Let’s face it- inspection time is extremely stressful! No matter how much you have prepared or how long you have been in the “industry” when an inspector shows up to your community it can be a nerve-wracking experience. In the state of Minnesota the DOH or ALLHRD can show up anytime they see fit to conduct an inspection of every nook and cranny of the facility. Be prepared, be cordial and be open with inspectors and you will certainly have a much better experience.
144G.30 SURVEYS AND INVESTIGATIONS.
Subdivision 1.Regulatory powers.
(a) The Department of Health is the exclusive state agency charged with the responsibility and duty of surveying and investigating all assisted living facilities required to be licensed under this chapter. The commissioner of health shall enforce all sections of this chapter and the rules adopted under this chapter.
(b) The commissioner, upon request to the facility, must be given access to relevant information, records, incident reports, and other documents in the possession of the facility if the commissioner considers them necessary for the discharge of responsibilities. For purposes of surveys and investigations and securing information to determine compliance with licensure laws and rules, the commissioner need not present a release, waiver, or consent to the individual. The identities of residents must be kept private as defined in section 13.02, subdivision 12.
Subd. 2.Surveys.
The commissioner shall conduct a survey of each assisted living facility on a frequency of at least once every two years. The commissioner may conduct surveys more frequently than every two years based on the license category, the facility’s compliance history, the number of residents served, or other factors as determined by the commissioner deemed necessary to ensure the health, safety, and welfare of residents and compliance with the law.
Subd. 3.Scheduling surveys.
Surveys and investigations shall be conducted without advance notice to the facilities. Surveyors may contact the facility on the day of a survey to arrange for someone to be available at the survey site. The contact does not constitute advance notice. The surveyor must provide presurvey notification to the Office of Ombudsman for Long-Term Care.
Subd. 4.Information provided by facility.
(a) The assisted living facility shall provide accurate and truthful information to the department during a survey, investigation, or other licensing activities.
(b) Upon request of a surveyor, assisted living facilities shall within a reasonable period of time provide a list of current and past residents and their legal representatives and designated representatives that includes addresses and telephone numbers and any other information requested about the services to residents.
Subd. 5.Correction orders.
(a) A correction order may be issued whenever the commissioner finds upon survey or during a complaint investigation that a facility, a managerial official, or an employee of the facility is not in compliance with this chapter. The correction order shall cite the specific statute and document areas of noncompliance and the time allowed for correction.
(b) The commissioner shall mail or e-mail copies of any correction order to the facility within 30 calendar days after the survey exit date. A copy of each correction order and copies of any documentation supplied to the commissioner shall be kept on file by the facility and public documents shall be made available for viewing by any person upon request. Copies may be kept electronically.
(c) By the correction order date, the facility must document in the facility’s records any action taken to comply with the correction order. The commissioner may request a copy of this documentation and the facility’s action to respond to the correction order in future surveys, upon a complaint investigation, and as otherwise needed.
Subd. 6.Follow-up surveys.
The commissioner may conduct follow-up surveys to determine if the facility has corrected deficient issues and systems identified during a survey or complaint investigation. Follow-up surveys may be conducted via phone, e-mail, fax, mail, or on-site reviews. Follow-up surveys, other than complaint investigations, shall be concluded with an exit conference and written information provided on the process for requesting a reconsideration of the survey results.
Subd. 7.Required follow-up surveys.
For assisted living facilities that have Level 3 or Level 4 violations under section 144G.31, the commissioner shall conduct a follow-up survey within 90 calendar days of the survey. When conducting a follow-up survey, the surveyor shall focus on whether the previous violations have been corrected and may also address any new violations that are observed while evaluating the corrections that have been made.
Subd. 8.Notice of noncompliance.
If the commissioner finds that the applicant or a facility has not corrected violations by the date specified in the correction order or conditional license resulting from a survey or complaint investigation, the commissioner shall provide a notice of noncompliance with a correction order by e-mailing the notice of noncompliance to the facility. The noncompliance notice must list the violations not corrected.
Pro Tip:
- Work with the surveyor and their team’s needs
- Be professional and try to develop a rapport with the surveyor
- Be honest
- Use their feedback to make needed changes to your facility
Remember, they are not here to hurt your facility. They are there to make sure we as operators are doing all we can do to ensure residents are being cared for in the best way possible.