0920-1290 LTCF Resident Impact and Facitlity Capacity - POC 26AUG2

OMB Approved

O MB No. 0920-1290

Exp. Date 09/30/2020

www.cdc.gov/nhsn

COVID-19 Module

Long Term Care Facility: Resident Impact and Facility Capacity

Page 1 of 3 *Required; **Conditional

NHSN Facility ID:

CMS Certification Number (CCN):

Facility Name:

*Date for which responses are reported: ________/________/________

For the following questions, report data on the same day each week at least once a week. For questions requiring counts, include only new data since the last date the counts were collected for reporting in the NHSN Module.

Resident Impact
_____	ADMISSIONS: Residents admitted or readmitted from another facility who were previously diagnosed with COVID-19 and continue to require transmission-based precautions
_____	CONFIRMED: Residents with new positive COVID-19 test results from a viral test (nucleic acid or antigen)
_____	SUSPECTED: Residents with new suspected COVID-19
_____	TOTAL DEATHS: Residents who have died for any reason in the facility or another location
_____	COVID-19 DEATHS: Residents with a suspected or positive COVID-19 test result who died in the facility or another location

Facility Capacity and SARS-CoV-2 Testing
______	ALL BEDS (FIRST SURVEY ONLY)
______	CURRENT CENSUS: Total number of beds that are currently occupied
RESIDENTS
	TESTING: Does the LTCF have the ability to perform or to obtain resources for performing COVID-19 viral testing (nucleic acid or antigen) on all current residents within the next 7 days, if needed? □ YES □ NO **If NO, indicate reason(s) below (select all that apply): Lack of recommended personal protective equipment (PPE) for personnel to wear during specimen collection Lack of supplies for specimen collection Lack of access to a laboratory for submitting specimens Lack of access to trained personnel to perform testing (including internal and external resources) Uncertainty about testing reimbursement Other: Specify_________________________________________ 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)). CDC estimates the average public reporting burden for this collection of information as 25 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information 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 Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-XXXX). CDC 57.144 (Front) V.4 (8-2020)

Page 2 of 3 *Required; **Conditional

Facility Capacity and SARS-CoV-2 Testing
RESIDENTS
	During the past two weeks, on average how long did it take your LTCF to receive COVID-19 viral (nucleic acid or antigen) test results of residents? (Check one) Less than one day 1-2 days 3-7 days More than 7 days No resident testing performed in the last two weeks
	Since the last date of data entry in the Module, has your LTCF performed COVID-19 viral testing on residents? □ YES □ NO **If YES, indicate the reason COVID-19 testing was performed (Check all that apply): Testing residents with new signs/symptoms consistent with COVID-19 Testing asymptomatic residents on a unit/section of the facility in response to a new case with COVID-19 Testing asymptomatic residents, facility-wide in response to a new case with COVID-19 Testing asymptomatic residents without a known exposure to COVID-19 as part of surveillance None of the above: testing of another subgroup of residents occurred
STAFF AND PERSONNEL Includes anyone working or volunteering in the facility, such as contractors, temporary staff, resident care givers, shared staff, etc.
	TESTING Does the LTCF have the ability to perform or to obtain resources for performing COVID-19 viral testing (nucleic acid or antigen) on all staff and/or facility personnel within the next 7 days, if needed? □ YES □ NO **If NO, indicate reason(s) below (Check all that apply): Lack of recommended personal protective equipment (PPE) for personnel to wear during specimen collection Lack of supplies for specimen collection Lack of access to a laboratory for submitting specimens Lack of access to trained personnel to perform testing (including internal and external resources) Uncertainty about testing reimbursement Other: Specify_________________________________________
	On average, how long does it take your LTCF to receive COVID-19 viral (nucleic acid or antigen) test results of staff and/or facility personnel? (Check one) Less than one day 1-2 days 3-7 days More than 7 days
	Since the last date of data entry in the Module, has your LTCF performed COVID-19 viral testing on staff and/or facility personnel? □ YES □ NO **If YES, indicate the reason for COVID-19 testing was performed (Check all that apply): Testing staff and/or facility personnel with new signs/symptoms consistent with COVID-19 Testing asymptomatic staff and/or facility personnel on a unit/section of the facility in response to a new case with COVID-19 Testing asymptomatic staff and/or facility personnel facility-wide in response to a new case with COVID-19 Testing asymptomatic staff and/or facility personnel without a known exposure to COVID-19 as part of surveillance None of the above: testing of another subgroup of staff and/or facility personnel occurred
Page 3 of 3 *Required; **Conditional
IN-HOUSE, POINT-OF-CARE COVID-19 TESTING
	Does the LTCF have an in-house point-of-care test machine (capability to perform COVID-19 testing within your facility)? □ YES □ NO
	**Since the last date of data entry in the Module, how many COVID-19 point-of-care tests has the LTCF performed on residents? _________________
	**Since the last date of data entry in the Module, how many COVID-19 point-of-care tests has the LTCF performed on staff and/or facility personnel? _________________
	**Based on this week’s inventory, do you have enough supplies to test all staff and/or facility personnel for COVID-19 using the point-of-care test machine? □ YES □ NO