New Requirements for Facility Assessment in Long-Term Care Facilities: What Leaders Need to Know
The Centers for Medicare & Medicaid Services (CMS) have implemented new regulations under §483.71, Facility Assessment, as part of the final rule on Minimum Staffing Standards for Long-Term Care (LTC) Facilities and Medicaid Institutional Payment Transparency Reporting. These changes, effective August 8, 2024, bring significant updates that long-term care leaders must understand and integrate into their operational strategies.
Key Changes in Facility Assessment Requirements
Comprehensive Evaluation of Resident Population.
The new regulations mandate a thorough evaluation of the resident population, including:
Resident Count and Capacity: Detailed accounting of the number of residents and the facility’s capacity.
Care Needs: Assessment of the types of diseases, conditions, physical and cognitive limitations, and overall acuity. This evaluation must be evidence-based and data-driven.
Staff Competencies: Determining the skills and competencies required to meet the care needs of the resident population.
Physical Environment and Equipment: Identifying necessary physical space, equipment, and other resources.
Cultural and Religious Considerations: Including activities and food services tailored to the diverse needs of residents.
Annual and As-Needed Updates
Facilities must conduct and document these assessments at least annually and whenever there is a significant change in the resident population or other circumstances that could affect the assessment. This ensures that the assessment remains current and reflective of the actual needs and resources required.
Active Involvement and Input
To ensure a complete and accurate assessment, the facility must involve key personnel in the assessment process:
Leadership and Management: Including members of the governing body, medical director, administrator, and director of nursing.
Direct Care Staff: Such as RNs, LPNs/LVNs, and nursing assistants.
Resident and Family Input: Soliciting feedback from residents and their families to inform the assessment.
Utilizing the Facility Assessment
The facility assessment should directly inform various operational aspects:
Staffing Decisions: Ensuring sufficient staffing levels and appropriate competencies to meet residents’ needs.
Resource Allocation: Identifying and planning for necessary physical, technological, and service resources.
Contingency Planning: Preparing for events that could impact resident care without activating the emergency plan, such as staffing shortages.
Compliance and Survey Procedures
Surveyors will continue to assess compliance with staffing requirements. Even if a facility meets the assessment requirements, it may still be cited for noncompliance if resident needs are unmet due to insufficient staffing. Therefore, it is crucial that the facility assessment accurately reflects and addresses staffing and resource needs.
Preparing for the New Requirements
As leaders in long-term care, it is imperative to take the following steps to ensure compliance with the new facility assessment requirements:
Review and Update Policies: Ensure all facility policies align with the new regulations.
Conduct Thorough Assessments: Implement a detailed and data-driven approach to evaluating resident needs and resources.
Engage Key Stakeholders: Involve leadership, staff, residents, and families in the assessment process.
Regularly Update Assessments: Maintain an ongoing process for updating the facility assessment as required.
Train Staff: Educate staff on the new requirements and their role in the assessment process.
By proactively adapting to these changes, long-term care facilities can ensure they provide high-quality care that meets the needs of their residents while maintaining compliance with CMS regulations.
Resources for Further Information
For more detailed information, visit the CMS website and review the updated State Operations Manual (SOM), Appendix PP.
By staying informed and prepared, long-term care leaders can navigate these regulatory changes effectively, ensuring continued excellence in resident care.