§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 staff interviews and a review of facility documentation, it was determined the facility failed to timely review and update its facility-wide assessment to identify the specific needs of residents, including those with dementia and behavioral health needs. The facility also failed to develop and maintain a plan to maximize recruitment and retention of direct care staff, which is necessary to ensure care for the current resident population.
At the time of the survey ending March 28, 2025, the most recent documented facility-wide assessment was dated July 15, 2024. While the assessment included general population data, it failed to reflect changes in the resident population and staffing levels, including those required to care for the 39 residents on the locked D1 Dementia/Memory Care Unit and the 21 residents on the C1 Male Behavioral Health Unit.
The assessment failed to describe the facility's specific strategies or resources needed to care for residents with dementia, Alzheimer's disease, and behavior-related diagnoses.
The assessment tool provided to the survey team on March 25, 2025, did not include the activity needs or psychosocial needs of residents residing in the specialty units (D1 and C1).
No documentation was found indicating a dedicated or tailored activities program or corresponding budget for these units. As a result, the facility failed to demonstrate it had the capacity to meet the unique needs of residents with cognitive and behavioral health diagnoses.
A review of the January 23, 2025, state survey indicated previous citations related to inadequate services for residents with dementia and behavioral health needs. Despite this, the facility's assessment was not updated to reflect needed improvements or resource allocation to address these findings.
The facility assessment did not include a documented plan to maximize the recruitment and retention of direct care staff.
Facility documentation reviewed during the survey showed ongoing reliance on agency staff to meet basic staffing needs, with no evidence of initiatives or strategies to reduce agency dependency or enhance permanent staff retention.
The assessment did not inform or guide budget decisions, staffing allocations, or operational adjustments necessary to ensure compliance with licensure and certification standards. There was no documented evidence the facility used the assessment to plan for or provide the necessary resources to safely care for its resident population.
Refer F679
28 Pa. Code 201.14(a) Responsibility of licensee
28 Pa. Code 201.18(b)(1)(e)(2) Management
| | Plan of Correction - To be completed: 04/11/2025
The facility conducts and documents 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 reviews and updates that assessment, as necessary, and at least annually. The facility also reviews and updates this assessment whenever there is, or the facility plans for, any change that would require a substantial modification to any part of this assessment. By 4/11/25, the Administrator reviewed and updated the Facility Assessment to address the following: to identify the specific activity and psychosocial needs of residents, including those with dementia and behavioral health needs; to reflect changes in the resident population and staffing levels, including those required to care for residents on the locked D1 Dementia/Memory Care Unit and the C1 Male Behavioral Health Unit; specific strategies and resources needed to care for residents with dementia, Alzheimer's disease, and behavior-related diagnoses; and the compliance and ethics program and related staff training as a component of risk or operations. Further, the Administrator included documentation indicating a dedicated or tailored activities program and corresponding budget for the D1 and C1 units; a documented plan to maximize the recruitment and retention of permanent direct care staff and strategies to reduce agency dependency. By 4/11/25, the Temporary Manager and/or designee educated the Administrator on the need for the Facility Assessment to inform or guide budget decisions, staffing allocations, and operational adjustments necessary to ensure compliance with licensure and certification standards to ensure care of its resident population. The Administrator will review the Facility Assessment on a monthly basis for three months to ensure it continues to inform or guide budget decisions, staffing allocations, and operational adjustments necessary to ensure compliance with licensure and certification standards to ensure care of its resident population. The results of audits will be presented to the QA&A Committee by the Administrator. The QA&A Committee will determine the need for further auditing beyond three months.
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