Nursing facilities are mandated to conduct, document, and annually review a comprehensive facility-wide assessment (42 CFR §483.71). This crucial assessment serves as an Snf Care Plan Audit Tool, enabling facilities to evaluate their resident population and determine the necessary resources for delivering competent care. This process is vital for both daily operations and emergency preparedness, ensuring the highest standards of resident well-being.
The primary goal of this assessment is to proactively analyze resident needs and align them with available resources. By utilizing this SNF care plan audit tool, facilities can make informed decisions regarding staffing, service provision, and overall capabilities. This includes evaluating direct care staff, contracted services, and volunteer resources. The ultimate aim is to adopt evidence-based, data-driven approaches that guarantee each resident receives care that promotes their maximum physical, mental, and psychosocial well-being.
This facility assessment tool acts as an effective SNF care plan audit tool by focusing on three core components:
- Resident Profile Analysis: This involves a detailed examination of resident demographics, including the number of residents, prevalent diseases and conditions, physical and behavioral health needs, cognitive disabilities, acuity levels, and ethnic, cultural, and religious factors influencing care requirements. This detailed profile is fundamental to any effective SNF care plan audit tool.
- Service and Care Evaluation: Based on the identified resident needs, the tool facilitates an audit of the services and care currently offered by the facility. This section focuses on the types of care required by the resident population, ensuring alignment between needs and services. It’s important to note that this SNF care plan audit tool focuses on facility-level assessment, not individual care plans.
- Resource and Infrastructure Audit: This critical component assesses the facility’s resources required to deliver competent care. This includes evaluating staffing levels, staffing plans (with an emphasis on direct care staff recruitment and retention), staff training and competency programs, the physical environment and building infrastructure, and other essential resources. Agreements with third-party providers, health information technology systems, and comprehensive risk assessments are also integral parts of this resource audit, making it a holistic SNF care plan audit tool.
To effectively utilize this SNF care plan audit tool, facilities should draw data from diverse sources. These may include MDS reports, Quality Measures, 671 and 802 reports, pharmacy records, Payroll-Based Journal (PBJ) data, and internally generated reports. Examples of in-house reports include resident diagnosis and demographic data, 24-hour reports, psychotropic medication usage, pressure injury incidents, resident falls, behavior tracking and intervention logs, and resident/family survey results.
By implementing a robust facility assessment as an SNF care plan audit tool, nursing facilities can proactively ensure they are equipped to meet the diverse needs of their residents, maintain regulatory compliance, and continuously improve the quality of care provided.
Disclaimer: Please remember that this tool is an optional template and its use does not guarantee regulatory compliance. Always refer to the official CMS guidelines for complete compliance requirements. Last updated 09/05/2024.
