Title Page

  • Conducted on

  • Prepared by

  • Location

Screening

  • This checklist is derived from https://www.ahcancal.org/facility_operations/disaster_planning/Documents/COVID19-Screening-Checklist-SNF-Visitors.pdf

  • On March 13, 2020, CMS and CDC updated guidance on restricting all SNF visitors and non-essential healthcare personnel, except for certain compassionate care situations, such as end-of-life

  • ALL individuals (employees, family, visitors, government officials) entering the building must be asked the following questions:

  • Has this individual washed their hands or used alcohol-based hand rub (ABHR) on entry?

  • Please ask them to do so

  • Ask the individual if they have any of the following respiratory symptoms? (If YES to any, restrict them from entering the building)

  • Restrict them from entering the building

  • If NO to all, is the individual an employee of this institution?

  • 3A. For employees, check temperature and document results (not required for visitors)

  • Fever present?

  • Restrict from entering the building

  • 3B. For employees, ask if they have:

  • Worked in facilities with recognized COVID-19 cases?

  • If YES, ask if they worked with person with confirmed COVID-19?

  • If YES, restrict them from entering the building

  • 4. Allow entry to building and remind the individual to:

  • Wash their hands or use ABHR throughout their time in the building.

  • Not shake hands with, touch or hug individuals during their visit.

  • Visitors that are permitted for compassionate care situations must wear a facemask while in the building and restrict their visit to the resident’s room or other location designated by the facility.

  • 4. Allow entry to building and remind the individual to:

  • Wash their hands or use ABHR throughout their time in the building.

  • Not shake hands with, touch or hug individuals during their visit.

  • Visitors that are permitted for compassionate care situations must wear a facemask while in the building and restrict their visit to the resident’s room or other location designated by the facility.

  • 4. Allow entry to building and remind the individual to:

  • Wash their hands or use ABHR throughout their time in the building.

  • Not shake hands with, touch or hug individuals during their visit.

  • Visitors that are permitted for compassionate care situations must wear a facemask while in the building and restrict their visit to the resident’s room or other location designated by the facility.

  • Note: Assisted Living Providers can use this checklist as feasible for their community

Completion

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