Incomplete Facility-Wide Assessment of Staffing, Competencies, and Resources
Penalty
Summary
The deficiency involves the facility’s failure to conduct a thorough, facility-wide assessment to determine the resources necessary to care for residents competently during routine operations and emergencies. With a census of 29 residents and a sample of 12 residents, surveyors reviewed an undated Long-Term Care Self-Assessment provided by administrative staff. The assessment did not identify specific staffing levels needed for each unit, nor did it specify the number of RNs, LPNs/LVNs, CMAs, and CNAs required based on unit, resident acuity, and census. It also lacked staffing levels for each shift, including evenings and weekends. The assessment did not fully document resident condition reports or any extenuating circumstances that would make those condition reports unusual. The assessment further failed to document staff competencies and skill sets necessary to provide the level and types of care needed for the facility’s resident population. It did not fully document contractual agreements with outside providers for services such as laboratory, radiology, therapy, hospital, or transportation, and it omitted contracts for lawn care and snow removal. Administrative staff reported that the assessment was reviewed annually, most recently on a specific date, and acknowledged that the facility did not have a vision or mission statement. The administrative staff member stated he was unaware that certain sections of the assessment (orange boxes) were required to be completed, confirmed that the staffing breakdown per unit was missing, and verified that unchecked competencies (including Safety and Missing Resident for all staff) indicated those staff were not responsible for those competencies. The facility’s own Facility Assessment Policy stated that the assessment was to be the foundation for determining staffing levels, competencies, and resources, and was to address resident care needs, staff competencies, and third-party contracts during normal operations and emergencies, but the completed assessment did not meet these requirements.
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