Clgv Assisted Living Memory

Summary: MDH found the licensee failed to ensure the assisted living contract did not include language waiving the facility's liability for health, safety, or personal property for two of two residents (R1, R2) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the assisted living contract did not include language waiving the facility's liability for health, safety, or personal property for two of two residents (R1, R2) with records reviewed. [...]”

Rule cited: “The contract must not include a waiver of facility liability for the health and safety or personal property of a resident. [...]”

Summary: MDH found the licensee failed to ensure training and competency was completed for one of one employee (unlicensed personnel (ULP)-C) to include all required content with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure training and competency was completed for one of one employee (unlicensed personnel (ULP)-C) to include all required content with records reviewed. [...]”

Rule cited: “(a) Training and competency evaluations for all unlicensed personnel must include the following: (1) documentation requirements for all services provided; (2) reports of changes in the resident's condition to the supervisor designated by the facility; (3) [...]”

MDH’s finding, as written: “Based on observation, interview and record review the licensee failed to ensure training and competency evaluations were completed for all required skill areas prior to providing services for one of one unlicensed personnel ((ULP)-C) with record reviewed. [...]”

Rule cited: “(b) In addition to paragraph (a), training and competency evaluation for unlicensed personnel providing assisted living services must include: (1) observing, reporting, and documenting resident status; (2) basic knowledge of body functioning and changes in [...]”

Summary: MDH found the licensee failed to ensure employees received orientation to assisted living licensing requirements and regulations for one of one employee (unlicensed personnel (ULP)-C) with employee record reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure employees received orientation to assisted living licensing requirements and regulations for one of one employee (unlicensed personnel (ULP)-C) with employee record reviewed. [...]”

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 the current service plan included a signature or other authentication by the resident and/or representative to document agreement on the services to be provided for four of five residents (R1, R4, R5, R6) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the current service plan included a signature or other authentication by the resident and/or representative to document agreement on the services to be provided for four of five residents (R1, R4, R5, R6) with records reviewed. [...]”

Rule cited: “(a) No later than 14 calendar days after the date that services are first provided, an assisted living facility shall finalize a current written service plan. [...]”

Summary: MDH found the licensee failed to ensure the service plan included the required content for five of five residents (R1, R2, R4, R5, R6) with records reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure the service plan included the required content for five of five residents (R1, R2, R4, R5, R6) with records reviewed. [...]”

Rule cited: “(f) The service plan must include: (1) a description of the services to be provided, the fees for services, and the frequency of each service, according to the resident's current assessment and resident preferences; (2) the identification of staff or [...]”

Summary: MDH found the licensee failed to ensure medication was administered as ordered for one of one resident (R2) with record reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure medication was administered as ordered for one of one resident (R2) with record reviewed. [...]”

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 document in the resident's record the disposition of the medication including the medication's name, strength, prescription number as applicable, quantity, to whom the medications were given, date of disposition, and names of staff and other individuals involved in the disposition for one of one discharged resident (R3) with record reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to document in the resident's record the disposition of the medication including the medication's name, strength, prescription number as applicable, quantity, to whom the medications were given, date of disposition, and names of staff and other individuals involved in the disposition for one of one discharged resident (R3) with record reviewed. [...]”

Rule cited: “(a) Any current medications being managed by the assisted living facility must be provided to the resident when the resident's service plan ends or medication management services are no longer part of the service plan. [...]”

Summary: MDH found the licensee failed to develop, implement, and maintain up-to-date written treatment or therapy management policies and procedures with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to develop, implement, and maintain up-to-date written treatment or therapy management policies and procedures with records reviewed. [...]”

Rule cited: “(a) An assisted living facility that provides treatment and therapy management services must develop, implement, and maintain up-to-date written treatment or therapy management policies and procedures. [...]”

Summary: MDH found the licensee failed to develop a treatment management plan to include all required content for one of one resident (R5) with record reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to develop a treatment management plan to include all required content for one of one resident (R5) with record reviewed. [...]”

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 up-to-date written or electronically recorded orders were maintained for treatment of application of TED stockings for one of one resident (R5) with record reviewed.

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure up-to-date written or electronically recorded orders were maintained for treatment of application of TED stockings for one of one resident (R5) with record reviewed. [...]”

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

Summary: MDH found the licensee failed to provide a hazard vulnerability or safety risk assessment that identified hazards on and around the property.

MDH’s finding, as written: “Based on observation, document review, and interview, the licensee failed to provide a hazard vulnerability or safety risk assessment that identified hazards on and around the property. Mitigation of hazards to protect residents from harm was not included. This had the potential to directly affect all residents and staff. [...]”

Rule cited: “An assisted living facility with dementia care that has a secured dementia care unit must meet the requirements of section 144G.45 and the following additional requirements: (1) a hazard vulnerability assessment or safety risk must be performed on and around [...]”

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the required policies and procedures were provided to each resident and/or the resident's legal and designated representative at the time of move-in. [...]”

Rule cited: “(a) In addition to the policies and procedures required in the licensing of all facilities, the assisted living facility with dementia care licensee must develop and implement policies and procedures that address the: (1) philosophy of how services are [...]”

Summary: MDH found the licensee failed to provide in written or electronic form to residents, families, or other persons who request it, an accurate description of the dementia care training program with the required content with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to provide in written or electronic form to residents, families, or other persons who request it, an accurate description of the dementia care training program with the required content with records reviewed. [...]”

Rule cited: “An assisted living facility with dementia care shall make available in written or electronic form, to residents and families or other persons who request it, a description of the training program and related training it provides, including the categories of [...]”