The Hows and Whys of Facility Assessment

Are you ready?


Ellen Kuebrich

Chief Strategy Officer, Providigm

Published Mar 07, 2018

The November 28, 2017 deadline has come and gone, but many providers are still working to understand the new survey process and comply with Phase 2 requirements of the Final Rule, including the Facility Assessment.

The Facility Assessment is a written document you create to outline the resources you need (equipment, staff, policies, etc.) to properly care for your residents’ specific health issues and other needs. It will ensure you’re prepared for each new admission – as you improve quality in the process.

The Guidance to Surveyors* states:

The facility assessment will enable each nursing home to thoroughly assess the needs of its resident population and the required resources to provide the care and services the residents need.

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So, let’s get started. First, we’ll break it down into five easy steps.

1. Define your resident population.

Tally every resident/stay from the last six months to one year. Although there is no defined time period in the regulation, a 6- to 12-month look back will provide an ample overview of your population.

Now, record the following about each individual:

  • Type of disease(s)/condition(s)
  • Cognitive or physical deficits, if any
  • Overall level of acuity
  • Cultural, spiritual or dietary needs
  • Functional ability and needs
  • Rehabilitation requirements
  • Cognitive or behavioral conditions

2. Define the resources you need to take care of the individuals you admit.

List the services you provided for each resident/stay (e.g., continence care, gluten-free diet, physical therapy, wound care). Be specific about the frequency of the care. Remember to include internal as well as contracted services.

3. Identify the staffing you need and the competencies your staff requires.

Now, document the type of staff (e.g., RN, dietitian, physical therapist) required to provide the services you defined. Next, look at your population as a whole. How many of each type of professional did you need per shift? For example, if a large portion of your population required a one-person assist with toileting, how many CNAs did you need?

You’ll also need to consider the staff competencies necessary for the level and types of care your residents  require. Keep in mind that the definition of staff competency has changed under the Final Rule. You must conduct pre- and post-tests, or observe the caregiver actually demonstrating the competency.

4. Identify the equipment and services necessary to care for your population.

Remember to think about medical supplies, transportation, physical space to provide care, and third-party services or equipment. Also consider health information technology resources required to manage resident records and electronically share information with other organizations.

The Guidance to Surveyors* states:

…the assessment should address how the facility will securely transfer health information to a hospital, home health agency, or other providers for any resident transferred or discharged from the facility.

5. Create an all-hazards approach to emergency preparedness.

An all-hazards approach means you should consider all possible hazards that could occur in your facility or your community.  For example, if your facility is located in a flood zone, the risk assessment must include an evaluation of how you will keep residents safe and meet their needs during a flood that affects your facility. Your risk-based assessment should evaluate your facility’s ability to maintain continuity of operations and secure required supplies.

Consider involving your local/county Office of Emergency Preparedness when conducting the community-based risk assessment. Also, there are a number of Hazard Vulnerability Assessments available online to help you with your analysis.

With new E-Tags also being surveyed either by state surveyors or life safety surveyors (depending on your state), do not let this requirement slide.

Next question: When and how will surveyors evaluate your Facility Assessment?

Within four hours of entering the building your survey team lead will ask you to provide a copy of your Facility Assessment. Also be aware that surveyors are instructed to thoroughly review your Facility Assessment if they identify any systemic care concerns.

For example, if your facility recently started accepting residents with renal failure and other genitorurinary issues, and the surveyor has systemic concerns related to how dialysis and other renal care was provided, the surveyor may want to review your Facility Assessment.

The bottom line: High quality care

As you prepare your Facility Assessment, remember the purpose is to help you thoroughly evaluate your resident population to identify the resources you need to provide high quality, person-centered care and services.

Guidance to Surveyors*

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