Federal regulations require each facility to 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 intent of the facility assessment is to help you determine the resources you need to competently care for your resident population during day to day operation, as well as in emergencies. In completing the assessment, you will determine what resources you currently have available and what additional resources are needed based on the assessment of the population you serve. The facility assessment also serves as a means to record your reasoning for the decisions you make regarding how you staff your facility and allocate your resources.


Required components of the facility assessment include:

      • The facility’s resident population – This includes census and resident capacity, care required by the resident population, staff competencies necessary to provide resident care, and ethnic, cultural, or religious factors that may affect care provided
      • The facility resources – This includes buildings, physical structures, and vehicles; equipment; personnel; third-party contracts; and health information technology resources
      • A facility-based and community-based risk assessment, utilizing an all hazards approach

This assessment must be reviewed and updated, as necessary, and at least annually. The facility must also review and update the facility assessment whenever there is, or the facility plans for, any changes that would require a substantial modification to any part of the assessment. The COVID-19 pandemic has contributed to major disruptions in facility normal operations and facility resources. As your facility continues to face challenges and changes in normal operations related to the pandemic, it is important that the facility assessment is used as a guide in helping you to determine the resources you need to competently care for your residents. The following are key areas to consider when reviewing and updating your facility assessment during the pandemic:

      • Changes in census
      • Changes in facility layout to accommodate COVID-19
      • Number of residents in isolation
      • Changes in activities, food service processes, religious services
      • Changes in facility and community-based risk assessment related to pandemic, considering COVID-19 activity in community and facility
      • Changes in staffing and execution of emergency staffing plan
      • Inventory of PPE
      • Use of telehealth services
      • Policy and procedure updates

Struggling to keep up with Facility Assessment updates for COVID-related organizational changes?  Proactive’s Facility Assessment Tool helps achieve compliance through a user-friendly combination of checklist worksheets, fill-in-the-blank resource tables, and narrative response fill in items in a pdf fill-in-the-blank tool that may be saved and updated as needed over time.


Blog by Shelly Maffia, MSN, MBA, RN, LNHA, QCP, CHC, CLNC, Proactive Medical Review

Click here to learn more about Shelly and the rest of the Proactive team.