2024 Residential Care Community Questionnaire

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

National Post-acute and Long-term Care Study

2024 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.

• 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
  1-855-500-1435.

• 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.

Please provide your contact information. Your information may be used for contact related to participation in current and future NPALS waves and will be kept confidential. 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 H21 -8, 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 or 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.

Background Information

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 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 ONLY 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

9. Does this residential care community only serve adults with dementia or Alzheimer disease?

	Yes  Skip to question 12
	No

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

	Yes
	No  skip to question 13

11. How many licensed beds are in the dementia, Alzheimer, 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

12. Does this residential care community or designated unit, wing, or floor have each of the following? MARK YES OR NO IN EACH ROW

	Yes	No
a. High staff-to-resident ratios compared to other units, wings, or floors
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

13. 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

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

	Yes
	No  Skip to question 16

15. 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

16. 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 18

17. 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

18. 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)

19. 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
g. Screen residents daily for infection (e.g., screen for fever or respiratory symptoms) if an outbreak occurs
h. Limit communal dining and recreational activities in common areas if an outbreak occurs
i. Impose restrictions on family, relatives, visitors, volunteers, or non-essential consultant personnel (e.g., barbers, delivery personnel) entering the building if an outbreak occurs
j. Masking if an outbreak occurs

Services Offered

20. Services currently offered by this residential care community can include services offered at this physical location or virtually (on-line 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 or palliative care 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, support groups, and referral services
c. Mental or behavioral health services—target residents’ mental, emotional, psychological, or psychiatric well-being and may include diagnosing, describing, evaluating, and treating mental conditions
d. Therapy services—physical, occupational, or speech therapies
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, LPN or LVN and are medical in nature
h. Transportation services for medical or dental appointments
i. Routine and emergency dental services by a licensed dentist
j. Home health care—medical, therapeutic, and other heath care services to help with post-acute and chronic illnesses
k. Home care—assistance with completing self-care, activities of daily living, and instrumental activities of daily living such as housekeeping, errands, and appointments

Resident Profile

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

Number of COVID-19 cases

 If you answered “0”, skip to question 23

22. 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

23. 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.

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

	Number of Residents
a. Male
b. Female
c. Transgender, non-binary, or another gender
TOTAL

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

25. 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.

26. 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

27. 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
a. Alzheimer disease or other dementias
b. Arthritis
c. Asthma
d. Chronic kidney disease
e. COPD (chronic bronchitis or emphysema)
f. Depression
g. Diabetes
h. Heart disease (for example, congestive heart failure, coronary or ischemic heart disease, heart attack, stroke)
i. High blood pressure or hypertension
j. Intellectual or developmental disability
k. Osteoporosis

28. As best you know, 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

29. As best you know, 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

30. As best you know, of the residents currently living in this residential care community, about how many had a fall in the last 90 days?  Include falls that occurred in your residential care community or off-site, whether or not the resident was injured, and whether or not anyone saw the resident fall or caught them. Please just count one fall per resident who fell, even if the resident fell more than one time. If one of your residents fell during the last 90 days, but is currently in the hospital or rehabilitation facility, please include that person in your count. If no residents had a fall, enter “0.”

Number of residents

Staff Profile

31. 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

32. 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 34

33. 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

34. In the last 12 months, how often was this residential care community short-staffed?

	Always
	Sometimes
	Never

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.

35. 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. Dental, vision, or prescription drug benefits
d. Life insurance
e. A pension, a 401(k), or a 403(b)
f. Paid childcare, childcare subsidies, or assistance
g. Paid personal time off, vacation time, or sick leave
h. Overtime pay
i. Bonuses or regular pay increases
j. Reimburse/pay for initial training

36. 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. Initial training prior to providing care
b. Continuing education, on-going, or on-the-job training

37. Does this residential care community provide assistive devices, such as lifting aides, belts, trapeze bars, or other assistive equipment, to your aide employees when they are moving or lifting residents who cannot move around on their own?

	Yes
	No

38. How often does this residential care community offer training to prepare aide employees for each of the following aspects of their jobs? Include any training offered when becoming an aide and any training offered since aides started working. 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
g. Infection control (putting on and taking off personal protective equipment, hand washing)

These next questions ask for information to help inform planning for future waves of NPALS. The National Center for Health Statistics (NCHS) recently conducted a Direct Care Worker (DCW) Pilot Study as part of NPALS. We asked directors of residential care communities to sample and provide contact information for two direct care employees or contract staff. We then invited the sampled direct care workers to complete a questionnaire by mail or web.

39. If we were to invite you to participate in a future DCW Study, would you have access to the following information for your direct care employees? If yes, would you be able to provide us with this information to contact your direct care employees?

	Have Access?		If yes 			Able to Provide?
	No	Yes			No		Yes
a. Full name				
b. Mailing address				
c. Email address				

40. Would you have access to the following information for your direct care contract staff? If yes, would you be able to provide us with this information to contact your direct care contract staff?

	Have Access?		If yes 			Able to Provide?
	No	Yes			No		Yes
a. Full name				
b. Mailing address				
c. Email address				

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

NPALS

RTI International

ATTN: Data Capture

5265 Capital Boulevard

Thank you for participating in the
2024 National Post-acute and Long-term Care Study.

Raleigh, NC 27690