Requirement
Nursing facilities will conduct, document, and review a facility-wide assessment, which includes both their resident population and the resources the facility needs to care for their residents (42 CFR §483.71). The assessment will be reviewed annually and updated as needed. The requirement for the facility assessment may be found in Attachment 1.
Purpose
The purpose of the assessment is to evaluate the resident population and determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. Use this assessment to make decisions about your direct care staff needs (including those who provide services under contract and volunteers), as well as your capabilities to provide services to the residents in your facility, at least annually and as necessary, per the above requirement. Using evidence-based, data driven methods focuses on ensuring that each resident is provided care that allows the resident to maintain or attain their highest practicable physical, mental, and psychosocial well-being.
Overview of the Assessment Tool
This is an optional template provided for nursing facilities, and if used, it needs to be modified to capture facility specific information. Each facility has flexibility to decide the best way to comply with this requirement.
The tool is organized in three parts:
- Resident profile including numbers, diseases/conditions, physical/behavioral health needs, cognitive disabilities, acuity, and ethnic/cultural/religious factors that impact care
- Services and care offered based on resident needs (includes types of care your resident population requires; the focus is not to include individual level care plans in the facility assessment)
- Facility resources needed to provide competent care for residents, including staff, staffing plan (maximizing direct care staff recruitment and retention) staff training/education and competencies, physical environment and building needs, and other resources, including agreements with third parties, health information technology resources and systems, a facility-based and community-based risk assessment, and other information that you may choose
This assessment asks you to collect and use information from a variety of sources. Some of the sources may include but are not limited to MDS reports, Quality Measures, 671, 802 (Roster/Sample Matrix Form) reports, pharmacy reports, Payroll-Based Journal data or reports, and in-house developed reports (e.g., resident diagnosis and demographics, a 24-hour report, psychotropic medications use, pressure injuries, resident falls, behavior tracking and interventions, resident/family surveys, etc.).
Disclaimer: Use of this tool is not mandated by CMS, nor does it ensure regulatory compliance. Last updated 09/05/2024.
