Ftag of the Week – F838 Facility Assessment (Pt 1)

This week’s Ftag of the Week is F838 Facility Assessment, which is part of the Administration regulatory group. The Facility Assessment requirement has been in effect for long enough that most facilities have a document put together, but now it may be time for a review or enhancement based on changes made for Phase 3 RoPs or services being provided post-PDPM. This information will be reviewed by surveyors if they have identified systemic care concerns that may be related to how the facility has planned for care – whether it is a service need or number of staff needed.

The purpose behind this regulation is to ensure that facilities have evaluated their resident population thoroughly and have identified all the resources necessary to care for and provide services to their residents. This includes everything from the number of staff to the training those staff need for service provision to equipment and facility resources, so this document requires a lot of work and input from multiple departments. The regulation is clear that the Facility Assessment should be the foundation for a facility to determine what “sufficient staff” is for their unique population.

Components of the Facility Assessment

The Facility Assessment must include/address the resident population. This includes:

  • Number of residents and facility capacity
  • Types of care necessary to provide care for the residents, including:
    • Diseases
    • Health conditions
    • Physical disabilities
    • Cognitive disabilities
    • Overall acuity
    • Any other pertinent information that provides information about the resident population

Staff responsible for completing the Facility Assessment should then use that information as a basis for determining what is necessary to provide care for those residents. In order to maximize reimbursements under PDPM, many providers added increasingly complex care services to their offerings. If so, hopefully their FAs were updated to reflect these changes. Likewise, now that Phase 3 of the Requirements of Participation is in effect, new types of training and competencies may have needed to be added to the Facility Assessment to provide a more accurate picture of how the facility is ensuring staff are able to provide, for instance, culturally competent and trauma-informed care.

This means that the Facility Assessment also needs to include:

  • Required staff competencies that are necessary to provide the level and types of care that have been identified for the resident population. Remember, competencies are not just for Nursing.
  • Identification of specific factors that may impact resident care from a religious, cultural or ethnic perspective.

After looking at the bigger picture of the residents, their needs and staffing requirements, providers are also required to identify a wide range of resources in their Facility Assessment. These include:

  • All personnel (facility staff as well as contract staff) and volunteers. When was the last time someone scrubbed this information at your facility?
  • Education and/or training and competencies that staff have related to resident care
  • List of services provided – many facilities have been cited for using a template Facility Assessment and not tailoring it to the actual services being provided in the facility
  • EMR/EHR/HIT resources
  • Medical and non-medical equipment
  • Buildings and physical structures
  • Transportation vehicles
  • Third-party service provider contracts, MOUs and/or other agreements the facility has in place for services and equipment to be provided both during day-to-day operations as well as emergencies.

The final component of the Facility Assessment is the all-hazards Facility-based and Community-based Risk Assessment, which you are probably familiar with as a component of the EPP as well.

In the second part of our Ftag of the Week – F838 Facility Assessment, we will dig into some of the components and look at how facilities have been cited under this regulation. In the meantime, think about how comprehensive your organization’s Facility Assessment is and whether it is up to date. Have you even looked at this document since you prepared in in 2017 when this regulation became effective?  Changes to leadership or ownership? It probably warrants a review. Has it been updated, minimally, annually as required? You may want to double check. Also – and quite significantly – do your actual staffing levels reflect what you have (hopefully) set out as necessary to adequately care for your residents? Pull a few of your daily schedules that reflect who was actually on duty and see how you fare against your FA.

Stay tuned for Part 2 next Friday! If you haven’t signed up for CMSCG’s mailing list, you can do so by clicking here.

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