PROTECTING, MAINTAINING AND IMPROVING THE HEALTH OF ALL MINNESOTANS

Transcription

1 PROTECTING, MAINTAINING AND IMPROVING THE HEALTH OF ALL MINNESOTANS Certified Mail # MARKGLESENER@GLESENERS.COM August 1, 2016 Mr. Mark Glesener, Administrator Gleseners Assisted Living Serv 160 South Main Street Bird Island, MN Re: Enclosed State Licensing Orders Project Number SL Dear Mr. Glesener: On July 15, 2016, staff of the completed a follow up survey of your agency to determine correction of orders found on the survey completed on February 24, 2016, with orders received by you on March 18, 2016; and follow up survey completed on May 10, 2016, with orders including penalties received by you on May 21, At this time these correction orders were found corrected and are listed on the attached State Form: Revisit Report. Penalties assessed resulting from the May 10, 2016, follow up survey, received by you on May 21, 2016, in the amount of $300.00, remain outstanding. This amount is to be paid by check within 15 calendar days of the receipt of this notice and made payable to the Commissioner of Finance, Treasury Division and sent to: Health Regulation Division P.O. Box East 7th Place, Suite 220 St. Paul, Minnesota If you have questions, contact Jeri Cummins at (218) An equal opportunity employer.

2 Gleseners Assisted Living Serv August 1, 2016 Page 2 It is your responsibility to share the information contained in this letter and the results of the visit with the President of your organization s Governing Body. Sincerely, PAULA M. BASTIAN Senior Health Program Representative Health Regulation Division Home Care & Assisted Living Program cc: Home Care & Assisted Living Program File Renville County Social Services Cheryl Hennen, Office of the Ombudsman

3 : REVISIT REPORT PROVER / SUPPLIER / CLIA / ENTIFICATION NUMBER H24783 Y1 MULTIPLE CONSTRUCTION A. Building B. Wing Y2 OF REVISIT 7/15/2016 Y3 NAME OF FACILITY This report is completed by a State surveyor to show those deficiencies previously reported that have been corrected and the date such corrective action was accomplished. Each deficiency should be fully identified using either the regulation or LSC provision number and the identification prefix code previously shown on the State Survey Report (prefix codes shown to the left of each requirement on the survey report form). ITEM ITEM ITEM Y4 Y5 Y4 Y5 Y4 Y5 Prefix Prefix Prefix 144A.4791, Subd. 9(f) 144A.4793, Subd. 3 LSC 07/15/2016 LSC 07/15/2016 LSC Prefix Prefix Prefix LSC LSC LSC Prefix Prefix Prefix LSC LSC LSC Prefix Prefix Prefix LSC LSC LSC Prefix Prefix Prefix LSC LSC LSC REVIEWED BY STATE AGENCY: MDH REVIEWED BY (INITIALS): PMB : 8/1/16 SIGNATURE OF SURVEYOR: : 7/15/16 REVIEWED BY CMS RO REVIEWED BY (INITIALS) TITLE FOLLOWUP TO SURVEY D ON 2/24/2016 CHECK FOR ANY UNCORRECTED DEFICIENCIES. WAS A SUMMARY OF UNCORRECTED DEFICIENCIES (CMS-2567) SENT TO THE FACILITY? YES NO Page 1 of 1 EVENT : 7JRR13 : REVISIT REPORT (11/06)

4 Certified Mail # May 16, 2016 Mr. Mark Glesener, Administrator Gleseners Assisted Living Serv 160 South Main Street Bird Island, MN Re: Enclosed State Licensing Orders Project Number SL Dear Mr. Glesener: On May 10, 2016, staff of the completed a follow up survey of your agency to determine correction of orders found on the survey completed on February 24, 2016, with orders received by you on March 18, State licensing orders issued pursuant to the survey completed on February 24, 2016, found corrected at the time of the May 10, 2016, follow up survey, are listed on the attached State Form: Revisit Report. State licensing orders are delineated on the attached order form. The is documenting the State Licensing Orders using federal software. Tag numbers have been assigned to Minnesota state statutes for Home Care Providers. The assigned tag number appears in the far left column entitled " Prefix Tag." The state statute number and the corresponding text of the state statute out of compliance is listed in the "Summary Statement of Deficiencies" column. This column also includes the findings that are in violation of the state statute after the statement, "This MN Requirement is not met as evidenced by." IMPOSITION OF FINES Level 1, no fines or enforcement. Level 2, fines ranging from $0 to $500, in addition to any of the enforcement mechanisms authorized in section 144A.475 for widespread violations. Level 3, fines ranging from $500 to $1,000, in addition to any of the enforcement mechanisms authorized in section 144A.475. Level 4, fines ranging from $1,000 to $5,000, in addition to any of the enforcement mechanisms authorized in section 144A.475. Protecting, maintaining and improving the health of all Minnesotans

5 Gleseners Assisted Living Serv May 16, 2016 Page 2 At the time of this survey it was determined, in accordance with Minnesota Statutes, section 144A.474, subdivision 11, the following fines were issued: NO FINE Level/1; Scope/Widespread Contents of Service Plan, Minnesota Statutes 144A.4791, subdivision 9 (f) $ Level/2; Scope/Pattern Indiv Treatment/Therapy Mgmt Plan, Minnesota Statutes 144A.4793, subdivision 3 Total = $ The details of the violations noted at the time of this follow up survey completed on May 10, 2016, (listed above), are on the attached State Form. Brackets around the Prefix Tag in the left hand column, e.g., {2 } will identify the uncorrected tags. Therefore, in accordance with Minnesota Statutes, sections 144A.43 to 144A.484, the total amount that you are assessed is $ This amount is to be paid by check within 15 calendar days of the receipt of this notice and made payable to the Commissioner of Finance, Treasury Division and sent to: Health Regulation Division P.O. Box East 7th Place, Suite 220 St. Paul, Minnesota In accordance with Minnesota Statutes, section 144A.475, subdivision 4, you may request a hearing on any fines resulting from noncompliance with these orders provided that a written request is made to the Department within 15 calendar days of receipt of this notice. If, upon follow up, it is found that the correction order(s) cited herein are not corrected, a fine for each order not corrected shall be assessed in accordance with a schedule of fines described in Minnesota Statutes, section 144A.474, subdivision 11. DOCUMENTATION OF ACTION TO COMPLY In accordance with Minnesota Statutes, section 144A.474, subdivision 8 (c), by the correction order date, the home care provider must document in the provider's records any action taken to comply with the correction order. The commissioner may request a copy of this documentation and the home care provider's action to respond to the correction orders in future surveys, upon a complaint investigation, and as otherwise needed.

6 Gleseners Assisted Living Serv May 16, 2016 Page 3 CORRECTION ORDER RECONSERATION PROCESS In accordance with Minnesota Statutes, section 144A.474, subdivision 12, you have one opportunity to challenge the correction order issued, including the level and scope, and any fine(s) assessed. The written request for reconsideration must be received by the Commissioner within 15 calendar days of the correction order receipt date. In an effort to accurately review each citation challenged, please also submit all supporting documents within the same 15 calendar days of the correction order receipt date. The Commissioner shall then begin reviewing the request for reconsideration and supporting documents. The Commissioner shall respond in writing to the request within 60 days of the date the provider requests a reconsideration. Any documentation received after the Commissioner s response is completed will not be considered. You are required to send your written request and all supporting documents to the following: Home Care Order Reconsideration Process Health Regulation Division P.O. Box East 7th Place, Suite 220 St. Paul, Minnesota We urge you to review these orders carefully. If you have questions, contact Jeri Cummins at (218) It is your responsibility to share the information contained in this letter and the results of the visit with the President of your organization s Governing Body. Sincerely, PAULA M. BASTIAN Senior Health Program Representative Health Regulation Division Home Care & Assisted Living Program Enclosure cc: Home Care & Assisted Living File Renville County Social Services Cheryl Hennen, Office of the Ombudsman Kelly Kemp, Office of Attorney General

7 : REVISIT REPORT PROVER / SUPPLIER / CLIA / ENTIFICATION NUMBER H24783 Y1 MULTIPLE CONSTRUCTION A. Building B. Wing Y2 OF REVISIT 5/10/2016 Y3 NAME OF FACILITY This report is completed by a State surveyor to show those deficiencies previously reported that have been corrected and the date such corrective action was accomplished. Each deficiency should be fully identified using either the regulation or LSC provision number and the identification prefix code previously shown on the State Survey Report (prefix codes shown to the left of each requirement on the survey report form). ITEM ITEM ITEM Y4 Y5 Y4 Y5 Y4 Y5 Prefix Prefix Prefix A.44, Subd. 1(2) 144A.479, Subd A.4791, Subd. 1 LSC 05/10/2016 LSC 05/10/2016 LSC 05/10/2016 Prefix Prefix Prefix A.4791, Subd A.4792, Subd A.4792, Subd. 7 LSC 05/10/2016 LSC 05/10/2016 LSC 05/10/2016 Prefix Prefix Prefix A.4792, Subd A.4792, Subd. 10(a) 144A.4796, Subd. 2 LSC 05/10/2016 LSC 05/10/2016 LSC 05/10/2016 Prefix Prefix Prefix 144A.4798, Subd. 1 LSC 05/10/2016 LSC LSC Prefix Prefix Prefix LSC LSC LSC REVIEWED BY STATE AGENCY: MDH REVIEWED BY (INITIALS): PMB : 5/16/16 SIGNATURE OF SURVEYOR: : 5/10/16 REVIEWED BY CMS RO REVIEWED BY (INITIALS) TITLE FOLLOWUP TO SURVEY D ON 2/24/2016 CHECK FOR ANY UNCORRECTED DEFICIENCIES. WAS A SUMMARY OF UNCORRECTED DEFICIENCIES (CMS-2567) SENT TO THE FACILITY? YES NO Page 1 of 1 EVENT : 7JRR12 : REVISIT REPORT (11/06)

8 (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: PRINTED: 05/16/2016 (X3) SURVEY D R H /10/2016 NAME OF PROVER OR SUPPLIER (X4) REGULATORY OR LSC ENTIFYING INFORMATION) PROVER'S PLAN OF CORRECTION {0 000} Initial Comments {0 000} *****ATTENTION****** HOME CARE PROVER LICENSING CORRECTION ORDER In accordance with Minnesota Statutes, section 144A.43 to 144A.482, this correction order(s) has been issued pursuant to a survey. Determination of whether a violation has been corrected requires compliance with all requirements provided at the Statute number indicated below. When Minnesota Statute contains several items, failure to comply with any of the items will be considered lack of compliance. INITIAL COMMENTS: On May 10, 2016, surveyors of this Department's staff conducted a revisit at the above provider to follow-up on orders issued pursuant to a survey completed on February 24, At the time of the survey, there were 13 clients that were receiving services under the comprehensive license. is documenting the State Licensing Orders using federal software. Tag numbers have been assigned to Minnesota State Statutes for Home Care Providers. The assigned tag number appears in the far left column entitled " Prefix Tag." The state Statute number and the corresponding text of the state Statute out of compliance is listed in the "Summary Statement of Deficiencies" column. This column also includes the findings which are in violation of the state requirement after the statement, "This Minnesota requirement is not met as evidenced by." Following the surveyors ' findings is the Time Period for. PLEASE DISREGARD THE HEADING OF THE FOURTH COLUMN WHICH STATES,"PROVER ' S PLAN OF CORRECTION." THIS APPLIES TO FEDERAL DEFICIENCIES ONLY. THIS WILL APPEAR ON EACH PAGE. THERE IS NO REQUIREMENT TO SUBMIT A PLAN OF CORRECTION FOR VIOLATIONS OF MINNESOTA STATE STATUTES. {0 870} 144A.4791, Subd. 9(f) Contents of Service Plan {0 870} (f) The service plan must include: (1) a description of the home care services to be provided, the fees for services, and the frequency of each service, according to the client's current review or assessment and client preferences; LABORATORY DIRECTOR'S OR PROVER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) 7JRR12 If continuation sheet 1 of 6

9 (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: PRINTED: 05/16/2016 (X3) SURVEY D R H /10/2016 NAME OF PROVER OR SUPPLIER (X4) REGULATORY OR LSC ENTIFYING INFORMATION) PROVER'S PLAN OF CORRECTION {0 870} Continued From page 1 {0 870} (2) the identification of the staff or categories of staff who will provide the services; (3) the schedule and methods of monitoring reviews or assessments of the client; (4) the frequency of sessions of supervision of staff and type of personnel who will supervise staff; and (5) a contingency plan that includes: (i) the action to be taken by the home care provider and by the client or client's representative if the scheduled service cannot be provided; (ii) information and a method for a client or client's representative to contact the home care provider; (iii) names and contact information of persons the client wishes to have notified in an emergency or if there is a significant adverse change in the client's condition, including identification of and information as to who has authority to sign for the client in an emergency; and (iv) the circumstances in which emergency medical services are not to be summoned consistent with chapters 145B and 145C, and declarations made by the client under those chapters. This MN Requirement is not met as evidenced by: Based on interview and record review, the licensee failed to ensure the service plan included all of the required contents for three of three clients (#1, #2 and #4) with records reviewed. 7JRR12 If continuation sheet 2 of 6

10 (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: PRINTED: 05/16/2016 (X3) SURVEY D R H /10/2016 NAME OF PROVER OR SUPPLIER (X4) REGULATORY OR LSC ENTIFYING INFORMATION) PROVER'S PLAN OF CORRECTION {0 870} Continued From page 2 This practice resulted in a level one violation (a violation that has no potential to cause more than a minimal impact on the client and does not affect health or safety), and was issued at a widespread scope (when problems are pervasive or represent a systemic failure that has affected or has potential to affect a large portion or all of the clients). The findings include: Client #1 Client #1's diagnoses included traumatic brain injury, and had a service plan dated March 21, Client #2 Client #2's diagnoses included traumatic brain injury and left hemiparesis, and had a service plan dated March 21, Client #4 Client #4's diagnoses included traumatic brain injury, and had a service plan dated March 21, {0 870} Client #1, #2 and #4's service plans failed to include the method in which monitoring reviews or assessments of the client would occur. Client #1 and 2's service plans also failed to include a description of all the home care services to be provided to include AFO splints (orthotic device to provide foot and ankle support for foot drop). On May 10, 2016, at 11:30 a.m., employee B (licensed practical nurse) verified client #1 and #2's service plans did not include all of the treatments provided. Employee B further verified all the licensee's clients service plans lacked the method in which monitoring reviews or assessments of the client would occur. 7JRR12 If continuation sheet 3 of 6

11 (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: PRINTED: 05/16/2016 (X3) SURVEY D R H /10/2016 NAME OF PROVER OR SUPPLIER (X4) REGULATORY OR LSC ENTIFYING INFORMATION) PROVER'S PLAN OF CORRECTION {0 870} Continued From page 3 {0 870} The licensee's policy and procedure titled "Contents of Service Plans" dated as January 1, 2014, indicated "A service plan established after completion of a full individualized initial assessment and each subsequent reassessment includes: a. a description of the home care services, including nursing and medication management services, treatments and or therapy services, to be provided by our agency, f. the schedule and methods of monitoring reviews or re-assessments of the client. No further information was provided. {01035} 144A.4793, Subd. 3 Individualized Treatment/Therapy Mgt Plan {01035} Subd. 3. Individualized treatment or therapy management plan. For each client receiving management of ordered or prescribed treatments or therapy services, the comprehensive home care provider must prepare and include in the service plan a written statement of the treatment or therapy services that will be provided to the client. The provider must also develop and maintain a current individualized treatment and therapy management record for each client which must contain at least the following: (1) a statement of the type of services that will be provided; (2) documentation of specific client instructions relating to the treatments or therapy administration; (3) identification of treatment or therapy tasks that will be delegated to unlicensed personnel; 7JRR12 If continuation sheet 4 of 6

12 (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: PRINTED: 05/16/2016 (X3) SURVEY D R H /10/2016 NAME OF PROVER OR SUPPLIER (X4) REGULATORY OR LSC ENTIFYING INFORMATION) PROVER'S PLAN OF CORRECTION {01035} Continued From page 4 {01035} (4) procedures for notifying a registered nurse or appropriate licensed health professional when a problem arises with treatments or therapy services; and (5) any client-specific requirements relating to documentation of treatment and therapy received, verification that all treatment and therapy was administered as prescribed, and monitoring of treatment or therapy to prevent possible complications or adverse reactions. The treatment or therapy management record must be current and updated when there are any changes. This MN Requirement is not met as evidenced by: Based on interview and record review, the licensee failed to ensure the service plan included a written statement of the treatment or therapy services that will be provided for two of two clients (#1 and #2) with records reviewed. This practice resulted in a level two violation (a violation that did not harm a client's health or safety but had the potential to have harmed a client's health or safety, but was not likely to cause serious injury, impairment, or death), and was issued at a pattern scope (when more than a limited number of clients are affected, more than a limited number of staff are involved, or the situation has occurred repeatedly but is not found to be pervasive). The findings include: Client #1 Client #1's diagnoses included traumatic brain injury, and the client record contained a service plan dated March 21, JRR12 If continuation sheet 5 of 6

13 (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: PRINTED: 05/16/2016 (X3) SURVEY D R H /10/2016 NAME OF PROVER OR SUPPLIER (X4) REGULATORY OR LSC ENTIFYING INFORMATION) PROVER'S PLAN OF CORRECTION {01035} Continued From page 5 {01035} Client #2 Client #2's diagnoses included traumatic brain injury and left hemiparesis, and had a service plan dated March 21, Client #1 and #2's "Weekly Task Specific Completion Documentation Forms," dated May 9-15, 2016, indicated staff assisted to apply and remove AFO's daily. However, the service plans did not include the treatment being provided. On May 10, 2016, at 11:30 a.m. employee B (licensed practical nurse) verified both client #1 and client #2 wore AFO's during the day, and staff assist with applying and removing them. Employee B further verified the AFOs were not included in client #1 and #2's service plan. The licensee's policy and procedure titled "Contents of Service Plans" dated as January 1, 2015, indicated "A service plan established after completion of a full individualized initial assessment and each subsequent reassessment includes: a. a description of the home care services, including nursing and medication management services, treatments and or therapy services, to be provided by our agency, f. the schedule and methods of monitoring reviews or re-assessments of the client. g. the frequency of supervision of staff providing services and the identification of the supervisor who will be providing the supervision. No further information was provided. 7JRR12 If continuation sheet 6 of 6

14 Certified Mail # March 14, 2016 Mr. Mark Glesener, Administrator Gleseners Assisted Living Serv 160 South Main Street Bird Island, MN Re: Enclosed State Licensing Orders Project Number SL Dear Mr. Glesener: A survey of the Home Care Provider named above was completed on February 24, 2016 for the purpose of assessing compliance with State licensing regulations. At the time of survey, staff from the noted one or more violations of these regulations that are issued in accordance with Minnesota Statutes, sections 144A.43 to 144A.484. If, upon follow up, it is found that the correction order(s) cited herein are not corrected, a fine for each order not corrected may be assessed in accordance with a schedule of fines described in Minnesota Statutes, section 144A.474, subdivision 11. State licensing orders are delineated on the attached order form. The is documenting the State Licensing Orders using federal software. Tag numbers have been assigned to Minnesota Statutes for Home Care Providers. The assigned tag number appears in the far left column entitled " Prefix Tag." The state statute number and the corresponding text of the state statute out of compliance is listed in the "Summary Statement of Deficiencies" column. This column also includes the findings that are in violation of the state statute after the statement, "This MN Requirement is not met as evidenced by." DOCUMENTATION OF ACTION TO COMPLY In accordance with Minnesota Statutes, section 144A.474, subdivision 8 (c), by the correction order date, the home care provider must document in the provider's records any action taken to comply with the correction order. The commissioner may request a copy of this documentation and the home care provider's action to respond to the correction orders in future surveys, upon a complaint investigation, and as otherwise needed. CORRECTION ORDER RECONSERATION PROCESS In accordance with Minnesota Statutes, section 144A.474, subdivision 12, you have one opportunity Protecting, maintaining and improving the health of all Minnesotans

15 Gleseners Assisted Living Serv March 14, 2016 Page 2 to challenge the correction order issued, including the level and scope, and any fine(s) assessed. The written request for reconsideration must be received by the Commissioner within 15 calendar days of the correction order receipt date. In an effort to accurately review each citation challenged, please also submit all supporting documents within the same 15 calendar days of the correction order receipt date. The Commissioner shall then begin reviewing the request for reconsideration and supporting documents. The Commissioner shall respond in writing to the request within 60 days of the date the provider requests a reconsideration. Any documentation received after the Commissioner s response is completed will not be considered. You are required to send your written request and all supporting documents to the following: Home Care Order Reconsideration Process Health Regulation Division P.O. Box East 7th Place, Suite 220 St. Paul, Minnesota We urge you to review these orders carefully. If you have questions, contact Jeri Cummins at (218) It is your responsibility to share the information contained in this letter and the results of the visit with the President of your organization s Governing Body. Sincerely, PAULA M. BASTIAN Senior Health Program Representative Health Regulation Division Home Care & Assisted Living Program Enclosure cc: Home Care and Assisted Living Program File Michael Budion, Minnesota Department of Human Services Cheryl Hennen, Office of the Ombudsman for Long Term Care Renville County Social Services

16 (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY D NAME OF PROVER OR SUPPLIER (X4) REGULATORY OR LSC ENTIFYING INFORMATION) PROVER'S PLAN OF CORRECTION Initial Comments *****ATTENTION****** HOME CARE PROVER LICENSING CORRECTION ORDER In accordance with Minnesota Statutes, section 144A.43 to 144A.482, this correction order(s) has been issued pursuant to a survey. Determination of whether a violation has been corrected requires compliance with all requirements provided at the Statute number indicated below. When Minnesota Statute contains several items, failure to comply with any of the items will be considered lack of compliance. INITIAL COMMENTS: On February 22, 2016 through February 24, 2016, surveyors of this Department's staff, visited the above provider and the following correction orders are issued. At the time of the survey, there were 13 clients that were receiving services under the comprehensive license. is documenting the State Licensing Orders using federal software. Tag numbers have been assigned to Minnesota State Statutes for Home Care Providers. The assigned tag number appears in the far left column entitled " Prefix Tag." The state Statute number and the corresponding text of the state Statute out of compliance is listed in the "Summary Statement of Deficiencies" column. This column also includes the findings which are in violation of the state requirement after the statement, "This Minnesota requirement is not met as evidenced by." Following the surveyors ' findings is the Time Period for. PLEASE DISREGARD THE HEADING OF THE FOURTH COLUMN WHICH STATES,"PROVER ' S PLAN OF CORRECTION." THIS APPLIES TO FEDERAL DEFICIENCIES ONLY. THIS WILL APPEAR ON EACH PAGE. THERE IS NO REQUIREMENT TO SUBMIT A PLAN OF CORRECTION FOR VIOLATIONS OF MINNESOTA STATE STATUTES A.44, Subd. 1(2) Up-To-Date Plan/Accepted Standards Practice Subdivision 1. Statement of rights. A person who receives home care services has these rights: (2) the right to receive care and services according to a suitable and up-to-date plan, and subject to accepted health care, medical or nursing LABORATORY DIRECTOR'S OR PROVER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) If continuation sheet 1 of 36

17 (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY D NAME OF PROVER OR SUPPLIER (X4) REGULATORY OR LSC ENTIFYING INFORMATION) PROVER'S PLAN OF CORRECTION Continued From page 1 standards, to take an active part in developing, modifying, and evaluating the plan and services; This MN Requirement is not met as evidenced by: Based on observation, interview and record review, the licensee failed to ensure one of one employee (C) provided care and services following appropriate infection control standards. In addition, the licensee failed to provide cares according to accepted medical and nursing standards for two of two clients (#1 and #2) observed with bed rails, and with mobility deficits. This practice resulted in a level two violation (a violation that did not harm a client's health or safety but had the potential to have harmed a client's health or safety, but was not likely to cause serious injury, impairment, or death), and was issued at a pattern scope (when more than a limited number of clients are affected, more than a limited number of staff are involved, or the situation has occurred repeatedly but is not found to be pervasive). The findings include: INFECTION CONTROL Employee C (unlicensed personnel/ulp) failed to ensure appropriate infection control standards were used while completing morning cares. On February 23, 2016, employee C was observed to provide morning cares to client #2. -with gloves on, employee C removed a soiled incontinent product and rolled it up. -without removing her gloves and cleansing hands, employee put a clean brief onto the client. -employee C took the soiled brief in one hand and opened the client's door with the other hand. If continuation sheet 2 of 36

18 (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY D NAME OF PROVER OR SUPPLIER (X4) REGULATORY OR LSC ENTIFYING INFORMATION) PROVER'S PLAN OF CORRECTION Continued From page 2 -disposed the soiled brief, removed the gloves and washed her hands. -Employee C returned to client #2's room and applied new gloves. -Washed the client's eyes with a washcloth -Gave a different washcloth to the client and instructed him to wash his face. -rinsed out the washcloth and instructed client to wash his peri area. -rinsed out the washcloth and employee C washed client #2's buttocks, dried, applied ointment and fastened the incontinent product; removed gloves. -without washing her hands employee C got clothes out of the closet, and assisted with dressing the patient, then washed her hands. On February 24, 2016, employee B (licensed practical nurse) and employee E (registered nurse consultant) both indicated employee C's practice was not acceptable and their expectation is removal of gloves and handwashing immediately after glove use. The licensee's "Handwashing Procedure" policy, revised July 2009, indicated handwashing must occur each time the hands come in contact with someone who is ill, after contact with blood or infections materials, and with an object that is potentially contaminated. This includes, but is not limited to: before and after removal of gloves or other protective equipment, after toileting or diapering a client, immediately after any contact with blood, semen, vaginal secretions, or any body fluid visibly contaminated with blood. No further information was provided BED RAILS If continuation sheet 3 of 36

19 (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY D NAME OF PROVER OR SUPPLIER (X4) REGULATORY OR LSC ENTIFYING INFORMATION) PROVER'S PLAN OF CORRECTION Continued From page 3 Client #1 and #2's records lacked evidence the registered nurse (RN) completed an assessment of the client's functional status, and the need for a bed rail. Client #1 Client #1's diagnoses included traumatic brain injury. Client #1's "Vulnerability and Risk Assessment," dated July 13, 2015, indicated the client had a diagnosis of dementia secondary to traumatic brain injury, and had deficits in memory. Client #1 also had right hemiparesis and required staff assist for repositioning. On February 23, 2016, client #1's bed was observed unoccupied, with bilateral bed rails. The right bed rail was in an up position against the wall; and the left bed rail was in a lowered position. The bed rails on the right and left side of the twin size bed, measured 31 inches wide, 17 inches high, and 3 inches between the bars, which met the FDA guidelines. Client #1 stated she used the bed rails to move around in bed. Client #1's record included evidence education was provided explaining the risks and benefits to the client of bed rail use, however the record lacked evidence a functional use assessment had been completed. On February 23, 2016, employee B (licensed practical nurse/lpn) verified the bilateral metal bed rails were attached to a hospital bed with the measurements as listed above. Employee B further verified the record lacked evidence an assessment for the use of a bed rail had been completed If continuation sheet 4 of 36

20 (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY D NAME OF PROVER OR SUPPLIER (X4) REGULATORY OR LSC ENTIFYING INFORMATION) PROVER'S PLAN OF CORRECTION Continued From page 4 Client #2 Client #2's diagnoses included traumatic brain injury and left hemiparesis. Client #2's "Vulnerability and Risk Assessment," dated October 13, 2015, indicated the client was disoriented to time and place, and exhibited memory deficits. Client #2 also had left sided hemiparesis with hand contracture, and required staff assist for repositioning. On February 23, 2016, client #2's bed was observed with client #2 in it, with bilateral bed rails. Both bed rails were in the up position. The bed rails on both sides measured 35 inches wide, 17 inches high, and 2 inches between the bars, which met the FDA guidelines. Client #2 was observed to use the bed rails to assist with turning in bed. Client #2's record included evidence education was provided explaining the risks and benefits to the client of bed rail use, however the record lacked evidence a functional use assessment had been completed. On February 23, 2016, employee B verified the bilateral metal bed rails were attached to a hospital bed with the measurements listed. Employee B further verified the record lacked evidence an assessment for the use of the bed rails had been completed. Employee B further verified that none of the clients with bed rails had a functional use assessment completed The Food and Drug Administration (FDA), "A Guide to Bed Safety," revised April 2010, included the following information: "When bed rails are used, perform an on-going assessment of the If continuation sheet 5 of 36

21 (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY D NAME OF PROVER OR SUPPLIER (X4) REGULATORY OR LSC ENTIFYING INFORMATION) PROVER'S PLAN OF CORRECTION Continued From page 5 patient's physical and mental status, closely monitor high-risk patients." The FDA also identified; "Patients who have problems with memory impairment, sleeping, incontinence, pain, uncontrolled body movement, or who get out of bed and walk unsafely without assistance, must be carefully assessed for the best ways to keep them from harm, such as falling. Assessment by the patient's health care team will help to determine how best to keep the patient safe." No further information was provided TIME PERIOD FOR CORRECTION: Seven (7) days A.479, Subd. 7 Employee Records Subd. 7. Employee records. The home care provider must maintain current records of each paid employee, regularly scheduled volunteers providing home care services, and of each individual contractor providing home care services. The records must include the following information: (1) evidence of current professional licensure, registration, or certification, if licensure, registration, or certification is required by this statute or other rules; (2) records of orientation, required annual training and infection control training, and competency evaluations; (3) current job description, including If continuation sheet 6 of 36

22 (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY D NAME OF PROVER OR SUPPLIER (X4) REGULATORY OR LSC ENTIFYING INFORMATION) PROVER'S PLAN OF CORRECTION Continued From page 6 qualifications, responsibilities, and identification of staff providing supervision; (4) documentation of annual performance reviews which identify areas of improvement needed and training needs; (5) for individuals providing home care services, verification that required health screenings under section 144A.4798 have taken place and the dates of those screenings; and (6) documentation of the background study as required under section Each employee record must be retained for at least three years after a paid employee, home care volunteer, or contractor ceases to be employed by or under contract with the home care provider. If a home care provider ceases operation, employee records must be maintained for three years This MN Requirement is not met as evidenced by: Based on interview and record review, the licensee failed to ensure one of one employee records (D) contained an annual performance review, as required. This practice resulted in a level two violation (a violation that did not harm a client's health or safety but had the potential to have harmed a client's health or safety, but was not likely to cause serious injury, impairment, or death), and was issued at a widespread scope (when If continuation sheet 7 of 36

23 (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY D NAME OF PROVER OR SUPPLIER (X4) REGULATORY OR LSC ENTIFYING INFORMATION) PROVER'S PLAN OF CORRECTION Continued From page 7 problems are pervasive or represent a systemic failure that has affected or has potential to affect a large portion or all of the clients). The findings include: Employee D (unlicensed personnel/ulp) was hired November 4, Employee D's personnel record lacked evidence to indicate an annual performance review had been completed to identify potential areas of improvement needed and possible training needs. On February 24, 2016, employee B (licensed practical nurse) verified annual employee performance reviews were not completed for employee D, or any other employee last year (2015). The licensee's "Performance Review" policy and procedure dated June 30, 2014, indicated the supervisor would complete the annual performance review form for each employee prior to the employee's anniversary date, and would meet with the employee annually on or before their anniversary date to review the employee's feedback, review the supervisor's assessment of the employee's performance, and discuss goals for the upcoming period. The licensee's "Personnel Records" policy and procedure dated January 1, 2015, indicated each employee's personnel record would contain "annual performance evaluations which identify areas of improvement needed and training needs (performance reviews must be conducted at least annually.)" No further information was provided. If continuation sheet 8 of 36

24 (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY D NAME OF PROVER OR SUPPLIER (X4) REGULATORY OR LSC ENTIFYING INFORMATION) PROVER'S PLAN OF CORRECTION Continued From page TIME PERIOD FOR CORRECTION: Twenty-one (21) days A.4791, Subd. 1 HBOR Notification to Client Subdivision 1. Home care bill of rights; notification to client. (a) The home care provider shall provide the client or the client's representative a written notice of the rights under section 144A.44 before the initiation of services to that client. The provider shall make all reasonable efforts to provide notice of the rights to the client or the client's representative in a language the client or client's representative can understand. (b) In addition to the text of the home care bill of rights in section 144A.44, subdivision 1, the notice shall also contain the following statement describing how to file a complaint with these offices. "If you have a complaint about the provider or the person providing your home care services, you may call, write, or visit the Office of Health Facility Complaints,. You may also contact the Office of Ombudsman for Long-Term Care or the Office of Ombudsman for Mental Health and Developmental Disabilities." The statement should include the telephone number, Web site address, address, mailing If continuation sheet 9 of 36

25 (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY D NAME OF PROVER OR SUPPLIER (X4) REGULATORY OR LSC ENTIFYING INFORMATION) PROVER'S PLAN OF CORRECTION Continued From page 9 address, and street address of the Office of Health Facility Complaints at the Minnesota Department of Health, the Office of the Ombudsman for Long-Term Care, and the Office of the Ombudsman for Mental Health and Developmental Disabilities. The statement should also include the home care provider's name, address, , telephone number, and name or title of the person at the provider to whom problems or complaints may be directed. It must also include a statement that the home care provider will not retaliate because of a complaint. (c) The home care provider shall obtain written acknowledgment of the client's receipt of the home care bill of rights or shall document why an acknowledgment cannot be obtained. The acknowledgment may be obtained from the client or the client's representative. Acknowledgment of receipt shall be retained in the client's record This MN Requirement is not met as evidenced by: Based on interview and record review, the licensee failed to provide clients with the current home care bill of rights for two of three clients (#2 and #1) receiving home care services. This practice resulted in a level one violation (a violation that has no potential to cause more than a minimal impact on the client and does not affect health or safety), and is issued at a widespread If continuation sheet 10 of 36

26 (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY D NAME OF PROVER OR SUPPLIER (X4) REGULATORY OR LSC ENTIFYING INFORMATION) PROVER'S PLAN OF CORRECTION Continued From page 10 scope (when problems are pervasive or represent a systemic failure that has affected or has the potential to affect a large portion or all of the clients). The findings include: Client #2 Client #2 was admitted for services on July 10, Client #2's record lacked evidence of receiving the 2014, home care bill or rights, which was confirmed by employee A (administrator), on February. Client #1 Client #1 was admitted for services on October 22, Client #1's record indicated receipt of policy, titled "Home Care Bill of Rights," dated January 20, 2009, and reviewed by client #1's guardian on July 13, The home care bill of rights for client#1 lacked the full content as required and the complete statement: "If you have a complaint about the provider or the person providing your home care services, you may call, write, or visit the Office of Health Facility Complaints, Minnesota Department of Health. You may also contact the Office of Ombudsman for Long-Term Care or the Office of Ombudsman for Mental Health and Developmental Disabilities." In addition, the home care bill of rights provided to client #1 lacked the Web site address and address for the Office of Health Facility Complaints at the Minnesota Department of Health and the Office of the Ombudsman for Long-Term Care, and the Web site address, If continuation sheet 11 of 36

27 (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY D NAME OF PROVER OR SUPPLIER (X4) REGULATORY OR LSC ENTIFYING INFORMATION) PROVER'S PLAN OF CORRECTION Continued From page 11 address, mailing address, and street address of the Office of the Ombudsman for Mental Health and Developmental Disabilities. The bill of rights also failed to include the of the provider and the current name and title of the person at the provider to whom problems or complaints may be directed. On February 24, 2016, employee A (administrator) provided the current home care bill of rights as part of the admission packet. Employee A verified the licensee had not provided clients #1 and #2 the current copy of the home care bill of rights and had not implemented a process to ensure all clients residing in the setting had received the correct copy of the home care bill of rights. The licensee's "Content of Client Record" policy, dated January 1, 2015, indicated the client record will contain documentation that the client has received the following: i. the home care bill of rights and documentation that the agency staff has reviewed the bill of rights with the client. No further information was provided TIME PERIOD FOR CORRECTION: Twenty-one (21) days A.4791, Subd. 3 Statement of Home Care Services Subd. 3. Statement of home care services. Prior to the initiation of services, a home care provider must provide to the client or the client's representative a written statement which identifies if the provider If continuation sheet 12 of 36

28 (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY D NAME OF PROVER OR SUPPLIER (X4) REGULATORY OR LSC ENTIFYING INFORMATION) PROVER'S PLAN OF CORRECTION Continued From page 12 has a basic or comprehensive home care license, the services the provider is authorized to provide, and which services the provider cannot provide under the scope of the provider's license. The home care provider shall obtain written acknowledgment from the clients that the provider has provided the statement or must document why the provider could not obtain the acknowledgment This MN Requirement is not met as evidenced by: Based on interview and record review, the licensee failed to ensure two of two clients (#1 and #2) or client representative were provided a written statement of services, which identified the provider had a comprehensive home care license, the services the provider provides under the license. This practice resulted in a level one violation (a violation that has no potential to cause more than a minimal impact on the client and does not affect health or safety), and was issued at a widespread scope (when problems are pervasive or represent a systemic failure that has affected or has potential to affect a large portion or all of the clients). The findings include: Client #1 and #2's records lacked evidence the client and/or the client's representative was provided with a written statement that identified the licensee as a comprehensive home care provider, and the services provided under their license. On February 23, 2016, employee A (administrator) stated client #1, #2, and all other If continuation sheet 13 of 36

29 (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY D NAME OF PROVER OR SUPPLIER (X4) REGULATORY OR LSC ENTIFYING INFORMATION) PROVER'S PLAN OF CORRECTION Continued From page 13 clients receiving home care services, had not received a written statement of comprehensive home care services. The licensee's "Content of Client Records" policy, dated January 1, 2015, indicated the client record will contain documentation that the client has received: ii. the statement of explaining the agency holds a comprehensive home care license, a description of the services the agency is authorized to provide under the comprehensive home care license and which services the agency cannot provide under the scope of our license and a statement about the limitations of the agency's services. No further information was provided TIME PERIOD FOR CORRECTION: Twenty-one (21) days A.4791, Subd. 9(f) Contents of Service Plan (f) The service plan must include: (1) a description of the home care services to be provided, the fees for services, and the frequency of each service, according to the client's current review or assessment and client preferences; (2) the identification of the staff or categories of staff who will provide the services; (3) the schedule and methods of monitoring reviews or assessments of the client; (4) the frequency of sessions of supervision of If continuation sheet 14 of 36

30 (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY D NAME OF PROVER OR SUPPLIER (X4) REGULATORY OR LSC ENTIFYING INFORMATION) PROVER'S PLAN OF CORRECTION Continued From page 14 staff and type of personnel who will supervise staff; and (5) a contingency plan that includes: (i) the action to be taken by the home care provider and by the client or client's representative if the scheduled service cannot be provided; (ii) information and a method for a client or client's representative to contact the home care provider; (iii) names and contact information of persons the client wishes to have notified in an emergency or if there is a significant adverse change in the client's condition, including identification of and information as to who has authority to sign for the client in an emergency; and (iv) the circumstances in which emergency medical services are not to be summoned consistent with chapters 145B and 145C, and declarations made by the client under those chapters. This MN Requirement is not met as evidenced by: Based on interview and record review, the licensee failed to ensure the service plan included all of the required contents for two of two clients (#1 and #2) with records reviewed This practice resulted in a level one violation (a violation that has no potential to cause more than a minimal impact on the client and does not affect health or safety), and was issued at a widespread scope (when problems are pervasive or represent a systemic failure that has affected or has potential to affect a large portion or all of the clients). The findings include: If continuation sheet 15 of 36

31 (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY D NAME OF PROVER OR SUPPLIER (X4) REGULATORY OR LSC ENTIFYING INFORMATION) PROVER'S PLAN OF CORRECTION Continued From page Client #1 Client #1's diagnoses included traumatic brain injury, and the client record contained a service plan dated July 1, Client #2 Client #2's diagnoses included traumatic brain injury and left hemiparesis, and had a service plan dated July 23, Client #1 and #2's service plans listed "Assessment, monitor care plan, supervise care aides and health review" with a frequency of once per week by the RN/LPN, and "frequency of supervision by an RN" was listed as every 62 days or less. The service plans failed to indicated the required contents including: - a description of the home care services to be provided to include treatments. - the schedule and methods of monitoring reviews or assessments of the client: initial within five days, 14 days, and as needed based on change of condition, but not to exceed 90 days, as required -the frequency of sessions of supervision of staff and the type of personnel who will supervise staff: within 30 days after date of hire and periodically as needed based on performance. On February 24, 2016, employee A (administrator), employee B (licensed practical nurse) and employee E (registered nurse consultant) verified that all of the required content was not included in client #1 and #2's service plan. They further verified all the licensee's clients service plans were the same format. The licensee's policy and procedure titled If continuation sheet 16 of 36