f838 -facility assessment: what you need to know
TRANSCRIPT
©2018 Briggs Healthcare
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
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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.”
©2018 Briggs Healthcare
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)
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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
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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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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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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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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
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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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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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©2018 Briggs Healthcare
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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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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©2018 Briggs Healthcare
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
©2018 Briggs Healthcare
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
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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/