SMQT Study Guide 3
Appendix Z Emergency Preparedness - SA
Used to guide FA task investigations Facility task CEP(athways) &
Appendix PP
Census number Immediately
Complete matrix for new admissions in last 30 days Immediately
An alphabetical list of all residents (note any resident out Immediately
of the faciltiy)
Smokers + designated smoking time/locations Immediately
A list of Confirmed/suspected COVID cases Immediately
Staff responsible for Infection Prevention/Control Immediately
Program
Staff responsible for COVID vaccination effort Immediately
Info regarding full time DON coverage (verbal Entrance Conference
confirmation)
Info re: facility's emergency water source (verbal Entrance Conference
confirmation)
Signs announcing survey Entrance Conference
are posted in high-visibility areas.
Updated facility floor plan Entrance Conference
including COVID Resident locations/separate unit areas
Name of Resident Council President Entrance Conference
Provide the facility with a copy of the CASPER 3 Entrance Conference
, SMQT Study Guide 3
Schedules of meals Needed within 1 hour
dining rooms locations
copies of current menus - including therapeutic - that will
be served for duration of the survey
policy for food brought in from visitors
Schedule of Medication Administration times Needed within 1 hour
Number and location of med storage rooms and med Needed within 1 hour
carts
The actual working schedules for all staff, separated by Needed within 1 hour
departments, for the survey time period
List of key personnel, location, and phone numbers Needed within 1 hour
Note contract staff (e.g.rehab services)
Also include staff responsible for notifying all residents,
representatives, & families of confirmed or suspected
COVIDcases in facility
Paid Feeding assistants Needed within 1 hour
a) State-approved program (min. 8 hrs training)
b) Staff names who completed training & currently assisting
(c) A list of resident eligible for & currently receiving assistance
(d) only used for selected residents with eating meals and/or snacks assist
The facility's mechanism used to inform residents/their Needed within 1 hour
reps/families of (confirmed or suspected) COVID activity
&
actions taken to prevent/reduce risk of transmission
normal facility operations to be altered?
COVID Docs: testing plan, logs of positivity rates, testing Needed within 1 hour
schedules, list of staff who have (confirmed or
suspected) cases, and if testing issues (contact with
state/ local health departments)
TC confirms Matrix was completed accurately Within 4 hours
Admission packet Within 4 hours
Dialysis contracts / within 4 hours
Agreements / P&Ps for transports to treatment/
Qualified staff if applicable
Does the facility have an onsite separately certified Notify Within 4 hours
ESRD unit?
Hospice Agreements / P&Ps for each hospice used Within 4 hours
(name of facility designee who coordinate services with
hospice providers)
Appendix Z Emergency Preparedness - SA
Used to guide FA task investigations Facility task CEP(athways) &
Appendix PP
Census number Immediately
Complete matrix for new admissions in last 30 days Immediately
An alphabetical list of all residents (note any resident out Immediately
of the faciltiy)
Smokers + designated smoking time/locations Immediately
A list of Confirmed/suspected COVID cases Immediately
Staff responsible for Infection Prevention/Control Immediately
Program
Staff responsible for COVID vaccination effort Immediately
Info regarding full time DON coverage (verbal Entrance Conference
confirmation)
Info re: facility's emergency water source (verbal Entrance Conference
confirmation)
Signs announcing survey Entrance Conference
are posted in high-visibility areas.
Updated facility floor plan Entrance Conference
including COVID Resident locations/separate unit areas
Name of Resident Council President Entrance Conference
Provide the facility with a copy of the CASPER 3 Entrance Conference
, SMQT Study Guide 3
Schedules of meals Needed within 1 hour
dining rooms locations
copies of current menus - including therapeutic - that will
be served for duration of the survey
policy for food brought in from visitors
Schedule of Medication Administration times Needed within 1 hour
Number and location of med storage rooms and med Needed within 1 hour
carts
The actual working schedules for all staff, separated by Needed within 1 hour
departments, for the survey time period
List of key personnel, location, and phone numbers Needed within 1 hour
Note contract staff (e.g.rehab services)
Also include staff responsible for notifying all residents,
representatives, & families of confirmed or suspected
COVIDcases in facility
Paid Feeding assistants Needed within 1 hour
a) State-approved program (min. 8 hrs training)
b) Staff names who completed training & currently assisting
(c) A list of resident eligible for & currently receiving assistance
(d) only used for selected residents with eating meals and/or snacks assist
The facility's mechanism used to inform residents/their Needed within 1 hour
reps/families of (confirmed or suspected) COVID activity
&
actions taken to prevent/reduce risk of transmission
normal facility operations to be altered?
COVID Docs: testing plan, logs of positivity rates, testing Needed within 1 hour
schedules, list of staff who have (confirmed or
suspected) cases, and if testing issues (contact with
state/ local health departments)
TC confirms Matrix was completed accurately Within 4 hours
Admission packet Within 4 hours
Dialysis contracts / within 4 hours
Agreements / P&Ps for transports to treatment/
Qualified staff if applicable
Does the facility have an onsite separately certified Notify Within 4 hours
ESRD unit?
Hospice Agreements / P&Ps for each hospice used Within 4 hours
(name of facility designee who coordinate services with
hospice providers)
