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

11/01/2011

Question Number Facility Question Item Code Categories Facility Asked Skip Pattern
F_A1_Intro1 This survey is about the characteristics of residential care facilities and the individuals who live in them.
Residential care facilities are known by many names, so just to be clear I would like to read a definition that we are using to describe a residential care facility that we have provided on this card.
HAND R SHOWCARD
Residential care facilities are places that are licensed, registered, listed, certified, or otherwise regulated by the state and that provide room and board with at least two meals a day, around-the-clock on-site supervision, and help with personal care such as bathing and dressing or health related services such as medication management. These facilities serve a predominantly adult population. Facilities licensed to exclusively serve the severely mentally ill or the developmentally disabled populations are excluded.
1 CONTINUE All facilities  
F_A1_Intro2 We are interviewing [SAMPLED FACILITY]because it is currently licensed as a [LICENSURE CATEGORY], which is a type of residential care facility.
READ IF MULTI-LEVEL FACILITY
[When you answer the questions, please answer only about the residential care component of this facility.]
1 CONTINUE All facilities  
F_A1 This is the first of many questions included in the Pre-interview Worksheet that we mailed to your facility. If you have that form available it would be helpful to reference that now.
At this facility, what is the number of licensed, registered, or certified residential care beds? Include both occupied and unoccupied beds.
0-995 BEDS All facilities  
F_A1_CONFIRM Does your facility have less than four beds? 1 YES
2 NO
  F_A1 = 0-3
F_A1_ABORT I am sorry but your facility is not eligible for this study. Thank you for your time. 1 CONTINUE   F_A1_CONFIRM = 1
F_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.
1-995 All facilities  
F_S14 Is this facility owned by a chain, group, or multi-facility system?
INTERVIEWER, EXPLAIN IF NECESSARY: A chain means more than one facility under common ownership or management. This may include facilities within-state or across multiple states.
1 YES
2 NO
All facilities  
F_S15 What is the type of ownership of this facility?
Private, for profit
Private Nonprofit
State, county, or local government
1 Private, for profit
2 Private Nonprofit
3 State, county, or local government
All facilities  
F_S3a Does this residential care facility only serve adults with dementia or Alzheimer's disease? 1 YES
2 NO
All facilities  
F_A3 What is the current number of residents living at this residential care facility? 1-905 All facilities  
F_ANEW1 HAND R SHOWCARD
The next questions are about the residents living quarters (in the residential care component) at this facility.
Which of these types of living quarters does your facility offer to residents?
Any others?
SELECT ALL THAT APPLY
1 ROOM DESIGNED FOR ONE PERSON
2 ROOM DESIGNED FOR TWO PERSONS
3 ROOM DESIGNED FOR THREE OR MORE PERSONS
4 STUDIO APARTMENT
5 ONE BEDROOM APARTMENT
6 TWO BEDROOM APARTMENT
7 THREE BEDROOM APARTMENT
All facilities  
F_ANEW2 Intro I'll now ask about the rooms (at/in the residential care portion of) this facility. 1 CONTINUE   F_ANEW1 = 1–3
F_ANEW2a How many rooms in this facility are designed for one person? 1-995   F_ANEW1 = 1
F_ANEW2b How many rooms in this facility are designed for two persons? 1-995   F_ANEW1 = 2
F_ANEW2c How many rooms in this facility are designed for three or more persons? 1-995   F_ANEW1 = 3
F_ANEW3a HAND R SHOWCARD
(Does this room/do any rooms) contain any of these features? Which ones?
SELECT ALL THAT APPLY
1 MICROWAVE
2 COOK TOP OR HOT PLATE
3 OVEN
4 REFRIGERATOR
5 KITCHEN SINK
6 NONE OF THE ABOVE
  F_ANEW1 = 1–3
F_ANEW3b Do all or only some of the rooms have a microwave? 1 All
2 Some
  F_ANEW 3a = 1 and of F_ANEW2a-2c ≠ 1
F_ANEW3b1 How many? 1-995   F_ANEW3b = 2
F_ANEW3c Do all or only some of the rooms have a cook top or hot plate? 1 All
2 Some
  F_ANEW3a = 2 and of NEW2a-2c ≠ 1
F_ANEW3c1 How many? 1-995   F_ANEW3 c = 2
F_ANEW3d Do all or only some of the rooms have an oven? 1 All
2 Some
  F_ANEW3a = 3 and of F_ANEW2a-2c ≠ 1
F_ANEW3d1 How many? 1-995 All facilities F_ANEW3d = 2
F_ANEW3e Do all or only some of the rooms have a refrigerator? 1 All
2 Some
All facilities F_ANEW3a = 4 and of F_ANEW2 a-2c ≠ 1
F_ANEW3e1 How many? 1-995   F_ANEW3e = 2
F_ANEW3f Do all or only some of the rooms have a sink in the kitchen area? 1 All
2 Some
  F_ANEW3a = 5 and of F_ANEW2a-2c ≠ 1
F_ANEW3f1 How many? 1-995   F_ANEW3f = 2
F_A7rev How many rooms have a door to the hallway that can be locked from the inside: All, some, or none? 1 All
2 Some
3 None
  F_ANEW1 = 1-3
F_A7rev1 How many? 1-995   F_ANEWF_A7 rev = 2
F_A7_within rev How many rooms have a bathroom located within the room or between rooms: All, some, or none? 1 All
2 Some
3 None
  F_ANEW1 = 1-3
F_A7_within rev1 How many? 1-995   F_A7withinrev = 2
F_A7arev How many rooms have a full bathroom including a toilet, sink, and shower or tub located within the room or between rooms: All, some, or none? 1 All
2 Some
3 None
  F_A7_withinrev = 1-2
F_A7arev1 How many? 1-995   F_A7a rev = 2
F_A7brev How many rooms have a half-bath including a sink and toilet located within the room or between rooms: All, some, or none? 1 All
2 Some
3 None
  F_A7a = 2-3
F_A7brev1 How many? 1-995   F_A7b rev = 2
F_ANEW4 Intro The next questions are about this facility's apartments. 1 CONTINUE   F_ANEW1 = 4-7
F_ANEW4a How many studio apartments are there? 1-995   F_ANEW1 = 4
F_ANEW4b How many one bedroom apartments are there? 1-995   F_ANEW1 = 5
F_ANEW4c How many two bedroom apartments are there? 1-995   F_ANEW1 = 6
F_ANEW4d How many three bedroom apartments are there? 1-995   F_ANEW1 = 7
F_ANEW5a HAND R SHOWCARD
(Does this apartment/do any apartments) contain any of these features? Which ones?
SELECT ALL THAT APPLY
1 MICROWAVE
2 COOK TOP OR HOT PLATE
3 OVEN
4 REFRIGERATOR
5 KITCHEN SINK
6 NONE OF THE ABOVE
  F_ANEW1 = 4-7
F_ANEW5b Do all or only some of the apartments have a microwave?
NOTE: APARTMENT IS CONSIDERED TO HAVE A MICROWAVE EVEN IF MICROWAVE CANNOT BE PLUGGED IN/HAS BEEN DISABLED FOR THE RESIDENTS SAFETY.
1 All
2 Some
  F_ANEW5a = 1 and of F_ANEW4a-4d ≠ 1
F_ANEW5b1 How many? 1-995   F_ANEW5b = 2
F_ANEW5c Do all or only some of the apartments have a cooktop or hot plate? 1 All
2 Some
  F_ANEW5a = 2 and of F_ANEW4a-4d ≠ 1
F_ANEW5c1 How many? 1-995   F_ANEW5c = 2
F_ANEW5d Do all or only some of the apartments have an oven? 1 All
2 Some
  F_ANEW5a =
3 and of F_ANEW4a-4d ≠ 1
F_ANEW5d1 How many? 1-995   F_ANEW5d = 2
F_ANEW5e Do all or only some of the apartments have a refrigerator? 1 All
2 Some
  F_ANEW5a = 4 and of F_ANEW4a-4d ≠ 1
F_ANEW5e1 How many? 1-995   F_ANEW5e = 2
F_ANEW5f Do all or only some of the apartments have a sink in the kitchen area? 1 All
2 Some
  F_ANEW5a = 5 and of F_ANEW4a-4d ≠ 1
F_ANEW5f1 How many? 1-995   F_ANEW5f = 2
F_A7rev_apt How many apartments have a door to the hallway that can be locked from the inside: All, some, or none? 1 All
2 Some
3 None
  F_ANEW1 = 4-7
F_A7rev1_apt How many? 1-995   F_A7rev_apt = 2
F_A7_within rev_apt How many apartments have a bathroom located within the apartment or between apartments: All, some, or none? 1 All
2 Some
3 None
  F_ANEW1 = 4-7
F_A7_within rev1_apt How many? 1-995   F_A7_withinrev_apt =2
F_A7arev_apt How many apartments have a full bathroom including a toilet, sink, and shower or tub located within the apartment or between apartments: All, some or none? 1 All
2 Some
3 None
  F_A7_withinrev_apt = 1-2
F_A7arev1_apt How many? 1-995   F_A7arev_apt = 2
F_A7b_apt How many apartments have a half-bath including a sink and toilet located within the apartment or between apartments: All, some, or none? 1 All
2 Some
3 None
  F_A7_withinrev_apt = 1-2
F_A7b1_apt How many? 1-995   F_A7b_apt = 2
F_A8 Does the facility have a common kitchen area that any resident can use? 1 YES
2 NO
All facilities  
F_A9 How many of the [NUMBER]residents live with a spouse or other relative?
For example, if there is one couple who lives together, you would report that two residents live with a spouse or relative.
0-995 All facilities  
F_A10 READ RESPONSES IF NECESSARY.
What is the total number of years this facility has been (in operation/operating as a residential care facility)?
1 LESS THAN 5 YEARS
2 5 TO 9 YEARS
3 10 TO 19 YEARS
4 20 OR MORE YEARS
All facilities  
F_A11 Was [SAMPLED FACILITY]purposely built as a residential care facility? 1 YES
2 NO
All facilities  
F_A12a (In the residential care portion of this facility,) how many resident (rooms/apartments) have... smoke detectors?
Would you say...?
All
Some
None
1 All
2 Some
3 None
All facilities  
F_A12b (In the residential care portion of this facility,) how many common areas have... smoke detectors?
Would you say...?
All
Some
None
1 All
2 Some
3 None
All facilities  
F_A12c (In the residential care portion of this facility,) how many resident (rooms/apartments) have... a sprinkler system?
Would you say...?
All
Some
None
1 All
2 Some
3 None
All facilities  
F_A12d (In the residential care portion of this facility,) how many common areas have... a sprinkler system?
Would you say...?
All
Some
None
1 All
2 Some
3 None
All facilities  
F_A12e (In the residential care portion of this facility,) how many hallways have supported or grab rails on one or both sides?
Would you say...?
All
Some
None
1 All
2 Some
3 None
All facilities  
F_A12f (In the residential care portion of this facility,) how many common areas have widened hallways or doorways that can accommodate wheelchairs?
Would you say...?
All
Some
None
1 All
2 Some
3 None
All facilities  
F_A12g (In the residential care portion of this facility,) how many (rooms/apartments) have an emergency call or personal response system? This may include emergency devices worn by residents.
Would you say...?
All
Some
None
1 All
2 Some
3 None
All facilities  
F_A12h (In the residential care portion of this facility,) how many (rooms/apartments) are...wheelchair accessible?
Would you say...?
All
Some
None
1 All
2 Some
3 None
All facilities  
F_A12i (In the residential care portion of this facility,) how many bathrooms have enough space for a wheelchair to enter, about 3 ft, and turn around, about 5ft x 5ft?
Would you say...?
All
Some
None
1 All
2 Some
3 None
All facilities  
F_A12j (In the residential care portion of this facility,) how many bathrooms have grab bars in the shower or tub area?
Would you say...?
All
Some
None
1 All
2 Some
3 None
All facilities  
F_A15 During the past 90 days, did this residential care facility provide any short-term respite care? 1 YES
2 NO
All facilities  
F_A16 Does this facility provide adult day health or adult day care services to non-residents? 1 YES
2 NO
All facilities  
F_A17 Does this facility currently serve any persons with developmental disabilities such as mental retardation, autism, or Down syndrome? 1 YES
2 NO
All facilities  
F_A18 Does this facility currently serve any persons with severe mental illness such as schizophrenia and psychosis? Please do not include Alzheimer's disease or other dementias. 1 YES
2 NO
All facilities  
F_A18a HAND R SHOWCARD
Please look at this card. We would now like to ask you about how the facility manages risky behavior by residents. By risky behavior, we mean when residents do things that staff think pose a risk to their health and safety--such as refusing to take prescribed medications, not using a walker when their balance is poor, or not complying with prescribed diets.
Some facilities use a formal written document called a managed risk agreement or a formal negotiated risk agreement, which documents the risky behavior, discussions with the resident about the behavior, alternatives to the behavior presented by staff, and agreements reached between the facility and the resident about the behavior. Some facilities also use these documents as liability waivers for harm resulting from risky behavior. This document is different from a Plan of Care or a Resident Agreement.
Does this facility develop a formal negotiated risk agreement with any of the residents?
1 YES
2 NO
All facilities  
F_A18b Instead of a formal negotiated risk agreement, does this facility address risky behaviors in some other formal written document? 1 YES
2 NO
  F_A18a = 2
F_A19_Intro The next questions ask about items residents are allowed to bring when they move into this facility. 1 CONTINUE All facilities  
F_A19 What types of personal items or furniture may residents bring?
Large furniture such as a couch, bed, or dining room table. Small furniture such as a desk, bookcase, chair, lamp, or small table. Personal items such as pictures, bed linens, or wall decorations.
CODE ALL THAT APPLY
1 Large furnituresuch as a couch, bed, or dining room table.
2 Small furniture such as a desk, bookcase, chair, lamp, or small table.
3 Personal items such as pictures, bed linens, or wall decorations.
4 NONE OF THE ABOVE
All facilities  
F_A20 Does the facility provide a common pet such as a cat, dog, or bird? 1 YES
2 NO
All facilities  
F_A20a Are residents ever allowed to have a personal pet such as a cat, dog, or bird that lives at the facility? 1 YES
2 NO
All facilities  
F_A21 Is there space at this facility for residents to park their car? 1 YES
2 NO
All facilities  
F_A22_Intro The next questions ask about resident source of payment. 1 CONTINUE All facilities  
F_A22 Is this residential care facility certified or registered to participate in Medicaid? 1 YES
2 NO
All facilities  
F_A23 During the last 30 days, how many of the residents had some or all of their long-term care services paid by Medicaid? 0-995   F_A22 = 1
F_A24 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? 1 YES
2 NO
All facilities  
F_A25 What is the current number of people waiting to be admitted to this facility as soon as a place becomes available? 1-500   F_A24 = 1
F_A26 What is the average length of time that prospective residents are waiting to be admitted to this facility?
Please respond in months and/or days.
MONTHS DAYS   F_A24 = 1
F_A27_Intro The next questions ask about resident admission and discharge. 1 CONTINUE All facilities  
F_A27 How many residents moved into this facility over the past 12 months?
Please count each couple as 2 residents. Also, do not include someone returning from a hospital stay if this facility held the bed for the resident. Residents should be counted only once.
0-500 All facilities  
F_A32 In the last 12 months, how many residents died? 0-500 All facilities  
F_A30 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.
0-500 All facilities  
F_A31_hosp Where did the residents go after they moved out?
Hospital
0-500   F_A30 = 1-500
F_A31_nursing (Where did the residents go after they moved out?)
Nursing home
0-500   F_A30 = 1-500
F_A31_otherrcf (Where did the residents go after they moved out?)
Other residential care facility
0-500   F_A30 = 1-500
F_A31_residence (Where did the residents go after they moved out?)
Private residence
0-500   F_A30 = 1-500
F_A31_other (Where did the residents go after they moved out?)
Some other place
0-500   F_A30 = 1-500
F_A30a 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? 0-500   F_A30 = 1-500
F_A33_Intro The next questions are about facility staff. First, we will ask how many total hours were worked in the last 7 days (or the last work week) by paid staff (for the residential care component of this facility).
In your calculations of staff hours, please include all staff that provide direct care to residents, including full-time and part-time staff employees, and contract, temporary, and agency workers.
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.
1 CONTINUE All facilities  
F_A33a During the last 7 days or last work week, how many total hours were worked by the following paid staff (for the residential care component this facility)?
Registered Nurses or RNs
0-999 All facilities  
F_A33b (During the last 7 days or last work week, how many total hours were worked by the following paid staff (for the residential care component of this facility)?)
Licensed Practical Nurses, also called an L.P.N. or Licensed Vocational Nurses also called an LVN.
0-999 All facilities  
F_A33c (During the last 7 days or last work week, how many total hours were worked by the following paid staff (for the residential care component of this facility)?)
Personal care aides, including certified nursing assistants (CNAs), and medication technicians.
0-1999 All facilities  
F_A33d (During the last 7 days or last work week, how many total hours were worked by the following paid staff (for the residential care component of this facility)?)
Activities director or activities staff
0-999 All facilities  
F_A33e (During the last 7 days or last work week, how many total hours were worked by the following paid staff (for the residential care component of this facility)?)
Administrators, directors, assistant administrators or assistant directors--direct care time only
(Direct care time by administrators or directors refers to time spent meeting the needs of individual residents, such as helping them walk to dinner, helping them dress, or providing them with medications. It does not include the time spent on the overall management of the facility.)
0-999 All facilities  
F_A34 Does this facility use contract workers to provide direct care to residents? 1 YES
2 NO
All facilities  
F_A35 During the past 7 days or last work week, did your facility use any volunteers to help your residents or this facility's staff in any way? 1 YES
2 NO
All facilities  
F_A36 During the last 7 days or last work week, about how many volunteer workers provided services at the facility at least once? 0-995   F_A35 = 1
F_A36a What kinds of services do they provide?
CODE ALL THAT APPLY
General office help
Homemaker/Household services
Personal care (haircuts, nail care, massage, etc.)
Transportation services
Visiting with patients
Bereavement/family support
Religious/spiritual activities
Assist residents at Mealtime
Shopping
Social and recreational activities
Exercise
Other service
1 General office help
2 Homemaker/household services
3 Personal care (haircuts, nail care, massage, etc.)
4 Transportation services
5 Visiting with patients
6 Bereavement/family support
7 Religious/spiritual activities
8 Assist residents at Mealtime
9 Shopping
10 Social and recreational activities
11 Exercise
12 Other services
  F_A35 = 1
F_A36b During the last 7 days or last work week, how many of your facility's residents received services from any of your volunteer workers? 0-500   F_A35 = 1
F_A37 During a typical night how many staff are on-duty and awake? Please do not count security guards. 0-500 All facilities  
F_A38a These next questions ask how many full-time and part-time persons are currently employed by this facility (for residential care). Please count full-time and part-time employees. Do not include contract, temporary, and agency workers. Please count each employee only once based upon their primary responsibilities.
As of today, how many of the following full-time and part-time persons are currently employed by this facility (for residential care)?
Administrators, Directors, assistant Administrators and assistant Directors?
0-99 All facilities  
F_A38b (As of today, how many of the following full-time and part-time staff are currently employed at this facility) (for residential care)?
Registered Nurses or RNs
0-99 All facilities  
F_A38c (As of today, how many of the following full-time and part-time staff are currently employed by this facility) (for residential care)?
Licensed Practical Nurses also called LPNs or Licensed Vocational Nurses also called LVNs
0-99 All facilities  
F_A38d (As of today, how many of the following full-time and part-time staff are currently employed by this facility) (for residential care)?
Personal Care Aides, including Certified Nursing Assistants and medication technicians
0-995 All facilities  
F_A39a During the past 12 months, how many of the following full-time and part-time employees have resigned or been terminated (from residential care)?
Administrators, Directors, Assistant Administrators and Assistant Directors
0-99 All facilities  
F_A39b (During the past 12 months, how many of the following full-time and part-time employees have resigned or been terminated) (from residential care)?
Registered Nurses or RNs
0-99 All facilities  
F_A39c (During the past 12 months, how many of the following full-time and part-time employees have resigned or been terminated) (from residential care)?
Licensed Practical Nurses also called LPNs or Licensed Vocational Nurses also called LVNs
0-99 All facilities  
F_A39d (During the past 12 months, how many of the following full-time and part-time employees have resigned or been terminated) (from residential care)?
Personal Care Aides and nursing assistants, including CNAs and medication technicians
0-99 All facilities  
F_A40a HAND R SHOWCARD
About what percentage of this facilitys employees received a flu shot last flu season?
1 0%
2 1 to 20%
3 21-40%
4 41-50%
5 51-60%
6 61-80%
7 81-99%
8 100%
All facilities  
F_A40b HAND R SHOWCARD
Does this facility do any of the following to encourage employees influenza vaccinations? Anything else?
SELECT ALL THAT APPLY
1 VACCINATIONS RECOMMENDED
2 VACCINATIONS OFFERED ON SITE
3 VACCINATIONS OFFERED FOR FREE
4 VACCINATIONS OFFERED AT REDUCED COST
5 STAFF INCENTIVES PROVIDED FOR VACCINATION
6 PROOF OF VACCINATION (OR CONTRAINDICATION) REQUIRED AS A CONDITION OF WORK/ EMPLOYMENT
7 FURLOUGH OR PATIENT RESTRICTION POLICY FOR EMPLOYEES DEVELOPING INFLUENZA--LIKE ILLNESS
8 NONE OF THE ABOVE
All facilities  
F_A40c HAND R SHOWCARD
Which vaccination program best describes what is being used in your facility for influenza?
HELP SCREEN1
1 FACILITY-WIDE STANDING ORDERS
2 PRE-PRINTED ADMISSION ORDERS
3 ADVANCE PHYSICIAN/ NURSE PRACTITIONER ORDERS FOR ALL OF THEIR RESIDENTS
4 PERSONAL PHYSICIAN ORDER FOR EACH RESIDENT
5 NONE OF THE ABOVE
All facilities  
F_A40d Which type of vaccination program best describes what is being used in your facility for pneumonia?
Please select one.
HELP SCREEN2
1 FACILITY-WIDE STANDING ORDERS
2 PRE-PRINTED ADMISSION ORDERS
3 ADVANCE PHYSICIAN/ NURSE PRACTITIONER ORDERS FOR ALL OF THEIR RESIDENTS
4 PERSONAL PHYSICIAN ORDER FOR EACH RESIDENT
5 NONE OF THE ABOVE
All facilities  
F_A40e Has this facility developed a written plan for management of residents during an influenza pandemic? 1 NO, NOT STARTED
2 YES, IN PROGRESS
3 YES, COMPLETED
All facilities  
F_A40 Does this facility provide on-going, in-service training to personal care aides? 1 YES
2 NO
  F_A38 ≠ 0
F_A41 Prior to providing care to residents, how many hours of formal training are required of personal care aides?
READ CHOICES
No formal training
Less than 75 hours of training
75 hours of training
More than 75 hours of training
1 No formal training
2 Less than 75 hours of training
3 75 hours of training
4 More than 75 hours of training
  F_A38 ≠ 0
F_A43 In addition to helping with activities of daily living, such as dressing and assistance with medications, do personal care aides routinely perform any of the following tasks...?
Housekeeping
Janitorial services
Assistance with food preparation
Assistance with recreational activities
Residents personal laundry
Assistance with medications
Transportation or escort services for residents
1 Housekeeping
2 Janitorial services
3 Assistance with food preparation
4 Assistance with recreational activities
5 Resident's personal laundry
6 Transportation or escort services for residents
7 NONE OF THE ABOVE
  F_A38 ≠ 0
F_A44a Does this facility offer the following to personal care aides...?
health insurance that includes family coverage
1 YES
2 NO
  F_A38 ≠ 0
F_A44b (Does this facility offer the following to personal care aides...?)
health insurance for the employee only
1 YES
2 NO
  F_A38 ≠ 0 and F_A44a = 2
F_A44c (Does this facility offer the following to personal care aides...?)
life insurance
1 YES
2 NO
  F_A38 ≠ 0
F_A44e (Does this facility offer the following to personal care aides...?)
a pension, a 401(k), or a 403(b)
1 YES
2 NO
  F_A38 ≠ 0
F_A44f (Does this facility offer the following to personal care aides...?)
personal time off, vacation time, or sick leave
1 YES
2 NO
  F_A38 ≠ 0
F_A45 Does this facility pay for more than half of the personal care aide's health insurance premium? 1 YES
2 NO
  F_A38 ≠ 0 and (F_A44a or F_A44b = 1)
F_A46_Intro The next questions ask about the types of information maintained by this facility. 1 CONTINUE All facilities  
F_A46 Before or upon admission, does this facility conduct a formal functional assessment of residents using a standardized tool? Functional means physical activities of daily living, such as eating, bathing, and dressing, or cognitive functioning. 1 YES
2 NO
All facilities  
F_A47 Does this assessment include a physical assessment, cognitive assessment, or both? 1 PHYSICAL ASSESSMENT
2 COGNITIVE ASSESSMENT
3 BOTH PHYSICAL AND COGNITIVE ASSESSMENT
  F_A46 = 1
F_A48 An individual service plan details the personalized services needed by the resident and what will be provided to him or her by the facility. The service plan is usually updated regularly or as the residents' care needs change.
Does this facility develop formal individual service plans?
1 YES
2 NO
All facilities  
F_A49 Other than for accounting or billing purposes, does this facility use Electronic Health Records?
This is a computerized version of the residents health and personal information used in the management of the residents health care.
1 YES
2 NO
All facilities  
F_A49b Other than for accounting or billing purposes, does this facility have a computerized system for its Resident Service Records to keep track of the services provided to each resident?
IF NEEDED:
Resident service records are the facilitys record of the services being provided to each resident.
1 YES
2 NO
  F_A49A = 2
F_A50 HAND R SHOWCARD
Which of the following computerized capabilities does this facility have?
SELECT ALL THAT APPLY
1 RESIDENT DEMOGRAPHICS
2 MEDICAL PROVIDER INFORMATION
3 FUNCTIONAL ASSESSMENTS
4 INDIVIDUAL SERVICE PLANS
5 CLINICAL NOTES, SUCH AS MEDICAL HISTORY AND DAILY PROGRESS NOTES
6 PATIENT PROBLEMS LIST
7 MEDICATION ADMINISTRATION
8 MAINTAINING LISTS OF RESIDENT'S MEDICATIONS
9 MAINTAINING ACTIVE MEDICATION ALLERGY LIST
10 ORDERS FOR PRESCRIPTIONS
11 WARNING OF DRUG INTERACTIONS OR CONTRAINDICATIONS
12 ORDERS FOR TESTS
13 VIEWING LABORATORY/ IMAGING RESULTS
14 REMINDERS FOR GUIDELINE BASED INTERVENTIONS OR SCREENING TESTS
15 DISCHARGE and TRANSFER SUMMARIES
16 PUBLIC HEALTH REPORTING
17 NONE OF THE ABOVE
All facilities  
F_A51 HAND R SHOWCARD
Does this facilitys computerized system support electronic health information exchange with any of the following--for example, sending electronic records from this facility to a hospital?
SELECT ALL THAT APPLY
1 PHYSICIAN
2 NURSING HOME
3 HOSPITAL
4 PHARMACY
5 LABORATORY/TESTS
6 OTHER HEALTH OR LONG-TERM CARE PROVIDER
7 RESIDENT'S PERSONAL HEALTH RECORD
8 PUBLIC HEALTH REPORTING
9 CORPORATE OFFICE
10 ELECTRONIC INFORMATION IS NOT EXCHANGED
  F_A50 ≠ 17
F_A51a Does this facility's staff use any system for Electronic Point of Care Documentation? This includes PDA's (Personal Digital Assistants), Notebook PCs, or other portable hand held devices. 1 YES
2 NO
All facilities  
F_A52a_Intro The next questions involve resident demographics. 1 CONTINUE All facilities  
F_A53 As of midnight last night, how many residents are of Hispanic, Latino, or Spanish origin or descent? 0-999 All facilities  
F_A52_male As of midnight last night, what is the total number of male residents living at this facility? 0-995 All facilities  
F_A52_female As of midnight last night, what is the total number of female residents living at this facility? 0-995 All facilities  
F_A52a_1 As of midnight last night, how many residents are in the following age categories?
17 and under
0-999 All facilities  
F_A52a_2 (As of midnight last night, how many residents are in the following age categories?)
18-54
0-999 All facilities  
F_A52a_3 (As of midnight last night, how many residents are in the following age categories?)
55-64
0-999 All facilities  
F_A52a_4 (As of midnight last night, how many residents are in the following age categories?)
65-74
0-999 All facilities  
F_A52a_5 (As of midnight last night, how many residents are in the following age categories?)
75-84
0-999 All facilities  
F_A52a_6 (As of midnight last night, how many residents are in the following age categories?)
Age 85 and over
0-999 All facilities  
F_A54_1 As of midnight last night, how many residents are...?
White or Caucasian
0-999 All facilities  
F_A54_2 (As of midnight last night, how many residents are...?)
Black or African American
0-999 All facilities  
F_A54_3 (As of midnight last night, how many residents are...?)
Asian
0-999 All facilities  
F_A54_4 (As of midnight last night, how many residents are...?)
Native Hawaiian or other Pacific Islander
0-999 All facilities  
F_A54_5 (As of midnight last night, how many residents are...?)
American Indian or Alaska Native
0-999 All facilities  
F_A55_Intro The next questions ask about the cognitive, functional, and health status of residents (in the residential care component of this facility) 1 CONTINUE All facilities  
F_A55 During the last 7 days, how many of this facility's current residents had short-term memory problems or seemed disoriented all or most of the time?
This includes, for example, residents who are not able to remember things after a short while and residents who have difficulty remembering where their room is, or difficulty recognizing staff names or faces.
0-500 All facilities  
F_A56a HAND R SHOWCARD
(What percentage of the residents...)
have had an episode of urinary incontinence during the last 7 days?
1 100%
2 75-99%
3 50-74%
4 25-49%
5 11-24%
6 1-10%
7 0%
All facilities  
F_A56b (What percentage of the residents...)
are confined to a bed or chair because of health problems?
1 100%
2 75-99%
3 50-74%
4 25-49%
5 11-24%
6 1-10%
7 0%
All facilities  
F_A56c (What percentage of the residents...)
use a wheelchair or electric scooter to get around in the facility?
1 100%
2 75-99%
3 50-74%
4 25-49%
5 11-24%
6 1-10%
7 0%
All facilities  
F_A56d (What percentage of the residents...)
currently receive assistance in transferring in and out of bed or a chair?
1 100%
2 75-99%
3 50-74%
4 25-49%
5 11-24%
6 1-10%
7 0%
All facilities  
F_A56e (What percentage of the residents...)
currently receive assistance in eating, like cutting up food?
1 100%
2 75-99%
3 50-74%
4 25-49%
5 11-24%
6 1-10%
7 0%
All facilities  
F_A57a (For what percentage of the residents do you...)
manage, supervise or store medications or provide assistance with self-administration of medications?
1 100%
2 75-99%
3 50-74%
4 25-49%
5 11-24%
6 1-10%
7 0%
All facilities  
F_A57b (For what percentage of the residents do you...)
provide or arrange assistance with locomotion, that is, helping the resident walk or wheel him/herself around the facility?
1 100%
2 75-99%
3 50-74%
4 25-49%
5 11-24%
6 1-10%
7 0%
All facilities  
F_A57c (For what percentage of the residents do you...?)
provide or arrange assistance using the bathroom? This includes reminders to use the toilet, scheduled toileting, getting on or off the toilet, cleaning him/herself, arranging clothing, and changing adult incontinence supplies.
1 100%
2 75-99%
3 50-74%
4 25-49%
5 11-24%
6 1-10%
7 0%
All facilities  
F_A58 Does this residential care facility have a distinct unit, wing, or floor that is designated as a Dementia or Alzheimer's Special Care Unit? 1 YES
2 NO
  F_S3a ≠ 1
F_A59_Intro The next set of questions is about the Dementia or Alzheimer's unit, floor, or wing. When answering these questions, please answer only for that unit. 1 CONTINUE   F_A58 = 1
F_A59a In the Dementia or Alzheimer's Special Care unit, please tell me the number of licensed beds. 0-500   F_A58 = 1
F_A60 What is the current number of residents living in the Dementia/Alzheimer's unit? 0-500   F_A58 = 1
F_A61 HAND R SHOWCARD
Which of the following features does this (facility/Dementia or Alzheimers Special Care Unit) have?
1 LOCKED EXIT DOORS
2 DOORS WITH ALARMS
3 DOORS WITH KEY PADS/ELECTRONIC KEYS
4 CLOSED CIRCUIT TV MONITORING
5 PERSONAL MONITORING DEVICES
6 AN ENCLOSED COURTYARD
7 HIGHER STAFF-TORESIDENT RATIOS COMPARED TO OTHER UNITS
8 SPECIALLY TRAINED STAFF
9 DEMENTIA-SPECIFIC ACTIVITIES AND PROGRAMMING
  F_A58 = 1 or F_S3a = 1
F_BIntro The next questions will be about policies and services provided (at FACILITY NAME/by the residential care component of this facility). 1 CONTINUE All facilities  
F_B1a In terms of this facility's admission policy, do you admit a resident who...?
Is unable to leave the facility in an emergency without help
1 YES
2 NO
3 NO SPECIFIC POLICY --WE MAKE DECISIONS ON A CASE BY CASE BASIS
All facilities  
F_B3a In terms of this facility's discharge policy, do you discharge a resident who...?
Is unable to leave the facility in an emergency without help
1 YES
2 NO
3 NO SPECIFIC POLICY --WE MAKE DECISIONS ON A CASE BY CASE BASIS
  F_B1a = 2 or 3
F_B1b In terms of this facility's admission policy, do you admit a resident who...?
Has moderate to severe cognitive impairment, that is, the resident does not know who they are
1 YES
2 NO
3 NO SPECIFIC POLICY --WE MAKE DECISIONS ON A CASE BY CASE BASIS
All facilities  
F_B3b In terms of this facility's discharge policy, do you discharge a resident who...?
Has moderate to severe cognitive impairment, that is, the resident does not know who they are
1 YES
2 NO
3 NO SPECIFIC POLICY --WE MAKE DECISIONS ON A CASE BY CASE BASIS
  F_B1b = 2 or 3
F_B1c In terms of this facility's admission policy, do you admit a resident who...?
Exhibits problem behavior such as wandering, temper outbursts, or combative behavior to other residents
1 YES
2 NO
3 NO SPECIFIC POLICY --WE MAKE DECISIONS ON A CASE BY CASE BASIS
All facilities  
F_B3c In terms of this facility's discharge policy, do you discharge a resident who...?
Exhibits problem behavior such as wandering, temper outbursts, or combative behavior to other residents
1 YES
2 NO
3 NO SPECIFIC POLICY --WE MAKE DECISIONS ON A CASE BY CASE BASIS
  F_B1c = 2 or 3
F_B1d In terms of this facility's admission policy, do you admit a resident who...?
Needs skilled nursing care on a regular basis
1 YES
2 NO
3 NO SPECIFIC POLICY --WE MAKE DECISIONS ON A CASE BY CASE BASIS
All facilities  
F_B3d In terms of this facility's discharge policy, do you discharge a resident who...?
Needs skilled nursing care on a regular basis
1 YES
2 NO
3 NO SPECIFIC POLICY --WE MAKE DECISIONS ON A CASE BY CASE BASIS
  F_B1d = 2 or 3
F_B1e In terms of this facility's admission policy, do you admit a resident who...?
Needs daily monitoring for a health condition like assistance taking insulin or monitoring blood sugar
1 YES
2 NO
3 NO SPECIFIC POLICY --WE MAKE DECISIONS ON A CASE BY CASE BASIS
All facilities  
F_B3e In terms of this facility's discharge policy, do you discharge a resident who...?
Needs daily monitoring for a health condition like assistance taking insulin or monitoring blood sugar
1 YES
2 NO
3 NO SPECIFIC POLICY --WE MAKE DECISIONS ON A CASE BY CASE BASIS
  F_B1e = 2 or 3
F_B1f In terms of this facility's admission policy, do you admit a resident who...?
s regularly incontinent of urine
1 YES
2 NO
3 NO SPECIFIC POLICY --WE MAKE DECISIONS ON A CASE BY CASE BASIS
All facilities  
F_B3f In terms of this facility's discharge policy, do you discharge a resident who...?
Is regularly incontinent of urine
1 YES
2 NO
3 NO SPECIFIC POLICY --WE MAKE DECISIONS ON A CASE BY CASE BASIS
  FB1f = 2 or 3
F_B1g In terms of this facility's admission policy, do you admit a resident who...?
Is regularly incontinent of feces
1 YES
2 NO
3 NO SPECIFIC POLICY --WE MAKE DECISIONS ON A CASE BY CASE BASIS
All facilities  
F_B3g In terms of this facility's discharge policy, do you discharge a resident who...?
Is regularly incontinent of feces
1 YES
2 NO
3 NO SPECIFIC POLICY --WE MAKE DECISIONS ON A CASE BY CASE BASIS
  F_B1g = 2 or 3
F_B1h In terms of this facility's admission policy, do you admit a resident who...?
Is regularly incontinent of urine and feces
1 YES
2 NO
3 NO SPECIFIC POLICY --WE MAKE DECISIONS ON A CASE BY CASE BASIS
All facilities  
F_B3h In terms of this facility's discharge policy, do you discharge a resident who...?
Is regularly incontinent of urine and feces
1 YES
2 NO
3 NO SPECIFIC POLICY --WE MAKE DECISIONS ON A CASE BY CASE BASIS
  F_B1h = 2 or 3
F_B1i In terms of this facility's admission policy, do you admit a resident who...?
Needs two people to help them get in and out of bed or needs a Hoyer lift to get in and out of bed
1 YES
2 NO
3 NO SPECIFIC POLICY --WE MAKE DECISIONS ON A CASE BY CASE BASIS
All facilities  
F_B3i In terms of this facility's discharge policy, do you discharge a resident who...?
Needs two people to help them get in and out of bed or needs a Hoyer lift to get in and out of bed
1 YES
2 NO
3 NO SPECIFIC POLICY --WE MAKE DECISIONS ON A CASE BY CASE BASIS
  F_B1i = 2 or 3
F_B1j In terms of this facility's admission policy, do you admit a resident who...?
Has a history of drug or alcohol abuse
1 YES
2 NO
3 NO SPECIFIC POLICY --WE MAKE DECISIONS ON A CASE BY CASE BASIS
All facilities  
F_B3j In terms of this facility's discharge policy, do you discharge a resident who...?
Abuses drugs or alcohol
1 YES
2 NO
3 NO SPECIFIC POLICY --WE MAKE DECISIONS ON A CASE BY CASE BASIS
  F_B1j = 2 or 3
F_B1k In terms of this facility's admission policy, do you admit a resident who...?
Requires end of life care?
1 YES
2 NO
3 NO SPECIFIC POLICY --WE MAKE DECISIONS ON A CASE BY CASE BASIS
All facilities  
F_B3k_ In terms of this facility's discharge policy, do you discharge a resident who...?
Requires end of life care?
1 YES
2 NO
3 NO SPECIFIC POLICY --WE MAKE DECISIONS ON A CASE BY CASE BASIS
  F_B1k = 2 or 3
F_B2 Are there any (other) reasons for which you would refuse to admit someone? 1 YES
2 NO
All facilities  
F_B2sp What are these other reasons you would refuse to admit someone? SPECIFY   F_B2 = 1
F_B4 Are there any (other) reasons for which you would discharge someone? 1 YES
2 NO
All facilities  
F_B4sp What are those (other) reasons you would discharge someone? SPECIFY   F_B4 = 1
F_B5Intro Does this facility provide any of the following services to residents...? 1 CONTINUE All facilities  
F_B5a (Does this facility provide any of the following services to residents...?) Special diets 1 YES
2 NO
All facilities  
F_B5a1_1 Is this service provided by paid facility employees, other types of workers, or both? 1 FACILITY EMPLOYEES
2 OTHER TYPES OF WORKERS
3 BOTH
  F_B5a = 1
F_B5b Does this facility provide...?
Assistance with activities of daily living
1 YES
2 NO
All facilities  
F_B5b1_1 Is this service provided by paid facility employees, other types of workers, or both? 1 FACILITY EMPLOYEES
2 OTHER TYPES OF WORKERS
3 BOTH
  F_B5b = 1
F_B5c Does this facility provide...?
Assistance with a bath or shower at least once a week
1 YES
2 NO
All facilities  
F_B5c1_1 Is this service provided by paid facility employees, other types of workers, or both? 1 FACILITY EMPLOYEES
2 OTHER TYPES OF WORKERS
3 BOTH
  F_B5c = 1
F_B5d 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.
Does this facility provide...?
Skilled nursing services
1 YES
2 NO
All facilities  
F_B5d1_1 Is this service provided by paid facility employees, other types of workers, or both? 1 FACILITY EMPLOYEES
2 OTHER TYPES OF WORKERS
3 BOTH
  F_B5d = 1
F_B5e Does this facility provide...?
Basic health monitoring, such as blood pressure and weight checks.
1 YES
2 NO
All facilities  
F_B5e1_1 Is this service provided by paid facility employees, other types of workers, or both? 1 FACILITY EMPLOYEES
2 OTHER TYPES OF WORKERS
3 BOTH
  F_B5e = 1
F_B5f Does this facility provide...?
Social and recreational activities within the facility
1 YES
2 NO
All facilities  
F_B5f1_1 Is this service provided by paid facility employees, other types of workers, or both? 1 FACILITY EMPLOYEES
2 OTHER TYPES OF WORKERS
3 BOTH
  F_B5f = 1
F_B5g Does this facility provide...?
Social and recreational activities outside the facility
1 YES
2 NO
All facilities  
F_B5g1_1 Is this service provided by paid facility employees, other types of workers, or both? 1 FACILITY EMPLOYEES
2 OTHER TYPES OF WORKERS
3 BOTH
  F_B5g = 1
F_B5h Does this facility provide...?
Incontinence care
1 YES
2 NO
All facilities  
F_B5h1_1 Is this service provided by paid facility employees, other types of workers, or both? 1 FACILITY EMPLOYEES
2 OTHER TYPES OF WORKERS
3 BOTH
  F_B5h = 1
F_B5i Does this facility provide...?
Transportation to medical or dental appointments
1 YES
2 NO
All facilities  
F_B5i1_1 Is this service provided by paid facility employees, other types of workers, or both? 1 FACILITY EMPLOYEES
2 OTHER TYPES OF WORKERS
3 BOTH
  F_B5i = 1
F_B5j Does this facility provide...?
Transportation to stores and elsewhere
1 YES
2 NO
All facilities  
F_B5j1_1 Is this service provided by paid facility employees, other types of workers, or both? 1 FACILITY EMPLOYEES
2 OTHER TYPES OF WORKERS
3 BOTH
  F_B5j = 1
F_B5k Does this facility provide...?
Personal laundry
1 YES
2 NO
All facilities  
F_B5k1_1 Is this service provided by paid facility employees, other types of workers, or both? 1 FACILITY EMPLOYEES
2 OTHER TYPES OF WORKERS
3 BOTH
  F_B5k = 1
F_B5l Does this facility provide...?
Linen laundry services
1 YES
2 NO
All facilities  
F_B5l1_1 Is this service provided by paid facility employees, other types of workers, or both? 1 FACILITY EMPLOYEES
2 OTHER TYPES OF WORKERS
3 BOTH
  F_B5l = 1
F_B5m Social services counseling is counseling related to obtaining and keeping benefits provided by programs such as Supplemental Security income, Social Security, and Medicaid. Does this facility provide...?
Social services counseling
1 YES
2 NO
All facilities  
F_B5m1_1 Is this service provided by paid facility employees, other types of workers, or both? 1 FACILITY EMPLOYEES
2 OTHER TYPES OF WORKERS
3 BOTH
  F_B5m = 1
F_B5n Case management is generally a process of assessment, planning, and facilitation of options and services for an individual. Does this facility provide...?
Case management
1 YES
2 NO
All facilities  
F_B5n1_1 Is this service provided by paid facility employees, other types of workers, or both? 1 FACILITY EMPLOYEES
2 OTHER TYPES OF WORKERS
3 BOTH
  F_B5n = 1
F_B5o Does this facility provide...?
Occupational therapy
1 YES
2 NO
All facilities  
F_B5o1_1 Is this service provided by paid facility employees, other types of workers, or both? 1 FACILITY EMPLOYEES
2 OTHER TYPES OF WORKERS
3 BOTH
  F_B5o = 1
F_B5p Does this facility provide...?
Physical therapy
1 YES
2 NO
All facilities  
F_B5p1_1 Is this service provided by paid facility employees, other types of workers, or both? 1 FACILITY EMPLOYEES
2 OTHER TYPES OF WORKERS
3 BOTH
  F_B5p = 1
F_B5q Does this facility provide...?
Transportation to a sheltered workshop, work training program or supported employment
1 YES
2 NO
All facilities  
F_B5q1_1 Is this service provided by paid facility employees, other types of workers, or both? 1 FACILITY EMPLOYEES
2 OTHER TYPES OF WORKERS
3 BOTH
  F_B5q = 1
F_B5r Does this facility provide...?
Transportation to an education program
1 YES
2 NO
All facilities  
F_B5r1_1 Is this service provided by paid facility employees, other types of workers, or both? 1 FACILITY EMPLOYEES
2 OTHER TYPES OF WORKERS
3 BOTH
  F_B5r = 1
F_B5_cable Does this facility offer...?
Cable TV access in resident (rooms/apartments/rooms and apartments).
1 YES
2 NO
All facilities  
F_B5_tele Does this facility offer...?
A landline telephone in resident (rooms/apartments/rooms and apartments).
1 YES
2 NO
All facilities  
F_B5_int Does this facility offer...?
Internet access in resident (rooms/apartments/rooms and apartments).
1 YES
2 NO
All facilities  
F_B5s Does this facility have public internet access elsewhere in the facility? 1 YES
2 NO
All facilities  
F_B5_assist_a HAND R SHOWCARD
Do any of the residents use...?
An amplifier for the telephone. Please do not include a hearing aid.
1 YES
2 NO
All facilities  
F_B5_assist_b A telecommunications device for the deaf, or TDD, is an electronic device for text communication via a telephone line, used when one or more of the parties has hearing or speech difficulties. It is also referred to as a TTY or teletype. Do any of the residents use...?
TDD, TTY or teletype? Please do not include a hearing aid.
1 YES
2 NO
All facilities  
F_B5_assist_c Do any of the residents use...?
Any other types of assistive listening devices. Please do not include a hearing aid.
1 YES
2 NO
All facilities  
F_B5_assist_d Do any of the residents use...?
Signaling devices--that is, devices that can visually alert the hearing impaired person to auditory signals that may not be heard.
1 YES
2 NO
All facilities  
F_B5_assist_e A communication board is another type of device sometimes used by individuals with speech or hearing impairments. They can be plain boards that you erase or have pictures or words on them that the individual points to as a means of communication. Do any of the residents use...?
A communication board
1 YES
2 NO
All facilities  
F_B5_assist_f Do any of the residents use...?
Other equipment for people with hearing or speech impairments? Please do not include a hearing aid.
1 YES
2 NO
All facilities  
F_B7a HAND R SHOWCARD
Do you or other staff assist residents with medications in any of the following ways? Please tell me the numbers that apply from this card.
1 PROVIDING A CENTRAL LOCATION WHERE MEDICATIONS ARE STORED PRIOR TO ADMINISTRATION TO RESIDENTS
2 PROVIDING MEDICATION REMINDERS, FOR EXAMPLE, PROMPTING THAT IT IS TIME TO TAKE MEDICATIONS
3 DELIVERING PREPACKAGED UNIT DOSES
4 HELPING WITH, ADMINISTRATION FOR EXAMPLE, OPENING THE BOTTLE AND HANDING THE RESIDENT THE CORRECT DOSE
5 HELPING THE RESIDENT TAKE THE MEDICINE, FOR EXAMPLE, PUTTING IT IN THEIR MOUTH AND HANDING THE RESIDENT A GLASS OF WATER
6 PROVIDING OVERSIGHT AND CUEING TO MAKE SURE THE RESIDENT ACTUALLY TAKES THE MEDICATION
7 ADMINISTERING DROPS, TOPICAL OINTMENTS, ETC.
8 ADMINISTERING IV MEDICATIONS
9 ADMINISTERING INJECTIONS
10 OTHER TYPE OF ASSISTANCE
11 FACILITY DOES NOT ASSIST RESIDENTS WITH MEDICATIONS
All facilities  
F_B7b HAND R SHOWCARD
Who passes or hands the residents their prescription medications?
Passing medications includes the delivery of pre-packaged doses or opening the bottle and handing the resident the correct dose. Please tell me the numbers that apply from this card.
1 RN
2 LPN
3 CERTIFIED MEDICATION AIDE, MEDICATION SUPERVISOR, OR MEDICATION TECHNICIAN
4 PERSONAL CARE AIDE
5 OWNER, DIRECTOR, ASSISTANT DIRECTOR, OR MANAGER
6 OTHER
  F_B7a = 3 or 4
F_B8 Who administers prescription medications to the residents?
Administering medications includes placing the medication in residents mouths and handing them glasses of water, giving injections, giving IV medications, or applying prescription topical ointments and creams. Please tell me the numbers that apply from this card.
1 RN
2 LPN
3 CERTIFIED MEDICATION AIDE, MEDICATION SUPERVISOR, OR MEDICATION TECHNICIAN
4 PERSONAL CARE AIDE
5 OWNER, DIRECTOR, ASSISTANT DIRECTOR, OR MANAGER
6 OTHER
  F_B7a = 5, 7, 8, or 9
F_B8_lic (Is this person a licensed nurse, certified medication aide, medication supervisor, or medication technician/Are each of these individuals licensed nurses,certified medication aides, medication supervisor, or medication technician)? 1 YES
2 NO
  (F_B8 is not only 1, not only 2, and not only 1 and 2) AND (F_B7a = any selection of 5, 7, 8 or 9.)
F_B9 Does the facility have a pharmacist or doctor, either on staff or through a contract with an outside service provider, review the medications that residents receive for appropriateness? 1 YES
2 NO
All facilities  
F_B10 Does this (residential care) facility ever use physical restraints such as lap buddies, posey restraint, bed rails, or Gerry chairs? 1 YES
2 NO
All facilities  
F_B11 Do facility staffregularly give drugs to any resident to control behavior or to reduce agitation?
This includes drugs prescribed by a physician or other medical provider.
1 YES
2 NO
All facilities  
F_B12Intro The next series of questions are about charges to the resident. 1 CONTINUE All facilities  
F_B12a How is the base rate structured? Does this facility offer a flat base rate or is there a rate that varies by disability or services received? Do not include variations in charges by room type or size. 1 FLAT BASE RATE
2 BASE RATE VARIES BY DISABILITY
All facilities  
F_B12b Can the residents obtain additional services, beyond the base rate, on a fee-for-service basis? 1 YES
2 NO
All facilities  
F_B13 Is a security deposit required? 1 YES
2 NO
All facilities  
F_B14 Does this facility charge an entrance fee prior to moving in? 1 YES
2 NO
All facilities  
F_B15Intro The next questions are about the average monthly base rate for (the room/the apartment/both the room and apartment) rent and the services.
IF NEEDED: If two people are living in the same room and are related, please compute the average as if only one person lived in the room.
1 CONTINUE All facilities  
F_B15a1 What is the average monthly base rate for a single individual living in a studio apartment (for a regular, non-Alzheimer's unit)? 0-9995   F_ANEW1 = 4 & F_S3a = 2
F_B15a2 What is the average monthly base rate for a single individual living in a studio apartment for an Alzheimer's unit? 0-9995   F_ANEW1 = 4 & F_S3A or F_A58 = 1
F_B15b1 What is the average monthly base rate for a single individual living in a 1-bedroom apartment (for a regular, non-Alzheimer's unit)? 0-9995   F_ANEW1 = 5 & F_S3a = 2
F_B15b2 What is the average monthly base rate for a single individual living in a 1-bedroom apartment for an Alzheimer's unit? 0-9995   F_ANEW1 = 5 & F_S3A or F_A58 = 1
F_B15c1 What is the average monthly base rate for a single individual living in a 2-bedroom apartment (for a regular, non-Alzheimer's unit)? 0-9995   F_ANEW1 = 6 & F_S3a = 2
F_B15c2 What is the average monthly base rate for a single individual living in a 2-bedroom apartmentfor an Alzheimer's unit? 0-9995   F_ANEW1 = 6 & F_S3A or F_A58 = 1
F_B15c3 What is the average monthly base rate for a single individual living in a 3-bedroom apartment (for a regular, non-Alzheimer's unit)? 0-9995   F_ANEW1 = 7 & F_S3a = 2
F_B15c4 What is the average monthly base rate for a single individual living in a 3-bedroom apartment for an Alzheimer's unit? 0-9995   F_ANEW1 = 7 & F_S3A or F_A58 = 1
F_B15d1 What is the average monthly base rate for a single individual living in a room designed for one person (for a regular, non-Alzheimer's unit)? 0-9995   F_ANEW1 = 1 & F_S3a = 2
F_B15d2 What is the average monthly base rate for a single individual living in a room designed for one person for an Alzheimer's unit? 0-9995   F_ANEW = 1 & F_S3A or F_A58 = 1
F_B15e1 What is the average monthly base rate for a single individual living in a room designed for two persons (for a regular, non-Alzheimer's unit)? 0-9995   F_ANEW1 = 2 & F_S3a = 2
F_B15e2 What is the average monthly base rate for a single individual living in a room designed for two persons for an Alzheimer's unit? 0-9995   F_ANEW = 2 & F_S3A or F_A58 = 1
F_B15f1 What is the average monthly base rate for a single individual living in a room for three or more residents (for a regular, non-Alzheimer's unit)? 0-9995   F_ANEW1 = 3 & F_S3a = 2
F_B15f2 What is the average monthly base rate for a single individual living in a room for three or more residents for an Alzheimer's unit? 0-9995   F_ANEW = 3 & F_S3A or F_A58 = 1
F_B16Intro HAND R SHOWCARD
For the next questions, please tell me if the following services provided by this facility are included in the base rate or provided at an extra charge.
1 CONTINUE All facilities  
F_B16b Is assistance with activities of daily living included in the base rate or provided at an extra charge? 1 INCLUDED IN BASE RATE
2 PROVIDED AT EXTRA CHARGE
  F_B5b = 1
F_B16c Is assistance with a bath or shower at least once a week included in the base rate or provided at an extra charge? 1 INCLUDED IN BASE RATE
2 PROVIDED AT EXTRA CHARGE
  FB5c = 1
F_B16d Are skilled nursing services included in the base rate or provided at an extra charge? 1 INCLUDED IN BASE RATE
2 PROVIDED AT EXTRA CHARGE
  FB5d = 1
F_B16h Is incontinence care included in the base rate or provided at an extra charge? 1 INCLUDED IN BASE RATE
2 PROVIDED AT EXTRA CHARGE
  F_B5h = 1
F_B16i Is transportation to medical or dental appointments included in the base rate or provided at an extra charge? 1 INCLUDED IN BASE RATE
2 PROVIDED AT EXTRA CHARGE
  F_B5i = 1
F_B16o Is occupational therapy included in the base rate or provided at an extra charge?
CODE ALL THAT APPLY
1 INCLUDED IN BASE RATE
2 PROVIDED AT EXTRA CHARGE
  F_B5o = 1
F_B16p Is physical therapy included in the base rate or provided at an extra charge?
CODE ALL THAT APPLY
1 INCLUDED IN BASE RATE
2 PROVIDED AT EXTRA CHARGE
  F_B5p = 1
F_B17 Are privately hired nurses, aides, or private duty nurses permitted to provide services to residents? 1 YES
2 NO
All facilities  
F_B18 How many meals are included in the base rate? 1 ONE MEAL PER DAY
2 TWO MEALS PER DAY
3 THREE MEALS PER DAY
4 NO MEALS PROVIDED
All facilities  
F_B19 Are residents required to eat during a scheduled meal time? 1 YES
2 NO
All facilities  
F_B20 Are residents required to eat meals in a specific location like a dining room? 1 YES
2 NO
All facilities  
F_B21 Does this facility have residents who speak limited or no English? 1 YES
2 NO
All facilities  
F_B22 How do staff communicate with these residents? 1 CAREGIVERS ALSO SPEAK THEIR LANGUAGE 2 RELY ON FAMILY MEMBERS TO TRANSLATE
3 USE A TRANSLATION SERVICE
4 NON-VERBAL CUEING/HAND SIGNS/GESTURES
5 OTHER METHOD
  F_B21 = 1
F_C1_Intro INTERVIEWER:
ARE YOU SPEAKING WITH THE...?
1 HIGHEST RANKING ADMINISTRATOR OR DIRECTOR OF THE RESIDENTIAL CARE PORTION OF THIS FACILITY
2 SOMEONE OTHER THAN THE HIGHEST RANKING ADMINISTRATOR OR DIRECTOR OF THE RESIDENTIAL CARE PORTION OF THIS FACILITY
All facilities  
F_C1 How long have you worked at this facility as the administrator or director? Please include the total time worked even if you have left the facility and then returned. YEARS MONTHS   F_C1_Intro = 1
F_C2 How long, in total, have you worked at this and other residential care facilities or nursing homes in an administrative position? YEARS MONTHS   F_C1_Intro = 1
F_C3 Do you have a certificate or license related to managing facilities for older people? 1 YES
2 NO
All facilities  
F_C4 HAND R SHOWCARD
What position(s) do you hold at this facility?
1 Owner or Operator
2 Administrator, Manager, or Director
3 Supervisor-in-charge
4 Wellness Director
5 Director of Nursing
6 Other
  F_C1_Intro = 2
F_C4_OTH What other position do you hold at this facility? SPECIFY   F_C3 = 6
F_C5 How long has the director or administrator worked at this facility as the administrator? Please include the cumulative time worked even if they have left the facility and then returned. SPECIFY   F_C1_Intro = 2
F_C6 Does the director or administrator have a certificate or license related to managing facilities for older people? 1 YES
2 NO
  F_C1_Intro = 2
F_D1_Intro Please answer the last few questions about the highest ranking administrator or director of this residential care facility. 1 CONTINUE All facilities  
F_D1 What is the gender of the director or administrator? 1 MALE
2 FEMALE
All facilities  
F_D2 HAND R SHOWCARD
Please look at this card and tell me which range includes the administrator or directors age.
1 18-29
2 30-39
3 40-49
4 50-59
5 60-69
6 70 or older
All facilities  
F_D3 Is the administrator or director of Hispanic, Latino, or Spanish origin or descent? 1 YES
2 NO
All facilities  
F_D4 HAND R SHOWCARD
Which of these groups best describes the administrator or director?
You may select more than one category.
1 WHITE OR CAUCASIAN
2 BLACK OR AFRICAN AMERICAN
3 ASIAN
4 NATIVEHAWAIIANOR OTHER PACIFIC ISLANDER
5 AMERICAN INDIAN OR ALASKA NATIVE
All facilities  
F_D5 What is the highest grade or level of education the administrator or director completed?
Less than high school
High school graduate or GED
Vocational, trade school, or technical school graduate
Some college
College graduate
Post graduate
1 Less than high school
2 High school graduate or GED
3 Vocational, trade school, or technical school graduate
4 Some college
5 College graduate
6 Post graduate
All facilities  
F_D6a In the near future you may receive a telephone call from my supervisor at RTI International. This call is designed to verify the quality of my work and will only take a few minutes of your time. 1 CONTINUE All facilities  
F_D6 Thank you, those are all the questions for this Facility section of the interview. 1 CONTINUE All facilities  
  1. 1.Immunization Program Definitions:
    1. Facility wide standing orders: An institutional policy authorizes appropriate nursing or other non-physician staff to immunize residents by institution- or medical director-approved protocol without the need for a written or verbal order from the residents personal physician before administering the vaccine.
    2. Pre-printed admission orders: Each residents personal physician signs the facilitys preprinted admission order before administering the vaccine to the resident. The preprinted order may address the residents current vaccination needs as well as those in the future.
    3. Advance physician/nurse practitioner orders for all of their patients: Issued by an attending physician and authorizes immunization of ALL of the physicians patients who are residents of the facility.
    4. Personal physician order for each resident: Each residents personal physician is responsible for signing an individual order for every vaccine before it is administered to the resident.
  2. SEE Footnote 1.

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