Facility Assessment

HERO Facility Needs Assessment

This questionnaire is to help us assess your staff and facility in order to determine what resources are necessary to develop and implement quality improvement initiatives for your organization.
Facility Name*
Facility Address*

Street Address

Street Address Line 2

CityState

Zip Code
Background information
1. Number of licensed beds *
2. Occupancy rate*
3. Identify any specialized services or special needs of the resident population*
4. Identify health literacy needs of residents*
5. Identify ethnic, cultural, or religious factors that may affect care*
6. Select level of implementation of trauma-informed care*
7. EMR*
8. Number of employees*
9. Staffing model*
10. Contracted services (i.e. therapy, pharmacy, agency nurses)*
YesNo
Train the trainerTele-educationOn-demand web modulesPrint materialsOther

Emergency Operations and Infection Control
1. Identify any physical environment challenges*
2. List community or regional resources available and indicate if collaboration is already in place*
3. Rate readiness/state of development of the following on a scale of 1-5 with 1=not started, 5=fully developed and ready

a. All hazards emergency operations plan
*
b. Administrative preparedness for continuity of services
*
c. Contingency plan for staffing
*
d. Communication plan to keep residents and families informed of facility status, vaccine status, community status, new guidance, visitation procedures, etc.
*
e. Communication plan to keep staff informed of facility status, vaccine status, community status, new guidance, policy and procedures changes, etc.
*
f. Plan for transitions to and from other levels of care/emergency transport
*
g. Coordination with other local or regional preparedness/response partners
*
4. Identify other risks associated with maintenance of operations*
5. Please provide your facility’s floor plans

Cancelof

Age-Friendly Infection Prevention
YesNo
1) Rate your level of incorporation of age-friendly health system concepts into infection prevention policies and procedures on the scale of 1-5 with 1=not incorporated, 5=fully incorporated

a. Advanced directive completion rate   Numeric value*
b. POLST completion rate   Numeric value*

2) Rate the state of the following on a scale of 1-5 with 1=not started, 5=fully implemented

a. Process for requiring resident mobility during outbreak or quarantine   Numeric value*
b. Process for maintaining/continuing to improve functional abilities of residents during outbreak or quarantine   Numeric value*
c. Process to support the cognitive and psychological well-being of residents during outbreak or quarantine   Numeric value*

3) Rate the status of COVID-19 readiness and experience in terms of the following on the scale of 1-5 with 1=no experience, 2=novice, 3=intermediate, 4=proficient, 5=expert

a. Testing   Numeric Value*
b. Cohorting   Numeric Value*
c. Education   Numeric Value*
d. Regulatory compliance   Numeric Value*
e. Fit-testing   Numeric Value*
f. Don and doff PPE   Numeric Value*
g. Specimen collection   Numeric Value*
h. Transmission-based precautions   Numeric Value*
I. Environmental cleaning, engineering controls, administrative controls   Numeric Value*
j. Data management and informatics, ingestion of lab reports with culture data and susceptibility profiles   Numeric Value*
k. Policies and protocols to enhance communication about the presence of infection   Numeric Value*
Should be Empty:

HERO Facility Needs Assessment

Background information

Emergency Operations and Infection Control

Workforce Resiliency

Age-Friendly Infection Prevention