Compassion Home Health Care Ll

Summary: MDH found 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)-F).

MDH’s finding, as written: “Based on 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)-F). [...]”

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) [...]”

Summary: MDH found 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)-F).

MDH’s finding, as written: “Based on 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)-F). [...]”

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, including all required content, for one of three employees (unlicensed personnel (ULP)-F).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure employees received orientation to assisted living, including all required content, for one of three employees (unlicensed personnel (ULP)-F). [...]”

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 employees received at

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure employees received at least eight (8) hours of training for each 12 months of employment for two of three employees (owner/registered nurse (O/RN)-B and unlicensed personnel (ULP)-F). [...]”

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 a supervisor of direct-care employees received at least eight hours of initial training on topics specified under paragraph (b) within 120 working hours of the employment start date for two of two nurses (owner/clinical nurse supervisor (O/CNS)-C, owner/registered nurse (O/RN)-B).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure a supervisor of direct-care employees received at least eight hours of initial training on topics specified under paragraph (b) within 120 working hours of the employment start date for two of two nurses (owner/clinical nurse supervisor (O/CNS)-C, owner/registered nurse (O/RN)-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 medications were transcribed as prescribed for one of one resident (R1).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure medications were transcribed as prescribed for one of one resident (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 a widespread scope (when problems are pervasive or represent a systemic failure [...]”

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 written or electronically recorded prescriptions were obtained for one of one resident (R1) who received medication management.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure written or electronically recorded prescriptions were obtained for one of one resident (R1) who received medication management. [...]”

Rule cited: “There must be a current written or electronically recorded prescription as defined in section 151.01, subdivision 16a, for all prescribed medications that the assisted living facility is managing for the resident.”

MDH’s finding, as written: “No further action required.”

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 [...]”

MDH’s finding, as written: “No further action required.”

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

Summary: MDH found the licensee failed to ensure training and competency evaluations were completed for all required skill areas, prior to providing services, for two of two unlicensed personnel ((ULP)-D, ULP-F).

MDH’s finding, as written: “Based on 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 two of two unlicensed personnel ((ULP)-D, ULP-F). [...]”

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) [...]”

Summary: MDH found the licensee failed to ensure training and competency evaluations for the required topics for two of two unlicensed personnel (ULP)-D, ULP-F)).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure training and competency evaluations for the required topics for two of two unlicensed personnel (ULP)-D, ULP-F)). [...]”

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, including all required content, for three of three employees (clinical nurse specialist (CNS)-B, unlicensed personnel (ULP)-D, ULP-F).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure employees received orientation to assisted living, including all required content, for three of three employees (clinical nurse specialist (CNS)-B, unlicensed personnel (ULP)-D, ULP-F). [...]”

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 employees received at least eight (8) hours of training for each 12 months of employment for two of three employees (clinical nurse supervisor (CNS)-B, unlicensed personnel (ULP)-D).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure employees received at least eight (8) hours of training for each 12 months of employment for two of three employees (clinical nurse supervisor (CNS)-B, unlicensed personnel (ULP)-D). [...]”

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 for three of three employees (clinical nurse supervisor (CNS)-B, unlicensed personnel (ULP)-D, ULP-F).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the required amount of dementia care training was completed in the required time frame for three of three employees (clinical nurse supervisor (CNS)-B, unlicensed personnel (ULP)-D, ULP-F). [...]”

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 medications were transcribed as prescribed for one of one resident (R1).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure medications were transcribed as prescribed for one of one resident (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 [...]”

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 documentation of medication setup included all the required content for one of one resident (R1) receiving medication management.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure documentation of medication setup included all the required content for one of one resident (R1) receiving medication management. [...]”

Rule cited: “Documentation of dates of medication setup, name of medication, quantity of dose, times to be administered, route of administration, and name of person completing medication setup must be done at the time of setup.”

Summary: MDH found the licensee failed to ensure written or electronically recorded prescriptions were obtained for one of one resident (R1).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure written or electronically recorded prescriptions were obtained for one of one resident (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 [...]”

Rule cited: “There must be a current written or electronically recorded prescription as defined in section 151.01, subdivision 16a, for all prescribed medications that the assisted living facility is managing for the resident.”

Summary: MDH found the licensee failed to engage in and maintain documentation of ongoing quality management (QM) activities relevant to the facility size and services provided.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to engage in and maintain documentation of ongoing quality management (QM) activities relevant to the facility size and services provided. This had the potential to affect all residents, staff and visitors. [...]”

Rule cited: “The facility shall engage in quality management appropriate to the size of the facility and relevant to the type of services provided. [...]”

Summary: MDH found the licensee failed to ensure an accurate individual abuse prevention plan (IAPP) contained statements of the specific measures to be taken by staff to minimize the risk of abuse for one of one resident (R1).

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure an accurate individual abuse prevention plan (IAPP) contained statements of the specific measures to be taken by staff to minimize the risk of abuse for one of one resident (R1). [...]”

Rule cited: “(b) The facility must develop and implement an individual abuse prevention plan for each vulnerable adult. [...]”

Summary: MDH found the licensee failed to support protection and safety by not posting information and phone numbers for reporting to the Minnesota Adult Abuse Reporting Center (MAARC) and failed to post the 911 emergency number in common areas and near telephones provided by the assisted living facility.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to support protection and safety by not posting information and phone numbers for reporting to the Minnesota Adult Abuse Reporting Center (MAARC) and failed to post the 911 emergency number in common areas and near telephones provided by the assisted living facility. This had the potential to affect the one resident, staff, and visitors. [...]”

Rule cited: “The facility shall support protection and safety through access to the state's systems for reporting suspected criminal activity and suspected vulnerable adult maltreatment by: (1) posting the 911 emergency number in common areas and near telephones provided [...]”

Summary: MDH found the licensee failed to complete a Minnesota Department of Human Services (DHS) NETStudy 2.0 background study and clearance upon hire for one of one volunteer (V-E).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to complete a Minnesota Department of Human Services (DHS) NETStudy 2.0 background study and clearance upon hire for one of one volunteer (V-E). This had the potential to affect one of one resident (R1) residing in the facility. This resulted in an immediate correction order issued on October 23, 2023, at 2:44 p.m. [...]”

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. [...]”

Summary: MDH found the facility failed to establish and maintain a tuberculosis (TB) prevention program, based on the most current guidelines issued by the Centers for Disease Control and Prevention (CDC) which included documentation of a completed health history and symptom screening, baseline screening, and TB training for three of three employees (clinical nurse supervisor (CNS) -B, unlicensed personnel (ULP)-D, and ULP-F).

MDH’s finding, as written: “Based on interview and record review, the facility failed to establish and maintain a tuberculosis (TB) prevention program, based on the most current guidelines issued by the Centers for Disease Control and Prevention (CDC) which included documentation of a completed health history and symptom screening, baseline screening, and TB training for three of three employees (clinical nurse supervisor (CNS) -B, unlicensed personnel (ULP)-D, and ULP-F). [...]”

Rule cited: “(a) The facility must establish and maintain a comprehensive tuberculosis infection control program according to the most current tuberculosis infection control guidelines issued by the United States Centers for Disease Control and Prevention (CDC), Division [...]”

MDH’s finding, as written: “Based on interview and record review the licensee failed to have a written emergency preparedness plan (EPP) with all the required content. This had the potential to affect one resident receiving services under the assisted living license. [...]”

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 licensee failed to provide documentation of monthly inspections of all the fire extinguishers.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to provide documentation of monthly inspections of all the fire extinguishers. 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 [...]”

MDH’s finding, as written: “Based 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; 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 ensure there were no non-contracted residents living in the building (volunteer (V)-E).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure there were no non-contracted residents living in the building (volunteer (V)-E). This had the potential to affect the one of one resident (R1). [...]”

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 ensure training and competency evaluations were completed for all required skill areas, prior to providing services, for two of two (unlicensed personnel (ULP)-D, ULP-F).

MDH’s finding, as written: “Based on 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 two of two (unlicensed personnel (ULP)-D, ULP-F). [...]”

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) [...]”

Summary: MDH found the licensee failed to ensure training and competency evaluations for the required topics for two of two (unlicensed personnel (ULP)-D, ULP-F) with records reviewed.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure training and competency evaluations for the required topics for two of two (unlicensed personnel (ULP)-D, ULP-F) with records 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, including all required content, for three of three employees (clinical nurse specialist (CNS) -B, unlicensed personnel (ULP)-D, ULP-F).

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure employees received orientation to assisted living, including all required content, for three of three employees (clinical nurse specialist (CNS) -B, unlicensed personnel (ULP)-D, ULP-F). [...]”

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 employees received at least eight (8) hours of training for each 12 months of employment for three of three employees (clinical nurse supervisor (CNS) -B, and unlicensed personnel (ULP)-D, ULP-F).

MDH’s finding, as written: “Based on observation, interview and record review, the licensee failed to ensure employees received at least eight (8) hours of training for each 12 months of employment for three of three employees (clinical nurse supervisor (CNS) -B, and unlicensed personnel (ULP)-D, ULP-F). [...]”

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 three of three employees (clinical nurse supervisor (CNS) -B, and unlicensed personnel (ULP)-D, ULP-F).

MDH’s finding, as written: “Based on observation, 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 three of three employees (clinical nurse supervisor (CNS) -B, and unlicensed personnel (ULP)-D, ULP-F). [...]”

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 an individualized medication management plan included all the required content for one of one resident (R1).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure an individualized medication management plan included all the required content for one of one resident (R1). [...]”

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 written or electronically recorded prescriptions were obtained for one of one resident (R1).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure written or electronically recorded prescriptions were obtained for one of one resident (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) and was issued at a widespread scope (when problems are pervasive or represent a systemic failure that has affected or has the potential to affect a large [...]”

Rule cited: “There must be a current written or electronically recorded prescription as defined in section 151.01, subdivision 16a, for all prescribed medications that the assisted living facility is managing for the resident.”