insurance for the employee only
b. Health insurance that includes family coverage
c. Life insurance
d. A pension, a 401(k), or a 403(b)
e. Paid personal time off, vacation time, or sick leave
f. Reimburse/pay for initial training

39. How often does this residential care community offer training to prepare aide employees for each of the following aspects of their jobs? MARK ONLY ONE RESPONSE IN EACH ROW

	Training is always offered	Training is offered occasionally or as needed	Training is offered rarely or never	Don’t Know
a. Discussing resident care with residents’ families
b. Dementia care
c. Working with residents that act out or are abusive
d. Preventing personal injuries at work
e. End of life issues (advance care planning and help families cope with grief)
f. Relating to residents of different cultures or ethnicities, or with different values or beliefs

Information on COVID-19

40. In the last 12 months, how often did this residential care community use each of the following practices or policies to prevent or manage COVID-19 infections, whether or not there were any presumptive positive or confirmed COVID-19 cases? MARK ONLY ONE RESPONSE IN EACH ROW

	Always	Some of the time or as needed	Rarely or never	Don’t Know
a. Screened residents daily for fever or respiratory symptoms
b. Limited communal dining and recreational activities in common areas
c. Experienced shortages of eye protection, gloves, face masks, or isolation gowns
d. Experienced shortages of N95 respirators
e. Experienced shortages of test kits
f. Imposed restrictions on family and relatives entering the building
g. Imposed restrictions on visitors or volunteers entering the building
h. Imposed restrictions on non-essential consultant personnel (e.g., barbers, delivery personnel) entering the building

Thank you for participating in the 2022 National Post-Acute and Long-Term

Care Study.

41. Please return your questionnaire in the enclosed return envelope or mail it to:

NPALS

RTI International

ATTN: Data Capture

5265 Capital Boulevard

Raleigh, NC 27690