Facility Assessment: Impact on Staffing Requirements

June 14, 2024

Overview

The Centers for Medicare & Medicaid Services has updated the requirements of the Facility Assessment in order to require facilities to use evidenced based methods when care planning for their residents, including those with behavioral health needs. New requirements require the use of the Facility Assessment to address staffing needs and resident needs for each nursing unit and to adjust the assessment based on significant changes in the resident population. The nursing home leadership including Governing Body, Medical Director, Nursing Home Administrator, Director of Nursing, as well as direct care staff including RNs, LPNs and CNAs must have input. And the facility should solicit input from residents and families as well. Nursing homes must also develop a staffing plan to maximize recruitment and retention of staff consistent with the President’s April Executive Order on Increasing Access to High Quality Care and Supporting Caregivers.

The Facility Assessment must be completed no later than 8/8/24 and be presented to the survey team on admission to the facility for a survey. Surveyors should review the Facility Assessment and report if the Skilled Nursing Facility is in compliance with the staffing and care regulations and the Facility Assessment requirements. The Facility Assessment requires staff to measure their residents’ acuity and to use an evidence-based process to determine needed staffing. Staff education must also be planned, documented and reported. Facilities must share their Facility Assessment with potential admissions to show the care and services they provide at the facility. The Facility Assessment must also show facility resources needed to care for the residents every day and in an emergency. A staffing plan and education plan must also be present on the Facility Assessment. This presentation will focus on the new requirements as well as the total requirements that must be met by the Facility Assessment.

Learning Objectives:
1. Identify the deadline to update the Facility Assessment related to the instructions in the Minimum Staffing Regulation.
2. Give some examples of how the facility staff can measure their residents’ acuity using an evidence-based process to determine staffing needs.
3. State which staff and community members should have input for the Facility Assessment.

Instructor

Carol Maher, RN, GERO-BC, RAC-MTA, RAC-MT, CPC

Carol Maher is a Board Certified Gerontological Registered Nurse with over 30 years of long term care experience and has worked in long term care in many roles. She worked as the MDS Coordinator in a 300 bed SNF in Pennsylvania for 8 years before moving to CA to become the MDS Coordinator/Director for a 1200 bed SNF in San Francisco. She has also worked as the MDS Coordinator in a SNF that typically had 60-75 residents on Medicare in addition to 160 long-term care residents. Most recently she was the Senior VP of Utilization Services and Director of Reimbursement for large multi-facility organizations.

Carol has worked as one of the Gold Standard nurses for MDS 3.0, serving on the RAP workgroup to prepare the way for the CAAs for MDS 3.0, and participating on a number of Technical Expert Panels related to MDS, Quality Measures and care planning. A sought-after speaker, she has given presentations at AANAC, AHCA and Leading Age national conferences as well as many state organization presentations. She is also a frequent author of articles related to the RAI process and PPS. Carol served as a member of the AANAC Board of Directors for 9 years. She is presently serving as the chair of the AANAC Expert Advisory Panel and as an AANAC Master Teacher of the RAC-CT and RAC-CTA certification courses. Ms. Maher is the Director of Education for Hansen Hunter, providing MDS and Medicare classes across the country, presenting monthly educational webinars and completing compliance audits. She is the author of Long-Term Care MDS Coordinator’s Field Guide (HCPRO 2016).

Credit Hours

  • 1.5 hours for Licensed Nurses
  • 1.5 NAB hours for Nursing Home Adminstrators

This pre-recorded webinar expires on June 14, 2026.

$99.00

Hansen Hunter clients are invited to access any of our webinars for free by contacting Allison Johnson at our office at 503.244.2134 to receive your free registration code.

Disclosures

  • This nursing continuing professional development activity was approved by Montana Nurses Association, an accredited approver with distinction by the American Nurses Credentialing Center’s Commission on Accreditation.
  • Enduring material: To meet the requirements for these contact hours, you must watch the entire recorded presentation as well as answer and submit the post-test evaluation that is provided as a link along with the link to your webinar which you will receive via email after completing your purchase.
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