Shoulder Flexion (PROM) | Procedure
  1. Adjust the height of the bed, if necessary and possible, to ensure optimal positioning for the procedure.
  2. Position the client lying on their back with the arm at their side and the thumb facing towards the ceiling.
  3. Caregiver Hand Positions: Place one hand on the client’s elbow while using the other hand on their wrist or palm to support and guide the movement.
  4. Keep your back as straight as possible during the procedure to maintain proper body mechanics.
  5. If needed, place your knee on the bed to support your back and maintain a straight posture.
  6. Inform the client of the intended action before initiating the movement, ensuring they are aware of what will take place.
  7. Perform the motion through a pain-free range, respecting the client’s comfort and limitations.
  8. Move the client’s limb in a straight line from the starting position to the end position, following a smooth and controlled motion.
  9. Conduct the movement slowly, avoiding any rapid or abrupt motions that could cause discomfort or injury.
  10. Hold the stretch at the designated time specified in the client’s care plan, providing adequate time for the muscle to stretch and relax.
  11. Document the care provided, including details of the procedure, in the appropriate documentation records or forms.

Remember to communicate with the client throughout the process, ensuring their comfort and monitoring for any signs of pain or discomfort. Adjust the procedure as needed to accommodate the client’s individual needs and abilities.

Sample Video

Shoulder Passive Range of Motion (PROM)
Position Client from Side to Back | Procedure
  1. Adjust the height of the client’s bed to maintain a straight back alignment during the positioning process.
  2. Prepare pillows and other positioning equipment before initiating the movement.
  3. Inform the client of the intended action prior to repositioning them, ensuring they are aware of what will take place.
  4. Remove the back and buttock pillows before rolling the client onto their back.
  5. Keep a pillow between the client’s knees while performing the rolling motion to provide support and alignment.
  6. Assist the client in moving their bent knees from the side to a position where the knees are pointing towards the ceiling.
  7. Reposition the client slowly, taking care to ensure their comfort and safety throughout the process.
  8. Request assistance from another caregiver if the client proves difficult to position or if their limbs are too heavy to be moved safely alone.
  9. Maintain proper body mechanics during the procedure, such as keeping the back straight, minimizing bending, and placing a knee on the bed if needed to maintain proper alignment.
  10. Remove the pillow between the client’s knees once they are in the supine (on their back) position.
  11. Assist the client in placing their legs on the bed, taking care to provide support as needed.
  12. Place a pillow under the client’s calves to keep their ankles off the bed, ensuring proper alignment.
  13. Ensure that the client’s ankles extend over the edge of the pillow, allowing for optimal positioning.
  14. Make an effort to position the client as flat as possible, ensuring their comfort and alignment once the repositioning is completed.
  15. If the client complains of back pain, consider placing a pillow under their knees to provide additional support.
  16. Document the care provided, including details of the positioning procedure, in the appropriate documentation records or forms.

Remember to communicate with the client throughout the process, addressing any concerns or discomfort they may experience. Regularly assess the client’s well-being and adjust the position as necessary to maintain their comfort and safety

Sample Video

Positioning Lateral & Supine
Positioning Client from Back to Side | Procedure
  1. Adjust the height of the client’s bed to maintain a straight back alignment during the positioning process.
  2. Prepare pillows and other positioning equipment before initiating the movement.
  3. Inform the client of the intended action prior to repositioning them, ensuring they are aware of what will take place.
  4. Move the client slowly and with care during the repositioning process to minimize discomfort or risk of injury.
  5. Seek assistance from another caregiver if the client proves difficult to position or if their limbs are too heavy to be safely moved alone.
  6. Maintain proper body mechanics throughout the procedure, keeping the back straight, minimizing bending, and placing a knee on the bed if necessary to maintain proper alignment.
  7. Assist the client in bending their knees before rolling them onto their side.
  8. Place a pillow between the client’s knees before completing the rolling motion to provide support and alignment.
  9. Ensure that the client’s ankles and knees do not touch once the positioning is completed, allowing for proper alignment and reducing the risk of pressure points.
  10. Position a pillow behind the client’s buttocks and back, placing it under the draw sheet if present, to provide additional support and comfort.
  11. Document the care provided, including details of the positioning procedure, in the appropriate documentation records or forms.

Remember to prioritize the client’s comfort and safety throughout the process, communicating with them and providing reassurance as needed. Regularly assess the client’s well-being during and after the positioning to address any discomfort or potential issues promptly.

Sample Video

Positioning a Client from the Supine to the Lateral Side-Lying Position
Transfer from Sitting to Standing | Procedure
  1. The caregiver should examine the height of the chair to ensure it is suitable for the transfer.
  2. Confirm that the client is wearing appropriate shoes for stability during the transfer.
  3. Ensure that the wheelchair brakes are locked securely to prevent any movement.
  4. If the client uses a walker for walking, have it available for use during the transfer.
  5. Unless approved by a physical therapist (PT), instruct the client not to pull up on the walker to stand.
  6. Position the client correctly by scooting them forward so that their buttocks are at the edge of the chair.
  7. Instruct the client to place their feet slightly back with their heels slightly off the ground.
  8. Encourage the client to lean forward, with their nose positioned past their knees.
  9. Instruct the client to prepare for the transfer by getting into a “launch” position, ready to stand.
  10. Allow the client to push up from the armrests of the chair, if they are capable of doing so, before providing assistance in lifting.
  11. Give the client time to initiate each stage of the transfer independently before offering assistance.
  12. Speak to the client using short, slow phrases to ensure clear communication and understanding.
  13. Do not proceed to the next stage of the transfer until the client has completed and maintained the previous stage successfully.
  14. Utilize the correct method of using a transfer belt to assist with the transfer, ensuring it is applied properly and securely.

Remember to provide continuous support and reassurance to the client throughout the transfer process, closely monitoring their safety and comfort. Adjust the level of assistance as necessary to accommodate the client’s individual needs and capabilities.

Sample Video

How to do a Assisted Stand Pivot Transfer
Assisting Client with Walker while Walking | Procedure
  1. Begin by communicating with the client, explaining the process of walking with the walker to ensure they understand what will be done.
  2. Properly use a transfer belt by positioning yourself at the bottom of the client and bringing the belt up, ensuring your palm is facing away from the client.
  3. Ensure that the client is wearing appropriate footwear, such as shoes, for walking safely.
  4. Keep one hand on the transfer belt at all times to maintain a secure hold and provide support to the client.
  5. Encourage the client to stand for a few seconds before initiating the walking activity to help them adjust and prepare for movement.
  6. If appropriate, place your hand on the side of the walker to assist the client in moving forward.
  7. Provide clear and concise directions to the client, using short phrases, speaking clearly and slowly to ensure they understand the instructions.
  8. Use the term “lift knees” instead of “lift feet” when guiding the client’s movements.
  9. Encourage the client to take short breaks and rest while standing, rather than sitting down, before continuing with the walking activity.
  10. Position yourself appropriately while walking with the client – stay at the client’s side if minimal assistance is required and walk behind the client if more assistance is needed.
  11. Encourage the client to focus on looking forward rather than constantly looking at their feet.
  12. Set a distance goal for the client to help them maintain motivation and track progress during the walking activity.
  13. Adjust the assistive device, in this case, the walker, to ensure it is set at the appropriate height and properly aligned with the client’s needs.
  14. Avoid encouraging the client to engage in conversation during the walking activity to minimize distractions and maintain their focus on walking safely.
  15. Safely remove the transfer belt when the walking activity is completed, ensuring the client’s comfort and safety.

Remember to provide continuous support and reassurance to the client throughout the walking activity, monitoring their response and adjusting the level of assistance as necessary.

Sample Video

Ambulation with Walker
Blood Glucose Testing | Procedure
  1. Begin by communicating with the client, explaining the blood glucose testing procedure to ensure they understand what will be done.
  2. Gather all the necessary supplies for the blood glucose test:
    • Gloves
    • Penlet/Lancet
    • Glucometer and test strips
    • Moist cotton ball, tissue, or cloth (if required)
    • Dry cotton ball or tissue
    • Sharps container for safe disposal
  3. Wash your hands thoroughly to maintain proper hygiene.
  4. Put on gloves to protect against contamination.
  5. Cleanse the client’s fingertip with an alcohol swab or have the client wash their hands with soap and water.
  6. Load the test strip into the Glucometer according to the manufacturer’s instructions.
  7. Gently massage or “milk” the client’s finger toward the tip to enhance blood flow.
  8. Use the lancing device (Penlet/Lancet) to prick the side of the client’s fingertip.
  9. Gently squeeze the finger to produce a small drop of blood, which should be directed onto the test strip.
  10. Insert the test strip into the Glucometer following the device’s instructions.
  11. Instruct the client to apply pressure to the puncture site using a dry cotton ball or tissue to stop any bleeding.
  12. Safely eject the lancet from the lancing device into the sharps container.
  13. Allow the Glucometer to process the blood sample and read the results as displayed on the device.
  14. Document the blood glucose test results accurately in the appropriate location, such as the client’s medical records or designated documentation forms.

Remember to properly dispose of used supplies and remove gloves, following standard precautions and infection control protocols.

Sample Video

Checking Blood Sugar (Glucose) Level | How to Use a Glucometer (Glucose Meter)
ACE Wrap | Procedure
  1. Begin by explaining the ACE Wrap procedure to the client, ensuring they understand what will be done.
  2. Wash your hands thoroughly to maintain proper hygiene.
  3. Hold the rolled ACE Wrap with one hand, keeping the loose end on top of the roll. With the other hand, place the loose end on top of the foot, a few inches back from the base of the toes.
  4. Starting at the base of the toes, wrap the ACE Wrap around the foot twice, making sure to overlap it by approximately half its width. Apply slightly firmer pressure in the area near the toes compared to farther up the leg.
  5. Proceed to wrap the ACE Wrap in a spiral or figure 8 pattern, gradually moving towards the ankle.
  6. Ensure that the heel remains uncovered and not wrapped with the ACE Wrap.
  7. Cross the ACE Wrap over the foot, moving upward, and pass it behind the ankle.
  8. Guide the ACE Wrap down and cross it over the top of the foot, then underneath the foot, and back up around the ankle. Repeat this step 3-4 times to provide adequate support.
  9. Wrap the ACE Wrap around the ankle or under the foot to complete the figure 8 pattern. Repeat this step one more time for added stability.
  10. Finish the ACE Wrap at the front of the leg or on top of the foot, and secure the end using tape or metal clips, ensuring it remains in place.
  11. Wash your hands again to maintain cleanliness, and make sure to document the procedure accurately, including any relevant observations or client feedback

Sample Video

How to apply Elastic Compression for Swelling of the Leg or Ankle
Entrance Conference

STATE EVALUATION: ASSISTED LIVING PROVIDERS (144G)

Surveyor Name:

Provider Information Provider:

HFID: Date:

Time:

License effective date:

License expiration date:

Branch office address(s):

In attendance:

Agent/Director Name:

Email: Housing Manager

Name: ___________Email:__________ Licensed Assisted Living Director (LALD):

  • LALD listed as Director of Record on BELTSS website.
  • LALD completed continued education as required.
  • If licensed for dementia care, Supervising Staff overseeing/providing staff training must have 2 years of work experience related to dementia, health care, gerontology or another related field. Also, must pass a competency/knowledge test in required dementia training. (144G.82 Subd. 3)
  • Is the provider familiar with current assisted living laws and regulations? (144G.03, Subd. 1-6):

Nurse/Licensed Health Professional Information Primary nurse: Phone number: Hours/Days: Previous experience: Additional nurse(s): Hours/Days: PT/OT/Speech therapist:

How many licensed staff does licensee employ? How do staff contact on-call nurse/licensed health care professional?

  • Provides system for residents to summon staff 24/7 (i.e., call light)

Type of services offered

  • ADLs
  • Medication Management
  • Wound Care
  • Simple
  • Complex
  • Mechanical Lifts
  • Modified Diets
  • Mechanical/Texture
  • Nutritional (low sodium, renal, etc.)
  • Ventilators
  • Tube Feeding
  • Chronic Illness Management
  • 3 meals per day, served per MN Food Code
  • Weekly housekeeping and laundry
  • At resident request, assist with transportation, arranging appointments, shopping, accessing community resources
  • Provide culturally sensitive programs
  • Provide a daily program of social and recreational activity
Required Document

These documents and policies should be provided to the surveyor at the beginning of the survey to facilitate the assessment process.

Reports | Documents:

  • Assisted Living bill of rights
  • Written complaint notice
  • Uniform Checklist Disclosure of Services (UDALSA)
  • Website or advertising information
  • Assisted living contract
  • Current resident roster
  • Discharged/deceased resident roster
  • Current employee roster
  • List of all licensed staff and evidence of current licensure, including LALD
  • Documentation of incidents, accidents, and/or medication errors for the past six (6) months
  • Abuse/neglect reports for the past six (6) months (MAARC)
  • Any complaints for the past six (6) months
  • 24-hour report book or communication book, if applicable
  • ULP daily assignment work/shift forms
  • Admission information/packets
  • Descriptions of training program for dementia care
  • CLIA waiver
  • Current quality management plan

Policies and Procedures:

  • Training of ULP on:
    • Documentation requirements
    • Medication administration
    • Delegated Tasks
    • Treatment or therapy
    • Dementia and related disorders
  • Infection control
  • Disaster and emergency plan (Appendix Z)
  • Quality management plan and activities
  • Orientation and annual training
  • Vulnerable adult reporting/Reporting of maltreatment of minors (if serving minors)
  • Handling of complaints from residents and/or resident representatives
  • Medications management services
  • Treatment and therapy services
  • Service plan

Interview: Resident or Representative

During the survey process, the surveyor will conduct interviews with residents or their representatives to gather feedback about the care and services provided by the facility. The following are sample interview questions that may be asked:

Services and service plan:

  1. Can you please describe the care and services you receive from the provider? How do the staff assist you?
  2. Do you have a written service plan or agreement that outlines the specific services the provider is supposed to provide for you?
  3. Were you involved in the process of determining what services would be provided and how they would be delivered?
  4. Are you receiving the services as specified in your service plan?
  5. Do the staff provide the services in the manner that you have requested?
  6. Are you aware of the charges associated with the care and services you receive?
  7. Do the services meet your expectations?

Staff interactions with residents:

  1. How would you describe the way staff members communicate with you? Do they treat you with respect?
  2. Have you encountered any concerns regarding the way staff members treat you?
  3. Have you observed staff members treating other residents respectfully?
  4. Have you experienced any issues with staff members not handling your personal belongings with care?

Availability of staff:

  1. In case you need assistance, how do you typically call for help?
  2. Are staff members readily available to respond to your requests in a timely manner?
  3. Have you ever needed to call for assistance during nighttime? If so, did someone respond promptly?
  4. Do staff members arrive on time to provide the scheduled services?
  5. Has there been any instance where staff members did not keep a scheduled appointment? If yes, please describe what happened.

Resident rights and making a complaint:

  1. Did you receive a copy of the Minnesota Assisted Living Bill of Rights?
  2. Do you know whom to contact if you have any concerns or complaints about the care or services you receive? How would you reach out to them?
  3. Have you ever filed a complaint? If so, could you share the nature of the complaint?
  4. What was the outcome when you voiced a complaint?

Registered nurse visits:

  1. Does a registered nurse visit you? If so, how frequently do they visit?
  2. During the nurse’s visit, what specific tasks or assistance do they provide for you?

Additional information:

  1. Is there anything else you would like to share or discuss about the care and services you receive?

These interview questions aim to gather feedback from residents or their representatives regarding the quality of care, staff interactions, availability of assistance, knowledge of resident rights, and overall satisfaction with the services provided. The surveyor will document the responses to assist in the evaluation process.

Meal and Menu Requirements

To ensure compliance with meal and menu requirements in an assisted living facility, the following criteria should be verified:

  1. At least three nutritious meals daily with snacks available seven days per week.
  2. Meals include seasonal fresh fruit and vegetables.
  3. Menus are prepared at least one week in advance and made available to all residents.
  4. Residents are encouraged to participate in menu planning.
  5. Meal substitutions are provided of similar nutritional value if a resident refuses a served food.
  6. Residents are informed in advance of any menu changes.
  7. The facility does not require a resident to include and pay for meals in their contract that they do not want.
  8. Meals are prepared according to the recommended dietary allowances in the United States Department of Agriculture (USDA) guidelines, specifically the “My Plate Guide.”
  9. Half of the plate consists of fruits and vegetables of all colors, with a preference for whole fruits and non-starchy vegetables.
  10. One-quarter of the plate consists of grains, preferably whole grains instead of refined (white) grains.
  11. One-quarter of the plate consists of protein, preferably lean sources such as chicken, fish, beans, or nuts.
  12. Three servings of dairy per day are provided, preferably low-fat options.

During the survey, the facility’s adherence to these meal and menu requirements will be assessed to ensure compliance. The surveyor will review the menus, observe meal service, and potentially interview residents to verify that the facility is meeting these standards.

Drug Storage and Labeling

To ensure proper drug storage and labeling in an assisted living facility, the following requirements must be met:

  1. Written policies and procedures: The facility should have written policies and procedures in place that cover various aspects of medication management, including requesting and receiving prescriptions, preparing and administering medications, verifying proper administration, documenting medication management, controlling medications, storing medications, monitoring medication use, resolving medication errors, communicating with prescribers, pharmacists, or residents, educating residents about medications, and disposing of medications.
  2. Secure storage and temperature control: Drugs and biologicals should be stored in locked compartments with proper temperature controls. Access to the storage areas should be limited to authorized staff members. Additionally, documentation of refrigerator temperature logs should be maintained to ensure appropriate storage conditions.
  3. Management of controlled substances: If the facility handles controlled substances, specific policies and procedures should be in place to ensure their security and accountability. These procedures should outline how the provider maintains control over the management, storage, and disposition of these substances.
  4. Proper labeling: Prescription drugs should be stored in their original containers, which should bear a prescription label. This helps ensure accurate identification and prevents the use or sharing of medications intended for other residents.

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To assess compliance with these requirements, the surveyor will review the facility’s drug storage and labeling practices. The surveyor will determine whether drugs and biologicals are stored and labeled properly according to the established policies and procedures.

Medication Administration Observation


During the survey process, if possible, the surveyor will observe the medication administration in order to verify that staff members are following proper techniques and administering medications as ordered. The surveyor aims to observe a minimum of 10 medication administrations by three or more different staff members, utilizing three or more different routes of administration, and occurring at three or more medication times. This observation allows the surveyor to assess the adherence to medication administration protocols and ensure the safe and accurate administration of medications within the facility.

Records Request

To facilitate a smooth survey start, the Minnesota Department of Health (MDH) requires certain records and policies to be reviewed. The following is a sample list of items that you need to provide within specified time frames. Please note that surveyors may request information earlier or ask for additional documentation as needed. You may use the forms provided on the MDH’s Assisted Living and Self-Audit Tools webpage or your own forms, as long as they contain the required content:

Within one hour of the survey:

  • Up-to-date Current Resident Roster
  • Up-to-date Discharged/Deceased Resident Roster
  • Up-to-date Employee Roster with hire dates
  • Current week’s Daily Staffing Schedule
  • Admission information, including Assisted Living contract, Uniform Disclosure of Assisted Living Services and Amenities, advertising material, complaint notice procedure, and the bill of rights given to residents upon admission
  • Accident, incident, or medication error documentation from the past six months
  • 24-hour report book or communication book (if applicable)

Within two hours of the survey:

  • Facility’s tuberculosis risk assessment and infection control policies
  • Documentation of M.A.A.R.C (Minnesota Adult Abuse Reporting Center) reports for the past six months
  • Documentation of complaints for the past three to six months
  • Policies and procedures related to unlicensed personnel, including initial orientation, training, competency evaluations, and medication administration
  • Current week’s menus
  • Direct Care Staffing Plan

Providing these requested items in a timely manner will help ensure a smooth survey process. It’s important to have these records and policies readily available for review by the surveyors.

Required Postings

In an assisted living facility, there are various required postings that must be displayed prominently for residents, staff, and visitors. Here are some examples:

  1. Resident grievances: A notice or information should be posted that explains the process for residents to file grievances or complaints regarding their care, treatment, or living conditions within the facility. This ensures that residents are aware of their rights and how to voice their concerns.
  2. Reporting maltreatment: Assisted living facilities are typically required to post information on how to report suspected abuse, neglect, or maltreatment of residents. This helps ensure that residents, staff, and visitors are aware of the appropriate channels for reporting any concerns or incidents.
  3. Posting information for reporting suspected crime and maltreatment: Facilities may be required to display information regarding the reporting of suspected crimes or maltreatment happening within or involving the facility. This could include contact information for local law enforcement or relevant regulatory agencies.
  4. Disaster planning and emergency preparedness plan: Assisted living facilities must have a disaster planning and emergency preparedness plan in place. Posting this plan in a visible location informs residents, staff, and visitors about the facility’s procedures for responding to emergencies and ensures everyone is familiar with evacuation routes, emergency contacts, and safety protocols.
  5. Notice of dementia training: If the facility provides specialized care for residents with dementia, there may be a requirement to post a notice indicating that staff have received the necessary dementia training. This helps assure families and residents that the facility has trained staff who are knowledgeable about dementia care.
  6. License to be posted: Assisted living facilities are typically required to display their license in a visible location, such as the main entrance or reception area. This informs residents, staff, and visitors that the facility is licensed and regulated by the appropriate governing body.
  7. Electronic Monitoring: Electronic monitoring devices, including security cameras and audio devices, may be present to record persons and activities. This statement must be prominently displayed in assisted living facilities, regardless of whether the facility utilizes camera surveillance or not.
  8. Daily Staffing Schedule: Assisted living facilities are required to prominently display a daily staffing schedule that clearly states the number and types of staff members on duty during each shift. This helps ensure transparency and allows residents, staff, and visitors to be aware of the staffing levels and responsibilities at any given time.
Resident Observation and Record Review

Here’s an overview of the different types of resident observation and record reviews that may be conducted during survey:

  1. Discharged Resident Record Review: This involves reviewing the records of residents who have been discharged from the facility. It includes assessing the documentation related to their care, treatments, therapies, and any relevant follow-up plans or referrals.
  2. Current/Recent Emergency Relocation Review: In cases where residents have been emergency relocated due to unforeseen circumstances, surveyors may review the facility’s documentation and procedures related to the relocation process. This includes assessing how the facility managed the relocation, ensured residents’ safety and well-being, and communicated with residents, families, and relevant authorities.
  3. Resident Daily Life Review: Surveyors may review documentation related to the daily life and routines of residents. This includes assessing whether the facility is providing appropriate support, engagement, and care to residents in their activities of daily living (ADLs), social and recreational activities, and overall quality of life.
  4. Resident Record Review: This involves reviewing individual resident records to assess the documentation of their care, assessments, care plans, and any changes in their condition. Surveyors may review the records to ensure that residents are receiving appropriate and person-centered care based on their individual needs.
  5. Documentation of Resident’s Receipt and Review: This review focuses on documentation that confirms residents have received and reviewed important information related to their rights, facility policies, and services provided. This ensures that residents are well-informed about their rights and responsibilities within the facility.
  6. Medication Management Services: Surveyors may assess the facility’s medication management practices, including the administration, storage, documentation, and monitoring of medications for residents. They will review records to ensure compliance with regulations and the proper handling of medications.
  7. Treatment and Therapy Management Services: This involves reviewing the documentation and records related to the provision of treatments and therapies to residents. Surveyors will assess whether the facility has appropriate procedures in place, properly documents the provision of treatments and therapies, and ensures the continuity and effectiveness of these services.

It’s important for assisted living facilities to maintain accurate and up-to-date records and documentation for resident care and services. This helps ensure continuity of care, resident safety, and compliance with regulations and standards.

Treatment or Therapy Observations

Here are some examples of treatments and therapies that may be reviewed by surveyors in the context of assisted living facilities:

  1. Oxygen therapy: This involves the use of supplemental oxygen to support individuals with respiratory conditions or low blood oxygen levels.
  2. Breathing apparatus: Surveyors may assess the proper use and maintenance of breathing apparatus, such as nebulizers or ventilators, which assist individuals with respiratory issues.
  3. Pulse oximetry: This non-invasive procedure measures the oxygen saturation level in a person’s blood and helps monitor their respiratory function.
  4. Blood glucose checks: Surveyors may review the procedures and documentation related to monitoring blood glucose levels for individuals with diabetes or other conditions requiring regular blood sugar monitoring.
  5. Tube feedings: Assisted living facilities may provide tube feedings for individuals who are unable to consume food orally. Surveyors may assess the implementation and safety of tube feeding protocols.
  6. Application of TED hose or splints: These measures are used to support circulation and reduce the risk of blood clots or to immobilize and stabilize injured body parts. Proper application and monitoring of such measures may be reviewed.
  7. Physical/occupational/speech-language therapy exercises: Surveyors may review the provision of therapy exercises for residents who require physical, occupational, or speech-language therapy to improve mobility, functional abilities, or communication skills.
  8. Wound care: Proper wound care procedures, including dressing changes, wound assessments, and infection control protocols, may be assessed by surveyors to ensure residents receive appropriate care.

In addition to the treatments and therapies themselves, surveyors will also review the maintenance procedures for the equipment used in these interventions. This includes ensuring that equipment is properly maintained, calibrated, and regularly inspected for safety and effectiveness.

Tuberculosis Prevention and Control Documentation

The provider in question utilized the Regulations for Tuberculosis Control in Minnesota Health Care Settings guide as a reference for their tuberculosis (TB) infection control program. Here are the specific elements required:

  1. Designated qualified person or team: The provider designated and documented a qualified person or team with the primary responsibility for the TB infection control program. This individual or team is responsible for implementing and overseeing TB control measures in the healthcare setting.
  2. Written TB risk assessment: The provider had a current written TB risk assessment, which is periodically reviewed and updated. This assessment helps identify the level of risk for TB transmission within the healthcare setting.
  3. Infection control plan: The provider had a written infection control plan that included procedures for handling persons with active TB disease. This plan outlines the measures and protocols to prevent the transmission of TB in the healthcare setting. It also includes documentation of initial and ongoing TB-related training and education for all healthcare workers.
  4. Review of the infection control plan: The date of the most recent review of the infection control plan is documented. Regular reviews help ensure that the plan remains up to date and effective in preventing TB transmission.
  5. Baseline and serial TB screening: The provider documented the results of baseline TB screening for all paid and unpaid healthcare workers. This screening typically includes tuberculin skin tests (TSTs) or TB blood tests, medical evaluations if necessary, TB history and symptom screening, and chest radiograph results. For settings classified as “medium risk” or higher, the results of serial TB screening were also documented.
Employee record review

The record review for employees, volunteers, individual contractors, and temporary staff in an assisted living facility may include the following:

  1. Credentials: This refers to the professional qualifications and certifications held by the individual, such as nursing licenses, certifications in specific healthcare specialties, or relevant educational degrees.
  2. Orientation record: Documentation that confirms the completion of an orientation program specifically focused on the assisted living regulations. This orientation must be completed before the individual starts providing services to residents.
  3. Current license or certification: This includes verifying the validity of the individual’s license or certification, along with the expiration date. It ensures that the individual maintains the required licensure or certification for their role.
  4. Background study: This refers to the completion of a background check as required by the relevant regulations (in this case, referring to Section 144G.60, Subdivision 1). The background study is typically conducted to assess an individual’s criminal history and ensure the safety of residents.
  5. Current job description: The job description outlines the responsibilities, duties, and scope of work for the individual’s specific role in the assisted living facility. It helps to ensure that the individual’s tasks align with their authorized job functions.
  6. Annual performance review(s): This involves conducting regular performance evaluations for the individual, typically on an annual basis. The performance review assesses their job performance, identifies areas for improvement, and recognizes their achievements.
  7. Assisted Living with Dementia Care Specific Training: If the individual provides direct care to residents with dementia, there are specific training requirements. This includes an initial 8-hour dementia care training within a specified timeframe and annual training to enhance knowledge and skills related to dementia care.
  8. Last annual training date(s): This indicates the date when the individual completed their most recent annual training, ensuring their knowledge and skills are up to date.
  9. TB screening and training: This refers to the requirement of tuberculosis (TB) screening for individuals working in the assisted living facility, as well as any training related to TB control and prevention.
  10. Training and competency in the required 22 areas: Assisted living regulations often define specific training areas that staff must receive to ensure competence in their roles. This requirement ensures that individuals have completed the necessary training in these areas.
  11. Supervision of Unlicensed Personnel (ULP): Assisted living facilities have specific requirements for the supervision of unlicensed personnel. This include guidelines and documentation related to the supervision, training, and delegation of tasks to unlicensed staff members.
Request for employees’ name list

Providers are required to provide the Minnesota Department of Health surveyors with the names, titles, and hire dates of all current employees, including contracted and licensed staff, upon request. You may use the provided form or your own preferred format to submit this information. It is essential to ensure accurate and up-to-date employee records to comply with regulatory requirements.

Name List

MDH Sample Form