LTC Provider Questionnaire on COVID-19 Surge Capacity

Purpose: As the state prepares for a surge of COVID-19 cases in the coming days, the three long-term care associations are working together to find out about long term care providers plans, capacity and current practice.

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* 1. Please have only one person respond from your organization & Systems please fill out a survey for each site:

Name

Company/Organization

Email Address

Phone Number

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* 2. Are you planning to set up a separate multi-person isolation wing or unit within your existing building or campus, with dedicated staffing, for COVID-19 care or recovery?

Yes

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* 3. If yes to question #2, please complete to the best of your ability:

City?

County?

Number of beds?

When will it be functional?

Who can be contacted for more information?

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* 4. If no to question #2, please complete to the best of your ability:

Please provide major reasons (e.g. lack of sufficient PPE, lack of sufficient staff, other):

Other comments:

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* 5. Are you planning to set up a new separate dedicated facility for COVID-19 recovery?

Yes

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* 6. If yes to question #5, please complete to the best of your ability:

City?

County?

Number of beds?

When will it be functional?

Who can be contacted for more information?

Other comments:

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* 7. If no to question #5, please complete to the best of your ability:

Please share if you are aware of any such facility being set up in your area?

Other comments:

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* 8. Are you taking new admissions from the community at this time?

Yes

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* 9. If yes to question #8, please complete to the best of your ability:

Under what circumstances?

What precautions will be taken to assure other residents are kept safe?

Other comments:

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* 10. If no to question #8, please complete to the best of your ability:

Please provide major reasons:

Thoughts on where these individuals will receive care?

Other comments:

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* 11. Are you taking back your residents who will/have been discharged from the hospital?

Yes

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* 12. If yes to question #11, please complete to the best of your ability:

Under what circumstances?

What precautions will be taken to assure other residents are kept safe?

Other comments:

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* 13. If no to question #11, please complete to the best of your ability:

Please provide major reasons:

Thoughts on where these individuals will receive care?

Other comments:

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* 14. Please mark below who your organization has contacted:

Your County Emergency Management System

Your County Public Health Dept

Your Regional Health Care Coalition

The associations STRONGLY RECOMMEND that you reach out to the above, below is the information with links to make contact if you have not already.

County Emergency Management System
http://www.kansastag.gov/KDEM.asp?PageID=200

County Public Health Dept
http://www.kdheks.gov/olrh/download/health_directory.pdf

Regional Health Care Coalition
http://www.kdheks.gov/cphp/download/HCC_map_&_contacts.pdf

Thank you from your long-term care provider associations!