Healing Home Services

Summary: MDH found the licensee failed to ensure employee records included all required content for three of three employees (licensed assisted living director/clinical nurse supervisor (LALD/CNS)-A, unlicensed personnel (ULP)-B, and ULP-E).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure employee records included all required content for three of three employees (licensed assisted living director/clinical nurse supervisor (LALD/CNS)-A, unlicensed personnel (ULP)-B, and ULP-E). [...]”

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 licensee failed to maintain a tuberculosis (TB) prevention and control program, based on the most current guidelines issued by the Centers for Disease Control and Prevention (CDC), to include baseline screening for one or three employees (licensed assisted living director/clinical nurse supervisor (LALD/CNS)-A), failed to complete TB testing upon hire for two of three employees (LALD/CNS-A and unlicensed personnel (ULP)-E), and failed to follow-up on positive TB results for one of three employees (ULP-E).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to maintain a tuberculosis (TB) prevention and control program, based on the most current guidelines issued by the Centers for Disease Control and Prevention (CDC), to include baseline screening for one or three employees (licensed assisted living director/clinical nurse supervisor (LALD/CNS)-A), failed to complete TB testing upon hire for two of three employees (LALD/CNS-A and unlicensed personnel (ULP)-E), and failed to follow-up on [...]”

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 [...]”

Summary: MDH found the licensee failed to develop a written emergency preparedness plan (EPP) with all the required content.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to develop a written emergency preparedness plan (EPP) with all the required content. This had the potential to affect all residents, employees, and visitors to the facility. [...]”

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 ensure that personnel and resident records were readily available for timely access to employees, vendors, and the commissioner authorized to access the records.

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure that personnel and resident records were readily available for timely access to employees, vendors, and the commissioner authorized to access the records. [...]”

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 ensure the resident records included documentation of activities of daily living for four of four residents (R2, R3, R4, and R5).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the resident records included documentation of activities of daily living for four of four residents (R2, R3, R4, and R5). [...]”

Rule cited: “Contents of a resident record include the following for each resident: (1) identifying information, including the resident's name, date of birth, address, and telephone number; (2) the name, address, and telephone number of the resident's emergency contact, [...]”

Summary: MDH found the licensee failed to provide smoke alarms that functioned and were interconnected so that the actuation of one alarm caused all alarms in the dwelling unit to actuate.

MDH’s finding, as written: “Based on observation and interview, the licensee failed to provide smoke alarms that functioned and were interconnected so that the actuation of one alarm caused all alarms in the dwelling unit to actuate. This deficient condition had the ability to affect all staff and residents. [...]”

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 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 potential to affect all staff, residents, and visitors. [...]”

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 the fire safety and evacuation plan with the required content and provide the required training and drills.

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 and provide the required training and drills. 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 develop and execute a written assisted living contract with the required content for one of four residents (R3).

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 one of four residents (R3). [...]”

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 provide a written notice with required content for an emergency relocation and failed to notify the Office of Ombudsman for Long-Term Care (OOLTC) of the emergency relocation for one of one resident (R2).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to provide a written notice with required content for an emergency relocation and failed to notify the Office of Ombudsman for Long-Term Care (OOLTC) of the emergency relocation for one of one resident (R2). [...]”

Rule cited: “(a) A facility may remove a resident from the facility in an emergency if necessary due to a resident's urgent medical needs or an imminent risk the resident poses to the health or safety of another facility resident or facility staff member. [...]”

Summary: MDH found the licensee failed to ensure a background study was submitted and received in affiliation with the assisted living license prior to staff providing services for three of eight employees (house manager (HM)-C, unlicensed personnel (ULP)-E, and ULP-F).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure a background study was submitted and received in affiliation with the assisted living license prior to staff providing services for three of eight employees (house manager (HM)-C, unlicensed personnel (ULP)-E, and ULP-F). [...]”

Rule cited: “(a) Employees, contractors, and regularly scheduled volunteers of the facility are subject to the background study required by section 144.057 and may be disqualified under chapter 245C. [...]”

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure all employees that performed direct services completed all required training components for each twelve months of employment for four of four employees (licensed assisted living director/clinical nurse supervisor (LALD/CNS)-A, unlicensed personnel (ULP)-B, ULP-D, and ULP-E) 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 [...]”

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 registered nurse (RN) conducted a comprehensive assessment not to exceed 90 calendar days from the last date of the assessment for two of four residents (R3 and R5).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure the registered nurse (RN) conducted a comprehensive assessment not to exceed 90 calendar days from the last date of the assessment for two of four residents (R3 and R5). In addition, the licensee failed to ensure the RN conducted reassessment and monitoring as needed based on changes in the needs of the residents for one of one resident (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 revise the service plan when changes in service needs occurred for two of three residents (R3 and R4).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to revise the service plan when changes in service needs occurred for two of three residents (R3 and R4). [...]”

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 one of four residents (R5).

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 one of four residents (R5). 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: “(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 the registered nurse (RN) conducted a face-to-face medication management assessment, prior to providing medication management services, to include all required content for one of four residents (R3).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the registered nurse (RN) conducted a face-to-face medication management assessment, prior to providing medication management services, to include all required content for one of four residents (R3). [...]”

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 monitor and reassess the resident's medication management services at least annually for four of four residents (R2, R3, R4, and R5).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to monitor and reassess the resident's medication management services at least annually for four of four residents (R2, R3, R4, and R5). In addition, the licensee failed to ensure the registered nurse (RN) conducted an accurate medication assessment for one of four residents (R3). [...]”

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 develop and maintain a current individualized medication management record for each resident to include all required content for four or four residents (R2, R3, R4, and R5).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to develop and maintain a current individualized medication management record for each resident to include all required content for four or four residents (R2, R3, R4, and R5). [...]”

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 medications were administered as prescribed; failed to ensure medication administration was documented accurately to include the time of administration; failed to ensure the Medication Administration Record (MAR) contained documentation of the reason and follow-up when medication was not administered as prescribed; and failed to ensure the MAR documentation included the signature and title of person administering medications.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure medications were administered as prescribed; failed to ensure medication administration was documented accurately to include the time of administration; failed to ensure the Medication Administration Record (MAR) contained documentation of the reason and follow-up when medication was not administered as prescribed; and failed to ensure the MAR documentation included the signature and title of person administering [...]”

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. [...]”

MDH’s finding, as written: “Based on interview and record review, the licensee failed to obtain a current written or electronically recorded prescription for all prescribed medications that the assisted living was managing for three of four residents (R2, R4, and R5). In addition, the licensee failed to obtain clarification on a duplicate order for two different doses from the same provider on the same day for one of four residents (R5). [...]”

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 ensure prescriptions were renewed at least every 12 months for three of four residents (R2, R4, and R5).

MDH’s finding, as written: “Based on interview and record review, the licensee failed to ensure prescriptions were renewed at least every 12 months for three of four residents (R2, R4, and R5). 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: “Prescriptions must be renewed at least every 12 months or more frequently as indicated by the assessment in subdivision 2. Prescriptions for controlled substances must comply with chapter 152.”

Summary: MDH found the licensee failed to store all medications in a securely locked location for one of four residents (R3).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to store all medications in a securely locked location for one of four residents (R3). 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: “An assisted living facility must store all prescription medications in securely locked and substantially constructed compartments according to the manufacturer's directions and permit only authorized personnel to have access.”

Summary: MDH found the licensee failed to provide documentation in the resident's record regarding the disposition of medication to include the medication name, strength, prescription number, quantity, date of disposition, and the names of staff involved in the deposition for all unused expired medications.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to provide documentation in the resident's record regarding the disposition of medication to include the medication name, strength, prescription number, quantity, date of disposition, and the names of staff involved in the deposition for all unused expired medications. This had the potential to affect all four residents at the facility. [...]”

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 ensure an individualized treatment and therapy management plan was developed with all the required information for one of one resident with treatments(R2).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure an individualized treatment and therapy management plan was developed with all the required information for one of one resident with treatments(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 registered nurse (RN) provided specific written instructions for each resident's treatment and documented those instructions in the resident's record for one of one resident with a treatment (R2) and instructed unlicensed personnel (ULP) in proper methods including documentation of demonstrated ability of unlicensed personnel to competently follow the procedure.

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure the registered nurse (RN) provided specific written instructions for each resident's treatment and documented those instructions in the resident's record for one of one resident with a treatment (R2) and instructed unlicensed personnel (ULP) in proper methods including documentation of demonstrated ability of unlicensed personnel to competently follow the procedure. [...]”

Rule cited: “Ordered or prescribed treatments or therapies must be administered by a nurse, physician, or other licensed health professional authorized to perform the treatment or therapy, or may be delegated or assigned to unlicensed personnel by the licensed health [...]”

Summary: MDH found the licensee failed to document treatment procedure of managing blood glucose monitoring arm sensor for one of one resident (R2).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to document treatment procedure of managing blood glucose monitoring arm sensor for one of one resident (R2). [...]”

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 there were up to date written or electronically recorded orders from an authorized prescriber for all treatments and therapies for one of one resident with a treatment (R2).

MDH’s finding, as written: “Based on observation, interview, and record review, the licensee failed to ensure there were up to date written or electronically recorded orders from an authorized prescriber for all treatments and therapies for one of one resident with a treatment (R2). [...]”

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