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12001501998345Facility Assessment Template020000Facility Assessment TemplateDisclaimer: The Facility Assessment is mandated by CMS but no specific format has been dictated. This template was created by PointClickCare for your use but use of this template does not ensure your regulatory compliance. This tool must be adapted to your facility’s needs, to your state regulatory requirements and, for your resident population. This template has been compiled using a variety of resources. Further information on the Facility Assessment can be found here: QSO-24-13-NH () and through CMS (Final Rule).Facility Assessment for{Facility Name Here}Company Bio:Company Logo:Completed By:Date Completed/Updated: Date Reviewed with QAPI CommitteeTable of Contents TOC \o "1-3" \h \z \u Revision History PAGEREF _Toc173249866 \h 5Resident Profile PAGEREF _Toc173249867 \h 6Number of Residents for which our Facility is Licensed to Provide Care PAGEREF _Toc173249868 \h 6Diseases/Conditions, Physical and Cognitive Disabilities PAGEREF _Toc173249869 \h 7Acuity PAGEREF _Toc173249870 \h 8Acuity Affecting Licensed Nurses PAGEREF _Toc173249871 \h 10Ethnic, Cultural or Religious Factors PAGEREF _Toc173249872 \h 13Services and Care Offered PAGEREF _Toc173249873 \h 13Resident Preferences PAGEREF _Toc173249874 \h 13Resident Care Needs PAGEREF _Toc173249875 \h 14Facility Resources Needed PAGEREF _Toc173249876 \h 16Nurse Staffing Plans PAGEREF _Toc173249877 \h 16Staff Assignments PAGEREF _Toc173249878 \h 17Staff Recruitment and Retention of Staff PAGEREF _Toc173249879 \h 18Staff Training and Education PAGEREF _Toc173249880 \h 19Staff Competencies PAGEREF _Toc173249881 \h 21Policies and Procedures for Provision of Care PAGEREF _Toc173249882 \h 23Medical Professionals PAGEREF _Toc173249883 \h 23Physical environment and building/plant needs PAGEREF _Toc173249884 \h 23Health Information Technology (HIT) Resources PAGEREF _Toc173249885 \h 25Infection Control Program Evaluation PAGEREF _Toc173249886 \h 25Facility Based Risk Assessment PAGEREF _Toc173249887 \h 26Community Based Risk Assessment PAGEREF _Toc173249888 \h 27Revision HistoryDate Person Revising Items UpdatedResident ProfileNumber of Residents for which our Facility is Licensed to Provide CareITEMFACILITY RESPONSE# of Licensed Beds# of Certified Beds# of Specialty Unit BedsCensus Date Range _________________Average Daily CensusAverage Weekday AdmissionsAverage Weekend AdmissionsAverage Weekday DischargesAverage Weekend DischargesDiseases/Conditions, Physical and Cognitive DisabilitiesCategory Common diagnosesPsychiatric/Mood Disorders/Substance Use DisordersHeart/Circulatory SystemNeurological System Intellectual DisabilitiesVisionHearingMusculoskeletal SystemNeoplasm Metabolic Disorders Respiratory SystemGenitourinary SystemDiseases of Blood Digestive SystemIntegumentary SystemInfectious Diseases Conditions not listedAcuity (Date Range: ______________)ProfileNumber/Average or Range of ResidentsMajor Joint Replacement or Spinal SurgeryNon-Orthopedic Surgery and Acute NeurologicOther OrthopedicMedical ManagementFunction Score: 0 – 5Function Score: 6 – 9Function Score: 10 – 23Function Score: 24Mechanically Altered Diet or Swallowing DisorderExtensive ServicesSpecial Care HighSpecial Care LowClinically ComplexBehavioral Symptoms and Cognitive PerformanceReduced Physical FunctionNursing Function Score: 0 – 5 Nursing Function Score: 6 – 10Nursing Function Score: 11 – 16NTA Score: 12+NTA Score: 9-11NTA Score: 6-8NTA Score: 3-5NTA Score: 1-2NTA Score: 0Acuity Affecting Licensed NursesProblem Special Treatments Number/Average or Range of ResidentsCancer TreatmentsChemotherapyRadiationRespiratory Treatments Oxygen therapySuctioningTracheostomy CareVentilator or RespiratorBIPAP/CPAPBehavioral and Mental Health Behavioral Health NeedsActive or Current Substance Use DisordersOther IV MedicationsInjectionsTransfusionsDialysis CareHemodialysisPeritoneal dialysisOstomy CareIndwelling catheter (including suprapubic catheter and nephrostomy tube)Intermittent catheterizationHospice CareRespite CareIsolation or Quarantine for Active Infectious Disease (affects all staff)Advanced Wound Care NeedsTube Feedings/ Parenteral NutritionDrain/Tube ManagementAcuity Affecting Nurse AidesAssistance with Activities of Daily LivingIndependentHelper AssistanceDependentDressingBathingTransfersEatingToiletingOral HygieneMobilityUpper Body DressingLower Body DressingOther care, describe:Ethnic, Cultural or Religious FactorsITEMFACILITY RESPONSEActivitiesFood and Nutrition ServicesLanguagesClothing PreferencesAccess to Religious ServicesReligious-based Advanced DirectivesOtherServices and Care OfferedResident PreferencesITEMFACILITY RESPONSEWaking Times Outside Routine ScheduleBathing Preferences - MorningBathing Preferences - EveningBathing Preferences - NightActivitiesMeal Times Outside Routine ScheduleBed Times Outside Routine ScheduleOtherResident Care NeedsCategorySpecific Care or PracticesActivities of daily livingMobility and fall/fall with injury preventionBowel/bladderSkin integrity Behavioral and Mental Health Medication ManagementPain management Infection prevention and control Management of medical conditionsRehabilitation ServicesOther special care needs NutritionProvide person-centered/directed care: Psycho/social/spiritual support: Medical Social ServicesDischarge PlanningFacility Resources NeededNurse Staffing PlansStaff Plan RNs providing direct careLPNs/LVNs providing direct careRNs Available to Provide Direct Care (includes DON and RNs with admin duties)LPNs/LVNs Available to Provide Direct Care (i.e. LPNs/LVNs with admin duties)Nurse Aides (CNAs, NAs, Med. Techs Other (e.g., department heads, nurse educator, quality assurance, ancillary staff in maintenance, housekeeping, dietary, laundry)Staff AssignmentsStaffing Needs as per Resident UnitUnitStaff PositionRatio of Staff to Resident or #HPRDRN Coverage / ShiftRNLPN/LVNCNAMed TechNurse AideOtherStaffing Needs as per ShiftShiftStaff PositionRatio of Staff to Resident or #HPRDRN Coverage / ShiftDaysRNLPN/LVNCNAMed TechNurse AideOtherEveningsRNLPN/LVNCNAMed TechNurse AideOtherNightsRNLPN/LVNCNAMed TechNurse AideOtherStaff Recruitment and Retention of StaffStaff Recruitment and RetentionCurrent Strategies for recruitment and retention of nursing staff:Plans to maximize strategies:Contingency Planning for StaffingIn the case of an emergency event, the facility’s emergency plan will be activated. If the event does not rise to the level of activation of the facility’s emergency plan the facility will:Staff Training and EducationTopicStaff Type and Timing (on hire, annual, PRN, On Demand), HowCommunication – effective communications for direct care staffResident’s rights and facility responsibilities – ensure that staff members are educated on the rights of the resident and the responsibilities of a facility to properly care for its residentsAbuse, neglect, and exploitation – training that at a minimum educates staff on— (1) Activities that constitute abuse, neglect, exploitation, and misappropriation of resident property; (2) Procedures for reporting incidents, of abuse, neglect, exploitation, or the misappropriation of resident property; and (3) Care/management for persons with dementia and resident abuse preventionInfection control – a facility must include as part of its infection prevention and control program mandatory training that includes the written standards, policies, and procedures for the program Culture change (that is, person-centered and person-directed care)State-approved training program for feeding assistantsIdentification of resident changes in condition, including how to identify medical issues appropriately, how to determine if symptoms represent problems in need of intervention, how to identify when medical interventions are causing rather than helping relieve suffering and improve quality of lifeCultural competency (ability of organizations to effectively deliver health care services that meet the social, cultural, and linguistic needs of residents)Staff CompetenciesCompetency Staff Type and Timing (on hire, annual, PRN, On Demand), HowPerson-centered careActivities of Daily LivingDisaster PlanningInfection Control – Hand HygieneInfection Control – Universal PrecautionsInfection Control – Protective EquipmentMedication Administration Measurements – Vitals and Intake and OutputResident AssessmentCaring for People with Dementia. Alzheimer’s and Cognitive ImpairmentsCaring for Residents with Mental and Psychosocial disordersNon-pharmacological management of Responsive Behaviors Caring for Residents with Trauma/PTSDCaring for Residents with Substance Abuse Disorder (SUD)Policies and Procedures for Provision of CareProcess for Updating and Rolling Out New/Updated policiesMedical Professionals Physical environment and building/plant needsPhysical Resource CategoryResourcesIf applicable, process to ensure adequate supply, appropriate maintenance, replacement Buildings and/or other structures Building description, garage, storage shedVehicles Transportation vanPhysical equipmentBath benches, shower chairs, bathroom safety bars, bathing tubs, sinks for residents and for staff, scales, bed scales, ventilators, wheelchairs and associated positioning devices, bariatric beds, bariatric wheelchairs, lifts, lift slings, bed frames, mattresses, room and common space furniture, exercise equipment, therapy tables/equipment, walkers, canes, nightlights, steam table, oxygen tanks and tubing, dialysis chair and station, ventilatorsServicesWaste management, hazardous waste management, telephone, HVAC, dental, barber/beauty, pharmacy, laboratory, radiology, occupational, physical, respiratory, and speech therapy, gift shop, religious, exercise, recreational music, art therapy, café/snack bar/bistro Other physical plant needs Sliding doors, ADA compliant entry/exit ways, nourishment accessibility, nurse call system, emergency powerMedical supplies (if applicable)Blood pressure monitors, compression garments, gloves, gowns, hand sanitizer, gait belts, infection control products, heel and elbow suspension products, suction equipment, thermometers, urinary catheter supplies, oxygen, oxygen saturation machine, Bi-PAP, bladder scannerNon-medical supplies (if applicable)Soaps, body cleansing products, incontinence supplies, waste baskets, bed and bath linens, individual communication devices, computers Health Information Technology (HIT) ResourcesInfection Control Program Evaluation47548806444615 0 Facility Based Risk AssessmentSWOT AnalysisStrengths:Weakness:Opportunities:Threats:(1)Asset or Operation at Risk(2)Hazard(3)Scenario (Location, Timing, Magnitude)(4)Opportunity for Preventionor Mitigation(5)Probability(L, M, H)Impacts with Existing Mitigation (L, M, H)(11)Overall Hazard Rating(6)People(7)Property(8)Operations(9)Environment(10)EntityCommunity Based Risk AssessmentSWOT AnalysisStrengths:Weakness:Opportunities:Threats:(1)Asset or Operation at Risk(2)Hazard(3)Scenario (Location, Timing, Magnitude)(4)Opportunity for Preventionor Mitigation(5)Probability(L, M, H)Impacts with Existing Mitigation (L, M, H)(11)Overall Hazard Rating(6)People(7)Property(8)Operations(9)Environment(10)Entity ................
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