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.

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