HRC Licensed Homes Status Check

HRC Licensed Home 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. Vendor Name

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* 2. Vendor Number

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* 3. Are there any clients in your home that have tested positive for the Corona Virus?

YES

If YES, How many?

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* 4. Do you have any staff that are symptomatic?

Yes

If YES, how many?

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* 5. Are any of your residents symptomatic?

Yes

If YES, how many?

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* 6. If one of your residents become ill, do you have a area to keep them separate from other residents?

Yes

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* 7. Are any of your residents still participating in day program, such as through remote contact with their day program provider?

Yes

If YES, How many clients, and how are they participating?

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* 8. Are you adeequately staffed?

Yes

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* 9. Do you have backup staff if you need them?

Yes

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* 10. Do you have enough medication on hand for each resident?

Yes

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* 11. Do you have ample supplies for your residents?

Yes

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* 12. Do you have available capacity and are you willing to accept more residents?

Yes

If yes, how many?

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* 13. Has your staff received training on Center for Disease Control (CDC) precautions for avoiding exposure to illness and contagious disease?

Yes

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* 14. Have your clients received training on how to avoid illness?

Yes

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* 15. Do you have a masks?

Yes

For how many days supply?