0920-25-0097 0920-0943 NPALS_ADSC_Final_Updated

Form Approved OMB No. 0920-0943 Exp. Date: 10/31/2025

National Post-acute and Long-term Care Study

2024 Adult Day Services Center 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 adult day services center at the location listed below.

 If this adult day services center is associated with another adult day services center or is part of a facility or

campus that offers multiple levels of care, please answer only for the adult day services portion 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 OR “CURRENT DIRECTOR”

FACILITY NAME, LICENSE NUMBER

FACILITY PHYSICAL STREET ADDRESS

CITY, ST ZIP

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.

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Background Information

1. What is the type of ownership of this adult day

services center? MARK ONLY ONE ANSWER

Private—nonprofit

Private—for profit

Publicly traded company or limited liability

company (LLC)

Government—federal, state, county, or local

2. Is this adult day services center…

MARK YES OR NO IN EACH ROW

Yes No

a. licensed or certified by your State

specifically to provide adult day

services, or accredited by the

Commission on Accreditation of

Rehabilitation Facilities (CARF)?

b. 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)?

 If you answered “No” to both 2a and 2b, skip to

question 37

3. What is the total number of participants currently

enrolled at this adult day services center? Include

all participants on this center’s roster, no matter

how frequently they attend, if they are receiving

services at their residence or virtually (on-line or by

telephone), if they share an enrollment spot, or if the

center has temporarily closed or suspended services.

If none, enter “0.”

Number of participants

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

4. Based on a typical week, what is the approximate

average number of participants this adult day

services center serves daily, either at this physical

location, at the participant’s residence, or virtually

(on-line or by telephone)? If none, enter “0.”

Average daily attendance

of participants

5. What is the maximum number of participants

allowed at this adult day services center at this

location? This may be called the allowable daily

capacity and is usually determined by law or by fire

code but may also be a program decision.

If none, enter “0.”

Maximum number of

participants allowed

6. Is this center owned by a person, group, or

organization that owns or manages two or more

adult day services centers? This may include a

corporate chain.

Yes

No

7. Which one of the following best describes the

participant needs that the services of this center

are designed to meet? MARK ONLY ONE ANSWER

ONLY social/recreational needs—NO

health/medical needs

PRIMARILY social/recreational needs and SOME

health/medical needs

EQUALLY social/recreational needs and

health/medical needs

PRIMARILY health/medical needs and SOME

social/recreational needs

ONLY health/medical needs—NO

social/recreational needs

8. Of this center’s revenue from paid participant fees,

about what percentage comes from each of the

following sources? Your entries should add up to

100%. Enter “0” for any sources that do not apply.

a. Medicaid (include revenue from

Medicaid state plans, Medicaid

waivers, Medicaid managed care, or

California regional centers)

%

b. Medicare (include Medicare

Advantage and Traditional or

Original Medicare)

%

c. Older Americans Act/Title III %

d. Veteran’s Administration %

e. Other federal, state, or local

government %

f. Out-of-pocket payment by the

participant or family %

g. Private insurance %

h. Other source %

TOTAL %

NOTE: Your entries should add up to 100%.

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9. An Electronic Health Record (EHR) is a

computerized version of the participant’s health

and personal information used in the management

of the participant’s health care. Other than for

accounting or billing purposes, does this adult day

services center use Electronic Health Records?

Yes

No  Skip to question 11

10. Does this adult day services center’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

11. Is this a specialized center that serves only

participants with particular diagnoses, conditions,

or disabilities?

Yes

No  Skip to question 13

12. In which of the following diagnoses,

conditions, or disabilities does this center

specialize? MARK YES OR NO IN EACH ROW

Yes No

a. Alzheimer disease or other

dementias

b. Intellectual and other

developmental disabilities

c. Multiple sclerosis

d. Parkinsons disease

e. Severe mental illness

f. Traumatic brain injury

g. Other (please specify)

13. In the last 12 months, did this center use any of the

following types of telehealth tools to assess,

diagnose, monitor, or treat participants? 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)

14. Does this center 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 participants

d. Offer annual influenza vaccination to all employees or contract staff

e. Offer COVID-19 vaccination to participants

f. Offer COVID-19 vaccination to all employees or contract staff

g. Screen participants daily for infection (e.g., screen for fever or respiratory symptoms) if an

outbreak occurs

h. Limit hours or temporarily close this center 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

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Services Offered

15. Services currently offered by this center can include services offered at this physical location, at a participant’s

residence, or virtually (on-line or by telephone). For each service listed below, MARK ALL THAT APPLY IN EACH ROW

This adult day services center...

Provides the service by

paid center employees

or

Arranges for the service

to be provided by

outside service providers

Refers participants or

family to outside service

providers

Does not

provide, arrange,

or refer for this

service

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 participants' 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—

including meal pickup or delivery

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. Daily round trip transportation services

to or from this center

j. Routine and emergency dental services

by a licensed dentist

k. Home health care—medical,

therapeutic, and other health care

services to help with post-acute and

chronic illnesses

l. Home care—assistance with completing

self-care, activities of daily living, and

instrumental activities of daily living such

as housekeeping, errands, and

appointments

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Participant Profile

When answering questions 16-26, include all participants on this center’s roster, no matter how frequently they attend,

if they are receiving services at their residence or virtually (on-line or by telephone), if they share an enrollment spot, or if

the center has temporarily closed or suspended services.

16. Of the participants currently enrolled at this

center, what is the age breakdown? Enter “0” for

any categories with no participants.

Number of

Participants

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 participants provided in question 3.

17. Of the participants currently enrolled at this center,

what is the racial-ethnic breakdown? Count each

participant only once. If a non-Hispanic participant

falls under more than one category, please include

them in the “Two or more races” category.

Enter “0” for any categories with no participants.

Number of

Participants

a. Hispanic or Latino, of any race

b. Two or more races, not Hispanic

or Latino

c. Middle eastern or North African,

not Hispanic or Latino

d. American Indian or Alaska

Native, not Hispanic or Latino

d. Asian, not Hispanic or Latino

f. Black, not Hispanic or Latino

g. Native Hawaiian or Other Pacific

Islander, not Hispanic or Latino

h. White, not Hispanic or Latino

i. Some other category reported in

this center’s system

j. Not reported (race and ethnicity

unknown)

TOTAL

NOTE: Total should be the same as the number of

participants provided in question 3.

18. Of the participants currently enrolled at this center,

what is the sex breakdown? Enter “0” for any

categories with no participants.

Number of

Participants

a. Male

b. Female

TOTAL

NOTE: Total should be the same as the number of

participants provided in question 3.

19. Of the participants currently enrolled at this center,

about how many have been diagnosed with each of

the following conditions? Enter “0” for any

categories with no participants.

Number of

Participants

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

20. As best you know, of the participants currently

enrolled at this center, about how many were

treated in a hospital emergency department in the

last 90 days? If none, enter “0.”

Number of participants

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21. As best you know, of the participants currently

enrolled at this center, 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 participants

22. During the last 30 days, for how many of the

participants currently enrolled at this adult day

services center did Medicaid pay for some or all of

their services received at this center? Please include

any participants that received funding from a

Medicaid state plan, Medicaid waiver, Medicaid

managed care, or California regional center. If none,

enter “0.”

Number of participants

23. In the last 12 months, how many coronavirus

disease (COVID-19) cases did this center have

among participants? If none, enter “0.”

Number of COVID-19 cases

 If you answered “0”, skip to question 25

24. Of the COVID-19 cases in your center 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

25. Assistance refers to needing any help or supervision

from another person, or use of assistive devices. Of

the participants currently enrolled at this center,

about how many now need any assistance at their

usual residence or this center in each of the

following activities? Enter “0” for any categories

with no participants.

Number of

Participants

a. With transferring in and out of a

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

26. As best you know, of the participants currently

enrolled at this center, about how many had a fall in

the last 90 days? Include falls that occurred in your

center or off-site, whether or not the participant was

injured, and whether or not anyone saw the

participant fall or caught them. Please just count one

fall per participant who fell, even if the participant fell

more than one time. If one of your participants fell

during the last 90 days, but is currently in the hospital

or rehabilitation facility, please include that person in

your count. If no participants had a fall, enter “0.”

Number of participants

Staff Profile

27. An individual is considered an employee if the center 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 center

currently has. Include employees who work at this physical location, at a participant’s residence, 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

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28. Contract or agency staff refer to individuals or organization staff under contract with and working at this center

but are not directly employed by the center. Does this center have any nursing, aide, social work, or activities

contract or agency staff? Include contract staff who work at this physical location, at a participant’s residence, or

virtually (on-line or by telephone).

Yes

No Skip to question 30

29. For each staff type below, indicate how many full-time contract or agency staff and part-time contract or

agency staff this center currently has. Do not include individuals directly employed by this center.

Enter “0” for any categories with no contract or agency staff.

Number of Full-Time

Contract or Agency

Staff

Number of Part-Time

Contract or Agency

Staff

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

30. In the last 12 months, how often was this center 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.

31. Does this center offer the following benefits to fulltime

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

32. How many hours of training does this center require

aide employees to have for each of the following?

Enter “0” if no hours of training are required.

Number of hours

a. Initial training prior to

providing care

b. Continuing education, ongoing,

or on-the-job

training

33. Does this center provide assistive devices, such as

lifting aides, belts, trapeze bars, or other assistive

equipment, to your aide employees when moving

or lifting participants who cannot move around on

their own?

Yes

No

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Thank you for participating in the

2024 National Post-acute and Long-term Care Study.

34. How often does this center 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 participant care with participants’

families

b. Dementia care

c. Working with participants 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 participants 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 adult day services centers 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.

35. 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 

36. 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 

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

Cox Building (FDC Fulfillment – Data Capture)

NPALS (0219308.001)

PO Box 12194

Research Triangle Park, NC 27709-2194

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