Form a3 Structural Asse a3 Structural Asse Attachment C: Structural Assessment for Long Term Care S

Form Approved
OMB No. 0935-0238
Exp. Date 09/30/2020

Attachment C: Structural Assessment Form for Long-Term Care Settings

STRUCTURAL ASSESSMENT

1. How many certified beds are in your facility?

2. What is the approximate proportion of residents in skilled beds (compared to residential beds)?

3. Has your facility been actively involved in quality improvement projects or programs in the last 2 years? Yes No

3a. If yes, please briefly describe previous quality improvement programs.

4. How many days does the consultant pharmacist spend at your facility each month?

4a. What percent of their time at your facility is dedicated to antibiotic review?

5. Does your institution have an existing Antibiotic Stewardship Program (ASP)? Yes No

5a. If yes, does the Infection Prevention and Control nurse or practitioner help run the ASP? Yes No

5b. If yes, does the Medical Director help run the ASP? Yes No

• What percent FTE does the Medical Director receive for stewardship activities?

5c. Are there any other members of your ASP? (Please describe)

6. 

   
   

   
   

   
   

   
   

   
   

   
   

   
   

   What are the current antibiotic stewardship activities of your facility? (Check all that apply) Working with the contracted laboratory to develop an antibiogram

Giving in-service training to nurses on topics related to antibiotic use Developing antibiotic prescribing recommendations for your facility Formulary restriction of some antibiotics

Post-prescription review with feedback of select antibiotics

Developing protocols for diagnosis and treatment of common infectious syndromes (i.e. UTI vs. asymptomatic bacteriuria)

Other activities, please describe

Our nursing home does not have active initiatives to improve antibiotic use

7. Are you measuring antibiotic use at your facility? Yes No

7a. If yes, how are you measuring it?

Antibiotic starts

Antibiotic days of therapy per 1000 resident-days Defined daily doses per 1000 resident-days

Other measures, please describe

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