HRC Supported Living and FFA Status Update

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

SLS

FFA

FHA

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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?)

Yes

If Yes, how many clients?

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

Yes

If yes, please enter the number of clients

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* 7. Do you have mask?

Yes

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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?

Yes

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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?

Yes

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

Yes

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

Yes

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

Yes

For how many days do the clients you serve have medication on hand? (ie 30-day supply, 60-day supply, 90-day supply, etc.)

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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?

Yes

If no, what staffing support do you need?

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

Yes

If Yes, how many?

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

Yes

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

Yes

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

Yes

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

Yes

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

Yes

If yes, how many clients?

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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

Use of hand sanitizer

Use of disinfectant wipes

Regular deep cleaning of the client's home (enter frequency below)

Daily cleaning of all high-touch surfaces such as counters, tabletops, doorknobs, bathroom fixtures, toilets, phones, keyboards, tablets, and beside tables

Require staff to stay home if they are sick

Require staff to wear face mask, gloves, or gowns

Require clients and staff to avoid sharing household items, eg drinking glasses, cups, utensils, towels, bedding or other items.

Require the immediate laundering of bedding, soiled clothes that have blood, body fluids, and or excretions on them.

Require soiled face masks, gloves, or gowns be placed in a lined container before disposing of them with other household waste.

Other (please specify)

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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?

Yes

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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?

Yes

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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?

Yes

HRC Supported Living and FFA Status Update

HRC Supported Living and FFA Service Provider Survey

Question Title

* 1. Agency Name

Question Title

* 2. Vendor Number

Question Title

* 3. Type of Service

Question Title

* 4. Number of clients you currently serve:

Question Title

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

Question Title

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

Question Title

* 7. Do you have mask?

Question Title

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

Question Title

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

Question Title

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

Question Title

* 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?

Question Title

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

Question Title

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

Question Title

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

Question Title

* 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?

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

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

Question Title

* 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?

Question Title

* 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?

Question Title

* 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