Attachment J-Facility Showcards

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Attachment J

SHOWCARDS

Facility Questionnaire

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SHOWCARD 1

DEFINITION OF RESIDENTIAL CARE FACILITIES

“Residential care facilities are places that are licensed, registered, listed, certified, or otherwise regulated by the state and that provide room and board with at least two meals a day, around-the-clock on-site supervision, and help with personal care such as bathing and dressing or health related services such as medication management. These facilities serve an adult population. Facilities licensed to exclusively serve people with mental illness or mental retardation/developmental disabilities are excluded.”

SHOWCARD 2

DEFINITION OF A FORMAL NEGOTIATED RISK AGREEMENT

We would now like to ask you about how the facility manages risky behavior by residents.  

By risky behavior, we mean when residents do things that staff think pose a risk to their health and safety - such as refusing to take prescribed medications, not using a walker when their balance is poor, or not complying with prescribed diets. 

 

Some facilities use a formal document called a managed risk agreement or a formal negotiated risk agreement, which documents the risky behavior, discussions with the resident about the behavior, alternatives to the behavior presented by staff, and agreements reached between the facility and the resident about the behavior. Some facilities also use these documents as liability waivers for harm resulting from risky behavior.

SHOWCARD 3

A50. PLEASE SELECT ALL THAT APPLY.

1. Resident demographics

2. Functional assessments

3. Individual service plans

4. Clinical notes, such as daily progress notes

5. Medication administration

(for example, for maintaining lists of resident’s medications)

6. Discharge and transfer summaries

7. Electronic Point of Care Documentation

(for example, handheld devises for charting or for other clinical notations)

SHOWCARD 4

A51. PLEASE SELECT ALL THAT APPLY.

1. Physicians

2. Nursing homes

3. Hospitals

4. Pharmacies

5. Other health or long-term care providers

6. Resident’s personal health record

7. Corporate office

8. Electronic information is NOT exchanged.

SHOWCARD 5

A56-A57.

1. 75% to 100%

2. 50% to 74%

3. 25% to 49%

4. 0% to 24%

SHOWCARD 6

A61. PLEASE SELECT ALL THAT APPLY.

1. Locked exit doors

2. Doors with alarms

3. Doors with keypads

4. Personal monitoring devices

5. An enclosed courtyard

6. Higher staff-to-resident ratios compared to other units

7. Specially trained staff

8. Dementia-specific activities and programming

9. Other: SPECIFY:____________________

SHOWCARD 7

B5_assist. PLEASE SELECT ALL THAT APPLY.

1. Amplifier for the telephone

2. TDD, TTY or teletype

3. Assistive listening devices

4. Signaling devices (devices which can visually alert the hearing impaired person to auditory signals that may not be heard)

5. Communication board

6. Other equipment for people with hearing or speech impairments?

SHOWCARD 8

B7a. PLEASE SELECT ALL THAT APPLY.

1. Central location where medications are stored prior to administration to residents

2. Providing medication reminders (e.g. prompting that it is time to take medications)

3. Delivering pre-packaged unit doses

4. Helping with administration, for example, open the bottle and hand the resident the correct dose

5. Helping the resident take the medicine (e.g., putting it in their mouth and handing the resident a glass of water)

6. Providing oversight and cueing to make sure the resident actually takes the medication

7. Administering drops, topical ointments, etc.

8. Administering IV medications

9. Administering injections

SHOWCARD 9

B7b-B8. PLEASE SELECT ALL THAT APPLY.

1. RN

2. LPN

3. Certified medication aide / supervisor / medication technician

4. Personal care aide

5. Owner /Administrator / assistant director / manager

SHOWCARD 10

D2.

1. 18 – 29

2. 30 – 39

3. 40 – 49

4. 50 – 59

5. 60 – 69

6. 70 or older

SHOWCARD 11

D4. PLEASE SELECT ALL THAT APPLY.

1. White/Caucasian

2. Black or African American

3. Asian

4. Native Hawaiian or other Pacific Islander

5. American Indian or Alaskan Native

6. Other (SPECIFY)____________________

SHOWCARD 12

D5.

1. Less than high school

2. High school graduate or GED

3. Vocational, trade school, or technical school graduate

4. Some college

5. College graduate

6. Post graduate

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