Design and Operation of the 2010 National Survey of Residential Care Facilities. APPENDIX XIII: NSRCF Screener Questionnaire

11/01/2011

Question Number Screener Question Item Code Categories Facility Asked Skip Pattern
S_I_STATEMENT_A I would like to verify some information we have about [SAMPLED FACILITY]. The questions I have right now should take just a few minutes.
Your family was chosen by a random selection process to represent residential care facilities like yours. All information you provide will be held in strict confidence and only will be used for statistical purposes. All published information will be presented in such a way that no individual facility, staff, or residents can be identified. Your participation is voluntary and there are no penalties for not participating in the survey, however, data from your facility are necessary to accurately portray residential care facilities.
1 CONTINUE All facilities  
S_1 Our records show that this facility is currently licensed, registered, or certified in [STATE] as a [LICENSURE CATEGORY}
Is this correct?
1 YES
2 NO
  Single licensure facilities
S_1_MULT Our records show that this facility has multiple [licenses/ registrations/ certifications] in [STATE] as a [LICENSE CATEGORIES]
Is this correct?
1 YES
2 NO
  Multiple licensure facilities
S_1A Is this facility licensed as…
READ THIS STATE’S LICENSE CATEGORIES TO RESPONDENT…
IF NONE OF THE LISTED CATEGORIES APPLY TO THE FACILITY, SELECT ‘NONE OF THE ABOVE’
SPECIFY   S_1 = 2 or S_1_MULT = 2
S_2 Does the residential care facility have 4 or more licensed, registered, or certified beds? 1 YES
2 NO
All sampled facilities  
S_4 Does this facility exclusively serve adults with mental retardation or a developmental disability, such as Down syndrome or autism? 1 YES
2 NO
3 SERVES BOTH MR/DD AND SEVERELY MENTALLY ILL EXCLUSIVELY
All sampled facilities  
S_5 Does this facility exclusively serve adults with severe mental illness, such as schizophrenia or psychosis? Please do not include Alzheimer’s disease or other dementias. 1 YES
2 NO
3 SERVES BOTH MR/DD AND SEVERELY MENTALLY ILL EXCLUSIVELY
  S_4 = 2
S_6 Does the facility provide or arrange for a personal care aide, RN, or LPN to be located in the same building, in an attached building or next door, or on the same campus 24 hours a day, 7 days a week, to meet any resident needs that may arise? These needs can be met by the director or assistant director, if they provide personal care or nursing services to residents. 1 YES
2 NO
3 PROVIDED ON AN AS NEEDED BASIS
All sampled facilities  
S_7 Does this facility offer help with activities of daily living, such as health with bathing, either directly or arranged through an outside vendor? 1 YES
2 NO
All sampled facilities  
S_8 Does this facility offer assistance with the administration of medications, give reminders, or provide central storage of medications? 1 YES
2 NO
All sampled facilities  
S_9 Does this facility offer at least 2 meals a day to residents? 1 YES
2 NO
All sampled facilities  
S_10 Is there at least one resident living at the residential care facility? 1 0 RESIDENTS
2 AT LEAST ONE RESIDENT
All sampled facilities  
S_11 Are any of the following types of places on this same property or at this same location? By at the same location, I mean this campus or address, not necessarily the same building.
You may select all that apply.
Independent living or independent apartments
Nursing home
Rehabilitation subacute or postacute care unit in a nursing home
Hospital
1 INDEPENDENT LIVING OR INDEPENDENT APARTMENTS
2 NURSING HOME
3 REHABILITATION SUBACUTE OR POSTACUTE CARE UNIT IN A NURSING HOME
4 HOSPITAL
5 NONE OF THE ABOVE
All eligible facilities  
S_12 Does this facility have a designated Alzheimer’s of dementia special care unit that is part of the nursing home? 1 YES
2 NO
  S_11 = 2 or 3
S_13 Is this 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 gives residents the opportunity to remain in the same community as their needs change? 1 YES
2 NO
  S_11 = 1 and (S_11 = 2 or 3)
S_16 Based on your responses, your facility is eligible to participate in our study. I would like to set up an appointment for an in person interview. The questions about [SAMPLED FACILITY], which will take about an hour, should be completed by someone who is familiar with the operations of the facility, usually the administrator or director of the facility.
In [SAMPLED FACILITY] is that you or someone else?
1 THE RESPONDENT
2 SOMEONE ELSE
3 DONT KNOW YET
All eligible facilities  
S_16_OTH Can you please give me his or her name? SPECIFY NAME   S_16 = 2
S_17 Then we collect data about three to six residents, depending on the size of your facility. These take about 20 minutes per resident. We do not interview residents directly, rather we interview the staff person most familiar with the resident and the resident’s records. Will that be someone else on your staff, or will you do that (as well)?
ADD IF NECESSARY: You do not need to decide now.
1 THE RESPONDENT
2 SOMEONE ELSE ON THE STAFF
3 DONT KNOW YET
All eligible facilities  
S_17_OTH Can you please give me his or her name? SPECIFY NAME   S_17 = 1 or 2
S_18a Let me verify that I have the correct name and address for your facility.
Is the correct name of your facility [NAME OF SAMPLED FACILITY]?
1 YES
2 NO
All eligible facilities  
S_18a_NAME Please tell me the correct name of your facility. SPECIFY NAME   S_18a = 2
S_18b Is your facility located at: [STREE ADDRESS OF SAMPLED FACILITY]? 1 YES
2 NO
All eligible facilities  
S_18B_ADD Please tell me the correct street address of your facility. SPECIFY   S_18b = 2
S_18B_CITY What is the city? SPECIFY   S_18b = 2
S_18B_STATE What is the state? SPECIFY   S_18b = 2
S_18B_Zip What is the zip code? SPECIFY   S_18b = 2
S_18C Is this also your mailing address? 1 YES
2 NO
All eligible facilities  
S_18C_MAIL Please tell me the correct mailing address of your facility STREET ADDRESS
CITY
STATE
ZIP
  S_18C = 2
S_RESP_ NAME Let me verify the spelling of the name of [RESPONDENT NAME] SPECIFY All eligible facilities  
S_END CONTINUE WITH SETTING THE APPOINTMENT ON THE FACESHEET 1 CONTINUE All eligible facilities  
S_OUTREACH Before you received the package about this study, had you heard about this study through newsletters or other information provided by national organizations that support it, such as American Association of Homes and Services for the Aging (AAHSA), American Seniors Housing Association (ASHA), Assisted Living Federation of America (ALFA), National Center for Assisted Living (NCAL), or Board and Care Quality Forum? 1 YES
2 NO
All sampled facilities  
S_ELIG_1 INTERVIEWER: READ A CLOSING STATEMENT AS APPROPRIATE.
(Are there any questions I can answer for you?)
(IF APPOINTMENT WA SET: We look forward to seeing you.)
(Thank you. Good bye.)
1. CONTINUE All eligible facilities  
S_ELIG_2 Thank you very much for answering these questions. Unfortunately, this facility does not qualify for our study which is focused on facilities that are in some way regulated by the State and provide a broader array of residential care services. I appreciate your time today.   All ineligible facilities  

 

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