Public Health Emergency Preparedness
This resource was part of AHRQ's Public Health Emergency Preparedness program, which was discontinued on June 30, 2011, in a realignment of Federal efforts.
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Appendix B: Model Long-term Care Preparedness Needs Assessment
Contents
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will not be published and the identification requested on this cover page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.
Model Long-term Care Preparedness Needs Assessment
| 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.) |
A. General Information
| 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 |
Return to Appendix B Contents
Section B. Facility Specifics
| 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 |
Return to Appendix B Contents
Section C. Vaccination Status
| 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. |
Return to Appendix B Contents
Section D. Physical Plant and Operations
Support
| 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. |
Return to Appendix B Contents
Section E. Emergency Plan
| 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. |
Return to Appendix B Contents
Proceed to Next Section
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