| Question No. | Question | Answer |
|---|---|---|
| F1 | Does the facility have a system
in place for early recognition of patients exposed to (check all
that apply): |
__ Biological agents |
| __ Chemical agents | ||
| __ Radiological agents | ||
| __ Nuclear agents | ||
| __ None of these | ||
| F2 | Does the facility have a system in place for training staff in the care of contaminated patients (check all that apply): | __ Biological |
| __ Chemical | ||
| __ Radiological | ||
| __ Nuclear | ||
| __ None of these | ||
| F3 | Does the facility have annual safety education that includes training to facility employees on (check all that apply): | __ Bioterrorism |
| __ Weapons of Mass Destruction | ||
| __ Chemical Contamination | ||
| __ Infectious Disease Outbreak | ||
| __ Radiological Disaster | ||
| __ Nuclear Disaster | ||
| __ None of these | ||
| F4 | Does the facility have general orientation that includes training to new facility employees on (check all that apply): | __ Bioterrorism |
| __ Weapons of Mass Destruction | ||
| __ Chemical Contamination | ||
| __ Infectious Disease Outbreak | ||
| __ Radiological Disaster | ||
| __ Nuclear Disaster | ||
| __ None of these | ||
| Continue to Section G. | ||
Which of the following exercises or drills (actual or staged), whether held at the facility or elsewhere, have staff participated in some or all over the past 12 months? (check all that apply)
Definitions:
Table Top = Simulations or Classroom exercises
Facility Drills = Actual exercises at your facility
Community Drills = Exercises run by area hospitals or community organizations
Real Event = An actual real life occurrence
| Question No. | Question | A Table Top (or Class Room) Exercises |
B Facility Drills |
C Community Wide Drill |
D Real Wide Drill Event |
|---|---|---|---|---|---|
| G1 | Mass Casualty | __ | __ | __ | __ |
| G2 | Chemical | __ | __ | __ | __ |
| G3 | Biological | __ | __ | __ | __ |
| G4 | Radiological | __ | __ | __ | __ |
| G5 | Nuclear | __ | __ | __ | __ |
| G6 | Bomb Threat or Terrorist Threat | __ | __ | __ | __ |
| G7 | Evacuation Drills | __ | __ | __ | __ |
| G8 | Utility Failures: telephone, water, electric, computer, sewer, HVAC, etc. | __ | __ | __ | __ |
| G9 | Hostage/Barricade | __ | __ | __ | __ |
| G10 | Extreme Weather (Hurricane, etc.) | __ | __ | __ | __ |
| Question No. | Question | Answer |
|---|---|---|
| G12 | Has the facility conducted drills during the following times or under the following circumstances? (check all that apply) | __ Day shift (7AM-3PM) |
| __ Evening Shift (3PM-11PM) | ||
| __ Night Shift (11PM-7AM) | ||
| __ Weekend (Saturday, Sunday) | ||
| G13 | Within the last 3 years, has the facility performed a staff recall to determine the number of staff who could report to work in the event of an emergency? | __ Yes |
| __ No | ||
| Continue to Section H. | ||
| Question No. | Question | Answer |
|---|---|---|
| H1 | Does your facility keep stocks of antibiotics on site for emergency use? | __ Yes |
| __ No | ||
| __ Don't Know | ||
| H2 | Does your facility keep Intravenous (IV) fluids on site for emergency use? | __ Yes |
| __ No | ||
| __ Don't Know | ||
| H3 | Does your facility maintain oxygen on site for emergency use? | __ Yes |
| __ No | ||
| __ Don't Know | ||
| H4 | Does your facility maintain respiratory bronchodilators (albuterol nebulizers) on site for emergency use? | __ Yes |
| __ No | ||
| __ Don't Know | ||
| Continue to Section I. | ||
| Question No. | Question | Answer |
|---|---|---|
| I1 | Does your facility require all staff to wear ID badges? | __ Yes |
| __ No | ||
| I2 | Are the facility's security staff (check all that apply): | __ Facility-Employed |
| __ Contracted | ||
| __ Facility does not have security staff (If so, skip to Section K) | ||
| I3 | Is the facility's Security Department staffed 24/7? | __ Yes |
| __ No | ||
| I4 | Does the facility have a procedure
in place to lock down all exterior doors within 30 minutes, without requiring
"outside" personnel? (If no, skip to Section K) |
__ Yes |
| __ No | ||
| I5 | The lock down procedure includes notification of (check all that apply): | __ Personnel in the building |
| __ Fire, Police, and EMS | ||
| __ Area hospitals | ||
| __ Medical Director/Administration | ||
| Continue to Section J. | ||
| Question No. | Question | Answer |
|---|---|---|
| J1 | Does your facility have a computer with Internet access? | __ Yes | __ No |
| J2 | If yes, please estimate the number of computers with Internet access | Number _____________ |
| J3 | How are the facility's PCs connected to the Internet? (check all that apply) | __ Dial Up |
| __ High Speed (DSL/Cable) | ||
| __ Dedicated T1/ISDN | ||
| __ Combination of above | ||
| J4 | Which of the following people have access to computers with internet access (check all that apply) | __ Administrator |
| __ Medical Director | ||
| __ Billing Staff | ||
| __ Nursing Director | ||
| __ Staff RNs | ||
| __ Staff LPNs | ||
| __ Physicians | ||
| __ Patients | ||
| __ Other (Please list) _________________ | ||
| J5 | Does your facility provide employees with E-mail access? | __ Yes |
| __ No | ||
| J6 | Does the facility have video-conferencing capability? | __ Yes |
| __ No | ||
| J7 | Does the facility have a fax machine? | __ Yes |
| __ No | ||
| J8 | Does the facility have a "Power
safe" emergency phone? (i.e. a phone that does not require electrical power) |
__ Yes |
| __ No | ||
| J9 | Facility computers can be used for which of the following? (check all that apply) | __ E-mail |
| __ Web Access | ||
| __ Care Plan Access | ||
| __ Looking up labs reports | ||
| __ Looking up radiology reports | ||
| __ Documentation (H & Ps) | ||
| __ MDS Entry | ||
| __ Electronic Order Entry | ||
| __ MAR (medication) use | ||
| Continue to Section K. | ||
Indicate the facility's priorities in getting financial or other training/education or technical assistance for emergency preparedness using a 5-point scale where 1 indicates highest priority and 5 indicates lowest priority. It is important to distinguish higher priority from lower priority and not mark all items "Highest Priority."
| Question No. | Preparedness Category | Financial | Technical or Training/Education | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| Highest Priority 1 |
2 | 3 | 4 | Lowest Priority 5 |
Highest Priority 1 |
2 | 3 | 4 | Lowest Priority 5 |
||
| K1 | Implementing an Emergency Incident Command System | __ | __ | __ | __ | __ | __ | __ | __ | __ | __ |
| K2 | Conducting or Participating in Emergency Exercises | __ | __ | __ | __ | __ | __ | __ | __ | __ | __ |
| K3 | Training Staff in Emergency Procedures | __ | __ | __ | __ | __ | __ | __ | __ | __ | __ |
| K4 | Diagnosis and Treatment of Victims of Chemical Agents | __ | __ | __ | __ | __ | __ | __ | __ | __ | __ |
| K5 | Diagnosis and Treatment of Victims of Biological Agents | __ | __ | __ | __ | __ | __ | __ | __ | __ | __ |
| K6 | Diagnosis and Treatment of Victims of Radiological Agents | __ | __ | __ | __ | __ | __ | __ | __ | __ | __ |
| K7 | Evacuation Planning (during storms, etc.) | __ | __ | __ | __ | __ | __ | __ | __ | __ | __ |
| K8 | Staff/Family Protection (vaccination, logistical arrangements, etc.) | __ | __ | __ | __ | __ | __ | __ | __ | __ | __ |
| K9 | Regional Planning with Other Institutions, such as Red Cross, EMAs, or Other Government Agencies | __ | __ | __ | __ | __ | __ | __ | __ | __ | __ |
| K10 | Formalizing Mutual Aid Agreements | __ | __ | __ | __ | __ | __ | __ | __ | __ | __ |
| K11 | Enhancing Patient Care Surge Capacity | __ | __ | __ | __ | __ | __ | __ | __ | __ | __ |
| K12 | Selecting and Purchasing Personal Protective Equipment (PPE) | __ | __ | __ | __ | __ | __ | __ | __ | __ | __ |
| K13 | Upgrading Respiratory Isolation Capacity | __ | __ | __ | __ | __ | __ | __ | __ | __ | __ |
| K14 | Upgrading Emergency Power Capability | __ | __ | __ | __ | __ | __ | __ | __ | __ | __ |
| K15 | Other Physical Plant Improvements (list below and rate): | ||||||||||
| K15A | (user input—other physical plant improvements) | __ | __ | __ | __ | __ | __ | __ | __ | __ | __ |
| K15B | (user input—other physical plant improvements) | __ | __ | __ | __ | __ | __ | __ | __ | __ | __ |
| K15C | (user input—other physical plant improvements) | __ | __ | __ | __ | __ | __ | __ | __ | __ | __ |
| K16 | Increasing Emergency Stockpiles of Medications and Other Supplies | __ | __ | __ | __ | __ | __ | __ | __ | __ | __ |
| K17 | Upgrading Communications Equipment | __ | __ | __ | __ | __ | __ | __ | __ | __ | __ |
| K18 | Upgrading Security Arrangements | __ | __ | __ | __ | __ | __ | __ | __ | __ | __ |
Comments:
Thank you for participating in the Long-term Care Emergency Preparedness Needs Assessment.