Survey Forms posted for Assisted Living Licensed Settings

Posted on July 21, 2021 by Bobbie Guidry

On Friday, the Minnesota Department of Health (MDH) posted the forms staff will use to conduct a survey under the new assisted living licensure laws.

Minnesota assisted living laws require that MDH survey licensed assisted living providers at least once every two years. For providers who converted from a home care license, this two-year period begins on Aug. 1. Provisional license applicants will have an initial full survey within one year of notifying MDH that they provide services to a resident.

The survey forms, posted last Friday, are the same forms MDH staff use when conducting a survey. Reviewing the forms will help providers understand what MDH will look at when they visit and complete self-audits.

Assisted living statutes are included throughout the forms to help providers understand state requirements.

• Current Resident Roster (P5060) (PDF)
• Discharged or Deceased Resident Roster (P5061) (PDF)
• Employee List (P5066) (PDF)
• Employee Record Review (P5021) (PDF)
• Entrance Conference (P5065) (PDF)
• Exit Conference Attendance (P5068) (PDF)
• Medication Administration Observation and Drug Storage (P5028) (PDF)
• Resident and Employee Record Review List (P5044) (PDF)
• Resident Observation and Record Review (P5022) (PDF)
• Treatment Observation (P5027) (PDF)