Title Page
-
Conducted on
undefined
-
-
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)
- Fever
- Sore throat
- Cough
- New shortness of breath
-
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
-
Comments
-
Signature
