NSLTP - Residential Care Community

Attachment 1a.

Note to reviewers: No changes have been made to the questionnaire since OMB’s approval of OMB# 0902-0943. In addition to the questions presented in the questionnaire below, additional questions probing the respondents’ cognitive processes will be administered, following the methodology laid out in the QDRL Generic IRC, OMB# 0902-0222 (ex 06/30/2015).

2012 National Study of Long-Term Care Providers (NSLTCP) Residential Care Community Questionnaire

Dear Administrator / Executive Director, The Centers for Disease Control and Prevention’s National Center for Health Statistics (NCHS) is conducting the new National Study of Long-Term Care Providers (NSLTCP), which includes a national survey of residential care communities. RTI International has been contracted to carry out the data collection. Please answer all of the questions in reference to the residential care community at the location shown on the pre-printed label below. If your residential care community is part of a multi-facility campus, please only answer for the residential care community portion of the campus. The accuracy of your answers is important to this study. Residential care places are known by many different names. 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 service establishments. For this study, we refer to these places and others like them as residential care communities. Nursing homes are excluded. If you need assistance or have any questions while completing this questionnaire, please call 1‑800-957-6456 to speak to a member of the NSLTCP project team. Thank you for taking the time to complete this questionnaire. Label here Sincerely, Angela M. Greene RTI International, Survey Contractor to NCHS NOTICE – The Public Health Service Act provides us with the authority to do this research (42 United States Code 242k). All information which would permit identification of any individual, a practice, or an establishment will be held confidential, will be used for statistical purposes only by NCHS staff, contractors, and agents only when required and with necessary controls, and will not be disclosed or released to other persons without the consent of the individual or the establishment in accordance with section 308(d) of the Public Health Service Act (42 USC 242m) and the Confidential Information Protection and Statistical Efficiency Act (PL-107-347). Public reporting burden for this collection of information is estimated to average 1 hour per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data 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 Reports Clearance Officer; 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0222). OMB #0920-0222; Expiration Date: 06/30/2015

INSTRUCTIONS:

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• ^{Please clearly mark your responses in the boxes provided. Examples or}

  

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• Written answers should be printed in the space provided. Example

Residential care places are known by many different names. 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 service establishments. For this study, we refer to these places and others like them as residential care communities. Nursing homes are excluded.

1

Study Eligibility

3b. Does this residential care community exclusively serve both persons with mental retardation/a developmental disability and persons with severe mental illness?

Yes SKIP TO BOX A

No CONTINUE

4. Does this residential care community provide or arrange for a personal care aide, registered nurse (RN), licenses practical nurse (LPN), or the director or assistant director (if they provide personal care or nursing services to residents) to be on-site 24 hours a day, 7 days a week to meet any resident needs that may arise? On-site means they are located in the same building, in an attached building or next door, or on the same campus.

Yes CONTINUE

No SKIP TO BOX A

5. Does this residential care community offer help with activities of daily living, such as help with bathing, either directly or arranged through an outside vendor?

Yes SKIP TO QUESTION 6

No CONTINUE

5a. Does this residential care community offer assistance with the administration of medications, give reminders, or provide central storage of medications?

Yes CONTINUE

No SKIP TO BOX A

The answers to the questions below determine if this residential care community meets the study definition for the 2012 National Study of Long-Term Care Providers. Please answer the following question(s) and follow the instructions next to the answer you mark.

1. Is this residential care community currently licensed, registered, listed, certified, or otherwise regulated by the state?

Yes CONTINUE

No SKIP TO BOX A

2. Does this residential care community have 4 or more licensed, registered, or certified beds?

Yes CONTINUE

No SKIP TO BOX A

3. Does this residential care community exclusively serve adults with mental retardation or a developmental disability, such as Down's syndrome or autism?

Yes SKIP TO BOX A

No CONTINUE

3a. Does this residential care community exclusively serve adults with severe mental illness, such as schizophrenia or psychosis? Please do not include Alzheimer’s disease or other dementias.

Yes SKIP TO BOX A

No CONTINUE

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

Yes CONTINUE

No SKIP TO BOX A

7. Is there at least one resident living at this residential care community?

Yes SKIP TO QUESTION 8

THIS RESIDENTIAL CARE COMMUNITY IS ELIGIBLE TO PARTICIPATE IN THIS STUDY.

No SKIP TO BOX A

BOX A

Thank you very much for answering these questions. Unfortunately, this residential care community does not meet the study definition. This study is focused on residential care communities that are in some way regulated by the state and provide a broader array of residential care services.

Please return this questionnaire in the enclosed return envelope so we will know that this residential care community is not eligible to participate in the 2012 National Study of Long-Term Care Providers. After receiving this questionnaire, we will not need to contact you again.

9. Is this residential care community owned by a person, group, or organization that owns or manages two or more residential care communities? This may include a corporate chain.

Yes

No

10. Is this residential care community owned by any other type of organization?

Yes CONTINUE

No, not part of another
organization SKIP TO QUESTION 11

10a. For each item (a–f) below, please indicate whether or not this type of organization owns this residential care community.

	Yes	No
a. Hospital
b. Nursing home or skilled nursing facility
c. Home health agency
d. Hospice agency
e. Adult day services center
f. Other

11. At this residential care community, what is the number of licensed, registered, or certified residential care beds? Include both occupied and unoccupied beds.

Number of beds

12. What is the total number of residents currently living at this residential care community? Include respite care residents.

Number of residents

2

Background Information

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

Please provide answers only for the residential care community portion of your campus.

8. What is the type of ownership of this residential care community?

MARK ONLY ONE ANSWER

Private, nonprofit

Private, for profit

Publicly traded company or limited liability company (LLC)

Government—federal, state, county, or local government

13. Of the residents currently living in this residential care community, how many are respite care residents?

Number of residents OR None

14. Is this residential care community certified or otherwise set up to participate in Medicaid, either through the Medicaid State Plan or a home and community-based services waiver program?

Yes

No

15. During the last 30 days, how many of this residential care community’s residents had some or all of their long-term care services paid by Medicaid?

Number of residents OR None

16. A continuing care retirement community is a community that offers multiple levels of care such as independent living, residential care, and skilled nursing care, and provides residents the opportunity to remain in the same community as their needs change. Is this residential care community part of a continuing care retirement community?

Yes

No

17. What is the total number of years this residential care community has been operating as a residential care community at this location?

Less than 1 year

1 to 4 years

5 to 9 years

10 to 19 years

20 or more years

3

Services Offered

Please provide answers only for the residential care community portion of your campus.

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

Yes CONTINUE

No SKIP TO QUESTION 18b

18a. Does this residential care community have specially trained staff for residents with dementia or Alzheimer’s disease?

Yes SKIP TO QUESTION 19

No SKIP TO QUESTION 19

18b. Does this residential care community have a distinct unit, wing, or floor that is designated as a dementia or Alzheimer’s Special Care Unit?

Yes CONTINUE

No SKIP TO QUESTION 19

18c. How many licensed beds are in the dementia or Alzheimer’s Special Care Unit?

Number of beds

18d. Does this dementia or Alzheimer's Special Care Unit have . . .

MARK YES OR NO IN EACH ROW
	Yes	No
a. Higher staff-to-resident ratios compared to other units?
b. Specially trained staff for residents with dementia or Alzheimer’s disease?

19. For each item (a–k) below, please mark whether or not this residential care community provides the service and, if it does, whether it is provided only by residential care community employees, only by others through arrangement, or by both. Please mark “Not provided” if the residential care community only refers residents to service providers.

a. Routine and emergency dental services by a licensed dentist	Not provided Provided only by residential care community employees Provided only by others through arrangement Provided by both residential care community employees and others through arrangement
b. Hospice services	Not provided Provided only by residential care community employees Provided only by others through arrangement Provided by both residential care community employees and others through arrangement
c. Social work services—provided by licensed social workers or persons with a bachelor’s or master’s degree in social work, and include an array of services such as psychosocial assessment, individual or group counseling, and referral services	Not provided Provided only by residential care community employees Provided only by others through arrangement Provided by both residential care community employees and others through arrangement
d. Any case management services—generally a process of assessment, planning, and facilitation of options and services for an individual	Not provided Provided only by residential care community employees Provided only by others through arrangement Provided by both residential care community employees and others through arrangement
e. Mental health services—target residents' mental, emotional, psychological, or psychiatric well-being and include diagnosing, describing, evaluating, and treating mental conditions	Not provided Provided only by residential care community employees Provided only by others through arrangement Provided by both residential care community employees and others through arrangement
f. Any therapeutic services—physical, occupational, or speech	Not provided Provided only by residential care community employees Provided only by others through arrangement Provided by both residential care community employees and others through arrangement
g. Pharmacy services—including filling of and delivery of prescriptions	Not provided Provided only by residential care community employees Provided only by others through arrangement Provided by both residential care community employees and others through arrangement
h. Podiatry services	Not provided Provided only by residential care community employees Provided only by others through arrangement Provided by both residential care community employees and others through arrangement
i. Skilled nursing services—must be performed by a RN or LPN and are medical in nature	Not provided Provided only by residential care community employees Provided only by others through arrangement Provided by both residential care community employees and others through arrangement
j. Transportation services for medical or dental appointments	Not provided Provided only by residential care community employees Provided only by others through arrangement Provided by both residential care community employees and others through arrangement
k. Transportation services for social and recreational activities, or shopping	Not provided Provided only by residential care community employees Provided only by others through arrangement Provided by both residential care community employees and others through arrangement

20. For about how many of the current residents does this residential care community manage, supervise, or store medications; administer medications; or provide assistance with self-administration of medications?

Number of residents OR None

21. As a part of the admission process, does this residential care community screen residents for depression with a standardized tool such as the Geriatric Depression Scale, Beck Depression Inventory, or the Center for Epidemiological Studies-Depression (CES-D) scale?

Yes

No

22. Disease-specific programs may include one or more of the following services—educational programs, physical activity programs, diet/nutrition programs, medication management programs, and weight management programs. For each condition (a–d) below, please indicate whether or not this residential care community offers any of these services for residents with this condition.

	Yes	No
a. Alzheimer’s disease and other dementias
b. Cardiovascular disease (e.g., heart disease, stroke, high blood pressure)
c. Depression
d. Diabetes

23. On a regular basis, does this residential care community create daily schedules based on each resident’s life history, abilities, and interests?

Yes

No

24. On a regular basis, does this residential care community seek input from residents and their families into…

MARK YES OR NO IN EACH ROW
	Yes	No
a. What personal care services are received by the resident?
b. How the resident’s room is decorated?

25. On a regular basis, does this residential care community give residents choices for each of the following?

MARK YES OR NO IN EACH ROW
	Yes	No
a. Meal times
b. Where they eat
c. Meal types/menus

4

Staff Profile

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

Please provide answers only for the residential care community portion of your campus.

26. For each item (a–d) below, please indicate the number of staff that currently work at this residential care community full-time and part-time. Please include:

• both full-time and part-time residential care community employees (an individual is considered a community employee if the community is required to issue a Form W-2 on their behalf), and

• other individuals or organization staff under contract with and working at this residential care community full-time and part-time.

Please report either the number of full-time and part time staff OR the number of full-time equivalent (FTE) staff, but not both, for the residential care community employee category and the contract staff category. If this residential care community does not have any staff for a specific category, enter “0” under the number of full-time and part-time staff.

Current Residential Care Community Staff		Number of Full-Time Staff If none, enter “0”	Number of Part-Time Staff If none, enter “0”		Number of Full-Time Equivalent (FTE) Staff If none, enter “0”
a. RNs	Residential care community employee(s)			OR
	Contract staff			OR
b. LPNs/licensed vocational nurses (LVNs)	Residential care community employee(s)			OR
	Contract staff			OR
c. Certified nursing assistants, nursing assistants, home health aides, home care aides, personal care aides, personal care assistants, and medication technicians or medication aides	Residential care community employee(s)			OR
	Contract staff			OR
d. Social workers—licensed social workers or persons with a bachelor’s or master’s degree in social work	Residential care community employee(s)			OR
	Contract staff			OR

27. Do any activities directors or activities staff work at this residential care community? Include residential care community employees and contract staff.

Yes CONTINUE

No SKIP TO QUESTION 29

28. On an average shift, how many activities directors or activities staff are on-site providing services? Include residential care community employees and contract staff.

Number of activities directors or activities staff OR None

5

Resident Profile

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

Please provide answers only for the residential care community portion of your campus.

29. Of the residents currently living in this residential care community, how many are in each of the following categories? Count each resident only once. Enter “0” for any categories with no residents.

	NUMBER OF RESIDENTS
a. Hispanic or Latino, of any race
b. American Indian or Alaska Native, not Hispanic or Latino
c. Asian, not Hispanic or Latino
d. Black, not Hispanic or Latino
e. Native Hawaiian or Other Pacific Islander, not Hispanic or Latino
f. White, not Hispanic or Latino
g. Two or more races, not Hispanic or Latino
h. Some other category reported in this residential care community’s system
i. Not reported (race and ethnicity unknown)
TOTAL

NOTE: Total should be the same as provided in Question 12.

30. Of the residents currently living in this residential care community, how many are in each of the following categories? Enter “0” for any categories with no residents.

	NUMBER OF RESIDENTS
a. Male
b. Female
TOTAL

NOTE: Total should be the same as provided in Question 12.

31. Of the residents currently living in this residential care community, how many are in each of the following age categories? Enter “0” for any categories with no residents.

	NUMBER OF RESIDENTS
a. 17 years or younger
b. 18–44 years
c. 45–54 years
d. 55–64 years
e. 65–74 years
f. 75–84 years
g. 85 years and older
TOTAL

NOTE: Total should be the same as provided in Question 12.

32. Of the residents currently living in this residential care community, about how many have been diagnosed with each of the following conditions?

NUMBER OF RESIDENTS
a. Alzheimer’s disease or other dementias		OR	None
b. Developmental disability, such as mental retardation, autism, or Down's syndrome		OR	None
c. Severe mental illness, such as schizophrenia and psychosis		OR	None
d. Depression		OR	None

33. Before or upon admission, does this residential care community use a standardized tool to conduct a formal assessment of its residents to identify anyone with a cognitive impairment?

Yes CONTINUE

No SKIP TO QUESTION 34

33a. Based on this assessment, about how many of the residents currently living in this residential care community have been identified as having a cognitive impairment?

Number of residents OR None

34. This next question asks about the number of residents at this residential care community who currently need assistance in activities of daily living (ADLs).

Assistance refers to needing any help or supervision from another person, or use of special equipment. As a reminder, please provide answers only for the residential care portion of your campus.

Of the residents currently living in this residential care community, about how many need any assistance in each of the following activities?

NUMBER OF RESIDENTS
a. Transferring in and out of bed		OR	None
b. Transferring in and out of a chair		OR	None
c. With eating, like cutting up food		OR	None
d. With dressing		OR	None
e. With bathing or showering		OR	None
f. In using the bathroom (toileting)		OR	None
g. With locomotion or walking—this includes using a cane, walker, or wheelchair and/or help from another person.		OR	None

35. Of the residents currently living in this residential care community, about how many use a manual, electric, or motorized wheelchair or scooter?

Number of residents OR None

36. 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.

Number of residents CONTINUE

None SKIP TO QUESTION 37

36a. Of the residents who were discharged from an overnight hospital stay in the last 90 days, about how many of those residents were re-admitted to the hospital for an overnight stay within 30 days of their hospital discharge?

Number of residents OR None

37. 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?

Number of residents OR None

Questions 38–40b refer to the last 12 months.

38. In the last 12 months, about how many residents moved into this residential care community? Count all residents who moved in—including respite care residents, residents who later died, and residents who no longer live here—regardless of the reason.

Number of residents OR None

39. In the last 12 months, about how many residents living in this residential care community died? Include respite care residents.

Number of residents OR None

40. In the last 12 months, about how many residents, including respite care residents, moved out of this residential care community? Exclude deaths and residents for whom the community is currently holding a bed for the resident.

Number of residents CONTINUE

None SKIP TO QUESTION 41

40a. Where did each of these residents go immediately after they moved out? Enter “0” for any categories with no residents.

	NUMBER OF RESIDENTS
a. Another assisted living or similar residential care community (e.g., adult care or personal care residence)
b. Hospital
c. Nursing home
d. Private residence (house or apartment)
e. Some other place
TOTAL

NOTE: Total should be the same as provided in
Question 40.

40b. Of the residents who moved out in the last 12 months, about how many left because the cost of care, including housing, meals, and services required to meet their needs, exceeded their ability to pay?

Number of residents OR None

6

Record Keeping

Please provide answers only for the residential care community portion of your campus.

41. An Electronic Health Record 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

42. For each item (a–s) below, please indicate in Column 1 whether or not this residential care community collects or tracks this information about residents. If this community does collect or track the information, please indicate in Column 2 whether or not this community has the computerized capability to collect or track it.

	Column 1 Does this residential care community collect/track this information?	IF YES IN COLUMN 1	Column 2 Does this residential care community have the computerized capability to collect/track this information?
a. Contact information for the resident’s medical providers	Yes No		Yes No
b. Resident demographics	Yes No		Yes No
c. Functional assessments	Yes No		Yes No
d. Individual service plans	Yes No		Yes No
e. Resident service records (a record of the services being provided to each resident)	Yes No		Yes No

42. Cont’d

	Column 1 Does this residential care community collect/track this information?	IF YES IN COLUMN 1	Column 2 Does this residential care community have the computerized capability to collect/track this information?
f. Clinical notes, such as medical history and daily progress notes	Yes No		Yes No
g. Resident problem list (medical and behavioral concerns)	Yes No		Yes No
h. Advance directives	Yes No		Yes No
i. Automatic reminders for updating records, scheduling screening tests or guideline based interventions	Yes No		Yes No
j. Lists of medications	Yes No		Yes No
k. Medication administration records	Yes No		Yes No
l. Active medication allergy lists	Yes No		Yes No
m. Warning of drug interactions or contraindications	Yes No		Yes No
n. Discharge and transfer summaries	Yes No		Yes No
o. Outside health care visits, including emergency room visits and overnight hospital admissions	Yes No		Yes No
p. Orders for prescriptions	Yes No		Yes No
q. Orders for tests	Yes No		Yes No
r. Viewing laboratory/imaging results (seeing and reading test results)	Yes No		Yes No
s. Public health reporting	Yes No		Yes No

43. Does this residential care community’s computerized system support electronic health information exchange with each of the following providers?

MARK YES OR NO IN EACH ROW
	Yes	No
a. Physician
b. Pharmacy

7

Contact Information

We would like to reach you if we have questions about your answers. Please provide your name, telephone number, work e-mail address, and job title. Your contact information will be kept confidential and will not be shared with anyone outside the project team. PLEASE PRINT Your full name: ( ) Your work telephone number, with extension: Your work e-mail address: Your job title: Thank you for participating in the NSLTCP.