The Centers for Medicare & Medicaid Services has issued updated guidance that surveyors will use to weigh nursing homes’ compliance with expanded facility assessment requirements included in the minimum staffing rule.
The guidance details an array of new provider responsibilities. It codifies requirements to use evidence-based strategies for an assessment, highlights the need to include behavioral health considerations and more specifically outlines who should be involved in the assessment process.
The guidance, which was issued Tuesday, will be used starting Aug. 8, by which date a new facility assessment must be completed by every federally funded nursing home in the US. It is the first provision of the staffing mandate to come into play, with other, more controversial, hiring requirements rolling out over the next two to five years.
“The assessment of the resident population should drive staffing decisions and inform the facility about what skills and competencies staff must possess in order to deliver the necessary care required by the residents being served,” CMS said in its QSO memo. “The assessment of the resident population should also contribute to identifying additional needs for residents, such as the physical space, equipment, assisted technology, individual communication devices, or other material resources that are needed to provide the required care and services to residents.”
For the first time, providers are explicitly directed to consider behavioral health needs of patients, as well physical needs, cognitive limitations and chronic conditions.
The revised regulatory requirements and updated guidance for F838 – Facility Assessment have been added to the State Operations Manual. CMS said it still must update related survey documents, such as the Extended Survey and Infection Prevention Control and Immunization Critical Element Pathways.
While the facility assessment itself is not new, some provider advocates have warned it may trip up operators who fail to take into account new criteria or don’t reassess conditions often enough to meet a requirement to update their documents when patient conditions change.
Some had previously criticized the vagueness of that specific language when the staffing rule was announced in April; the guidance does not appear to offer much more detail as to what events or changes should precipitate an assessment modification.
“The facility must review and update that assessment, as necessary, and at least annually,” the memo said. “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.”
Some providers said they are uncertain whether “substantial” includes major changes among regularly fluctuating patient admissions, or if updates would only be triggered if a facility were to launch a speciality program or intentionally work to add or fill a unit for patients with a specific needs, such as dialysis or respiratory services.
Each resident’s needs considered
Regardless, the guidance tells surveyors an assessment must “consider specific staffing needs for each resident unit in the facility and adjust as necessary based on changes to its resident population … [and] consider specific staffing needs for each shift, such as day, evening, night, and adjust as necessary based on any changes to its resident population.”
In addition, CMS said assessments must show what resources are necessary to care for its residents “competently” during both day-to-day operations — calling out special attention to be given to nights and weekends — and during emergencies. Each facility must determine the needs of its residents, it capacity and its care needs “using evidence-based, data-driven methods that consider the types of diseases, conditions, physical and behavioral health needs, cognitive disabilities, overall acuity, and other pertinent facts that are present within that population.”
Needed staff competencies and skill sets also must be enumerated.
In another change from the current assessment process, nursing homes also must involve more stakeholders in developing their daily and all-hazards plans. CMS said providers should now include nursing home leadership and management, including but not limited to, the medical director, administrator, and director of nursing; direct care staff, including nurses, nurse aides and representatives of the direct care staff, which has been largely taken to mean union leaders.
The facility also must solicit and consider input received from residents, resident representatives, and family members.
As part of the process, providers also must develop a plan to “maximize recruitment and retention of direct care staff” and make contingency plans for staff shortages. The assessment is seen as the base by which staffing needs that go beyond hourly requirements might be assessed during an on-site survey.
“While the facility assessment is intended to help facilities identify the appropriate amount of staff and resources needed, surveyors will continue to assess if facilities have sufficient nursing staff to meet residents’ needs,” CMS warned. “In other words, while facilities may be found to be in substantial compliance with the requirements … for a facility assessment, if surveyors find that residents’ needs are not being met due to insufficient staffing, the facility will be cited for noncompliance at §483.35 and required to implement a plan of correction.”
