In a June 18 Quality, Safety & Oversight Group (QSOG) and Survey & Operations Group (SOG) QSO 24-13-NH Memo, CMS is revising the requirements for the Facility Assessment to align with the Minimum Staffing Standards for Long-Term Care (LTC) Facilities and Medicaid Institutional Payment Transparency Reporting final rule, which was published in the Federal Register on May 10.  The Facility Assessment revised requirements have been moved to 42 CFR 483.71 and existing 42 CFR 483.70(f) through (q) have been redesignated as paragraphs (e) through (p), respectively. The new provisions must be implemented by August 8, 2024.   

Nursing homes must conduct and document a facility wide assessment that takes into account the care for all residents and services needed on a day-to-day, including nights and weekends, basis as well as in emergencies. Per the final rule, nursing homes will now be required to use evidence-based, data-driven methods that consider the types of behavioral health residents need and the skill sets for staff to take care of them. Nursing homes will be required to have active participation in the facility assessment process, including the governing board, leadership, direct care staff, residents, and resident families or representatives. 

The final rule is explicit in its expectations of the facility assessment to inform staffing decisions, ensuring sufficient staffing is available and adjusting to the changing conditions of residents. Nursing homes must maintain recruitment and retention efforts and inform their organization of a staffing contingency plan. A Facility Assessment will need to be reviewed and updated at least annually or as needed. The June 18 Memo addresses the specific guidance at F 838, the intent of the facility assessment and definitions for the regulation. The guidance expands to give nursing homes the investigative procedures that will be used by surveyors to determine Facility Assessment compliance. Along with the specific questions surveyors will use, the Memo outlines areas of non-compliance and additional tags for potential investigation. Nursing homes will be able to use this information to perform quality improvement activities and mock surveys. Lastly, the Memo provides deficiency examples that may help a nursing home avoid a potential non-compliance.   

LeadingAge is helping to support members to understand the new enhancements of the facility assessment and be compliant via a two part webinar series. LeadingAge’s first Facility Assessment webinar was held May 15 and is available on the LeadingAge Learning Hub. LeadingAge’s upcoming July 9 webinar is open for registration and will be a deep dive into the specifics components of the facility assessment and how to use the members-only Facility Assessment toolkit. LeadingAge will continue to analyze the CMS memo and release a more in-depth article in the coming days.