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Standards of Practice

  • What happens when someone complains about me?
    A very detailed description of complaints, individual rights and board policies is found on this website under the "Complaints" tab.
  • I just got a letter from the complaint committee, what’s next?
    The three person panel needs to investigate all complaints or concerns that are presented to the Board. Typically, any administrative tag will result in an inquiry by the committee. The board must investigate complaints but takes into consideration compliance history, tenure of employment as the Administrator of Record, and the individual complaint received. Sometimes, it closes the case without inquiry, other times it must get the administrator perspective as to why this happened and compare the response to the community or peer standard. 
  • Why did I get this letter?
    Any OHFC finding that involves resident rights or a MDH substandard care finding in quality of care, quality life or Facility Practices and resident rights will be reviewed by the SOPC. The standard response from the SOPC is to request the administrator perspective of why the finding was identified while focusing on administrative systems only.

    Be brief and to the point in the response. The committee desires that you involved your team, looked at the root cause of the problem and identify how to achieve system correction. They know it's a challenge, but expect you to think resident first and make progressive changes. 
  • I just had a complaint from OHFC, does that mean the board will be contacting me?
    Not necessarily. The board doesn’t receive all OHFC complaints, but primarily those involving VAA systems, operational systems, or any specific administrative issues.
  • The Minnesota Department of Health just left and I have a substandard quality of care finding, will I need to appear in front of the Standards of Practice Committee?
    Not necessarily. The board does receive all substandard quality of care, quality of life and resident behavior and facility practices findings per federal requirements. The three person complaint panel looks at the findings to determine if those findings are significantly out of industry or community standards. How do they compare to the industry trends, what is the facility and administrator history for compliance, and how did the facility respond? The SOPC is concerned with a forward response and action to resident centered improvements. The administrator should be engaged in the QI/QA process using all of the multidisciplinary teams talents to work towards continuous improvement of this and other issues presented. The committee will ask for the administrator’s assessment of the identified problem, solutions presented and action plans delivered. A lack of action is inexcusable. A planned, coordinated, best effort is usually assessed as acceptable. 
  • When does the complaint become public?
    The complaint becomes public if formal action is warranted by the committee, is written in a formal document that is eventually agreed upon by the licensee and the board. Information is only public when classified as public and investigatory material is considered private or confidential, neither of which can be made public unless a formal agreed upon stipulation and order is determined. 
  • What is “Just Culture"?
    “Just Culture” is a model of assuring accountability and responsibility without assigning individual blame for all cases that the BENHA believes creates transparency and accountability. For some cases, an individual is the only person that should and will be held individually accountable. For most cases, the system or unintentional actions by an individual need to be coached, counseled and educated for changes within the system. Just Culture originated in the airline industry where it was determined that individual blame produces more cover ups, avoidance of large issues and consequences which ultimately creates an unsafe environment. 
  • What is the Best Practices Change Package

    The Best Practices-Change Package for Administrators is a great tool developed by Stratis Health, as the Quality Improvement Organization (QIO) contracted with the Center for Medicare and Medicaid Services.  This tool kit can help reinforce a seasoned administrator as well as assist a newer administrator with basic reminders of proven action steps to reinforce the administrator’s global core competencies.   Stratis Health is an excellent partner for the Executive Administrator of Long Term Care Supports and Services with various quality improvement projects,


  • How does the public know if the administrator of a facility is licensed?
    Licensees are required to post their license in a conspicuous place in the facility which the licensee administers, visible to residents and families. If you don’t see one, ask to see the administrator's license. 
  • How does the board ensure that once an administrator gets a license s/he remains competent to practice?
    Like all health licensing boards, our board sets requirements for a certain amount of continuing education in order to get their LNHA license renewed annually. Our licensees need 20 hours of continuing education in pertinent areas each year. 
  • How many complaints does the board get each year?
    In the past five years, we have averaged 110 per year. 
  • How does a person with a complaint about treatment or conditions in a nursing home go about filing it?
    Work with staff at the facility to correct or improve care of your family member. There is usually a resident advocate at each facility who will assist you in resolving issues as a team concerned about your loved one.

    If communication fails and you don’t see resolution, a number of resident advocates exist.
    Office of Health Facility Complaints: 651.201.4201
    This agency, through the Minnesota Department of Health, has trained investigators to perform unannounced onsite visits regarding facility practices related to the presented concerns.

    Ombudsman Office(s): Ombudsman for Older Minnesotans 800-657-3591
    A program of the Minnesota Board on Aging, the Office advocates for person-directed living throughout the health care continuum, which respects individual values and preferences and preserves individual rights.

    An ombudsman is an independent consumer advocate. Ombudsmen investigate complaints concerning the health, safety, welfare and rights of long-term care consumers, work to resolve individual concerns, and identify problems and advocate for changes to address them, at no charge to the consumer.

    If directly regarding the administrator or needing direction, contact our office 651.201.2730. 
  • I’m disappointed in the care at the nursing home. What should I do?
    Our advice is to always speak with staff and then the administrator to work through issues or concerns you may have. If the issue remains unresolved and is a care related issue, the Office of Health Facility Complaints (OHFC) is the best source for action. They have Registered Nurses trained as investigators assigned to complete unannounced visits regarding onsite care issues. If the issue is substantiated, a report is forwarded to our agency to review for administrative systems and to assure the facility is meeting community standards. If the issue is directly related to the Administrator, the complaint panel of the board will take action. 
  • I have a complaint about Assisted Living. How can I report it?
    The board has no jurisdiction over Assisted Living or Housing with Services as Minnesota does not credential those managers. Follow the same guidance: Office of Health Facility Complaints (OHFC) will accept complaints about those organizations and can be reached at 651.201.4201.