June 22, Ms. Erin Hilligan, Administrator Ebenezer Home Care 2722 Park Ave South Saint Louis Park, MN 55416

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Poppy Rebecca Ferguson
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Email: EHILLIG1@FAIRVIEW.ORG June 22, 2016 Ms.

1 June 22, 2016 Ms. Erin Hilligan, Administrator Ebenezer Home Care 2722 Park Ave South Saint Louis Park, MN Re: Enclosed State Licensing Orders Project Number SL Dear Ms. Hilligan On June 8, 2016, staff of the completed a follow up survey of your agency to determine correction of orders found on the survey completed on March 10, 2016, with orders received by you on April 4, At this time these correction orders were found corrected and are listed on the attached State Form: Revisit Report. If you have questions, contact Jonathan Hill at (651) 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 Tim D. Sullivan, Henn Cty HSPHD County Social Services Cheryl Hennen, Office of the Ombudsman Protecting, maintaining and improving the health of all Minnesotans

2 : REVISIT REPORT PROVER / SUPPLIER / CLIA / ENTIFICATION NUMBER H28789 Y1 MULTIPLE CONSTRUCTION A. Building B. Wing Y2 OF REVISIT 6/8/2016 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 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 Y A.4791, Subd. 8 06/08/ A.4791, Subd. 9(a-e) 06/08/ A.4792, Subd /08/2016 REVIEWED BY STATE AGENCY REVIEWED BY (INITIALS) SIGNATURE OF SURVEYOR REVIEWED BY CMS RO REVIEWED BY (INITIALS) TITLE FOLLOWUP TO SURVEY D ON 3/10/2016 CHECK FOR ANY UNCORRECTED DEFICIENCIES. WAS A SUMMARY OF UNCORRECTED DEFICIENCIES (CMS-2567) SENT TO THE FACILITY? YES NO Page 1 of 1 EVENT : Q83T12 : REVISIT REPORT (11/06)

3 Certified Mail # March 30, 2016 Ms. Lucy Boxrud, Administrator Ebenezer Home Care 2722 Park Ave South Saint Louis Park, MN Re: Enclosed State Licensing Orders Project Number SL Dear Ms. Boxrud: A survey of the Home Care Provider named above was completed on March 10, 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 " 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

4 Ebenezer Home Care March 30, 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 Jonathan Hill at (651) 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 Kathy Rogers, Hennepin County Long Term Services & Supports

5 (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY D REGULATORY OR 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 March 7 through March 10, 2016, a surveyor of this Department's staff, visited the above provider and the following correction orders are issued. At the time of the survey, there were 323 clients in six housing with services 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. 144A.4791, Subd. 8 Comprehensive Assessment and Monitoring Subd. 8. Comprehensive assessment, monitoring, and reassessment. (a) When the services being provided are comprehensive home care services, an individualized initial assessment must be LABORATORY DIRECTOR'S OR PROVER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) If continuation sheet 1 of 9

6 (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY D REGULATORY OR ENTIFYING INFORMATION) PROVER'S PLAN OF CORRECTION Continued From page 1 conducted in person by a registered nurse. When the services are provided by other licensed health professionals, the assessment must be conducted by the appropriate health professional. This initial assessment must be completed within five days after initiation of home care services. (b) Client monitoring and reassessment must be conducted in the client's home no more than 14 days after initiation of services. (c) Ongoing client monitoring and reassessment must be conducted as needed based on changes in the needs of the client and cannot exceed 90 days from the last date of the assessment. The monitoring and reassessment may be conducted at the client's residence or through the utilization of telecommunication methods based on practice standards that meet the individual client's needs. This MN Requirement is not met as evidenced by: Based on interview and record review, the licensee failed to conduct a nursing re-assessment following a change in client needs for one of one client (C1) with records reviewed at the housing with services site C. 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 an isolated scope (when one or a If continuation sheet 2 of 9

7 (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY D REGULATORY OR ENTIFYING INFORMATION) PROVER'S PLAN OF CORRECTION Continued From page 2 limited number of clients are affected or one or a limited number of staff are involved or the situation has occurred only occasionally). The findings include: C1's record lacked a nursing re-assessment post-hospitalization. C1 was admitted for services on September 15, C1's "medication assessment" dated September 15, 2015, indicated "no medication services" as "family will manage". C1 was hospitalized from December 5, 2015, through December 10, 2015, and went to a transitional care unit from December 10, 2015, through December 31, On March 9, 2016, at 11:00 a.m. employee CA (registered nurse/rn) stated C1 was admitted to the hospital on December 5, 2015, for confusion and left leg cellulitis. Employee CA stated the family and care team were concerned about C1's self-administration of medications and at a care conference it was determined the client would need medication management services when she returned to the assisted living. C1's record lacked a nursing re-assessment post-hospitalization. The most recent nursing assessment titled, "nursing assessment form" was the admission assessment dated September 15, On March 9, 2016, at 11:15 a.m. employee CA (RN) and employee C (RN/assisted living corporate nurse) confirmed the client record lacked a nursing re-assessment post-hospitalization and verified the only nursing documentation post-hospitalization was a If continuation sheet 3 of 9

8 (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY D REGULATORY OR ENTIFYING INFORMATION) PROVER'S PLAN OF CORRECTION Continued From page 3 progress note, a revised vulnerable adult plan and care plan dated December 31, The licensee's "Initial and On-Going Assessment of Clients" policy dated March 1, 2014, indicated the RN would review the nursing assessment and service plan and, if necessary, will update the assessment and service plan, whenever the client had returned from a hospital or nursing home stay, had a change in condition or experienced and incident such as a fall. No further information was provided. TIME PERIOD FOR CORRECTION: Seven (7) days 144A.4791, Subd. 9(a-e) Service Plan, Implementation & Revisions Subd. 9. Service plan, implementation, and revisions to service plan. (a) No later than 14 days after the initiation of services, a home care provider shall finalize a current written service plan. (b) The service plan and any revisions must include a signature or other authentication by the home care provider and by the client or the client's representative documenting agreement on the services to be provided. The service plan must be revised, if needed, based on client review or reassessment under subdivisions 7 and 8. The provider must provide information to the client about changes to the provider's If continuation sheet 4 of 9

9 (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY D REGULATORY OR ENTIFYING INFORMATION) PROVER'S PLAN OF CORRECTION Continued From page 4 fee for services and how to contact the Office of the Ombudsman for Long-Term Care. (c) The home care provider must implement and provide all services required by the current service plan. (d) The service plan and revised service plan must be entered into the client's record, including notice of a change in a client's fees when applicable. (e) Staff providing home care services must be informed of the current written service plan. This MN Requirement is not met as evidenced by: Based on observation, interview and record review, the licensee failed to ensure implementation of a service listed on the service plan (service of a functional call pendant) for one of one client (A1) at housing with services site A. 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 an isolated scope (when one or a limited number of clients are affected or one or a limited number of staff are involved or the situation has occurred only occasionally). The findings include: Client A1 was not provided a functional emergency call pendant as identified on the service plan. If continuation sheet 5 of 9

10 (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY D REGULATORY OR ENTIFYING INFORMATION) PROVER'S PLAN OF CORRECTION Continued From page 5 On March 7, 2016, 1:00 p.m. client A1 stated the emergency call pendant had been "broken about a month" and stated she would like it working "in case I fall." Client A1 pressed the emergency call pendant. The pendant was observed to not light up and staff did not come in response. A sign observed on the client's wall directed, "Press Pendant for Assistance". On March 7, 2016, at 2:30 p.m., employee AA (unlicensed personnel/ulp) was asked if staff routinely checked the function of emergency call pendants, employee AA stated, "No, because she usually lets us know if it's not working, she didn't let us know." The clients "service plan agreement" dated as effective on January 1, 2016, directed ULP to "check on resident, make sure call pendant nearby for use." Client A1's "assessment for determining level of care" dated 2015, indicated the home care package minimum included "an emergency pendant and twenty four hour emergency staff response." On March 7, 2016, at 1:45 p.m. employee C (registered nurse/assisted living corporate nurse) confirmed the emergency call pendant was not functional and indicated she would follow up with the pendant company to resolve the issue. The licensee's "Content of Home Care Service Agreement" policy dated March 1, 2014, indicated "the RN develops a Home Care Service Agreement to be entered into between our agency and each client and/or client If continuation sheet 6 of 9

11 (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY D REGULATORY OR ENTIFYING INFORMATION) PROVER'S PLAN OF CORRECTION Continued From page 6 representative for the purpose of establishing an agreement about the business terms of the relationship between the client and our agency." A policy for emergency call pendants was requested however, no further information was provided. TIME PERIOD FOR CORRECTION: Seven (7) days A.4792, Subd. 18 Medications Provided by Client or Family Subd. 18. Medications provided by client or family members. When the comprehensive home care provider is aware of any medications or dietary supplements that are being used by the client and are not included in the assessment for medication management services, the staff must advise the registered nurse and document that in the client's record. This MN Requirement is not met as evidenced by: Based on observation, interview and record review, the licensee failed to ensure staff advised the registered nurse (RN), and documented in the client record the client had medications in the room that were provided by the client or family member, for one of one client (C1) at the housing with services site C. 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 an isolated scope (when one or a If continuation sheet 7 of 9

12 (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY D REGULATORY OR ENTIFYING INFORMATION) PROVER'S PLAN OF CORRECTION Continued From page 7 limited number of clients are affected or one or a limited number of staff are involved or the situation has occurred only occasionally). The findings include: Staff failed to notify the RN the client had medications in the room that were provided by the client or family member. On March 9, 2016, at 10:30 a.m. observations in C1's apartment revealed a large bottle of Tylenol (pain reliever) on the kitchen table and a bottle of amoxicillin (antibiotic) 500 milligram (mg) capsules on a ledge above the clients bed. C1 stated the Tylenol was taken for "headaches" and the amoxicillin was for "dental appointments." On March 9, 2016, at 1:00 p.m. employee CA (RN) stated she was unaware client C1 had medications she was self-administering and indicated direct care staff should have notified her about the medications in the room. Record review revealed staff (unlicensed personnel/ulp) were providing direct care to C1 on a daily basis including medication administration three times daily and safety checks and monitoring visits twice daily. The licensee's "Medication Management Services" policy dated, March 1, 2014, indicated the director of health services would assure ULP were trained, competent and oriented to the client whenever ULP were to perform medication management services for the client. No further information was provided. TIME PERIOD FOR CORRECTION: Seven (7) If continuation sheet 8 of 9

13 (X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY D REGULATORY OR ENTIFYING INFORMATION) PROVER'S PLAN OF CORRECTION Continued From page 8 days If continuation sheet 9 of 9

PROTECTING, MAINTAINING AND IMPROVING THE HEALTH OF ALL MINNESOTANS

PROTECTING, MAINTAINING AND IMPROVING THE HEALTH OF ALL MINNESOTANS Email: DAN.ARNOLD@HOMEINSTEAD.COM March 14, 2017 Mr. Daniel Arnold, Administrator Home Instead Senior Care 1883 Station Parkway NW, Ste