2015 Biennial Survey of Long-Term Care Facilities - RESIDENTIAL … · 2016. 5. 11. · 2015...
Transcript of 2015 Biennial Survey of Long-Term Care Facilities - RESIDENTIAL … · 2016. 5. 11. · 2015...
2015 Biennial Survey of Long-Term Care Facilities - RESIDENTIAL CARE FACILITIES
1/1/2015-12/31/2015
*** This is a pdf of the survey, not the RCF survey itself ***
May 2016
Dear Administrator,
The Ohio Department of Aging has once again contracted with the Scripps Gerontology Center at Miami University to conduct the Ohio Biennial Survey of Long-Term Care Facilities. Participation in this survey is mandated for all nursing homes and residential care facilities by Section 173.44 of the Ohio Revised Code.
Beyond the statutory mandate for the survey, we wanted you to know how important and useful the survey results are. Data that you provide by completing the survey questionnaire are used for, among other purposes, continuing the longitudinal study of long-term care utilization in Ohio. We have found that data from the survey are used by the General Assembly, state agencies, and long-term care facilities themselves. We need your assistance to continue this important effort.
If you are interested in findings from previous surveys, you may view the most recent report on the Scripps Gerontology Center website at:
miamioh.edu/cas/academics/centers/scripps/research/publications/2015/06/the-road-to-balance-two-decades-of-progress.html
Thank you for taking the time to complete the Biennial Survey. This survey provides the only source of information for every facility in Ohio - your participation is extremely important.
Sincerely,
Bonnie Kantor-Burman
Director, Ohio Department of Aging
Dear Colleagues,
The Biennial Survey of Long-Term Care Facilities is being conducted by the Scripps Gerontology Center at Miami University. This year’s survey has been streamlined in an effort to make it easier for you to complete and is done online. Scripps has collected and used these data to track the changes underway in the field of long-term care. Results from the study are communicated to long term care facilities by Scripps researchers through written reports and through presentations at our association meetings.
We believe that good information places providers, industry representatives, and policy makers in a better position to make good decisions about skilled nursing facilities and residential care facilities. We strongly support these data-gathering and analysis activities and feel they are highly beneficial to a better understanding of our profession, by policy makers, and the general public. We urge you to complete this important and mandated survey within the next two weeks.
Sincerely,
Kathryn BrodLeadingAge Ohio
Peter Van RunkleOhio Health Care Association
Jean ThompsonOhio Assisted Living Association
Chris MurrayThe Academy of Senior Health Sciences, Inc.
Instructions
****Please complete your survey by June 17, 2016****
-Use information from the calendar year 2015 to complete this survey.
-If your organization has both a licensed nursing home and a residential care facility, your organization will receive one survey for the nursing home and another for the RCF. Complete this survey based on information from the RCF only.
-You may save your partially completed survey and return to it another time by choosing “Save Responses” at the bottom of the page where you end your work. Return to your survey from the link in your e-mail invitation and log in with your password, which can be found in your email invitation.
-If you are using a HIPAA compliant connection or your web browser has a time-out feature, you may be logged off after a period of inactivity. Save your work often so you do not lose it.
-Use the “Back” and “Next” buttons at the bottom of the page to move through the survey, not the buttons on your browser. If you use the back or forward buttons in your browser, you may be disconnected from the survey and will lose your work.
-You may print your responses at any time by choosing the “Print responses” button on the bottom of the screen. When you choose "Print responses" a new page will appear with the entire survey displayed. You will need to allow pop-ups in your browser in order to see the screen to print your survey responses. Do not choose “Submit” until you have completed all work on your survey, printed a copy (if desired) and are ready to leave the survey. If you submit the survey before you are finished we will have to reset your survey and your work will be lost.
-If you choose to complete a paper version of the survey or want a paper copy to use as a worksheet, please print the PDF version of the survey found here:
www.cas.miamioh.edu/scripps/doc/2015_Biennial_RCF.pdf
You may mail your survey to:
Biennial Survey of LTC Facilities
Scripps Gerontology Center
Miami University
Oxford, OH 45056
If you have any questions about this survey, please call or email:
Scripps Gerontology Center1-844-850-0043
****Please complete your survey by June 17, 2016****
If any of the following information is not correct, please overwrite it with the correct information.
Q1 Name of Facility as it appeared on your license December 31, 2015
Q2 Did this name change during 2015?
Yes
No
Q3 You indicated that your facility's name changed during 2015. Please enter the previous name.
Q4 Facility e-mail address (General facility e-mail or administrator e-mail if no general email)
If we have questions about your survey responses, whom should we contact?
Q5 Contact Name
Q6 Contact Phone Number
Q7 Contact Email
Q8 Did your facility change ownership or operator during 2015?
Ownership
Operator
No change
You checked a facility ownership or operator change during 2015. If you have resident census records about your facility for only part of 2015, please provide the dates for which you have information.
Q9 From: mm-dd-yy
Q10 To: mm-dd-yy
Q11 Ownership (check appropriate category):
Not-for-profit
For-profit
Government
Q12 Is your residential care facility owned or leased by a multi-facility organization? (Two or more RCFs in different locations.)
Yes
No
Q13 Is your facility part of a Continuing Care Retirement Community? (For our purposes, a CCRC has independent living and assisted living/residential care facility along with the nursing home on the same campus.)
Yes
No
Residential Care in a CCRC
Q14 Currently, how many independent living units are there in your CCRC?
Q15 Currently, how many independent living units are occupied in your CCRC?
Q16 How many independent living units were in your CCRC at the end of 2015?
Q17 How many independent living units were occupied at the end of 2015?
Q18 Is your facility a free-standing (i.e. only RCF beds at your location) residential care facility?
Yes
No
Q19 Does your organization have both nursing home beds and residential care at this location?
Yes
No
Residential Care Facility Occupancy
Because the number of licensed beds in residential care facilities is often many more than the actual number of residents the facility intends to house, occupancy trends in residential care facilities have been difficult to track. The following questions will be used to calculate the occupancy rate for your facility.
Q20 How many residents were you licensed to care for as of 12/31/2015?
Q21 How many RCF units/apts. were in your facility as of 12/31/2015?
Q22 Did your facility have any units/apts. out of service in 2015? (By out of service we mean closed for renovation or otherwise unavailable to residents.)
Yes
No
Please describe the extent of out-of-service units and days in 2015.
Q23 During 2015, how many units were out of service at any time?
Q24 During 2015, how many total days were units out of service (i.e. if one unit was out of service for 10 days and another for 30 days, then the total days out of service is 40)
Please complete the following chart regarding your average monthly RCF number of residents and unit occupancy. Do not include residents in other levels of care. If a resident is out of the facility (vacation, hospital) but their unit is being paid for, include them in your monthly census and occupied units.
Q25 Average monthly number of residents
January 2015
February 2015
March 2015
April 2015
May 2015
June 2015
July 2015
August 2015
September 2015
October 2015
November 2015
December 2015
Q26 Occupied units
January 2015
February 2015
March 2015
April 2015
May 2015
June 2015
July 2015
August 2015
September 2015
October 2015
November 2015
December 2015
Resident Payment Source
What payment sources were accepted by your facility during 2015? Please enter a percentage of total residents during the year (no percent sign, only enter whole numbers) for each payment source. Enter 0 if no residents had this as a payment source during 2015. Questions 27 through 33 should add up to 100%.
Q27 What percentage of your residents had private pay as their primary payment source?
Q28 What percentage of your residents had the Medicaid Assisted Living Waiver as their primary payment source?
Q29 What percentage of your residents had County DD Authority as their primary payment source?
Q30 What percentage of your residents had County Behavioral Health Authority as their primary payment source?
Q31 What percentage of your residents had Veteran's Administration as their primary payment source?
Q32 What percentage of your residents had long-term care insurance as their primary payment source?
Q33 What percentage of your residents used other funds as their primary payment source?
Q34 You indicated other payment source(s). Please describe:
Your total percentage of residents by payment sources is {V2}%. This is not 100%. Please click the "Back" button to re-enter your payment source percentages.
Q35 What percentage of your residents had long-term care insurance as any (both primary and secondary) part of their payment?
Resident Admissions and Discharges
Q36 How many new residents were admitted to your facility during 2015? (Do not count as a new admission those residents who returned to your facility while still having their room held or were paying monthly fees/rent.)
Of these {Q36} 2015 move-ins, how many residents came from each of the places below? If no residents came from a place listed below, mark zero "0".
Q37 The community (include independent living in this or another retirement community/CCRC)
Q38 Another assisted living/RCF facility
Q39 A nursing home independent of this RCF
Q40 A nursing home associated with this RCF
Q41 A hospital
Q42 Other
Q43 You indicated admissions from other places. Please describe:
You indicated {Q36} residents were admitted, and {V3} came from different places. These numbers are different. Please go back and correct them on the previous page.
Q44 How many residents permanently left your facility during 2015? (Include deaths)
Of the {Q44} discharges in 2015, how many residents moved out of your RCF to go to each of the places below? If no residents went to a place below, mark zero "0".:
Q45 The community (include independent living in this or another retirement community/CCRC)
Q46 Another assisted living/RCF facility
Q47 A nursing home outside this facility
Q48 A nursing home associated with this facility
Q49 A hospital
Q50 Discharge due to death (Include deaths at the hospital if residents were still having their units/apts. held)
Q51 Other discharge places
You indicated {Q44} residents left your facility, and {V4} went to different places. These numbers do not match. Please go back and correct them on the previous page.
Q52 You indicated other discharge places. Please describe:
Q53 Of the {V1} discharges to nursing homes in 2015, how many were due to residents' skilled nursing care needs?
Q54 Of the {V1} discharges to nursing homes in 2015, how many were due to residents' high memory care/dementia needs?
Facility Rates
Of the {Q21} units/apts. in your facility, provide the number of units of each type as of December 31, 2015. If your facility doesn't have units of the type listed enter 0.
Q55 Number of: One room, private bath units in facility
Q56 Number of: One bedroom units (has separate rooms for sleeping, cooking/sitting, and bathing) in facility
Q57 Number of: Two bedroom units (has 2 separate rooms for sleeping, 1 cooking/sitting, and bathing) in facility
Q58 Number of: Private units/rooms with shared bath in facility
Q59 Number of: Semi-private units/rooms with shared or private bath in facility
Q60 Number of: Rooms with 3 or more beds, with shared or private bath in facility
Q61 Number of other units in facility
Q62 Other type of units. Please describe:
Your total number of units, according to type, is {V5}. This is not the same as your total number of units, {Q21}, stated previously. Please go back and correct your number of units by type of unit.
Q63 Do you have a memory support/dementia unit?
Yes
No
Q64 How many apts./rooms are in your memory support/dementia unit?
Q65 What is the average monthly total charge for residents in the memory unit? Please enter numbers only (no dollar signs, commas, or decimal points) rounded to the nearest whole number.
Q66 Excluding memory care, what is the average monthly private pay total charge for residents in private units? (Include average cost of services plus the average base rates among different types of private units). Please enter numbers only (no dollar signs, commas, or decimal points) rounded to the nearest whole number.
Q67 Excluding memory care, what is the average monthly private pay total charge for residents in semi-private units? (Include average cost of services plus the average base rates among different types of private units). Please enter numbers only (no dollar signs, commas, or decimal points) rounded to the nearest whole number.
Assisted Living
Do at least some of your units/apts. have all of the following features and services?
Single occupancy
Access to visitors at any time
Lockable by resident
In-unit bathroom with toilet, sink and tub or shower
Identifiable in-unit space for socialization (e.g. space for a visitor)
Stove or cooktop and refrigerator or 24-hour access to food or kitchen
Licensed nurse available to respond to residents' needs
Q68
Yes
No
Q69 In your marketing and promotional materials, do you refer to your facility as assisted living?
Yes
No
Q70 Are you participating in the Assisted Living Waiver Program?
Yes
No
Q71 To what extent do you perceive the following are barriers to your RCF's participation in the Assisted Living Waiver Program?
Client assessment process
Not a barrier at all
A little bit of a barrier
Somewhat of a barrier
A major barrier
A large enough barrier to hinder
participation
Not familiar with this aspect of the
waiver
Client enrollment process
Length of client Medicaid eligibility determination process
Facility Medicaid waiver certification process
Nurse staffing requirement
Adequacy of service reimbursement rate
Adequacy of Room and Board rate
Current occupancy levels
Compatibility of frail Medicaid residents with the type of residents already served
Q72 To what extent do you perceive the following are barriers to your facility's participation in the Assisted Living Waiver Program? (cont'd)
Additional agency oversight by Ohio Department of Aging
Not a barrier at all
A little bit of a barrier
Somewhat of a barrier
A major barrier
A large enough barrier to hinder
participation
Not familiar with this aspect of the
waiver
Additional oversight by MyCare Health Plan
Additional agency oversight by local Area Agency on Aging
Lack of evidence/history of program success
Completion of application process
Length of time to become certified as a provider
Your facility's capacity to provide nursing services
Your facility's capacity to provide medication administration
Your facility's capacity to provide things such as special diets
Your facility's ability to collect room and board from residents
Your facility's need to "subsidize" Medicaid residents with fees from other residents
Lack of Medicaid payment for temporary absence days (no bedholds)
Recent CMS rules regarding AL and HCBS settings
Q73 Other (Please describe)
Q74 What changes would improve the AL waiver program?
Q75 What changes would encourage your facility, or assisted living facilities in general, to become certified to participate in the assisted living waiver, if your facility has not already done so?
Q76 How many total residents were in your facility’s Assisted Living Waiver on December 31, 2015?
Q77 How many of these {Q76} Assisted Living waiver residents were previously private-pay residents in your facility?
Q78 Please rate your local Area Agency on Aging on the following aspects of the Assisted Living Waiver process:
Assistance with the waiver provider certification process
Very Good
Good
Poor
Very Poor
Case manager's assistance with resident enrollment
Ongoing case management monitoring and assistance
Q79 Anything else we should know about your experience with the Area Agency on Aging?
MyCare
Q80 Does your facility have experience with MyCare Ohio?
Yes
No
In the last 3 months, to what extent have each of the issues below been a challenge in implementing and participating in MyCare for your facility?
Q81
Timeliness of payment
Not a challenge
A little bit of a challenge
Somewhat of a challenge
Major challenge
Not familiar with issue
Transportation providers Policies and procedures vary by MyCare plan
Resident identification as a member of a MyCare plan
Communication with plans
Q82 If there are other challenges, please describe:
Q83 If you could change one thing about MyCare Ohio, what would it be?
Resident FunctioningPrevious questions asked you to report on 2015. Use information about your current residents to complete the following questions.
Q84 How many residents currently reside in your RCF?
How many current residents received assistance in the previous week with the following?
Q85 Bathing
Q86 Dressing
Q87 Walking
Q88 Transferring (e.g. bed to chair)
Q89 Toileting
Q90 Eating
Q91 Medication assisting by an aide (e.g. opening bottles, reminders, but NOT administering)
Q92 Medication administration by a licensed nurse
Q93 How many need assistance with 2 or more of the activities above or require extensive monitoring or supervision due to cognitive impairments?
Q94 How many current residents use a mobility device (e.g. walker, wheelchair, or scooter)?
Q95 How many current residents usually exhibit moderate to severe cognitive impairment (make poor decisions, require extensive supervision, or never/rarely make decisions about their daily lives)?
Q96 How many current residents have a diagnosis of severe mental illness (e.g. schizophrenia, bipolar disease)?
Q97 How many current residents receive part-time exempted skilled care in your RCF? (i.e. dressing changes, medication administration, and supervision of special diets)
Q98 How many current residents receive skilled nursing care through a home health agency?
Q99 How many current residents receive hospice services?
Q100 How many current residents have behavior issues (e.g. socially inappropriate behavior, verbally or physically abusive)?
Q101 How many current residents have behavioral issues as a result of dementia?
How many residents reside in a designated behavioral health unit of the following types?
Q102 Secured
Q103 Unsecured
Employee Safety
This section provides aggregate information regarding the extent to which employee injuries are an issue for Residential Care Facilities in Ohio.
Please report the following summary values from the OSHA Form 300A that you filed in the first quarter of 2016 if it includes information only for your RCF. Letters and numbers in ( ) refer to the item on OSHA Form 300A. If you file another similar form, please provide comparable information here. Include only information for staff in your RCF.
Aggregate Employment Information for 2015
Q104 Total number of RCF employees paid in all pay periods. (Include part-time, contract, and any other paid staff. Round to the highest whole number).
Q105 Total hours worked by all RCF employees last year - sum of hours paid in all pay periods.
Number of cases
Q106 Total number of RCF employee injuries with days away from work (H).
Q107 Total number of RCF employee injuries with job transfer or restriction (I).
Q108 Total number of other recordable cases (J). (Recordable cases as defined by OSHA on Form 300A include work-related injuries and illnesses that result in death, loss of consciousness, days away from work, restricted work activity or job transfer, or medical treatment beyond first aid.)
Number of cases
Q109 Total number of days away from work (K).
Q110 Total number of days of job transfer or restriction (L).
Injuries and Illness Types
Q111 Total number of injuries (1).
Q112 Total number of other illnesses (2-6). (Recordable cases as defined by OSHA on Form 300A include work-related injuries and illnesses that result in death, loss of consciousness, days away from work, restricted work activity or job transfer, or medical treatment beyond first aid.)
Q113 Does your facility have a written policy about lifting residents?
Yes
No
Facility Staffing
Q114 What pay schedule is used for the majority of your employees?
a. Monthly
b. Semi-monthly (e.g. 15th and 31st)
c. Bi-weekly (e.g. every other Friday)
d. Weekly (e.g. every Friday)
Q115 What is the minimum number of hours worked per pay period to be considered full-time?
Report the total number of hours worked by employees in your facility in each category for the first payroll period in 2015.
RNs in the RCF
Q116 Total RN hours (Include all hours during the pay period worked by full-time, part-time, and other RNs employed by your facility - not contract hours)
Q117 Total RN contract hours (Include contract, agency, contingent or other "as needed" RNs)
LPNs in the RCF
Q118 Total LPN hours (Include all hours during the pay period worked by full-time, part-time, and other LPNs employed by your facility - not contract hours)
Q119 Total LPN contract hours (Include contract, agency, contingent or other "as needed" LPNs)
Q120 How many RNs/LPNs were employed during the first payroll period of 2015?
Q121 Of the {Q120} RNs/LPNs employed during the first payroll period of 2015, how many of the same RNs/LPNs were employed during the last payroll period of 2015?
Other direct care frontline staff (e.g. Personal Care Aides, Resident Assistants, Medication Aides, STNAs)
Q122 Total direct care staff hours (Include all hours during the pay period worked by full-time, part-time, and other direct care staff employed by your facility - not contract hours
Q123 Total contract aide hours (Include contract, agency, contingent or other "as needed" aides)
Q124 How many other direct care frontline staff (e.g. Personal Care Aides, Resident Assistants, Medication Aides, STNAs) were employed during the first payroll period of 2015?
Q125 How many other direct care frontline staff (e.g. Personal Care Aides, Resident Assistants, Medication Aides, STNAs) were employed during the last payroll period of 2015?
Q126 Do you have a calculated annual turnover rate for your facility as a whole?
Yes
No
Q127 What is your turnover rate? Round to nearest whole number. No percent sign, no decimal point please.
Q128 Do you have a calculated annual turnover rate for your RNs/LPNs?
Yes
No
Q129 What is your RN/LPN turnover rate? Round to nearest whole number. No percent sign, no decimal point please.
Q130 Do you have a calculated annual turnover rate for your other direct care frontline staff (e.g. Personal Care Aides, Resident Assistants, Medication Aides, STNAs)?
Yes
No
Q131 What is your other direct care frontline staff turnover rate? Round to nearest whole number. No percent sign, no decimal point please.
Social Service Staff
Q132 Do you have a licensed social worker on your staff?
Yes
No
Q133 Total hours worked by all full-time, part-time and other social service staff employed AND contracted by your facility.
Facility Leadership
Q134 Do you have a Director of Nursing in your RCF?
Yes
No
What is the start date of your current Director of Nursing?
Q135 Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
--Click Here--
Q136 Year (YYYY) Q137 How many Directors of Nursing (including the current one) has your facility had since 2013?
Q138 Is the administrator a licensed nursing home administrator?
Yes
No
What is the start date of your current administrator?
Q139 Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
--Click Here--
Q140 Year (YYYY) Q141 How many administrators (including the current one) has your facility had since 2013?
Guardianship
Q142 As of April 1, 2016, how many residents have court-appointed legal guardians?
In your estimation, what proportion of those guardians are (enter whole numbers, no percent signs):
Q143 Resident's family member or friend
Q144 Professional guardians
Q145 Volunteer or paid guardians from a county guardianship program
Q146 Don't know
Q147 When you determine a resident needs a guardian, how difficult is it to secure one?
Not difficult
Somewhat difficult
Very difficult
Hospital Readmissions
Q148 Are you working on any programs to reduce hospital readmissions or admissions?
Yes
No
Q149 To what extent are each of the following entities your partners in reducing hospitalizations and hospital readmissions? Check all partnership agreements/arrangements that apply.
Individual physician(s) or physician practice(s)
Do not work with this group
Formal partnership such as memo of
understanding, contract, business partnership
Informal Partnership
Individual hospitals Hospital or health care system Local or regional hospital council/consortium
Health information exchange/electronic health record consortium
Accountable Care Organization(s) Medicaid managed care organization Medicare Advantage organization Area Agency on Aging Nursing home(s) Assisted living facility(s) Home care agencies Hospice agencies Pharmacy or pharmacist Veteran’s Administration (home care services contracts, VA medical centers)
Q150 If there are any other partners, please describe:
Q151 For each activity described below, please indicate the extent to which you and/or your network of partners have made progress in reducing hospital readmissions and avoidable admissions?
Developed a clear understanding of new healthcare regulations and initiatives
Do not plan to work on this
Plan to work on this but have not
begun
Have begun working on this
but have not completed the
activity
Have completed the activity or
implemented the practice
Chose or developed an evidence-based practice model
Hired new personnel or retrained current staff to implement new program(s)
Developed strategies for effective communication of patient information among providers
Developed/purchased technology or record systems for access across multiple providers
Participating in alternative payment approach (e.g. risk-based payments, bundled payments)
Developed tools for monitoring patient outcomes
Developed marketing and advertising plan for new networks/partnership
Developed a plan for measuring/ensuring quality
Treated patients/residents under this new model of care
Q152 What specific evidence-based transition programs do you use? Check all that apply.
Interventions to Reduce Acute Care Transfers (INTERACT)
Other evidence-based program
Our program is not based on any current evidence-based model; ours is a hybrid of existing models or newly developed for us
Don't know
Q153 You indicated other evidence-based program. Please specify:
Q154 To what extent are the following issues challenges or barriers to collaborative efforts with acute care and other long-term care providers in order to reduce hospital readmissions and avoidable admissions?
Lack of a common language
Not a barrier
Little bit of a
barrier
Somewhat of a
barrier
Major barrier
Enough to stop
efforts
Not familiar with the
issue
Lack of common understanding of proposed programs/services
Differences in technology availability between our facility and acute care providers
Resistance of hospital/health care staff to working with RCFs
Additional funds to implement changes/plans( e.g. new staff, new EMR system)
Lack of time to implement changes/make new plans
Establishing fair and sufficient reimbursement rates
Establishing new billing methods/systems
Confusion with billing and bundled payments
Unwillingness of our health care partners to take financial risk
Competition within the healthcare community
Slow, inconsistent or unreliable payment
Q155 To what extent are the following issues challenges or barriers to collaborative efforts with acute care and other long-term care providers in order to reduce hospital readmissions and avoidable admissions?
Competition within the long-term care community
Not a barrier
Little bit of a
barrier
Somewhat of a
barrier
Major barrier
Enough to stop
efforts
Not familiar with the
issue
Health care system expectations regarding our RCF’s financial resources
Unwillingness of our own facility/board or corporate office to take financial risk
Our facility’s lack of expertise with outreach and marketing to acute care patients
Attitudes of health care professionals towards RCFs and/or our facility
Attitudes of our RCF staff toward health care community
Lack of clarity regarding division of labor between our facility and other partners
Determining leadership within the partnership
Lack of clarity regarding program accountability
Legal issues/agreements that will be needed
Lack of data sharing Resources required for new training of staff
Lack of physical facilities to accommodate acute care needs
Q156 If there are other challenges or barriers to collaborative efforts, please describe:
Emergency Issues and Planning
Q157 During the past 12 months has your facility experienced any of the following? (Check all that apply)
Power outage of more than 12 hours
Water outage of more than 12 hours
Flooding which impacted your facility
A fire
An event that required you to lock-down your facility
A need to evacuate residents to another facility
A need to evacuate residents to another section of your facility
Another emergency that damaged your facility and/or impacted your residents
Q158 You indicated another emergency. Please describe:
Q159 Does your facility have an emergency plan?
Yes
No
Q160 Has your facility reviewed its emergency plan ?
Yes
No
Q161 When did your facility last review its emergency plan (MM/YYYY)?
Q162 Has your facility conducted an emergency planning exercise?
Yes
No
Q163 When did your facility last conduct an emergency planning exercise? (MM/YYYY)?
Q164 Did you work with any of the following local partners to develop your emergency plan ? (Check all that apply)
Local emergency management agency
Local hospital
Area Agency on Aging
Fire department
Police department
Nursing home(s)
Senior center(s)
Ambulance companies
American Red Cross
YMCA
Public health department
Utility (electric, water) provider
Other
Did not work with any local partners to develop emergency plan
Q165 You indicated other local partner. Please describe:
Q166 Did you work with any of the following local partners to conduct an emergency plan exercise? (Check all that apply)
Local emergency management agency
Local hospital
Area Agency on Aging
Fire department
Police department
Nursing home(s)
Senior center(s)
Ambulance companies
American Red Cross
YMCA
Public health department
Utility (electric, water) provider
Other
Did not work with any local partners to conduct emergency plan exercise
Q167 You indicated other local partner. Please describe:
Q168 Have you discussed your facility's emergency plan with your area's representative of the Office of the State Long-Term Care Ombudsman program?
Yes
No
Q169 In Ohio, there are 7 regional healthcare coalitions (one in each of the state's Homeland Security Regions), which focus on preparedness-planning activities, and primarily comprised of public health, emergency management, and healthcare organizations. Has your facility been contacted by or been engaged with your regional coalition?
Yes, our facility has had contact and has worked with our regional healthcare coalition
Yes, our facility has had contact, but has not begun working with our regional healthcare coalition
No, our facility has not had contact with our regional healthcare coalition
Not sure
Emergency Supplies
For how many days does your facility store an emergency supply of each of the items below? If you do not have emergency supplies, mark “0”.
Q170 A supply of bottled water:
Q171 Do you hold an agreement with supplier(s) to provide additional bottled water during an emergency?
Yes
No
Q172 Extra medical supplies and equipment:
Q173 Do you hold an agreement with supplier(s) to provide additional medical supplies and equipment during an emergency?
Yes
No
Q174 Extra pharmacy stocks of common medications:
Q175 Do you hold an agreement with supplier(s) to provide additional common medications during an emergency?
Yes
No
Q176 Non-perishable foods:
Q177 Do you hold an agreement with supplier(s) to provide additional non-perishable foods during an emergency?
Yes
No
Q178 Does your facility have a back-up generator?
Yes
No
Q179 What type of fuel does it use
Propane
Natural gas
Gasoline
Diesel fuel
Q180 Is your facility wired to accept a portable generator?
Yes
No
Q181 How many days’ supply of generator fuel do you have on hand?
Q182 Does your facility have other forms of communication in place (walkie-talkies, ham radios, text messaging systems, etc.) in the event of telephone and cellular failure?
Yes
No
Emergency Plan Details
Q183 Does your plan include specific actions to be taken for the following hazards or emergencies? (Check all that apply)
Freezing temperatures/loss of heat
Extreme heat/loss of air conditioning
Facility flooding
Facility fire
Tornado/windstorm
Extended loss of power
Hostile action (active shooter, etc.)
Q184 Does your plan address specific actions to be taken for indirect hazards (those that affect the community, but not the facility and as a result interrupt necessary utilities, supplies or staffing) such as impassable roads or wildfires?
Yes
No
Q185 Does your plan have communication procedures to inform staff, families, and individuals receiving care, before, during, and after an emergency?
Yes
No
Sheltering in Place
Procedures to shelter in place ensure that there is water, extra pharmacy stocks of common medications, and extra medical supplies to last at least 7 days.
Q186 Does your emergency plan address procedures to shelter in place?
Yes
No
Q187 Do the procedures specify: (Check all that apply)
Need to communicate with local agencies about the decision to shelter in place
Requirements for sufficient staffing levels during emergencies
Plans for assisting/accommodating staff families and pets
Triggers to move from sheltering in place to evacuation
Evacuation Procedures
Q188 Does your emergency plan address evacuation procedures?
Yes
No
Q189 Do the procedures specify: (Check all that apply)
Agreements or contracts with hospitals to shelter high-acuity residents
Agreements or contracts with other pre-determined evacuation sites with suitable space, utilities, security and sanitary facilities for individuals receiving care and staff
Agreements or contracts with appropriate transportation providers during evacuation (e.g. accommodate wheelchairs) with assurances that they are capable of providing service even if the emergency affects an entire area (e.g. their staff, vehicles and other vital equipment are not overbooked)
How medication and other supplies will be transported during evacuation
How water will be transported during evacuation
How resident information will be transferred with resident
A strategy for tracking residents during relocation
Mode for transferring resident information during evacuation
Whether/how staff will be deployed if residents move to another facility
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