As we move into a new year, it’s a great time to review and update your 2022 education plan. According to QSO-22-02-ALL issued last month, during annual surveys in 2022, surveyors will be paying additional attention to compliance with the requirements for F-726 sufficient and competent staff, which states:

The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility’s resident population in accordance with the facility assessment required at §483.70(e).” (F726, State Operations Manual, Appendix PP)

Ensuring Competency

Facility leadership can use a variety of metrics to determine the competency-based education needs for ongoing staff training. To start, nurse leaders should consider the staff members’ skills, the resident population, and any special services the facility offers (i.e., a ventilator unit, a post-acute unit, a pediatric unit, or a dementia unit). An evaluation of your facility assessment is a great starting point for this analysis. As required under F838, §483.70(e), your facility assessment must address/include an evaluation of staff competencies that are necessary to provide the level and types of care needed for the resident population.

Next, to identify any potential gaps in care delivery, leadership should examine resident acuity, diagnoses, and the intensity of services required for care. Some examples might include:

      • Reviewing readmission rates and common trends for hospital readmissions, which may show continuing education and competency evaluations are needed to address knowledge deficits in staff;
      • Analyzing any increased number of infections, which may show that additional training and competency evaluations are needed to ensure proper infection-control measures are being used by all staff;
      • Look at the specialized services your new admissions need. For example, if you have an increased number of admissions requiring intravenous (IV) medications, you should consider including evaluation of competency and the skills of the nurses in administering IV meds; and
      • Identify common diagnoses amongst your resident population and consider including additional training specific to the common diagnosis in your resident population.

You also want to make sure that your staff are competent in all of the areas addressed in the §483.95 Training Requirements at F940-949, which states:

“A facility must develop, implement, and maintain an effective training program for all new and existing staff; individuals providing services under a contractual arrangement; and volunteers, consistent with their expected roles. A facility must determine the amount and types of training necessary based on a facility assessment as specified at § 483.70(e). Training topics must include but are not limited to”—

      • Communication
      • Resident’s rights & facility responsibilities
      • Abuse, neglect, & exploitation
      • QAPI
      • Infection Control
      • Compliance & Ethics
      • Nurse aide required in-service training
      • Required training for feeding assistants
      • Behavioral health

Specific things to think about when developing and evaluating your training program include:

      • Do you have a good process in place for evaluating staff competencies and skill sets upon initial hire and routinely thereafter? When new technologies/equipment are put into use?
      • Does your facility assessment describe the type of competencies required to meet each resident’s needs considering your census and resident acuity and do the competencies of your staff reflect the expectations described in the facility assessment?
      • Is there evidence that staff are able to identify and address resident changes in condition? What are the practices or tools used that demonstrate this ability? Is there evidence of a lack of competency, such as: Adverse events that could have been prevented; Conditions that occurred that could have been identified and addressed earlier to prevent them from worsening; or Hospital transfers that could have been potentially avoided if the reason for the transfer had been identified and addressed earlier.
      • How are staff evaluated to determine that they demonstrate knowledge of individual residents and how to support resident preferences?
      • When doing care observations, does your staff demonstrate the necessary competencies and skill sets in accordance with current standards of practice? For example, if the resident requires a manual lift for transferring, do staff demonstrate knowledge and skill in the proper use of the lift and perform the activity in a safe manner?
      • How do you ensure that Agency staff used possess the required competencies to care for each resident? What is your process for evaluating competency of agency staff?
      • What methods do you currently use to demonstrate that your staff are competent?

According to CMS, “Competency may not be demonstrated simply by documenting that staff attended a training, listened to a lecture, or watched a video. A staff’s ability to use and integrate the knowledge and skills that were the subject of the training, lecture or video must be assessed and evaluated by staff already determined to be competent in these skill areas” (F726 Interpretive Guidance, State Operations Manual, Appendix PP). This means that you need to think about how you are ensuring that staff who are responsible for assessing & evaluating staff competency are competent themselves before assessing other staff member’s competency. Examples of methods of evaluating competencies may include, but are not limited to:

      • Lecture with return demonstration for physical activities;
      • A pre- and post-test for documentation issues;
      • Demonstrated ability to use tools, devices, or equipment that were the subject of training and used to care for residents;
      • Reviewing adverse events that occurred as an indication of gaps in competency; or
      • Demonstrated ability to perform activities that is in the scope of practice an individual is licensed or certified to perform.

Contact Proactive to learn more about Competency-based training and consulting services including:

      • Staff Development training
      • Staff Development program consultation services
      • Review of facility assessment & training plans for competency gaps with written recommendations to improve training plans
      • Mock Surveys to assist in identifying potential risks
      • Assistance with plan of correction development for staff competency related citations


Shelly Maffia, MSN, MBA, RN, LNHA, QCP, CHC, CLNC, CPC
Director of Regulatory Services

Learn more about the rest of the Proactive team.