MN - State Survey Guide

Minnesota Residex users may find the following tips helpful during a survey, whether it is an initial, follow-up, or complaint-driven survey. The MN Department of Health website is a good survey resource and offers some helpful documents: https://www.health.state.mn.us/facilities/regulation/assistedliving/survey.html

Survey Preparation

Some actions you can take to be fully prepared for survey:

1. Review the report Current Resident Roster - Assisted Living to ensure the data is accurate. Note that some data may need to be manually entered (see those in the key marked '9').
2. Consider how you want to provide data to the surveyor. Users may opt to provide paper reports as printed in Residex in the Tag: State of MN Survey folder. Alternatively, add them as a surveyor user in Profiles > Staff and limit their access to those residents selected for chart review. You can provide information to them about how to navigate in Residex as well.
3. Some consultants recommend destroying 'informal' communications such as a written communications log or snap messages periodically, as these are discoverable at time of survey. If you wish to follow this advice, contact ResiDex support and we can set up snap messages to auto-purge at specified intervals.
4. Familiarize yourself with the collection of reports we reference later in this article, located in the Tag: State of MN Survey folder. These are the most commonly requested reports. Your knowledge of these can set the right tone for the survey.
5. Contact ResiDex support at 866.512.8369 and let us know you're in survey! We're on standby to assist.
6. Are you fully using Residex? These features play a part in compliance
   • Assessments in Residex, using notes liberally throughout. This will create your Individual Abuse Prevention Plan, Individual Medication Management Plan, Fall Risk and Bed Safety evaluations, and orient your staff to the plan of care.
   • Incident Entry with the Clinical Review
   • Treatment and Supervision services to create the Individual Treatment and Therapy Plan. Be detailed in your instructions to staff, including when to notify the nurse.
   • Meds Sent out of Facility with review of those medications
   • Staff Meetings including documentation of Quality Management activities
7. Have a plan for survey. Identify a convenient space where the surveyor can set up, offer a cup of coffee or water, and follow the directions below

Initial Surveyor Requests

Surveyors, upon arrive at the facility, will request some key information

1. Current Client Roster. Print the Client Roster - MN or the Client Roster - MN SOC. The first bases data off the date of admission, the second bases data off the date of the first home care service provided.
2. Discharged Client Roster. Print the Discharged Client Roster.
3. Admission Information (advertising or marketing materials, complaint notice procedure, Bill of Rights and other materials provided to your residents on admission).
4. Incident reports from the last 6 months. Print the report Incident Summary - All Residents.

Once these have been provided, the surveyor will likely request:

1. TB Risk assessment and Infection Control policies. If you enter and maintain current policies in Residex, the report Policy Document can be selected and printed. Or you might keep these in Campus Documents.
2. Documentation of any MAARC (Minnesota Adult Abuse Reporting Center) reports AND client complaints for the past 6 months. These might be filed as Campus Documents.
3. Policies and Procedures related to unlicensed personnel orientation, training, competency testing, and med administration.
4. Completed Medication documentation for selected residents. Print Admin Summary Month.
   Med Setup Summary would show med setup/review done by the nurse.
5. The CLIA waiver, if applicable. This could be kept in Campus Documents.
6. A list of current employees and their hire dates. Staff List by Hire Date will show this.
7. Licensed staff proof of licensure. These might be attached to the Staff Profile > Documents.
8. Disaster and Emergency Plan. This might be either a Policy or Campus Document.
9. Dementia Training Notice. This, too, might be a Campus Document.

Client Record Review

Based upon data in the Current Client Roster, the surveyor will request access to specific resident charts. This might include:

1. Individual Abuse Prevention Plan. This report pulls current data from the last completed assessment.
2. Individual Treatment and Therapy Plan. This report shows treatment services that have linked supervision services for the selected resident.
3. Service Plan / Agreement. This document should be reviewed with the resident / family, signed, and scanned into that resident's documents. This report in Residex will automatically include the acknowledgment of receipt of the Home Care Bill of Rights and other documents on admission AND will include the Home Care Services Offered documentation that is required.
4. History of assessments - the report Assessment History by Client or navigate to Assessment History under Clinical > Assessments > select the resident and Assessment History.
5. The report Service Recap Summary Month will show services completed, service notes, etc...
6. Current services can be shown on Planned Services report
7. Resident notes can be shown on the report Resident Notes - One Resident.
8. Client Record Security. If questioned, some features in Residex that support HIPAA Security include
   • Secure login processes
   • Staff Roles and Provider types limit access to screens and limit ability to enter data
     -Location based controls limit access to Residex for some users by IP Address.
9. Significant Changes or Incidents and the actions taken would be reflected in
   • Assessments performed and or the report Assessment Changes that shows differences between the last 2 assessments performed.
   • Resident Notes
   • Incidents

Medication Management Services

1. Initial Individual Medication Management Plan. This data pulls from the assessment Med Admin and Med Management categories. If the surveyor wishes to see how this was answered on Admission, guide him/her to the Admission Assessment > Medication Category. For the current report, simply provide Individual Medication Management Plan. This report always shows current data.
2. Nurse review of medications including contraindications, side effects, etc.... is in the Assessment > Medication category and so is updated with each reassessment. Data pulls to the IMMP (above). If you do NOT have this item in your assessment, contact ResiDex support and we will update your assessment.
3. Medication Administration Records - Med Admin Summary Month report
4. Med setup - if you do this, it is recorded in Med Setup Summary report
5. Documentation of Medications sent out of facility is Meds Sent out of Facility
6. Prescriber's orders are documented as Provider Orders and may be saved as documents in the Resident Profile > Documents.

Treatment and Therapy Management Services

Three pieces of documentation support this requirement

1. Individual Medication Management Plan shows the plan
2. Service Plan / Agreement informs the residents of these services
3. Service Recap Summary Month shows that they were actually provided

Frequently Asked Questions by Surveyors

1. How do you orient staff to the Plan of Care?
   • Care Plans are sent electronically to staff to review and acknowledge upon completion of the assessment
   • A link to the current care plan is available in any service for that resident
   • Master Care Plan reports are available to staff as reports
   • Care Plans Reviewed - Staff and Care Plans Reviewed by Resident will show that staff have reviewed Plans of Care.
2. How can you demonstrate Disposition of Medications (including Discharged Medications)? If you've documented these under Clinical > Dispose of Medications, the report Discharge Medications and Medication Disposition - Resident will demonstrate this.
3. How can you demonstrate compliance with Quality management activities?
   • Staff Meeting Report shows meeting dates, notes, and attendees. Recording quality management activities as a staff meeting meets the requirement.
   • Audits can be completed and printed
   • Quality Assurance Dashboard report will not show the actual activities, but can illustrate progress toward certain goals.

MN State Survey Reports

All are available in Residex and are in the Tag: State of MN Survey category unless stated otherwise

1. Service Plan - customizable, includes private pay and waiver options, located in Agreements reports category
2. Admission Assessment shows any resident's assessment as of date completed
3. Assessment by Date shows each completed assessment following the Admission assessment
4. Assessment as of Date shows how assessment items were answered as of any point in time
5. Assessment History by Client is a summary of the dates assessments were completed
6. Care Plans Reviewed by Resident shows that staff were oriented to the plan of care
7. Care Plans Reviewed by Staff will show by staff person what care plans they reviewed
8. Current Client Roster or Current Client Roster SOC is the document asked for initially detailing information across the campus. You may need to manually enter some data here.
9. Discharged esident/Client Roster is requested initially and shows only discharged residents in the last 6 months.
10. Incident Report is the report of a single resident incident
11. Incident Summary - All Residents is a summary of the incidents that occurred across the campus for given date range. Incident Summary - One Resident only shows one resident's history of incidents
12. Individual Abuse Prevention Plan pulls current vulnerabilities based upon the last assessment. The notes entered for that item become the plan of action. If they want a history of this report, refer to the Resident Assessment report.
13. Individual Medication Management Plan pulls from the last updated assessment.
14. Individual Treatment and Therapy Plan pulls data from treatment services and their corresponding supervision services.
15. Master Care Plan is the paper version of the care plan staff review when an assessment is marked complete
16. Provider Orders shows the comprehensive orders for the resident, signed by the Provider. Can be saved in documents.
17. Med Admin Summary month shows med charting for a given month- a completed MAR. Med Admin Summary - Actual Month includes the time the med was actually charted.
18. Med Setup Summary shows the nurse review/setup completed under the Clinical > Med Setup step.
19. Medications Controlled Recap by Staff compares administration frequency of PRN controlled meds by staff persons. Helpful in OHFC investigations or suspected drug diversion investigations.
20. Medication Disposition - Controlled shows all controlled meds disposed of for a specified period
21. Medication Disposition all meds destroyed or disposed of during a given period
22. Medications Current - by Time and Medications Current both show a resident's current med list
23. Meds Sent Out of Facility accounts for meds packaged up and sent with residents to be administered outside the facility. Includes nurse review.
24. Resident Notes - One Resident shows resident notes for a period.
25. Schedule of Care Visit Worksheet shows for a given day what each resident's schedule of services is. Allows the surveyor to plan for staff observations.
26. Service Recap Summary Month or Services Delivered One Resident is the completed Treatment record including service notes.
27. Staff In-service Training with CEU shows staff training recorded in Residex by staff.
28. Staff List by Hire Date is a simple list of staff with provider type and date of hire
29. Staff Meeting Report is the summary of a staff meeting, including required Quality meetings
30. Staff Supervision Summary is the summary of staff supervisions completed for a staff member.
31. Treatment and Therapy Plans - Campus is a campus wide view of all treatment