COVID 19: Screening Checklist - For VisitorsOn March 13,2020, CMS and CDC updated guidelines on restricting all SNF visitors and non-essential healthcare, personal, execpt for certain compassionate care situations. All Individuals (staff and other health care workers, family,visitor, Goverment officials, etc) entering the building must be asked for following questions:First Name Middle Initial Last Name Email Address Phone (###-###-####) 1. I will wash my hands or use an alcohol-based hand rub (ABHR) on entry. Yes2. Have you had any of following respiratory Symptoms? CoughShortness of breath OR at least TWO of these symptoms FeverRepeated shaking with chillsHeadcheNew loss of test or smellDiarrheaChillsMuscle PainSore throatVomitingIf YES to any, restrict them from entering the building.If NO to all, proceed to question #4.3. For Staff & health care provider(HCP) (e.g. agency staff, regional or corporate staff, Health care workers such as hospice, EMS, Dialysis technicians that provide care to residents): 3A. Check temprature and document results Fever Present? If YES, please wait for our direction before entering our building.if NO, Proceed to step 3B.3B. Have you worked in facilities or loactions with recognized COVID-19 cases?If YES, have you worked with the person who has confirmed COVID-19?If YES, please wear PPE including mask and gloves when you come to our facility. We will give you a gown before any contact with residents. Also, please proceed to step 4.If NO, Proceed to step 4.4. Please do the following before you entering our building: Wash your hands or use ABHR throughout your time in the building.Do not shake hands with, touch or hug individuals during your visit.Wear a facemask while in the buiding & restrict your visit to the residents room or other location designed by the facility.By hitting "Submit," you are agreeing to have your form signed and submitted electronically.
