RCC Questionnaire Items

Attachment B: RCC Questionnaire Items Form Approved OMB No. XXXX-XXXX Exp. Date __xx/xx/20xx 2012 National Study of Long-Term Care Providers (NSLTCP)

Dear Administrator/Executive Director,

The Centers for Disease Control and Prevention’s National Center for Health Statistics is conducting the National Study of Long-Term Care Providers (NSLTCP), a new national survey to be conducted every two years on a sample of about 11,000 residential care communities. RTI International has been contracted to carry out the data collection.

Please answer all of the questions in reference to this residential care community. If your residential care community is part of a multi-facility campus, please only answer for the residential care portion of the campus. The accuracy of your answers is important to this voluntary survey.

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 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-###-#### to speak to a member of the NSLTCP project team.

Thank you for taking the time to complete this questionnaire.

Sincerely,

Angela M. Greene

Project Director, RTI International

NOTICE – Public reporting burden of this collection of information is estimated to average 30 minutes per response. 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 (XXXX-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 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).

INSTRUCTIONS:

• Please clearly mark your responses in the boxes provided Examples  or 

• Written answers should be printed in the space provided Example

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1. Study Eligibility

The answers to the questions below determine if THIS residential care community is eligible to participate in the 2012 National Study of Long-Term Care Providers.

FIRST, please answer the following question(s). Then follow the instructions provided next to the answer box(es) you mark.

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

Yes (continue)

No (skip to BOX A)

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

Yes (continue)

No (skip to BOX A)

5a. 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)

5b. 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)

6. Does this residential care community provide or arrange for a personal care aide, RN, 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 arise? Onsite 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)

7a. Does this residential care community exclusively serve adults with mental retardation or a developmental disability, such as Down syndrome or autism?

Yes (skip to BOX A)

No (continue)

7b. 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- This residential care community exclusively serves both persons with mental retardation/a developmental disability and severe mental illness. (skip to BOX A)

No- (Go now to next page- QUESTION 1)

YOUR COMMUNITY IS ELIGIBLE TO PARTICIPATE IN THIS STUDY.

BOX A

Thank you very much for answering these questions. Unfortunately, this residential care community does not qualify for our study which is focused on 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 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.

Thank you.

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 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.

Please refer to community records or request assistance from other staff if you need help answering any question.

2. Background Information

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

1. Is this residential care community part of a continuing care retirement community, that 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?

Yes

No

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

Private, nonprofit

Private, for profit

Publically traded or limited liability company (LLC)

Government – federal, state, county or local government

3. 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

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

No, not part of another organization

Yes

4a. For each item below, please indicate whether or not this type of organization owns this residential care community.

Yes No

1. Hospital  

2. Nursing Home or Skilled Nursing Facility  

3. Home Health Agency  

4. Hospice Agency  

5. Adult day services center  

6. Other  

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

______ Year(s)

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

________ Beds

7. 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

8. 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

3. Services Offered at this Residential Care Community

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

9a. Does this residential care community only serve adults with dementia or Alzheimer’s disease?

Yes

No (skip to question 10)

9b. Does this residential care community have specially trained staff for residents with dementia or Alzheimer’s disease?

Yes (skip to question 13)

No (skip to question 13)

10. 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

No (skip to question 13)

11. How many licensed beds are in the dementia or Alzheimer’s special care unit?

______ Beds

12. Does this Dementia or Alzheimer's Special Care unit have . . .

MARK YES OR NO IN EACH ROW

Yes No

1. Higher staff-to resident ratios compared to other units?

   

2. Specially trained staff for residents with dementia or

Alzheimer’s disease?

13. For each service listed below, please indicate whether or not this service is provided directly or through arrangement. Providing services through arrangement excludes referring residents to service providers.

Type of service	Does this residential care community provide or arrange for this service for its residents?	Is this service provided directly by residential care community employees, provided by others through arrangement, or both?
a. Routine and emergency dental services by a licensed dentist	Yes No	Provided directly by residential care community employees Provided by others through arrangement Provided by residential care community employees and by others through arrangement
b. Hospice services	Yes No	Provided directly by residential care community employees Provided by others through arrangement Provided by residential care community employees and by others through arrangement
c. Social work services Social work services are 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.	Yes No	Provided directly by residential care community employees Provided by others through arrangement Provided by residential care community employees and by others through arrangement

d. Any case management services Case management is generally a process of assessment, planning, and facilitation of options and services for an individual.	Yes No	Provided directly by residential care community employees Provided by others through arrangement Provided by residential care community employees and by others through arrangement
e. Mental health services Mental health services are services that target residents' mental, emotional, psychological, or psychiatric well-being and include diagnosing, describing, evaluating, and treating mental conditions.	Yes No	Provided directly by residential care community employees Provided by others through arrangement Provided by residential care community employees and by others through arrangement
f. Any therapeutic services- physical, occupational, or speech	Yes No	Provided directly by residential care community employees Provided by others through arrangement Provided by residential care community employees and by others through arrangement
g. Pharmacy services- including filling of and delivery of prescriptions	Yes No	Provided directly by residential care community employees Provided by others through arrangement Provided by residential care community employees and by others through arrangement
h. Podiatry services	Yes No	Provided directly by residential care community employees Provided by others through arrangement Provided by residential care community employees and by others through arrangement
i. Skilled nursing services 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.	Yes No	Provided directly by residential care community employees Provided by others through arrangement Provided by residential care community employees and by others through arrangement

j. Transportation services for medical or dental appointments	Yes No	Provided directly by residential care community employees Provided by others through arrangement Provided by residential care community employees and by others through arrangement
k. Transportation services for social and recreational activities, or shopping	Yes No	Provided directly by residential care community employees Provided by others through arrangement Provided by residential care community employees and by others through arrangement

14. Of the residents currently living in this residential care community, for about how many do you manage, supervise, or store medications, administer medications, or provide assistance with self-administration of medications?

____ Number of residents (or) None

15. As a part of admission process, does this community screen residents for depression with a standardized tool such as the Geriatric Depression Scale, Beck Depression Inventory, or Center for Epidemiological Studies-Depression screen?

Yes

No

16. 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 below, please indicate whether or not this residential care community offers any of these to residents?

Yes No

a. Alzheimer’s disease and other dementias  

d. Depression  

e. Diabetes  

f. Cardiovascular disease  

(e.g., heart disease, high blood pressure, stroke)

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

Yes

No

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

Yes No

b. What personal care services are received by the resident?

c. How the resident’s room is decorated?

19. Does this residential care community give residents choices in each of the following ways?

Yes No

a. Meal times?

c. Meal types/menus?

4. Staff Profile

Please consult records as needed to answer questions.

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

The next questions are about staff that currently works at this residential care community.

This includes:

• both full-time and part-time residential care community employees, and

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

An individual is considered a community employee if the community is required to issue a Form W-2 on their behalf

20. How many of the following staff currently work at this residential care community?

Current Residential Care Community Staff If you do not have any staff for a specific category, enter “0” under number of full time / part time staff.		Number of Full Time Staff	Number of Part Time Staff		Number of FTE (Full-time equivalent) staff
a. Registered Nurses (RN)	Community employee	____	____	(or)	____
	Contract staff	____	____	(or)	____
b. Licensed Practical Nurses (LPN) / Licensed Vocational Nurses (LVN)	Community employee	____	____	(or)	____
	Contract staff	____	____	(or)	____
e. Social Workers Licensed social workers or persons with a bachelor’s or master’s degree in social work	Community employee	____	____	(or)	____
	Contract staff	____	____	(or)	____
i. Certified nursing assistants, nursing assistants, home health aides, home care aides, personal care assistants, and medication technicians or medication aides. * Note: Exclude employees/staff that were included in previous rows.	Community employee	____	____	(or)	____
	Contract staff	____	____	(or)	____

ADD: ON an average shift, how many activities director or activity staff are on site providing services? Include community employees and contract staff.

__________ Number of activities director or activities staff

5. Resident Profile

Please consult records as needed to answer questions.

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

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

________ Residents

22. Of the residents currently living in this residential care community, how many are…
22a. 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. Total should be the same as the total number of residents currently living in this residential care community. ___Hispanic or Latino, of any race ___American Indian or Alaska Native, not Hispanic or Latino ___Asian, not Hispanic or Latino ___Black, not Hispanic or Latino ___Native Hawaiian or Other Pacific Islander, not Hispanic or Latino ___White, not Hispanic or Latino ___Two or more races, not Hispanic or Latino ___Some other category reported in this residential care community’s system ___Not reported (race and ethnicity unknown) ____ TOTAL	22b. Gender distribution _____ Male ___­­__ Female _______ TOTAL	22c. Age distribution _____ 17 or less _____ 18 – 44 years _____ 45 - 54 years _____ 55 - 64 years _____ 65 - 74 years _____ 75 - 84 years _____ 85 years and older _____ TOTAL
NOTE: Please make sure that the total number of residents for each of the 3 columns is the same as the number provided in question 21.

23a. Of the residents currently living in this residential care community, 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 25)

23b. Of the residents who were discharged from an overnight hospital stay in the last 90 days, 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

24. Of the residents currently living in this residential care community, how many were treated in a hospital emergency department in the last 90 days?

___ Number of residents (or) None

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

________ Residents

Now please think about the last 12 months.

25. In the last 12 months, how many residents living in this residential care community died?

____ Number of residents (or) None

26. In the last 12 months, how many residents moved out of this residential care community? Include all departures, regardless of reason, but exclude deaths. Also do not include residents for whom the community is currently holding a bed for the resident and respite care residents.

_____ Number of residents (continue)

None (skip to question 30)

27. Where did these residents go immediately after they moved out?

Number of Residents

1. Another assisted living or similar residential care community

(e.g. adult care or personal care residence) _____

2. Hospital _____

3. Nursing home _____

4. Private residence _____

5. Some other place _____

TOTAL _____

NOTE: Total should be the same as provided in question 27.

28. In 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?

____ Number of residents left due to cost of care (or) None

29. In the last 12 months, how many residents moved into this residential care community?

Count all residents who moved in- including persons who later died and residents who no longer live here, regardless of the reason.

____ Number of residents (or) None

These next questions ask 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.

30. Of the residents currently living in this residential care community, about how many need any assistance…

Number of Residents

1. transferring in and out of bed? ______ (or) None

   

2. transferring in and out of a chair? ______ (or) None

   

3. with eating, like cutting up food? ______ (or) None

   

4. with dressing? ______ (or) None

   

5. with bathing or showering? ______ (or) None

6. in using the bathroom (toileting)? ______ (or) None

7. with locomotion or walking? This includes using a cane,

walker, or wheelchair and/or help from another person. _____ (or) None

31. 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

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 dementia ____ (or) None

b. Developmental disability, such as mental ____ (or) None

retardation, autism, or Down Syndrome

c. Severe mental illness, such as schizophrenia ____ (or) None

and psychosis

d. Depression ____ (or) None

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

Yes (continue)

No (skip to question 36)

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

____ Number of residents (or) None

6. Record Keeping

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

34. Other than for accounting or billing purposes, does this residential care community 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.

Yes

No

35. 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 this community has the computerized capability to collect or track it.

	Column 1 Does this community collect/track this information?		IF YES IN COLUMN 1	Column 2 Does this community have the computerized capability to collect/track this information?
a. Contact information for the resident’s medical providers	[ ] No	[ ] Yes		[ ] No	[ ] Yes
b. Resident demographics	[ ] No	[ ] Yes		[ ] No	[ ] Yes
c. Functional assessments	[ ] No	[ ] Yes		[ ] No	[ ] Yes
d. Individual service plans	[ ] No	[ ] Yes		[ ] No	[ ] Yes
e. Resident service records (a record of the services being provided to each resident)	[ ] No	[ ] Yes		[ ] No	[ ] Yes
f. Clinical notes, such as medical history and daily progress notes	[ ] No	[ ] Yes		[ ] No	[ ] Yes
g. Resident problem list (medical and behavioral concerns)	[ ] No	[ ] Yes		[ ] No	[ ] Yes
h. Advance directives	[ ] No	[ ] Yes		[ ] No	[ ] Yes
i. Automatic reminders for updating records, scheduling screening tests or guidelines based interventions	[ ] No	[ ] Yes		[ ] No	[ ] Yes
j. Lists of medications	[ ] No	[ ] Yes		[ ] No	[ ] Yes
k. Medication administration records	[ ] No	[ ] Yes		[ ] No	[ ] Yes
l. Active medication allergy lists	[ ] No	[ ] Yes		[ ] No	[ ] Yes
m. Warning of drug interactions or contraindications	[ ] No	[ ] Yes		[ ] No	[ ] Yes
n. Discharge and transfer summaries	[ ] No	[ ] Yes		[ ] No	[ ] Yes
o. Outside health care visits: including emergency room visits and overnight hospital admissions	[ ] No	[ ] Yes		[ ] No	[ ] Yes
p. Orders for prescriptions	[ ] No	[ ] Yes		[ ] No	[ ] Yes
q. orders for tests	[ ] No	[ ] Yes		[ ] No	[ ] Yes
r. Viewing laboratory / imaging results (seeing and reading test results)	[ ] No	[ ] Yes		[ ] No	[ ] Yes
s. Public health reporting	[ ] No	[ ] Yes		[ ] No	[ ] Yes

36. For each item below, please indicate whether or not this residential care community’s computerized system support electronic health information exchange.

Yes No

1. Physician  

2. Pharmacy  

7. Contact Information

We would like to reach you if we have questions about your answers. Please provide your name, telephone number, and job title. Your contact information will be kept confidential and will not be shared with anyone.

Your name: _______________________________________

Your work telephone number: (_ _ _) _ _ _ - _ _ _ _

Your job title: ______________________________________

Thank you for participating in the NSLTCP. Please return your completed survey in the postage-paid self-addressed envelope provided to:

NSLTCP

RTI International

Suite 100 Imperial Court Business Park

1000 Parliament Court

Durham, NC 27703

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