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How to Conduct Your Nursing Home's Facility Assessment

January 09, 2018
Compliance By Emile LeDoux, Senior Consultant

On November 28th 2017, the Centers for Medicare and Medicaid Services (CMS) required senior living facilities to create a facility assessment. The facility assessment is designed to ensure that all facilities have the appropriate staff, equipment and programs to provide for the level of care required to take care of residents on a day to day basis, as well as during an emergency. Since the implementation of the program in November, the state, federal and local inspectors are able to request each facilities' program during a survey or complaint investigation.



The team responsible for creating each facility assessment should include at minimum, the facility Administrator, the Director of Nursing, the Medical Director and a representative of the governing party. Additional staff, family members and residents could and should be used as members of the team at the facility's discretion. By including the Administrator, Director of Nursing, Medical Director and a representative of the governing party, CMS is holding each member accountable for the decisions made during the creation of the facility assessment.

The assessment can be broken down into three parts:

  • Population of the facility.
    The facility must list the number of residents cared for. Additionally, the facility must present the resident profile, whereas they look at the population’s common diseases and conditions, disabilities, acuity levels and the community's ethnic/cultural/religious factors.

  • Services provided to the community.
    The facility must look at both the services provided, using information cataloged from the first section, as well as general services (e.g., dining services, assistance with daily living and pain management). The facility must ensure services are in place to provide for the resident population.

  • Resources required to care for all residents of the facility.
    While the facility must show that there is equipment in place to allow for the care of residents, the facility must also show that qualified employees are scheduled to appropriately meet the needs of the facility. The burden is on the facility to show thorough documentation of how it intends to staff the building to take care of residents and their acuity levels based on the first section of the assessment. The facility must document the credentials of the staff and show documented training.

Resources in the third section also include the physical environment. Facilities must be able to support the resident population and needs. A risk assessment from the Emergency Preparedness Plan must also be provided. The risk assessment will show that the facility has identified all possible emergencies and has programs in place to care for the residents, in the event of an emergency.

The facility assessment must be reviewed annually, and when there has been a change to the levels of care provided. For example, if a facility were to admit a resident with a illness that was not covered in the original plan, the facility assessment would have to be revised to show that services and resources (staff, equipment and programs) are in place to care for that resident's illness.  

Contact LW Consulting, Inc. to learn more about how we can review and adapt
your facility assessment to ensure you are in compliance.
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