Skip Navigation U.S. Department of Health and Human Services www.hhs.gov
Agency for Healthcare Research Quality www.ahrq.gov
Archive print banner
Nursing Homes in Public Health Emergencies

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.

This information is for reference purposes only. It was current when produced and may now be outdated. Archive material is no longer maintained, and some links may not work. Persons with disabilities having difficulty accessing this information should contact us at: https://info.ahrq.gov. Let us know the nature of the problem, the Web address of what you want, and your contact information.

Please go to www.ahrq.gov for current information.

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 Individual facility data will not be published and the identification requested on this cover page will be used only for ensuring response.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

 

The information on this page is archived and provided for reference purposes only.

 

AHRQ Advancing Excellence in Health Care