A. General Information
B. Facility Specifics
C. Vaccination Status
D. Physical Plant and Operations Support
E. Emergency Plan
F. Bioterrorism
Readiness and Training
G. Exercises and
Drills
H. Pharmaceutical
Stockpile
I. Logistics,
Facilities, and Security
J. Distributed Learning
Capability
K. Priority Checklist
This needs assessment is an example of the kind of survey that can be used either by planners surveying long-term care facilities within their jurisdictions or by facilities as an aid to assessing their own emergency preparedness. We recommend assembling a team of facility staff to complete and review all the survey elements.
For planners administering this assessment, it is recommended that a confidentiality statement/disclaimer be included, such as:
We will maintain the confidentiality of each respondent's data. The information will be summarized for statewide and regional planning purposes and there are no foreseeable risks to individual facilities. Individual facility data will not be published and the identification requested on this cover page will be used only for ensuring response. Thank you for your participation in this survey.
Note: AHRQ is offering this questionnaire as a model only. AHRQ is not administering this questionnaire and will not be collecting data compiled from it. Please do not send completed questionnaires or compiled data to AHRQ.
| Requested Information | |
|---|---|
| Name of Nursing Facility: | _______________________________________________________ |
| Provider Number: | _______________________________________________________ |
| City: | _______________________________________________________ |
| County: | _______________________________________________________ |
| Who is Facility's Key Contact for Emergency Preparedness? | _______________________________________________________ |
| Telephone number: | _______________________________________________________ |
| FAX Number: | _______________________________________________________ |
| E-mail: | _______________________________________________________ |
FAX or E-mail completed survey to: (FAX number here.) Questions about the survey should be directed to: (Address here. ) No Later Than: (Date here.) |
| Question No. | Question | Answer |
|---|---|---|
| A1 | Please provide the name of your facility: | _______________________________________________________ |
| A2 | Please list your nearest hospital: | _______________________________________________________ |
| A3 | Please identify the county or locality that your facility resides in: | _______________________________________________________ |
| A4 | How far is your facility from the nearest hospital with emergency services? | __ < 1 mile |
| __ 1-5 miles | ||
| __ 5-10 miles | ||
| __ > 10 miles | ||
| A5 | How many hospitals (on average) do you refer patients to? | Number _________________ |
| A6 | Please describe the primary affiliation of your facility (Check all that applies)? | __ Faith Based |
| __ Secular | ||
| __ For Profit | ||
| __ Non-Profit | ||
| __ Chain | ||
| A7 | Does your facility have a contingency plan (or procedure) for giving or receiving mutual aid/support to/from: (check all that apply) | __ A local or state emergency planning agency |
| __ A neighboring hospital or hospital system | ||
| __ Another nursing home or nursing home consortium | ||
| __ Other community health providers (home health, physicians' offices) | ||
| __ Do not have such an agreement | ||
| A8 | Do you perceive your facility as having a formal role in a community/state/federal response to an emergency situation such as a hurricane or pandemic flu situation? | __ Yes |
| __ No | ||
| __ Not Sure | ||
| A9 | Do you perceive bioterrorism as a potential concern in your region? | __ Yes |
| __ No | ||
| __ Not Sure | ||
| If yes, on a scale of 1 (not likely) to 10 (exceedingly likely), how likely do you think a bioterrorist threat is to your region? | __________ (Scale 1 to 10) | |
| A. General Information | ||
| A10 | Does your facility budget financial resources to preparedness for a disaster or mass casualty incident? | __ Yes |
| __ No | ||
| If
you answered 'No' to question A10, Skip to question A13. Otherwise, continue to question A11: Provide an estimate of your facility's expenditures in preparation for a disaster or mass casualty incident. |
||
| A11 | Estimated emergency preparedness expenditures for the last 12 months | $ __________________ |
| A12 | For which of the following activities has the facility incurred expenditures over the last 12 month period? (check all that apply) | __ training and disaster exercises |
| __ enhanced security | ||
| __ staffing reorganization | ||
| __ protocols and plans | ||
| __ physical plant changes | ||
| __ upgraded computerized IT systems | ||
| __ inter-institutional arrangements | ||
| __ increased pharmaceuticals | ||
| __ housekeeping | ||
| __ equipment purchases | ||
| __ upgraded communication | ||
| __ Other: | ||
| A13 | Estimated emergency preparedness expenditures for the next 12 months | $ __________________ |
| A14 | For which of the following activities does the facility expect to incur expenses over the next 12 month period? (check all that apply) | __ training and disaster exercises |
| __ enhanced security | ||
| __ staffing reorganization | ||
| __ protocols and plans | ||
| __ physical plant changes | ||
| __ upgraded informational systems | ||
| __ inter-institutional arrangements | ||
| __ increased pharmaceuticals | ||
| __ housekeeping and other stocks | ||
| __ equipment purchases | ||
| __ upgraded communication | ||
| __ Other: | ||
| A15 | Does your facility maintain a vendor contract with a transportation company to provide for emergency evacuation? | __ Yes |
| __ No | ||
| Continue to Section B | ||
| Question No. | Bed Category | Current Census (No. of patients) |
Licensed Beds (No. of patients) |
|---|---|---|---|
| B1 | Skilled Nursing Care | ___ | ___ |
| Assisted Living Beds | ___ | ___ | |
| Other | ___ | ___ | |
| For each of the above bed
categories, indicate: __ The facility's current census __ The number of licensed beds |
|||
| B2 | Does your facility have isolation or reverse ventilation rooms? | __ Yes | |
| __ No | |||
| __ Don't Know | |||
| B3 | If your answer to B2 is yes, how many isolation rooms are there? | Number ____________ | |
| Continue to Section C | |||
| Question No. | Question | Answer |
|---|---|---|
| C1 | Does your facility keep records on resident vaccination status? | __ Yes |
| __ No | ||
| C2 | Does your facility maintain records on employee vaccination status? | __ Yes |
| __ No | ||
| C3 | How many staff members regularly give vaccinations? (e.g., Giving intramuscular or subcutaneous injections) | Number: ______________ |
| C4 | Does your facility provide vaccination to all eligible patients against pneumonia (pneumovax)? | __ Yes |
| __ No | ||
| C5 | If your answer to C4 is yes, what percentage of patients is vaccinated against pneumonia (pneumovax)? | Number _________% (Percentage) |
| C6 | Does your facility provide vaccination to all eligible clients/patients against influenza (flu)? | __ Yes |
| __ No | ||
| C7 | If your answer to C6 is yes, what percentage of patients is vaccinated against influenza (flu)? | Number _________% (Percentage) |
| C8 | Does your facility provide vaccination against influenza (flu) to all eligible employees? | __ Yes |
| __ No | ||
| C9 | If your answer to C8 is yes, what percentage of employees is vaccinated against influenza? | Number _________% (Percentage) |
| C10 | What barriers do you perceive contribute to or prevent complete vaccination of staff against influenza? (Check all that apply) | __ Lack of interest by facility |
| __ Lack of interest by employees | ||
| __ Cost of vaccination | ||
| __ Lack of knowledge by facility as to benefits | ||
| __ Lack of knowledge by employees as to benefits | ||
| __ Other __________________ | ||
| C11 | In case of emergency, would your facility be willing to provide vaccination services to the community? | __ Yes |
| __ No | ||
| Continue to Section D. | ||
| Question No. | Question | Answer |
|---|---|---|
| D1 | Does your facility have a generator for providing emergency power? | __ Yes |
| __ No (Go to question D5) | ||
| D2 | How long could your facility supply emergency power? | Hours = _____________________ |
| D3 | Does your generator control all electrical circuits (including AC, oxygen generators)? | __ Yes |
| __ No | ||
| D4 | If your answer to D3 is no, does your generator fail to control: | __ Lights |
| __ Computer | ||
| __ Kitchen | ||
| __ Air Conditioners | ||
| __ Oxygen | ||
| __ Refrigeration | ||
| D5 | Does your facility have one or multiple ventilation systems for the building? | __ One |
| __ Multiple | ||
| D6 | Does your facility have internal capabilities for Food Preparation or do you rely on an external food distributor? | __ Internal |
| __ External | ||
| D7 | Does your facility maintain emergency rations in case food delivery cannot be made? | __ Yes |
| __ No | ||
| D8 | If your answer to D7 is no, how many days rations does your facility maintain for each patient? | Number of days _______________ |
| D9 | Does your facility have the ability to filter your own water? | __ Yes |
| __ No | ||
| __ Don't Know | ||
| D10 | Does your facility maintain bottled water in case of emergency? | __ Yes |
| __ No | ||
| __ Don't Know | ||
| D11 | If your answer to D10 is yes, how many days of bottled water does your facility have on hand? | Number of days _______________ |
| Continue to Section E. | ||
| Question No. | Question | Answer |
|---|---|---|
| E1 | Does your facility have an emergency
plan for use in case of natural disaster, act of terrorism, or infectious
disease emergency? If No, Please Skip to Section F |
__ Yes |
| __ No | ||
| __ Don't Know | ||
| E2 | Has your facility's emergency plan been reviewed by state or local officials? | __ Yes |
| __ No | ||
| __ Don't Know | ||
| E3 | Does the emergency plan call for an on-site designated command center? | __ Yes |
| __ No | ||
| __ Don't Know | ||
| E4 | If your answer to E3 is yes, does the command center have access to... (check all that apply) | __ Radio |
| __ 2-Way Radio | ||
| __ NOAA Radio | ||
| __ Telephone | ||
| __ Multiple Phone lines | ||
| __ Internet | ||
| __ TV, Local | ||
| __ TV, Cable | ||
| __ Satellite | ||
| __ Video Conferencing | ||
| E5 | In case of an emergency (after calling 911) who is your facility's first contact? | __ Medical Director |
| __ Administrative Director | ||
| __ Nursing Director | ||
| __ 911 or external source | ||
| __ Other | ||
| List: _______________________ | ||
| Does the facility's emergency plan address the following...? | ||
| E6 | Evacuation planning? | __ Yes |
| __ No | ||
| E7 | Isolation of infected patients? | __ Yes |
| __ No | ||
| E8 | Triage of casualties? | __ Yes |
| __ No | ||
| E9 | Quarantine? | __ Yes |
| __ No | ||
| E10 | Decontamination? | __ Yes |
| __ No | ||
| E11 | Contingency for power failure? | __ Yes |
| __ No | ||
| E12 | Reconfiguration of facility space for quarantine of communicable diseases and treatment of infectious disease epidemics? | __ Yes |
| __ No | ||
| E13 | Transfer of multiple or mass casualties? | __ Yes |
| __ No | ||
| E14 | Credentialing, orientation and supervision of clinicians not normally working in facility responding to a bioterrorism event or infectious disease outbreak? | __ Yes |
| __ No | ||
| E15 | Mechanisms to manage unsolicited clinical help and donated items? | __ Yes |
| __ No | ||
| E16 | An abbreviated patient registration process for disaster victims? | __ Yes |
| __ No | ||
| E17 | A process for identifying and incorporating spokespersons and/or subject matter experts to provide information to the media? | __ Yes |
| __ No | ||
| E18 | A process for sharing patient information and/or victim's lists with other hospitals/providers/public agencies? | __ Yes |
| __ No | ||
| E19 | If the answer to E18 is yes, is the process... (select one) | __ Computer-based, using internet/email connection to distribute |
| __ Paper-based, using fax/courier/runners to distribute | ||
| __ Other | ||
| __ Not Applicable | ||
| E20 | Coordination with Local or Regional Hospitals | __ Yes |
| __ No | ||
| E21 | Coordination with Local or State Emergency Planning Agencies | __ Yes |
| __ No | ||
| E22 | Coordination with Red Cross / Local Relief Agencies | __ Yes |
| __ No | ||
| Continue To Section F. | ||