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. 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.
The facility must address or include:
(1) the facility's resident population, including:
(A) both the number of residents and the facility's
resident capacity;
(B) the care required by the resident population considering
the types of diseases, conditions, physical and cognitive disabilities,
overall acuity, and other pertinent facts that are present within
that population;
(C) the staff competencies that are necessary to provide
the level and types of care needed for the resident population;
(D) the physical environment, equipment, services,
and other physical plant considerations that are necessary to care
for this population; and
(E) any ethnic, cultural, or religious factors that
may potentially affect the care provided by the facility, including
activities and food and nutrition services;
(2) the facility's resources, including:
(A) all buildings and other physical structures and
vehicles;
(B) equipment (medical and non-medical);
(C) services provided, such as physical therapy, pharmacy,
and specific rehabilitation therapies;
(D) all personnel, including managers, employees, contractors,
and volunteers, as well as their education, training and any competencies
related to resident care;
(E) contracts, memorandums of understanding, or other
agreements with their parties to provide services or equipment to
the facility during both normal operations and emergencies; and
(F) health information technology resources, such as
systems for electronically managing patient records and electronically
sharing information with other organizations; and
(3) a facility-based and community-based risk assessment,
utilizing an all-hazards approach.
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| Source Note: The provisions of this §554.1931 adopted to be effective March 24, 2020, 45 TexReg 2025; transferred effective January 15, 2021, as published in the Texas Register December 11, 2020, 45 TexReg 8871 |
