Latest Updates on the MDH Assisted Living License Survey Trends

From the desk of Julie  —

It’s hard to believe a year has passed since the Minnesota Department of Health (MDH) introduced new assisted living regulations. To date, there have been 346 survey results posted by MDH. The average number of deficiencies per survey is approximately 14. The top five most common survey deficiencies cited following a state survey were:

1. Tag 0810: 144G.45 Subd. 2 (b)-(f) Fire protection and physical environment – Fire Safety and Evacuation Plans, Training, and Drills (79% of surveys)
Common problems identified:

• No evidence employees were trained on fire safety and evacuation plans upon hire and twice per year
• No evidence of a plan or policy/procedure to make available annual fire safety and evacuation training for residents able to assist in their own evacuation
• Fire/evacuation drills were not planned or documented
• Failure to ensure fire safety and evacuation plans were readily available to residents, staff, and visitors
• Failure to identify residents who may need additional assistance for evacuations

2. Tag 0480: 144G.41 Subdivision 1. (13) (i) (B) facility is not following the Minnesota Food Code, Ch. 4626; Completed by EH – (75% of surveys)
Common problems identified:

• Inaccurate refrigerator temperature or no thermometer to check the temperature
• TCS food not date-labeled or stored past date
• No method to verify sanitizing solution (test strips) or no solution available
• No certified food protection manager is employed or being shared across multiple communities
• No proof staff had been trained in vomit or fecal matter cleanup procedures, and no PPE or cleanup kit made readily available
• Improper food storage – dry goods on the floor, food stored on the floor of the walk-in cooler, raw foods not on the lowest level of the refrigerator
• Unkempt kitchen area – rusty shelves, soiled mugs, slime on ice machine, light bulbs burned out, grease on the floor, floor drain missing a cover

3. Tag 0680: 144G.42 Subd. 10 – Disaster planning and emergency preparedness plan – (60% of surveys)
Common problems identified:

• No prominent signage or postings regarding the facility’s emergency plan at the facility entrance, in the hallways, in the dining area, or the living areas
• Emergency exit diagrams were not posted on each floor
• Emergency preparedness staff training (on hire and twice annually) was not planned or documented
• Emergency drills were not planned or documented
• Hazard Vulnerability Analysis lacking analysis of potential vulnerabilities
• Emergency Preparedness Plan failed to describe the population served by the facility, the process for cooperation with state and local officials, and policies and procedures for sheltering in place

4. Tag 0800: 144G.45 Subd. 2 (a) Physical environment – Good Repair and Condition – (48% of surveys)
Common problems identified:

• Emergency lights or regular lights that do not work
• Doors held open by wedges or that do not latch properly
• Exit doors blocked
• Inadequate unobstructed space below sprinkler heads
• Loose or missing handrails
• Flooring – cracked or missing tiles, worn or torn carpeting
• Windows in secured unit missing stoppers to restrict resident elopement
• Windows in sleeping rooms that are too small.

5. Tag 0780: 144G.45 Subd. 2. (a) (1) Fire protection and physical environment – Smoke Alarms – (42% of surveys)
Common problems identified:

• Unplugged smoke alarms
• Smoke alarms not installed where required
• Disconnected or disabled smoke alarms
• Smoke alarms with dead batteries or expired (more than10 years old)
• Smoke alarms that were not interconnected within a unit
• Obstructed sprinkler heads or covered in lint
• Use of unfused and unapproved power strips and multiplug adapters

* Data obtained from Care Providers of Minnesota

What this means for you:
Be prepared for when the state arrives at your facility. As you can see, most of the top deficiencies are areas new to the assisted living license – food code and environmental. Make sure your maintenance and kitchen staff understand the new regulations. Have your maintenance team conduct environmental inspections to ensure that your facility is in good condition and that the emergency plan is up to code. Make sure to have a Certified Food Protection Manager and that there is always a person in charge. Managers should conduct  routine audits of kitchens and staff to ensure proper food safety.

For assistance with updating your documents please visit our website at srcaresolutions.net.

Julie Dietz, RN, PHN
Senior Assisted Living Consultant
julie.dietz@srcaresolutions.net