COVID Bundle: Questionnaire

IPRO, your friendly quality improvement organization (QIO) is here to help. Along with education, technical assistance and resources, we keep providers current on changes and updates coming out of CMS. Currently, an area of special focus is ensuring that all providers have updated COVID policies and training. Please take a few moments to complete these questions.

Question Title

* 1. Today's Date

Date:

Date

Question Title

* 2. Your Name

Question Title

* 3. Your Telephone Number

Question Title

* 4. Your Email Address

Question Title

* 5. List the Organization Name. If completing for multiple facilities, please list each.

Organization 1: Name

Organization 2: Name

Organization 3: Name

Question Title

* 6. What is the CCN for each organization? - I don't know my CCN?

Organization 1: CCN

Organization 2: CCN

Organization 3: CCN

Question Title

* 7. State (This organization is in the State of ...)

Organization 1: State

Organization 2: State

Organization 3: State

Question Title

* 8. Do you have an established/documented safe visitor policy?

Yes

Question Title

* 9. Do you have an established/documented cohorting plan?

Yes

Question Title

* 10. Have 75% of staff, both managers and frontline staff completed an Infection Prevention & Control training program?

Yes

Question Title

* 11. If you know which one, please add below:

CDC's Project Firstline Training

CMS' Scenario-Based Training for Frontline Staff & Managers

The Infection Prevention & Control Modules on the following platforms (Relias, Healthstream, Healthcare Academy)

AHRQ ECHO National Nursing Home COVID-19 Action Network

A Program designed by your organization or corporation

Question Title

* 12. Do you have an Emergency Preparedness Plan (EPP)?

Yes

Question Title

* 13. Within the last year, have you reviewed your EPP?

Yes

Question Title

* 14. Have you completed the Risk Assessment within the last year?

Yes

Question Title

* 15. Does your plan outline individual roles, both clinical and non-clinical, during an emergency?

Yes

Question Title

* 16. Do you have an agreement with community facilities and transportation?

Yes

Question Title

* 17. Does your facility have a post-evacuation plan/policy?

Yes

Question Title

* 18. Does your EPP have an elopement policy (lost/missing resident)?

Yes

Question Title

* 19. Do you have a communication plan?

Yes

Question Title

* 20. Are you training all staff members upon hire, annually, and with changes?

Yes

Question Title

* 21. Does your facility conduct a Full-Scale, Functional Exercise, or Table-Top Exercise at least once annually?

Yes

Question Title

* 22. Is a Hazard Vulnerability Assessment (HVA) completed and used to identify potential gaps in your EPP?

Yes

COVID Bundle: Questionnaire

Question Title

* 1. Today's Date

Question Title

* 2. Your Name

Question Title

* 3. Your Telephone Number

Question Title

* 4. Your Email Address

Question Title

* 5. List the Organization Name. If completing for multiple facilities, please list each.

Question Title

* 6. What is the CCN for each organization? - I don't know my CCN?

Question Title

* 7. State (This organization is in the State of ...)

Question Title

* 8. Do you have an established/documented safe visitor policy?

Question Title

* 9. Do you have an established/documented cohorting plan?

Question Title

* 10. Have 75% of staff, both managers and frontline staff completed an Infection Prevention & Control training program?

Question Title

* 11. If you know which one, please add below:

Question Title

* 12. Do you have an Emergency Preparedness Plan (EPP)?

Question Title

* 13. Within the last year, have you reviewed your EPP?

Question Title

* 14. Have you completed the Risk Assessment within the last year?

Question Title

* 15. Does your plan outline individual roles, both clinical and non-clinical, during an emergency?

Question Title

* 16. Do you have an agreement with community facilities and transportation?

Question Title

* 17. Does your facility have a post-evacuation plan/policy?

Question Title

* 18. Does your EPP have an elopement policy (lost/missing resident)?

Question Title

* 19. Do you have a communication plan?

Question Title

* 20. Are you training all staff members upon hire, annually, and with changes?

Question Title

* 21. Does your facility conduct a Full-Scale, Functional Exercise, or Table-Top Exercise at least once annually?

Question Title

* 22. Is a Hazard Vulnerability Assessment (HVA) completed and used to identify potential gaps in your EPP?

Question Title

* 23. Have you attended any state, local, or national COVID education programs in the last 18 months?

Question Title

* 24. Do you need support or resources with your EPP?

Question Title

* 25. If yes, how can we help?