Recalling the history of the initial requirement, is helpful in appreciating why it is worthwhile to take a second look at the August 8, 2024, changes to the regulation.  Originally, the requirement for a facility assessment was included in the 2016 revisions to the Requirements of Participation, rather than nurse staff ratios, at §483.70(e). 

“The requirement was that 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 and emergencies, and must review and update that assessment, as necessary and at least annually. The assessment must address or include: the facility’s resident population; the care required by the resident population; staff competencies; the physical environment; cultural factors; the facility’s resources; contracts, health information technology resources, and an all-hazard facility and community-based risk assessment utilizing an all-hazards approach.”

Serious compliance would require a time-consuming and complex self-assessment process. LeadingAge published a RoP Facility Assessment Toolkit that included an INTERACT version 4.0 Tool “Nursing Home Capacities List.”  This was a basic checklist. No enforcement of this original regulation has been conducted, according to the Center for Medicare and Medicaid Advocacy (https://medicareadvocacy.org).

As of August 8, 2024, enhancements to the regulation were added and are itemized in Publication No QN-12SOW-XC-07162024-01. CMS contracted with a QIN-QIO to produce Publication No. QN-12SOW-XC-07162024-01, a 23-page comprehensive “Facility Assessment Tool”. 

An important regulatory enhancement is that nursing home leadership, (including a member of the governing body and the medical director), and management (including the administrators and the director of nursing) must be included in the Facility Assessment process. 

CMS has not mandated the use of the tool. Its completion does not ensure regulatory compliance, nor is there a specific, recognized, evidence-based data-driven methodology to assist in developing a staffing plan. 

Given this caveat, one might conclude that the expanded regulation of the facility assessment may be more performative than a sincere effort to advance nursing home quality. As you recall, in 2025, the US Department of Health and Human Services repealed the Biden-era minimum staffing requirements for long-term care facilities. So, other than state-specific laws for staffing ratios, the federal requirements for  “sufficient to meet the needs” nurse staffing remain as they have been since the 1987 Nursing Home Reform Act – 39 years ago.

How might advocates interested in advancing improvements in nursing home staffing use the current facility assessment requirement?  Keep in mind that the definition of sufficient is “having enough of what is required to meet a specific purpose, need, or end, without necessarily having an abundance.”  Common sense suggests that sufficiency is associated with the needs of facility residents and/or the aggregate acuity level of facility residents. 

One methodology that is evidence-based and data-driven, consistent with resident assessments, is the use of data from the Minimum Data Set; data derived from the Patient-Driven Data Model (PDPM); or other valid and reliable acuity tools. Charlene Harrington and colleagues have published a “Nursing Home Guide to Adjusting Nurse Staffing for Resident Case-Mix” published in 2025. Given the data-driven nature of producing a quality Facility Assessment, it would be helpful if AI could be used in synthesizing facility data to make this a more feasible process to implement.

Researchers might consider studying any association between receipt of Immediate Jeopardy citations at the widespread (L) and patterned (K) level of noncompliance and receipt or lack of receipt of a citation issued for the facility assessment requirement. That is, if a serious pattern of non-compliance is widespread or patterned, it suggests that something may be lacking in the facility’s assessment of its “sufficient” resources versus resident needs.

Others could share ideas on how advocates might effectively use the facility assessment requirement to advance, however modest, efforts to improve nursing home staffing levels as a fundamental means of improving quality.