Nursing facilities operate under a mandate to conduct, meticulously document, and regularly review a comprehensive facility-wide assessment. This critical evaluation encompasses both the resident population and the resources essential for providing exemplary care (42 CFR §483.71). This assessment is not a static document; it requires annual review and updates as necessary to remain relevant and effective.
The core purpose of this facility assessment is to thoroughly evaluate the characteristics of the resident population and, based on this understanding, determine the resources that are indispensable for delivering competent care. This extends beyond routine daily operations, encompassing nights, weekends, and the preparedness for emergency situations. The insights gained from this assessment are pivotal in making informed decisions about direct care staff needs – including contracted services and volunteer contributions – and in evaluating the facility’s overall capabilities to meet resident needs. Conducted at least annually and updated as needed, this process, when grounded in evidence-based, data-driven methodologies, ensures that every resident receives care that facilitates the maintenance or attainment of their highest practicable physical, mental, and psychosocial well-being.
Understanding the Optional Assessment Tool
To aid facilities in meeting these requirements, an optional template, known as the , is available. It’s crucial to understand that while this tool is provided as a resource, its use is not mandated by regulatory bodies. Facilities retain the flexibility to determine the most effective approach to comply with the assessment requirement. If a facility chooses to utilize this template, it must be adapted to accurately reflect the facility’s specific context and information.
This valuable tool is thoughtfully structured into three distinct sections:
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Resident Profile: This section focuses on compiling a detailed profile of the resident population. Key elements include:
- Numbers of residents
- Prevalent diseases and conditions
- Physical and behavioral health needs
- Cognitive disabilities
- Levels of acuity
- Ethnic, cultural, and religious factors that significantly influence care delivery.
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Services and Care Offered: Building upon the resident profile, this part requires an evaluation of the services and care currently offered in relation to the identified resident needs. The emphasis here is on the types of care required by the resident population as a whole, rather than delving into individual resident care plans. This broader perspective allows for strategic resource allocation and service planning.
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Facility Resources Needed: This final section is dedicated to identifying and assessing the resources necessary to ensure competent resident care. This comprehensive evaluation includes:
- Staffing levels and skill mix
- Strategic staffing plans focused on maximizing direct care staff recruitment and retention
- Staff training, education, and competency assessment programs
- Physical environment and building infrastructure needs
- Agreements with third-party service providers
- Health information technology resources and systems
- A thorough facility-based and community-based risk assessment
- Any other pertinent information deemed relevant by the facility.
To ensure the assessment is robust and data-driven, facilities are encouraged to draw upon a diverse range of information sources. These may include, but are not limited to: MDS reports, Quality Measures data, 671 and 802 reports (Roster/Sample Matrix Forms), pharmacy reports, Payroll-Based Journal (PBJ) data, and internally generated reports. In-house reports can offer valuable insights into resident diagnosis and demographics, 24-hour care needs, psychotropic medication utilization, pressure injury rates, resident falls, behavior tracking and interventions, and feedback from resident/family surveys.
By leveraging the long term care optional assessment & care planning tool – or a similar comprehensive approach – nursing facilities can proactively identify resident needs and strategically allocate resources. This ultimately leads to enhanced quality of care, improved resident outcomes, and a more efficiently run facility.
Disclaimer: Please note that the use of this tool is optional and is not mandated by CMS. Furthermore, utilizing this tool does not guarantee regulatory compliance. This information is current as of 09/05/2024.
