The surveyors walk into your facility on November 28, 2017, and hand you the Entrance Conference form. The facility assessment is due within four hours. Are you ready? Do you know how surveyors will use this information?
The intent of the Facility-Wide Assessment (FWA), according to Appendix PP of the State Operations Manual, is “for the facility to evaluate its resident population and identify the resources needed to provide the necessary care and services the residents require,” by assessing the facility’s unique resident population, including residents’ conditions, diseases, functional status, cognitive status, and acuity. The FWA provides valuable information about your residents that the survey team will use to ensure that your facility has the appropriate resources by the time of your facility’s next survey.
Here’s what you need to know.
The FWA requires an in-depth look at your facility’s unique population and resources, the requirements of which are clearly outlined in the regulations.
According to federal regulation §483.70(e):
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 facility assessment must address or include:
§483.70(e)(1) The facility’s resident population, including, but not limited to,
(i) Both the number of residents and the facility’s resident capacity;
(ii) The care required by the resident population considering the types of diseases, conditions, physical and cognitive disabilities, overall acuity, and other pertinent facts that are present within that population;
(iii) The staff competencies that are necessary to provide the level and types of care needed for the resident population;
(iv) The physical environment, equipment, services, and other physical plant considerations that are necessary to care for this population; and
(v) Any ethnic, cultural, or religious factors that may potentially affect the care provided by the facility, including, but not limited to, activities and food and nutrition services.
§483.70(e)(2) The facility’s resources, including but not limited to,
(i) All buildings and/or other physical structures and vehicles;
(ii) Equipment (medical and non-medical);
(iii) Services provided, such as physical therapy, pharmacy, and specific rehabilitation therapies;
(iv) All personnel, including managers, staff (both employees and those who provide services under contract), and volunteers, as well as their education and/or training and any competencies related to resident care;
(v) Contracts, memorandums of understanding, or other agreements with third parties to provide services or equipment to the facility during both normal operations and emergencies; and
(vi) Health information technology resources, such as systems for electronically managing patient records and electronically sharing information with other organizations.
§483.70(e)(3) A facility-based and community-based risk assessment, utilizing an all-hazards approach.
According to the guidance provided in Appendix PP under F838, the facility assessment should involve, at a minimum, the administrator, a representative of the governing body, the medical director, and the director of nursing. Department heads, the environmental operations manager, the director of rehabilitation services, and other such individuals should also be involved as necessary. CMS also indicates that facility staff should seek input from the resident/family council, residents, and family members and incorporate that information into the FWA when appropriate.
The Facility-Wide Assessment and the Director of Nursing Services
Although it might seem daunting, the FWA should be regarded as a tool to help guide facility leaders through the decision-making process in determining the correct amount of staffing and other resources. It may also include the operating budget necessary to carry out facility functions (§483.70[e] Guidance).
Nurse leaders should be sure to involve all levels of staff in the FWA process. The survey team will use the Sufficient and Competent Nurse Staffing Review to guide them in making decisions about whether the facility has the staffing needed to meet each resident’s needs. For example, surveyors may ask, “Does management ask for your input into their Facility-Wide Assessment for sufficient staffing?”
Given that staff members might be asked this and other questions regarding staffing, it is imperative to include staff in discussions related to the FWA so they are aware of it, know its use, and understand their role in its completion. For example, nurse aides may need to be aware that ADL information they document will be used to help construct a picture of overall facility acuity and helps to determine future staffing needs.
Most importantly, DNSs need to understand that the analysis of the information they collect about their resident population and resources is critical to a successful assessment process, which should expose areas needing improvements in care delivery. Examples may include:
· Facility leaders complete their FWA and uncover the high number of residents who are dependent; in analyzing the FWA information, the DNS concludes that she needs to purchase additional lift equipment.
· Facility leaders compile information on resident diagnoses and find that there are many residents with the diagnosis of CHF. The DNS also realizes that the hospital recently voiced concerns about the number of CHF residents being sent to the ER from the facility. The DNS uses this information to develop a training program on CHF, with case studies that will help demonstrate staff competency in caring for CHF residents.
The FWA can also help identify the need for specialty staff. A given unit of the facility may have a high number of residents with dementia and may benefit from having dementia specialists, while another unit might have a number of wounds and may benefit from a wound care specialist. Done correctly, your facility’s Facility-Wide Assessment should be a tool for identifying gaps in care delivery and steps for improvement.
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