Assisted Living Forms and Self-Audit Tools

Notifications

Licensed providers are required to notify MDH and/or the Office of the Ombudsman for Long Term Care (OOLTC) at the Minnesota Board on Aging when certain changes occur.

• Closure Form (F4045) (PDF)
• Change of Information (F4040) (PDF)
• Minnesota Board on Aging - Provider & Partners Resources

Waiver and Variance Forms

• Assisted Living Licensure Innovation Variance Request (PDF): Use this variance request if the assisted living facility licensee or assisted living facility with dementia care licensee is requesting an innovation variance under Minnesota Statutes, section 144G.33.
• Assisted Living Licensure Rules Variance Request (PDF): Use this variance request if the applicant for, or licensee of, either an assisted living facility license or an assisted living facility with dementia care license is requesting a rules variance under Minnesota Rules, part 4659.0080.
• Sections 144G.45 or 144G.81 Waiver Request (PDF): Use this request form if the assisted living facility licensee or assisted living facility with dementia care licensee is requesting a waiver under Minnesota Statutes, sections 144G.45, subd. 7, or 144G.81, subd. 5.

Be Prepared for Your Survey

Minnesota assisted living laws require that the Minnesota Department of Health (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 August 1, 2021. Provisional license applicants will have an initial full survey within one year of notifying MDH that they are providing services to a resident.

To prepare for a survey, providers can use the forms on these pages. These are the same forms MDH staff use when conducting a survey. Reviewing the forms will help providers and their staff understand what MDH will look at when they visit.

Forms

Use the forms to:

• Understand the requirements of assisted living statutes
• Conduct self-audits
• Be ready for an MDH survey

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

• Clinical Laboratory Improvement Amendment Information (P5050) (PDF)
• Correction Order Documentation Guidelines (P5040) (PDF)
• Current Resident Roster (P5060) (PDF)
• Discharged or Deceased Resident Roster (P5061) (PDF)
• Emergency Preparedness: Appendix Z (P5069) (PDF)
• Employee List (P5066) (PDF)
• Employee Record Review (P5021) (PDF)
• Entrance Conference (P5065) (PDF)
• Exit Conference Attendance (P5068) (PDF)
• Exit Conference Guidelines (P5067) (PDF)
• Guide to the Survey Process (P5019) (PDF)
• HIPAA Information (P5035) (PDF)
• Interview: Resident or Resident Representative (P5043) (PDF)
• Medication Administration Observation and Drug Storage (P5028) (PDF)
• Records Request (P5036) (PDF)
• Requesting Reconsideration of Correction Orders (P4123) (PDF)
• Requesting Reconsideration of License Denial (P4125) (PDF)
• Resident and Employee Record Review List (P5044) (PDF)
• Resident Observation and Record Review (P5022) (PDF)
• Resources (P5000) (PDF)
• Treatment Observation (P5027) (PDF)
• Tuberculosis Prevention and Control: Surveyor Checklist (F5051) (PDF)