Design and Operation of the 2010 National Survey of Residential Care Facilities. APPENDIX XIV: Pre-Interview Worksheet

11/01/2011

OMB No. 0920-0780
Exp. Date 12/31/2012

 

2010 National Survey of Residential Care Facilities
Pre-Interview Worksheet

Dear {NAME OF DIRECTOR} at {NAME OF FACILITY}

Thank you for agreeing to participate in the 2010 National Survey of Residential Care Facilities. The date and time of your interview and your interviewer's name are:

{Appointment date}
{Time}
{Interviewer's name}
For reschedules, call:

Supervisor: {Supervisor's name} at the Toll Free Number: 1-877-XXX-XXXX

Please fill out this worksheet prior to the interview. It should take about 15 minutes to complete. It contains some of the questions that will be asked during the interview. You may need to consult facility records to answer some questions. Completing this worksheet in advance will result in a shorter on-site interview.

If you do not have information for particular items, skip those questions; your interviewer will address them during the on-site interview.

Also before the interview, prepare a complete list of current residents of your residential care facility as of midnight before this interview date. Your interviewer will use this list to randomly select a few residents about whom you will be asked to provide some information.

If you have questions while completing this worksheet or questions about preparing the current resident list call Sara Zuckerbraun at: 1-800-334-8571 Ext 2-5206.

Sincerely,

/Angela M. Greene/
Project Director, RTI International

Information regarding Office of Management and Budget (OMB) approval, reporting burden and data confidentiality is on the back cover.

INSTRUCTIONS

If you need help answering any question, refer to facility records or request assistance from other staff.

The accuracy of your answers is important to this survey.

Residential care facilities are places that:

  • Are licensed, registered, listed, certified or otherwise regulated by the state;

  • Provide two meals a day; around-the-clock on-site supervision; help with personal care, such as bathing and dressing; or health related services such as medication management; and

  • Include, for example, assisted living, adult care homes, personal care homes, and community-based facilities.

If your facility is part of a campus that includes other types of care, such as a nursing home, rehabilitation center, hospital, or independent living/apartments, exclude these components in the answers you provide. Provide answers only for the residential care portion of the campus.

A. Facility

A1. At this facility, what is the number of licensed, registered, or certified residential care beds? Include both occupied and unoccupied beds.
_____ BEDS

A2. At this facility, what is the number of licensed, registered, or certified residential care rooms or apartments, where residents live? Exclude rooms within apartments.
_____ ROOMS OR APARTMENTS

A3. What is the current number of residents living at this residential care facility?
_____ RESIDENTS

B. Facility Rooms and Apartments

These next questions are about the residents' living quarters.

B1. How many rooms in this facility are
NUMBER OF ROOMS
_____ Rooms designed for one person?
_____ Rooms designed for two persons?
_____ Rooms designed for three or more persons?

B2. How many apartments in this facility are
NUMBER OF APARTMENTS
_____ Studio apartments?
_____ 1-bedroom apartments?
_____ 2-bedroom apartments?
_____ 3-bedroom apartments?

C. Source of Payment

C1. During the last 30 days, how many of the residents had some or all of their long-term care services paid by Medicaid?
_____ RESIDENTS WITH MEDICAID?

D. Waiting Lists

D1. 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?
_____ YES GO TO QUESTION D2
_____ NO SKIP TO E. RESIDENT TURNOVER

D2. What is the current number of people waiting to be admitted to this facility as soon as a place becomes available
_____ NUMBER ON WAITING LIST?

D3. What is the average length of time that prospective residents are waiting to be admitted to this facility?
Please respond as convenient, using months, days, or a combination of months and days.
_____ MONTHS
_____ DAYS

E. Resident Turnover

E1. How many residents moved into this facility over the past 12 months?
Exclude someone returning from a hospital stay if this facility held the bed for the resident.
Count each couple as 2 residents. Residents should be counted only once.
_____ RESIDENTS MOVED IN

E2. In the last 12 months, how many residents died?
_____ RESIDENTS DIED

E3. Over the last 12 months, how many residents moved out of this facility?
Exclude someone who has moved out if the facility is currently holding a bed for the resident.
Exclude deaths.
_____ RESIDENTS MOVED OUT
IF "0", SKIP TO F. STAFFING

E4. Where did the residents go after they moved out?
NUMBER OF RESIDENTS
_____ Hospital
_____ Nursing home
_____ Other residential care facility
_____ Private residence
_____ Some other place

E5. 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?
_____ RESIDENTS LEFT DUE TO COST OF CARE

F. Staffing

F1. During the last 7 days (or last work week), how many total hours were worked by the following paid staff?
Include all staff that provide direct care to resients, including full-time and part-time employees, and contract, temporary, and agency workers. Count hours for each staff person only once based on their primary job title.
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.
NUMBER OF HOURS WORKED
_____ Registered Nurses (RNs)
_____ Licensed Practical Nurses (LPNs) or Licensed Vocational Nurses (LVNs)
_____ Personal care aides, including certified nursing assistants (CNAs), and medication technicians
_____ Activities director or Activities staff
_____ Administrators, directors, assistant administrators, or assistant directors. Note: Include time meeting the needs of residents but exclude the time spent on the overall management of the facility.

For these next questions, exclude contract, temporary, or agency workers. Please count each employee only once based upon their primary responsibilities.

F2. As of taoday, how many of the following full-time and part-time persons are currently employed by this facility?
NUMBER CURRENTLY EMPLOYED
_____ Administrators, directors, assistant administrators or assistant directors
_____ Registered Nurses
_____ Licensed Practical Nurses or Licensed Vocational Nurses
_____ Personal care aides, including certified nursing assistants, and medication technicians

F3. During the past 12 months, how many of the following full-time and part-time employees have resigned or been terminated from residential care?
NUMBER RESIGNED OR TERMINATED
_____ Administrators, directors, assistant administrators or assistant directors
_____ Registered Nurses
_____ Licensed Practical Nurses or Licensed Vocational Nurses
_____ Personal care aides, including certified nursing assistants, and medication technicians

G. Resident Demographics

G1. How many residents are to Hispanic, Latino, or Spanish origin or descent?
_____ NUMBER OF RESIDENTS

G2. How many residents are
NUMBER OF RESIDENTS
_____ Male?
_____ Female?

G3. How many residents are in the following age categories?
NUMBER OF RESIDENTS
_____ 17 and under
_____ 18-54
_____ 55-64
_____ 65-74
_____ 75-84
_____ Age 85 and over

G4. How many residents are
NUMBER OF RESIDENTS
_____ White or Caucasian?
_____ Black or African American?
_____ Asian?
_____ Native Hawaiian or other Pacific Islander?
_____ American Indian or Alaska Native?

H. Dementia/Alzheimer's Unit

H1. Does this residential care facility have a distinct unit, wing, or floor that is designated as a dementia or Alzheimer's special care unit?
_____ YES GO TO QUESTION H2
_____ NO SKIP TO NEXT PAGE SECTION J. FACILITY CHARGES.

H2. In the dementia/Alzheimer's special care unit, what is the number of licensed beds?
_____ NUMBER OF LICENSED BEDS

H3. What is the current number of residents living in the dementia/Alzhiemer's unit?
_____ NUMBER OF RESIDENTS

I. Facility Charges

The next questions are about the average monthly base rate for rent and the services.

IF NO APARTMENTS, SKIP TO QUESTION I2.

I1. What is the average monthly base rate for a single individual living in a ...
(If two related people are living in the same apartment, compute the average as if only one person lived in the apartment.)
$_____ Studio apartment for a non-Alzheimer's unit?
$_____ Studio apartment for an Alzheimer's unit?
$_____ 1-bedroom apartment for a non-Alzheimer's unit?
$_____ 1-bedroom apartment for an Alzheimer's unit?
$_____ 2-bedroom apartment for a non-Alzheimer's unit?
$_____ 2-bedroom apartment for an Alzheimer's unit?
$_____ 3-bedroom apartment for a non-Alzheimer's unit?
$_____ 3-bedroom apartment for an Alzheimer's unit?

I2. What is the average monthly base rate for a single individual living in a ...
IF NO ROOMS, SKIP TO END.
$_____ Room designed for one person for a non-Alzheimer's unit?
$_____ Room designed for one person for an Alzheimer's unit?
$_____ Room designed for two person for a non-Alzheimer's unit?
$_____ Room designed for two person for an Alzheimer's unit?
$_____ Room designed for three person for a non-Alzheimer's unit?
$_____ Room designed for three person for an Alzheimer's unit?

J. Facility Charges

The next questions are about the average monthly base rate for rent and the services.

IF NO APARTMENTS, SKIP TO QUESTION J2.

J1. What is the average monthly base rate for a single individual living in a ...
(If two related people are living in the same apartment, compute the average as if only one person lived in the apartment.)
$_____ Studio apartment?
$_____ 1-bedroom apartment?
$_____ 2-bedroom apartment?
$_____ 3-bedroom apartment?
IF NO ROOMS, SKIP TO END.

J2. What is the average monthly base rate for a single individual living in a ...
$_____ Room designed for one person?
$_____ Room designed for two persons?
$_____ Room designed for three or more persons?

END

Thank you for completing this worksheet. Please retain this document to refer to during the in-person interview.

Also, please remember to prepare a list of current residents of your residential care facility as of midnight before the interview date.

OMB No. 0920-0780
Exp. Date 12/31/2012

NOTICE--Public reporting burden of this collection of information is estimated to average 15 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).

 

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