HRC Supported Living and FFA Service Provider Survey

We will use this survey to stay in contact with you and to share information about the status of our clients during the COVID-19 Pandemic

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* 1. Agency Name

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* 2. Vendor Number

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* 3. Type of Service

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* 4. Number of clients you currently serve:

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* 5. Do you serve any clients that are high-risk (i.e. medical conditions or those with compromised immune systems?)

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* 6. Do you serve any clients over the age of 65?

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* 7. Do you have mask?

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* 8. For how many days do you have masks? (ie 30-day supply, 60-day supply, 90-day supply, etc.)

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* 9. How many staff do you need that are essential for providing care to clients in their homes?

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* 10. Do you have a staff backup plan, in the event that staff call out sick or become unavailable?

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* 11. Have you provided training to your staff on the Center for Disease Control (CDC) precautions to avoid exposure to illness and other contagious/communicable diseases?

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* 12. Have you provided training to clients you serve on precautions to avoid illness?

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* 13. Does your staff know when to contact the client's medical provider to have the client evaluated for illness?

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* 14. Do all of your clients (or do you) have all of their prescribed medication on hand?

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* 15. Do you have sufficient staff to help clients with basic needs in their home and provide support for getting groceries, prescriptions, and other personal needs? 

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* 16. Do you have the capacity to serve more clients?

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* 17. Would you be willing to accept clients who need to be relocated to prevent illness?

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* 18. Would you be willing to accept clients who have an illness?

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* 19. Are you able to separate a client who is ill to prevent exposure to others? 

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* 20. Are clients who are ill able to use a separate bathroom  to prevent exposure to others?

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* 21. Are you serving clients that have no involved family support?

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* 22. Below, please indicate all of the measures that you have currently implemented to prevent illness and communicable/contagious diseases. Check all that apply

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* 23. Do you have a plan to provide daily cleaning of all high-touch surfaces such as counters, tabletops, doorknobs, bathroom fixtures, toilets, phones, keyboards, tablets, and bedside tables?

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* 24. Do the clients you serve have a plan to restrict visitors who do not have an essential need to be in the home, to prevent exposure to illness?

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* 25. Does the shared space in the client's home provide for good air flow, such as an air conditioner or an opened window, weather permitting? 

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* 26. Person completing survey

0 of 26 answered
 

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