SNF Clinical Capability Survey

SNF Clinical Capability Survey

Facility Street Address*

Facility Representative Name*

Facility Representative Title*

Facility Representative Position/Role*

Facility Representative Email*

Facility Representative Phone Number*

Phone

Number of Total Beds*

Number of Private Rooms*

Does your facility have isolation rooms for infectious patients?*

Yes

Will your facility bunk like patients in the same room?*

Yes

Does your facility have staff sitters?*

Yes

Other Staff Sitter Availability

Does your facility have a locked memory care unit?

Yes

How many beds are available?*

Does your facility have assisted living units?*

Yes

How many units are available?

Can your facility provide non-emergent transportation?*

Yes

Does your facility allow patients to bring their own prescription medications?*

*Example: high-cost drugs

Yes

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?

Provide details of 'Other'*

Does your facility have any age restrictions for admission?*

Yes

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

Provide details of 'Other'*

What type and/or brand of specialized therapy equipment?*

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

Provide details of 'Other'*

How many IV fluids/medications can your facility administer for a single patient?*

Select

Does your facility provide 24-hour coverage for IV therapy?*

Yes

Can your facility administer IV cardiac medications via push and/or infusion?*

Yes

Provide details of 'Other'*

Can your facility provide coordination and transportation for chemotherapy or radiation therapy services?*

Yes

Provide details of 'Other'*

Select all of the following services/care your facility offers*

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

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

Provide details of 'Other'*

Are there any high-flow oxygen quantity limitations?*

Yes

What is the quantity limitation?*

Provide details of 'Other'*

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