Form 6 Line 6 National Survey Advance Data Collection Form

Form Approved OMB No. 0920-XXXX Exp. Date 00/00/0000

NOTICE – Public reporting burden of this collection of information is estimated to average 15 minutes 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 E-11, Atlanta, GA 30333, ATTN: PRA (0920-XXXX).

Assurance of Confidentiality – All information which would permit identification of an individual, a practice, or an establishment will be held confidential, will be used only by persons engaged in and for the purpose of the survey and will not be disclosed or released to other persons or used for any other purpose without the consent of the individual or the establishment in accordance with section 308(d) of the Public Health Service Act (42 USC 242m).

Attachment N

National Advance Data Collection Form

Questions mailed to facility prior to site visit

This form contains some of the questions that will be asked in the interview. We have mailed these to you in advance because they may require you to check reports or other sources of information. Having answers to these questions in advance of our visit will reduce the time we need to spend talking with you during the interview process. The survey is about residential care. For this study, residential care is defined as:

“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 serve the mentally ill or the MR/DD populations exclusively are excluded.”

If your facility is part of a campus that includes other types of care, please obtain answers only for the residential care portion of the facility and have them ready on the day of the site visit.

Number of beds /Residents

Some states license, register, or certify residential care facilities by number of beds, while other states regulate by the number of units. The next questions are about both the number of beds and the number of units in this facility. A unit is defined as a room or apartment where residents live. Do not include rooms within apartments.

A1. At this facility, what is the number of licensed, registered, or certified residential care beds _______

A2. IF YOUR STATE LISCENSE BY UNITS: At this facility, what is the number of licensed, registered, or certified residential care units _______

A3. What is the current number of residents living at this residential care facility? ____

The next few questions are about apartments. An apartment is a living unit that includes lockable doors, a bathroom with a sink, toilet, and shower or bath, and a kitchen area which includes a sink, at least a cook top, hotplate, or microwave and a refrigerator.

A4. Based on this definition, do any of your units qualify as an apartment?

O YES

O NO – PLEASE SKIP QUESTIONS A5a, A5b, and A5c

A5. How many of your units are….
		Number of Apartments/ Rooms
a. Studio apartments	________
b. One bedroom apartments	________
c. Two bedroom apartments	________
d. Room designed for one person	________
e. Double occupancy rooms	________
f. Rooms for three or more residents	________

If YOU ANSWERED “NO” TO A4 – GOTO A7

A6. How many apartments include a kitchen area that contains…

A6a. A cook top or hot plate [ ]

A6b. A microwave [ ]

A6c. An oven [ ]

If YOU ANSWERED “YES” TO A4 – GOTO A23

A7. How many units have a door to the hallway that can be locked? [ ]

A7_within. How many rooms have a bathroom located within the room? ______

IF THIS FACILITY HAS NO ROOMS WITH A BATHROOM LOCATED WITHIN THE ROOM -- SKIP QUESTIONS A7a AND A7b

How many rooms…

A7a. have a full bathroom including a toilet, sink, and shower or tub

located within the room [ ]

A7b. have a half-bath including a sink and toilet located within the room [ ]

Source of Payment

The next questions ask about items resident source of payment.

A23. During the last 30 days, how many of the residents had some or all of their long-term care services at this facility paid by Medicaid?______

Waiting Lists

IF THIS FACILITY DOES NOT HAVE A WAITING LIST SKIP QUESTIONS A25-A26.

A25. What is the current number of people on the active waiting list for residential care?

________

A26. What is the average length of time that prospective residents are on the waiting list for residential care before admission? Please respond in months and/or days.

________DAYS

________MONTHS

Resident Turnover: Admissions/Discharges

The next questions ask about resident admission and discharge.

A27. How many residents moved into this facility over the past 12 months?

Note: Please count couples separately. Do not include as an admission, returning from a “temporary discharge” to a hospital if this facility held the bed for the resident.

________ADMISSIONS IN PAST 12 MONTHS

A30. Over the last 12 months, how many residents moved out of this facility? Do not include deaths. _______

AXX. Over the last 12 months, of those residents who moved elsewhere, how many left because the cost of care (including housing, meals, and services required to meet their needs) exceeded their ability to pay? _____________

IF THIS FACILITY DID NOT HAVE ANY RESIDENTS MOVE OUT IN THE PAST 12 MONTHS SKIP QUESTION A31.

A31. Where did the residents go after they moved out? Please provide the total number in each category?

_____Hospital

_____Nursing home

_____Another residential care facility

_____Private residence

_____Other

A32. In the last 12 months, how many residents died? _______

Staffing (e.g., RNs, LPNs)

The next questions are about facility staff.

A33. During the last 7 days, how many total hours were worked by paid employees for the residential care portion of this facility}? - Please only include employees that provide direct care to residents. - Please include full-time and part-time staff - Please count hours for each staff person only ONCE based on their primary responsibilities	HOURS WORKED
a. Registered Nurses (R.N.)	________
b. Licensed Practical Nurses (L.P.N.) or Licensed Vocational Nurses (L.V.N.)	________
c. Personal care aides /nursing assistants	________
d. Activities director/ activities staff	________
e. Administrator/assistant administrator - direct care time only	________

A38. As of today, how many of the following full time and part time staff are currently employed at this facility? Please count each staff person only ONCE based on their primary responsibilities Please only count staff for the residential care component of this facility.	Current Staff
a. Administrators/Director	________
b. Registered Nurses (R.N.)	________
c. Licensed Practical Nurses (L.P.N.) / Licensed Vocational Nurses (L.V.N.)	________
d. Personal Care Aide	________

A39. During the past 12 months, how many of the following full time and part time staff have resigned or been terminated? Please count each staff person only ONCE based on their primary responsibilities Please only count staff for the residential care component of this facility.	Resigned/ Terminated
a. Administrators/Director	________
b. Registered Nurses (R.N.)	________
c. Licensed Practical Nurses (L.P.N.) / Licensed Vocational Nurses (L.V.N.)	________
d. Personal Care Aide	________

Demographics of residents

The next questions involve resident demographics.

A52_male. What is the total number of male residents living at this facility? ______

A52_female. What is the total number of female residents living at this facility? ______

A52. What percentage of residents are in the following age categories?

a. 17 and under ______%

b. 18-54 ______%

c. 55-64 ______%

d. 65-74 ______%

e. 75-84 ______%

f. Age 85 and over ______%

A53. How many residents are of Hispanic, Latino, or Spanish origin or descent? ______

A54. What percentage of residents are…

______ % White/Caucasian

______ % Black or African American

______ % Asian

______ % Native Hawaiian or other Pacific Islander

______ % American Indian or Alaskan Native

______ % Other

Dementia/Alzheimer’s Unit

A58. Does this residential care facility have a distinct unit/wing/floor that is designated as a Dementia/Alzheimer’s Special Care Unit?

O YES

O NO – DO NOT ANSWER QUESTIONS A59-A60

The next set of questions is about the Dementia or Alzheimer’s unit / floor / wing. When answering these questions, please answer only for that unit.

A59. In the Dementia/Alzheimer’s Special Care unit, please tell me the number of licensed beds _______

A60. What is the current number of residents living in the Dementia/ Alzheimer’s unit? _______

THANK YOU

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