Ask the Nursing Expert about ... the Facility-Wide Assessment

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Judi Kulus, MSN, MAT, RN, NHA, RAC-MT, DNS-CT, Curriculum Development Specialist for AADNS
Judi Kulus, MSN, MAT, RN, NHA, RAC-MT, DNS-CT, Curriculum Development Specialist for AADNS

My administrator has asked me to lead the effort to prepare our Facility-Wide Assessment (FWA). What does this mean for me, as the director of nursing?

The FWA is mentioned more than 90 times in the State Operations Manual's Appendix PP, “Guidance to Surveyors.” It's a big deal in the new survey process. As DON, your participation in developing the FWA is required by regulation and imperative for reducing citations. Here's what you should do:

Work with the administrator, governing body member and medical director to analyze your facility's resident population — including residents' diseases, conditions, physical and cognitive disabilities and overall acuity — to determine the need for resources, including staff, equipment, specialized training and the need for new contracts. 

Ask your MDS nurse to pull resident information from the Minimum Data Set, section I, or the Facility Characteristics Report (form CMS-672). Because these data sources can be up to three months old, be sure to include current resident data for your FWA snapshot.

Evaluate residents' acuity to select competencies and education that cover the most prominent conditions. Consider drilling down to the unit level to determine staffing levels by competencies. 

Include residents' dependencies with activities of daily living and their preferences. Do you need an additional lift? Do your resident referrals include individuals requiring culturally specific foods or activities? 

Be prepared to show surveyors your analysis with a detailed report. The process should result in a clear guide to the right equipment, staff, competency-based education program, actions in an emergency, technology and more.