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F-Tags in Review: F838 Facility Assessment

August 31, 2018
Healthcare Consulting By Cathy Benfer, Interim Services Manager

According to the Centers for Medicare & Medicaid Services (CMS):

The facility must conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. The facility must review and update that assessment, as necessary, and at least annually. The facility must also review and update this assessment whenever there is, or the facility plans for, any change that would require a substantial modification to any part of this assessment.”


The requirement of the facility assessment was rolled out with Phase II of the new skilled nursing regulations in November 2017; however, it will be considered for deficiency beginning November 2018.

Below are some points that need to be remembered related to the facility assessment.

The assessment is broken into 3 distinct parts.

  • Resident Profile
  • Services and care offered in the facility
  • Facility resources needed to provide the care

Additionally, CMS has created guidelines for conducting the facility assessment.

  • Minimum staff required to participate:
    • The Administrator
    • A representative from the governing body
    • The Medical Director
    • The Director of Nursing
    • Other department heads are identified on an as needed basis
  • Input from residents and family members is highly encouraged.
  • Corporate involvement is encouraged, but the assessment must be conducted at the facility level.
  • The assessment must be updated at least annually or any time a new segment of services is proposed as a modification of the assessment.
    • This does not mean that the assessment is updated for every new admission, only for significant changes to the resident population.
  • This assessment should be utilized and shared with staff to identify the reasoning behind staffing patterns and allocation of other resources within the facility. A facility budget may also be included.
  • If during a survey, there are systematic care concerns, a look back to the facility assessment will indicate poor planning or incomplete planning for that particular type of resident.

1. Resident Profile

  • Indications are needed on the number of residents the facility is licensed to care for.
  • Differentiate between long term and short term residents.
  • Include average daily census.
  • Indicate the number of new admissions (on average) per day, weekday and weekend.
  • List the conditions and/or diseases of the residents the facility is able to admit.
  • Describe the process of consideration admitting a new type of resident condition, or if an existing resident develops a new condition not previously identified.
  • Describe the residents’ acuity levels over the past year or during a typical month. You may utilize RUGS scores, identify by type of treatment and/or condition, or by assistance needed with ADL care.
  • Include cultural, ethnic or religious considerations that could affect the care delivered to the residents.
  • Describe any other facts that are considered when developing staffing levels and resource needs (resident preferences for daily schedules, waking, bathing, activities, etc.).

2. Services and Care Offered Based on the Resident Needs

  • List the types of care provided by general category groupings.
  • List the general care grouping then specifically what is contained in that grouping.


Pain Management: Assessment of pain levels with what tool. Pharmacological and non-pharmacologic approaches

Other special care needs: dialysis, hospice, ostomy care, trach and vent care, bariatric care, palliative care, end of life care

3. Facility resources needed to care for the resident population outlined every day and during emergencies

  • Identify the staffing plan
  • Others such as vocational workers, clinical laboratory, diagnostic/X-ray services workers, blood services workers, infusion companies
  • Volunteers and students
  • Chaplain and religious services
  • Support staff: maintenance, housekeeping, laundry, groundskeepers
  • Behavioral and mental health professionals
  • Pharmacist
  • Medical and physician services: medical director, attending physician, PA, CRNP, dentist, podiatrist, ophthalmologist
  • Therapy services: PT, PTA, OT, COTA, RT, RTA
  • Food and nutrition services: registered dietician, director and support staff
  • Identify the types of staff necessary to care for the population of residents you have identified.
    • You could use staffing directories, payroll data, organizational chart or simply a listing of the types of staff needed to care for a particular kind of resident.
  • Identified staff could include but not be limited to:  administration,  administrative assistants, staff development, QAPI, infection control and prevention, etc.
  • Nursing services: DON, ADON, RN, LPN, C.N.A., medication aide or technician, MDS nurse:
    • Identify position: total # of staff required or average
    • Plan: i.e. charge nurse for each unit for each shift
    • Describe how the staff assignments are determined in order to deliver individualized care.
    • How are the staff trained for each of the types of residents that are identified and what competencies are used to assure understanding?
    • Suggested training includes communication, resident rights, abuse neglect and exploitation, infection control, culture change.

Remember, the facility assessment does not need to read like a doctoral thesis, but what it does need to do is reflect your facility population, your resources, your education plan for staff and the process by which you add specific care types to the population.


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