Facility Assessment Tool


SNF Quality Assurance Performance Improvement

Facility Assessment Tool

Requirement

Nursing facilities will conduct, document, and annually review a facility-wide assessment, which includes both their resident population and the resources the facility needs to care for their residents (§483.70(e)).

The requirement for the facility assessment may be found in Attachment 1.

Purpose

The intent of the facility assessment is for the facility to evaluate its resident population and identify the resources needed to provide the necessary person-centered care and services the residents require.

Overview of the Assessment Tool

The tool is organized in three parts:

Resident profile including numbers, diseases/conditions, physical and cognitive disabilities, acuity, and ethnic/cultural/religious factors that impact care.
Services and care offered based on resident needs (includes types of care your resident population requires; the focus is not to include individual level care plans in the facility assessment).
Facility resources needed to provide competent care for residents, including staff members, staffing plan, staff members training/education and competencies, education and training, physical environment and building needs, and other resources, including agreements with third parties, health information technology resources and systems, a facility-based and community-based risk assessment, and other information that you may choose.

FACILITY ASSESSMENT TOOL

Facility Name	Stanford Post Acute Rehab
Persons (names / titles) involved in completing assessment	Administrator: John Edwards Director of Nursing: Robert Jones Governing Body Rep: Jim Carlson Medical Director: Mary Smith Other: Judy Jenkins Input from resident council, residents, families and representatives: Please delete if not going to obtain, please unbold and don't italicize if using.
Date(s) of assessment or update	11/28/2017 The facility will update this assessment whenever there is a change that would require a modification to any part of the assessment.
Date(s) assessment reviewed with Quality Assessment & Assurance /Quality Assurance & Performance Improvement (QAA/QAPI) committee	12/28/2017

Part 1: Our Resident Profile

Numbers

Indicate the number of residents you are licensed to provide care for: 98 with 2 physical nursing stations and 4 medication carts and 2 treatment carts.
Indicate your average daily census: 80-85. The facility does not have a distinct part and residents are admitted to beds in which is appropriate for their diagnoses and individual needs. The average admission and discharge rate from November 28, 2016 through November 28, 2017 was 322 admissions or an average of 27 admissions per month and 249 discharges or an average of 22 discharges per month. Staffing needs are flexed depending on the number of admissions and discharges and the acuity of the patients.

Consider if it would be helpful to describe the number of persons admitted and discharged, as these processes can impact staffing needs.

	Number (enter average or range) of persons admitted	Number (enter average or range) of persons discharged
Weekday	Average of 5.25 admissions per week days	Average of 3.69 discharges per week days
Weekend	Average of 1.3 admissions per weekend	Average of 1.09 discharges per weekend

Diseases/conditions, physical and cognitive disabilities

The facility accepts residents with the following diseases, conditions, physical and cognitive disabilities, or combinations of conditions that require complex medical care and management as listed in the chart below. The facility also will care for those existing residents who have declined and/or developed the conditions below after they have been medically stabilized or per the individual’s or representative’s preferred intensity of care.

Category	Common Diagnoses
Psychiatric/ mood disorders	Psychosis (Hallucinations, Delusions, etc.), Impaired Cognition, Mental Disorder, Depression, Bipolar Disorder (i.e., Mania/Depression), Schizophrenia, Post-Traumatic Stress Disorder, Anxiety Disorder, Behavior that Needs Interventions
Heart/circulatory system	Congestive Heart Failure, Coronary Artery Disease, Angina, Dysrhythmias, Hypertension, Orthostatic Hypotension, Peripheral Vascular Disease, Risk for Bleeding or Blood Clots, Deep Venous Thrombosis (DVT), Pulmonary Thrombo-Embolism (PTE)
Neurological system	Parkinson’s Disease, Hemiparesis, Hemiplegia, Paraplegia, Quadriplegia, Multiple Sclerosis, Alzheimer’s Disease, Non-Alzheimer’s Dementia, Seizure Disorders, CVA, TIA, Stroke, Traumatic Brain Injuries, Neuropathy, Down’s Syndrome, Autism, Huntington’s Disease, Tourette’s Syndrome, Aphasia, Cerebral Palsy
Vision	Visual Loss, Cataracts, Glaucoma, Macular Degeneration
Hearing	Hearing Loss
Musculoskeletal system	Fractures, Osteoarthritis, Other Forms of Arthritis
Neoplasm	Prostate Cancer, Breast Cancer, Lung Cancer, Colon Cancer
Metabolic disorders	Diabetes, Thyroid Disorders, Hyponatremia, Hyperkalemia, Hyperlipidemia, Obesity, Morbid Obesity
Respiratory system	Chronic Obstructive Pulmonary Disease (COPD), Pneumonia, Asthma, Chronic Lung Disease, Respiratory Failure
Genitourinary system	Renal Insufficiency, Nephropathy, Neurogenic Bowel or Bladder, Renal Failure, End Stage Renal Disease, Benign Prostatic Hyperplasia, Obstructive Uropathy, Urinary Incontinence
Diseases of blood	Anemia
Digestive system	Gastroenteritis, Cirrhosis, Peptic Ulcers, Gastroesophageal Reflux, Ulcerative Colitis, Crohn’s Disease, Inflammatory Bowel Disease, Bowel Incontinence
Integumentary system	Skin Ulcers, Injuries
Infectious diseases	Skin and Soft Tissue Infections, Respiratory Infections, Tuberculosis, Urinary Tract Infections, Infections with Multi-Drug Resistant Organisms, Septicemia, Viral Hepatitis, Clostridium difficile, Influenza, Scabies, Legionellosis

Decisions regarding caring for residents with conditions not listed above

The process for admitting new residents is to have a clinician review the referral to determine whether the facility has the skill set to take care of the needs of the resident. If the facility has not admitted a resident with the current diagnosis or treatment, the facility would hold off on the admission while education and training would be provided to the line staff, equipment and supplies would be obtained and the policy and procedure would be revised and updated prior to the admission. For residents who are current residents and have developed a diagnosis new to the facility, the Director of Nursing would contact the Medical Director and/or attending physician to determine whether the facility could meet the needs of the resident. If it determined that the resident will require a higher level of care, the resident would be transferred to the hospital. If the resident is deemed stable to stay at the facility, the Director of Nursing and/or Director of Staff Development would arrange education to the staff through the assistance of the Medical Director and/or attending physician so the resident receives the necessary care and services. The facility also maintains a relationship with the Woodland Clinic and the Nurse Practitioners have and will provide education to staff regarding various diagnoses, assessments and interventions. In addition, the QAPI Services Team which have a team of RNs, Nurse Practitioners, Pharmacists and Registered Dieticians are also available to provide ongoing education to meet the needs of the residents by providing essential education.

Acuity

The facility does not have a distinct part or specialized units. Although the front hall is mainly used for the short stay resident, a resident could be admitted to any units in the facility. The residents who have dementia and cognitive disorders are not placed by their diagnosis of dementia but are placed by what is appropriate for their necessary care and services. Over the last 6 months from 06/01/2017-11/30/2017, the facility had an observed percent of 55.8% of residents with a psychiatric diagnosis and 2.9% of residents with an intellectual disability or developmental delay. These residents are admitted to rooms which are appropriate for their necessary care and services and not placed per their diagnoses.


Quality Assurance Performance Improvement Changes to Facility Assessment

Revision	Reason	Date Approved / By

This material (template) was prepared by Telligen, the Quality Innovation Network National Coordinating Center, and revised by Health Services Advisory Group, the Medicare Quality Improvement Organization for Arizona, California, Florida, Ohio, and the U.S. Virgin Islands, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy.

QN-11SOW-C.2-09062017-02. No permissions are required by SNFQAPI, LLC registered users to edit the contents of this tool to meet the individual needs of your facility.