Facility Assessment Tool Updates Effective 8/8/2024

8/14/2024 - By Jennifer Ziolkowski, MBA, CLSSYB

New, revised guidance for the CMS Facility Assessment tool requirement (F838) is now in effect, and providers need to be prepared to avoid non-compliance. While this tool was initially designed to be reviewed annually and include information on both the resident population and the resources required to provide adequate care, additional provisions have been defined which expand the scope of the tool and impose new expectations on providers. Specifically, CMS has provided additional insight into what surveyors will be looking for in specific areas, including but not limited to:

Use of evidence-based, data-driven methods to evaluate the resident population.
Use of data related to the resident population and resident capacity to determine facility resources required to provide adequate care such as:

Information on staffing levels on all shifts (day, night, evening) and weekends;
Skills and competencies required by caregivers (staff, agency staff and volunteers);
Equipment, supplies, services (including behavioral health), technology and physical environment needs.

Plans for recruiting and retaining direct care staff.
Contingency plans that address issues not necessarily addressed/identified in the Comprehensive Emergency Management Plan.

The guidance concerning solicitation of information and input into the assessment was also revised to suggest the necessity of broader inclusion of nursing home leadership and management beyond that of the governing body, the medical director, administrator and director of nursing. Notably, CMS suggests the input from direct care staff or representatives of direct care staff and residents, their families, and/or resident representatives should also be taken into consideration. Consequently, this new guidance will require more frequent reviews of the Facility Assessment to ensure compliance is maintained when changes in the resident population occur.

Providers can review the revised guidance on the CMS website. Additional resources on CMS expectations can be found here.

If you have any questions or need assistance with reviewing your Facility Assessment, contact the Saltmarsh Healthcare Consulting team.

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About the Author | Jennifer Ziolkowski, MBA, CLSSYB

Jennifer is a director in the Healthcare Consulting practice of Saltmarsh, Cleaveland & Gund. She has over 30 years of long-term care (LTC) experience, specifically within the skilled nursing, assisted living, home health and short-term rehabilitation sectors. She has extensive knowledge of Medicare and Medicaid compliance and reimbursement, business insurance contracting, process improvement and strategic planning. Jennifer provides consulting services to LTC providers utilizing principles of the Baldridge Framework for Performance Excellence which elevates process improvement, strategic planning and financial responsibility.