Protecting, Maintaining and Improving the Health of Minnesotans. Re: Enclosed Follow-up Survey Results - Project Number SL

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Nathaniel Page
5 years ago
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Email: JENNIFERCAREFULLY@YAHOO.COM August 31, 2015 Ms.

Persaud: On August 6, 2015, survey staff of the Minnesota Department of Health completed a follow-up survey of your facility, to determine correction of orders found on the survey completed on

1 August 31, 2015 Ms. Jennifer Persaud, Administrator Care-Fully Senior Home Care Wyola Road Minnetonka, MN Re: Enclosed Follow-up Survey Results - Project Number SL Dear Ms. Persaud: On August 6, 2015, survey staff of the Minnesota Department of Health completed a follow-up survey of your facility, to determine correction of orders found on the survey completed on February 12, 2015, with orders received by you on March 14, 2015; and follow-up survey completed on May 11, 2015, with orders including penalty assessments received by you on June 13, The penalty assessments were paid in full on June 15, At this time these correction orders were found corrected and are listed on the attached State Form: Revisit Report. Please note, it is your responsibility to share the information contained in this letter and the results of this visit with the President of your facility's Governing Body. Please feel free to contact Alice Sanders at (651) with any questions. Sincerely, Protecting, Maintaining and Improving the Health of Minnesotans Paula Bastian Senior Health Program Representative Health Regulation Division Home Care & Assisted Living Program cc: Home Care & Assisted Living File Kathy Rogers, Henn. Cty. Long Term Svs & Supports Michael Budion, Minnesota Department of Human Services Cheryl Hennen, Office of the Ombudsman Minnesota Department of Health Health Regulation Division Home Care & Assisted Living Program General Information: Toll-free: An equal opportunity employer

2 AH Form Approved 8/31/2015 (Y1) Provider / Supplier / CLIA / Identification Number H29620 Name of Facility CARE-FULLY SENIOR HOME CARE State Form: Revisit Report (Y2) Multiple Construction A. Building B. Wing Street Address, City, State, Zip Code WYOLA ROAD MINNETONKA, MN (Y3) Date of Revisit 8/6/2015 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). (Y4) Item (Y5) Date (Y4) Item (Y5) Date (Y4) Item (Y5) Date /06/2015 Reg. # 144A.4798, Subd Reg. # ZZZZ Reg. # ZZZZ Reg. # ZZZZ Reg. # ZZZZ Reg. # ZZZZ Reg. # ZZZZ Reg. # ZZZZ Reg. # ZZZZ Reg. # ZZZZ Reg. # ZZZZ Reg. # ZZZZ Reg. # ZZZZ Reg. # ZZZZ Reg. # ZZZZ Reviewed By MDH Reviewed By PBastian State Agency Reviewed By Reviewed By CMS RO Followup to Survey on: 2/12/2015 STATE FORM: REVISIT REPORT (5/99) Date: 8/31/15 Date: Signature of Surveyor: Signature of Surveyor: Check for any Uncorrected Deficiencies. Was a Summary of Uncorrected Deficiencies (CMS-2567) Sent to the Facility? Page 1 of 1 Event ID: Date: 8/6/15 Date: YES 55US13 NO

3 Certified Mail # June 10, 2015 Ms. Jennifer Persaud, Administrator Care-Fully Senior Home Care Wyola Road Minnetonka, MN Re: Enclosed State Licensing Orders - Project Number SL Dear Ms. Persaud: Protecting, Maintaining and Improving the Health of Minnesotans On May 11, 2015, survey staff of the Minnesota Department of Health completed a reinspection of your agency, to determine correction of orders found on the survey completed on March 12, 2015, with orders received by you on March 14, State licensing orders issued pursuant to the last survey completed on March 14, 2015, and found corrected at the time of the May 11, 2015 reinspection, are listed on the attached State Form: Revisit Report. In accordance with Minnesota Statutes, sections 144A.474, subd. 11, state licensing orders issued pursuant to the last survey completed on March 12, 2015, found not corrected at the time of the May 11, 2015, revisit and subject to penalty assessment are as follows: $ Level/2; Scope/Widespread TB Prevention & Control, Minn. Stat. Sec. 144A.4798, subd. 1 The details of the violations noted at the time of this revisit completed on May 11, 2015 (listed above), are on the attached State Form. Brackets around the Tag in the left hand column, e.g., {2 ----} will identify the uncorrected tags. Therefore, in accordance with Minnesota Statute, sections 144A.43 to 144A.482, the total amount you are assessed is $ This amount is to be paid by check made payable to the Commissioner of Finance, Treasury Division and sent to the Minnesota Department of Health, Health Regulation Division, Home Care & Assisted Living Program, P.O. Box 64900, St. Paul, Minnesota within 15 days of the receipt of this notice. 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 Minnesota Department of Health Health Regulation Division Home Care & Assisted Living Program General Information: Toll-free: An equal opportunity employer

4 Care-Fully Senior Home Care June 10, 2015 Page 2 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. CORRECTION ORDER RECONSIDERATION PROCESS: In accordance with Minnesota Statute, section 144A.474, subd. 12, you have one opportunity to challenge the correction order issued, including the level and scope, and any fine assessed through the correction order reconsideration process. This written request must be received by the Department within 15 calendar days of the correction order receipt date. You are required to send your written request to the following: Home Health Agency Order Reconsideration Process Minnesota Department of Health Health Regulation Division Home Care & Assisted Living Program P.O. Box St. Paul, Minnesota You may request a hearing on the above assessment provided that a written request is made to the Minnesota Department of Health, Health Regulation Division, within 15 days of the receipt of this notice. Any request for a hearing as well as payment of the assessment shall be sent to the Minnesota Department of Health, Health Regulation Division, P.O. Box 64900, St. Paul, Minnesota We urge you to review these orders carefully. If you have questions, please contact Alice Sanders at (651) Please note, 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, Josh Berg, Program Manager Minnesota Department of Health Health Regulation Division Home Care and Assisted Living Program P.O. Box St. Paul, Minnesota Telephone Number: (651) Fax: (651) Encl. cc: Home Care & Assisted Living Program Kathy Rogers, Hennepin County Long Term Svs & Supports Michael Budion, Department of Human Services Sherilyn Moe, Office of Ombudsman Kelly Kemp, Office of the Attorney General Penalty Assessment Deposit Staff

5 AH Form Approved 6/9/2015 (Y1) Provider / Supplier / CLIA / Identification Number H29620 Name of Facility CARE-FULLY SENIOR HOME CARE State Form: Revisit Report (Y2) Multiple Construction A. Building B. Wing Street Address, City, State, Zip Code WYOLA ROAD MINNETONKA, MN (Y3) Date of Revisit 5/12/2015 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). (Y4) Item (Y5) Date (Y4) Item (Y5) Date (Y4) Item (Y5) Date /11/ /11/ /11/2015 Reg. # 144A.471, Subd Reg. # 144A.479, Subd Reg. # 144A.479, Subd. 6(b) /11/ /11/ /11/2015 Reg. # 144A.479, Subd Reg. # 144A.4791, Subd Reg. # 144A.4791, Subd /11/ /11/ /11/2015 Reg. # 144A.4791, Subd Reg. # 144A.4791, Subd. 9(a-e) 0865 Reg. # 144A.4791, Subd /11/ /11/ /11/2015 Reg. # 144A.4791, Subd Reg. # 144A.4794, Subd. 1(a) 1060 Reg. # 144A.4796, Subd Reg. # ZZZZ Reg. # ZZZZ Reg. # ZZZZ Reviewed By MDH Reviewed By PMB State Agency Reviewed By Reviewed By CMS RO Followup to Survey on: 2/12/2015 STATE FORM: REVISIT REPORT (5/99) Date: 6/10/15 Date: Signature of Surveyor: Signature of Surveyor: Check for any Uncorrected Deficiencies. Was a Summary of Uncorrected Deficiencies (CMS-2567) Sent to the Facility? Page 1 of 1 Event ID: Date: 5/11/15 Date: YES 55US12 NO

6 Minnesota Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING: PRINTED: 06/09/2015 FORM APPROVED (X3) DATE SURVEY COMPLETED R H29620 B. WING 05/12/2015 NAME OF PROVIDER OR SUPPLIER CARE-FULLY SENIOR HOME CARE (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR IDENTIFYING INFORMATION) STREET ADDRESS, CITY, STATE, ZIP CODE WYOLA ROAD MINNETONKA, MN ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE {0 000} Initial Comments {0 000} *****ATTENTION****** HOME CARE PROVIDER 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 11, 2015, a surveyor 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 12, At the time of the survey, there was one client that was receiving services under the basic license. As a result of the revisit, the following order was reissued. Minnesota Department of Health 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 "ID 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,"PROVIDER'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/RULES, THOUGH, THE COMMISIONER MAY REQUEST A COPY OF THE DOCUMENTATION OF ANY ACTION TAKEN TO COMPLY WITH THE CORRECTION ORDER AS NEEDED. {01245} 144A.4798, Subd. 1 TB Prevention and Control {01245} Subdivision 1. Tuberculosis (TB) prevention and control. A home care provider must establish and maintain a TB prevention and control Minnesota Department of Health LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE STATE FORM US12 If continuation sheet 1 of 3

7 Minnesota Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING: PRINTED: 06/09/2015 FORM APPROVED (X3) DATE SURVEY COMPLETED R H29620 B. WING 05/12/2015 NAME OF PROVIDER OR SUPPLIER CARE-FULLY SENIOR HOME CARE (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR IDENTIFYING INFORMATION) STREET ADDRESS, CITY, STATE, ZIP CODE WYOLA ROAD MINNETONKA, MN ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE {01245} Continued From page 1 program based on the most current guidelines issued by the Centers for Disease Control and Prevention (CDC). Components of a TB prevention and control program include screening all staff providing home care services, both paid and unpaid, at the time of hire for active TB disease and latent TB infection, and developing and implementing a written TB infection control plan. The commissioner shall make the most recent CDC standards available to home care providers on the department's Web site. This MN Requirement is not met as evidenced by: Based on interview and record review, the licensee failed to establish and maintain a TB prevention and control program based on the most current guidelines issued by the Centers for Disease Control and Prevention (CDC) as well as a facility risk assessment. In addition, the licensee failed to ensure TB symptom screening was completed as well as screening for TB including a tuberculin skin test (TST), chest x-ray, or blood test (IGRA) for one of one employee (A) reviewed. This practice resulted in a level two violation (did not harm a client's health or seafety but had the potential to have harmed a client's health or safety, but not likely to cause serious injury, impairment or death) and is issued at a widespread scope (problems are pervasive and represent a systemic failure that has affected or the potential to affect a large portion or all of the clients). The findings include: {01245} Minnesota Department of Health STATE FORM US12 If continuation sheet 2 of 3

8 Minnesota Department of Health STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING: PRINTED: 06/09/2015 FORM APPROVED (X3) DATE SURVEY COMPLETED R H29620 B. WING 05/12/2015 NAME OF PROVIDER OR SUPPLIER CARE-FULLY SENIOR HOME CARE (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR IDENTIFYING INFORMATION) STREET ADDRESS, CITY, STATE, ZIP CODE WYOLA ROAD MINNETONKA, MN ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE {01245} Continued From page 2 TB Prevention and Control Program: On May 11, 2015, employee A (owner) confirmed she did not complete a facility risk assessment. Employee A confirmed the undated TB policy and procedure lacked identification of an infection control team or supervisory responsiblity. TB Screening: Employee A's hire date was May 30, On May 11, 2015, employee A confirmed she did not have a symptom screen, TST, chest x-ray or IGRA at the time of hire. The licensee's "Tuberculosis" policy and procedure, dated September 18, 2014, did not included documentation of supervisory responsiblity for the TB infection control program, a written TB risk assessment process, or written infection control program for handling persons with active TB disease, documentation of intitial and ongoing TB related training and education for all health care workers, nor results of baseline TB screening of all health care workers. No other information was provided. {01245} Minnesota Department of Health STATE FORM US12 If continuation sheet 3 of 3

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

June 22, Ms. Erin Hilligan, Administrator Ebenezer Home Care 2722 Park Ave South Saint Louis Park, MN 55416 Email: EHILLIG1@FAIRVIEW.ORG June 22, 2016 Ms. Erin Hilligan, Administrator Ebenezer Home Care 2722 Park Ave South Saint Louis Park, MN 55416 Re: Enclosed State Licensing Orders Project Number SL28789004