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 B Andover, MN 55304 Re: Enclosed State Licensing Orders Project Number SL23591007 Dear Mr. Arnold: On February 23, 2017, staff of the completed a follow up survey of your agency to determine correction of orders found on the survey completed on January 5, 2017, with orders received by you on January 27, 2017. 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) 201 3993. 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 Anoka County Social Services Cheryl Hennen, Office of the Ombudsman An equal opportunity employer.
: REVISIT REPORT PROVER / SUPPLIER / CLIA / ENTIFICATION NUMBER H23591 Y1 MULTIPLE CONSTRUCTION A. Building B. Wing Y2 OF REVISIT 2/23/2017 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 Y5 Prefix 00870 Prefix 00875 Prefix 00905 144A.4791, Subd. 9(f) 144A.4791, Subd. 10 144A.4792, Subd. 2 02/23/2017 02/23/2017 02/23/2017 Prefix Prefix Prefix Prefix Prefix Prefix Prefix Prefix Prefix Prefix Prefix Prefix REVIEWED BY STATE AGENCY: MDH REVIEWED BY (INITIALS): PMB : 3/14/17 SIGNATURE OF SURVEYOR: 30239 : 2/23/17 REVIEWED BY CMS RO REVIEWED BY (INITIALS) TITLE FOLLOWUP TO SURVEY D ON 1/5/2017 CHECK FOR ANY UNCORRECTED DEFICIENCIES. WAS A SUMMARY OF UNCORRECTED DEFICIENCIES (CMS-2567) SENT TO THE FACILITY? YES NO Page 1 of 1 EVENT : 33RI12 : REVISIT REPORT (11/06)
Email: DAN.ARNOLD@HOMEINSTEAD.COM Certified Mail # 7015 1730 0001 0904 9414 January 24, 2017 Mr. Daniel Arnold, Administrator Home Instead Senior Care 1883 Station Parkway NW, Ste B Andover, MN 55304 PROTECTING, MAINTAINING AND IMPROVING THE HEALTH OF ALL MINNESOTANS Re: Enclosed State Licensing Orders Project Number SL23591007 Dear Mr. Arnold: A survey of the Home Care Provider named above was completed on January 5, 2017 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 to An equal opportunity employer.
Home Instead Senior Care January 24, 2017 Page 2 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 64900 85 East 7th Place, Suite 220 St. Paul, Minnesota 55164 0900 We urge you to review these orders carefully. If you have questions, contact Jonathan Hill at (651) 201 3993. 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(s) cc: Home Care and Assisted Living Program File Cheryl Hennen, Office of the Ombudsman for Long Term Care Anoka County Social Services
(X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY D NAME OF PROVER OR SUPPLIER (X4) REGULATORY OR ENTIFYING INFORMATION) 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 January 3rd through January 5th, 2017, 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 16 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. THE LETTER IN THE LEFT COLUMN IS USED FOR TRACKING PURPOSES AND REFLECTS THE SCOPE AND LEVEL ISSUED PURSUANT TO 144A.474 SUBDIVISION 11 (b)(1)(2) 0 825 SS=A 144A.4791, Subd. 1 HBOR Notification to Client Subdivision 1. Home care bill of rights; notification to client. (a) The home care provider LABORATORY DIRECTOR'S OR PROVER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) 0 825 If continuation sheet 1 of 12
(X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY D NAME OF PROVER OR SUPPLIER (X4) REGULATORY OR ENTIFYING INFORMATION) 0 825 Continued From page 1 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, e-mail address, mailing 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 0 825 If continuation sheet 2 of 12
(X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY D NAME OF PROVER OR SUPPLIER (X4) REGULATORY OR ENTIFYING INFORMATION) 0 825 Continued From page 2 provider's name, address, e-mail, 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. 0 825 This MN Requirement is not met as evidenced by: Based on observation, interview and record review, the licensee failed to ensure the client received the current Home Care Bill of Rights for one of two clients (#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 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 #2's record lacked evidence the licensee provided the client with the 2014 Home Care Bill of Rights. Client #2 was admitted on June 4, If continuation sheet 3 of 12
(X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY D NAME OF PROVER OR SUPPLIER (X4) REGULATORY OR ENTIFYING INFORMATION) 0 825 Continued From page 3 2013. On January 4, 2017, at 1:30 p.m. in the clients home, the client record was observed to contain the 2007 home care bill of rights which lacked web site and email addresses 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. On January 5, 2017, at 12:20 p.m. employee B (registered nurse) verified client #2 had not received the 2014 Home Care Bill of Rights. The licensee's "Home Care Bill Of Rights" policy dated January 2015, indicated, "The Home Care Bill of Rights shall be redistributed to clients following any revisions or modifications." No further information was provided. TIME PERIOD FOR CORRECTION: Twenty One (21) days 0 825 0 870 SS=F 144A.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; 0 870 If continuation sheet 4 of 12
(X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY D NAME OF PROVER OR SUPPLIER (X4) REGULATORY OR ENTIFYING INFORMATION) 0 870 Continued From page 4 (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 plans included all the required content for two of two clients (#1 and #2) with records reviewed. 0 870 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 If continuation sheet 5 of 12
(X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY D NAME OF PROVER OR SUPPLIER (X4) REGULATORY OR ENTIFYING INFORMATION) 0 870 Continued From page 5 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's and #2's service plans lacked a description of the home care services to be provided and the schedule and methods of monitoring reviews or assessments of the clients. Client #1's service plan dated October 31, 2016, listed the services to be provided as "personal care service". On January 5, 2017, at 9:35 a.m. client #1 stated he received the following services: hands on assistance with transfers, bathing, housekeeping, meal preparation and assistance with oxygen delivery. The service plan lacked a description of the home care services to be provided and the schedule and methods of monitoring reviews or assessments of the clients. Client #2's service plan dated February 3, 2015, listed the services to be provided as "24 hour care". On January 4, 2017, at 1:15 p.m. client #2 stated she received the following services: Hands on assistance with transfers, bathing, housekeeping, meal preparation and assistance with oxygen delivery. The service plan lacked a description of the home care services to be provided and the schedule and methods of monitoring reviews or assessments of the clients. 0 870 On January 5, 2017, at 12:25 p.m. employee B (registered nurse) verified all client's service plans lacked a detailed description of the home care services to be provided and the schedule and methods of monitoring reviews or assessments of the clients. If continuation sheet 6 of 12
(X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY D NAME OF PROVER OR SUPPLIER (X4) REGULATORY OR ENTIFYING INFORMATION) 0 870 Continued From page 6 0 870 The licensee's "Service Plan" policy dated January, 2015, indicated "the service plan will include a description of the home care services to be provided and the schedule and methods of monitoring reviews or assessments of the client." No further information was provided. TIME PERIOD FOR CORRECTION: Twenty One (21) days 0 875 SS=D 144A.4791, Subd. 10 Termination of Service Plan Subd. 10. Termination of service plan. (a) If a home care provider terminates a service plan with a client, and the client continues to need home care services, the home care provider shall provide the client and the client's representative, if any, with a written notice of termination which includes the following information: 0 875 (1) the effective date of termination; (2) the reason for termination; (3) a list of known licensed home care providers in the client's immediate geographic area; (4) a statement that the home care provider will participate in a coordinated transfer of care of the client to another home care provider, health care provider, or caregiver, as required by the home care bill of rights, section 144A.44, subdivision 1, clause (17); (5) the name and contact information of a person If continuation sheet 7 of 12
(X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY D NAME OF PROVER OR SUPPLIER (X4) REGULATORY OR ENTIFYING INFORMATION) 0 875 Continued From page 7 employed by the home care provider with whom the client may discuss the notice of termination; and (6) if applicable, a statement that the notice of termination of home care services does not constitute notice of termination of the housing with services contract with a housing with services establishment. (b) When the home care provider voluntarily discontinues services to all clients, the home care provider must notify the commissioner, lead agencies, and ombudsman for long-term care about its clients and comply with the requirements in this subdivision. This MN Requirement is not met as evidenced by: Based on interview and record review, the licensee failed to ensure the client's written notice of service plan termination included all of the required content for one of one client (#1) with record 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 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: 0 875 The written notice provided to client #1 lacked a statement the home care provider would participate in a coordinated transfer of care of the If continuation sheet 8 of 12
(X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY D NAME OF PROVER OR SUPPLIER (X4) REGULATORY OR ENTIFYING INFORMATION) 0 875 Continued From page 8 client to another home care provider, health care provider or caregiver as required by the home care bill of rights. Client #1 was admitted for services on November 4, 2016. On December 30, 2016, a written notice of service termination was sent via certified mail to client #1's representative. The written notice of service plan termination listed the effective date of termination, the reason for termination and a list of known licensed home care providers in the client's immediate geographic area, however the written notice lacked a statement the home care provider would participate in a coordinated transfer of care of the client to another home care provider, health care provider or caregiver as required by the home care bill of rights. On January 5, 2017, at 12:30 p.m., employee B (registered nurse) verified the written notice of service termination given to client #1's representative lacked a statement the home care provider would participate in a coordinated transfer of care of the client to another home care provider, health care provider or caregiver as required by the home care bill of rights. The licensee's "Termination of a Service Plan" policy dated January 2015, indicated "a written notice of termination would include a statement that the home care provider will participate in a coordinated transfer of care of the client to another home care provider, health care provider or caregiver as required by the home care bill of rights." No further information was provided. 0 875 TIME PERIOD FOR CORRECTION: Twenty-one (21) days If continuation sheet 9 of 12
(X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY D NAME OF PROVER OR SUPPLIER (X4) REGULATORY OR ENTIFYING INFORMATION) 0 905 SS=D 144A.4792, Subd. 2 Provision of Medication Mgt Services 0 905 Subd. 2. Provision of medication management services. (a) For each client who requests medication management services, the comprehensive home care provider shall, prior to providing medication management services, have a registered nurse, licensed health professional, or authorized prescriber under section 151.37 conduct an assessment ot determine what medication management services will be provided and how the services will be provided. This assessment must be conducted face-to-face with the client. The assessment must include an identification and review of all medications the client is known to be taking. The review and identification must include indciations for medications, side effects, contraindications, allergic or adverse reactions, and actions to address these issues. (b) The assessment must identify interventions needed in management of medications to prevent diversion of medication by the client or others who may have access to the medications. "Diversion of medications" means the misuse, theft, or illegal or improper disposition of medications. This MN Requirement is not met as evidenced by: Based on interview and record review, the licensee failed to ensure the registered nurse (RN) conducted an assessment to determine what medication management services would be If continuation sheet 10 of 12
(X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY D NAME OF PROVER OR SUPPLIER (X4) REGULATORY OR ENTIFYING INFORMATION) 0 905 Continued From page 10 provided and how the services would be provided for one of one client (#2) with record 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 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 #2's record lacked documentation of an assessment by the RN for medication management services. Client #2 was admitted for services on June 4, 2013. The client's "Comprehensive Care Plan" dated October 31, 2016, indicated client #2 received "Medication administration for O2 [oxygen] and PRN's [as needed medications]". Client #2's record included physician's orders dated October 24, 2016, for "Citrucel [fiber used to maintain bowel regularity] one heaping teaspoon per day in a glass of water. Adjust dose up or down as needed." On January 4, 2017, at 1:30 p.m. in client #2's home, employee D (unlicensed personnel) stated staff assisted with preparing and administering Citrucel. Employee D also indicated client #2 was self-administering all of the other regularly scheduled medications and also stated she was not sure if client #2 was taking all of her pills properly. 0 905 On January 5, 2017, at 12:25 p.m. employee B If continuation sheet 11 of 12
(X1) PROVER/SUPPLIER/CLIA ENTIFICATION NUMBER: (X3) SURVEY D NAME OF PROVER OR SUPPLIER (X4) REGULATORY OR ENTIFYING INFORMATION) 0 905 Continued From page 11 (RN) confirmed client #2's ability to self-administer medications was unknown and verified the client record lacked an assessment to determine what medication management services would be provided and how the services would be provided. The licensee's "Medication Management" policy dated January, 2015, indicated "Comprehensive client assessment performed at start of care and other defined points in time include review of all medications the client is taking and records this in the client record." No further information was provided. TIME PERIOD FOR CORRECTION: Seven (7) days 0 905 If continuation sheet 12 of 12