Facility Assessment for Activities Directors

7/8/2021

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Facility Assessment

for Activities Directors

Idaho Healthcare Association

7.14.21

V.5.22.21 Copyright © 2021 All Rights Reserved 1

Facility Assessment for Activities Directors

Harmony Healthcare International (HHI)

“HHI C.A.R.E.S. about Care”

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About KrisKris Mastrangelo OTR/L, LNHA, MBAPresident and CEO

Owns and operates Harmony Healthcare International (HHI) a Nationally recognized, premier Healthcare Consulting firm specializing in C.A.R.E.S.There are no nonfinancial disclosures to share.

“HHI C.A.R.E.S. About Care.”

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Speaker and Planning CommitteeDisclosure

• Disclosures: The planners and presenters of this educational activity have no relationship with commercial entities or conflicts of interest to disclose. Please visit https://www.harmony-healthcare.com/hhi-team for all speaker’s financial and nonfinancial disclosures

• Planners:

– Kris Mastrangelo, OTR/L, LNHA, MBA

– Joyce Sadewicz, PT, RAC-CT

– Pamela Duchene, PhD, APRN-BC, NEA, FACHE

• Presenter:

– Kris Mastrangelo, OTR/L, LNHA, MBA


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Learning Objectives


1. 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 and emergencies

2. State the 4 elements to which the Facility Assessment Results will be applied

Facility Assessment


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Facility AssessmentPurpose and Intent

• Per CMS, the purpose and intent of the Facility Assessment is:

– Purpose: to determine what resources are necessary to care for residents competently during day-to-day operations and emergencies

– May be used to make decisions about direct care staff needs as well as capabilities to provide services to the residents in your facility

– Intent: For the facility to evaluate their resident population andidentify resources needed to provide necessary person-centered care and services required by residents

7V.5.22.21 Copyright © 2021 All Rights Reserved

Administration (§483.70)

• Address in the facility assessment:

1. The facility’s resident population (that is, number of residents, overall types of care and staff competencies required by the residents and cultural aspects)

2. Resources (for example, equipment and overall personnel)

3. A facility-based and community-based risk assessment


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Facility AssessmentImplementation Regulation

• 4 elements to which the Facility Assessment Results will be applied:

– Staffing Requirements

– Staff Competencies

– Services Provided

– Establishing QAPI Program


Administration (§483.70)

• Facility Assessment at §483.70 to be Implemented in Phase 2

– 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 and emergencies

– The facility must review and update that assessment as necessary, and at least annually


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Facility Assessment Requirement (483.70(e))

• Determine what resources are needed to care for residents for day-to-day operations and in emergencies:

– Determining staffing requirements

– Establishing a QAPI program

– Emergency preparedness planning


Nursing Services (§ 483.35)

• Sufficient Staffing

– Add a competency requirement for determining sufficient nursing staff based on a facility assessment

– Includes (but is not limited) to:

• Number of residents

• Resident acuity

• Range of diagnoses

• Content of Care Plans


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Nursing Services (§ 483.35)

• Competency Approach

– Require that staff must have the appropriate competencies

• Provide behavioral health care and services, which include

– Caring for residents with mental and psychosocial illnesses and implementing non-pharmacological interventions


Facility Assessment Element: #1. Resident Population

The facility’s resident population, including, but not limited to:• Both the number of residents ______and the facility’s resident

capacity______• The care required by the resident population considering the types of:

– Diseases– Conditions– Physical and cognitive disabilities– Acuity

• PDPM/RUG Categories• Special treatments and conditions• Assistance with activities of daily living

– Ethnicity (culture, religion, or other factors that may affect care)14V.5.22.21 Copyright © 2021 All Rights Reserved

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Facility Assessment Element#1. Resident Population

• Per CMS (Part 2: Services and Care)

– Resident support and care needs based on resident population requires-to identify and reflect on resources needed to provide these types of care

– Sample list provided – to be modified based on your population



Destination: Percent Patients

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Performance By Diagnosis


Percent Patients And CAS By Diagnosis

• Top 3 Diagnosis

V.5.22.21 Copyright © 2021 All Rights Reserved

Diagnosis % Patients CAS

PNA 8.0% 19.8 Days

CHF 5.7% 20.0 Days

UTI 5.5% 20.2 Days

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Home CAS By Categories

• Top 3 Categories


Categories % Patients CAS

Orthopedic 22.0% 16.3 Days

Respiratory 16.2% 19.2 Days

Cardiac 11.1% 19.5 Days

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Facility Assessment Element: #2. Resources

• Per CMS, the following facility resources are needed to provide competent care:– Staff type– Sample list provided for type of staff and other

professionals/practitioners– Staffing plan –general approach to staffing

• Determine sufficient staffing (CMS Attachment 2, 7.b)• Two examples provided

–Overall number of staff needed–General staffing plan

– Individual staff assignment


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– Staff training/education and competencies– Sample lists provided (not inclusive)– Policies and procedures for provision of care– The staff competencies that are necessary to provide the level and types of

care needed for the resident population– The physical environment, equipment, services, and other physical plant

considerations that are necessary to care for this population– 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



• The facility’s resources, including but not limited to

– All buildings and/or other physical structures and vehicles

– Equipment (medical and non-medical)

– Services provided, such as physical therapy, pharmacy, and specific rehabilitation therapies

– All personnel, including managers, 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


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– Contracts, memorandums of understanding, or other agreements with third parties to provide services or equipment to the facility during both normal operations and emergencies

– Health information technology resources, such as systems for electronically managing patient records and electronically sharing information with other organizations


Facility Assessment Element #3. Risk Assessment

• Conduct a facility-based and community-based risk assessment, utilizing an all-hazards approach

• CMS definition of an all-hazards approach

– an integrated approach to emergency preparedness planning that focuses on capacities and capabilities that are critical to preparedness for a full spectrum of emergencies or disasters, including internal emergencies and a man-made emergency (or both) or natural disaster.


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• This approach is specific to the location of the provider or supplier and considers the hazards most likely to occur in their areas

• These may include, but are not limited to

– Care-related emergencies

– Equipment and power failures

– Interruptions in communications, including cyber-attacks

– Loss of a portion or all of a facility

– Interruptions in the normal supply of essentials such as water and food



• All-hazards planning does not specifically address every possible threat but ensures those hospitals and all other providers and suppliers will have the capacity to address a broad range of related emergencies


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Natural Hazards

• Natural Hazards

– Meteorological -Flooding, Dam/Levee Failure, Severe Thunderstorm (Wind, Rain, Lightning, Hail), Tornado, Windstorm, Hurricanes and Tropical Storms, Winter Storm (Snow/Ice)

– Geological -Earthquake, Tsunami, Landslide, Subsidence/Sinkhole, Volcano

– Biological - Pandemic Disease, Foodborne Illnesses


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Human-Caused Hazards

• Human-Caused Hazards

– Accidents -Workplace Accidents, Entrapment/Rescue (Machinery, Water, Confined Space, High Angle), Transportation Accidents (Motor Vehicle, Rail, Water, Air, Pipeline), Structural Failure/Collapse, Mechanical Breakdown

– Intentional Acts - Labor Strike, Demonstrations, Civil Disturbance (Riot), Bomb Threat, Lost/Separated Person, Child Abduction, Kidnapping/Extortion, Hostage Incident, Workplace Violence, Robbery , Sniper Incident, Terrorism (Chemical, Biological, Radiological, Nuclear, Explosives), Arson, Cyber/Information Technology (Malware Attack, Hacking, Fraud, Denial of Service, etc.)


Technological Hazards

• Technological Hazards

– Information Technology - Loss of Connectivity, Hardware Failure, Lost/Corrupted Data, Application Failure

– Utility Outage - Communications, Electrical Power, Water, Gas, Steam, Heating/Ventilation/Air Conditioning, Pollution Control System, Sewage System

– Fire/Explosion - Fire (Structure, Wildland), Explosion (Chemical, Gas, or Process failure)

– Hazardous Materials -Hazardous Material spill/release, Radiological Accident, Hazmat Incident off-site, Transportation Accidents, Nuclear Power Plant Incident, Natural Gas Leak Supply

– Chain Interruption - Supplier Failure, Transportation Interruption30V.5.22.21 Copyright © 2021 All Rights Reserved

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Facility AssessmentResident Profile

1.3 Types of Diseases and Conditions


Category Common DiagnosesPsychiatric/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 intervention

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




Category Common Diagnoses

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

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Category Common Diagnoses

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


1.4 Overall Acuity


Major RUG-IV Categories Average Annual Number of Residents

Long Stay Short Stay

Rehabilitation Plus Extensive Services

0% 0% 0%

Rehabilitation 62% 21% 90%

Extensive Services 0% 1% 0%

Special Care High 6% 10% 3%

Special Care Low 3% 7% 1%

Clinically Complex 8% 16% 3%

Behavioral Symptoms and Cognitive Performance

3% 8% 0%

Reduced Physical Function 17% 37% 3%

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1.4a Special Treatments and Condition


Special Treatments Average Annual Number of Residents

Cancer Treatments Chemotherapy 0

Radiation 0

Mental Health Active or Current Substance Use Disorders 9

Behavioral Health Needs 23

Other Dialysis 0

Hospice Care 0

Injections 79

Isolation or Quarantine for Active Infectious Disease 0

IV Medications 4

Ostomy Care 2

Respite Care 0

Transfusions 0

Respiratory Treatments BIPAP / CPAP 5

Oxygen Therapy 70

Suctioning 0

Tracheostomy Care 0

Ventilator Respirator 0


1.4b Assistance with Activities of Daily Living


ADL Independent Supervision Limited Assist Extensive Assist Dependent

Bathing 5 7 13 205 22

Bed Mobility 14 47 50 139 1

Dressing 9 60 45 131 4

Eating 192 19 1 38 2

Locomotion off Unit 23 62 35 18 14

Locomotion on Unit 10 67 73 71 12

Personal Hygiene 12 74 44 117 4

Toilet Use 18 53 44 132 4

Transfer 24 67 37 100 19

Walk in Corridor 13 66 65 34 0

Walk in Room 35 67 37 77 0

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1.4c All Facility Case Mix (CMI)

All Facility CMI Based

Trend


Jun 20 Jul 20 Aug 20 Sep 20 Oct 20 Nov 201.4390 1.5386 1.4731 1.5761 1.5257 1.4725

Nov 19 Dec 19 Jan 20 Feb 20 Mar 20 Apr 20 May 201.6650 1.6220 1.5667 1.4762 1.5645 1.5759 1.6390


1.4c All Facility Case Mix (CMI) continued


1.4000

1.4500

1.5000

1.5500

1.6000

1.6500

1.7000

Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct 12.12.20

1.6650

1.6220

1.5667

1.4762

1.56451.5759

1.6390

1.4390

1.5386

1.4731

1.5761

1.5257

1.4725

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All Facility Case Mix Historical DataNovember 2019 - December 2020

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All Facility CMI

Distribution



All Facility CMI

Distribution


RUG Category Percent

Rehab 10.85%

Extensive Services 8.93%

Special Care 4.16%

Clinically Complex 12.75%

Other 63.32%

Total 100.0%%

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All Facility CMI

Distribution by RUG Level


No. of

Residents

Bi l led

% of

Revenue

Total Rate

Total

Revenue

CMI

No. Totals

Rehab

RUC 0.00% $306.51 $0.00 1.9860 0.000

RUB 0.00% $250.75 $0.00 1.4260 0.000

RUA 0.00% $224.77 $0.00 1.1650 0.000

RVC 0.00% $283.61 $0.00 1.7560 0.000

RVB 0.00% $264.29 $0.00 1.5620 0.000

RVA 0.00% $229.94 $0.00 1.2170 0.000

RHC 0.00% $297.65 $0.00 1.8970 0.000

RHB 0.00% $263.99 $0.00 1.5590 0.000

RHA 0.00% $234.23 $0.00 1.2600 0.000

RMC 4 7.27% $312.97 $1,251.87 2.0510 8.204

RMB 1 1.82% $271.56 $271.56 1.6350 1.635

RMA 0.00% $246.26 $0.00 1.4110 0.000

RLB 0.00% $290.88 $0.00 1.8290 0.000

RLA 0.00% $233.83 $0.00 1.2560 0.000

Total Rehab 5 10.85% $1,523.43 9.839

Extensive Serv ices

SE3 0.00% $356.09 $0.00 2.4840 0.000

SE2 4 8.93% $313.57 $1,254.28 2.0570 8.228

SE1 0.00% $298.94 $0.00 1.9100 0.000

Total Extensive

Serv ices

4 8.93% $1,254.28 8.228

Spec ial Care

SSC 2 4.16% $292.07 $584.14 1.8410 3.682

SSB 0.00% $278.93 $0.00 1.7090 0.000

SSA 0.00% $259.22 $0.00 1.5110 0.000

Total Spec ial Care 2 4.16% $584.14 3.682

Clinical ly Complex

CC2 0.00% $290.58 $0.00 1.8260 0.000

CC1 4 7.81% $274.35 $1,097.40 1.6630 6.652

CB2 0.00% $258.42 $0.00 1.5030 0.000

CB1 1 1.76% $247.07 $247.07 1.3890 1.389

CA2 0.00% $241.29 $0.00 1.3310 0.000

CA1 2 3.18% $223.17 $446.34 1.1490 2.298

Total Cl in ical ly

Complex

7 12.75% $1,790.81 10.339

All O ther

IB2 0.00% $228.15 $0.00 1.1990 0.000

IB1 0.00% $223.47 $0.00 1.1520 0.000

IA2 0.00% $202.86 $0.00 0.9450 0.000

IA1 1 1.40% $197.19 $197.19 0.8880 0.888

BB2 0.00% $226.26 $0.00 1.1800 0.000

BB1 0.00% $220.59 $0.00 1.1230 0.000

BA2 0.00% $198.88 $0.00 0.9050 0.000

BA1 0.00% $184.35 $0.00 0.7590 0.000

PE2 18 32.49% $253.54 $4,563.72 1.4540 26.172

PE1 0.00% $250.25 $0.00 1.4210 0.000

PD2 12 20.55% $240.50 $2,886.00 1.3230 15.876

PD1 1 1.68% $236.32 $236.32 1.2810 1.281

PC2 2 3.28% $230.14 $460.28 1.2190 2.438

PC1 0.00% $217.10 $0.00 1.0880 0.000

PB2 0.00% $191.71 $0.00 0.8330 0.000

PB1 0.00% $193.80 $0.00 0.8540 0.000

PA2 0.00% $186.04 $0.00 0.7760 0.000

PA1 3 3.92% $183.35 $550.05 0.7490 2.247

BC1 0.00% $183.35 $0.00 0.7490 0.000

Total Al l O ther 37 63.32% $8,893.56 48.902

55 80.990

$14,046.22

$255.39

1.4725Total Case Mix Index

Classif ications

Total No. of Residents

Total Case Mix Revenue

Average MaineCare Dai ly Rate


1.4d Case Mix Medicaid Only (CMI)

Medicaid CMI

Trend


Nov 19 Dec 19 Jan 20 Feb 20 Mar 20 Apr 20 May 20 Jun 20 Jul 20 Aug 20 Sep 20 Oct 201.5304 1.5060 1.4587 1.3556 1.4049 1.4851 1.4855 1.3796 1.4741 1.3741 1.4381 1.4257

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1.4d Case Mix Medicaid Only (CMI) (continued)


1.3500

1.3700

1.3900

1.4100

1.4300

1.4500

1.4700

1.4900

1.5100

1.5300

1.5500

Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct

1.5304

1.5060

1.4587

1.3556

1.4049

1.4851 1.4855

1.3796

1.4741

1.3741

1.4381

1.4257

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Case Mix Historical DataNovember 2019 - October 2020


1.4e Case Mix Medicare Only (CMI)

Medicare Part A CMI

Trend


Nov 19 Dec 19 Jan 20 Feb 20 Mar 20 Apr 20 May 20 Jun 20 Jul 20 Aug 20 Sep 20 Oct 202.1114 2.0570 2.0530 1.9100 2.0540 2.0037 2.0570 1.8730 2.5070 1.9975 2.1400 2.2705

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1.4e Case Mix Medicare Only (CMI) (continued)


1.8500

1.9500

2.0500

2.1500

2.2500

2.3500

2.4500

2.5500

Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct

2.1114

2.0570 2.0530

1.9100

2.0540

2.0037

2.0570

1.8730

2.5070

1.9975

2.1400

2.2705

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Medicare Part A CMI TrendNovember 2019 - October 2020


1.5 Other Pertinent Facts Present Within Populations• Overall, the average daily occupancy of this facility has increased by 7%

since 2015 but is down 7% over 2018. • Skilled Care is currently 8.4 occupied beds (14%), a decrease of 4%

below last year due to fewer orthopedic patients meeting the Medicare 3 midnights rule.

• Private Pay is currently 10.2 occupied beds (17%), an increase of 2% over last year.

• Medicaid is currently 42.7 occupied beds (70%), an increase of 3% over last year.

• The census does not appear to have significant seasonal variation but is greatly affected by payment policies.


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Facility AssessmentServices Offered

2.1 Support and Care Services


General Care Specific Care or PracticesActivities of Daily Living • Bathing, showers, oral/denture care, dressing, eating, support with needs related to

hearing/vision/sensory impairment; supporting resident independence in doing as much of these activities by himself/herself.

Mobility and Fall/Fall with Injury Prevention

• Transfers, ambulation, restorative nursing, contracture prevention/care; supporting resident independence in doing as much of these activities by himself/herself.

Bowel/Bladder • Bowel/bladder toileting programs, incontinence prevention and care, intermittent or indwelling or other urinary catheter, ostomy, responding to requests for assistance to the bathroom/toilet promptly in order to maintain continence and promote resident dignity.

Skin Integrity • Pressure injury prevention and care, skin care, wound care (surgical, other skin wounds).


2.1 Support and Care Services (continued)


General Care Specific Care or PracticesMental Health and Behavior • Manage the medical conditions and medication-related issues causing psychiatric

symptoms and behavior, identify and implement interventions to help support individuals with issues such as dealing with anxiety, care of someone with cognitive impairment, care of individuals with depression, trauma/PTSD, other psychiatric diagnoses, intellectual or developmental disabilities.

Medications • Awareness of any limitations of administering medications.• Administration of medications that residents need.• By route: oral, nasal, buccal, sublingual, topical, subcutaneous, rectal, intravenous

(peripheral or central lines), intramuscular, inhaled (nebulizer), vaginal, ophthalmic, etc.

• Assessment/management of polypharmacy.

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General Care Specific Care or PracticesPain Management • Assessment of pain, pharmacologic and non-pharmacological pain management.

Infection Prevention and Control • Identification and containment of infections, prevention of infections.

Management of Medical Conditions • Assessment, early identification of problems/ deterioration, management of medical and psychiatric symptoms and conditions such as heart failure, diabetes, chronic obstructive pulmonary disease (COPD), gastroenteritis, infections such as UTI and gastroenteritis, pneumonia, hypothyroidism.

Therapy • PT, OT, Speech/Language, Respiratory, Music, Art, management of braces, splints.

Other Special Care Needs • Dialysis, hospice, ostomy care, tracheostomy care, ventilator care, bariatric care, palliative care, end of life care.




General Care Specific Care or PracticesNutrition • Individualized dietary requirements, liberal diets, specialized diets, IV nutrition, tube feeding, cultural or

ethnic dietary needs, assistive devices, fluid monitoring or restrictions, hypodermoclysis.

Provide Person-Centered/ Directed Care: Psycho/ Social/Spiritual support

• Build relationship with resident/get to know him/her; engage resident in conversation.• Find out what resident’s preferences and routines are; what makes a good day for the resident; what

upsets him/her and incorporate this information into the care planning process. • Make sure staff caring for the resident have this information.• Record and discuss treatment and care preferences.• Support emotional and mental well-being; support helpful coping mechanisms.• Support resident having familiar belongings.• Provide culturally competent care: learn about resident preferences and practices regarding culture and

religion; stay open to requests and preferences and work to support those as appropriate.

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General Care Specific Care or Practices• Provide or support access to religious preferences, use or encourage

prayer as appropriate/desired by the resident.• Provide opportunities for social activities/life enrichment (individual, small

group, community).• Support community integration if resident desires.• Prevent abuse and neglect.• Identify hazards and risks for residents.• Offer and assist resident and family caregivers (or other proxy as

appropriate) to be involved in person-centered care planning and advance care planning.

• Provide family/representative support.

Facility AssessmentFacility Resources

3.1 Tangible Resources


Physical Resource Category Resources If applicable, process to ensure adequate supply, appropriate maintenance, replacement

Physical Structures:

Buildings and/or Other Structures

The facility was built in 1942 with significant additions and remodeling haven been completed. The facility was designed and built to be a nursing facility. It is a brick building with a single hallway for resident rooms and a perpendicular wing for services.

Vehicles • One wheelchair van is available for transport to local medical appointments. This van can accommodate up to two residents.

• The facility does its own snow removal and has a 6’ wide snow-blower, Skid-steer, and pick-up truck with V plow and dump body.

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3.1 Tangible Resources (continued)


Physical Resource Category Resources If applicable, process to ensure adequate supply, appropriate maintenance, replacement

Equipment (Medical) • Bladder Scanner• All beds are electric. • Bariatric beds are available weight limit of 500 Ibs. • Portable Hoyer-lift for transfers of residents unable to

bear weight with a weight capacity of 400 Ibs. • Ceiling mounted lifts are installed in 9 rooms within

the facility therefore serving 18 residents.• 2 I.V. Pumps• Adaptive Equipment such as tub/toilet transfer seats,

positioning devices.


3.1 Tangible Resources (continued)


Physical Resource Category Resources If applicable, process to ensure adequate supply, appropriate maintenance,

replacementEquipment (Non- Medical) • A beauty parlor is located within the facility for

resident use and visiting hairdressers. • 3 Whirlpool Bathing Tubs

Services • Rehab gym with parallel bars, exercise bike, stairs, an E-Stem unit, strengthening equipment, and hot/cold modalities. Kitchenette and laundry area

Other physical plant needs • Snow Moving Equipment• Grounds Maintenance

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3.2 Staff Type

The facility administrator oversees the facility and reports to the Shareholders. The facility has a Medical Director that oversees the clinical programs. There is a full time DON and Assistant DON that oversees the nursing department and provides clinical assistance, oversight, training and education.



3.2 Staff Type Additional Staff includes

• Department Heads/Directors

• Nursing Supervisory staff

– Staff Development, Infection Preventionist, Charge Nurse

• Nursing Staff: RN, LPN, CNA, Med Tech

• Administrative assistants, business office personnel

• Human Resources personnel

• Dietary staff, Registered Dietician, Cook, kitchen aides

• Therapy Staff including Occupational, Physical and Speech Therapists56V.5.22.21 Copyright © 2021 All Rights Reserved

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3.2 Staff Type

• Physical Plant: Maintenance, Housekeeping, Grounds and Laundry personnel

• Pharmacist (Under contract)

• Hairdresser Independent

• Clergy/Religious personnel for end of life

• Social Worker

• Recreation/Activities Staff

• Volunteers

• Student Interns57V.5.22.21 Copyright © 2021 All Rights Reserved


3.2 Staff Type

• Physical Plant: Maintenance, Housekeeping, Grounds and Laundry personnel

• Pharmacist (Under contract)

• Hairdresser Independent

• Clergy/Religious personnel for end of life

• Social Worker

• Recreation/Activities Staff

• Volunteers

• Student Interns58V.5.22.21 Copyright © 2021 All Rights Reserved

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3.2b Staffing Plan

The table below describes the number of staff budgeted to meet resident needs. Nursing staffing is evaluated daily and may be adjusted to accommodate resident acuity. Staffing hours are posted for review.



3.2b Staffing Plan Staffing Nursing Hours PPD

PBJ data for April 1, 2020, to June 30, 2020 (submitted and accepted by the August 14, 2020, deadline) are being used to calculate the staffing ratings for three months starting with the October 2020 NHC website update. The data listed below include the reported, expected and adjusted staffing levels for your facility, using the PBJ data for April 1, 2020, to June 30, 2020,and the average MDS-based resident census for your facility. The expected staffing values are based on resident acuity levels using RUG-IV data. The Five-Star Rating Technical Users’ Guide contains a detailed explanation of the staffing rating and the Case Mix adjustment methodology.


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3.2b Staffing Plan (continued)

PBJ Nursing Staffing Information for April 1, 2020, to June 2020


Position ReportedHours per

Residents perDay (HRD)

ReportedHours per

Residents perDay (HRD)(Decimal)

Case-MixHRD

Case-MixAdjusted

HRD

Total number of Licensed Nurse Staff hours per resident per day

1 hour and 26 minutes

RN hours per resident per day 1 hour and 4 minutes

1.065 0.272 1.510

LPN/LVN hours per resident per day 22 minutes 0.362 0.690 0.388

Nurse Aide hours per resident per day 4 hour and 51 minutes

4.854 2.234 4.486

Total number of Nurse staff (RN, LPN/LVN, and Nurse Aide) hours per resident per day

6 hours and 17 minutes

6.282 3.196 6.267

Physical Therapist hours per resident per day*

6 minutes


3.2c Individual Staff Assignments

Direct Care staffing is adjusted based on the needs of the residents. Occasional 1 x1, or 2-person assistance for those that have a higher acuity are examples of facility required staffing assignment adjustments. This is reviewed and determined on a day-to-day basis by nursing supervisory staff.


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3.4 Policies and Procedures for Provisions of Care

The provisions of care are outlined in the facility policies and procedures. These policies are reviewed by the administrative team including the DON, Medical director and Administrator at least annually. Examples of newer policies include:

• Trauma Informed care

• Infection Control areas.



3.8 Infection Prevention/Control Program• The infection control program is reviewed regularly. The Director of

Nurses and Asst. DON are certified in Infection Control. An antibiotic stewardship program is in place. There are no new patterns or trends with respect to infectious diseases. The organization has an on-going hand hygiene program. Random compliance checks are done throughout the year.

• The Infection Preventionist maintains a line listing which is reviewed regularly to identify trends in Respiratory illnesses, Urinary Tract Infections, wound/skin, COVID-19, GI infections, etc. Clusters or outbreaks are identified. Data is reported to the Medical Director, Quality Improvement team and governmental agencies as required.


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Facility AssessmentRisk Assessment

4.1 Facility-Based

SWOT Analysis


Strengths:• The “Owner is in the Store” philosophy of leadership with a family owned and

operated facility• Physicians who are invested and dedicated to the program and the residents• Orthopedic surgeon support • Robust CNA training (200-hour course)• CNA programs • Organization can “grow their own CNAs”• Commitment to quality care as demonstrated through the consistently high

performance in the 5 Star Program• Strong clinical leadership team with trust among the team members with longevity.• Secure and up-to-date dementia care unit• Activity program for the dementia care unit 7 days/week• Skilled unit with a private entrance and proximity to a large and spacious therapy room• Skilled Rooms with private baths• Dedicated and engaged clinical staff who have a sense of pride in their work• Strong pharmacy support

Weakness:• Dependence on a few instructors for the CNA programs (absence or illness

of an instructor can limit the availability of new CNAs)• Community population is declining• Access to nurses with acute care experience• Lack of full 24/7 RN availability• Work ethic of the new millennial generation of workers• Area is very rural making access to some resources and medical specialties

limited• Finding new and relevant speakers and content for dementia training


4.1 Facility-Based (continued)

SWOT Analysis (Continued)


Strengths:• In-house BLS training for licensed staff• AEDs at each nursing station• Close proximity to the community ambulance service

(<2-minute response time)• Close proximity and relationships with Cary Hospital• Panic alarms connected to the Caribou Police

Department located throughout the facility• Swift 911 for family & off duty staff notification• Strong in-house dementia training for all staff members

(8 hours on hire; 1 hour every quarter)• Large and well-equipped classroom available for use by

the facility and used by community agencies• 24 video cameras located inside/outside• Facility lock down capability

Weakness:

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4.1 Facility-Based (continued)

SWOT Analysis (Continued)


Opportunities:• Change to the badge access system to

control access to the facility after business hours

• Wound vac units (new technology/low cost and easy skill set)

• Pleur X-Drainage• PICC line removal

Threats:• Changing regulations and

reimbursement• Insecure Funding from Gov’t• Staff availability • Salary competition• Building security ~ the community

members know the entrance code used to secure the entry doors after business hours


4.2 Community-Based

SWOT Analysis


Strengths:●

Weakness:● Rural location

Opportunities:●

Threats:● Weather

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4.3 InstructionsColumn 1: Compile a list of assets (people, facilities, machinery, equipment, raw materials, finished goods, information technology, etc.) in the left column.Column 2: For each asset, list hazards (review the “Risk Assessment” page from Ready Business) that could cause an impact. Since multiple hazards could impact each asset, you will probably need more than one row for each asset. You can group assets together as necessary to reduce the total number of rows but use a separate row to assess those assets that are highly valued or critical.Column 3: For each hazard consider both high probability/low impact scenarios and low probability/high impact scenarios.



4.3 Instructions Column 4: As you assess potential impacts, identify any vulnerabilities or weaknesses in the asset that would make it susceptible to loss. These vulnerabilities are opportunities for hazard prevention or risk mitigation. Record opportunities for prevention and mitigation in column 4.Column 5: Estimate the probability that the scenarios will occur on a scale of “L” for low, “M” for medium and “H” for high.Columns 6-10: Analyze the potential impact of the hazard scenario in columns 6 - 10. Rate impacts “L” for low, “M” for medium and “H” for high.Column 8: Information from the business impact analysis should be used to rate the impact on “Operations.”


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4.3 Instructions

Column 10: The “entity” column is used to estimate potential financial, regulatory, contractual, and brand/image/reputation impacts.

Column 11: The “Overall Hazard Rating” is a two-letter combination of the rating for “probability of occurrence” (column 5) and the highest rating in columns 6 – 10 (impacts on people, property, operations, environment, and entity).

Carefully review scenarios with potential impacts rated as “moderate” or “high.” Consider whether action can be taken to prevent the scenario or to

reduce the potential impacts.


Facility AssessmentSynthesis/Use of Assessment Findings

Synthesis of and Use of the Assessment Findings1. Review the findings of the assessment, to make decisions about needed

resources, including direct care staff needs, as well as their capabilities to provide services to the residents in the facility.

2. Consider the questions below:a. How has the resident population- diseases, conditions, acuity, etc.

changed since the last assessment? b. Are any changes needed in staffing?

i. Based on resident number, acuity, and diagnoses of resident population and our current level of staffing, do we have sufficient nursing staff (nurses and CNAs) with the appropriate competencies and skills?


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Synthesis of and Use of the Assessment Findingsii. How do we determine if we have sufficient staffing? Consider the

following:– Gather input from residents, family members, and/or resident

representatives, CNAs, licensed nurses providing direct care, and the local long-term care ombudsman about how well the current staffing plan has been working and any concerns, and make sure to consider this information when developing the staffing plan.

– Calculate the type of staff and the amount of staff time needed to meet residents’ daily needs, preferences, and routines in order to help each resident attain or maintain the highest practicable physical, mental, and psychosocial well-being.



Synthesis of and Use of the Assessment Findings

– Review expectations for minimum staffing requirements at the federal and state level. Federal law requires nursing homes to have sufficient staff to meet the needs of residents, to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week. §483.35(b)(1) and must designate a licensed nurse to serve as a charge nurse on each tour of duty (§483.35(a)(2). However, there is no current federal requirement for specific nursing home staffing levels.


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– Review comparative data (at the nursing home, state and national level) available on the staff measure on Nursing Home Compare. Ask how do we compare, and if we have different HRPD from other homes, the state, and nation, why? What might that mean and how might it inform our staffing plan? Note that the Nursing Home Compare staffing rating considers differences in the levels of residents’ care needs in each nursing home. For example, a nursing home with residents that have more health problems would be expected to have more nursing staff than a nursing home where the residents need less health care.



Synthesis of and Use of the Assessment Findingsiii. Based on resident number, acuity, and diagnoses of resident

population, do we have sufficient staff with the appropriate skills and competencies to carry out functions of food and nutrition services; for example, dietitian?

c. Are there any training, education and/ or competency needs based on resident and/or staff data or trends identified in the Facility Assessment?

i. Does our current behavioral health training sufficiently address our resident population, as identified by the Facility Assessment?

ii. Does our current CNA training program sufficiently address our resident population as identified by the Facility Assessment?


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Synthesis of and Use of the Assessment Findingsiii. Do we need to update job descriptions to coincide with new

competencies identified?iv. Are new requirements incorporated into our annual performance

evaluation process?d. What opportunities do we have to further collaborate closely with

our medical practitioners to enhance our approaches to resident/patient care?

e. Are there any infection control issues (e.g., increase in or new infectious diseases, surveillance needs) that require a change in our infection prevention resources and methods?



Synthesis of and Use of the Assessment Findingsf. What opportunities exist for quality initiatives (QAA/QAPI) as a result

of what we learned from the Facility Assessment to improve our facility’s services and resources?

i. Do the trends identified in the Facility Assessment suggest areas where we need to improve the quality of our care, quality of life for our residents and/or quality of our services?

ii. What findings in the assessment indicate a need for us to collect and use additional data to inform decision making for future care and improvement?


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g. Are there any other resources we need to care for residents competently during day-to-day operations and emergencies, based on the Facility Assessment?

h. Has our facility’s anticipated income been evaluated with relation to anticipated needs in the coming year, as identified in the assessment? Are adjustments needed in our operating budget to address any gaps in resource needs?



Areas Facility Assessment Informed Action To Be Taken/Already Taken This YearPayment • Understanding and working new

payment system (PDPM)

Staffing • Involvement in IDTM and UR meetings Infection Prevention/Control • Antibiotic stewardship program in place

• Educational program for all staff on infection prevention

• Infection Control Preventionist

Training, Competencies • Implement new competency documentation form to complement current competency and education program for staff.

QAPI Initiatives/Performance Improvement Projects

• Focus on pain assessment / management and falls

• Identify strategies and alternatives to the use of antianxiety and hypnotic medications

• Infection Control

Behavioral Health • Training for all staff on providing care for residents with mental health issues (psychosocial disorders) with hx of trauma or PTSD

• Understanding Isolation and Loneliness

Vaccines • Hep A provided for dietary staff• New policy / procedure during shortage

of tuberculin vaccine. Update facilities policy/ procedure with CDC guidelines.


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Facility AssessmentAppendix


Hazard and Vulnerability AssessmentNaturally Occurring EventsTechnologic EventsHuman Related EventsEvents Involving Hazardous MaterialsEducational Requirements for Nursing StaffSNF New Hire Orientation – Direct CareSNF New Hire Orientation – All StaffSNF Annual Mandatory – Direct CareInfection Control Policies & Procedures



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HHI Facility Assessment Template

• To Download (also a handout)

https://www.harmony-healthcare.com/harmonyhelp/facility-assessment-template-word


Thank You!


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Connect With [email protected]

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Our Process

• Prescribed medical record review process that encompasses HHI’s core business

• HHI Specialists provide expertise through teaching and training and an extensive chart audit process in order to ensure:

– MDS Accuracy

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With HarmonyHelp, Harmony Healthcare International (HHI) provides an invaluable resource for the entire interdisciplinary team. Imagine having questions answered by a HHI Specialist within minutes of the inquiry. Fill out the form on the right to learn more about HarmonyHelp and our various Service Plans.


HarmonyHelp The Knowledge Center is loaded with information that will assist with your daily responsibilities at your facility. This self-help site

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Documents

Facility Assessment for Activities Directors