Healthcare Facility Assessment (HFA) Form

Last edit: 02/02/2016 Facility ID: ____-_____

Form Approved

OMB No. 0920-XXXX

Exp. Date xx/xx/20xx

Healthcare Facility Assessment (HFA) Form: Nursing Home

Instructions:

1) The nursing home team lead is responsible for ensuring completion of this assessment and submitting it to the EIP Team point of contact.

2) To ensuring accurate completion of the assessment consult as needed with other facility colleagues to answer the questions included in the assessment.

3) The assessment should be completed using the most up-to-date information available.

4) The assessment should be completed and returned to the EIP Team point of contact within 1-2 weeks.

If you are the individual responsible for ensuring completion of this assessment, please tell us which of the following best describes your role at the nursing home?

Medical director (physician)

Other physician

Director of nursing

Infection prevention and control officer (IPCO)

Other (specify):________________________

Section A: Facility Size

1. What is your facility’s capacity? (please fill in the following):

		Number	Don’t know
1a.	Total number of facility beds:
1b.	Number that are PEDIATRIC beds (age <21):
1c.	Total number of resident rooms
1d.	Number that are SINGLE rooms:
1e.	Average daily census

Public reporting burden of this collection of information is estimated to average 45 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/ATSDR Information Collection Request Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX).

Section B: Primary & Clinical Services Provided

2. Which of the following primary service types are provided in your facility?

	Yes	No	Don’t Know
Long-term general nursing
Long-term dementia
Skilled nursing/short-term (subacute) rehabilitation
Long-term psychiatric (non-dementia)
Ventilator
Bariatric
Hospice/Palliative
Other primary services please specify:_________________________________________

3. Which of the following clinical services are available in your facility (please check all that apply):

	Yes	No	Don’t Know
IV infusions using central lines
Hemodialysis (provided in your facility)
Management of residents with a tracheostomy
Dedicated facility staff to provide wound care
Dedicated facility staff to perform blood draws
24-hour a day on-site supervision by an RN

Section C: Medical Care and Coordination

4a. Which providers provide resident medical care in your facility (check all that apply):

Physicians provide medical care for residents

Non-physician clinical providers

Other (specify):___________________

Don’t Know

4b. If Non-physician clinical providers is checked, how many days per week are they present in your facility?

___________ days per week

5. How many attending physicians currently provide resident medical care in your facility?

__________ physicians

6. On average, how many days per week is the medical director present on-site in your facility?

___________ days per week

Section D: Infection control resources and practices

7a. What is the highest level of professional training of the designated IPCO in your facility?

CNA

LPN

RN

MD

Other, please specify:_______________________

No individual primarily responsible for IC (skip to question 8a)

7b. How long has this individual been in that position at your facility?

______years

7c. How many years of experience do they have doing infection control-related work?

_______years

7d. Has this person received any specific infection control training?

APIC/Certification in Infection Control (CIC)

State or Regional training course with certificate

SHEA Long Term/Post-Acute Care Training course

Other IC training, please specify:______________________________________________________

No specific infection control training

7e. Is the IPCO a full-time role for this individual?

Yes No Don’t Know

7f. If No, please indicate which of the activities listed below also are performed by that individual (please check all that apply):

Administration (i.e., Director of Nursing [DON])

Quality manager

Staff education/staff development

Employee health

Direct resident care

Other, please specify:_______________________________________________________________

8a. Is there a team or committee in your facility that reviews infection control-related activities (e.g., reports, policies, and procedures)?

Yes No Don’t Know

8b. If YES, how frequently does this committee meet?

Annually

Quarterly

Monthly

Weekly

Other, please specify:_________________________

9. For each statement below check YES or NO for the policies and procedures in place at your facility:

	Yes	No
Our facility performs surveillance for one or more types of infection
Our facility shares infection surveillance data with the medical director
Our facility shares infection surveillance data with resident care staff
Our facility has a hand hygiene policy
Our facility has an Isolation or Contact Precautions policy
Our facility has an environmental cleaning policy

Section E: Antimicrobial Use Resources and Practices

10. For each statement check YES or NO for the policies and procedures in place at your facility:	Yes No
Our facility reviews antibiotic use and resistance data in quality assurance/performance improvement committee meetings
Our facility has written statements from leadership in support of improving antibiotic use that is shared with staff, residents and families
Our facility has an individual responsible for overseeing activities to improve the use of antibiotics. If yes, what is the position/title of this individual? ___________________________
Our facility medical director reviews antibiotic use data
Our facility has access to a pharmacist with specialized infectious diseases or antibiotic stewardship training, who provides guidance and expertise on antibiotic use (on-staff or by consultation)
Our facility has access to an infectious disease physician, who provides guidance on antibiotic stewardship activities (on-staff or by consultation)
Our facility requires providers to document the dose and route of antibiotics
Our facility requires providers to document the anticipated duration of antibiotics, including a start date, end date, and the planned days of therapy
Our facility requires providers to document the indication of antibiotic, including the rationale and treatment site
Our facility provides medical personnel (physicians and non-physician clinical providers) with resources to guide their decisions about antibiotic use (e.g., treatment algorithms, clinical practice guidelines)
Our facility requires providers to perform a follow-up assessment (an antibiotic “time-out”) 2-3 days after a new antibiotic start to determine whether it is still indicated and appropriate
Our facility has a defined formulary of antimicrobial agents, and prescribing is generally restricted to the agents listed on the formulary
Our facility routinely (weekly, monthly, quarterly) receives reports of antibiotic use (e.g., new orders of antibiotic treatment) from the pharmacy service
Our facility receives a summary report of antibiotic resistance from the laboratory (e.g., antibiogram)
Our facility provides feedback on antibiotic prescribing practices to medical personnel (physicians and non-physician clinical providers)
Our facility provides training on appropriate antibiotic use to nursing personnel (e.g., aides, LPNs, RNs)
Our facility provides education to residents and family about antibiotic use
Our facility has a copy of “CDC’s Core Elements of Antibiotic Stewardship in Nursing Homes”?

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Healthcare Facility Assessment (HFA) Form: Nursing Home