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New Facility Assessment Guidance Released

(July 1, 2024) The Centers for Medicare and Medicaid Services (CMS) has released interpretive guidance on the new Facility Assessment requirements that take effect on Aug. 8, 2024. Although the Facility Assessment has been a requirement for several years, the new regulations and guidance (QSO-24-13-NH) incorporate additional elements related to staffing, the evidence basis for decisions about the care needed by residents, behavioral health, and stakeholder engagement in the assessment process.

The guidance maintains and builds on the existing elements of the Facility Assessment described under F-Tag 838 of the CMS State Operations Manual – the resident population, the facility's resources, and the facility-based and community-based risk assessment – by adding new factors that must be considered. According to the guidance, the assessment of the resident population must cover, in addition to the number of residents and the facility's capacity, "an evaluation of diseases, conditions, physical or cognitive limitations of the resident population, acuity (the level of severity of residents’ illnesses, physical, mental, and cognitive limitations, and conditions) and any other pertinent information about the resident population as a whole that may affect the services the facility must provide." This element must be "evidence-based and data-driven" and must be consistent with individual resident assessments. It should also identify additional resident needs, such as physical space, equipment, assisted technology, and communication devices. The new regulations and guidance add an explicit requirement to include behavioral health services, along with other services such as pharmacy and therapies, in the assessment of facility resources.

In conducting the assessment, the facility must ensure the active involvement of leadership and management, direct care staff, and their representatives. It must also solicit and consider the input of residents, their representatives, and family members.

According to the guidance, the assessment should drive staffing decisions, including decisions about the number of staff and the skills and competencies they must possess to serve the residents appropriately. The assessment must be used to consider staffing needs for each unit and each shift and to develop a plan to maximize recruitment and retention of direct care staff. It should also be used to inform contingency planning for non-emergency events that may impact resident care (e.g., holiday periods). The assessment must be reviewed and updated annually and revised to address changes in the resident population and their needs.

LeadingAge National is making resources available to help facilities comply with the new requirements. They include:

  • an update to the members-only Facility Assessment Toolkit prepared in collaboration with Pathway Health, available here
  • a two-part webinar available at a discounted member price. A recording of Part 1, held in May, is available here. Part 2 will be held on July 9th, and registration is available here.

Contact: Karen Lipson, klipson@leadingageny.org