Form 0920-0943 RCC/ADSC Sampling and Services User Questionnaire

Attachment C-3 Sampling and Services User Questionnaire

Form Approved

OMB No.0920-0729

Assurance of Confidentiality - We take your privacy very seriously. All information that relates to or describes identifiable characteristics of individuals, a practice, or an establishment will be used only for statistical purposes. NCHS staff, contractors, and agents will not disclose or release responses in identifiable form without the consent of the individual or establishment in accordance with section 308(d) of the Public Health Service Act (42 U.S.C. 242m(d)) and the Confidential Information Protection and Statistical Efficiency Act of 2002 (CIPSEA, Title 5 of Public Law 107-347). In accordance with CIPSEA, every NCHS employee, contractor, and agent has taken an oath and is subject to a jail term of up to five years, a fine of up to $250,000, or both if he or she willfully discloses ANY identifiable information about you. In addition, NCHS complies with the Federal Cybersecurity Enhancement Act of 2015 (6 U.S.C. §§ 151 & 151 note). This law requires the federal government to protect federal computer networks by using computer security programs to identify cybersecurity risks like hacking, internet attacks, and other security weaknesses. If information sent through government networks triggers a cyber-threat indicator, the information may be intercepted and reviewed for cyber threats by computer network experts working for, or on behalf of, the government.

Public reporting burden of this collection of information is estimated to average 30 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information 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 Information Collection review Office, 1600 Clifton Road NE, MS D-74, Atlanta, GA 30333. ATTN: PRA (0920-0943).

Exp. Date xx/xx/20xx

Were you able to prepare a list of current [residents/participants] as of midnight yesterday?

IF YES: Using the list that you have prepared, I will talk you through a few steps to determine which two [residents/participants] currently [living/enrolled] at this [residential care community/adult day services center] to select. PROCEED TO SAMPLING INSTRUCTIONS.

IF NO: I can stay on the line now while you print or write a list of your current [residents/participants] [living/enrolled] at this [residential care community/adult day services center] as of midnight yesterday. IF ABLE TO DRAFT LIST WHILE ON THE PHONE PROCEED TO SAMPLING INSTRUCTIONS. IF NEEDS TIME TO DRAFT LIST: Is this a good time of day to call back or is there a better time to reach you? Thank you very much for your time. I will call you back. END CALL

SAMPLING INSTRUCTIONS

1. Starting at the top of the list, number each [resident/participant] and please let me know when you are done.

2. WHEN RESPONDENT IS DONE NUMBERING: How many residents/participants are on the list?

3. BASED ON THE NUMBER OF RESIDENTS/PARTICIPANTS REPORTED, CATI WILL GENERATE A LIST OF THOSE NUMBERS IN RANDOM ORDER USING THE RANDOM FUNCTION. PROVIDE THE 2 NUMBERS THAT ARE AT THE TOP OF THE LIST YOU RANDOMLY GENERATED. Please circle the two [residents/participants] that correspond with [number 1] and [number 2]. Our system randomly picked these two numbers.

4. Please record the first and last initials of the two [residents/participants] that you circled. What are the initials you recorded?

5. I will ask you questions about these two [residents/participants] that we have just selected using only their initials. You may need to access their records to answer some of the questions. OFFER TO WAIT WHILE R RETRIEVES RECORDS.

COMPLETE QUESTIONNAIRE FOR EACH RESIDENT/PARTICIPANT SELECTED

Services User Questionnaire Items Notes: 1) Brackets [ ] or { } indicate fills to be programmed into CATI, based on sector (ADSC or RCC) or a respondent's response to a previous item. 2) "Ask if only" column refers to skips to be programmed into CATI based on a respondent's response to a previous item. 3) Text in CAPITAL letters is not read to respondent.
Item wording Notes: 1) Brackets [ ] or { } indicate fills to be programmed into CATI, based on sector (ADSC or RCC) or a respondent's response to a previous item. 2) "Ask if only" column refers to skips to be programmed into CATI based on a respondent's response to a previous item. 3) Text in CAPITAL letters is not read to respondent.	ADSC	RCC	ASK ONLY IF…
	Item # on questionnaire (If cell blank, not on questionnaire)		If cell blank, ask for all cases
Introduction
In order to obtain national level data about the [residents/participants] of [residential care communities/adult day services centers], we are collecting information about a sample of current [residents/participants]. I will be asking questions about the background, health status, and charges for each of the two people sampled. The information you provide will be held in strict confidence and will be used only by persons involved in the survey and only for the purpose of the survey. The interview for each selected [resident/participant] should take on average about 10 minutes to complete. Throughout this interview, [community/center] refers to the [residential care community/adult day services center]. COMPLETE SAMPLING MODULE.	1	1
Now I am going to ask questions about the following [resident/participant] – [READ SAMPLED PERSON'S INITIALS].	2	2
We ask that you have [SAMPLED PERSON'S INITIALS]'s file to refer to as we talk. Do you have the records for [SAMPLED PERSON'S INITIALS]? IF NO: If you have not retrieved [SAMPLED PERSON'S INITIALS] records and would like to do so now, I can wait a few minutes while you get them. [PROCEED AFTER R GETS RECORDS OR WANTS TO CONTINUE WITHOUT RECORDS]	3	3

Demographics and Length of Stay
What is [SAMPLED PERSON'S INITIALS]'s gender? MALE, FEMALE	4	4
What is [SAMPLED PERSON'S INITIALS]'s age in years? [RECORD SPECIFIC AGE] [RANGE 0-120] IF NECESSARY: Please give your best estimate.	5	5
Is [SAMPLED PERSON'S INITIALS] of Hispanic, Latino, or Spanish origin or descent? YES, NO, DON'T KNOW	6	6
DIRECT R TO SHOWCARD Which one or more of the following would you say is [SAMPLED PERSON'S INITIALS]'s race? Please tell me the numbers that apply from the showcard. Any others? SELECT ALL THAT APPLY1 AMERICAN INDIAN OR ALASKA NATIVE2 ASIAN3 BLACK4 NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER5 WHITE	7	7
When did [SAMPLED PERSON'S INITIALS] first [move into this residential care community/become enrolled at this center]? (RECORD MONTH AND YEAR) IF NECESSARY: Please give your best estimate.	8	8
DIRECT R TO SHOWCARD Approximately how long has it been since [SAMPLED PERSON'S INITIALS] first [moved into this residential care community/became enrolled at this adult day services center]? 1 0 TO 3 MONTHS 2 MORE THAN 3 MONTHS TO 6 MONTHS 3 MORE THAN 6 MONTHS TO 1 YEAR 4 MORE THAN 1 YEAR TO 3 YEARS 5 MORE THAN 3 YEARS TO 5 YEARS 6 MORE THAN 5 YEARS	9	9	DON'T KNOW to previous item

Living Arrangements
DIRECT R TO SHOWCARD Where did [SAMPLED PERSON'S INITIALS] live immediately before moving to this residential care community? 1 PRIVATE RESIDENCE (HOUSE, APARTMENT, ROOM) 2 RETIREMENT OR INDEPENDENT LIVING COMMUNITY 3 DIFFERENT ASSISTED LIVING OR RESIDENTIAL CARE COMMUNITY OR GROUP HOME 4 ACUTE CARE HOSPITAL 5 LONG-TERM CARE HOSPITAL OR INPATIENT REHABILITATION FACILITY 6 SKILLED NURSING FACILITY (SNF) FOR SHORT-TERM REHABILITATION (< 100 DAYS) 7 NURSING HOME OR OTHER INSTITUTIONAL SETTING (> 100 DAYS) 8 INTERMEDIATE CARE FACILITY FOR INDIVIDUALS WITH INTELLECTUAL OR DEVELOPMENTAL DISABILITIES 9 PSYCHIATRIC FACILITY 10 HOMELESS 11 JAIL 12 OTHER		10
DIRECT R TO SHOWCARD Where does [SAMPLED PERSON'S INITIALS] now live? 1 PRIVATE RESIDENCE (HOUSE, APARTMENT, ROOM) 2 RETIREMENT OR INDEPENDENT LIVING COMMUNITY 3 ASSISTED LIVING, RESIDENTIAL CARE COMMUNITY, OR GROUP HOME 4 NURSING HOME OR OTHER INSTITUTIONAL SETTING (> 100 DAYS) 5 INTERMEDIATE CARE FACILITY FOR INDIVIDUALS WITH INTELLECTUAL OR DEVELOPMENTAL DISABILITIES 6 OTHER	10
Who does [SAMPLED PERSON'S INITIALS] live with? Do they live … SELECT ALL THAT APPLY 1 alone 2 with a relative such as spouse, partner, adult child including in-law, parent, or other relative, or 3 with non-relative?	11		Response option 1 or 2 is selected in previous item
At this residential care community, does [SAMPLED PERSON'S INITIALS] currently share [his/her] room or apartment with another person? YES, NO		11
Is this person [SAMPLED PERSON'S INITIALS]'s partner, spouse, or other relative? YES, NO		12	YES to previous item
Does [SAMPLED PERSON'S INITIALS] live in a distinct unit, wing, or floor that is designated as an Alzheimer's Disease, dementia, or memory care unit at this residential care community? YES, NO		13
Charges and Payment Sources
In a typical week, how many days does [SAMPLED PERSON'S INITIALS] attend the adult day services center? 1-7	12
On the day[s] when [SAMPLED PERSON'S INITIALS] attends the adult day services center, does [she/he] typically attend 5 hours or more, or less than 5 hours? 5 HOURS OR MORE, LESS THAN 5 HOURS	13
ADSC VERSION (DAILY CHARGE) For the last complete month, what was the typical daily charge for [SAMPLED PERSON'S INITIALS] to attend this adult day services center? Include the basic daily charge and charges for any additional services. (RECORD DOLLAR AMOUNT WITHOUT CENTS) RCC VERSION (MONTHLY CHARGE) For the last complete month, what was the total monthly charge for [SAMPLED PERSON'S INITIALS] to [live in this residential care community/attend this center]? Include the basic monthly charge and charges for any additional services. (RECORD DOLLAR AMOUNT WITHOUT CENTS) FOR BOTH ADSCs AND RCCs, PROGRAM CATI SO THAT "FOR THE LAST COMPLETE MONTH," A FILL INSERTS BASED ON THE MONTH AND YEAR OF THE INTERVIEW. FOR EXAMPLE, FOR AN INTERVIEW OCCURRING IN NOVEMBER 2018, THE QUESTION WOULD START, "For October 2018,..."	14	14	SU at ADSC/RCC > 1 month.
DIRECT R TO SHOWCARD For the last complete month, what is the one primary payment source for [SAMPLED PERSON'S INITIALS]'s adult day services charges? SELECT ONLY ONE IF PAYMENT NOT RECEIVED YET, ASK: What is the expected primary source of payment? 1 MEDICAID (INCLUDE MEDICAID STATE PLAN, MEDICAID WAIVER, MEDICAID MANAGED CARE, OR CALIFORNIA REGIONAL CENTER) 2 MEDICARE (INCLUDE MEDICARE ADVANTAGE MANAGED CARE PLAN) 3 OLDER AMERICANS ACT/TITLE III 4 VETERANS ADMINISTRATION 5 PROGRAM OF ALL-INCLUSIVE CARE FOR THE ELDERLY (PACE) 6 OTHER FEDERAL, STATE, OR LOCAL GOVERNMENT 7 OUT-OF-POCKET PAYMENT BY THE PARTICIPANT OR FAMILY 8 PRIVATE INSURANCE 9 OTHER SOURCE	15		SU at ADSC > 1 month.
{For the last complete month/(if < 30 days since moved in/started) Since [SAMPLED PERSON'S INITIALS] [started living at/was enrolled in]} this [residential care community/adult day services center], did Medicaid pay for any of the services that [SAMPLED PERSON'S INITIALS] received at this [residential care community/adult day services center]? Please include any funding from a Medicaid state plan, Medicaid waiver, Medicaid managed care [IF IN CALIFORNIA AND ADSC: or California regional center]. YES, NO, DON'T KNOW	16	15	Ask for all RCCs. For ADSCS, ask only if Medicaid (option 1) not selected in prior item.

Health and Functional Status, Health Care Use, and Service Use
DIRECT R TO SHOWCARD. As far as you know, has a doctor or other health professional ever diagnosed [SAMPLED PERSON'S INITIALS] with any of the conditions on the showcard? Please tell me the numbers that apply from the showcard. Any others? SELECT ALL THAT APPLY 1 ALCOHOL ABUSE 2 ALZHEIMER’S DISEASE OR OTHER DEMENTIA 3 ANEMIA 4 ANXIETY DISORDER 5 ARTHRITIS OR RHEUMATOID ARTHRITIS 6 ASTHMA 7 CANCER OR MALIGNANT NEOPLASM OF ANY KIND 8 CEREBRAL PALSY 9 CONGESTIVE HEART FAILURE 10 COPD (CHRONIC BRONCHITIS OR EMPHYSEMA) 11 DEPRESSION 12 DIABETES 13 EPILEPSY 14 GLAUCOMA 15 GOUT, LUPUS, OR FIBROMYALGIA 16 HEART ATTACK (MYOCARDIAL INFARCTION) 17 HEART DISEASE (CORONARY OR ISCHEMIC) 18 HIGH BLOOD PRESSURE OR HYPERTENSION 19 HUMAN IMMUNODEFICIENCY VIRUS (HIV)/AIDS 20 HUNTINGTON'S DISEASE 21 INTELLECTUAL OR DEVELOPMENTAL DISABILITIES 22 KIDNEY DISEASE 23 MACULAR DEGENERATION 24 MUSCULAR DYSTROPHY 25 MULTIPLE SCLEROSIS 26 OBESITY 27 OSTEOPOROSIS 28 PARKINSON’S DISEASE 29 PARTIAL OR TOTAL PARALYSIS 30 PRESSURE WOUND/INJURY 31 SEVERE MENTAL ILLNESS SUCH AS SCHIZOPHRENIA OR PSYCHOSIS OR BIPOLAR DISORDER (EXCLUDES DEPRESSION OR ANXIETY DISORDER) 32 SPINAL CORD INJURY 33 STROKE 34 TRAUMATIC BRAIN INJURY 35 NONE OF THESE	17	16
The next question asks about prescription medications [SAMPLED PERSON'S INITIALS] may take. Include standing and PRN or as needed medications, but exclude over-the-counter medications or supplements, unless they have been prescribed by a health care provider. About how many prescription medications does [SAMPLED PERSON'S INITIALS] currently take on a typical day? Would you say…0, 1-2, 3-4, 5-6, 7-8, 9-10, or more than 10?	18	17
DIRECT R TO SHOWCARD The showcard lists the generic and brand names of antipsychotic medications. In the last 7 days, which, if any, of these medications did [SAMPLED PERSON'S INITIALS] receive, either on an as needed PRN basis or on a routine basis? Please tell me the numbers that apply from the showcard. Any others? SELECT ALL THAT APPLY 1 ABILIFY (ARIPIPRAZOLE) 2 CLOZARIL OR FAZACLO (CLOZAPINE) 3 FANAPT (ILOPERIDON) 4 GEODON (ZIPRASIDONE) 5 HALDOL (HALOPERIDOL) 6 INVEGA (PALIPERIDONE) 7 LOXITANE (LOXAPINE) 8 NAVANE (THIOTHIXENE) 9 ORAP (PIMOZIDE) 10 RISPERDAL (RISPERIDONE) 11 SAPHRIS (ASENAPINE) 12 SEROQUEL (QUETIAPINE) 13 ZYPREXA (OLANZAPINE)	19	18	SU has ADOD in DX item above
The next questions ask about difficulties (SAMPLED PERSON'S INITIALS) may have doing certain activities because of a health problem. How much difficulty does (SAMPLED PERSON'S INITIALS) have remembering or concentrating? Would you say no difficulty, some difficulty, a lot of difficulty, or cannot do at all? 1 NO DIFFICULTY 2 SOME DIFFICULTY 2 A LOT OF DIFFICULTY 4 CANNOT DO AT ALL	20	19
How much difficulty does (SAMPLED PERSON'S INITIALS) have seeing, even if wearing glasses? No difficulty, some difficulty, a lot of difficulty, or cannot do at all? 1 NO DIFFICULTY 2 SOME DIFFICULTY 2 A LOT OF DIFFICULTY 4 CANNOT DO AT ALL	21	20
How much difficulty does (SAMPLED PERSON'S INITIALS) have hearing, even if using a hearing aid? (No difficulty, some difficulty, a lot of difficulty, or cannot do at all?) 1 NO DIFFICULTY 2 SOME DIFFICULTY 2 A LOT OF DIFFICULTY 4 CANNOT DO AT ALL	22	21
How much difficulty does (SAMPLED PERSON'S INITIALS) have walking or climbing steps? (No difficulty, some difficulty, a lot of difficulty, or cannot do at all?) 1 NO DIFFICULTY 2 SOME DIFFICULTY 2 A LOT OF DIFFICULTY 4 CANNOT DO AT ALL	23	22
How much difficulty does (SAMPLED PERSON'S INITIALS) have self-care such as washing all over or dressing? (No difficulty, some difficulty, a lot of difficulty, or cannot do at all?) 1 NO DIFFICULTY 2 SOME DIFFICULTY 2 A LOT OF DIFFICULTY 4 CANNOT DO AT ALL	24	23
Using [her/his] usual customary language, how much difficulty does (SAMPLED PERSON'S INITIALS) have communicating, for example understanding or being understood? (No difficulty, some difficulty, a lot of difficulty, or cannot do at all?) 1 NO DIFFICULTY 2 SOME DIFFICULTY 3 A LOT OF DIFFICULTY 4 CANNOT DO AT ALL	25	24
The next questions ask about assistance [SAMPLED PERSON'S INITIALS] may need to perform certain activities.	26	25
Which types of assistance, if any, does [SAMPLED PERSON'S INITIALS] currently need to (IF ADSC: Transfer in and out of a chair/IF RCC: Transfer in and out of a bed or chair) [(IF ADSC) at their usual residence or this adult day services center]?) Does [SAMPLED PERSON'S INITIALS] need any help or supervision from another person, use an assistive device, both, or need no assistance? 1 NEED HELP OR SUPERVISION FROM ANOTHER PERSON 2 USE AN ASSISTIVE DEVICE 3 BOTH 4 NEED NO ASSISTANCE	27	26
Which types of assistance, if any, does [SAMPLED PERSON'S INITIALS] currently need to eat, like cutting up food [(IF ADSC) at their usual residence or this adult day services center]?) Does [SAMPLED PERSON'S INITIALS] need any help or supervision from another person, use an assistive device, both, or need no assistance? 1 NEED HELP OR SUPERVISION FROM ANOTHER PERSON 2 USE AN ASSISTIVE DEVICE 3 BOTH 4 NEED NO ASSISTANCE	28	27
Which types of assistance, if any, does [SAMPLED PERSON'S INITIALS] currently need to dress [(IF ADSC) at their usual residence or this adult day services center]?) (Does [SAMPLED PERSON'S INITIALS] need any help or supervision from another person, use an assistive device, both, or need no assistance?) 1 NEED HELP OR SUPERVISION FROM ANOTHER PERSON 2 USE AN ASSISTIVE DEVICE 3 BOTH 4 NEED NO ASSISTANCE	29	28
Which types of assistance, if any, does [SAMPLED PERSON'S INITIALS] currently need to bathe or shower [(IF ADSC) at their usual residence or this adult day services center]?) (Does [SAMPLED PERSON'S INITIALS] need any help or supervision from another person, use an assistive device, both, or need no assistance?) 1 NEED HELP OR SUPERVISION FROM ANOTHER PERSON 2 USE AN ASSISTIVE DEVICE 3 BOTH 4 NEED NO ASSISTANCE	30	29
Which types of assistance, if any, does [SAMPLED PERSON'S INITIALS] currently need to use the bathroom or toileting [(IF ADSC) at their usual residence or this adult day services center]?) (Does [SAMPLED PERSON'S INITIALS] need any help or supervision from another person, use an assistive device, both, or need no assistance?) 1 NEED HELP OR SUPERVISION FROM ANOTHER PERSON 2 USE AN ASSISTIVE DEVICE 3 BOTH 4 NEED NO ASSISTANCE	31	30
Which types of assistance, if any, does [SAMPLED PERSON'S INITIALS] currently need for locomotion or to walk [(IF ADSC) at their usual residence or this adult day services center]?) (Does [SAMPLED PERSON'S INITIALS] need any help or supervision from another person, use an assistive device, both, or need no assistance?) 1 NEED HELP OR SUPERVISION FROM ANOTHER PERSON 2 USE AN ASSISTIVE DEVICE 3 BOTH 4 NEED NO ASSISTANCE	32	31
DIRECT R TO SHOWCARD As far as you know, has [SAMPLED PERSON'S INITIALS] had any episode of incontinence during the last 7 days [IF ADSC: either at their usual residence or this adult day services center]? 1 YES, BOWEL ONLY 2 YES, URINARY ONLY 3 YES, BOTH BOWEL AND URINARY 4 NO, NEITHER 5 NOT APPLICABLE (COLOSTOMY, ILEOSTOMY) 6 NOT APPLICABLE (INDWELLING CATHETER, UROSTOMY)	33	32
During the {past 12 months/(if < 12 months since moved in/started) # months since [SAMPLED PERSON'S INITIALS] (moved into this residential care community/became enrolled at this adult day services center)}, was [SAMPLED PERSON'S INITIALS] treated in a hospital emergency department? YES, NO, DON'T KNOW	34	33	At ADSC/RCC > 90 days (from prior LOS items)
During the {past 90 days/(if < 90 days moved in/started) # days since [SAMPLED PERSON'S INITIALS] moved into this residential care community/became enrolled at this adult day services center)}, was [SAMPLED PERSON'S INITIALS] treated in a hospital emergency department? YES, NO, DON'T KNOW	35	34	YES to 12-month ED visit item above.
During the {past 12 months/(if < 12 months since moved in/started) # months since [SAMPLED PERSON'S INITIALS] [started living at/was enrolled in] this [residential care community/adult day services center]}, was [SAMPLED PERSON'S INITIALS] discharged from an overnight hospital stay? Exclude trips to the hospital emergency department that did not result in an overnight hospital stay. YES, NO, DON'T KNOW	36	35	At ADSC/RCC > 90 days (from prior LOS items)
Was [SAMPLED PERSON'S INITIALS] discharged from an overnight hospital stay in the {past 90 days/(if < 90 days since moved in/started) # days since [SAMPLED PERSON'S INITIALS] [started living at/was enrolled in] this [residential care community/adult day services center]}? Exclude trips to the hospital emergency department that did not result in an overnight hospital stay. YES, NO, DON'T KNOW	37	36	YES to 12-month hospital discharge item above.
DIRECT R TO SHOWCARD What was the one primary reason for [SAMPLED PERSON'S INITIALS]'s hospitalization? If [she/he] had more than one hospital discharge in the last 90 days, answer for the most recent hospital discharge. 1 ASTHMA 2 BRONCHITIS 3 C. DIFFICILE INFECTION 4 CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) 5 CONGESTIVE HEART FAILURE (CHF) 6 CONSTIPATION/INTESTINAL IMPACTION 7 DEHYDRATION 8 DIABETES—SHORT-TERM COMPLICATION 9 DISEASES OF THE SKIN 10 FALLS AND TRAUMA 11 HYPERTENSION OR HYPOTENSION 12 MENTAL STATUS CHANGES 13 PNEUMONIA 14 PRESSURE INJURY/ULCER 15 URINARY TRACT OR KIDNEY INFECTION 16 NONE OF THE ABOVE	38	37	YES to 90-day hospital discharge item above.
Was [SAMPLED PERSON'S INITIALS] re-admitted to the hospital for an overnight stay within 30 days of this hospital discharge? Include outpatient observation and inpatient admission. YES, NO, DON'T KNOW"	39	38	YES to 90-day hospital discharge item above.
The next section asks whether [SAMPLED PERSON'S INITIALS] has had any falls. By falls we mean any fall, slip, or trip in which [SAMPLED PERSON'S INITIALS] lost [his/her] balance and landed on the floor or ground or at a lower level. Please include falls that occurred at your [adult day services center/residential care community] or off-site, whether or not [SAMPLED PERSON'S INITIALS] was injured, and whether or not anyone saw [SAMPLED PERSON'S INITIALS] fall or caught them. As best you know, during the {past 90 days/# days since [SAMPLED PERSON'S INITIALS] moved into this residential care community/became enrolled at this adult day services center), how many falls has [SAMPLED PERSON'S INITIALS] had? 0-100, DON'T KNOW	40	39
IF > 1 FALL IN "HOW MANY FALLS" ITEM ABOVE: As best you know, did any of these falls that [SAMPLED PERSON'S INITIALS] had in the {past 90 days/(if < 90 days since started) # days since [SAMPLED PERSON'S INITIALS] [moved into this residential care community/was enrolled in this adult day services center] occur at the [residential care community/adult day services center]? YES, NO, DON'T KNOW IF 1 FALL IN "HOW MANY FALLS" ITEM ABOVE: As best you know, did the fall [SAMPLED PERSON'S INITIALS] had in the {past 90 days/(if < 90 days since started) # days since [SAMPLED PERSON'S INITIALS] [moved into this residential care community/was enrolled in this adult day services center] occur at the [residential care community/adult day services center]? YES, NO, DON'T KNOW	41	40	>0 to how many falls item above.
DIRECT R TO SHOWCARD Did {[IF 1 FALL: [SAMPLED PERSON'S INITIALS]'s fall] [IF >1 FALL: any of these falls [SAMPLED PERSON'S INITIALS] had]} result in a minor injury, a major injury, or no injury? (SELECT ALL THAT APPLY) SHOWCARD: 1 MINOR INJURY - ABRASION, CUT, HEMATOMA, LACERATION, SCRATCH, SKIN TEAR, SPRAIN, SUPERFICIAL BRUISE 2 MAJOR INJURY - BONE FRACTURE, BROKEN BONE, CLOSED HEAD INJURY WITH ALTERED CONSCIOUSNESS, JOINT DISLOCATION, SUBDURAL HEMATOMA 3 NO INJURY	42	41	>0 to any falls item above.
DIRECT R TO SHOWCARD The following services may be offered by [adult day services center/residential care community] staff or provided at the [center/community] by non-[center/community] staff. Which of these services does [SAMPLED PERSON'S INITIALS] currently use? Please tell me the numbers that apply from the showcard. Any others? SELECT ALL THAT APPLY 1 ASSISTANCE FROM A PERSON WITH AT LEAST ONE ACTIVITY OF DAILY LIVING (BATHING, DRESSING, EATING, TOILETING, TRANSFERRING) 2 BEHAVIORAL OR MENTAL HEALTH—TARGET RESIDENTS' MENTAL, EMOTIONAL, PSYCHOLOGICAL, OR PSYCHIATRIC WELL-BEING, AND MAY INCLUDE DIAGNOSING, DESCRIBING, EVALUATING, AND TREATING MENTAL CONDITIONS 3 CONTINENCE MANAGEMENT (E.G., ABSORBENT PADS, BLADDER OR BOWEL RETRAINING, CATHETER, MEDICATION, TOILETING REGIME) 4 DENTAL (ROUTINE OR EMERGENCY BY LICENSED DENTIST) 5 DIETARY OR NUTRITIONAL 6 HOSPICE 7 MANAGE, SUPERVISE, OR STORE MEDICATIONS; ADMINISTER MEDICATIONS; OR PROVIDE ASSISTANCE WITH SELF-ADMINISTRATION OF MEDICATIONS 8 OCCUPATIONAL THERAPY 9 PAIN MANAGEMENT (MEDICATION OR NON-PHARMACOLGICAL APPROACHES) 10 PALLIATIVE CARE (RELIEF FROM SYMPTOMS, PAIN, AND STRESS OF SERIOUS ILLNESS, REGARDLESS OF DIAGNOSIS) 11 PHARMACY--INCLUDING FILLING OF OR DELIVERY OF PRESCRIPTIONS 12 PHYSICAL THERAPY 13 PODIATRY 14 SKILLED NURSING--MUST BE PERFORMED BY AN RN OR LPN/LVN AND ARE MEDICAL IN NATURE 15 SKIN WOUND/INJURY CARE 16 SOCIAL WORK—PROVIDED BY LICENSED SOCIAL WORKERS OR PERSONS WITH A BACHELOR’S OR MASTER’S DEGREE IN SOCIAL WORK, AND MAY INCLUDE AN ARRAY OF SERVICES SUCH AS PSYCHOSOCIAL ASSESSMENT, INDIVIDUAL OR GROUP COUNSELING, AND REFERRAL SERVICES 17 SPEECH THERAPY 18 TRANSPORTATION FOR MEDICAL OR DENTAL APPOINTMENTS 19 TRANSPORTATION FOR SOCIAL AND RECREATIONAL ACTIVITIES OR SHOPPING 20 TRANSPORTATION TO/FROM THIS CENTER [ADSC ONLY] 21 NONE OF THE ABOVE	43	42
DIRECT R TO SHOWCARD For which of the items on this showcard does this [adult day services center/residential care community] have documentation in [SAMPLED PERSON'S INITIALS] file? Please tell me the numbers that apply from the showcard. Any others? SELECT ALL THAT APPLY 1 ADVANCE DIRECTIVE 2 HEALTH CARE PROXY OR DURABLE MEDICAL POWER OF ATTORNEY 3 PHYSICIAN DOCUMENTATION OF CONDITION THAT MAY RESULT IN LIFE EXPECTANCY LESS THAN 6 MONTHS 4 PHYSICIAN ORDERS FOR LIFE-SUSTAINING TREATMENT (POLST) 5 NONE	44	43
DIRECT R TO SHOWCARD As far as you know, at any time in the last 7 days has [SAMPLED PERSON'S INITIALS] exhibited any verbal or physical behavioral symptoms directed toward others, for example threatening, screaming, cursing, hitting, kicking, pushing, scratching, grabbing, or abusing others sexually [IF ADSC: , either at their usual residence or this center]? 1 YES, VERBAL ONLY 2 YES, PHYSICAL ONLY 3 YES, BOTH VERBAL AND PHYSICAL 4 NO, NEITHER	45	44