MDH Integrates Federal Complaints and Federal Surveys in SNFs

Posted on February 26, 2019 by Sue Boyd

The Minnesota Department of Health (MDH) has integrated responsibility for federal surveys and federal complaints into the Licensing & Certification (L&C) Program. What does this mean for care centers?  

L&C staff is now conducting complaint investigations in conjunction with surveys, stand-alone complaints and follow up visits. Substantiated deficiencies will be forwarded to the Office of Health Facility Complaints (OHFC) for determination of maltreatment under the state Vulnerable Adult Act, including the determination of responsibility (individual, facility or both).

Through this process, L&C staff are triaging the complaints and provider-reported-incidents relating to certified providers, such as nursing facilities. To improve MDH’s compliance with CMS triage determination and deadlines, complaints are being investigated with federal priorities under CMS Chapter 5 for Complaint Procedures. 

Based on the initial report, in situations where a determination is made that immediate jeopardy may be present and ongoing, the surveyor is required to start an on-site investigation within two working days of receipt of the complaint or incident report. 

Under this new system, MDH is finding that some of the facility-reported incidents are very brief and contain only a word or short sentence to describe the situation.  Because MDH determines if a two-day onsite investigation is required based on information provided by the facility in the initial online report, MDH provided some tips to assist buildings:

• TIP:  Include in an initial report more information, if known, to assist the surveyor in determining priority for triage.
• TIP: Review the definitions of abuse, neglect, injury of unknown origin, resident to resident, misappropriation of property for what is reportable and the timelines for reporting. While a facility may be limited regarding what information it is able to gather and report within the two-hour deadline, the facility may be able to include additional details of the alleged violation in circumstances when 24 hours are permitted, thereby assisting MDH triaging on-site investigation determination.
• TIP: Know your federal enforcement cycle and ensure you are in compliance to avoid federal remedies and maintain certification. The facility needs to be aware for the federal survey cycle, recertification surveys and complaint visit.  Multiple visits may mean the survey cycle is open for multiple months.  MDH suggests that facilities should work on “closing” that survey cycle by getting back into compliance as soon as possible.

The next statewide MDH Nursing Home Regulatory conference call is on Monday, May 13 from 11 a.m. to Noon. Hold the date on your calendar and watch for more information regarding agendas and any registration information.