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Registered nurses from the Minnesota Department of Health MDH ; use this Licensing Survey Form during on-site visits to evaluate the care provided by Assisted Living home care providers ALHCP ; . ALHCP licensees may also use this form to monitor the quality of services provided to clients at any time. Licensees may use their completed Licensing Survey Form to help communicate to MDH nurses during an on-site regulatory visit. During an on-site visit, MDH nurses will interview staff, talk with clients and or their representatives, make observations and review documentation. The survey is an opportunity for the licensee to explain to the MDH nurse what systems are in place to provide Assisted Living Home Care services. Completing this Licensing Survey Form in advance may facilitate the survey process. Licensing requirements listed below are reviewed during a survey. A determination is made whether the requirements are met or not met for each Indicator of Compliance box. This form must be used in conjunction with a copy of the ALHCP home care regulations. Any violations of ALHCP licensing requirements are noted at the end of the survey form. Name of ALHCP: RIVER BIRCH RESIDENCE HFID #: 21266 Date s ; of Survey: November 15, 16, 2006 Project #: QL21266002 Indicators of Compliance 1. The provider only accepts and retains clients for whom it can meet the needs as agreed to in the service plan. Focus Survey MN Rule 4668.0815 Expanded Survey MN Rule 4668.0050 MN Rule 4668.0800 Subp. 3 MN Rule 4668.0825 Subp. 2 MN Rule 4668.0845 Outcomes Observed Comments.
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