Nursing facilities are mandated to conduct, document, and regularly review a comprehensive facility-wide assessment. This critical process includes evaluating the resident population and identifying the necessary resources to provide appropriate care (42 CFR §483.71). This assessment needs to be reviewed at least annually and updated as needed to ensure ongoing effectiveness.
The primary purpose of a Long Term Care Facility Assessment Tool is to thoroughly evaluate the resident demographic and determine the resources required to deliver competent care. This encompasses daily operations, including nights and weekends, as well as emergency situations. The assessment should guide decisions regarding direct care staff needs, including contracted services and volunteers, and evaluate the facility’s capabilities to meet resident needs. By employing evidence-based and data-driven methods, facilities can ensure that each resident receives care that supports them in maintaining or achieving their highest possible physical, mental, and psychosocial well-being.
A long term care facility assessment tool typically incorporates three key parts. Firstly, it establishes a detailed resident profile, capturing data on resident numbers, prevalent diseases and conditions, physical and behavioral health needs, cognitive disabilities, acuity levels, and relevant ethnic, cultural, and religious factors that may influence care delivery. Secondly, it outlines the services and care offered based on the identified resident needs. This section focuses on the types of care required by the resident population, rather than individual care plans. Finally, the tool assesses facility resources needed to provide competent care. This includes evaluating staffing levels, staffing plans focused on recruitment and retention of direct care staff, staff training and competency programs, the suitability of the physical environment and building infrastructure, and other essential resources. These additional resources can encompass agreements with external parties, health information technology systems, a comprehensive risk assessment covering both facility-based and community-based risks, and any other pertinent information deemed necessary.
To effectively conduct a long term care facility assessment, it’s crucial to gather data from diverse sources. These sources may include, but are not limited to, Minimum Data Set (MDS) reports, Quality Measures data, 671 and 802 reports, pharmacy reports, Payroll-Based Journal (PBJ) data, and internally generated reports. Examples of in-house reports include resident diagnosis and demographic summaries, 24-hour reports, psychotropic medication usage data, pressure injury statistics, resident fall records, behavior tracking and intervention logs, and results from resident and family surveys.
In conclusion, utilizing a robust long term care facility assessment tool is essential for nursing facilities to meet regulatory requirements and, more importantly, to ensure they are equipped to provide high-quality, resident-centered care. Regular assessment and review processes are vital for adapting to changing resident needs and maintaining optimal operational effectiveness within the facility.
