QIPMO ALF/RCF COVID-19 Survey

Thank you for taking the time to complete this survey. The QIPMO COVID Accountability Team (CAT) is trying to determine what is happening in the RCF and ALF side of Long-Term Care and if there is anything we can do to help. The CAT Team is a new component of the QIPMO project with the Sinclair School of Nursing, in cooperation with the Missouri Department of Health and Senior Services. Please do not hesitate to reach out to us for assistance or questions; contact information is located at the end of this survey.

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* 1. Facility name:

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* 2. In what county is your facility?

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* 3. Administrator information:

Name:

Email:

Phone:

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* 4. My facility is:

Stand-alone

Corporate-owned

If corporate-owned, what corporation?

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* 5. My facility's licensure is:

ALF

RCF

Independent living

Other (please specify)

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* 6. Facility information:

Number of beds:

Number of residents:

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* 7. Are you having trouble recruiting staff?

Yes

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* 8. Have you done any COVID-19 testing?

Yes

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* 9. If so, what type of testing have you done?

Lab

POC

Other (please specify)

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* 10. If testing, what was the date of your most recent testing?

Date / Time

Date

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* 11. Resident information (from your most recent testing):

Number tested positive:

Number tested negative:

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* 12. Staff information (from your most recent testing):

Number tested positive:

Number tested negative:

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* 13. Per state guidelines, what is the date you entered (or are planning to enter) each of the phases? (mm/dd/yyyy)

Phase 1

Phase 2 (no positives or 28 days since last positive test )

Phase 3

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* 14. Has your facility begun visitation?

Yes

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* 15. If yes, what type of visitation are you allowing?

Indoor

Outdoor