Have you completed the updates effective August 9th, 2024? Does Your Staffing Plan Meet the Medically Complex Needs of Your Resident?
Have you completed the updates effective August 9th , 2024? Does Your Staffing Plan Meet the Medically Complex Needs of Your Resident?
§483.71 FTag 838 states that facilities must conduct and document a facility-wide assessment to determine what resources are necessary to care for residents in everyday and in emergency situations and they must review and update the facility assessment, as necessary, at least annually, and whenever there is a change requiring substantial modification to any part of the assessment. The August 9th deadline is quickly approaching. Is your Facility assessment in compliance with the required changes related to FTag 838? While CMS already requires facilities to conduct and document an annual assessment, additional requirements were finalized on April 22, 2024.
Changes and Action Steps - What Polaris Group Recommends
The facility must address or include services necessary to provide adequate care for the resident population, using evidence-based, data-driven methods that consider types of diseases, conditions, and physical and behavioral needs.
Recommendation:
- Review and update policies and procedures to reflect health and medical disciplines including three elements: clinical expertise, best research evidence, and resident values.
Examples:
The use of oxygen will help residents with COPD and hypoxia.
McGeers criteria for Infection Surveillance is utilized to monitor infections as part of our antibiotic stewardship focus.
The facility utilizes a system of reinforcers that encourage acceptable behavior and discourage troublesome ones.
The facility must ensure direct care staff, especially physicians, NPs, and PAs are actively involved in the facility assessment process.
Recommendation:
- Include the rounding PCP, one licensed nurse, and one certified aide in your annual facility assessment review process.
Examples:
The facility NP, the night shift LPN, and the Restorative Aide are members of the Facility Assessment Committee for the Spring/Summer 2024 review.
The facility assessment review protocol dictates direct care members of the Facility Assessment Committee are rotated every 6 months.
The facility must solicit and consider input received from residents, resident representatives, and family members in conducting the facility assessment.
Recommendation:
- Ask for feedback from residents/representatives if needs are being met at care conferences, noting areas of potential improvement.
Example:
Resident concerns regarding wound care were addressed through in-services for the nurses and the implementation of wound care audits.
The facility must use the facility assessment to make staffing decisions that ensure staff with the necessary competencies and skills are available, including staffing needs for each shift and a contingency plan when adequate staffing is challenged.
Recommendation:
- Review your hiring process to ensure licensed and certified personnel have current licenses and appropriate certification updates.
Examples:
Provide in-house CPR courses and conduct a Skills Fair annually.
Adopt an “on-call” process for nursing personnel when staffing patterns are challenged.
The facility must develop and maintain a plan to maximize recruitment and retention of direct care staff.
Recommendation:
- Create a Recruitment/Retention Committee within your facility with identified goals, timelines, agendas, and action steps.
Example:
Employees from Nursing, including a licensed nurse and CNA, Housekeeping, Dietary, and Maintenance meet quarterly to review staff vacancies, offer ideas for theme days, and discuss internal recruitment bonuses for employees recommending new hires who stay 90 days.
As of May 22, 2024, CMS has not released the updated Facility Assessment template.
Polaris Group can help you identify and implement action steps and measurable timelines necessary to comply with the new requirements of FTag 838. We offer services specific to policy revision, employee retention, competency, and skills development. One of the most effective ways to identify your risks and vulnerabilities is to schedule a mock survey. This facility-wide evaluation indicates areas that need intentional focus and celebrates current areas of success and efficiency. Schedule your mock survey now! For more information, contact us.
