Ftag of the Week – F838 Facility Assessment (Revised – Effective 8/8/2024)

On June 18, 2024, the Centers for Medicare and Medicaid Services (CMS) issued a new QSO Memo, “Revised Guidance for Long-Term Care Facility Assessment Requirements.” The QSO Memo sets out the new guidance for the Facility Assessment requirements – and an updated version of the State Operations Manual Appendix PP – effective August 8, 2024. The good news if you’re a CMSCG client and you’ve asked us to review your Facility Assessment? There’s no surprises hidden in these requirements. However, many facilities have a lot of work to do to be compliant with these regulations, especially if they were using the QIO-created Facility Assessment template but didn’t bother to really customize the document to make it facility-specific.

Over the years on the CMSCG Blog, we’ve directed readers back to our Ftag of the Week for F838 Facility Assessment as a reminder that the FA was never intended to just be one more document that needed to be maintained. From the start, the intent of this regulation was to really understand your resident population and what you need to provide high quality care and services to them. The writing has been on the wall that eventually CMS would eventually use this document related to staffing, and we got that notice in May, along with the federal staffing requirements. The revised requirements for the Facility Assessment are the first of the batch to go into place with the upcoming August deadline, and providers should expect that even if the federal staffing requirements somehow don’t go into effect, that this regulation will be here to stay.

What’s in the New QSO Memo

The June 18 Memo reminds providers right at the beginning of the document that the facility must evaluate the resident population and use that assessment to drive staffing decisions and to inform the facility about the competencies and skill sets that staff need to care for their residents. These requirements aren’t new, per say, but CMS now wants providers to do some more critical thinking and tying all the pieces together, including resources needed to provide needed care and services. What is a new requirement, though, is to mandate the inclusion of direct care staff and solicit input from residents and resident representatives/ families. While you may be reading this and thinking, “all everyone is going to say is ‘more staff,’” this may present an opportunity for some ideas or needs from a different perspective.

The QSO Memo also states that the new Facility Assessment requirements will be included in the new SOM Appendix PP which will be effective August 8, 2024. Along with those updates will be updated LTCSP documents. Will surveyors be looking at what’s in the Facility Assessment and making a compliance determination only reviewing the document? No. The QSO Memo clearly states that a facility could be found to be in substantial compliance with the requirements at F838, but still have issues identified related to sufficient staffing which would be cited for noncompliance.

With that said, let’s look at the new expectations for your Facility Assessment.

F838 – Revised Requirements

Here are the highlights of the new requirements that you need to be aware of:

  • The Facility Assessment needs to include nights and weekends as part of “day-to-day operations” in addition to emergencies. This is a gap we see in many Facility Assessments – there is a “general” staffing plan, but nothing specific which addresses what is considered “sufficient,” particularly on weekends, and how the care required on a weekend shift is different than the care required on other shifts.
  • The facility needs to use evidence-based, data-driven methods to determine the care needs of the resident population. It’s not going to be enough to just pick and choose from a template that you’ve been updating for years indicating your resident population includes all kinds of conditions you don’t care for.
  • When assessing the care needs of your residents, you are also now required to include behavioral health needs. This is likely a gap for many facilities that haven’t considered in their Facility Assessment how 1:1s or other types of supervision impact the master staffing plan, or that the competencies for staff shouldn’t just have a list with the annual in-services.
  • Speaking of competencies, providers also need to include “skill sets” necessary for staff to provide care and services to the residents.
  • When determining resources, the Facility Assessment now needs to consider behavioral health services necessary to meet resident needs

If you didn’t catch it in the last couple bullets, there’s a lot of emphasis on behavioral health and competencies – guess what’s likely to be a focus on your next survey?

  • The resources section also specifically includes “nursing and other direct care” staff under the “all personnel” section, which doesn’t seem necessary, but heads up.

The Facility Assessment “Assessors”

There’s a list of required active participants who need to be included in the Facility Assessment process. These include, but are not limited to facility leadership and management, including:

  • Member of the governing body
  • Medical Director
  • Administrator
  • Director of Nursing

The indication in the regulation is for these individuals to be “active” participants, so it is not necessarily the case that reviewing the Facility Assessment after it is completed with a member of the governing body would be sufficient.

Pay attention to this next set of expectations:

  • Direct care staff, including but not limited to RNs, LPNs/LVNs and Nurse Aides
  • Representatives of the direct care staff, if applicable – This means union reps who can speak on behalf of staff who may be worried about the potential for retaliation if they raise concerns.

Here’s a definition:

“Representative of direct care employees” is an employee of the facility or a third party authorized by direct care employees at the facility to provide expertise and input on behalf of the employees for the purposes of informing a facility assessment.

The facility must also “solicit and consider input” from its residents and representatives/ family members. This requirement doesn’t state that they need to be involved in the process, but their thoughts and concerns should be identified and considered when conducting the assessment.

Facility Assessment – Required Use

Once the revised Facility Assessment includes all the new requirements, CMS has set forth clear expectations for how the document should be used. These aren’t “new” expectations, but more of required clarifications to get providers to use the Facility Assessment in a more meaningful way. Providers need to use the FA to:

  • Inform staffing decisions to ensure there are sufficient staff with the appropriate competencies and skill sets necessary to care for their residents. The number of staff and the competencies/ skill sets that are needed must be driven by all the resident data from the assessment.
  • Consider specific staffing needs for each resident unit in the facility and make adjustments if there are changes to the resident population. As we’ve been telling CMSCG clients, when you have different specialty clients, for example, you’ll likely need different staffing, competencies and skill sets to meet the resident needs on your Memory Care Unit versus your Subacute Rehab unit.
  • Not only does staffing for each unit need to be considered, staffing needs for each shift must also be addressed.
  • Should assist with the development of a plan which maximizes direct care staff retention and assists with recruitment.
  • Informs contingency planning for day-to-day events, such as staff call outs. The types of contingencies that should be addressed are issues which impact the facility and resident care, but do not require the facility to activate its emergency plan.

There’s more to the draft Interpretive Guidance, but we’ll save that for the final version since most likely, this is plenty to get you started. You can read the full QSO Memo (Ref: 23-13-NH) here. Need further assistance? Contact CMSCG to discuss our consulting services.

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