Facility Name ________________________________________________________ Palliative Care Hospice Care Part 2 completed Part 2 not completed Facility Name ________________________________________________________ Palliative Care Hospice Care Part 2 completed Part 2 not completed Facility Name ________________________________________________________ Palliative Care Hospice Care Part 2 completed Part 2 not completed Facility Name ________________________________________________________ Palliative Care Hospice Care Part 2 completed Part 2 not completed Facility Name ________________________________________________________ Palliative Care Hospice Care Part 2 completed Part 2 not completed
_________________________________________________________________ What are the triggers leading to this process? _________________________________________________________________ * Is there a plan for implementing social distancing measures? Yes No If yes, when would these measures begin? _________________________________________________________________ * Does the health department plan to close during an influenza pandemic? Yes No If yes, what are the triggers leading to this closure? _________________________________________________________________ * Does the surveillance plan for influenza pandemic cases include triggers for changing from passive to active surveillance? Yes No If yes, what are these triggers? _________________________________________________________________ * Please briefly describe the active surveillance plan for an influenza pandemic? _________________________________________________________________
Is the agency affiliated with a: Hospital system Long-term care facility Neither Does the agency provide hospice services? Yes No What is the role of the agency in the community's pandemic influenza planning? ____________________________________________________________________ * Has it been discussed with Emergency Medical Services (EMS) what services they would provide for the agency's patients during an influenza pandemic? Yes No If yes, what are those services? _________________________________________________________________ * Have there been discussions with the community's hospital(s) on their expectations of the types or levels of services the agency will provide to patients during an influenza pandemic? Yes No If yes, what are services? _________________________________________________________________ Has the scope of services been defined for those the agency will provide and that will be referred to other providers? Yes No
Ventilators ___________________________________________________________ Oxygen _____________________________________________________________ Does the facility have airborne infection isolation rooms (AIIRs)? Yes No * Is there a nurse staffing plan to manage patients on ventilators when 30% to 40% of the nurses may be out ill during an influenza pandemic (e.g., adjusted nurse-to-patient ratios or just-in-time training for volunteer nurses)? Yes No * Is a plan to use family members to provide care for their sick loved ones, if there are limited employees during an influenza pandemic? Yes No * Is a contingency plan for an increased need for post-mortem handling and disposition of bodies? Yes No * Is there a place in the facility that can be used as a temporary morgue, if needed? Yes No * Is there an alternate plan for body transport in the event that patients die at the LTC facility? Yes No