2015 Biennial Survey of Long-Term Care Facilities - RESIDENTIAL CARE FACILITIES

1/1/2015-12/31/2015

*** This is a pdf of the survey, not the RCF survey itself ***

May 2016

Dear Administrator,

The Ohio Department of Aging has once again contracted with the Scripps Gerontology Center at Miami University to conduct the Ohio Biennial Survey of Long-Term Care Facilities. Participation in this survey is mandated for all nursing homes and residential care facilities by Section 173.44 of the Ohio Revised Code.

Beyond the statutory mandate for the survey, we wanted you to know how important and useful the survey results are. Data that you provide by completing the survey questionnaire are used for, among other purposes, continuing the longitudinal study of long-term care utilization in Ohio. We have found that data from the survey are used by the General Assembly, state agencies, and long-term care facilities themselves. We need your assistance to continue this important effort.

If you are interested in findings from previous surveys, you may view the most recent report on the Scripps Gerontology Center website at:

miamioh.edu/cas/academics/centers/scripps/research/publications/2015/06/the-road-to-balance-two-decades-of-progress.html

Thank you for taking the time to complete the Biennial Survey. This survey provides the only source of information for every facility in Ohio - your participation is extremely important.

Sincerely,

Bonnie Kantor-Burman

Director, Ohio Department of Aging

Dear Colleagues,

The Biennial Survey of Long-Term Care Facilities is being conducted by the Scripps Gerontology Center at Miami University. This year’s survey has been streamlined in an effort to make it easier for you to complete and is done online. Scripps has collected and used these data to track the changes underway in the field of long-term care. Results from the study are communicated to long term care facilities by Scripps researchers through written reports and through presentations at our association meetings.

We believe that good information places providers, industry representatives, and policy makers in a better position to make good decisions about skilled nursing facilities and residential care facilities. We strongly support these data-gathering and analysis activities and feel they are highly beneficial to a better understanding of our profession, by policy makers, and the general public. We urge you to complete this important and mandated survey within the next two weeks.

Sincerely,

Kathryn BrodLeadingAge Ohio

Peter Van RunkleOhio Health Care Association

Jean ThompsonOhio Assisted Living Association

Chris MurrayThe Academy of Senior Health Sciences, Inc.

Instructions

****Please complete your survey by June 17, 2016****

-Use information from the calendar year 2015 to complete this survey.

-If your organization has both a licensed nursing home and a residential care facility, your organization will receive one survey for the nursing home and another for the RCF. Complete this survey based on information from the RCF only.

-You may save your partially completed survey and return to it another time by choosing “Save Responses” at the bottom of the page where you end your work. Return to your survey from the link in your e-mail invitation and log in with your password, which can be found in your email invitation.

-If you are using a HIPAA compliant connection or your web browser has a time-out feature, you may be logged off after a period of inactivity. Save your work often so you do not lose it.

-Use the “Back” and “Next” buttons at the bottom of the page to move through the survey, not the buttons on your browser. If you use the back or forward buttons in your browser, you may be disconnected from the survey and will lose your work.

-You may print your responses at any time by choosing the “Print responses” button on the bottom of the screen. When you choose "Print responses" a new page will appear with the entire survey displayed. You will need to allow pop-ups in your browser in order to see the screen to print your survey responses. Do not choose “Submit” until you have completed all work on your survey, printed a copy (if desired) and are ready to leave the survey. If you submit the survey before you are finished we will have to reset your survey and your work will be lost.

-If you choose to complete a paper version of the survey or want a paper copy to use as a worksheet, please print the PDF version of the survey found here:

www.cas.miamioh.edu/scripps/doc/2015_Biennial_RCF.pdf

You may mail your survey to:

Biennial Survey of LTC Facilities

Scripps Gerontology Center

Miami University

Oxford, OH 45056

If you have any questions about this survey, please call or email:

Scripps Gerontology Center1-844-850-0043

biennialltcsurvey@miamioh.edu

****Please complete your survey by June 17, 2016****

If any of the following information is not correct, please overwrite it with the correct information.

Q1 Name of Facility as it appeared on your license December 31, 2015

Q2 Did this name change during 2015?

Yes

No

Q3 You indicated that your facility's name changed during 2015. Please enter the previous name.

Q4 Facility e-mail address (General facility e-mail or administrator e-mail if no general email)

If we have questions about your survey responses, whom should we contact?

Q5 Contact Name

Q6 Contact Phone Number

Q7 Contact Email

Q8 Did your facility change ownership or operator during 2015?

Ownership

Operator

No change

You checked a facility ownership or operator change during 2015. If you have resident census records about your facility for only part of 2015, please provide the dates for which you have information.

Q9 From: mm-dd-yy

Q10 To: mm-dd-yy

Q11 Ownership (check appropriate category):

Not-for-profit

For-profit

Government

Q12 Is your residential care facility owned or leased by a multi-facility organization? (Two or more RCFs in different locations.)

Yes

No

Q13 Is your facility part of a Continuing Care Retirement Community? (For our purposes, a CCRC has independent living and assisted living/residential care facility along with the nursing home on the same campus.)

Yes

No

Residential Care in a CCRC

Q14 Currently, how many independent living units are there in your CCRC?

Q15 Currently, how many independent living units are occupied in your CCRC?

Q16 How many independent living units were in your CCRC at the end of 2015?

Q17 How many independent living units were occupied at the end of 2015?

Q18 Is your facility a free-standing (i.e. only RCF beds at your location) residential care facility?

Yes

No

Q19 Does your organization have both nursing home beds and residential care at this location?

Yes

No

Residential Care Facility Occupancy

Because the number of licensed beds in residential care facilities is often many more than the actual number of residents the facility intends to house, occupancy trends in residential care facilities have been difficult to track. The following questions will be used to calculate the occupancy rate for your facility.

Q20 How many residents were you licensed to care for as of 12/31/2015?

Q21 How many RCF units/apts. were in your facility as of 12/31/2015?

Q22 Did your facility have any units/apts. out of service in 2015? (By out of service we mean closed for renovation or otherwise unavailable to residents.)

Yes

No

Please describe the extent of out-of-service units and days in 2015.

Q23 During 2015, how many units were out of service at any time?

Q24 During 2015, how many total days were units out of service (i.e. if one unit was out of service for 10 days and another for 30 days, then the total days out of service is 40)

Please complete the following chart regarding your average monthly RCF number of residents and unit occupancy. Do not include residents in other levels of care. If a resident is out of the facility (vacation, hospital) but their unit is being paid for, include them in your monthly census and occupied units.

Q25 Average monthly number of residents

January 2015

February 2015

March 2015

April 2015

May 2015

June 2015

July 2015

August 2015

September 2015

October 2015

November 2015

December 2015

Q26 Occupied units

January 2015

February 2015

March 2015

April 2015

May 2015

June 2015

July 2015

August 2015

September 2015

October 2015

November 2015

December 2015

Resident Payment Source

What payment sources were accepted by your facility during 2015? Please enter a percentage of total residents during the year (no percent sign, only enter whole numbers) for each payment source. Enter 0 if no residents had this as a payment source during 2015. Questions 27 through 33 should add up to 100%.

Q27 What percentage of your residents had private pay as their primary payment source?

Q28 What percentage of your residents had the Medicaid Assisted Living Waiver as their primary payment source?

Q29 What percentage of your residents had County DD Authority as their primary payment source?

Q30 What percentage of your residents had County Behavioral Health Authority as their primary payment source?

Q31 What percentage of your residents had Veteran's Administration as their primary payment source?

Q32 What percentage of your residents had long-term care insurance as their primary payment source?

Q33 What percentage of your residents used other funds as their primary payment source?

Q34 You indicated other payment source(s). Please describe:

Your total percentage of residents by payment sources is {V2}%. This is not 100%. Please click the "Back" button to re-enter your payment source percentages.

Q35 What percentage of your residents had long-term care insurance as any (both primary and secondary) part of their payment?

Resident Admissions and Discharges

Q36 How many new residents were admitted to your facility during 2015? (Do not count as a new admission those residents who returned to your facility while still having their room held or were paying monthly fees/rent.)

Of these {Q36} 2015 move-ins, how many residents came from each of the places below? If no residents came from a place listed below, mark zero "0".

Q37 The community (include independent living in this or another retirement community/CCRC)

Q38 Another assisted living/RCF facility

Q39 A nursing home independent of this RCF

Q40 A nursing home associated with this RCF

Q41 A hospital

Q42 Other

Q43 You indicated admissions from other places. Please describe:

You indicated {Q36} residents were admitted, and {V3} came from different places. These numbers are different. Please go back and correct them on the previous page.

Q44 How many residents permanently left your facility during 2015? (Include deaths)

Of the {Q44} discharges in 2015, how many residents moved out of your RCF to go to each of the places below? If no residents went to a place below, mark zero "0".:

Q45 The community (include independent living in this or another retirement community/CCRC)

Q46 Another assisted living/RCF facility

Q47 A nursing home outside this facility

Q48 A nursing home associated with this facility

Q49 A hospital

Q50 Discharge due to death (Include deaths at the hospital if residents were still having their units/apts. held)

Q51 Other discharge places

You indicated {Q44} residents left your facility, and {V4} went to different places. These numbers do not match. Please go back and correct them on the previous page.

Q52 You indicated other discharge places. Please describe:

Q53 Of the {V1} discharges to nursing homes in 2015, how many were due to residents' skilled nursing care needs?

Q54 Of the {V1} discharges to nursing homes in 2015, how many were due to residents' high memory care/dementia needs?

Facility Rates

Of the {Q21} units/apts. in your facility, provide the number of units of each type as of December 31, 2015. If your facility doesn't have units of the type listed enter 0.

Q55 Number of: One room, private bath units in facility

Q56 Number of: One bedroom units (has separate rooms for sleeping, cooking/sitting, and bathing) in facility

Q57 Number of: Two bedroom units (has 2 separate rooms for sleeping, 1 cooking/sitting, and bathing) in facility

Q58 Number of: Private units/rooms with shared bath in facility

Q59 Number of: Semi-private units/rooms with shared or private bath in facility

Q60 Number of: Rooms with 3 or more beds, with shared or private bath in facility

Q61 Number of other units in facility

Q62 Other type of units. Please describe:

Your total number of units, according to type, is {V5}. This is not the same as your total number of units, {Q21}, stated previously. Please go back and correct your number of units by type of unit.

Q63 Do you have a memory support/dementia unit?

Yes

No

Q64 How many apts./rooms are in your memory support/dementia unit?

Q65 What is the average monthly total charge for residents in the memory unit? Please enter numbers only (no dollar signs, commas, or decimal points) rounded to the nearest whole number.

Q66 Excluding memory care, what is the average monthly private pay total charge for residents in private units? (Include average cost of services plus the average base rates among different types of private units). Please enter numbers only (no dollar signs, commas, or decimal points) rounded to the nearest whole number.

Q67 Excluding memory care, what is the average monthly private pay total charge for residents in semi-private units? (Include average cost of services plus the average base rates among different types of private units). Please enter numbers only (no dollar signs, commas, or decimal points) rounded to the nearest whole number.

Assisted Living

Do at least some of your units/apts. have all of the following features and services?

Single occupancy

Access to visitors at any time

Lockable by resident

In-unit bathroom with toilet, sink and tub or shower

Identifiable in-unit space for socialization (e.g. space for a visitor)

Stove or cooktop and refrigerator or 24-hour access to food or kitchen

Licensed nurse available to respond to residents' needs

Q68

Yes

No

Q69 In your marketing and promotional materials, do you refer to your facility as assisted living?

Yes

No

Q70 Are you participating in the Assisted Living Waiver Program?

Yes

No

Q71 To what extent do you perceive the following are barriers to your RCF's participation in the Assisted Living Waiver Program?

Client assessment process

Not a barrier at all

A little bit of a barrier

Somewhat of a barrier

A major barrier

A large enough barrier to hinder

participation

Not familiar with this aspect of the

waiver

Client enrollment process

Length of client Medicaid eligibility determination process

Facility Medicaid waiver certification process

Nurse staffing requirement

Adequacy of service reimbursement rate

Adequacy of Room and Board rate

Current occupancy levels

Compatibility of frail Medicaid residents with the type of residents already served

Q72 To what extent do you perceive the following are barriers to your facility's participation in the Assisted Living Waiver Program? (cont'd)

Additional agency oversight by Ohio Department of Aging

Not a barrier at all

A little bit of a barrier

Somewhat of a barrier

A major barrier

A large enough barrier to hinder

participation

Not familiar with this aspect of the

waiver

Additional oversight by MyCare Health Plan

Additional agency oversight by local Area Agency on Aging

Lack of evidence/history of program success

Completion of application process

Length of time to become certified as a provider

Your facility's capacity to provide nursing services

Your facility's capacity to provide medication administration

Your facility's capacity to provide things such as special diets

Your facility's ability to collect room and board from residents

Your facility's need to "subsidize" Medicaid residents with fees from other residents

Lack of Medicaid payment for temporary absence days (no bedholds)

Recent CMS rules regarding AL and HCBS settings

Q73 Other (Please describe)

Q74 What changes would improve the AL waiver program?

Q75 What changes would encourage your facility, or assisted living facilities in general, to become certified to participate in the assisted living waiver, if your facility has not already done so?

Q76 How many total residents were in your facility’s Assisted Living Waiver on December 31, 2015?

Q77 How many of these {Q76} Assisted Living waiver residents were previously private-pay residents in your facility?

Q78 Please rate your local Area Agency on Aging on the following aspects of the Assisted Living Waiver process:

Assistance with the waiver provider certification process

Very Good

Good

Poor

Very Poor

Case manager's assistance with resident enrollment

Ongoing case management monitoring and assistance

Q79 Anything else we should know about your experience with the Area Agency on Aging?

MyCare

Q80 Does your facility have experience with MyCare Ohio?

Yes

No

In the last 3 months, to what extent have each of the issues below been a challenge in implementing and participating in MyCare for your facility?

Q81

Timeliness of payment

Not a challenge

A little bit of a challenge

Somewhat of a challenge

Major challenge

Not familiar with issue

Transportation providers Policies and procedures vary by MyCare plan

Resident identification as a member of a MyCare plan

Communication with plans

Q82 If there are other challenges, please describe:

Q83 If you could change one thing about MyCare Ohio, what would it be?

Resident FunctioningPrevious questions asked you to report on 2015. Use information about your current residents to complete the following questions.

Q84 How many residents currently reside in your RCF?

How many current residents received assistance in the previous week with the following?

Q85 Bathing

Q86 Dressing

Q87 Walking

Q88 Transferring (e.g. bed to chair)

Q89 Toileting

Q90 Eating

Q91 Medication assisting by an aide (e.g. opening bottles, reminders, but NOT administering)

Q92 Medication administration by a licensed nurse

Q93 How many need assistance with 2 or more of the activities above or require extensive monitoring or supervision due to cognitive impairments?

Q94 How many current residents use a mobility device (e.g. walker, wheelchair, or scooter)?

Q95 How many current residents usually exhibit moderate to severe cognitive impairment (make poor decisions, require extensive supervision, or never/rarely make decisions about their daily lives)?

Q96 How many current residents have a diagnosis of severe mental illness (e.g. schizophrenia, bipolar disease)?

Q97 How many current residents receive part-time exempted skilled care in your RCF? (i.e. dressing changes, medication administration, and supervision of special diets)

Q98 How many current residents receive skilled nursing care through a home health agency?

Q99 How many current residents receive hospice services?

Q100 How many current residents have behavior issues (e.g. socially inappropriate behavior, verbally or physically abusive)?

Q101 How many current residents have behavioral issues as a result of dementia?

How many residents reside in a designated behavioral health unit of the following types?

Q102 Secured

Q103 Unsecured

Employee Safety

This section provides aggregate information regarding the extent to which employee injuries are an issue for Residential Care Facilities in Ohio.

Please report the following summary values from the OSHA Form 300A that you filed in the first quarter of 2016 if it includes information only for your RCF. Letters and numbers in ( ) refer to the item on OSHA Form 300A. If you file another similar form, please provide comparable information here. Include only information for staff in your RCF.

Aggregate Employment Information for 2015

Q104 Total number of RCF employees paid in all pay periods. (Include part-time, contract, and any other paid staff. Round to the highest whole number).

Q105 Total hours worked by all RCF employees last year - sum of hours paid in all pay periods.

Number of cases

Q106 Total number of RCF employee injuries with days away from work (H).

Q107 Total number of RCF employee injuries with job transfer or restriction (I).

Q108 Total number of other recordable cases (J). (Recordable cases as defined by OSHA on Form 300A include work-related injuries and illnesses that result in death, loss of consciousness, days away from work, restricted work activity or job transfer, or medical treatment beyond first aid.)

Number of cases

Q109 Total number of days away from work (K).

Q110 Total number of days of job transfer or restriction (L).

Injuries and Illness Types

Q111 Total number of injuries (1).

Q112 Total number of other illnesses (2-6). (Recordable cases as defined by OSHA on Form 300A include work-related injuries and illnesses that result in death, loss of consciousness, days away from work, restricted work activity or job transfer, or medical treatment beyond first aid.)

Q113 Does your facility have a written policy about lifting residents?

Yes

No

Facility Staffing

Q114 What pay schedule is used for the majority of your employees?

a. Monthly

b. Semi-monthly (e.g. 15th and 31st)

c. Bi-weekly (e.g. every other Friday)

d. Weekly (e.g. every Friday)

Q115 What is the minimum number of hours worked per pay period to be considered full-time?

Report the total number of hours worked by employees in your facility in each category for the first payroll period in 2015.

RNs in the RCF

Q116 Total RN hours (Include all hours during the pay period worked by full-time, part-time, and other RNs employed by your facility - not contract hours)

Q117 Total RN contract hours (Include contract, agency, contingent or other "as needed" RNs)

LPNs in the RCF

Q118 Total LPN hours (Include all hours during the pay period worked by full-time, part-time, and other LPNs employed by your facility - not contract hours)

Q119 Total LPN contract hours (Include contract, agency, contingent or other "as needed" LPNs)

Q120 How many RNs/LPNs were employed during the first payroll period of 2015?

Q121 Of the {Q120} RNs/LPNs employed during the first payroll period of 2015, how many of the same RNs/LPNs were employed during the last payroll period of 2015?

Other direct care frontline staff (e.g. Personal Care Aides, Resident Assistants, Medication Aides, STNAs)

Q122 Total direct care staff hours (Include all hours during the pay period worked by full-time, part-time, and other direct care staff employed by your facility - not contract hours

Q123 Total contract aide hours (Include contract, agency, contingent or other "as needed" aides)

Q124 How many other direct care frontline staff (e.g. Personal Care Aides, Resident Assistants, Medication Aides, STNAs) were employed during the first payroll period of 2015?

Q125 How many other direct care frontline staff (e.g. Personal Care Aides, Resident Assistants, Medication Aides, STNAs) were employed during the last payroll period of 2015?

Q126 Do you have a calculated annual turnover rate for your facility as a whole?

Yes

No

Q127 What is your turnover rate? Round to nearest whole number. No percent sign, no decimal point please.

Q128 Do you have a calculated annual turnover rate for your RNs/LPNs?

Yes

No

Q129 What is your RN/LPN turnover rate? Round to nearest whole number. No percent sign, no decimal point please.

Q130 Do you have a calculated annual turnover rate for your other direct care frontline staff (e.g. Personal Care Aides, Resident Assistants, Medication Aides, STNAs)?

Yes

No

Q131 What is your other direct care frontline staff turnover rate? Round to nearest whole number. No percent sign, no decimal point please.

Social Service Staff

Q132 Do you have a licensed social worker on your staff?

Yes

No

Q133 Total hours worked by all full-time, part-time and other social service staff employed AND contracted by your facility.

Facility Leadership

Q134 Do you have a Director of Nursing in your RCF?

Yes

No

What is the start date of your current Director of Nursing?

Q135 Month

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

--Click Here--

Q136 Year (YYYY) Q137 How many Directors of Nursing (including the current one) has your facility had since 2013?

Q138 Is the administrator a licensed nursing home administrator?

Yes

No

What is the start date of your current administrator?

Q139 Month

Jan

Feb

Mar

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

--Click Here--

Q140 Year (YYYY) Q141 How many administrators (including the current one) has your facility had since 2013?

Guardianship

Q142 As of April 1, 2016, how many residents have court-appointed legal guardians?

In your estimation, what proportion of those guardians are (enter whole numbers, no percent signs):

Q143 Resident's family member or friend

Q144 Professional guardians

Q145 Volunteer or paid guardians from a county guardianship program

Q146 Don't know

Q147 When you determine a resident needs a guardian, how difficult is it to secure one?

Not difficult

Somewhat difficult

Very difficult

Hospital Readmissions

Q148 Are you working on any programs to reduce hospital readmissions or admissions?

Yes

No

Q149 To what extent are each of the following entities your partners in reducing hospitalizations and hospital readmissions? Check all partnership agreements/arrangements that apply.

Individual physician(s) or physician practice(s)

Do not work with this group

Formal partnership such as memo of

understanding, contract, business partnership

Informal Partnership

Individual hospitals Hospital or health care system Local or regional hospital council/consortium

Health information exchange/electronic health record consortium

Accountable Care Organization(s) Medicaid managed care organization Medicare Advantage organization Area Agency on Aging Nursing home(s) Assisted living facility(s) Home care agencies Hospice agencies Pharmacy or pharmacist Veteran’s Administration (home care services contracts, VA medical centers)

Q150 If there are any other partners, please describe:

Q151 For each activity described below, please indicate the extent to which you and/or your network of partners have made progress in reducing hospital readmissions and avoidable admissions?

Developed a clear understanding of new healthcare regulations and initiatives

Do not plan to work on this

Plan to work on this but have not

begun

Have begun working on this

but have not completed the

activity

Have completed the activity or

implemented the practice

Chose or developed an evidence-based practice model

Hired new personnel or retrained current staff to implement new program(s)

Developed strategies for effective communication of patient information among providers

Developed/purchased technology or record systems for access across multiple providers

Participating in alternative payment approach (e.g. risk-based payments, bundled payments)

Developed tools for monitoring patient outcomes

Developed marketing and advertising plan for new networks/partnership

Developed a plan for measuring/ensuring quality

Treated patients/residents under this new model of care

Q152 What specific evidence-based transition programs do you use? Check all that apply.

Interventions to Reduce Acute Care Transfers (INTERACT)

Other evidence-based program

Our program is not based on any current evidence-based model; ours is a hybrid of existing models or newly developed for us

Don't know

Q153 You indicated other evidence-based program. Please specify:

Q154 To what extent are the following issues challenges or barriers to collaborative efforts with acute care and other long-term care providers in order to reduce hospital readmissions and avoidable admissions?

Lack of a common language

Not a barrier

Little bit of a

barrier

Somewhat of a

barrier

Major barrier

Enough to stop

efforts

Not familiar with the

issue

Lack of common understanding of proposed programs/services

Differences in technology availability between our facility and acute care providers

Resistance of hospital/health care staff to working with RCFs

Additional funds to implement changes/plans( e.g. new staff, new EMR system)

Lack of time to implement changes/make new plans

Establishing fair and sufficient reimbursement rates

Establishing new billing methods/systems

Confusion with billing and bundled payments

Unwillingness of our health care partners to take financial risk

Competition within the healthcare community

Slow, inconsistent or unreliable payment

Q155 To what extent are the following issues challenges or barriers to collaborative efforts with acute care and other long-term care providers in order to reduce hospital readmissions and avoidable admissions?

Competition within the long-term care community

Not a barrier

Little bit of a

barrier

Somewhat of a

barrier

Major barrier

Enough to stop

efforts

Not familiar with the

issue

Health care system expectations regarding our RCF’s financial resources

Unwillingness of our own facility/board or corporate office to take financial risk

Our facility’s lack of expertise with outreach and marketing to acute care patients

Attitudes of health care professionals towards RCFs and/or our facility

Attitudes of our RCF staff toward health care community

Lack of clarity regarding division of labor between our facility and other partners

Determining leadership within the partnership

Lack of clarity regarding program accountability

Legal issues/agreements that will be needed

Lack of data sharing Resources required for new training of staff

Lack of physical facilities to accommodate acute care needs

Q156 If there are other challenges or barriers to collaborative efforts, please describe:

Emergency Issues and Planning

Q157 During the past 12 months has your facility experienced any of the following? (Check all that apply)

Power outage of more than 12 hours

Water outage of more than 12 hours

Flooding which impacted your facility

A fire

An event that required you to lock-down your facility

A need to evacuate residents to another facility

A need to evacuate residents to another section of your facility

Another emergency that damaged your facility and/or impacted your residents

Q158 You indicated another emergency. Please describe:

Q159 Does your facility have an emergency plan?

Yes

No

Q160 Has your facility reviewed its emergency plan ?

Yes

No

Q161 When did your facility last review its emergency plan (MM/YYYY)?

Q162 Has your facility conducted an emergency planning exercise?

Yes

No

Q163 When did your facility last conduct an emergency planning exercise? (MM/YYYY)?

Q164 Did you work with any of the following local partners to develop your emergency plan ? (Check all that apply)

Local emergency management agency

Local hospital

Area Agency on Aging

Fire department

Police department

Nursing home(s)

Senior center(s)

Ambulance companies

American Red Cross

YMCA

Public health department

Utility (electric, water) provider

Other

Did not work with any local partners to develop emergency plan

Q165 You indicated other local partner. Please describe:

Q166 Did you work with any of the following local partners to conduct an emergency plan exercise? (Check all that apply)

Local emergency management agency

Local hospital

Area Agency on Aging

Fire department

Police department

Nursing home(s)

Senior center(s)

Ambulance companies

American Red Cross

YMCA

Public health department

Utility (electric, water) provider

Other

Did not work with any local partners to conduct emergency plan exercise

Q167 You indicated other local partner. Please describe:

Q168 Have you discussed your facility's emergency plan with your area's representative of the Office of the State Long-Term Care Ombudsman program?

Yes

No

Q169 In Ohio, there are 7 regional healthcare coalitions (one in each of the state's Homeland Security Regions), which focus on preparedness-planning activities, and primarily comprised of public health, emergency management, and healthcare organizations. Has your facility been contacted by or been engaged with your regional coalition?

Yes, our facility has had contact and has worked with our regional healthcare coalition

Yes, our facility has had contact, but has not begun working with our regional healthcare coalition

No, our facility has not had contact with our regional healthcare coalition

Not sure

Emergency Supplies

For how many days does your facility store an emergency supply of each of the items below? If you do not have emergency supplies, mark “0”.

Q170 A supply of bottled water:

Q171 Do you hold an agreement with supplier(s) to provide additional bottled water during an emergency?

Yes

No

Q172 Extra medical supplies and equipment:

Q173 Do you hold an agreement with supplier(s) to provide additional medical supplies and equipment during an emergency?

Yes

No

Q174 Extra pharmacy stocks of common medications:

Q175 Do you hold an agreement with supplier(s) to provide additional common medications during an emergency?

Yes

No

Q176 Non-perishable foods:

Q177 Do you hold an agreement with supplier(s) to provide additional non-perishable foods during an emergency?

Yes

No

Q178 Does your facility have a back-up generator?

Yes

No

Q179 What type of fuel does it use

Propane

Natural gas

Gasoline

Diesel fuel

Q180 Is your facility wired to accept a portable generator?

Yes

No

Q181 How many days’ supply of generator fuel do you have on hand?

Q182 Does your facility have other forms of communication in place (walkie-talkies, ham radios, text messaging systems, etc.) in the event of telephone and cellular failure?

Yes

No

Emergency Plan Details

Q183 Does your plan include specific actions to be taken for the following hazards or emergencies? (Check all that apply)

Freezing temperatures/loss of heat

Extreme heat/loss of air conditioning

Facility flooding

Facility fire

Tornado/windstorm

Extended loss of power

Hostile action (active shooter, etc.)

Q184 Does your plan address specific actions to be taken for indirect hazards (those that affect the community, but not the facility and as a result interrupt necessary utilities, supplies or staffing) such as impassable roads or wildfires?

Yes

No

Q185 Does your plan have communication procedures to inform staff, families, and individuals receiving care, before, during, and after an emergency?

Yes

No

Sheltering in Place

Procedures to shelter in place ensure that there is water, extra pharmacy stocks of common medications, and extra medical supplies to last at least 7 days.

Q186 Does your emergency plan address procedures to shelter in place?

Yes

No

Q187 Do the procedures specify: (Check all that apply)

Need to communicate with local agencies about the decision to shelter in place

Requirements for sufficient staffing levels during emergencies

Plans for assisting/accommodating staff families and pets

Triggers to move from sheltering in place to evacuation

Evacuation Procedures

Q188 Does your emergency plan address evacuation procedures?

Yes

No

Q189 Do the procedures specify: (Check all that apply)

Agreements or contracts with hospitals to shelter high-acuity residents

Agreements or contracts with other pre-determined evacuation sites with suitable space, utilities, security and sanitary facilities for individuals receiving care and staff

Agreements or contracts with appropriate transportation providers during evacuation (e.g. accommodate wheelchairs) with assurances that they are capable of providing service even if the emergency affects an entire area (e.g. their staff, vehicles and other vital equipment are not overbooked)

How medication and other supplies will be transported during evacuation

How water will be transported during evacuation

How resident information will be transferred with resident

A strategy for tracking residents during relocation

Mode for transferring resident information during evacuation

Whether/how staff will be deployed if residents move to another facility

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