This instrument was prepared under #HHS-100-94-0024 and #HHS-100-98-0013 between HHS's ASPE/DALTCP and the Research Triangle Institute. Additional funding was provided by American Association of Retired Persons, the Administration on Aging, the National Institute on Aging, and the Alzheimer's Association. For additional information about this subject, you can visit the DALTCP home page at http://aspe.hhs.gov/_/office_specific/daltcp.cfm or contact the ASPE Project Officer, Gavin Kennedy, at HHS/ASPE/DALTCP, Room 424E, H.H. Humphrey Building, 200 Independence Avenue, S.W., Washington, D.C. 20201. His e-mail address is: Gavin.Kennedy@hhs.gov.
**NOTE** The letter "B" brackets [B] in many of the variable names is a token that represents one of 7 possible letters that could be found in this position. The letters represent the section of the facility being asked about, and follows the lettering system defined in Question 1 (e.g., B=Assisted Living, C=Congregate Care, etc.) Not all letters in the list are represented since some units were ineligible for continued questions.
|SNGMULTA||1.||Is this a facility that provides multiple levels of care, such as nursing home, assisted living, residential care, or independent living at the same location?
1 YES (GO TO MULTI1@01)
|2.||Which of the following types or levels of care does your facility offer?|
|YES=1 NO=2 YES/NO|
|MULTI101||a)||licensed nursing home|
|MULTI103||c)||congregate apartments/congregate care|
|MULTI104||d)||independent living/independent apartments|
|MULTI105||e)||board and care/personal care/residential care|
|MULTI106||f)||continuing care retirement community or life care community|
|MULTI107||g)||designated Alzheimer's Special Care Unit in a residential care or assisted living section of the facility|
|MULTI108||h)||designated Alzheimer's Special Care Unit in a licensed nursing home|
|MULTI109||i)||rehabilitation hospital/subacute care unit|
|FOR EACH OF THE ABOVE TYPES OF CARE THE FACILITY SAYS THEY OFFER (THAT WE ARE INTERESTED IN) WE WILL ASK THE FOLLOWING:|
|MULTI2[B]A||3.||How do you refer to this assisted living section? (Or congregate care, or independent living)|
|Q1U[B]A||1.||Excluding any nursing home beds, do you have 11 or more beds in (the) NAME OF TYPE OF CARE SPECIFIED ABOVE (section)?
2 NO (SKIP to end of interview)
|Q3U[B]A||3.||Excluding any nursing home residents, are at least half of the residents 65 years of age or older?Excluding any nursing home beds, do you have 11 or more beds in (the) NAME OF TYPE OF CARE SPECIFIED ABOVE (section)?
2 NO (SKIP To END OF INTERVIEW)
|Q4U[B]A||4.||Do you refer to (the) (SECTION NAME FILL) (section) as an assisted living facility or do you advertise that you provide assisted living services in that section? This includes such things as having the phrase assisted living in the name of the facility or in any advertisements about what the (section/facility) provides.Excluding any nursing home beds, do you have 11 or more beds in (the) NAME OF TYPE OF CARE SPECIFIED ABOVE (section)?
I am now going to ask about specific services the (SECTION NAME FILL) (section) may offer. Please tell me whether you regularly provide or arrange for their provision with an outside agency. By "arranging," we mean that you have a formal contract with the agency or that the facility takes responsibility for helping the resident arrange to receive the service. That would include identifying resident needs, contacting an agency or provider, and monitoring the performance of the service. "Regularly" means not on an ad hoc or for only one special resident.
|5a.||Do you regularly provide or arrange..||[Yes=1 No=2]|
|IF THE RESPONDENT SAYS "YES" FOR A SERVICE, ASK:|
|5b.||Do you provide this service with staff who work for the facility or do you arrange the service with an outside agency?|
|b.||at least two meals per day||Q5AU[B]OM||Q5AU[B]OM2|
|c.||three meals a day||Q5AU[B]EM||Q5AU[B]EM2|
|d.||24-hour direct care staff who can respond to resident's needs for assistance or monitoring||Q5AU[B]DC||Q5AU[B]DC2|
|e.||medication reminders to residents||Q5AU[B]MR||Q5AU[B]MR2|
|f.||central storage or assitance with self-administration of medications||Q5BU[B]ST||Q5BU[B]ST2|
|g.||assistance with bathing||Q5BU[B]BT||Q5BU[B]BT2|
|h.||assistance with dressing||Q5BU[B]DR||Q5BU[B]DR2|
|i.||any care or monitoring by a licensed nurse (i.e., an RN or LPN/LVN)||Q5BU[B]MN||Q5BU[B]MN2|
|j.||any therapy services (e.g., speech, physical, occupational therapy)||Q5BU[B]TH||Q5BU[B]TH2|
|6.||How long has (the) (FACILITY NAME FILL) (section) been in operation?
IF LESS THAN 1 YEAR, CODE 00 FOR YEARS AND INDICATE NUMBER OF MONTHS. IF RANGE GIVEN, ACCEPT THE LOWEST ESTIMATE.
|Q6U[B]YRS _____YEARS||Q6U[B]MNTS _____MONTHS|
|IF IN BUSINESS FOR LESS THAN 3 MONTHS, STOP AND GO TO "GOODBYE"|
|DECIU[B]||6a.||Can you answer some more detailed questions about services and accommodations in (the) (SECTION NAME FILL) (section) or should I contact someone else?
1 I can answer
2 Contact someone else
INTRODUCTORY STATEMENT TO BE READ BEFORE Q9. FOR ONLY THOSE WHO ANSWER Q.7B.
In your response to the next questions, consider only those beds or units identified as part of (SECTION NAME FILL).
|Q9U[B]A||9a.||How many beds are currently in operation or available for residents in the (SECTION NAME FILL) (section)? NOTE: SHOULD BE AT LEAST 11.
|Q9U[B]B||9b.||How many residents are currently living in (the) (SECTION NAME FILL) section?
|Q11U[B]A||11.||Do any of the resident bedrooms (including those in apartments) house more than 2 unrelated people?
|Q12AU[B]A||12a.||Now, I'd like to ask you about the type of accommodations you provide in (the) (SECTION NAME FILL) (section). By "apartment," we mean a bathroom, bedroom, living room, and kitchen or kitchen area. A studio apartment is also included. Are any apartments in (the) (SECTION NAME FILL) (section)?
2 NO (SKIP to Q.13a)
|Q12BU[B]A||12b.||What is the total number of apartments in your facility?
|12c.||Please tell me the number of your accommodations that are described by the following:
|Q12DU[B]A||12d.||Do all apartments have a full bath, by which we mean sink, toilet, and either a tub or shower? (SOME PEOPLE CALL SINK, TOILET AND A SHOWER A ¾ BATH. THAT COUNTS AS A FULL BATH HERE.)
|Q13AU[B]A||13a.||Are any of the living units in (the) (SECTION NAME FILL) (section) only bedrooms (rather than apartments)?
2 NO (SKIP to Q.14)
|Q12BU[B]A||13b.||What is the total number of bedrooms (not counting those in apartments)?
|13c.||Please tell me the number of your accommodations that are described by the following: (Semi-private means shared by only two people.)
|Q14U[B]A||14.||We are also interested in learning if you have any "heavy care" residents, that is those who require significant help with certain activities of daily living or ADLs. This week, approximately what percentage of your residents receive hands-on help from staff with ANY of the following ADLs"
Percentage of residents: __________
|Q15U[B]A||15.||We would also like to know if you are serving persons with moderate to severe cognitive impairment. This means that residents have short-term memory problems or poor ability to make decisions about their daily lives.
This week, approximately what percentage of your residents are cognitively impaired?
Percentage of residents: __________
|Q16AU[B]A||16a.||Do you have a Registered Nurse (RN) on staff who works at least 40 hours per week? This includes contract staff.
1 YES (SKIP to Q.17)
|Q16BU[B]A||16.b||Do you have an RN on staff who works less than 40 hours per week?
|Q17U[B]A||17.||Do you have a Licensed Practical or Vocational Nurse on staff who works 40 or fewer hours per week? This includes contract staff.
Some facilities have policies about the level of disability they can serve. The next questions are about whether you would admit residents with certain problems and whether you would retain residents who develop these conditions.
FOR EACH CONDITION, READ BOTH QUESTIONS
|18a.||Will you admit a resident that:|
|18b.||Will you retain a resident that:|
|1-YES 2-NO 3-DEPENDS|
|a.||Has a behavior problem (e.g., wandering' socially inappropriate behavior)||Q18AU[B]1A||Q18AU[B]1B|
|b.||Has urinary incontinence||Q18AU[B]2A||Q18AU[B]2B|
|c.||Needs nursing care or monitoring by an RN or LPN||Q18AU[B]3A||Q18AU[B]3B|
|d.||Uses a wheelchair to get around||Q18AU[B]4A||Q18AU[B]4B|
|e.||Receives help getting around the facility (walking or using a wheelchair)||Q18BU[B]5A||Q18BU[B]5B|
|f.||Receives help transferring from bed to chair or wheelchair||Q18BU[B]6A||Q18BU[B]6B|
|g.||Has moderate to severe cognitive impairment||Q18BU[B]7A||Q18BU[B]7B|
|Q19U[B]A||19.||Will you retain a resident who requires temporary nursing care, for example for a condition like flu that is expected to last less than 14 days?
1-YES 2-NO 3-DEPENDS
|Q20U[B]A||20.||Will you retain a resident who needs longer term nursing care (e.g., for more than 14 day)?
1-YES 2-NO 3-DEPENDS
OTHER REPORTS AVAILABLE
A National Study of Assisted Living for the Frail Elderly: Discharged Residents Telephone Survey Data Collection and Sampling Report
A National Study of Assisted Living for the Frail Elderly: Final Sampling and Weighting Report
A National Study of Assisted Living for the Frail Elderly: Final Summary Report
A National Study of Assisted Living for the Frail Elderly: Report on In-Depth Interviews with Developers
Executive Summary http://aspe.hhs.gov/daltcp/reports/indpthes.htm
A National Study of Assisted Living for the Frail Elderly: Results of a National Study of Facilities
Executive Summary http://aspe.hhs.gov/daltcp/reports/facreses.htm
Assisted Living Policy and Regulation: State Survey
Differences Among Services and Policies in High Privacy or High Service Assisted Living Facilities
Family Members' Views: What is Quality in Assisted Living Facilities Providing Care to People with Dementia?
Guide to Assisted Living and State Policy
High Service or High Privacy Assisted Living Facilities, Their Residents and Staff: Results from a National Survey
Executive Summary http://aspe.hhs.gov/daltcp/reports/hshpes.htm
National Study of Assisted Living for the Frail Elderly: Literature Review Update
Abstract HTML http://aspe.hhs.gov/daltcp/reports/ablitrev.htm
Abstract PDF http://aspe.hhs.gov/daltcp/reports/ablitrev.pdf
Residents Leaving Assisted Living: Descriptive and Analytic Results from a National Survey
Executive Summary http://aspe.hhs.gov/daltcp/reports/alresdes.htm
State Assisted Living Policy: 1996
Executive Summary http://aspe.hhs.gov/daltcp/reports/96states.htm
State Assisted Living Policy: 1998
Executive Summary http://aspe.hhs.gov/daltcp/reports/98states.htm
Facility Screening Questionnaire