Six points to consider while updating your facility assessment.
CMS developed a Quality in Focus Program as a resource for all long-term care facilities around the country. The efforts to promote safe environments within long-term care (LTC) facilities are commendable, as they not only enhance the quality of care but also play a vital role in educating the public about the necessity behind what may seem like strict, rigid, and sometimes restrictive regulations. These measures ensure the safety, well-being, and dignity of residents, helping facilities deliver the high standards of care required in such settings. Using Quality in Focus as the foundation, Polaris Group highlights FTag 838 Facility Assessment.
In June of 2024, CMS issued a new QSO Memo, “Revised Guidance for Long Term Care Facility Assessment Requirements” which became effective August 8, 2024. Two months later, Polaris Consultants have identified that many facility assessments remain outdated, largely due to facility leadership’s unclear understanding of the recent regulatory changes.
The intent of this regulation is for you to better understand your resident population and what is needed to provide high-quality care for them. You must recognize that the Facility Assessment was never intended to be a ‘one and done’ document, it is an ongoing and facility-wide tool created with resident-specific services in mind.
F838 focuses on understanding who lives in your facility and ensuring that the competencies and skill sets of your staff meet the medical and social needs of residents. A key update to this requirement is the mandate to involve direct care staff and gather input from residents, their representatives, and families. Surveyors are closely examining the Facility Assessment, looking specifically at how well the needs of residents are integrated into staff competencies and awareness, ensuring that care is both responsive and resident-centered.
Six points to consider when updating your Facility Assessment
- Staffing: Does your staffing plan include nights and weekends as part of “day-to-day operations” in emergencies? Is each shift staffed adequately to provide necessary care for the residents?
- Services: Have you reviewed each service listed on your Facility Assessment? Is everything listed still accurate? Did you add an in-house dialysis unit but failed to identify that on your assessment? Do you offer specialized behavior training through outside sources, i.e., CPI training, but failed to identify that on your assessment? Did you close/re-assign your memory care unit but still have it listed on your assessment?
- Behavioral Health: Behavioral health needs are required to be included in the updated assessment, how are you doing this? Outside vendors? Contracts with mental health agencies? Gero-psych outpatient services? Quarterly in-services to all employees specific to a certain diagnosis, i.e., substance abuse?
- Skill Sets and Specialty Services: Have you included the skill sets required to provide care and services to the resident? Is HR a part of the facility assessment discussion? Does HR know the specialty services required for certain populations?
- Input and Involvement: Have you included direct care staff, union reps if applicable, family members, and residents as part of the group from which you seek thoughts, concerns, and feedback? Have you included this discussion in your assessment?
- Contingency Plans: Do you have a contingency plan for day-to-day events, such as staff callouts? Do your managers know when to assist with meal service in cases of staff absence? Does your charge nurse know to reassign the shower schedule when bath aides are absent?
If you find yourself in unfamiliar territory after reading the 6 questions listed above, do not panic. Polaris Group has informed consultants and updated templates. Let us help you by walking you through the facility assessment changes step by step. Contact us today for questions or additional information. We are here to help.
