Form CDC 57.137 CDC 57.137 Patient Safety Component --Annual Facility Survey for LT

* required for saving		Tracking #:
Facility ID:		*Survey Year:
*National Provider #:	*CMS certification #:	State Provider #:
Facility Characteristics
*Ownership (check one):       □ For profit             □ Not for profit, including church                 □ Government              □ Veteran’s Affairs
*Certification (check one): □ Dual Medicare/Medicaid      □ Medicare only           □ Medicaid only         □ State only
*Affiliation (check one):   □ Independent, free-standing  □ Independent, continuing care retirement community            □ Multi-facility organization (chain)    □ Hospital system, attached    □ Hospital system, free-standing
In the previous 12 months,                                                 □ No LTCF or not operational in this survey year *Average daily census:  _______                   *Number of Short stay residents (<90 days): _______                   *Number of Long-stay residents (>90 days): _______                                        Average Length of Stay for Short stay residents (<90 days): _______                    Average Length of Stay for Long-stay residents (>90 days): _______   *Number of New Admissions:  _________
* Total Number of Beds:   _________       *Indicate the percentage of beds represented by the following service types: (must sum to 100%)           a. Long-term General Nursing:                    __________           b. Long-term Dementia:                              __________           c. Skilled nursing/Short-term (subacute)               rehabilitation:                                         __________           d. Long-term psychiatric (non dementia):     __________           e. Ventilator:                                              __________           f. Bariatric:                                                 __________             g. Other:                                                    __________
Infection Control Practices *Number of FTE dedicated to infection control activity in facility:       __________            a. Total hours per week performing surveillance:                   __________            b. Total hours per week for infection control activities                other than surveillance:                                                   __________                              c. Total hours per week performing other duties, not                  related to infection control:                                              __________
Continued  >>
Assurance of Confidentiality:  The voluntarily provided information obtained in this surveillance system that would permit identification of any individual or institution is collected with a guarantee that it will be held in strict confidence, will be used only for the purposes stated, and will not otherwise be disclosed or released without the consent of the individual, or the institution in accordance with Sections 304, 306 and 308(d) of the Public Health Service Act (42 USC 242b, 242k, and 242m(d)). Public reporting burden of this collection of information is estimated to average 25 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.  An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC, Reports Clearance Officer, 1600 Clifton Rd., MS D-74, Atlanta, GA 30333, ATTN:  PRA (0920-0666). CDC 57.137 (Front) v6.4

 

1. Facility Microbiology Laboratory Practices

1. *1.  Does your facility have its own laboratory that performs microbiology/antimicrobial susceptibility testing?    

          □ Yes        □ No

          If No, where is your facility's antimicrobial susceptibility testing performed?  (check one)

• 1. □ Affiliated medical center, within same healthcare system

     □ Medical center, contracted locally  

     □ Commercial referral laboratory

     □ Other (specify):_________________

• 1.    

1. *2. Indicate whether your facility screens new admissions for any of the following multidrug-resistant organisms: (check all that apply)

             □ We do not screen new admissions for MDROs

1.              □ Methicillin-resistant Staphylococcus aureus (MRSA)

1.               If checked, indicate the specimen types sent for screening:(check all that apply)

                    □ Nasal swabs  □ Wound swabs  □ Sputum  □ Other skin site

              □ Vancomycin-resistant Enterococcus (VRE)

                 If checked, please indicate the specimen types sent for screening :(check all that apply)

                    □ Rectal swabs □ Wound swabs  □ Urine

              

              □ Multidrug-resistant gram-negative rods (includes carbapenemase resistant  

                Enterobacteriaceae; multidrug-resistant Acinetobacter, etc.)

                If checked, indicate the specimen types sent for screening:(check all that apply)

1.            □ Rectal swabs  □ Wound swabs  □ Sputum □ Urine

1.  

1. Facility Microbiology Laboratory Practices

1. Electronic Health Record Utilization

1. *Indicate whether any of the following are available in an electronic health record (check all that apply)

• 1. □ Microbiology lab culture and antimicrobial susceptibility results

     □ Medication orders  

     □ Medication administration record

     □ Resident vital signs

     □ Resident admission notes

     □ Resident progress notes

     □ Resident transfer or discharge notes

 

File Type	application/vnd.ms-powerpoint
File Title	Slide 1
Author	CDC
Last Modified By	fom7
File Modified	2010-09-14
File Created	2004-07-27

---

© 2024 OMB.report | Privacy Policy

---