General Information

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* 1. Name of Provider

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* 2. Name of Provider Staff Member

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* 3. Contact Information (email and/or phone)

Environment and Supplies

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* 4. What is your current policy regarding cleaning/disinfecting facilities?

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* 5. How many supplies does the facility have on hand (PPE, cleaning/disinfecting supplies, etc.)?

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* 6. Have you attempted to pre-order medications and other supplies for residents?

Staff

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* 7. Are you screening or testing staff for COVID-19?

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* 8. Have any staff tested positive? If so, how many/when/current status?

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* 9. What is your policy if a staff member shows symptoms of COVID-19?

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* 10. Have any staff stopped working due to being at risk of contracting COVID-19? (Including due to being in a high risk group or caring for a person in a high risk group?)

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* 11. What are your current staffing levels?

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* 12. How many back up staff do you have available?

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* 13. What contingency plans do you have if a staff member test positive?

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* 14. Are you providing training to staff on COVID-19? If so what training?

 Residents

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* 15. Are you educating residents about COVID-19? If so, how?

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* 16. Are you screening or testing residents for COVID-19?

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* 17. What is your policy if a resident shows symptoms of COVID-19?

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* 18. Have any residents tested positive? If so, how many/when/current status?

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* 19. What contingency plans do you have if a resident test positive, including plans for isolation rooms/quarantine rooms?

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* 20. Do residents have access to a phone or computer where they can contact friends, family in lieu of visitation, and us if needed?

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* 21. What contingency plans do you have in place in case there is a shelter in place order?

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* 22. At this time is there anything that you believe would help you better serve your residents?

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