42 CFR §483.71

Facility assessment.

The facility must 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 (including nights and weekends) and emergencies. The facility must review and update that assessment, as necessary, and at least annually. The facility must also review and update this assessment whenever there is, or the facility plans for, any change that would require a substantial modification to any part of this assessment.

(a) The facility assessment must address or include the following:

(1) The facility's resident population, including, but not limited to:

(i) Both the number of residents and the facility's resident capacity;

(ii) The care required by the resident population, using evidence-based, data-driven methods that consider the types of diseases, conditions, physical and behavioral health needs, cognitive disabilities, overall acuity, and other pertinent facts that are present within that population, consistent with and informed by individual resident assessments as required under § 483.20;

(iii) The staff competencies and skill sets that are necessary to provide the level and types of care needed for the resident population;

(iv) The physical environment, equipment, services, and other physical plant considerations that are necessary to care for this population; and

(v) Any ethnic, cultural, or religious factors that may potentially affect the care provided by the facility, including, but not limited to, activities and food and nutrition services.

(2) The facility's resources, including but not limited to the following:

(i) All buildings and/or other physical structures and vehicles;

(ii) Equipment (medical and non-medical);

(iii) Services provided, such as physical therapy, pharmacy, behavioral health, and specific rehabilitation therapies;

(iv) All personnel, including managers, nursing and other direct care staff (both employees and those who provide services under contract), and volunteers, as well as their education and/or training and any competencies related to resident care;

(v) Contracts, memorandums of understanding, or other agreements with third parties to provide services or equipment to the facility during both normal operations and emergencies; and

(vi) Health information technology resources, such as systems for electronically managing patient records and electronically sharing information with other organizations.

(3) A facility-based and community-based risk assessment, utilizing an all-hazards approach as required in § 483.73(a)(1).

(b) In conducting the facility assessment, the facility must ensure:

(1) Active involvement of the following participants in the process:

(i) Nursing home leadership and management, including but not limited to, a member of the governing body, the medical director, an administrator, and the director of nursing; and

(ii) Direct care staff, including but not limited to, RNs, LPNs/LVNs, NAs, and representatives of the direct care staff, if applicable.

(iii) The facility must also solicit and consider input received from residents, resident representatives, and family members.

(2) [Reserved]

(c) The facility must use this facility assessment to:

(1) Inform staffing decisions to ensure that there are a sufficient number of staff with the appropriate competencies and skill sets necessary to care for its residents' needs as identified through resident assessments and plans of care as required in § 483.35(a)(3).

(2) Consider specific staffing needs for each resident unit in the facility and adjust as necessary based on changes to its resident population.

(3) Consider specific staffing needs for each shift, such as day, evening, night, and adjust as necessary based on any changes to its resident population.

(4) Develop and maintain a plan to maximize recruitment and retention of direct care staff.

(5) Inform contingency planning for events that do not require activation of the facility's emergency plan, but do have the potential to affect resident care, such as, but not limited to, the availability of direct care nurse staffing or other resources needed for resident care.

Extracted obligations

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. · facility assessment · 99%
Review and update the facility assessment as necessary and at least annually. · facility assessment · 99%
Review and update the facility assessment whenever there is, or the facility plans for, any change that would require a substantial modification to any part of the assessment. · facility assessment · 99%
Address the facility's resident population in the assessment, including the number of residents and the facility's resident capacity. · facility assessment · 98%
Address the care required by the resident population using evidence-based, data-driven methods that consider types of diseases, conditions, physical and behavioral health needs, cognitive disabilities, overall acuity, and other pertinent facts, consistent with individual resident assessments. · facility assessment · 98%
Address in the facility assessment the staff competencies and skill sets necessary to provide the level and types of care needed for the resident population. · staffing · 98%
Address in the facility assessment the physical environment, equipment, services, and other physical plant considerations necessary to care for the resident population. · facility assessment · 97%
Address in the facility assessment any ethnic, cultural, or religious factors that may potentially affect the care provided by the facility, including activities and food and nutrition services. · resident rights · 97%
Document the facility's resources in the assessment, including all buildings, physical structures, and vehicles. · facility assessment · 97%
Document all medical and non-medical equipment as part of the facility's resources in the assessment. · facility assessment · 97%
Document all services provided (such as physical therapy, pharmacy, behavioral health, and specific rehabilitation therapies) as part of the facility's resources in the assessment. · facility assessment · 97%
Document all personnel—including managers, nursing and other direct care staff (employees and contractors), and volunteers, as well as their education, training, and competencies related to resident care—as part of the facility's resources in the assessment. · staffing · 97%
Document all contracts, memorandums of understanding, or other agreements with third parties to provide services or equipment during both normal operations and emergencies as part of the facility's resources in the assessment. · facility assessment · 97%
Document health information technology resources, such as systems for electronically managing patient records and electronically sharing information with other organizations, as part of the facility's resources in the assessment. · health information technology · 97%
Include a facility-based and community-based risk assessment utilizing an all-hazards approach as required in §483.73(a)(1) as part of the facility assessment. · emergency preparedness · 97%
Ensure active involvement of nursing home leadership and management—including at minimum a member of the governing body, the medical director, an administrator, and the director of nursing—in conducting the facility assessment. · facility assessment · 98%
Ensure active involvement of direct care staff—including at minimum RNs, LPNs/LVNs, NAs, and representatives of direct care staff (if applicable)—in conducting the facility assessment. · facility assessment · 98%
Solicit and consider input from residents, resident representatives, and family members in conducting the facility assessment. · resident rights · 98%
Use the facility assessment to inform staffing decisions to ensure a sufficient number of staff with appropriate competencies and skill sets necessary to care for residents' needs as identified through resident assessments and plans of care. · staffing · 98%
Use the facility assessment to consider specific staffing needs for each resident unit and adjust as necessary based on changes to the resident population. · staffing · 98%
Use the facility assessment to consider specific staffing needs for each shift (day, evening, night) and adjust as necessary based on changes to the resident population. · staffing · 98%
Use the facility assessment to develop and maintain a plan to maximize recruitment and retention of direct care staff. · staffing · 98%
Use the facility assessment to inform contingency planning for events that do not require activation of the emergency plan but have the potential to affect resident care, such as availability of direct care nurse staffing or other resources needed for resident care. · contingency planning · 97%

Source: eCFR 2024-12-31 · hash sha256:59b0613f71c13625bad3079dd63048731b6027f6e5fb95531792a05b423a943c