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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
(Required.)
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2.
Vendor Number
(Required.)
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3.
Type of Service
(Required.)
SLS
FFA
FHA
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4.
Number of clients you currently serve:
(Required.)
5.
Do you serve any clients that are high-risk (i.e. medical conditions or those with compromised immune systems?)
Yes
No
If Yes, how many clients?
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6.
Do you serve any clients over the age of 65?
(Required.)
Yes
No
If yes, please enter the number of clients
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7.
Do you have mask?
(Required.)
Yes
No
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?
(Required.)
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10.
Do you have a staff backup plan, in the event that staff call out sick or become unavailable?
(Required.)
Yes
No
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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?
(Required.)
Yes
No
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12.
Have you provided training to clients you serve on precautions to avoid illness?
(Required.)
Yes
No
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13.
Does your staff know when to contact the client's medical provider to have the client evaluated for illness?
(Required.)
Yes
No
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14.
Do all of your clients (or do you) have all of their prescribed medication on hand?
(Required.)
Yes
No
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?
(Required.)
Yes
No
If no, what staffing support do you need?
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16.
Do you have the capacity to serve more clients?
(Required.)
Yes
No
If Yes, how many?
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17.
Would you be willing to accept clients who need to be relocated to prevent illness?
(Required.)
Yes
No
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18.
Would you be willing to accept clients who have an illness?
(Required.)
Yes
No
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19.
Are you able to separate a client who is ill to prevent exposure to others?
(Required.)
Yes
No
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20.
Are clients who are ill able to use a separate bathroom to prevent exposure to others?
(Required.)
Yes
No
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21.
Are you serving clients that have no involved family support?
(Required.)
Yes
No
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
(Required.)
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?
(Required.)
Yes
No
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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?
(Required.)
Yes
No
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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?
(Required.)
Yes
No
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26.
Person completing survey
(Required.)
Current Progress,
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