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Run: COVID-19 Point Prevalence Survey Log for Skilled Nursing Facilities

Log a facility-wide COVID-19 point prevalence testing round in a skilled nursing facility, including who was tested, what the results were, and what isolatio...

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Inspection Details

Survey date and time recorded critical (required)

Note (optional)

Facility name and survey location identified critical (required)

Survey type documented as point prevalence testing round critical (required)

Note (optional)

Infection prevention lead or competent person identified critical (required)

Reference outbreak event or incident number recorded

Survey Scope and Unit Coverage

All intended units included in the survey scope critical (required)

Note (optional)

Number of residents included in survey critical (required)

Number of staff included in survey critical (required)

Residents or staff excluded from testing documented

Yes No N/A

Reason for any exclusion documented

Testing Administration and Results

Tests administered to all eligible residents and staff critical (required)

Yes No N/A

Test method documented critical (required)

Note (optional)

Number of positive results critical (required)

Number of negative results critical (required)

Number of pending or inconclusive results

Specimens collected and labeled per facility procedure

Yes No N/A

Isolation, Cohorting, and Unit Status

Positive residents placed in appropriate isolation or transmission-based precautions critical (required)

Yes No N/A

Positive staff removed from work and follow-up arranged critical (required)

Yes No N/A

Cohorting or unit segregation implemented where indicated

Yes No N/A

Unit-level isolation status documented critical (required)

Note (optional)

Isolation start time recorded for affected unit or residents

Reporting, Follow-up, and Sign-off

Results reported to infection prevention leadership and facility administration critical (required)

Yes No N/A

Public health or regulatory notification completed when required

Yes No N/A

Corrective actions documented for deficiencies or non-conformances

Yes No N/A

Follow-up testing date scheduled

Inspector or survey lead signature critical (required)

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