LTC Infection Control Audits - Video and Photo Uploads

FACILITY INFORMATION
Please provide the Organization ID shown in HCS. 
Facility Address
Please provide phone number for questions about this audit. 
Contact Person
Please provide name of contact person to answer questions regarding this audit. May or may not be person who submits this survey. May or may not be person who performed the audit. 
AUDIT STAFF INFORMATION
Auditor Name
Please enter name of person who performed the audit.
Please provide email address of the person who performed the audit. 
Please provide direct phone number to person who performed the audit. 
Nursing Home Staffing and Cohorting Plans
Please upload the facility COVID Staffing and Cohorting Plan based on CDC recommendations.
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Dedicated Space and Dedicated Staffing
Please upload a list of staff names and titles of staff who directly interact with residents who are confirmed or suspected to be infected with a contagious or infectious disease.
Attachment should include list of teams
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Attachement should include a list of staff who have direct resident contact to specific areas and not rotating staff between various areas of the facility.
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Upload as many photos as necessary to satify this requirement. You may copy all photos into one file. 
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Attachments should include photographic or video evidence of areas where residents are to be cohorted, signage outside of designated rooms and PPE outside rooms.
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Personal Protective Equipment Compliance
Please provide a list of staff who are responsible for ensuring the proper use of PPE by all staff. Attachment should include photograpic or video evidence to show sufficient supply of PPE, supply orders and supply rooms.
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Please provide photos of supply room where PPE is stored. 
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Additional photo upload
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Infectious Disease Outbreak
Please attach a photo, video or copy of proper signage in the facility during outbreaks to prevent transmission.
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Please attach a copy of the infection control line list at the time of the audit. See CDC link below for an example of this. 
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https://www.cdc.gov/longtermcare/pdfs/LTC-Resp-OutbreakResources-P.pdf
Please attach a copy the COVID 19 Policy and Procedure for your facility. 
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Please provide facility Infection Control Policy and Procedure 
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