Nursing Home Emergency Preparedness Assessment

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Nursing Home Emergency Preparedness Assessment

Thank you for completing the Emergency Preparedness Assessment. Please enter your CCN and select "Continue" in order to proceed to the questions.

CMS Certification Number (CCN) [6 characters]: *
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Don't know your CCN? Look it up

Name of Nursing Home: *

Name: *

Email Address: *

You will receive a copy of your answers to this checklist by email. If you answer "No" to any of the questions, those are potential areas to focus your improvements. Telligen can help support!

Does your Emergency Preparedness Team include at least one member from each department of your facility? (i.e. leadership, nurses, CNAs, food service, environmental services, etc.)?: *

Yes

Job Title (DON, NHA, etc) of the person who oversees the Emergency Preparedness Program?: *

Comments

Risk Assessment: Must occur at least once every 12 months

When did your facility last complete a Community Risk Assessment?: *

When did your facility last complete a Facility Risk Assessment?: *

Does your plan address all potential risks as identified by your risk assessments using an all-hazards approach?: *

Yes

Does your risk assessment use internal and external perspectives?: *

Yes

Risk Assessment Comments

Emergency Plan

When was your Emergency Plan last reviewed? (must be done annually): *

Does your plan clearly outline staff and/or volunteer roles in the event of an emergency?: *

Yes

Does your plan include what equipment or supplies (medical and non-medical) your facility would need during an emergency?: *

Yes

Does your plan include public health emergencies (pandemic, infection outbreaks, etc)?: *

Yes

Does your plan include a staffing plan for extended/reduced hours, use of volunteers, etc?: *

Yes

Does your plan include a strategy for shelter-in-place?: *

Yes

Does your plan include an agreement with community facilities should your building need to be evacuated?: *

Yes

Does your plan include emergency transportation should evacuation be necessary? (including backups if road closures, excess traffic, etc)?: *

Yes

Does your facilities emergency plan include a tracking system (list/log) to identify the location of on duty staff and sheltered residents before and after an emergency?: *

Yes

Does your facility have a post-evacuation plan/policy?: *

Yes

Does your EPP have an elopement policy (lost/missing resident)?: *

Yes

Are all aspects of your plan made with your facility's residents and case mix in mind?: *

Yes

Does your plan include continuity of operations?: *

Yes

Do you have your EPP in print/digital/etc formats to allow for access in all situations?: *

Yes

Emergency Plan Comments

The Communication Plan

Does your plan include how the facility (and who is responsible) will communicate with staff, residents, families, and other stakeholders (state/local agencies, etc)?: *

Yes

Does your plan include communication methods if standard communication routes (phones/cell phones/internet access) are unavailable?: *

Yes

Are all relevant and required phone numbers included and updated in your plan?: *

Yes

When was contact information last updated?: *

Communication Plan Comments

The Training Plan

After annual review and update, are ALL staff trained on the newest version of the Emergency Preparedness Plan - including the updates made?: *

Yes

Are all new staff, volunteers, etc. trained on the EPP and what their roles would be?: *

Yes

Where are your trainings documented: *

Would any staff member be able to tell you what their role would be during any emergency?: *

Yes

Are all EPP requirements incorporated into facility policy and procedures?: *

Yes

Where is your EPP located: *

Are all staff/volunteers able to access the EPP and know where they can find it?: *

Yes

Training Plan Comments

The Testing Plan

Does your facility conduct a full scale, functional exercise, or tabletop exercise at least once annually?: *

Yes

Date of last drill?: *

Following a drill or testing exercise, does your Emergency Preparedness Team create a report on how the exercise went, including areas of improvement?: *

Yes

Does the facility use disaster exercise scenarios based on risks that were identified in the community/facility assessments?: *

Yes

Testing Plan Comments

I would like Telligen assistance with my facility's Emergency Preparedness Plan and/or Program

If you need additional support or assistance with your Emergency Preparedness Plan, please contact the Telligen nursing home team at nursinghome@telligen.com