Infection Prevention (IP) Assessment Tool for COVID-19



PROVIDER’S NAME FORMTEXT ?????AGING AND LONG-TERM SUPPPORT ADMINISTRATIONCOMMUNITY RESIDENTIAL SERVICES AND SUPPORTING (CCRSS)Infection Prevention and Control (IPC)Assessment Tool for COVID-19CERTIFICATION NUMBER FORMTEXT ?????INTAKE NUMBER FORMTEXT ?????ADMININSTRATOR’S NAME FORMTEXT ?????INVESTIGATOR’S / EVALUATOR’S NAME FORMTEXT ?????CLIENT NAME(S) FORMTEXT ?????Instructions: Use this form to assess licensee’s compliance with strategies to prevent the spread of COVID-19. Assess through elements through observation, interview and record review. Submit this form with working papers.Refer to Safe Start for LTC Recommendations and Requirements for more guidance. Safe Start PlanCheck “Yes,” “No,” or “N/A” on this tool. If “No” is checked, document findings in the notes section and/or on DSHS 00-413a.Offsite Preparation, identify the following: FORMCHECKBOX Complaint Investigator / Evaluator reviewed the Governor’s Proclamations and Emergency Rules. Waiver Tracker (click on program, then waiver tracker).Determine COVID-19 or communicable disease outbreak present in home: FORMCHECKBOX Yes FORMCHECKBOX NoIf outbreak, contacted / collaborated with the DOH and/or Local Health Jurisdiction (LHJ): FORMCHECKBOX Yes FORMCHECKBOX NoCommunity Transmission Rate FORMTEXT ???. Link for COVID Data Tracker.PPE / source control plan for onsite visit: FORMCHECKBOX Yes FORMCHECKBOX NoUpon entrance, identify / observe the following:Identify Provider staff / visitor screening: FORMCHECKBOX Yes FORMCHECKBOX NoActive or suspected COVID-19 / communicable disease present in home: FORMCHECKBOX Yes FORMCHECKBOX NoStaff and residents wearing source control: FORMCHECKBOX Yes FORMCHECKBOX No Any Aerosol Generating procedure (AGP) (when there is substantial to high COVID-19 community transmission): FORMCHECKBOX Yes FORMCHECKBOX No If yes, who / where: FORMTEXT ?????Testing, Reporting, and SCREENINGYESNON/ANOTESAccess to adequate COVID-19 testing FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Outbreak testing for staff and residents FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Communicates known or suspected COVID-19 outbreaks to personnel, DOH, and LHJ FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Active screening and reviewing for signs and symptoms FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Access to adequate COVID-19 testing FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Visitor and NEW ADMISSIONSYESNON/ANOTESProvides accommodation for visitation for all clients FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Uses the Risk Assessment template to determine clients’ risk of exposure FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Provides residents immediate access to DDA Ombuds and/or Regional LTC Ombuds FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Follows guidance for Providers, Services, and Non-Healthcare Personnel entering the building FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Adheres to outbreak visitation guidance during an outbreak FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Personal Protective Equipment (PPE) YESNON/ANOTESEvaluates PPE, disinfectants and cleaning supplies FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Source control requirements followed FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Infection Control Standards, Policies AND ProceduresYESNON/ANOTESDisplays signage throughout the setting FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Observes proper hand hygiene social distancing and cleaning / disinfecting FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Observes staff wearing face covering / mask and eye protection FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX If COVID-19 is suspected, N95 or higher level respirator is used. Shows effort to obtain if not available FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Establishes policies and procedures: visitation, screening, new admission, cohorting, Infection control and RPP FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Provides education and training on COVID-19 and IPC practices to staff, clients and visitors FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Follows guidance for AGP (Aerosol Generating Procedures) use FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Follows requirements for “worker” vaccinations, exemptions/accommodations FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX Uses telemedicine when possible FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX GROUP ACTIVITIES AND COMMUNAL DININGYESNON/ANOTESFollows group activity and communal dining guidance for vaccinated and unvaccinated residents FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Follows guidance and identifies when resident in quarantine or isolation FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX COHORTINGYESNON/ANOTESDisplays effective cohorting of residents, if possible FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX FORMTEXT ?????Collaborates with DOH and/or LHJ in correlation to an outbreak FORMCHECKBOX FORMCHECKBOX FORMCHECKBOX ADDITIONAL NOTES FORMTEXT ????? ................
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