Form 57.144 Resident Impact and Facility Capacity form (57.144)

O MB Approved

OMB No. 0920-1290

Exp. Date 09/30/2020

www.cdc.gov/nhsn

COVID-19 Module

Long Term Care Facility: Resident Impact and Facility Capacity

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NHSN Facility ID: CMS Certification Number (CCN):

Facility Name:

*Date for which responses are being reported: _____/____/_____ Date Last Modified: ____/____/_____

Counts should be reported on the correct calendar day and include only the new counts for the calendar day (specifically, since counts were last collected). If the count is zero, a “0” must entered as the response. A blank response is equivalent to missing data. NON-count questions should be answered one calendar day during the reporting week.

Facility Capacity
	**ALL BEDS (enter on first survey only, unless the total bed count has changed)
	*CURRENT CENSUS: Total number of beds that are occupied on the reporting calendar day

Resident Impact for COVID-19 (SARS-CoV-2)
	ADMISSIONS: Number of residents admitted or readmitted from another facility who were previously diagnosed with COVID-19 and continue to require transmission-based precautions. Excludes recovered residents.
	CONFIRMED: Number of residents with a new positive COVID-19 viral test result, either from a NAAT (PCR) or an antigen test.
	TEST TYPE: Of the number of reported Confirmed COVID-19 residents, how many had the following: _____Positive SARS-CoV-2 antigen test only [no other testing performed] _____Positive SARS-CoV-2 NAAT (PCR) [no other testing performed] _____±Positive SARS-CoV-2 antigen test and negative SARS-CoV-2 NAAT (PCR) _____±Any other combination of SARS-CoV-2 NAAT (PCR) and/or antigen test(s) with at least one positive test ± Only include if the two tests were performed within 2 days of each other. Otherwise, count first test only.
	_____RE-INFECTIONS:** Of the number of reported Confirmed residents, how many were considered as re-infected? ­­_____SYMPTOMATIC: Of the number of reported residents with Re-Infections, how many had signs and/or symptoms consistent with COVID-19? _____ASYMPTOMATIC: Of the number of reported residents with Re-Infections, how many did not have signs and/or symptoms consistent with COVID-19?
	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.5 (11-2020)
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	TOTAL DEATHS: Number of residents who have died for any reason in the facility or another location:___ _____COVID-19 DEATHS:** Of the number of reported Total Deaths, report the number of residents with COVID-19 who died in the facility or another location.
Resident Impact for Non-COVID-19 (SARS-CoV-2) Respiratory Illness
		CONFIRMED INFLUENZA: Number of Residents with a new positive influenza (flu) test result.
		RESPIRATORY ILLNESS: Number of Residents with acute respiratory illness symptoms, excluding confirmed COVID-19 and/or influenza (flu).

Resident Impact for Co-Infections
	CONFIRMED INFLUENZA and COVID-19: Number of residents with a confirmed co-infection with influenza (flu) and SARS-CoV-2 (COVID-19).

SARS-CoV-2 TESTING

Since the last date of data entry in the Module, has your LTCF performed SARS-CoV-2 (COVID-19) viral testing? □ YES □ NO

** If YES, indicate counts of COVID-19 viral testing that were performed:

____POCRESIDENT** Since the last date of data entry in the Module, how many COVID-19 point-of-care tests has the LTCF performed on residents?

____POCSTAFF** 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?

____ NONPOCRESIDENT** Since the last date of data entry in the Module, how many COVID-19 NON point-of-care tests has the LTCF performed on residents?

____ NONPOCSTAFF** Since the last date of data entry in the Module, how many COVID-19 NON point-of-care tests has the LTCF performed on staff and/or facility personnel?

During the past two weeks, on average how long did it take your LTCF to receive SARS-CoV-2 (COVID-19) viral test results from NON point-of-care tests? (Check one)

• Less than one day

• 1-2 days

• 3-7 days

• More than 7 days

• No testing performed in the past two weeks on residents or staff and/or facility personnel

TESTINGSTAFF: Does the LTCF have the ability to perform or to obtain resources for performing SARS-CoV-2 viral testing (NAAT [PCR] or antigen) on all staff and facility personnel within the next 7 days, if needed?

□ YES □ NO

TESTINGRESIDENT: Does the LTCF have the ability to perform or to obtain resources for performing SARS-CoV-2 viral testing (NAAT [PCR] or antigen) on all current residents within the next 7 days, if needed?

□ YES □ NO