Leadership Insights: Regulatory Compliance Overview for Minnesota Assisted Living Providers
Insights from Colleen Toebe, MSN, CWCN, RAC-MTA, RAC-MT, DNS MT – Vice President of Clinical Services
Minnesota law requires the Minnesota Department of Health (MDH) to survey licensed assisted living providers at least once every two years. These surveys assess the care and services provided to residents and ensure compliance with state licensing requirements.
If MDH identifies noncompliance, a correction order is issued, categorized by scope and severity:
- Scope refers to how widespread the issue is (isolated, pattern, or widespread).
- Severity ranges from no actual harm with minimal potential risk to immediate harm to resident health or safety.
The purpose of these surveys is to evaluate and monitor the care and services provided to assisted living residents and determine if the provider is complying with assisted living licensing requirements.
When MDH identifies a provider is out of compliance with a licensing requirement, MDH issues a correction order to the provider. Correction orders are assigned a scope and severity level that categorizes the seriousness of the provider’s noncompliance with the requirement.
The scope of noncompliance refers to how widespread the problem is; it can be isolated, pattern, or widespread. The severity level of the noncompliance ranges from no actual harm.
Survey Updates:
The second round of the Assisted Living Survey began in November of 2024. The top five tags for the first round included for 2022-2024:
- Minnesota Food Code
- Fire Safety Evacuation Plans
- Physical Environment
- Emergency Preparedness
- Resident Reassessments
- Tuberculosis Prevention and Control
- Minimum Requirements: Staffing Plan
Assisted Living Report Card
In January 2024 the Assisted Living Report Card was publicly launched, with the first round of resident quality of life and family satisfaction ratings for over 450 assisted living facilities.
New Requirements
By July 1, 2025, providers must ensure that staff receive two hours of initial training on mental illness and de-escalation strategies.
Ongoing Report Card Initiatives (Feb 2024 – Feb 2025):
- Conducting a third round of statewide resident and family survey data collection in assisted living facilities with the capacity to serve five or more residents.
- Publishing resident quality of life and family satisfaction ratings on more assisted living facilities based on the third round of statewide resident and family surveys.
- Finalizing additional measures of quality, including the resident health, safety, and staffing measures, based on state licensing inspections and other data sources.
Leadership Considerations
As you prepare for Minnesota’s assisted living regulatory updates and ensure compliance, consider the following:
Strengthen Compliance Monitoring & Internal Audits
- Conduct regular audits aligned with MDH survey focus areas (e.g., food safety, emergency preparedness, staffing plans).
- Establish proactive compliance tracking to identify and address gaps before regulatory surveys.
- Conduct mock surveys to prepare teams for real inspections.
Enhance Staff Training & Readiness
- Implement ongoing education on state licensing requirements and compliance best practices.
- Ensure staff complete the new required 2-hour training on mental illness and de-escalation before the July 1, 2025, deadline.
Improve Resident-Centered Quality Measures
- Actively monitor and address feedback from the Assisted Living Report Card to improve resident and family satisfaction.
- Implement data-driven decision-making to enhance care quality and outcomes.
Strengthen Emergency Preparedness
- Update and test fire safety evacuation plans and emergency response protocols regularly.
- Ensure compliance with infection control measures, including Tuberculosis Prevention and Control.
Foster a Culture of Compliance & Accountability
- Encourage open communication between leadership, staff, and residents regarding compliance expectations.
- Assign compliance champions within teams to oversee best practices and training.
- Regularly review state updates and adjust policies accordingly to stay ahead of regulatory changes.
We’re Ready to Support
By focusing on these leadership strategies, assisted living providers can proactively navigate regulatory updates, enhance resident care, and maintain full compliance with MDH requirements. Contact us to get started.
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