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Are You Ready for the Long-Awaited Facility Assessment?

September 29, 2017
Compliance By Emile LeDoux, Senior Consultant

The Centers for Medicare & Medicaid Services' (CMS) Requirements of Participation mandates all nursing facilities conduct a facility assessment that documents the resources available to care for residents. It must be completed by November 28, 2017 and updated whenever there is a change in operations that would require revisions to the facility assessment, or once annually.


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Some of the components that must be included in the facility assessment include, but are not limited to:

  • Population of residents served
  • Facility staffing and competencies
  • Services provided
  • Resources to meet the needs of residents
  • Agreements with contracted providers to provide additional services to residents
  • Facility risk assessment and emergency preparedness plan

Who Should be Involved?

To ensure accuracy and thoroughness, according to CMS guidelines, staff involved in the facility assessment should include the administrator, a representative from the governing body, the medical director and director of  nursing. CMS further states the environmental operations manager, dietary manager, director of rehabilitation, and other direct care workers should be involved on an as needed basis.

Appendix PP of the State Operations Manual provides additional guidance to surveyors and says “If systemic care concerns are identified that are related to the facility’s planning, review the facility assessment to determine if these concerns were considered as part of the facility’s assessment process. For example, if a facility recently started accepting bariatric residents, and concerns are identified related to providing bariatric services, did facility staff update its assessment before accepting residents with these needs to identify the necessary equipment, staffing, etc., needed to provide care that is effective and safe for the residents and staff?”

Preparing for the November 28, 2017 Deadline

If you haven't began preparation for the November 28, 2017 deadline, then the time to start is now. With November fast approaching, it's imperative facilities meet all mandates outlined in the Requirements of Participation, including the facility assessment. A documented facility assessment will be required for surveys occurring after this date.

LW Consulting, Inc. provides a wide range of compliance and regulatory support, including operational assessment, training and education customized for your facility's needs. We can help you develop a process for conducting your facility assessment, in addition to assisting you with survey readiness through our mock survey process.

Need help conducting your facility assessment and don't know where to begin?
Contact us to get started.

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