Public Health Emergency Preparedness

Appendix B: Model Long-term Care Preparedness Needs Assessment (continued)

Section F. Bioterrorism Readiness and Training

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.

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Section G. Exercises and Drills

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.

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Section H. Pharmaceutical Stockpile

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.

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Section I. Logistics, Facilities, and Security

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.

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Section J. Distributed Learning Capability

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.

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Section K. Priority Checklist

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	__	__	__	__	__	__	__	__	__	__

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