CMS has issued updated guidance that surveyors will use to evaluate nursing home providers’ compliance with the expanded facility assessment requirements included in the minimum staffing rule, which become effective on August 8, 2024. Every nursing home provider must complete an updated facility assessment by this date. The facility assessment must include an evaluation of the diseases, conditions, physical and/or cognitive limitations, the severity of these conditions and other pertinent information about the resident population that may impact the services provided. This assessment of the resident population should be used by the facility to drive staffing decisions and determine the skills and competencies facility staff must possess to meet the needs of the residents under their care. Consider these tips for compliance with reviewing behavioral health as part of your Facility Assessment…

The guidance, which can be accessed at QSO-24-13-NH (, specifies that the facility assessment must utilize evidence based strategies to conduct the assessment. In addition, the guidance addresses the need to include an evaluation of the behavioral health needs of the facility population and the inclusion of behavioral health among the services provided in the facility assessment.

The identification and assessment of the resident population with behavioral needs may include an evaluation of the following:

      • Any patients with PASRR level 2 determinations and recommendations
      • Patients with mental health related diagnoses the impact behaviors
      • PHQ 2-9 score indicative of a depressed mood, which when unmanaged may result in increased behavioral issues
      • Patients with behavior issues coded documented and/or coded in section E of the MDS

Effective strategies for managing facility-wide behavioral needs may include the following:

      • If the demographics of the facility have changed, such that the number of patients with behavioral issues has increased, it is critical to assess whether the current staffing levels are sufficient to meet the needs of this population.
      • Conduct an assessment to determine whether the current facility staff have the skill set and competencies to address the residents’ behavioral health issues. Provide staff training with a focus on managing the specific behaviors identified in the resident population
      • Evaluate your partnership with your psychiatric mental health services provider. These services should include both medication management and psychotherapy services at the intensity and frequency necessary to meet the needs of your facility population.
      • Utilize an interdisciplinary approach to care planning that includes the development of resident centered care plans with individualized non-pharmacological interventions aimed at the root cause of the target behaviors.
      • Consider the inclusion of the recreation/therapy staff in the development of an activity program aimed at the management of behaviors. Assess whether the activity program provides sufficient activities for the residents that include evenings and weekend activities as appropriate.

Access Proactive’s Facility Assessment Tool to guide compliance with the enhanced requirements effective August 8, 2024.  Need help tackling the Facility Assessment updates? Contact Proactive for a facility assessment review and revision consultation.


Written by Christine Twombly, RN-BC, RAC-MT, RAC-MTA, HCRM, CHC
Clinical Consultant

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