Big Hearts Home Care

Summary: MDH found the licensee failed to develop the fire safety and evacuation plan with the required content.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to develop the fire safety and evacuation plan with the required content. This had the potential to directly affect all residents, staff, 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 include the required statutory language giving residents the right to identify a designated representative on its own separate page for two of two residents (R1, R2).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to include the required statutory language giving residents the right to identify a designated representative on its own separate page 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 staff completed an orientation to assisted living facility licensing requirements and regulations before providing services for three of three employees (unlicensed personnel (ULP)-A, ULP-B, clinical nurse supervisor (CNS)-C).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure staff completed an orientation to assisted living facility licensing requirements and regulations before providing services for three of three employees (unlicensed personnel (ULP)-A, ULP-B, clinical nurse supervisor (CNS)-C). [...]”

Rule cited: “(a) The orientation must contain the following topics: (1) an overview of this chapter; (2) an introduction and review of the facility's policies and procedures related to the provision of assisted living services by the individual staff person; (3) handling [...]”

Summary: MDH found the licensee failed to ensure staff completed two hours of initial mental illness and de-escalation training within 160 hours of providing direct care to residents for one of three employees (clinical nurse supervisor (CNS)-C).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure staff completed two hours of initial mental illness and de-escalation training within 160 hours of providing direct care to residents for one of three employees (clinical nurse supervisor (CNS)-C). [...]”

Rule cited: “All direct care staff and supervisors providing direct services must demonstrate an understanding of the training specified in section 144G.64.”

Summary: MDH found the licensee failed to ensure two of three employees (unlicensed personnel (ULP)-A, ULP-B) received at least eight hours of initial dementia care training within 160 working hours of their employment start date, and two hours of additional dementia training for each 12 months of employment.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure two of three employees (unlicensed personnel (ULP)-A, ULP-B) received at least eight hours of initial dementia care training within 160 working hours of their employment start date, and two hours of additional dementia training for each 12 months of employment. [...]”

Rule cited: “(a) All assisted living facilities must meet the following dementia care, mental illness, and de-escalation training requirements: (1) supervisors of direct-care staff must have at least eight hours of initial training on dementia topics specified under [...]”

Summary: MDH found the licensee failed to ensure the registered nurse (RN) developed training and competencies for unlicensed personnel (ULP) providing medications to residents for unplanned time away from home when the licensed nurse was not available for two of two employees (ULP-A, ULP-B).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the registered nurse (RN) developed training and competencies for unlicensed personnel (ULP) providing medications to residents for unplanned time away from home when the licensed nurse was not available for two of two employees (ULP-A, ULP-B). [...]”

Rule cited: “(2) for unplanned time away, when the pharmacy is not able to provide the medications, a licensed nurse or unlicensed personnel shall provide medications in amounts and dosages needed for the length of the anticipated absence, not to exceed seven calendar [...]”

Summary: MDH found the licensee failed to ensure all medications were included in the assessment for medication management or documented in the resident record for medication or dietary supplement the resident was self-administering for one of two residents (R1).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure all medications were included in the assessment for medication management or documented in the resident record for medication or dietary supplement the resident was self-administering for one of two residents (R1). [...]”

Rule cited: “When the assisted living facility is aware of any medications or dietary supplements that are being used by the resident and are not included in the assessment for medication management services, the staff must advise the registered nurse and document that in [...]”

Summary: MDH found the licensee failed to ensure a medication was labeled with the resident's name for one of two residents (R1).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure a medication was labeled with the resident's name for one of two residents (R1). 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 [...]”

Rule cited: “A prescription drug, prior to being set up for immediate or later administration, must be kept in the original container in which it was dispensed by the pharmacy bearing the original prescription label with legible information including the expiration or [...]”

Summary: MDH found the licensee failed to develop and implement a current treatment or therapy management plan to include all required content for two of two residents (R1, R2) who received blood glucose monitoring and oxygen therapy.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to develop and implement a current treatment or therapy management plan to include all required content for two of two residents (R1, R2) who received blood glucose monitoring and oxygen therapy. [...]”

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 treatments were performed as ordered for one of two residents (R1).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure treatments were performed as ordered for one of two residents (R1). 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 [...]”

Rule cited: “Each treatment or therapy administered by an assisted living facility must be in the resident record. [...]”

Summary: MDH found the licensee failed to ensure prescriber's orders were in place for treatments for two of two residents (R1, R2).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure prescriber's orders were in place for treatments for two of two residents (R1, R2). 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 a widespread scope (when problems are pervasive or represent a systemic [...]”

Rule cited: “There must be an up-to-date written or electronically recorded order from an authorized prescriber for all treatments and therapies. [...]”