Six Steps to Ensure Compliance with F838 Facility Assessment. Revisions Effective 8.8.24. Are You Prepared?
On May 10, 2024, CMS published new regulations under §483.71 Facility Assessment, as part of the Medicare and Medicaid Programs: Minimum Staffing Standards for Long Term are (LT) Facilities and Medicaid Institutional Payment Transparency Reporting final rule. Changes to the facility assessment requirements are effective August 8th. While most facilities have an existing facility assessment, we encourage you to utilize this checklist to verify that your assessment includes the required updates. [According to CMS, a new facility assessment template is set to be released soon.]
Has your Facility Assessment been reviewed and updated within the past 12 months?
If not, schedule a meeting to do so by July 31 and add this review to the July QAPI meeting minutes.
Does your Facility Assessment include the identification of resources necessary to care for residents during day-to-day operations, including nights, weekends, and emergencies?
Ensure your staffing matrix reflects who to call in periods of emergencies or off-hour disasters, i.e., an updated calling tree.
Does your Facility Assessment include front-line staff members, a resident spokesperson, and/or a family or community member?
Add a representative of your front-line staff, a resident spokesperson, and a family or community member to your Facility Assessment Committee and ensure they are included in the annual updates.
Does your facility have a plan for maximizing recruitment and retention of direct care staff?
Ensure HR, or HR representative, is a member of the committee and submits an updated recruitment and retention plan to the Facility Assessment Committee for review and comments.
Does your Facility Assessment include a summary of skills and competencies required by those providing care?
Ensure resident service needs are met through appropriately trained and licensed providers, i.e., Vent units include specialized RN oversight and include annual skills fairs.
Does your Facility Assessment include the identification of ethnic groups and individual food, cultural, and activity preferences?
Ensure menus, care services, and activity programs are tailored to support individualized needs and requests and that all staff are informed. i.e., vegan diets, Judaism faith, etc.
Surveyors are given guidance to cite deficient practice at F838 if these requirements are not met. Be aware there are 9 other FTags that can be cited if the survey investigation shows there are not sufficient or competent staff. These include:
- F656 Comprehensive Person-Centered Care Plan
- F725 Sufficient Nursing Staff
- F726 Competent Nursing Staff
- F741 Sufficient/Competent Staff – Behavioral Health Needs
- F801 Qualified Dietary Staff
- F826 Specialized Rehabilitation Services
- F839 Staff Qualifications
- F837 Governing Body
- F865 QAPI/QAA
While the required changes may seem daunting, ensuring that these changes are part of your updated Facility Assessment will offer valid proof of F838 compliance. You can read the full QSO-24-13 published on June 18 at QSO-24-13-NH (cms.gov).
Need further assistance? Contact Polaris Group to discuss consulting services and action plans to ensure your continued compliance.
