Focus Areas in Early AL Surveys: Postings, Plans, Procedures, Training, and Infection Control

Posted on October 28, 2021 by Bobbie Guidry

Findings during initial surveys of assisted living settings show a range of compliance with most providers well underway with incorporating new requirements. Several themes are evident in these initial findings. Learning more about these themes can assist providers in auditing their facilities for compliance. 

The Minnesota Department of Health (MDH) cited several findings related to required postings. In addition to what's specified in the assisted living statute, surveyors are also looking for the necessary posting regarding electronic monitoring. 

Several other areas frequently noted include:

• Service plans include all assisted living services provided. In several situations, cares were being delivered that were not reflected on the service plan.
• Hazard vulnerability assessments with mitigation plans in place for any identified high-risk vulnerabilities such as blizzards, tornados, power outages, etc. The assessment and mitigation plan should include identification of any hazards inside and outside of the facility such as ponds or busy roadways, a need required explicitly for assisted living with dementia care.
• Fire safety and evacuation plans, training and drills must be completed and scheduled and include an offer to train residents capable of participating in an evacuation at least once a year. Employees must receive training on the fire safety and evacuation plans upon hiring and at least twice per year after that. Evacuation drills are required for employees twice per year per shift, with at least one evacuation drill every other month. Evacuation of the residents is not required. Fire alarm system activation is not required to initiate the evacuation drill.
• Infection control, including TB screening and COVID-19 protocols, including eye protection, medical-grade masks for covid prevention, and screening visitors, including surveyors, is required upon entry.
• Employee records must be in place for contract and facility staff, including documentation of their training and orientation.
• The quality management plan must be in compliance with 144G.42 in keeping with the size of the facility.
• Food code requirements were also a focus. Safe food handling, temping of food, refrigerators and dishwashers, and having a Certified Food Protection Manager (CFPM) on staff were items frequently noted.

Regarding surveys, in her comments at the LeadingAge Minnesota Connect Conference yesterday, Lindsey Krueger of MDH informed LeadingAge Minnesota members, "Before one of our evaluators arrive, they may call you the morning of to notify you of the survey starting that day and will send an email with attachments and identify documents they would like you to have ready when they arrive.  When the survey starts, the survey starts. You are not able to ask for the survey to occur on a different day. We will also be providing presurvey notification to the Long-Term Care Ombudsman's Office as well."

In addition to surveyors from the Health Department's Health Regulations Division (HRD), engineering staff will inspect the physical plant. Sanitarians from the Environmental Health Division of MDH will also visit to inspect kitchens and foodservice. They may not all come at once but will be scheduled within a few days of each other to ensure the survey cycle has all of those required elements included.

MDH reported they will be conducting observations and interviews and looking at record reviews, including residents, employees, operational/administrative policies and procedures, reviews of the physical plant, food code requirements, Appendix Z and other required areas of the statute and rules. 

Self-auditing utilizing the MDH surveyor forms is an excellent way to prepare for surveys and ensure compliance with regulations. LeadingAge Minnesota also has many helpful resources, including our just-updated Essential Guide to Assisted Living in Minnesota.