The updated final rule requires a long-term care facility assessment to:

• evaluate resident diseases, conditions, and physical and/or cognitive limitations;
• evaluate resident care using evidence-based, data-driven methods;
• ensure the facility has sufficient staff with skills to address resident needs;
• evaluate the physical environment in terms of resident needs;
• assess resident needs for equipment or assistive technology.

Note that the rule’s new language requires facilities to address behavior health needs. Specifically, the update requires a care facility to provide residents with access to competent and skilled staff who can meet mental healthcare needs.

The facility assessment should ideally create a roadmap for staffing decisions, including a plan to recruit and retain direct care staff. Additionally, the assessment should take a hard look at whether a facility has enough staff to meet resident needs daily. Keep in mind that the best plans are only as good as the daily reality—if resident needs aren’t being met due to staffing issues, the facility can still be cited for noncompliance.

Assessments should also incorporate feedback from facility leaders and direct care staff, as well as input from residents and their families.

An organization should make a plan to review its facility assessment at least once per year, or whenever there is a significant change in the resident population or services needed. Some states have additional requirements for facility assessments, so it’s always a good idea to review those regulations together with the federal guidelines.

Friends Services Alliance (FSA) is a national professional association of values-aligned organizations that serve seniors. Our support services include a team of Compliance experts who have supported organizations in developing and maintaining effective Compliance and Ethics Programs for more than 20 years.