Industry Insights

Stay Compliant with an Up-to-Date Facility Assessment

September 2017
Author:  Sherri Robbins

Sherri Robbins

Senior Managing Consultant

Consulting

Health Care

910 E. St. Louis Street, Suite 200
P.O. Box 1190
Springfield, MO 65801-1190 (65806)

Springfield
417.865.8701

All skilled nursing facilities (SNF) are required to complete a detailed written facility assessment by November 28, 2017, according to the Centers for Medicare & Medicaid Services (CMS) Reform of Requirements for Long-Term Care Facilities Final Rule released October 4, 2016.

The facility assessment will serve as a basis for determining compliance in key areas, including adequacy of nurse staffing, in-service training, Quality Assurance and Performance Improvement (QAPI) activities, compliance efforts and emergency preparedness. This regulation requires facilities engage in a “facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies.” Facility- and community-based risk assessments should be components of the overall facility assessment. Each facility assessment must contain the following areas at a minimum:

  • Resident population (including number of residents, types of care required, diagnoses, overall acuity, cognitive functioning and any other pertinent information)
  • Staff competencies required to meet the resident population’s needs
  • Physical environment, equipment and services needed to provide appropriate care
  • Ethnic, cultural or religious factors
  • Facility resources, including buildings, vehicles and equipment
  • Services provided by the facility, including ancillary services and medications
  • Personnel and their education and training
  • Contracts and other third-party agreements for services and/or equipment
  • Health information technology resources

The facility assessment also is required to be updated “as necessary, and at least annually,” as well as “whenever there is, or the facility plans for, any change that would require a substantial modification to any part of this assessment.” Administrators should document actions to address the gaps between what’s currently available and what’s needed.

SNFs should anticipate that the facility assessment may be a focus for surveyors. Unfortunately, the final rule only includes minimal information on expectations for the assessment’s content and level of detail, leaving significant portions without specific guidance. Evaluating facility capacity has long been a common practice for SNFs, but assessment documentation hasn’t been required or accessible to surveyors. Under the new QAPI regulation, surveyors will have access to the facility assessment and the QAPI plan. Again, the facility assessment must be completed by November 28, 2017.

Contact your trusted BKD advisor if you have questions or concerns about completing your facility assessment.

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