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Considerations for Establishment of a Nursing Home Case - Investigation

Posted by attorney Kenneth LaBore

Investigation of Case and Provider

Minnesota Administrative Rule 4658.0135 Policy Records.

Subpart 1. Availability of policies.

All policies and procedures directly related to resident care adopted by the home must be placed on file and be made available upon request to nursing home personnel, residents, legal representatives, and designated representatives.

Subp. 2. Admission policies.

Admission policies must be made available upon request to prospective residents, family members, legal representatives, and designated representatives.

Minnesota Administrative Rule 4658.0110 Incident and Accident Reporting

All persons providing services in a nursing home must report any accident or injury to a resident, and the nursing home must immediately complete a detailed incident report of the accident or injury and the action taken after learning of the accident or injury.

Claim Investigation

Record Retrieval

Access to Record: Upon an oral or written request to access all records pertaining to resident…within 24 hours and after receipt of resident’s records for inspection, to purchase copies at cost not to exceed community standard within 2 working days of advanced notice to the facility. 42 CFR 483.10(b)(2).

Record-keeping Requirements:

Clinical record must contain:

  • sufficient information to identify resident;

  • a record of resident’s assessments (cognitive, fall risk, skin, etc);

  • the plan of care and services provided;

  • the results of any pre-admission screening conducted by the State and progress note. 42 CFR 483.75(I)(5).

Additional Records to Request:

-MDS, Minimum Data Set (Sets forth baseline for Medicare billing purposes)

-Nurses chart nursing notes, progress notes, medication administration records,

assessment plans.

  • Nursing Aides chart activities of daily living (ADLs).

  • Physician Orders

-Physical/Occupational/Speech Therapy


Staffing & Training Records:

Have sufficient nursing staff. 42 CFR § 483.30

Minnesota Rule 4658.0105 Competency

A nursing home must ensure that direct care staff are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through the comprehensive resident assessments and described in the comprehensive plan of care, and are able to perform their assigned duties.

Minnesota Rule 4658.0510 Nursing Personnel

Subpart 1. Staffing requirements.

A nursing home must have on duty at all times a sufficient number of qualified nursing personnel, including registered nurses, licensed practical nurses, and nursing assistants to meet the needs of the residents at all nurses' stations, on all floors, and in all buildings if more than one building is involved. This includes relief duty, weekends, and vacation replacements.

Subp. 2. Minimum hour requirements.

The minimum number of hours of nursing personnel to be provided is:

For nursing homes not certified to participate in the medical assistance program, a minimum of two hours of nursing personnel per resident per 24 hours.

Minnesota Rule 4658.0710 Admission Orders and Physical Evaluations

Subpart 1. Physical examination.

A resident must have a current admission medical history and complete physical examination performed and recorded by a physician, physician assistant, or nurse practitioner within five days before or within seven days after admission.

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