f838 -facility assessment: what you need to know

©2018 Briggs Healthcare

F838 - Facility Assessment: What

You Need to Know

July 26, 2018

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Learning Objectives/Outcomes

As a result of this presentation, participants will

be able to:

� Locate the regulation that addresses the Facility

Assessment

� Describe the regulatory requirements of this

assessment

� Lead/participate in the development of your

facility’s assessment

2

©2018 Briggs Healthcare 3

Purpose

The regulation for a Facility Assessment was

implemented on November 28, 2017 in Phase 2

of the Requirements of Participation.

Every LTC 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

Assessment is the

care plan for the

facility!


F838 - Facility Assessment

§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.

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The facility assessment must address

or include:

The facility’s resident population, including, but not limited to:

� Both the number of residents and the facility’s resident capacity

� 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

� The staff competencies that are necessary to provide the level and

types of care needed for the resident population

� The physical environment, equipment, services, and other physical

plant considerations that are necessary to care for this population and

� 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

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The facility assessment must address

or include:

The facility’s resources, including but not limited to:

� All buildings and/or other physical structures and vehicles

� Equipment (medical and non-medical)

� Services provided, such as physical therapy, pharmacy, and specific

rehabilitation therapies

� 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

� Contracts, memorandums of understanding, or other agreements with third

parties to provide services or equipment to the facility during both normal

operations and emergencies

� Health information technology resources, such as systems for electronically

managing patient records and electronically sharing information with other

organizations

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A facility-based and community-based risk

assessment, utilizing an all-hazards

approach. §483.70(e)(3)


Facility Assessment/Emergency

Preparedness Plan

The facility’s emergency preparedness

plans should be integrated and compatible

with the facility assessment. As one is

updated, so should the other.

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Let’s Look at: Frequency

• 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.

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Let’s Look at: Overall Requirement

Do you have the resources necessary to

care for its residents competently during

both day-to-day operations and

emergencies?

No specific tool is required.

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Let’s Look at: Who’s Involved

• Administrator *

• Representative of the Governing Body *

• Medical Director *

• Director of Nursing *

• Environmental Operations Manager

• Dietary Manager

• Other Department Heads

• Director of Rehabilitation/Therapy Services

• Members of the Direct Care Staff

• Resident/Family Council ^

• Residents ^

• Resident Representatives/Families ^

* Required (Minimal Requirements) ^ Seek input from 12


Assessment of Resident Population

• Evaluation of diseases and conditions

• Evaluation of physical, functional and cognitive

status

• Acuity of residents

• Any pertinent information about residents that

may affect the provision of care

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MDS – Section I

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MDS – Section I

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Resident Acuity

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Resident Population: Who Lives

Here

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Languages Spoken in This Facility


Assessment of Facility Resources

� Staff

� Daily Staffing Plan

� Staff Training and Competencies

� Policies and Procedures for Provision of Care

� Working with Medical Practitioners

� Physical Environment: Building/Plant Needs

� Contracts, MOUs, Agreement

� Budget

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Look at: Census, Admissions &

Admission Sources

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Staff Positions

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Let’s Look at: Staffing

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Staff Training & Competencies

Describe the staff training/education/in-services

necessary to provide the level and types of

support and care needed for your resident

population. Include areas such as certification

requirements, licensure, etc.

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Staff Training & Competencies

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Working with Medical Practitioners

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Physical Environment:

Building/Plant Needs

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Contracts, MOUs, Agreements

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HIT Resources/Secure

Transmission of Health Information

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Downtime Procedures/Record

Requests

� How does your facility develop and implement

downtime procedures?

� How does your facility ensure that residents and

their representatives can access their records

upon request?

� How are requested copies provided within required

timeframes?28


Infection Prevention and Control

Program

What steps are you taking to comply with the requirement

for an Infection Preventionist?

This position is required beginning November 28, 2019

(Phase 3). F882 is the Federal tag.

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Emergency Preparedness Plan:

Facility-Based Risk Assessment

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Emergency Preparedness Plan:

Community-Based Risk

Assessment

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Where to Begin and How to

Proceed

• Start NOW if you haven’t already!

• Facility Assessment is a team exercise.

• Assemble the team, delegate assignments & provide supervision

(and encouragement) as the data collection moves forward.

• Review the regulatory language with your team to ensure

understanding. Re-review as needed.

• Regroup frequently to assess progress with data collection and to

see if additional education or resources are needed to complete

assigned tasks.

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AndC• Utilize the data you’re already collecting:

• MDS

• Payroll-Based Journal

• Quality Measures/SNF QRP Measures

• CASPER reports

• Reports from EMR vendor found in your software

• Utilize your data analytics/EMR vendor for assistance.

• Bring the team together to analyze the data you’ve

collected. What does it mean??

• Keep your QAPI team in the loop – fully informed of your

Facility Assessment.

• Your facility is unique – your Facility Assessment will be as

well.

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Key Points for Analysis of Data

• Do we have sufficient staffing to meet the needs of our

residents?

• Is our staff competent to provide care/meet needs of

our residents?

• Are there any training or education needs for our staff

that are not being met?

• Do we have the equipment to provide care for our

residents?

• Are we current with our infection prevention and

control practices?

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More Key Point for Analysis

• What resources are needed to prepare for emergency

situations?

• Is additional data needed in order to fully assess our

ability to provide care on a daily basis as well as an

emergency basis?

• Were any trends or issues identified during review of

the data that would benefit from QAA/QAPI initiatives?

• Is our budget adequate to cover the needs identified in

the Facility Assessment?

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Don’t Forget

• 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.

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Facility Assessment Use During

Survey

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Guidance to Surveyors

• While you request the Facility Assessment upfront, you will only

review it if there are concerns with sufficient or competent staffing

or patterns of concerns.

• The facility must conduct a facility-wide assessment to determine

what resources are needed to competently care for residents each

day and during emergencies. If systemic concerns are identified in

resident-specific areas (e.g., hospice, dialysis, ventilators,

activities, nutrition, behavioral/emotional, dementia) or if there is a

systemic concern with a lack of adequate resources (e.g.,

specialized rehabilitation, pharmacy), review the facility

assessment.

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Critical Element Pathway & F838

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Top 25 (as of July 20, 2018)

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F838 Ranking - #72

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Survey Results - F838

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Scope & Severity

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A Few of the Survey ResultsC

• Not done/started

• Missing elements

• Not following staffing plans

• No Governing Body

representative listed

• Failed to assess resident

acuity

• No information about

required 12hrs/year for CNA

• No information on licensed

nurse competencies for 3+

years

• Included ventilators &

respirators on FA but facility

doesn’t care for these

• No information on infection

control program

• No evaluation of hot water &

HVAC systems

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Sources and Resources

• https://www.cms.gov/Regulations-and-

Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.p

df [Appendix PP – State Operations Manual; F838 begins on page 582]

• https://www.cms.gov/Regulations-and-

Guidance/Guidance/Manuals/downloads/som107ap_z_emergprep.pdf

[Appendix Z - State Operations Manual]

• https://www.cms.gov/Outreach-and-

Education/Outreach/NPC/Downloads/2017-09-07-Dementia-Care-in-

Nursing-Homes-Call-Presentation.pdf

[Nursing Home Facility Assessment Tool and State Operations Manual

Revisions CallTSeptember 7, 2017]

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Additional Sources and Resources

• https://qcor.cms.gov/main.jsp

[S&C Quality, Certification and Oversight Reports (QCOR) Application]

• https://www.cms.gov/Medicare/Provider-Enrollment-and-

Certification/GuidanceforLawsAndRegulations/Nursing-Homes.html

[LTC Survey Information]

• https://www.briggshealthcare.com/Facility-Assessment

[Briggs Healthcare Facility Assessment]

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Upcoming WebinarPDPM demystified: What you need to know

Say goodbye to RUGs-IV and say hello to PDPM.

The much-anticipated RCS-1 system is no longer on the horizon. Instead, the Centers for Medicare and Medicaid

Services (CMS) published the Patient-Driven Payment Model (PDPM) in the FY 2019 SNF PPS Proposed Rule.

The PDPM payment model for PPS SNF patients is proposed to be implemented in October 2019.

With barely a year to prepare, providers are hungry for information about PDPM. Understanding this model now will

help your facility prepare for the coming changes.

As we move away from a payment model driven by therapy minutes to one based on patient characteristics, how

will your facility continue to provide therapy in a fiscally responsible manner? How will you pay your therapy

contractor when therapy minutes do not drive payment?

We’ll address these and many more questions in this informative training session. We expect to run out of space for

this webinar, so register now!

Speaker: Mark McDavid, OTR, RAC-CT, Owner, Seagrove Rehab Partners

Wednesday, August 1, 2:00–3:15pm CT

Register at: https://register.gotowebinar.com/register/449321316533308675


Upcoming Webinar 30 Days Out and Counting: What's Changing with the

MDS 3.0 Item Set on October 1, 2018

Did you know that CMS has made more than 100 changes to the MDS 3.0 Item Set that we'll start using October 1,

2018??

Join Mary Madison for a look at the new items that are being added, the items that CMS has removed and an

overview of the SNF QRP measures. This 1-hour webinar is intended for MDS Coordinators, Directors of Nursing,

Social Workers, Therapists and Administrators as well as all members of your Interdisciplinary Team.

As a result of this presentation, participants will be able to:

� Locate the current DRAFT MDS 3.0 Item Sets as well as the Item Set Change History document.

� Describe the major changes to the MDS 3.0 Item Set effective October 1, 2018.

� Begin/enhance preparations for successful implementation of version 1.16.

� Identify SNF QRP items on the MDS 3.0 Item Set

Thursday, August 30, 2018 at 2:00 PM CDT

Register at: https://attendee.gotowebinar.com/register/976935165328004866

50


Speaker

Mary Madison is a registered nurse with 45 years of experience in the healthcare field;

40 years in the long-term care industry. Mary has held positions of Director of Nursing

in a 330-bed SNF, DON in two 60-bed SNFs, Reviewer with Telligen (Iowa QIO),

Director of Continuing Education, Manager of Clinical Software Support, Clinical

Software Implementer and Clinical Educator. Mary is a Certified Resident Assessment Coordinator (AANAC) and a Certified Dementia Practitioner (NCCDP). Mary has

conducted numerous MDS training and other LTC educational sessions across the

country in the past 2+ decades. She joined Briggs Healthcare® as their LTC/Senior

Care Clinical Consultant in July 2014.

Mary’s contact information is: [email protected]

Briggs Healthcare® website: https://www.briggshealthcare.com/

BriggsNetNews® Blog: https://briggshealthcare.blog/

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