OMB Clea,a”ce No.68 R1500 EXPlr,tlO” date Jm”ary 1977
U.S. DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE
Public Health Swvice Health Resources Administration National Center for Health Statistics
r
(OTHER HEALTH FACILITIES)1
L --l
1976 MASTER FACILITY
INVENTORY
RETURN COMPLETEO QUESTIONNAIRE TO:
Data Preparation Branch National Center for Health Statistics USPHS, Room 200
BOX 12214
Research Triangle Park, N.C. 27709
Dear Administrator:
As part of its responsibility to provide information on the Nation’s health resources, the National Center for Health Statistics (NCHS) collects information on all custodial and remedidpre facilities inthe United St&s. ‘
The purpose of this annual survey is TO OBTAIN CURRSNT INFORMATION FROM EACH FACILITY on its ownership, staff size, number of beds andother. related facility characteristics. The information will be used to provide statistics on the number and kinds of such facilities in the United States and the CHANGES THAT OCCURRED since the last Master Facility Inventory Survey.
The information from sections A and B of thk questionnaire, as related to individual facilities or listings, will be made available upon request to the NCHS. The data from sections C and D, however, are treated asconfidential and will not be released to anyone or used in anyway other than forstitisticd summties. Thcsesummxies tillbepresented ina manner toensure that noindividua.1 facility can be identified.
Please fill out the questionnaire and return itwitbin5 days intheenclosed preaddressed envelope.
Thank you for your cooperation in this voluntary survey.
Sincerely yours,
Elijah %,. White
Associate Dkector for Data Systems National Center for Health Statistics
Enclosure
SECTION A-IDENTIFICATION OF FACILITY
Please refer to the mailing label above, then mark all additions andcorrections according to the questions below. Oetailed identification information isneedwl toprevent duplicate listings andto assure that your facility is properly represented in the survey.
1. IS the NAME shown on the mailing Iahel correct for your facility?
~ARol 1
❑
Yes cc12ZDNo-Enter correct name c
2. Is the ADDRESS drown on the mailing label the correct mailing addrass for your facility?
(
NUMBER OR BOX STREETOR ROUTE
,,13 I
❑
Yes2
❑
NO -Enter correct mailing address ~ CITY OR TOWN“(
STATE ZIP COOE COUNTY3. What is the telephone numhar of your facility?
.. 14.23 AR EACOOE NUMBER
INSTRUCTIONS FOR COMPLETING THIS FORM
1.
2.
3.
Include in this report information only forthc facility named in the mailiig label or for its SUCCESSOR if the name or owmer has changed.
Due to name and address changes, duplicate listings, or other reasons, you may receive more than one question-naire under different names or addresses. Ifyou receive more than one form forthc same facility, compkteone only and retumall others with thenotation <<Completed and”returned under. . . (give name of facility o;
cmn-pleted form and the IDENTIFICATION NUMBER
found in the upper left comer of the mailing label).”
PIease answer all applicable questions. Definitiomand special instructions are given with the questions when needed. If your am.wcr to a question is “None,” put a
4.
zero in tbeappropriate space. DO NOT LEAVE THE SPACE BLANK.
Forquestions 4, 11,and 14, data should be reported for a 12.month period, prefembly the calendar year from Ianuarv 1. 1975 throuzh December 31. 1975. Ifdatais
~or a &ff&nt 12-mo;th period tbanthis, indicatetbe time period used:
“ff”i”gd”” --J--J_
..14,25 ,.16,27 .%19
Ending date: +
cc30,31 cc 32,33 ,.34,3s (The nm.ths, days, and wan are to b. 2d@ numbers.)
SECTION B - FACILITY INFORMATION .
4.
5.
Were you in operation during all 12 months of
1975? CC36 1Y32n
23
❑
Individual Read all the c;tageries, then mark (X) the ONE boxthat BEST describaa the TYPE OF OWNERSHIP which 24
❑
Partnershipopzrates this facility. 25
❑
Corporation I❑
Church related 2321 L
22 11
w 37,3, ‘2 13 14 15 16 17 18 la
2No D
For profit
❑
Nonprofit corpaation❑
Other nonprofit ownerzhip❑
State government (_J County government❑
City government❑
City-coumy government❑
Hospital Oktrict❑
U.S. Public Health Service❑
Armed Forcm❑
Veterans Admi”iatratio”❑
Other Federal Agency-Specify ~HRA-135 (2-76)
Pw2
6. Read all the categories, then mark (X) the ONE box Residentfachty orschool for tha-that BEST describes the TYPE OF SERVICE this
facili-ty offers the MAJORITY of its residents or patients. o!
❑
Blind Enter in the comments section on the last page any 02❑
Deaf remarks you may have regardhg the correct classificationof this facility.
os
❑
Emotionally disturbed w❑
Mentally retarded05
❑
Other neurologically handicapped CM❑
Physically handicapped.————— —--- ——— —— —-—.————— —
OT
❑
Orphanage or home for dependent children ,,39,40m
❑
HOme for unwed mothers-——-————————————————————
--Residenttreatment centerfor-.
m
❑
Alcoholics 10❑
Drug abusers——————---———————-————————
I I
❑
Other facility (specify) v—
w
❑
Skilled Nursing Facility (certified under either Medicare or Medic~d)m
❑
Skilled Nursing Facility unit of a hospital 33❑
Nursing care unit of a retirement center 24❑
Sheltered or Custodial care home (include homesfor the aced)“,
35
❑
Other type of nursing home7a.
b.
What is the licensed&d capaci~ of this faciliw? cc4144
(1) HOW many of thesa beds are cartified for Medicaid as intermediate care bads? —cc4s-s8
How many beds are currently set up and staffed for use(include .mly accommodations with supporting wrvicm, such M food, Immdr), and housekeeping, for patients or residents who stai, m excess of 24
htmrs)? c,49.52
8. Does this facility ACCEPT persona of all ages, including infants and children?
. .!3
!
❑
YE.5 (Skip t,, qucstmn 9)20N0
7
a. What is the minimum age accepted?
b. What ia the maximum age accepted?
m54, 55 a 36.57
8. Does this facdity mxept---,, so
I
❑
Males only?2
❑
Females only?3 UBoth males and females?
IINA-115 (2-76) Pacrl3 R
10. Please enter below the number of residents or patients who stayed in this facility last night, by their age and sex.
Age Male Female
Under 21 cc59.62 cc S3.86
21.44 cc63.66 cc 87.s0
45.64 cc67.70 cc 91.94
65-74 cc71.74 cc 95.98
75 and over c.75.78 cc 99.102
Total patients cc79.82 cc103.106
‘ha. How many inpatient days of cars (the sum of the daily patient ceIIs:: :ount from 1/1/75 through
12/3 1/75) were rendered in 1975? cc11.17
b. How many admissions were there during 1975? cc18.23
c, How many dischar@s (including deaths) were there during 1975? m24.29
d. How many deaths warm there during 1975? ,.30.32
SECTION C – CLASSIFICATION INFORMATION (Confidential)
12. Please enter below the number of full-time and part-time employses who work in thb facility. For each tyIM of past-time employae, enter the total number of bouts worked in this faciliW over the last s-evendays. (Full-time means 35 or more hours a week.) Include owners, managers, teaching staff, resaarch workers, etaff of outpatient facilities or extended care units, temporarily absant employees, trainees (if on the payroll), and members of religious orders whether paid or unpaid.
Number of Number of Number of hours
full-time staff part-time staff worked (over tbe (35+ hours (Under 35 hours last 7 days by afl
a week) a week) part-time employee~:
Administrators and CARD3 CARD4
Assistant Adminiattators cc33.3s cc11.13 cc11.1s
Physicians cc36-ss cc14.16 ,, 1a-20
Dentists u 3941 cc17.19 cc21.25
Registered Nurses cc4244 cc 20.22 cc 2a.30
LPN or Vocational Nurs~ cc4s-67 cc 13.7. s cc 31.35
Nursing Aides, Orderlies,
and Attendants cc48.S0 cc 26-28 cc 3640
Licensed Pharmacists ccS1.S3 cc29.31 ,04145
Dietitians and
Oietetic Technicians ccw.sa ,,32.34 . . 4a.so
Occupational Therapists ccS7.59 cc35.37 m S155
Occupational Therapy
Assistants and Aides ,.34.62 w 3840 c, s6.60
Speech Pathologists
and Audiologists ,,63.6S cc 4143 ,, 61.6s
Physical Therapista cc6s.68 ,, 4446 CC66.70
Physical Therapy
Assistants and Aides cc69.71 cc4749 m 7,.7s
Recreational Therapists ,, 72.74 ccSO.S2 cc76.8~
Medical Social Workers ,, 7s.77 ccS3.5S ccS1.ns
All other health professional
and technical personnel cc7a.sO cc53-58 ,, 86.)0
All nomhealth professional
and technical personnel ,.81.83 ccS9.61 m 91.9A
Total (all employees) cc84.87 sc62.64 ,. 9a.loa
hA-135 (’I.- 76) P,.# 4
SECTION D - FINANCES (Confidential)
13. Last month, what was your basic MONTHLY chaws for a resident’slodging, meals, and routine care?
(Exclude chwges for physician services, private duty nursing, therapy, drugs, special medical supplies, special dkt, laboratory tests, andmedical equipment.)
CARDS5
Medicare patients .$ cc11-14 ~~
Medicaid patients -$ m 1s.1s ~~
All other patientc -$ cc19.22
❑ No Medicare patients
❑ No Medicaid patients
I&. What were your facility’s TOTAL OPERATING EXPENSES for the 1975 calendar year?
$ cc23.29
b. How much of these total 1975 expensss were:
(1) Payroll costs? $ C. 30.36
(2) Nonpayroll costs? (Include equipment rent, insurance, taxes and licenses, interest, depreciation, buildin~ and kmd rent, food, dregs, laundry, utilities, supplies and eq”ipm.s”t, and all other miscellaneous expenses. )
$ cc 3743
COMMENTS:
SECTION E- R ESPONOENT Name and title of person completing form Oate completed
INFORMATION
HRA-135 (2-76) P.m 5 .“ , G$”,”.. C”T?“,”1!.00,,,,, ,9,6..,,,.,,,