How will the Facility Assessment be used during the survey process?



During your annual survey, you will be required to provide the survey team a copy of your completed Facility Assessment within four hours of them entering your facility. If systemic care concerns are identified that are related to your planning, surveyors will review the facility assessment to determine if these concerns were considered as part of your facility assessment process. For example, if you recently started accepting bariatric residents, and concerns are identified related to providing bariatric services, surveyors will evaluate your facility assessment to determine if you updated the assessment before accepting residents with these needs to identify the necessary equipment, staffing, etc., needed to provide care that is effective and safe for the residents and staff. Questions surveyors might consider include, but are not limited to, the following:

      • How did the facility assess the resident population?
        • Does this reflect the population observed?
      • How did the facility determine the acuity of the resident population?
      • How did the facility determine the staffing level?
      • How did the facility determine what skills and competencies would be required by those providing care?
      • Who was involved in conducting the facility assessment?
      • How did the facility determine what equipment, supplies, and physical environment would be required to meet all resident needs?
      • How did the facility develop its emergency plan?
      • If a deficient practice is systemic and is observed at another tag, was this related to an incomplete facility assessment? How?

Many of the citations occurring related to the Facility Assessment are related to facilities not having a completed facility assessment that is comprehensive and accurately reflects the facility,  not having a facility assessment that is developed and reviewed at the facility level, or not performing an annual review/update of the facility assessment.

To learn more about the requirements related to the Facility Assessment and how to use your assessment to guide decisions regarding staffing and resource allocation, plan to join our webinar on January 17th and check out the Facility Assessment Tool in our shop.


Director of Regulatory Services

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