Assisted Living 
Forms and Self-Audit Tools

• Notifications
• Requests
• Waiver and Variance Forms
• Closure Forms
• Be Prepared for Your Survey

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.

• Change of Information (F4040) (PDF): Statute requires licensed assisted living providers to notify MDH of changes in facility contact information.
• Closure Form (F4045) (PDF): Licensed assisted living facilities must formally notify MDH when they are closing their license. Make sure to check the Closure Forms section below for further resources to assist in the closing process.
• Submitting Notices to OOLTC: Assisted living providers are required to submit certain notices to the Office of the Ombudsman for Long Term Care.
• Notice of Providing Assisted Living Services (P4030) (PDF): Within two days of beginning to provide assisted living services, the provisional licensee must provide notice to the commissioner that they are providing assisted living services.

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Requests

Licensed Providers are required to use these documents to make formal requests.

• Licensed Resident Capacity Increase Request (PDF): Use this form if you are requesting an increase to your licensed resident capacity either during your renewal license renewal period or at any point during your current licensing period.
• Licensed Resident Capacity Decrease Request (PDF): Use this form if you are requesting a decrease to your licensed resident capacity either during your renewal license period or at any point during your current licensing period.

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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.

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Closure Forms

• Closure Form for Assisted Living Providers (PDF): Use this form to notify the Minnesota Department of Health if an assisted living facility elects to voluntary close.
• AL Closure Plan Provider Checklist (PDF): This checklist is meant to be a useful resource to help you complete your proposed plan.
• AL Post-Closure Provider Checklist (PDF): This checklist is meant to be a useful resource to help you complete the resident relocation evaluation and resident relocation plan, and to meet other requirements after the approval of the closure plan.
• AL Notice of Completed Closure (PDF): Use this form to notify the Commissioner that the licensee completed the closure and that the licensee complied with the coordinated move requirements in 144G.55. This form must be submitted within 14 calendar days of all residents having left the facility.
• AL Closure of a Campus Building (PDF): Use this form if you will be closing one or more (but not all) buildings within a licensed assisted living campus.

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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.

Survey 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 (144G) (PDF)
• Employee List (144G) (PDF)
• Employee Record Review (144G) (PDF)
• Entrance Conference (144G) (PDF)
• Exit Conference Attendance (144G) (PDF)
• Exit Conference Guidelines (P5067) (PDF)
• Guide to the Survey Process for Provisional Assisted Living Providers (144G) (PDF)
• Guide to the Survey Process for Licensed Assisted Living Providers (144G) (PDF)
• HIPAA Information (P5035) (PDF)
• Infection Prevention and Control Program (144G) (PDF)
• Interview: Resident or Resident Representative (144G) (PDF)
• Meal and Menu Requirements (144G) (PDF)
• Medication Administration Observation and Drug Storage (144G) (PDF)
• Pre-Survey Checklist (144G) (PDF)
• Records Request (144G) (PDF)
• Requesting Reconsideration of Correction Orders (P4123) (PDF)
• Requesting Reconsideration of License Denial (P4125) (PDF)
• Required Postings (144G) (PDF)
• Resident and Employee Record Review List (144G) (PDF)
• Resident Observation and Record Review (144G) (PDF)
• Resources (P5000) (PDF)
• Treatment Observation (144G) (PDF)
• Tuberculosis Prevention and Control (144G) (PDF)

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