Annual facility assessments still very necessary


There are a few days left to give input on one of the Centers for Medicare & Medicaid Services’ (CMS) latest proposals to help reduce the burden on facilities. Comments will be accepted until September 16 for “Medicare & Medicaid Programs; Requirements for Long-Term Care Facilties: Regulatory Provisions to Promote Efficiency and Transparency” (CMS-3347-P). The proposal would overhaul a number of areas for Facility Assessment (§483.70(e)). CMS changes include removing unnecessary requirements, requiring assessments every other year instead of annually and eliminating the need to conduct and document a facility-wide assessment for both daily operations and emergency preparedness. The future of the proposed rule remains to be seen. For now, annual facility assessment requirements are still in place. As many facilities around the nation eye their budgets for next year, this is also a good time to assess and identify their needs so they can ensure they are capable of providing quality care to residents.
CMS advises that facility assessments be done with a thorough team approach. This team should include facility leadership such as the administrator, medical director and director of nursing as well as other department heads. Facilities are also encouraged to get input from residents, their representatives or family members.
CMS’ Facility Assessment Tool is organized in three parts:
1. Resident profile. Information on resident population that includes census, diseases/conditions, physical and cognitive disabilities, acuity and ethnic/cultural/religious factors that impact care.
2. Services and care offered. Information on residents’ needs and type of care they require.
3. Facility resources needed. Resources required to provide competent care for residents. Includes information on staffing, training/education competencies, building needs, technology resources, and facility and community-based risk assessments.
Ideally, completing the assessment should be a learning process that opens up opportunities to pose questions and address concerns. During a 2017 Medicare Learning Network presentation addressing the Facility Assessment Tool, CMS suggested that facilities examine areas such as changes to the resident population and staffing, resources in the budget, opportunities for better collaboration with medical practitioners, infection control issues and opportunities for Quality Assessment and Assurance (QAA)/Quality Assurance and Performance Improvement (QAPI). The process itself should also be evaluated for room to improve and implement needed changes for future assessments. Whether required every year or biennially, ultimately, the assessment helps strengthen budget decision making, employee recruitment and retention and overall quality. They’re still a necessary win-win for facilities and residents.
The Compliance Store has resources, tools and forms that can help you easily complete your next facility assessment. To learn more, go to