Innovations in End-of-Life Care
an international journal of leaders in end-of-life care
Facility Needs Assessment
| Date: | ___________________________________ |
| Facility Name: | ___________________________________ |
| Address: | ___________________________________ |
| Telephone: | ( ) ________ FAX: ( ) _________ |
| Director of Nursing: | ___________________________________ |
| Medical Director: | ___________________________________ |
1. Number of beds in facility: ___________________________
2. Specialty units: (check all that apply)
| Alzheimers | _____________ | Medicare | _____________ |
| Subacute | _____________ | Hospice | _____________ |
| Rehab | _____________ | Other (please state) | _____________ |
3. Does your facility contract with a hospice agency or agencies?
| Yes | ______ | No | ______ |
| If yes, please list agencies: | _______________________________ |
4. Are Certified Medication Assistants utilized?
| Yes | ______ | No | ______ |
5. Is there a pharmacist onsite?
| Yes | ______ | No | ______ |
6. Is infusion therapy provided? (IVs, Subcu, PCA, etc.)
| Yes | ______ | No | ______ |
If yes, how is the service provided?
| Facility staff | _____________ | Contract agency | _____________ |
7. List policies and procedures for pain management practices currently in place.
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
8. Are standardized pain assessment tools in place at this time?
| For the cognitively intact resident? | Yes | ______ | No | ______ |
| For the cognitively impaired resident? | Yes | ______ | No | ______ |
9. What is your current facility standard for when pain assessment is done?
(check all
appropriate answers)
| Admission | ____ | Change of condition | ____ |
| Monthly | ____ | Change of medication | ____ |
| Quarterly | ____ | Annually | ____ |
| Other (please explain) | _________________________________________ |
| No standard at this time | ________ |
Reprinted by permission of Elsevier Science from "Building an institutional commitment to pain management in long-term care facilities," by DE Weissman, J Griffie, S Muchka, and S Matson. Journal of Pain and Symptom Management Volume 20, Number 1, Pages 35-43. Copyright 2000 by the US Cancer Pain Relief Committee.
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