SNF Clinical Capability Survey
Facility Name
*
Facility NPI
*
Facility Street Address
*
City
*
State
*
Select
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Zip Code
*
Facility Representative Name
*
Facility Representative Title
*
Facility Representative Position/Role
*
Facility Representative Email
*
Facility Representative Phone Number
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Phone
Number of Total Beds
*
Number of Private Rooms
*
Does your facility have isolation rooms for infectious patients?
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Yes
No
Will your facility bunk like patients in the same room?
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Yes
No
Does your facility have staff sitters?
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Yes
No
What are the staff sitters' availability?
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Days
Nights
PRN
Weekends
24/7
Other
Other Staff Sitter Availability
Does your facility have a locked memory care unit?
Yes
No
How many beds are available?
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Does your facility have assisted living units?
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Yes
No
How many units are available?
Can your facility provide non-emergent transportation?
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Yes
No
Does your facility allow patients to bring their own prescription medications?
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*Example: high-cost drugs
Yes
No
Select all of the following that your facility can accept
*
Short-term/Rehab admissions
Long-term/custodial admissions
Weekend and after-hours admissions
None of the above
On average, what is the percentage of long-term/custodial vs short-term?
What hours can your facility accept admissions?
*
Weekday Days
Weekday Nights
Weekend Days
Weekend Nights
24/7
Other
Provide details of 'Other'
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Does your facility have any age restrictions for admission?
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Yes
No
What is the minimum age your facility can accept?
*
Select all that your facility offers
*
Therapists with specialized training, certifications, and/or expertise
Specialized therapy equipment
Specialized clinical and rehab programs
None of the above
Select specific training, certifications, and/or expertise of therapists
*
*Select all that apply
Neuro
Ortho
NDT (Neuro Developmental Treatment)
Brain Injury
Cardiac
Dysphagia
Other
Provide details of 'Other'
*
What type and/or brand of specialized therapy equipment?
*
What specialized programs does your facility offer?
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*Select all that apply
Cardiac
Stroke
Wound Care
Orthopedic
Pulmonary
Behavioral Health
Other
What behavioral health services does your facility provide?
*
Provide details of 'Other'
*
Select the maximum weight limit your facility can accept
*
Up to 350lbs
351-500lbs
Over 500lbs
None of the above
How many days a week is your facility able to provide PT, OT, or ST services?
*
Select
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Select all that your facility can administer/accept/manage patients with
*
IV Fluids
IV Meds
IM Meds
PICC Line
Central Line
Port
None of the above
What frequency can your facility accommodate?
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Daily
Every 2 hours
Every 4 hours
Every 6 hours
Every 8 hours
Every 12 hours
All the above
Other
Provide details of 'Other'
*
How many IV fluids/medications can your facility administer for a single patient?
*
Select
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Does your facility provide 24-hour coverage for IV therapy?
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Yes
No
Can your facility administer IV cardiac medications via push and/or infusion?
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Yes
No
Select all medications your facility can administer
Diuretics
Digoxin
Diltiazem
Amiodarone
Labetolol
Esmolol
Other
All of the above
None of the above
Provide details of 'Other'
*
Select all the following types of patients your facility can accept and manage
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Stroke patient
Traumatic brain injury patient
Spinal cord injury patient
Orthopedic patient
Neurologic patient
Cancer patient
Complex Medical
Other
None of the above
Provide details of 'Other'
*
Can your facility provide coordination and transportation for chemotherapy or radiation therapy services?
*
Yes
No
Select all the following that your facility can accept/manage a patient with
*
PCA pump
CADD pump
Catheters
Chest tube
PleurX drain
LifeVest
LVAD (left ventricular assist device)
Ostomy
None of the above
Select all the following your facility can accept/manage patients with
*
Colostomy
Ileostomy
Urostomy
Nephrostomy
Other
All of the above
Provide details of 'Other'
*
Select all the following catheters your facility can accept/manage
*
Intermittent
Indwelling
Suprapubic
External
Other
All of the above
Provide details of 'Other'
*
Select all of the following services/care your facility offers
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Advanced wound care
Coordination/transportation for hemodialysis care
On-site hemodialysis care
Peritoneal dialysis
Tracheostomy care
Suctioning
Cardiac telemetry/monitoring
None of the above
Select all the following your facility has
*
Wound care nurse
Wound care team
Consultant wound care specialist that provides on-site advanced wound care services
None of the above
What is the frequency and availability of the consultant wound care specialist?
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Weekly
Multiple times a week
Monthly
24/7
As Needed
Select all the following your facility is capable of managing
*
Wound Vac
VeraFlo Wound Vac
None of the above
What specific advanced wound care services can your facility provide
*
Select all the following your facility can accept/manage
*
Acute/Complex tracheostomy care
Routine/Chronic tracheostomy care
Select all the following your facility can perform
*
Shallow suctioning
Deep tracheal suctioning
What frequency can your facility perform suctioning?
*
Every hour
Every 2 hours
Every 4 hours
Every 8 hours
Every 12 hours
Other
All of the above
Provide details of 'Other'
*
Select all the following that your facility can accept/manage/provide
*
Ventilator dependent patients
Ventilator weaning
Respiratory therapist coverage
Patients on CPAP
Patients on BiPAP
Patients on Trilogy
Patients receiving nebulized treatments
High-flow oxygen
All of the above
None of the above
What respiratory therapist coverage can your facility provide?
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24-hour coverage
Daily
Twice daily
As needed
Other
Are there any high-flow oxygen quantity limitations?
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Yes
No
What is the quantity limitation?
*
Select all the following your facility can administer/manage nutrition via
*
Total parenteral nutrition
Nasogastric
G-tube
J-tube
Other
None of the above
Provide details of 'Other'
*
Select all the following consultant specialists who can provide specialty medical care as needed
*
Cardiology
Neurology
Orthopedics
Pain Management
Physiatry
Psychiatry
Pulmonology
Other
None of the above
What is the frequency and availability of the cardiology specialist?
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Weekly
Multiple times a week
Monthly
24/7
As needed
What is the frequency and availability of the neurology specialist?
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Weekly
Multiple times a week
Monthly
24/7
As needed
What is the frequency and availability of the orthopedic specalist?
*
Weekly
Multiple times a week
Monthly
24/7
As needed
What is the frequency and availability of the pain managment specialist?
*
Weekly
Multiple times a week
Monthly
24/7
As needed
What is the frequency and availability of the physiatry specialist?
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Weekly
Multiple times a week
Monthly
24/7
As needed
What is the frequency and availability of the psychiatry specialist?
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Weekly
Multiple times a week
Monthly
24/7
As needed
What is the frequency and availability of the pulmonology specialist?
*
Weekly
Multiple times a week
Monthly
24/7
As needed
Provide details of 'Other'
*
What is the frequency and availability of the 'Other' specialist?
*
Weekly
Multiple times a week
Monthly
24/7
As needed
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