Amran Home Health Care

Summary: MDH found the licensee failed to ensure staff had access to a registered nurse (RN), 24-hours per day, seven days per week.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure staff had access to a registered nurse (RN), 24-hours per day, seven days per week. This affected all residents (R1, R2) and unlicensed staff. This resulted in an immediate correction order issued on August 7, 2023, at approximately 6:00 p.m. [...]”

Rule cited: “(14) provide staff access to an on-call registered nurse 24 hours per day, seven days per week”

Summary: MDH found the licensee failed to ensure the assisted living facility had a clinical nurse supervisor (CNS) who was a registered nurse (RN) licensed in Minnesota.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to ensure the assisted living facility had a clinical nurse supervisor (CNS) who was a registered nurse (RN) licensed in Minnesota. This had the potential to affect all residents. [...]”

Rule cited: “All assisted living facilities must have a clinical nurse supervisor who is a registered nurse licensed in Minnesota.”

Summary: MDH found the licensee failed to post the required information related to the grievance procedure, including the name, telephone number, and e-mail contact information for the individuals who were responsible for handling resident grievances.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to post the required information related to the grievance procedure, including the name, telephone number, and e-mail contact information for the individuals who were responsible for handling resident grievances. This had the potential to affect all residents receiving assisted living services. [...]”

Rule cited: “All facilities must post in a conspicuous place information about the facilities' grievance procedure, and the name, telephone number, and email contact information for the individuals who are responsible for handling resident grievances. [...]”

Summary: MDH found the licensee failed to ensure the employee record contained the required contend to include records of orientation, required annual training, and documentation of an annual performance review for two of two employees, licensed assisted living director (LALD)-A/owner and unlicensed personnel (ULP)-B.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the employee record contained the required contend to include records of orientation, required annual training, and documentation of an annual performance review for two of two employees, licensed assisted living director (LALD)-A/owner and unlicensed personnel (ULP)-B. [...]”

Rule cited: “(a) The facility must maintain current records of each paid employee, each regularly scheduled volunteer providing services, and each individual contractor providing services. [...]”

MDH’s finding, as written: “Based on observation, interview, and record review the licensee failed to have a written emergency preparedness plan (EP) with all the required content as defined in Appendix Z. [...]”

Rule cited: “(a) The facility must meet the following requirements: (1) have a written emergency disaster plan that contains a plan for evacuation, addresses elements of sheltering in place, identifies temporary relocation sites, and details staff assignments in the event [...]”

Summary: MDH found the facility failed to ensure records were readily available to employees authorized to have access, including maintaining records in a manner allowing for timely access of the records, including access for survey.

MDH’s finding, as written: “Based on observation and interview, the facility failed to ensure records were readily available to employees authorized to have access, including maintaining records in a manner allowing for timely access of the records, including access for survey. This had the potential to affect all residents and facility staff. [...]”

Rule cited: “The facility must ensure that the appropriate records are readily available to employees and contractors authorized to access the records. Resident records must be maintained in a manner that allows for timely access, printing, or transmission of the records. [...]”

Summary: MDH found the licensee failed to provide smoke alarms that were interconnected in some resident's apartments.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to provide smoke alarms that were interconnected in some resident's apartments. This had the potential to directly affect all residents, staff, and visitors. [...]”

Rule cited: “(a) Each assisted living facility must comply with the State Fire Code in Minnesota Rules, chapter 7511, and: (1) for dwellings or sleeping units, as defined in the State Fire Code: (i) provide smoke alarms in each room used for sleeping purposes; (ii) [...]”

Summary: MDH found the licensee failed provide adequately rated portable fire extinguishers as required for the facility.

MDH’s finding, as written: “Based on observation and interview, the licensee failed provide adequately rated portable fire extinguishers as required for the facility. This deficient condition had the ability to affect all staff and residents. [...]”

Rule cited: “(2) install and maintain portable fire extinguishers in accordance with the State Fire Code; (3) install portable fire extinguishers having a minimum 2-A:10-B:C rating within Group R-3 occupancies, as defined by the State Fire Code, located so that the travel [...]”

Summary: MDH found the licensee failed to maintain the physical environment, including walls, floors, ceiling, all furnishings, grounds, systems, and equipment in a continuous state of good repair and operation with regard to the health, safety, comfort, and well-being of the residents.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to maintain the physical environment, including walls, floors, ceiling, all furnishings, grounds, systems, and equipment in a continuous state of good repair and operation with regard to the health, safety, comfort, and well-being of the residents. This deficient condition had the ability to affect a limited number of staff and residents. [...]”

Rule cited: “(4) keep the physical environment, including walls, floors, ceiling, all furnishings, grounds, systems, and equipment in a continuous state of good repair and operation with regard to the health, safety, comfort, and well-being of the residents in accordance [...]”

Summary: MDH found the licensee failed to develop a fire safety and evacuation plan with required elements; failed to provide required employee training on fire safety and evacuation; failed to provide training to residents capable of assisting in their own evacuation; and failed to complete required employee evacuation drills.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to develop a fire safety and evacuation plan with required elements; failed to provide required employee training on fire safety and evacuation; failed to provide training to residents capable of assisting in their own evacuation; and failed to complete required employee evacuation drills. This had the potential to affect all staff, residents, and visitors. [...]”

Rule cited: “(b) Each assisted living facility shall develop and maintain fire safety and evacuation plans. [...]”

Summary: MDH found the licensee failed to develop and execute a written assisted living contract with the required content for two of two residents (R1, R2).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to develop and execute a written assisted living contract with the required content for two of two residents (R1, R2). The licensee further failed to ensure there were no non-contracted residents living in the building (licensed assisted living director/owner (LALD)-A). [...]”

Rule cited: “(a) An assisted living facility may not offer or provide housing or assisted living services to any individual unless it has executed a written contract with the resident. [...]”

Summary: MDH found the licensee failed to offer the opportunity to identify a designated representative on a separate form including statutory language, for two of two residents (R1, R2).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to offer the opportunity to identify a designated representative on a separate form including statutory language, for two of two residents (R1, R2). [...]”

Rule cited: “(a) Before or at the time of execution of an assisted living contract, an assisted living facility must offer the resident the opportunity to identify a designated representative in writing in the contract and must provide the following verbatim notice on a [...]”

Summary: MDH found the licensee failed to ensure a registered nurse (RN) was available for consultation to staff performing

MDH’s finding, as written: “Based on observation and interview, the licensee failed to ensure a registered nurse (RN) was available for consultation to staff performing delegated nurse tasks and services including therapies. This had the potential to affect all residents and facility staff. [...]”

Rule cited: “(a) Assisted living facilities must have a registered nurse available for consultation by staff performing delegated nursing tasks and must have an appropriate licensed health professional available if performing other delegated services such as therapies.”

Summary: MDH found the licensee failed to ensure staff providing services completed orientation to assisted living facility licensing requirements and regulations, before providing services, for two of two employees, (licensed assisted living director/owner (LALD)-A and unlicensed personnel (ULP)-B).

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure staff providing services completed orientation to assisted living facility licensing requirements and regulations, before providing services, for two of two employees, (licensed assisted living director/owner (LALD)-A and unlicensed personnel (ULP)-B). [...]”

Rule cited: “All staff providing and supervising direct services must complete an orientation to assisted living facility licensing requirements and regulations before providing assisted living services to residents. [...]”

Summary: MDH found the licensee failed to ensure employees received at least eight hours of annual training for each 12 months of employment for two of two employees (licensed assisted living director/owner (LALD)-A, unlicensed personnel (ULP)-B).

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure employees received at least eight hours of annual training for each 12 months of employment for two of two employees (licensed assisted living director/owner (LALD)-A, unlicensed personnel (ULP)-B). [...]”

Rule cited: “(a) All staff that perform direct services must complete at least eight hours of annual training for each 12 months of employment. [...]”

Summary: MDH found the licensee failed to ensure the required amount of dementia care training was completed in the required time frame in accordance with 144G.64 for two of two employees, licensed assisted living director (LALD)-A/owner and unlicensed personnel (ULP)-B.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the required amount of dementia care training was completed in the required time frame in accordance with 144G.64 for two of two employees, licensed assisted living director (LALD)-A/owner and unlicensed personnel (ULP)-B. [...]”

Rule cited: “(a) All assisted living facilities must meet the following training requirements: (1) supervisors of direct-care staff must have at least eight hours of initial training on topics specified under paragraph (b) within 120 working hours of the employment start [...]”

Summary: MDH found the licensee failed to ensure the registered nurse (RN) conducted a pre-admission assessment prior to move in for one of two residents (R2).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the registered nurse (RN) conducted a pre-admission assessment prior to move in for one of two residents (R2). [...]”

Rule cited: “(a) Residents who are not receiving any assisted living services shall not be required to undergo an initial nursing assessment. [...]”

Summary: MDH found the licensee failed to ensure a registered nurse (RN) conducted ongoing resident monitoring and reassessment 14 calendar days from the initial assessment, and not to exceed 90 calendar days from the previous assessment for two of two residents (R1, R2).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure a registered nurse (RN) conducted ongoing resident monitoring and reassessment 14 calendar days from the initial assessment, and not to exceed 90 calendar days from the previous assessment for two of two residents (R1, R2). [...]”

Rule cited: “(c) Resident reassessment and monitoring must be conducted no more than 14 calendar days after initiation of services. [...]”

Summary: MDH found the licensee failed to ensure a registered nurse (RN) conducted and individualized assessment to

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure a registered nurse (RN) conducted and individualized assessment to determine what medication management services would be provided, and how the services would be provided for one of two residents (R2). [...]”

Rule cited: “(a) For each resident who requests medication management services, the facility shall, prior to providing medication management services, have a registered nurse, licensed health professional, or authorized prescriber under section 151.37 conduct an [...]”

Summary: MDH found the licensee failed to ensure the registered nurse (RN) conducted a face-to-face medication management reassessment to include all required content for one of two (R2) residents.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the registered nurse (RN) conducted a face-to-face medication management reassessment to include all required content for one of two (R2) residents. [...]”

Rule cited: “The assisted living facility must monitor and reassess the resident's medication management services as needed under subdivision 2 when the resident presents with symptoms or other issues that may be medication-related and, at a minimum, annually.”

Summary: MDH found the licensee failed to document the resident's refusal of medication for one of two residents.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to document the resident's refusal of medication for one of two residents. This practice resulted in a level two violation (a violation that did not harm a resident's health or safety but had the potential to have harmed a resident's health or safety, but was not likely to cause serious injury, impairment, or death), and was issued at an isolated scope (when one or a limited number of residents are affected or one or a limited number of [...]”

Rule cited: “The assisted living facility must document in the resident's record any refusal for an assessment for medication management by the resident. [...]”

Summary: MDH found the licensee failed to develop and maintain a current individualized medication management plan for one of two residents (R2).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to develop and maintain a current individualized medication management plan for one of two residents (R2). This practice resulted in a level three violation (a violation that harmed a resident's health or safety, not including serious injury, impairment, or death, or a violation that has the potential to lead to serious injury, impairment, or death), and was issued at an isolated scope (when one or a limited number of residents are [...]”

Rule cited: “(a) For each resident receiving medication management services, the assisted living facility must prepare and include in the service plan a written statement of the medication management services that will be provided to the resident. [...]”

Summary: MDH found the licensee failed to ensure registered nurse (RN) specified, in writing, specific instructions of medication administration and to communicate with the unlicensed personnel (ULP) about the individual needs for two of two residents (R1,R2).

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure registered nurse (RN) specified, in writing, specific instructions of medication administration and to communicate with the unlicensed personnel (ULP) about the individual needs for two of two residents (R1,R2). [...]”

Rule cited: “When administration of medications is delegated to unlicensed personnel, the assisted living facility must ensure that the registered nurse has: (1) instructed the unlicensed personnel in the proper methods to administer the medications, and the unlicensed [...]”

Summary: MDH found the licensee failed to ensure medications were administered per provider orders for one of two residents (R2).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure medications were administered per provider orders for one of two residents (R2). This practice resulted in a level three violation (a violation that harmed a resident's health or safety, not including serious injury, impairment, or death, or a violation that has the potential to lead to serious injury, impairment, or death), and was issued at an isolated scope (when one or a limited number of residents are affected or one or a [...]”

Rule cited: “Each medication administered by the assisted living facility staff must be documented in the resident's record. The documentation must include the signature and title of the person who administered the medication. [...]”

Summary: MDH found the licensee failed to ensure a written prescription order was communicated to the register nurse and recorded in the resident's record for one of two residents (R2).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure a written prescription order was communicated to the register nurse and recorded in the resident's record for one of two residents (R2). [...]”

Rule cited: “When a written or electronic prescription is received, it must be communicated to the registered nurse in charge and recorded or placed in the resident's record.”

Summary: MDH found the licensee failed to develop and implement a treatment or therapy management plan to include all required content for one of two residents (R2).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to develop and implement a treatment or therapy management plan to include all required content for one of two residents (R2). [...]”

Rule cited: “For each resident receiving management of ordered or prescribed treatments or therapy services, the assisted living facility must prepare and include in the service plan a written statement of the treatment or therapy services that will be provided to the [...]”

Summary: MDH found the licensee failed to ensure the current "Minnesota Bill of Rights for Assisted Living Residents" was provided to the resident and a written acknowledgement received for two of two residents (R1, R2).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the current "Minnesota Bill of Rights for Assisted Living Residents" was provided to the resident and a written acknowledgement received for two of two residents (R1, R2). [...]”

Rule cited: “(a) An assisted living facility must provide the resident a written notice of the rights under section 144G.91 before the initiation of services to that resident. [...]”