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Facility Identification

Notice
Do not include any sensitive information on this form or (if applicable) files uploaded to this form. Sensitive information includes, but is not limited to, social security numbers, driver’s license numbers, bank account information, routing numbers, medical information, passport numbers, or passwords.
Facility Name*
Street Address
City*
State
Zip Code
Facility Contact Person Name*
Facility Contact Person Title
Facility Contact Person Phone Number*
Facility Contact Person Email*
Name of Person Completing Form*
Date of Form Completion*
Date of Form Completion
Affiliation of Person Completing Form*
Phone Number*
Email Address*
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1. Do you have outside medical staff (physicians, physician assistants, nurse practitioners, physical therapists, occupational therapists, and others) entering your facility to provide care to residents?
2. Has your facility been utilizing telehealth (video/online) visits in place of in-person visits?
3. If so, in which situations has your facility been using telehealth visits?
4. Are outside medical staff required to undergo screening prior to entering your facility and utilize PPE?
5. How are you ensuring that these policies are being followed?
6. Please provide a list of all outside medical staff who are entering your facility. To the best of your knowledge, please note if they provide services to other long-term care facilities, and the names of those facilities.
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1. Are your staff being screened for illness prior to coming to work?
2. Do these policies vary between departments (for example, nursing staff, food prep staff, cleaning staff)? How so?
3. What happens if a staff member reports that they are ill?
4. What happens if a staff member reports illness in someone else in their household?
5. How are you tracking staff illnesses?
6. How are you ensuring that these policies are being followed?
7. To the best of your knowledge, do any of your staff work second jobs at other long-term care facilities? If so, please list names of those staff and the names of their other workplace.
8. How many staff are currently out ill?
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1. How are residents being screened for illness? How frequently?
2. How are you tracking resident illness?
3. How is this data stored?
4. Are ill residents provided PPE?
5. Are residents regularly participating in group activities or having meals in groups?
6. If so, are residents being screened for illness prior to participating in group activities or having meals in groups?
7. How are you ensuring that these policies are followed?
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1. What is your policy for screening new incoming residents for illness?
2. What is your policy for readmitting residents who have left your facility for medical care or other purposes?
3. Are you utilizing the MDHHS Hospital to Post-Acute Care Transfer Form for COVID-19?
4. How are you ensuring that these policies are being followed?
5. Can you accommodate the isolation and droplet precautions required for someone with COVID-19?
6. Will you accept a COVID-19 patient?
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1. What does your facility need in order to keep operating safely (PPE, educational materials, additional staff)? The Berrien County Health Department will work to coordinate needs as much as possible.
2. Please provide an approximate inventory of your PPE materials in stock.
3. Do you have the ability to acquire additional PPE through your own channels?

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