NSRCF - Faciility Questionnaire

Attachment I: Facility Data Collection Questionnaire

Form Approved

OMB No. 0920-0780

Exp. Date __xx/xx/20xx

NOTICE – Public reporting burden of this collection of information is estimated to average 75 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 D-74, Atlanta, GA 30333, ATTN: PRA (0920-0780). Assurance of Confidentiality – All information which would permit identification of an 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 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).
Question number	Facility Survey Question item	Code categories	Facility asked and Skip pattern
F_A1_Intro1	This survey is about the characteristics of residential care facilities and the individuals who live in them. HAND R SHOWCARD Residential care facilities are known by many names, so just to be clear I would like to read a definition that we are using to describe a residential care facility that we have provided on this card. 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 a predominantly adult population. Facilities licensed to exclusively serve the severely mentally ill or the developmentally disabled populations are excluded. IF NEEDED: Facilities that serve only persons with Alzheimer’s disease or other dementias are included.	1 CONTINUE	All facilities
F_A1_Intro2	We are interviewing [SAMPLED FACILITY] because it is currently licensed as a [LICENSURE CATEGORY], which is a type of residential care facility. READ IF MULTI-LEVEL FACILITY [When you answer the questions, please answer only about the residential care component of this facility.]	1 CONTINUE	All facilities
F_A1	This is the first of many questions included in the Pre-interview Worksheet that we mailed to your facility. If you have that form available it would be helpful to reference that now. At this facility, what is the number of licensed, registered, or certified residential care beds? Include both occupied and unoccupied beds.	0…995	All facilities
F_A1_CONFIRM	Can you confirm that your facility has less than four beds?	1 YES 2 NO	F_A1 = 0-3
F_A1_ABORT	I am sorry but your facility is not eligible for this study. Thank you for your time.	1 CONTINUE	F_A1_CONFIRM = 1
F_A2	At this facility, what is the number of residential care rooms or apartments, where residents live? Do not include rooms within apartments.	1-995	All facilities
F_S14	Is this facility part of a chain, group, or multi-facility system? INTERVIEWER, EXPLAIN IF NECESSARY: A chain means more than one facility under common ownership or management. This may include facilities within-state or across multiple states.	1 YES 2 NO	All facilities
F_S15	What is the type of ownership of this facility? Private, for profit Private Nonprofit State, county, or local government INTERVIEWER: CODE PUBLICLY TRADED FACILITIES AS PRIVATE, FOR PROFIT.	1 Private, for profit 2 Private Nonprofit 3 State, county, or local government	All facilities
F_S3a	Does this residential care facility only serve adults with dementia or Alzheimer's disease?	1 YES 2 NO	All facilities
F_A3	What is the current number of residents living at this residential care facility?	1…995	All facilities
NEW1	HAND R SHOWCARD The next questions are about the residents’ living quarters (in the residential care component) at this facility. Which of these types of living quarters does your facility offer to residents? Any others? SELECT ALL THAT APPLY	1 ROOM DESIGNED FOR ONE PERSON 2 ROOM DESIGNED FOR TWO PERSONS 3 ROOM DESIGNED FOR THREE OR MORE PERSONS 4 STUDIO APARTMENT 5 ONE BEDROOM APARTMENT 6 TWO BEDROOM APARTMENT 7 THREE BEDROOM APARTMENT	All facilities
NEW2Intro	I’ll now ask about the rooms in (in the residential care portion of) this facility.	1 CONTINUE	NEW1 = 1-3
NEW2a	How many rooms in this facility are designed for one person?	1…995	NEW1 = 1
NEW2b	How many rooms in this facility are designed for two persons?	1..995	NEW1 = 2
NEW2c	How many rooms in this facility are designed for three or more persons?	1…995	NEW1 = 3
NEW3a	HAND R SHOWCARD (Does this room/do any rooms) contain any of these features? Which ones? SELECT ALL THAT APPLY	1 MICROWAVE 2 COOK TOP OR HOT PLATE 3 OVEN 4 REFRIGERATOR 5 KITCHEN SINK 6 NONE OF THE ABOVE	NEW1 = 1-3
NEW3b	Do all or only some of the rooms have a microwave?	1 All 2 Some	NEW3a=1 and ∑of NEW2a-2c≠1
NEW3b1	How many?	1-(number in NEW2a+NEW2b+ NEW2c)	NEW3b = 2
NEW3c	Do all or only some of the rooms have a cook top or hot plate?	1 All 2 Some	NEW3a=2 and ∑of NEW2a-2c≠1
NEW3c1	How many?	1-(number in NEW2a+NEW2b+ NEW2c)	NEW3c= 2
NEW3d	Do all or only some of the rooms have an oven?	1 All 2 Some	NEW3a=3 and ∑of NEW2a-2c≠1
NEW3d1	How many?	1-(number in NEW2a+NEW2b+ NEW2c)	NEW3d= 2
NEW3e	Do all or only some of the rooms have a refrigerator?	1 All 2 Some	NEW3a=4 and ∑of NEW2a-2c≠1
NEW3e1	How many?	1-(number in NEW2a+NEW2b+ NEW2c)	NEW3e= 2
NEW3f	Do all or only some of the rooms have a kitchen sink?	1 All 2 Some	NEW3a=5 and ∑of NEW2a-2c≠1
NEW3f1	How many?	1-(number in NEW2a+NEW2b+ NEW2c)	NEW3f= 2
F_A7 revised	How many rooms have a door to the hallway that can be locked from the inside- All, some, or none?	1 All 2 Some 3 None	NEW1=1-3
F_A7 revised1	How many?	1-(number in NEW2a+NEW2b+ NEW2c)	NEWF_A7revised = 2
F_A7_within revised	How many rooms have a bathroom located within the room or between rooms- All, some, or none?	1 All 2 Some 3 None	NEW1=1-3
F_A7_within revised1	How many?	1-(number in NEW2a+NEW2b+ NEW2c)	NEWF_A7withinrevised = 2
F_A7a revised	How many rooms … Have a full bathroom including a toilet, sink, and shower or tub located within the room- All, some, or none?	1 All 2 Some 3 None	F_A7_withinrevised = 1-2
F_A7a revised1	How many?	1-(number in NEW2a+NEW2b+ NEW2c)	F_A7a revised = 2
F_A7b revised	How many rooms … Have a half-bath including a sink and toilet located within the room- All, some, or none?	1 All 2 Some 3 None	F_A7a = 2-3
F_A7b Revised1	How many?	1-(number in NEW2a+NEW2b+ NEW2c)	F_A7b revised = 2
NEW4Intro	The next questions are about this facility’s apartments.	1 CONTINUE	NEW1 = 4-7
NEW4a	How many studio apartments are there?	1…995	NEW1 = 4
NEW4b	How many one bedroom apartments are there?	1…995	NEW1 = 5
NEW4c	How many two bedroom apartments are there?	1…995	NEW1 = 6
NEW4d	How many three bedroom apartments are there?	1…995	NEW1 = 7
NEW5a	HAND R SHOWCARD (Does this apartment/do any apartments) contain any of these features? Which ones? SELECT ALL THAT APPLY	1 MICROWAVE 2 COOK TOP OR HOT PLATE 3 OVEN 4 REFRIGERATOR 5 KITCHEN SINK 6 NONE OF THE ABOVE	NEW1 = 4-7
NEW5b	Do all or only some of the apartments have a microwave? NOTE: APARTMENT IS CONSIDERED TO HAVE A MICROWAVE EVEN IN MICROWAVE CANNOT BE PLUGGED IN/HAS BEEN DISABLED FOR THE RESIDENT’S SAFETY.	1 All 2 Some	NEW5a=1 and ∑of NEW4a-4d≠1
NEW5b1	How many?	1-number of apartments in NEW4a + NEW4b + NEW4c + NEW4d	NEW5b = 2
NEW5c	Do all or only some of the apartments have a cook top or hot plate?	1 All 2 Some	NEW5a=2 and ∑of NEW4a-4d≠1
NEW5c1	How many?	1-number of apartments in NEW4a + NEW4b + NEW4c + NEW4d	NEW5c = 2
NEW5d	Do all or only some of the apartments have an oven?	1 All 2 Some	NEW5a=3 and ∑of NEW4a-4d≠1
NEW5d1	How many?	1-number of apartments in NEW4a + NEW4b + NEW4c + NEW4d	NEW5d = 2
NEW5e	Do all or only some of the apartments have a refrigerator?	1 All 2 Some	NEW5a=4 and ∑of NEW4a-4d≠1
NEW5e1	How many?	1-number of apartments in NEW4a + NEW4b + NEW4c + NEW4d	NEW5e = 2
NEW5f	Do all or only some of the apartments have a sink in the kitchen area?	1 All 2 Some	NEW5a=5 and ∑of NEW4a-4d≠1
NEW5f1	How many?	1-number of apartments in NEW4a + NEW4b + NEW4c + NEW4d	NEW5f = 2
F_A7 Revised	How many apartments have a door to the hallway that can be locked from the inside, All, some, or none?	1 All 2 Some 3 None	NEW1=4-7
F_A7 Revised1	How many?	1-number of apartments in NEW4a + NEW4b + NEW4c + NEW4d	F_A7Revised = 2
F_A7_within revised	How many apartments have a bathroom located within the apartment or between apartments, All, some, or none?	1 All 2 Some 3 None	NEW1=4-7
F_A7_within Revised1	How many?	1-number of apartments in NEW4a + NEW4b + NEW4c + NEW4d	F_A7_withinrevised = 2
F_A7a revised	How many apartments have a full bathroom including a toilet, sink, and shower or tub located within the apartment- All, some or none?	1 All 2 Some 3 None	F_A7_withinrevised = 1-2
F_A7a revised1	How many?	1-number of apartments in NEW4a + NEW4b + NEW4c + NEW4d	F_A7a revised = 2
F_A7b	How many apartments have a half-bath including a sink and toilet located within the apartment- All, some, or none?	1 All 2 Some 3 None	F_A7_withinrevised = 1-2
F_A7b1	How many?	1-number of apartments in NEW4a + NEW4b + NEW4c + NEW4d	FA7b = 2
F_A8	Does the facility have a common kitchen area that any resident can use?	1 YES 2 NO	All facilities
F_A9	How many of the [NUMBER] residents live with a spouse or other relative? For example, if there is one couple who lives together, you would report that two residents live with a spouse or relative.	0…995	All facilities
F_A10	READ RESPONSES IF NECESSARY. What is the total number of years this facility has been operating as a residential care facility?	1 LESS THAN 5 YEARS 2 5 TO 9 YEARS 3 10 TO 19 YEARS 4 20 OR MORE YEARS	All facilities
F_A11	Was [SAMPLED FACILITY] purposely built as a residential care facility?	1 YES 2 NO	All facilities
F_A12a	(In the residential care portion of this facility,) how many resident (rooms/apartments) have… smoke detectors? Would you say…? None Some All	1 None 2 Some 3 All	All facilities
F_A12b	(In the residential care portion of this facility,) how many common areas have… smoke detectors? Would you say…? None Some All	1 None 2 Some 3 All	All facilities
F_A12c	(In the residential care portion of this facility,) how many resident (rooms/apartments) have… a sprinkler system? Would you say…? None Some All	1 None 2 Some 3 All	All facilities
F_A12d	(In the residential care portion of this facility,) how many common areas have… a sprinkler system? Would you say…? None Some All	1 None 2 Some 3 All	All facilities
F_A12e	(In the residential care portion of this facility,) how many hallways have supported or grab rails on one or both sides? Would you say…? None Some All	1 None 2 Some 3 All	All facilities
F_A12f	(In the residential care portion of this facility,) how many common areas have widened hallways or doorways that can accommodate wheelchairs? Would you say…? None Some All	1 None 2 Some 3 All	All facilities
F_A12g	(In the residential care portion of this facility,) how many (rooms/apartments) have an emergency call or personal response system? This may include emergency devices worn by residents. Would you say…? None Some All	1 None 2 Some 3 All	All facilities
F_A12h	(In the residential care portion of this facility,) how many (rooms/apartments) are… wheelchair accessible? Would you say…? None Some All	1 None 2 Some 3 All	All facilities
F_A12i	(In the residential care portion of this facility,) how many bathrooms have enough space for a wheelchair to enter, about 3 ft, and turn around, about 5ft x 5ft? Would you say…? None Some All	1 None 2 Some 3 All	All facilities
F_A12j	(In the residential care portion of this facility,) how many bathrooms have grab bars in the shower or tub area? Would you say…? None Some All	1 None 2 Some 3 All	All facilities
F_A15	During the past 90 days, did this residential care facility provide any short-term respite care?	1 YES 2 NO	All facilities
F_A16	Does this facility provide adult day health or adult day care services to non-residents?	1 YES 2 NO	All facilities
F_A17	Does this facility currently serve any persons with developmental disabilities such as mental retardation, autism, or Down syndrome?	1 YES 2 NO	All facilities
F_A18	Does this facility currently serve any persons with severe mental illness such as schizophrenia and psychosis? Please do not include Alzheimer's disease or other dementias.	1 YES 2 NO	All facilities
F_A18a	HAND R SHOWCARD Please look at this card. 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 written 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. This document is different from a Plan of Care or a Resident Agreement. Does this facility develop a formal negotiated risk agreement with any of the residents?	1 YES 2 NO	All facilities
F_A18b	Instead of a formal negotiated risk agreement, does this facility address risky behaviors in some other formal written document?	1 YES 2 NO	F_A18a = 2
F_A19_Intro	The next questions ask about items residents are allowed to bring when they move into this facility.	1 CONTINUE	All facilities
F_A19	What types of personal items or furniture may residents bring? Large furniture such as a couch, bed, or dining room table. Small furniture such as a desk, bookcase, chair, lamp, or small table. Personal items such as pictures, bed linens, or wall decorations. CODE SLL THAT APPLY	1 Large furniture such as a couch, bed, or dining room table. 2 Small furniture such as a desk, bookcase, chair, lamp, or small table. 3 Personal items such as pictures, bed linens, or wall decorations. 4 NONE OF THE ABOVE	All facilities
F_A20	Does the facility provide a common pet such as a cat, dog, or bird?	1 YES 2 NO	All facilities
F_A20a	Are residents ever allowed to have a personal pet such as a cat, dog, or bird that lives at the facility?	1 YES 2 NO	All facilities
F_A21	Is there space at this facility for residents to park their car?	1 YES 2 NO	All facilities
F_A22_Intro	The next questions ask about resident source of payment.	1 CONTINUE	All facilities
F_A22	Is this residential care facility certified or registered to participate in Medicaid?	1 YES 2 NO	All facilities
F_A23	This question was also provided on the Pre-interview Worksheet. 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?	0…995	F_A22 = 1
F_A24	Does this facility currently have anyone who is on a waiting list to be admitted to this facility as soon as a place becomes available?	1 YES 2 NO	All facilities
F_A25	(This question was also provided on the Pre-interview Worksheet.) What is the current number of people waiting to be admitted to this facility as soon as a place becomes available?	1…500	F_A24 = 1
F_A26	(This question was also provided on the Pre-interview Worksheet.) What is the average length of time that prospective residents are waiting to be admitted to this facility? Please respond in months and/or days.	MONTHS DAYS	F_A24 = 1
F_A27_Intro	The next questions ask about resident admission and discharge.	1 CONTINUE	All facilities
F_A27	(This question was also provided on the Pre-interview Worksheet.) How many residents moved into this facility over the past 12 months? Please count each couple as 2 residents. Also, do not include someone returning from a hospital stay if this facility held the bed for the resident. Residents should be counted only once.	0…500	All facilities
F_A30	(This question was also provided on the Pre-interview Worksheet.) Over the last 12 months, how many residents moved out of this facility? Do not include deaths.	0…500	All facilities
F_A30a	(This question was also provided on the Pre-interview Worksheet.) 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?	0…500	F_A30 = 1-500
F_A31_hosp	(This question was also provided on the Pre-interview Worksheet.) Where did the residents go after they moved out? Please provide the total number in each category. Hospital	0…500	F_A30 = 1-500
F_A31_nursing	(Where did the residents go after they moved out?) Please provide the total number in each category. Nursing home	0…500	F_A30 = 1-500
F_A31_otherrcf	(Where did the residents go after they moved out? Please provide the total number in each category.) Other residential care facility	0…500	F_A30 = 1-500
F_A31_residence	(Where did the residents go after they moved out? Please provide the total number in each category.) Private residence	0…500	F_A30 = 1-500
F_A31_other	(Where did the residents go after they moved out? Please provide the total number in each category.) Some other place	0…500	F_A30 = 1-500
F_A32	In the last 12 months, how many residents died?	0…500	All facilities
F_A33_Intro	The next questions are about facility staff. First, we will ask how many total hours were worked in the last 7 days (or the last work week) by paid staff (for the residential care portion of this facility). In your calculations of staff hours, please include all staff that provide direct care to residents, including full-time and part-time employees, and contract, temporary, and agency workers. Direct care refers to time spent meeting the needs of individual residents, such as helping them walk to dinner, helping them dress, or providing them with assistance with medications. Also, please count hours for each staff person only once based on their primary job title.	1 CONTINUE	All facilities
F_A33a	During the last 7 days or last work week, how many total hours were worked by the following paid staff (for the residential care portion of this facility). Registered Nurses or RNs	0..999	All facilities
F_A33b	(During the last 7 days or last work week, how many total hours were worked by the following paid staff (for the residential care portion of this facility).) Licensed Practical Nurses, also called an L.P.N. or Licensed Vocational Nurses also called an LVN.	0..999	All facilities
F_A33c	(During the last 7 days or last work week, how many total hours were worked by the following paid staff (for the residential care portion of this facility).) Personal care aides, including certified nursing assistants, (CNAs) and medication technicians.	0..1999 .	All facilities
F_A33d	(During the last 7 days or last work week, how many total hours were worked by the following paid staff (for the residential care portion of this facility).) Activities director or activities staff	0..999	All facilities
F_A33e	(During the last 7 days or last work week, how many total hours were worked by the following paid staff (for the residential care portion of this facility).) Administrators, directors, assistant administrators or assistant directors - direct care time only (Direct care time by administrators or directors refers to time spent meeting the needs of individual residents, such as helping them walk to dinner, helping them dress, or providing them with medications. It does not include the time spent on the overall management of the facility.)	0..999	All facilities
F_A34	Does this facility use contract workers to provide direct care to residents?	1 YES 2 NO	All facilities
F_A35	During the past 7 days or last work week, did your facility use any volunteers to help your residents or this facility's staff in any way?	1 YES 2 NO	All facilities
F_A36	During the last 7 days or last work week, about how many volunteer workers provided services at the facility at least once? NOTE: A GROUP OF VOLUNTEERS (e.g., CHURCH GROUP) SHOULD BE COUNTED INDIVIDUALLY. FOR EXAMPLE, 10 VOLUNTEERS FROM THE SAME GROUP SHOULD BE COUNTED AS “10” DO NOT INCLUDE FAMILY MEMBERS AS VOLUNTEERS IF THEY PROVIDE INFORMAL CARE TO A FAMILY MEMBER	0..995	F_A35 = 1
F_A36a	What kinds of services do they provide? READ CHOICES CODE ALL THT APPLY	1 General office help 2 Homemaker/Household services 3 Personal care (haircuts, nail care, massage, etc.) 4 Transportation services 5 Visiting with patients 6 Bereavement/family support 7 Religious/spiritual activities 8 Assist residents at Mealtime 9 Shopping 10 Social and recreational activities 11 Exercise 12. Other services	F_A35 = 1
F_A36b	During the last 7 days or last work week, how many of your facility's residents received services from any of your volunteer workers?	0..500	F_A35 = 1
F_A37	During a typical night how many staff are on-duty and awake? Please do not count security guards.	0..500	All facilities
F_A38a	This question was also provided on the Pre-interview Worksheet. These next questions ask how many full-time and part-time persons are currently employed at this facility (for residential care). Please count full-time and part-time employees. Do not include contract, temporary, or agency workers. Please count each employee only once based upon their primary responsibilities. As of today, how many of the following full-time and part-time persons are currently employed at this facility (for residential care). Administrators, Directors, assistant Administrators and assistant Directors?	0..99	All facilities
F_A38b	(As of today, how many of the following full time and part time staff are currently employed at this facility) (for residential care). Registered Nurses or RNs	0..99	All facilities
F_A38c	(As of today, how many of the following full-time and part-time persons are currently employed at this facility) (for residential care). Licensed Practical Nurses also called LPNs or Licensed Vocational Nurses also called LVNs	0..99	All facilities
F_A38d	(As of today, how many of the following full-time and part-time persons are currently employed at this facility) (for residential care). Personal Care Aides, including Certified Nursing Assistants and medication technicians	0..995	All facilities
F_A39a	During the past 12 months, how many of the following full-time and part-time employees have resigned or been terminated (from residential care). Administrators, Directors, assistant Administrators and assistant Directors	0..99	All facilities
F_A39b	(During the past 12 months, how many of the following full-time and part-time employees have resigned or been terminated (from residential care). Registered Nurses or RNs	0..99	All facilities
F_A39c	(During the past 12 months, how many of the following full-time and part-time employees have resigned or been terminated (from residential care). Licensed Practical Nurses also called LPNs or Licensed Vocational Nurses also called LVNs	0..99	All facilities
F_A39d	(During the past 12 months, how many of the following full-time and part-time employees have resigned or been terminated (from residential care). Personal Care Aides and nursing assistants, including CNAs and medication technicians	0..99	All facilities
F_A40a	HAND R SHOWCARD About what percentage of this facility’s employees received a flu shot last flu season?	1 0% 2 1 to 20% 3 21-40 % 4 41-50% 5 51-60% 6 61-80% 7 81-99% 8 100%	All facilities
F_A40b	HAND R SHOWCARD Does this facility do any of the following to encourage employees’ influenza vaccinations? Anything else? SELECT ALL THAT APPLY.	1 VACCINATIONS RECOMMENDED 2 VACCINATIONS OFFERED ON SITE 3 VACCINATIONS OFFERED FOR FREE 4 VACCINATIONS OFFERED AT REDUCED COST 4 STAFF INCENTIVES PROVIDED FOR VACCINATION PROOF OF VACCINATION (OR CONTRAINDICATION) 6 REQUIRED AS A CONDITION OF WORK/ EMPLOYMENT 7 FURLOUGH OR PATIENT RESTRICTION POLICY FOR EMPLOYEES DEVELOPING INFLUENZA-LIKE ILLNESS 8 NONE OF THE ABOVE	A facilities
F_A40c	HAND R SHOWCARD Which vaccination program best describes what is being used in your facility for influenza? HELP SCREEN1	1 FACILITY-WIDE STANDING ORDERS 2 PRE-PRINTED ADMISSION ORDERS 3 ADVANCE PHYSICIAN/ NURSE PRACTITIONER ORDERS FOR ALL OF THEIR RESIDENTS 4 PERSONAL PHYSICIAN ORDER FOR EACH RESIDENT 5 NONE OF THE ABOVE	All facilities
F_A40d	HAND R SHOWCARD Which type of vaccination program best describes what is being used in your facility for pneumonia? Please select one. HELP SCREEN2.	1 FACILITY-WIDE STANDING ORDERS 2 PRE-PRINTED ADMISSION ORDERS 3 ADVANCE PHYSICIAN/ NURSE PRACTITIONER ORDERS FOR ALL OF THEIR RESIDENTS 4 PERSONAL PHYSICIAN ORDER FOR EACH RESIDENT 5 NONE OF THE ABOVE	All faciliteis
F_A40e	Has this facility developed a written plan for management of residents during an influenza pandemic?	1 NO, NOT STARTED 2 YES, IN PROGRESS 3 YES, COMPLETED	All facilities
F_A40	Does this facility provide on-going, in-service training to personal care aides?	1 YES 2 NO	All facilities
F_A41	Prior to providing care to residents, how many hours of formal training are required of personal care aides? READ CHOICES No formal training Less than 75 hours of training 75 hours of training More than 75 hours of training	1 No formal training 2 Less than 75 hours of training 3 75 hours of training 4 More than 75 hours of training	All facilities
F_A43	In addition to helping with activities of daily living, such as dressing and assistance with medications, do personal care aides routinely perform any of the following tasks... READ CHOICES Housekeeping Janitorial services Assistance with food preparation Assistance with recreational activities Resident’s personal laundry Assistance with medications Transportation or escort services for residents	1 Housekeeping 2 Janitorial services 3 Assistance with food preparation 4 Assistance with recreational activities 5 Resident’s personal laundry 6 Transportation or escort services for residents 7 NONE OF THE ABOVE	All facilities
F_A44b	Does this facility offer the following to personal care aides…? Health insurance that includes family coverage	1 YES 2 NO	All facilities
F_A44a	(Does this facility offer the following to personal care aides?) Health insurance for the employee only	1 YES 2 NO	F_A44b = 2
F_A44c	(Does this facility offer the following to personal care aides…?) Life insurance	1 YES 2 NO	All facilities
F_A44e	(Does this facility offer the following to personal care aides…?) A pension, a 401(k), or a 403(b)	1 YES 2 NO	All facilities
F_A44f	(Does this facility offer the following to personal care aides…?) Personal time off, vacation time, or sick leave	1 YES 2 NO	All facilities
F_A45	Does this facility pay for more than half of the employee’s health insurance premium?	1 YES 2 NO	F_A44a or F_A44b = 1
F_A46_Intro	The next questions ask about the types of information maintained by this facility.	1 CONTINUE	All facilities
F_A46	Before or upon admission, does this facility conduct a formal functional assessment of residents using a standardized tool? Functional means physical activities of daily living, such as eating, bathing, and dressing, or cognitive functioning.	1 YES 2 NO	All facilities
F_A47	Does this assessment include a physical assessment, cognitive assessment, or both?	1 PHYSICAL ASSESSMENT 2 COGNITIVE ASSESSMENT 3 BOTH PHYSICAL AND COGNITIVE ASSESSMENT	F_A46 = 1
F_A48	An individual service plan details the personalized services needed by the resident and what will be provided to him or her by the facility. The service plan is usually updated regularly or as the residents’ care needs change. Does this facility develop formal individual service plans?	1 YES 2 NO	All facilities
F_A49A	Other than for accounting or billing purposes, does this facility use Electronic Health Records? This is a computerized version of the resident’s health and personal information used in the management of the resident’s health care.	1 YES 2 NO	All facilities
F_A49B	Other than for accounting or billing purposes, does this facility have a computerized system for its Resident Service Records to keep track of the services provided to each resident? IF NEEDED: Resident service records are the facility’s record of the services being provided to each resident.	1 YES 2 NO	F_A49A=2
F_A50	HAND R SHOWCARD Which of the following computerized capabilities does this facility have? SELECT ALL THAT APPLY	1 RESIDENT DEMOGRAPHICS 2 MEDICAL PROVIDER INFORMATION 3 FUNCTIONAL ASSESSMENTS 4 INDIVIDUAL SERVICE PLANS 5 CLINICAL NOTES, SUCH AS MEDICAL HISTORY AND DAILY PROGRESS NOTES 6 PATIENT PROBLEMS LIST 7 MEDICATION ADMINISTRATION 8 MAINTAINING LISTS OF RESIDENT’S MEDICATIONS 9 MAINTAINING ACTIVE MEDICATION ALLERGY LIST 10 ORDERS FOR PRESCRIPTIONS 11 WARNING OF DRUG INTERACTIONS OR CONTRAINDICATIONS 12 ORDERS FOR TESTS 13 VIEWING LABORATORY/ IMAGING RESULTS 14 REMINDERS FOR GUIDELINE BASED INTERVENTIONS OR SCREENING TESTS 15 DISCHARGE AND TRANSFER SUMMARIES 16 PUBLIC HEALTH REPORTING	F_A49A=1 and/or F_A49B=1
F_A51	Does this facility’s computerized system support electronic health information exchange with any of the following- for example, sending electronic records from this facility to a hospital? SELECT ALL THAT APPLY	1 PHYSICIAN 2 NURSING HOME 3 HOSPITAL 4 PHARMACY 5 LABORATORY/TESTS 6 OTHER HEALTH OR LONG-TERM CARE PROVIDER 7 RESIDENT’S PERSONAL HEALTH RECORD 8 PUBLIC HEALTH REPORTING 9 CORPORATE OFFICE 10 ELECTRONIC INFORMATION IS NOT EXCHANGED	F_A49A=1 and/or F_A49B=1
NEWF_A51A	Does this facility’s staff use any system for Electronic Point of Care Documentation? This includes PDA’s (Personal Digital Assistants), Notebook PCs, or other portable hand held devices.	1 YES 2 NO	All facilities
F_A52a_Intro	The next questions involve resident demographics.	1 CONTINUE	All facilities
F_A53	As of midnight last night, how many residents are of Hispanic, Latino, or Spanish origin or descent?	0..999	All facilities
F_A52_male	As of midnight last night, what is the total number of male residents living at this facility?	0..995	All facilities
F_A52_female	As of midnight last night, what is the total number of female residents living at this facility?	0..995	All facilities
F_A52a_1	As of midnight last night, how many residents are in the following age categories? 17 and under	0..999	All facilities
F_A52a_2	(As of midnight last night, how many residents are in the following age categories?) 18-54	0..999	All facilities
F_A52a_3	(As of midnight last night, how many residents are in the following age categories?) 55-64	0..999	All facilities
F_A52a_4	(As of midnight last night, how many residents are in the following age categories?) 65-74	0..999	All facilities
F_A52a_5	(As of midnight last night, how many residents are in the following age categories?) 75-84	0..999	All facilities
F_A52a_6	(As of midnight last night, how many residents are in the following age categories?) Age 85 and over	0..999	All facilities
F_A54_1	As of midnight last night, how many residents are...? White or Caucasian	0..999	All facilities
F_A54_2	(As of midnight last night, how many residents are...?) Black or African American	0..999	All facilities
F_A54_3	(As of midnight last night, how many residents are...?) Asian	0..999	All facilities
F_A54_4	(As of midnight last night, how many residents are...?) Native Hawaiian or other Pacific Islander	0..999	All facilities
F_A54_5	(As of midnight last night, how many residents are...?) American Indian or Alaska Native	0..999	All facilities
F_A55_Intro	The next questions ask about the cognitive, functional, and health status of residents (in the residential care portion of this facility) .	1 CONTINUE	All facilities
F_A55	During the last 7 days, how many of this facility's current residents had short-term memory problems or seemed disoriented all or most of the time? This includes, for example, residents who are not able to remember things after a short while and residents who have difficulty remembering where their room is, or difficulty recognizing staff names or faces.	0..500	All facilities
F_A56a	HAND R SHOWCARD What percentage of the residents… have had an episode of urinary incontinence during the last 7 days?	1 100% 2 75 - 99% 3 50 - 74% 4 25 - 49% 5 11-24% 6 1-10% 7 0%	All facilities
F_A56b	What percentage of the residents… are confined to a bed or chair because of health problems?	1 100% 2 75 - 99% 3 50 - 74% 4 25 - 49% 5 11-24% 6 1-10% 7 0%	All facilities
F_A56c	What percentage of the residents… use a wheelchair or electric scooter to get around in the facility?	1 100% 2 75 - 99% 3 50 - 74% 4 25 - 49% 5 11-24% 6 1-10% 7 0%	All facilities
F_A56d	What percentage of the residents… currently receive assistance in transferring in and out of bed or a chair?	1 100% 2 75 - 99% 3 50 - 74% 4 25 - 49% 5 11-24% 6 1-10% 7 0%	All facilities
F_A56e	What percentage of the residents… currently receive assistance in eating, like cutting up food?	1 100% 2 75 - 99% 3 50 - 74% 4 25 - 49% 5 11-24% 6 1-10% 7 0%	All facilities
F_A57a	For what percentage of the residents do you… manage, supervise or store medications or provide assistance with self-administration of medications?	1 100% 2 75 - 99% 3 50 - 74% 4 25 - 49% 5 11-24% 6 1-10% 7 0%	All facilities
F_A57b	For what percentage of the residents do yo… provide or arrange assistance with locomotion, that is, helping the resident walk or wheel him/herself around the facility?	1 100% 2 75 - 99% 3 50 - 74% 4 25 - 49% 5 11-24% 6 1-10% 7 0%	All facilities
F_A57c	For what percentage of the residents do you… provide or arrange assistance using the bathroom? This includes reminders to use the toilet, scheduled toileting, getting on or off the toilet, cleaning him/herself, arranging clothing, and changing adult incontinence supplies.	1 100% 2 75 - 99% 3 50 - 74% 4 25 - 49% 5 11-24% 6 1-10% 7 0%	All facilities
F_A58	Does this residential care facility have a distinct unit, wing, or floor that is designated as a Dementia or Alzheimer's Special Care Unit?	1 YES 2 NO	F_S3a ≠ 1
F_A59_Intro	The next set of questions is about the Dementia or Alzheimer's unit, floor, or wing. When answering these questions, please answer only for that unit.	1CONTINUE	F_A58 = 1
F_A59a	In the Dementia or Alzheimer's Special Care unit, please tell me the number of licensed beds.	0..500	F_A58 = 1
F_A60	What is the current number of residents living in the Dementia/Alzheimer's unit?	0..500	F_A58 = 1
F_A61	HAND R SHOWCARD Which of the following features does this (facility/Dementia or Alzheimer's Special Care Unit) have. Please tell me the numbers that apply from this card.	1 LOCKED EXIT DOORS 2 DOORS WITH ALARMS 3 DOORS WITH KEY PADS/ELECTRONIC KEYS 4 CLOSED CIRCUIT TV MONITORING 5 PERSONAL MONITOR ING DEVICES 6 AN ENCLOSED COURTYARD 7 HIGHER STAFF-TO-RESIDENT RATIOS COMPARED TO OTHER UNITS 8 SPECIALLY TRAINED STAFF 9 DEMENTIA-SPECIFIC ACTIVITIES AND PROGRAMMING	F_A58 = 1 or F_S3a = 1
F_A_END	PRESS "1" AND ENTER TO CONTINUE	1 CONTINUE
F_BIntro	The next questions will be about policies and services provided (at FACILITY NAME/ by the residential care portion of this facility).	1 CONTINUE	All facilities
F_B1a	In terms of this facility's admission policy, do you admit a resident who...? Is unable to leave the facility in an emergency without help	1 YES 2 NO 3 NO SPECIFIC POLICY -WE MAKE DECISIONS ON A CASE BY CASE BASIS	All facilities
F_B3a	In terms of this facility's discharge policy, do you discharge a resident who...? Is unable to leave the facility in an emergency without help	1 YES 2 NO 3 NO SPECIFIC POLICY -- WE MAKE DECISIONS ON A CASE BY CASE BASIS	F_B1a = 2 or 3
F_B1b	In terms of this facility's admission policy, do you admit a resident who..?. Has moderate to severe cognitive impairment, that is, the resident does not know who they are	1 YES 2 NO 3 NO SPECIFIC POLICY -- WE MAKE DECISIONS ON A CASE BY CASE BASIS	All facilities
F_B3b	In terms of this facility's discharge policy, do you discharge a resident who...? Has moderate to severe cognitive impairment, that is, the resident does not know who they are	1 YES 2 NO 3 NO SPECIFIC POLICY -- WE MAKE DECISIONS ON A CASE BY CASE BASIS	F_B1b = 2 or 3
F_B1c	In terms of this facility's admission policy, do you admit a resident who...? Exhibits problem behavior such as wandering, temper outbursts, or combative behavior to other residents	1 YES 2 NO 3 NO SPECIFIC POLICY -- WE MAKE DECISIONS ON A CASE BY CASE BASIS	All facilities
F_B3c	In terms of this facility's discharge policy, do you discharge a resident who...? Exhibits problem behavior such as wandering, temper outbursts, or combative behavior to other residents	1 YES 2 NO 3 NO SPECIFIC POLICY -- WE MAKE DECISIONS ON A CASE BY CASE BASIS	F_B1c = 2 or 3
F_B1d	In terms of this facility's admission policy, do you admit a resident who...? Needs skilled nursing care on a regular basis	1 YES 2 NO 3 NO SPECIFIC POLICY -- WE MAKE DECISIONS ON A CASE BY CASE BASIS	All facilities
F_B3d	In terms of this facility's discharge policy, do you discharge a resident who...? Needs skilled nursing care on a regular basis	1 YES 2 NO 3 NO SPECIFIC POLICY -- WE MAKE DECISIONS ON A CASE BY CASE BASIS	F_B1d = 2 or 3
F_B1e	In terms of this facility's admission policy, do you admit a resident who...? Needs daily monitoring for a health condition like assistance taking insulin or monitoring blood sugar	1 YES 2 NO 3 NO SPECIFIC POLICY -- WE MAKE DECISIONS ON A CASE BY CASE BASIS	All facilities
F_B3e	In terms of this facility's discharge policy, do you discharge a resident who...? Needs daily monitoring for a health condition like assistance taking insulin or monitoring blood sugar	1 YES 2 NO 3 NO SPECIFIC POLICY -- WE MAKE DECISIONS ON A CASE BY CASE BASIS	F _B1e = 2 or 3
F_B1f	In terms of this facility's admission policy, do you admit a resident who...? Is regularly incontinent of urine	1 YES 2 NO 3 NO SPECIFIC POLICY -- WE MAKE DECISIONS ON A CASE BY CASE BASIS	All facilities
F_B3f	In terms of this facility's discharge policy, do you discharge a resident who...? Is regularly incontinent of urine	1 YES 2 NO 3 NO SPECIFIC POLICY -- WE MAKE DECISIONS ON A CASE BY CASE BASIS	F B1f = 2 or 3
F_B1g	In terms of this facility's admission policy, do you admit a resident who...? Is regularly incontinent of feces	1 YES 2 NO 3 NO SPECIFIC POLICY -- WE MAKE DECISIONS ON A CASE BY CASE BASIS	All facilities
F_B3g	In terms of this facility's discharge policy, do you discharge a resident who...? Is regularly incontinent of feces	1 YES 2 NO 3 NO SPECIFIC POLICY -- WE MAKE DECISIONS ON A CASE BY CASE BASIS	F_B1g = 2 or 3
F_B1h	In terms of this facility's admission policy, do you admit a resident who...? Is regularly incontinent of both urine and feces	1 YES 2 NO 3 NO SPECIFIC POLICY -- WE MAKE DECISIONS ON A CASE BY CASE BASIS	All facilities
F_B3h	In terms of this facility's discharge policy, do you discharge a resident who...? Is regularly incontinent of both urine and feces	1 YES 2 NO 3 NO SPECIFIC POLICY -- WE MAKE DECISIONS ON A CASE BY CASE BASIS	F_B1h = 2 or 3
F_B1i	In terms of this facility's admission policy, do you admit a resident who...? Needs two people to help them get in and out of bed or needs a Hoyer lift to get in and out of bed	1 YES 2 NO 3 NO SPECIFIC POLICY -- WE MAKE DECISIONS ON A CASE BY CASE BASIS	All facilities
F_B3i	In terms of this facility's discharge policy, do you discharge a resident who...? Needs two people to help them get in and out of bed or needs a Hoyer lift to get in and out of bed	1 YES 2 NO 3 NO SPECIFIC POLICY -- WE MAKE DECISIONS ON A CASE BY CASE BASIS	F_B1i = 2 or 3
F_B1j	In terms of this facility's admission policy, do you admit a resident who...? Has a history of drug or alcohol abuse	1 YES 2 NO 3 NO SPECIFIC POLICY -- WE MAKE DECISIONS ON A CASE BY CASE BASIS	All facilities
F_B3j	In terms of this facility's discharge policy, do you discharge a resident who...? Abuses drugs or alcohol	1 YES 2 NO 3 NO SPECIFIC POLICY -- WE MAKE DECISIONS ON A CASE BY CASE BASIS	F_B1j = 2 or 3
NEWF_B1k	In terms of this facility's admission policy, do you admit a resident who...? Requires end of life care?	1 YES 2 NO 3 NO SPECIFIC POLICY -- WE MAKE DECISIONS ON A CASE BY CASE BASIS	All facilities
NEWF_B3k_	In terms of this facility's discharge policy, do you discharge a resident who...? Requires end of life care?	1 YES 2 NO 3 NO SPECIFIC POLICY -- WE MAKE DECISIONS ON A CASE BY CASE BASIS	NEWF_B1k = 2 or 3
F_B2	Are there any (other) reasons for which you would refuse to admit someone?	1 YES 2 NO	All facilities
F_B2sp	What are these other reasons you would refuse to admit someone?	SPECIFY	F_B2 = 1
F_B4	Are there any (other) reasons for which you would discharge someone?	1 YES 2 NO	All facilities
F_B4sp	What are those (other) reasons you would discharge someone?	SPECIFY	F_B4 = 1
F_B5Intro	Does this facility provide any of the following services to residents...?	1 CONTINUE	All facilities
F_B5a	(Does this facility provide any of the following services to residents...?) Special diets	1 YES 2 NO	All facilities
F_B5a1_1	Is this service provided by paid facility employees, other types of workers, or both?	1 FACILITY EMPLOYEES 2 OTHER TYPES OF WORKERS 3 BOTH	F_B5a = 1
F_B5b	Does this facility provide...? Assistance with activities of daily living	1 YES 2 NO	All facilities
F_B5b1_1	Is this service provided by paid facility employees, other types of workers, or both?	1 FACILITY EMPLOYEES 2 OTHER TYPES OF WORKERS 3 BOTH	F_B5b = 1
F_B5c	Does this facility provide...? Assistance with a bath or shower at least once a week	1 YES 2 NO	All facilities
F_B5c1_1	Is this service provided by paid facility employees, other types of workers, or both?	1 FACILITY EMPLOYEES 2 OTHER TYPES OF WORKERS 3 BOTH	F_B5c = 1
F_B5d	Skilled nursing services are services that must be performed by a registered nurse (RN), or a licensed practical nurse (LPN) and are medical in nature. Does this facility provide...? Skilled nursing services	1 YES 2 NO	All facilities
F_B5d1_1	Is this service provided by paid facility employees, other types of workers, or both?	1 FACILITY EMPLOYEES 2 OTHER TYPES OF WORKERS 3 BOTH	F_B5d = 1
F_B5e	Does this facility provide...? Basic health monitoring, such as blood pressure and weight checks.	1 YES 2 NO	All facilities
F_B5e1_1	Is this service provided by paid facility employees, other types of workers, or both?	1 FACILITY EMPLOYEES 2 OTHER TYPES OF WORKERS 3 BOTH	F_B5e = 1
F_B5f	Does this facility provide...? Social and recreational activities within the facility	1 YES 2 NO	All facilities
F_B5f1_1	Is this service provided by paid facility employees, other types of workers, or both?	1 FACILITY EMPLOYEES 2 OTHER TYPES OF WORKERS 3 BOTH	F_B5f = 1
F_B5g	Does this facility provide...? Social and recreational activities outside the facility	1 YES 2 NO	All facilities
F_B5g1_1	Is this service provided by paid facility employees, other types of workers, or both?	1 FACILITY EMPLOYEES 2 OTHER TYPES OF WORKERS 3 BOTH	F_B5g = 1
F_B5h	Does this facility provide...? Incontinence care	1 YES 2 NO	All facilities
F_B5h1_1	Is this service provided by paid facility employees, other types of workers, or both?	1 FACILITY EMPLOYEES 2 OTHER TYPES OF WORKERS 3 BOTH	F_B5h = 1
F_B5i	Does this facility provide...? Transportation to medical or dental appointments	1 YES 2 NO	All facilities
F_B5i1_1	Is this service provided by paid facility employees, other types of workers, or both?	1 FACILITY EMPLOYEES 2 OTHER TYPES OF WORKERS 3 BOTH	F_B5i = 1
F_B5j	Does this facility provide...? Transportation to stores and elsewhere	1 YES 2 NO	All facilities
F_B5j1_1	Is this service provided by paid facility employees, other types of workers, or both?	1 FACILITY EMPLOYEES 2 OTHER TYPES OF WORKERS 3 BOTH	F_B5j = 1
F_B5k	Does this facility provide...? Personal laundry	1 YES 2 NO	All facilities
F_B5k1_1	Is this service provided by paid facility employees, other types of workers, or both?	1 FACILITY EMPLOYEES 2 OTHER TYPES OF WORKERS 3 BOTH	F_B5k = 1
F_B5l	Does this facility provide...? Linen laundry services	1 YES 2 NO	All facilities
F_B5l1_1	Is this service provided by paid facility employees, other types of workers, or both?	1 FACILITY EMPLOYEES 2 OTHER TYPES OF WORKERS 3 BOTH	F_B5l = 1
F_B5m	Social services counseling is counseling related to obtaining and keeping benefits provided by programs such as Supplemental Security income, Social Security, and Medicaid. Does this facility provide...? Social services counseling	1 YES 2 NO	All facilities
F_B5m1_1	Is this service provided by paid facility employees, other types of workers, or both?	1 FACILITY EMPLOYEES 2 OTHER TYPES OF WORKERS 3 BOTH	F_B5m = 1
F_B5n	Case management is generally a process of assessment, planning, and facilitation of options and services for an individual. Does this facility provide . . .? Case management	1 YES 2 NO	All facilities
F_B5n1_1	Is this service provided by paid facility employees, other types of workers, or both?	1 FACILITY EMPLOYEES 2 OTHER TYPES OF WORKERS 3 BOTH	F_B5n = 1
F_B5o	Does this facility provide...? Occupational therapy	1 YES 2 NO	All facilities
F_B5o1_1	Is this service provided by paid facility employees, other types of workers, or both?	1 FACILITY EMPLOYEES 2 OTHER TYPES OF WORKERS 3 BOTH	F_B5o = 1
F_B5p	Does this facility provide...? Physical therapy	1 YES 2 NO	All facilities
F_B5p1_1	Is this service provided by paid facility employees, other types of workers, or both?	1 FACILITY EMPLOYEES 2 OTHER TYPES OF WORKERS 3 BOTH	F_B5p = 1
F_B5q	Does this facility provide...? Transportation to a sheltered workshop, work training program or supported employment	1 YES 2 NO	All facilities
F_B5q1_1	Is this service provided by paid facility employees, other types of workers, or both?	1 FACILITY EMPLOYEES 2 OTHER TYPES OF WORKERS 3 BOTH	F_B5q = 1
F_B5r	Does this facility provide...? Transportation to an education program	1 YES 2 NO	All facilities
F_B5r1_1	Is this service provided by paid facility employees, other types of workers, or both?	1 FACILITY EMPLOYEES 2 OTHER TYPES OF WORKERS 3 BOTH	F_B5r = 1
F_B5_cable	Does this facility offer...? Cable TV access in resident (rooms/apartments/rooms and apartments).	1 YES 2 NO	All facilities
F_B5_tele	Does this facility offer...? A landline telephone in resident (rooms/apartments/rooms and apartments).	1 YES 2 NO	All facilities
F_B5_int	Does this facility offer...? Internet access in resident (rooms/apartments/rooms and apartments).	1 YES 2 NO	All facilities
F_B5s	Does this facility have public internet access elsewhere in the facility?	1 YES 2 NO	All facilities
F_B5_assist_a	Do any of the residents use...? An amplifier for the telephone. Please do not include a hearing aid.	1 YES 2 NO	All facilities
F_B5_assist_b	A telecommunications device for the deaf, or TDD, is an electronic device for text communication via a telephone line, used when one or more of the parties has hearing or speech difficulties. It is also referred to as a TTY or teletype. Do any of the residents use... TDD, TTY or teletype? Please do not include a hearing aid.	1 YES 2 NO	All facilities
F_B5_assist_c	Do any of the residents use...? Any other types of assistive listening devices. Please do not include a hearing aid.	1 YES 2 NO	All facilities
F_B5_assist_d	Do any of the residents use...? Signaling devices -- that is, devices that can visually alert the hearing impaired person to auditory signals that may not be heard.	1 YES 2 NO	All facilities
F_B5_assist_e	A communication board is another type of device sometimes used by individuals with speech or hearing impairments. They can be plain boards that you erase or have pictures or words on them that the individual points to as a means of communication. Do any of the residents use...? A communication board	1 YES 2 NO	All facilities
F_B5_assist_f	Do any of the residents use...? Other equipment for people with hearing or speech impairments? Please do not include a hearing aid.	1 YES 2 NO	All facilities
F_B7a	HAND R SHOWCARD Do you or other staff assist residents with medications in any of the following ways? Please tell me the numbers that apply from this card.	1 PROVIDING A CENTRAL LOCATION WHERE MEDICATIONS ARE STORED PRIOR TO ADMINISTRATION TO RESIDENTS 2 PROVIDING MEDICATION REMINDERS, FOR EXAMPLE, PROMPTING THAT IT IS TIME TO TAKE MEDICATIONS 3 DELIVERING PRE- PACKAGED UNIT DOSES 4 HELPING WITH, ADMINISTRATION FOR EXAMPLE, OPENING THE BOTTLE AND HANDING THE RESIDENT THE CORRECT DOSE 5 HELPING THE RESIDENT TAKE THE MEDICINE, FOR EXAMPLE,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 10 OTHER TYPE OF ASSISTANCE 11 FACILITY DOES NOT ASSIST RESIDENTS WITH MEDICATIONS	All facilities
F_B7b	HAND R SHOWCARD Who passes or hands the residents their prescription medications? Passing medications includes the delivery of pre-packaged doses or opening the bottle and handing the resident the correct dose. Please tell me the numbers that apply from this card.	1 RN 2 LPN 3 CERTIFIED MEDICATION AIDE, MEDICATION SUPERVISOR, OR MEDICATION TECHNICIAN 4 PERSONAL CARE AIDE 5 OWNER, DIRECTOR, ASSISTANT DIRECTOR, OR MANAGER 6 OTHER	F_B7a = 3 or 4
F_B8	Who administers prescription medications to the residents? Administering medications includes placing the medication in residents' mouths and handing them glasses of water, giving injections, giving IV medications, or applying prescription topical ointments and creams. Please tell me the numbers that apply from this card.	1 RN 2 LPN 3 CERTIFIED MEDICATION AIDE, MEDICATION SUPERVISOR, OR MEDICATION TECHNICIAN 4 PERSONAL CARE AIDE 5 OWNER, DIRECTOR, ASSISTANT DIRECTOR, OR MANAGER 6 OTHER	F_B7a = 5, 7, 8, or 9
F_B8_lic	(Is this person a licensed nurse, certified medication aide, medication supervisor, or medication technician/Are each of these individuals licensed nurses,certified medication aides, medication supervisor, or medication technician)?	1 YES 2 NO	(F_B8 is not only 1, not only 2, and not only 1 and 2) AND (F_B7a = any selection of 5, 7, 8 or 9.)
F_B9	Does the facility have a pharmacist or doctor, either on staff or through a contract with an outside service provider, review the medications that residents receive for appropriateness?	1 YES 2 NO	All facilities
F_B10	Does this facility ever use physical restraints such as lap buddies, posey restraint, bed rails, or Gerry chairs?	1 YES 2 NO	All facilities
F_B11	Do facility staff regularly give drugs to any resident to control behavior or to reduce agitation? This includes drugs prescribed by a physician or other medical provider.	1 YES 2 NO	All facilities
F_B12Intro	The next series of questions are about charges to the resident.	1 CONTINUE	All facilities
F_B12a	How is the base rate structured? Does this facility offer a flat base rate or is there a rate that varies by disability or services received? Do not include variations in charges by room type or size.	1 FLAT BASE RATE 2 BASE RATE VARIES BY DISABILITY	All facilities
F_B12b	Can the residents obtain additional services, beyond the base rate, on a fee-for-service basis?	1 YES 2 NO	All facilities
F_B13	Is a security deposit required?	1 YES 2 NO	All facilities
F_B14	Does this facility charge an entrance fee prior to moving in?	1 YES 2 NO	All facilities
F_B15Intro	The next questions are about the average monthly base rate for (the room/the apartment/both the room and apartment) rent and the services. IF NEEDED: If two people are living in the same room and are related, please compute the average as if only one person lived in the room.	1 CONTINUE	All facilities
F_B15a1	What is the average monthly base rate for a single individual living in a studio apartment (for a regular, non-Alzheimer’s unit)?	0..9995	NEW1=4 & F_S3a = 2
F_B15a2	What is the average monthly base rate for a single individual living in a studio apartment for an Alzheimer’s unit.	0..9995	NEW1=4 & F_S3A or F_A58 = 1
F_B15b1	What is the average monthly base rate for a single individual living in a 1-bedroom apartment (for a regular, non-Alzheimer’s unit)?	0..9995	NEW1=5 & F_S3a = 2
F_B15b2	What is the average monthly base rate for a single individual living in a 1-bedroom apartment for an Alzheimer’s unit.?	0..9995	NEW1=5 & F_S3A or F_A58 = 1
F_B15c1	What is the average monthly base rate for a single individual living in a 2-bedroom apartment (for a regular, non-Alzheimer’s unit)?	0..9995	NEW1=6 & F_S3a = 2
F_B15c2	What is the average monthly base rate for a single individual living in a 2-bedroom apartment for an Alzheimer’s unit?	0..9995	NEW1=6 & F_S3A or F_A58 = 1
NEW QUESTION	What is the average monthly base rate for a single individual living in a 3-bedroom apartment (for a regular, non-Alzheimer’s unit)?	0..9995	NEW1=7 & F_S3a = 2
NEW QUESTION	What is the average monthly base rate for a single individual living in a 3-bedroom apartment for an Alzheimer’s unit?	0..9995	NEW1=7 & F_S3A or F_A58 = 1
F_B15d1	What is the average monthly base rate for a single individual living in a room designed for one person(for a regular, non-Alzheimer’s unit)?	0..9995	NEW1=1& F_S3a = 2
F_B15d2	What is the average monthly base rate for a single individual living in a room designed for one person for an Alzheimer’s unit?	0..9995	NEW=1 & F_S3A or F_A58 = 1
F_B15e1	What is the average monthly base rate for a single individual living in a room dssigned for two persons (for a regular, non-Alzheimer’s unit)?	0..9995	NEW1=2& F_S3a = 2
F_B15e2	What is the average monthly base rate for a single individual living in a room designed for two persons for an Alzheimer’s unit?	0..9995	NEW=2 & F_S3A or F_A58 = 1
F_B15f1	What is the average monthly base rate for a single individual living in a room for three or more residents (for a regular, non-Alzheimer’s unit)?	0..9995	NEW1=3 & F_S3a = 2
F_B15f2	What is the average monthly base rate for a single individual living in a room for three or more residents for an Alzheimer’s unit?	0..9995	NEW=3 & F_S3A or F_A58 = 1
F_B16Intro	For the next questions, please tell me if the following services provided by this facility are included in the base rate or provided at an extra charge.	1 CONTINUE	All facilities
F_B16b	Is assistance with activities of daily living included in the base rate or provided at an extra charge? CODE ALL THAT APPLY	1INCLUDED IN BASE RATE 2 PROVIDED AT EXTRA CHARGE	F_B5b=1
F_B16c	Is assistance with a bath or shower at least once a week included in the base rate or provided at an extra charge? CODE ALL THAT APPLY	1INCLUDED IN BASE RATE 2 PROVIDED AT EXTRA CHARGE	FB5c = 1
F_B16d	Are skilled nursing services included in the base rate or provided at an extra charge? CODE ALL THAT APPLY	1INCLUDED IN BASE RATE 2 PROVIDED AT EXTRA CHARGE	FB5d = 1
F_B16h	Is incontinence care included in the base rate or provided at an extra charge? CODE ALL THAT APPLY	1INCLUDED IN BASE RATE 2 PROVIDED AT EXTRA CHARGE	F_B5h = 1
F_B16i	Is transportation to medical or dental appointments included in the base rate or provided at an extra charge? CODE ALL THAT APPLY	1INCLUDED IN BASE RATE 2 PROVIDED AT EXTRA CHARGE	F_B5i = 1
F_B16o	Is occupational therapy included in the base rate or provided at an extra charge? CODE ALL THAT APPLY	1INCLUDED IN BASE RATE 2 PROVIDED AT EXTRA CHARGE	F_B5o = 1
F_B16p	Is physical therapy included in the base rate or provided at an extra charge? CODE ALL THAT APPLY	1INCLUDED IN BASE RATE 2 PROVIDED AT EXTRA CHARGE	F_B5p = 1
F_B17	Are privately hired nurses, aides, or private duty nurses permitted to provide services to residents?	1 YES 2 NO	All facilities
F_B18	How many meals are included in the base rate?	1 ONE MEAL PER DAY 2 TWO MEALS PER DAY 3 THREE MEALS PER DAY 4 NO MEALS PROVIDED	All facilities
F_B19	Are residents required to eat during a scheduled meal time?	1 YES 2 NO	All facilities
F_B20	Are residents required to eat meals in a specific location like a dining room?	1 YES 2 NO	All facilities
F_B21	Does this facility have residents who speak limited or no English?	1 YES 2 NO	All facilities
F_B22	How do staff communicate with these residents? CODE ALL THAT APPLY	1 CAREGIVERS ALSO SPEAK THEIR LANGUAGE 2 RELY ON FAMILY MEMBERS TO TRANSLATE 3 USE A TRANSLATION SERVICE 4 NON-VERBAL CUEING/ HAND SIGNS/GESTURES 5 OTHER METHOD	F_B21 = 1
F_B_END		1 CONTINUE
F_C1_Intro	INTERVIEWER: ARE YOU SPEAKING WITH THE...	1 HIGHEST RANKING ADMINISTRATOR OR DIRECTOR OF THE RESIDENTIAL CARE PORTION OF THIS FACILITY 2 SOMEONE OTHER THAN THE HIGHEST RANKING ADMINISTRATOR OR DIRECTOR OF THE RESIDENTIAL CARE PORTION OF THIS FACILITY	All facilities
F_C1	How long have you worked at this facility as the administrator or director? Please include the total time worked even if you have left the facility and then returned.	YEARS MONTHS	F_C1_Intro = 1
F_C2	How long, in total, have you worked at this and other residential care facilities or nursing homes in an administrative position?	YEARS MONTHS	F_C1_Intro = 1
F_C3	Do you have a certificate or license related to managing facilities for older people?	1 YES 2 NO	All facilities
F_C4	What position(s) do you hold at this facility? Owner or Operator Administrator, Manager, or Director Supervisor-in-charge Wellness Director Director of Nursing Other CODE ALL THAT APPLY	1 Owner or Operator 2 Administrator, Manager, or Director 3 Supervisor-in-charge 4 Wellness Director 5 Director of Nursing 6 Other	F_C1_Intro = 2
F_C4_OTH	What other position do you hold at this facility?	SPECIFY	F_C3 = 6
F_C5	How long has the director or administrator worked at this facility as the administrator? Please include the cumulative time worked even if they have left the facility and then returned. FOR THIS AND THE REMAINING QUESTIONS, IF FACILITY HAS MORE THAN 1 DIRECTOR IN THE RESIDENTIAL CARE PORTION OF THE FACILITY, SELECT THE DIRECTOR WHO HAS WORKED AT THE FACILITY THE LONGEST.	SPECIFY	F_C1_Intro = 2
F_C6	Does the director or administrator have a certificate or license related to managing facilities for older people?	1 YES 2 NO	F_C1_Intro = 2
F_C_END	PRESS "1" AND ENTER TO CONTINUE.	1 CONTINUE
F_D1_Intro	Please answer the last few questions about the highest ranking administrator or director of this residential care facility.	1 CONTINUE	All facilities
F_D1	What is the gender of the director or administrator?	1 MALE 2 FEMALE	All facilities
F_D2	HAND R SHOWCARD Please look at this card and tell me which range includes (your/the administrator or director) age. 18 - 29 30 - 39 40 - 49 50 - 59 60 - 69 70 or older	1 18 - 29 2 30 - 39 3 40 - 49 4 50 - 59 5 60 - 69 6 70 or older	All facilities
F_D3	Is the administrator or director of Hispanic, Latino, or Spanish origin or descent?	1 YES 2 NO	All facilities
F_D4	HAND R SHOWCARD Which of these groups best describes the administrator or director? You may select more than one category.	1 WHITE OR CAUCASIAN 2 BLACK OR AFRICAN AMERICAN 3 ASIAN 4 NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER 5 AMERICAN INDIAN OR ALASKA NATIVE	All facilities
F_D5	What is the highest grade or level of education the administrator or director completed? Less than high school High school graduate or GED Vocational, trade school, or technical school graduate Some college College graduate Post graduate	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	All facilities
NEWF_D6a	In the near future you may receive a telephone call from my supervisor at RTI International. This call is designed to verify the quality of my work and will only take a few minutes of your time.	1 CONTINUE	All facilities
F_D6	Thank you, those are all the questions for this Facility section of the interview.	1 CONTINUE

1 Immunization Program Definitions

1. Facility wide standing orders: An institutional policy authorizes appropriate nursing or other non-physician staff to immunize residents by institution- or medical director-approved protocol without the need for a written or verbal order from the resident’s personal physician before administering the vaccine.

2. Pre-printed admission orders: Each resident’s personal physician signs the facility’s preprinted admission order before administering the vaccine to the resident. The preprinted order may address the resident’s current vaccination needs as well as those in the future.

3. Advance physician/nurse practitioner orders for all of their patients: Issued by an attending physician and authorizes immunization of ALL of the physician’s patients who are residents of the facility.

4. Personal physician order for each resident: Each resident’s personal physician is responsible for signing an individual order for every vaccine before it is administered to the resident.

2 SEE Footnote 1.

38