§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.
§483.71(a) The facility assessment must address or include the following:
§483.71(a)(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 considering 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.
§483.71(a)(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.
§483.71(a)(3) A facility-based and community-based risk assessment, utilizing an all-hazards approach as required in §483.73(a)(1).
§ 483.71(b) In conducting the facility assessment, the facility must ensure:
§ 483.71(b)(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.
§483.71(c) The facility must use this facility assessment to:
§483.71(c)(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).
§483.71(c)(2) Consider specific staffing needs for each resident unit in the facility and adjust as necessary based on changes to its resident population.
§483.71(c)(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.
§483.71(c)(4) Develop and maintain a plan to maximize recruitment and retention of direct care staff.
§483.71(c)(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.
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Observations:
Based on review of facility documentation and staff interview it was determined that the facility failed to include active involvement from direct care staff and input from residents in the facility assessment process.
Findings Include:
Review of facility documentation "Facility Assessment" reviewed February 11, 2026, revealed individuals who were involved in completing the review included: Nursing Home Administrator (Employee E1), Director of Nursing (Employee E2), Admissions Director (Employee E3), Business Office Manager (Employee E4), House Keeping Director (Employee E5), Rehabilitation Director (Employee E6), Human Resources (Employee E7), Dietary (Employee E8), and the Medical Director (Employee E9).
Review of the facility assessment and the sign-in sheet for individuals involved in completing the annual review of the facility assessment revealed no documented evidence that the facility included active involvement from direct care staff (including but not limited to Registered Nurses (RNs), Licensed Practical Nurses (LPNs), or Nurse Aides (NA)).
Further review of the facility assessment revealed no documented evidence that the facility considered input from residents, their representative(s), family members, and representatives of direct care staff when formulating their assessment.
Interview on May 29, 2026, at 10:50 a.m. with Nursing Home Administrator, Employee E1, confirmed no documentation was available to support evidence of active involvement from direct care staff or input from residents.
28 Pa. Code 201.14 (a) Responsibility of licensee.
| | Plan of Correction - To be completed: 07/03/2026
F838 – Facility Assessment
A. Corrective Action for Residents Found Affected
No residents were identified as being impacted by not including a direct care provider in past facility assessments and there is no mechanism to retroactively include.
B. How Other Residents Were Identified as Potentially Affected
Potentially all residents could be affected if the Facility Assessment process does not accurately incorporate and document participation from direct care staff and resident and/or resident representative input when completing the assessment of facility resources and resident population needs.
C. Measures Put into Place to Ensure Deficient Practice Does Not Recur
The Administrator, Director of Nursing, Assistant Director of Nursing, Unit Managers, and Department Heads were educated regarding the requirements of F838 Facility Assessment.
Education included:
- Requirement for participation by direct care staff and who qualifies as a direct care staff (not DON or ADON)
- Requirement for obtaining resident and/or resident representative input.
- Documentation requirements for meeting attendance and participation.
- Annual review requirements and updates as facility needs change.
The facility implemented a Facility Assessment Participant Verification Form to ensure all required participants are identified and documented prior to completion of future Facility Assessments.
D. Monitoring
The Administrator or designee will review the Facility Assessment Participant Verification Form quarterly to ensure required participants have been identified and documentation remains current.
The Administrator will also review any Facility Assessment updates completed during the year to ensure participation and documentation requirements were met.
Audit results will be reported to the Quality Assurance and Performance Improvement (QAPI) Committee quarterly for three consecutive quarters. Additional monitoring will be implemented as indicated.
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