Email: [email protected]
March 8, 2016
Ms. Victoria Fore, Administrator
Signe And Olivias, LLC
1545 Harbor Street
Ogilvie, MN 56358
Re: Enclosed State Licensing Orders ‐ Project Number SL26359006 Dear Ms. Fore:
On February 11, 2016, staff of the Minnesota Department of Health completed a follow‐up survey of
your agency to determine correction of orders found on the survey completed on October 13, 2015,
with orders received by you on October 31, 2015; and follow‐up survey completed on December 24,
2015, with orders including penalties received by you on January 8, 2016. Penalties have been paid in
full. At this time these correction orders were found corrected and are listed on the attached State
Form: Revisit Report.
If you have questions, contact Jeri Cummins at (218) 302‐6193. 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
Kanabec County Social Services
Michael Budion, Minnesota Department of Human Services
Cheryl Hennen, Office of the Ombudsman
Protecting, maintaining and improving the health of all Minnesotans
STATE FORM: REVISIT REPORT
PROVIDER / SUPPLIER / CLIA /
IDENTIFICATION NUMBER
H26359
Y1
MULTIPLE CONSTRUCTION
A. Building
B. Wing
DATE OF REVISIT
Y2
NAME OF FACILITY
STREET ADDRESS, CITY, STATE, ZIP CODE
SIGNE AND OLIVIAS LLC
1545 HARBOR STREET
2/11/2016
Y3
OGILVIE, MN 56358
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
DATE
ITEM
Y4
Y5
Y4
ID Prefix 00825
Correction
ID Prefix 00835
Completed
Reg. #
LSC
02/08/2016
ID Prefix
Reg. #
Reg. #
144A.4791, Subd. 1
DATE
Y5
ITEM
DATE
Y4
Y5
Correction
ID Prefix 00905
Completed
Reg. #
LSC
02/08/2016
LSC
02/08/2016
Correction
ID Prefix
Correction
ID Prefix
Correction
Completed
Reg. #
Completed
Reg. #
Completed
LSC
144A.4791, Subd. 3
LSC
Correction
144A.4792, Subd. 2
Completed
LSC
ID Prefix
Correction
ID Prefix
Correction
ID Prefix
Correction
Reg. #
Completed
Reg. #
Completed
Reg. #
Completed
LSC
LSC
LSC
ID Prefix
Correction
ID Prefix
Correction
ID Prefix
Correction
Reg. #
Completed
Reg. #
Completed
Reg. #
Completed
LSC
LSC
LSC
ID Prefix
Correction
ID Prefix
Correction
ID Prefix
Correction
Reg. #
Completed
Reg. #
Completed
Reg. #
Completed
LSC
LSC
LSC
REVIEWED BY STATE
AGENCY: MDH
REVIEWED BY
(INITIALS): PMB
DATE: 3/8/16
SIGNATURE OF SURVEYOR: 33383
DATE: 2/8/16
REVIEWED BY
CMS RO
REVIEWED BY
(INITIALS)
DATE
TITLE
DATE
FOLLOWUP TO SURVEY COMPLETED ON
10/15/2015
CHECK FOR ANY UNCORRECTED DEFICIENCIES. WAS A SUMMARY OF
UNCORRECTED DEFICIENCIES (CMS-2567) SENT TO THE FACILITY?
Page 1 of 1
STATE FORM: REVISIT REPORT (11/06)
EVENT ID:
YES
FHNW13
NO
Email: [email protected]
Certified Mail # 7015 0640 0004 5870 9596 January 6, 2016
Ms. Victoria Fore, Administrator
Signe And Olivias, LLC
1545 Harbor Street
Ogilvie, MN 56358
Re: Enclosed State Licensing Orders ‐ Project Number SL26359006 Dear Ms. Fore:
On December 22, 2015, staff of the Minnesota Department of Health completed a follow‐up survey of
your agency to determine correction of orders found on the survey completed on October 13, 2015,
with orders received by you on October 31, 2015.
State licensing orders issued pursuant to the survey completed on October 13, 2015, and found
corrected at the time of the December 22, 2015, follow‐up survey, are listed on the attached State
Form: Revisit Report. State licensing orders are delineated on the attached Minnesota Department of Health order form.
The Minnesota Department of Health is documenting the State Licensing Correction 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 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
Signe And Olivias, LLC
January 6, 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
HBOR Notification to Client, Minnesota Statutes 144A.4791, subdivision 1
NO FINE Level/1; Scope/Pattern
Stmt of Home Care Services, Minnesota Statutes 144A.4791, subdivision 3
$500.00 Level/2; Scope/Widespread
Provision of Med Mgmt Svs, Minnesota Statutes 144A.4792, subdivision 2
Total = $500.00
The details of the violations noted at the time of this follow‐up survey completed on December 22,
2015, (listed above), are on the attached State Form. Brackets around the ID 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 $500.00. 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:
Minnesota Department of Health
Health Regulation Division
P.O. Box 64900
St. Paul, Minnesota 55164‐0900
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. Signe And Olivias, LLC
January 6, 2016
Page 3
CORRECTION ORDER RECONSIDERATION 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 Correction Order Reconsideration Process
Minnesota Department of Health
Health Regulation Division
P.O. Box 64900
St. Paul, Minnesota 55164‐0900
We urge you to review these orders carefully. If you have questions, contact Jeri Cummins at
(218) 302‐6193. 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 64900
St. Paul, Minnesota 55164
Telephone Number: (651) 201‐3708 Fax: (651) 215‐9697
Enclosure
cc: Home Care & Assisted Living Program File
Kanabec County Social Services
Michael Budion, Minnesota Department of Human Services
Cheryl Hennen, Office of Ombudsman
Kelly Kemp, Office of Attorney General
AH Form Approved
1/6/2016
State Form: Revisit Report
(Y1)
(Y2) Multiple Construction
A. Building
B. Wing
Provider / Supplier / CLIA /
Identification Number
H26359
(Y3) Date of Revisit
12/22/2015
Street Address, City, State, Zip Code
Name of Facility
1545 HARBOR STREET
OGILVIE, MN 56358
SIGNE AND OLIVIAS LLC
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).
(Y4)
(Y5)
Item
ID Prefix
00265
01080
(Y4) Item
Date
Correction
Completed
12/24/2015
Completed
12/24/2015
0265
ID Prefix
00900
Reg. # 144A.4792, Subd. 1
LSC
0900
Correction
Correction
Completed
12/24/2015
Completed
12/24/2015
Reg. # 144A.4794, Subd. 3
LSC
1080
ID Prefix
01170
Reg. # 144A.4796, Subd. 2
LSC
1170
Correction
Correction
Completed
Completed
ID Prefix
ID Prefix
Reg. #
LSC
ZZZZ
Reg. #
LSC
ZZZZ
Correction
Completed
Completed
ID Prefix
Reg. #
LSC
ZZZZ
Reg. #
LSC
ZZZZ
Correction
Completed
Completed
ID Prefix
Reg. #
LSC
ZZZZ
MDH
Date
Correction
ID Prefix
Completed
12/24/2015
01030
Reg. # 144A.4793, Subd. 2
LSC
1030
Correction
ID Prefix
Completed
12/24/2015
01245
Reg. # 144A.4798, Subd. 1
LSC
1245
Correction
Completed
Reg. #
LSC
ZZZZ
Correction
Completed
ID Prefix
Correction
ID Prefix
(Y5)
ID Prefix
Correction
ID Prefix
Reviewed By
(Y5)
Correction
Reg. # 144A.44, Subd. 1(2)
LSC
ID Prefix
(Y4) Item
Date
Reg. #
LSC
ZZZZ
Correction
Completed
ID Prefix
Reg. #
LSC
ZZZZ
Reg. #
LSC
ZZZZ
Reviewed By PMB
Date: 1/6/16
Signature of Surveyor: 33383
Date: 12/24/15
Reviewed By
Date:
Signature of Surveyor:
Date:
State Agency
Reviewed By
CMS RO
Followup to Survey Completed on:
10/15/2015
STATE FORM: REVISIT REPORT (5/99)
Check for any Uncorrected Deficiencies. Was a Summary of
Uncorrected Deficiencies (CMS-2567) Sent to the Facility?
Page 1 of 1
Event ID:
YES
FHNW12
NO
PRINTED: 01/06/2016
FORM APPROVED
Minnesota Department of Health
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING: ______________________
B. WING _____________________________
H26359
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
SIGNE AND OLIVIAS LLC
1545 HARBOR STREET
OGILVIE, MN 56358
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
(X4) ID
PREFIX
TAG
{0 000} Initial Comments
ID
PREFIX
TAG
(X3) DATE SURVEY
COMPLETED
R
12/22/2015
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
{0 000}
*****ATTENTION******
Minnesota Department of Health is
documenting the State Licensing
Correction 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 Correction.
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:
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.
On December 22, 23 and 24,2015, 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 October15,
2015. At the time of the survey, there were 9
clients that were receiving services. As a result
of the revisit, the following orders were reissued.
{0 825} 144A.4791, Subd. 1 HBOR Notification to Client
THERE IS NO REQUIREMENT TO
SUBMIT A PLAN OF CORRECTION FOR
VIOLATIONS OF MINNESOTA STATE
STATUTES.
{0 825}
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
Minnesota Department of Health
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
STATE FORM
6899
TITLE
FHNW12
(X6) DATE
If continuation sheet 1 of 9
PRINTED: 01/06/2016
FORM APPROVED
Minnesota Department of Health
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING: ______________________
B. WING _____________________________
H26359
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
SIGNE AND OLIVIAS LLC
1545 HARBOR STREET
OGILVIE, MN 56358
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
{0 825} Continued From page 1
ID
PREFIX
TAG
(X3) DATE SURVEY
COMPLETED
R
12/22/2015
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
{0 825}
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, 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."
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
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
Minnesota Department of Health
STATE FORM
6899
FHNW12
If continuation sheet 2 of 9
PRINTED: 01/06/2016
FORM APPROVED
Minnesota Department of Health
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING: ______________________
B. WING _____________________________
H26359
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
SIGNE AND OLIVIAS LLC
1545 HARBOR STREET
OGILVIE, MN 56358
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
{0 825} Continued From page 2
ID
PREFIX
TAG
(X3) DATE SURVEY
COMPLETED
R
12/22/2015
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
{0 825}
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 ensure the most recent
up-to-date bill of rights was provided to three of
three clients (#1, #2, #6) 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 is issued at a widespread
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:
Clients #1, #2, and #6 records, failed to include
acknowledgement they received the most
up-to-date home care bill of rights.
Client #1 was admitted for services with
diagnoses that included dementia and diabetes.
Client #2 was admitted for services with
Minnesota Department of Health
STATE FORM
6899
FHNW12
If continuation sheet 3 of 9
PRINTED: 01/06/2016
FORM APPROVED
Minnesota Department of Health
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING: ______________________
B. WING _____________________________
H26359
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
SIGNE AND OLIVIAS LLC
1545 HARBOR STREET
OGILVIE, MN 56358
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
{0 825} Continued From page 3
ID
PREFIX
TAG
(X3) DATE SURVEY
COMPLETED
R
12/22/2015
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
{0 825}
diagnoses that included diabetes.
Client #6 was admitted for services with
diagnoses that included atrial fibrillation and
chronic obstructive pulmonary disease.
On December, 23 , 2015, employee A
(administrator) verified that the above identified
client's had not yet received the latest version of
the home care bill of rights, as well as the rest of
the licensee's clients. Employee A stated that she
was aware that the licensee needed to provide
the latest version of the home care bill of rights to
it's clients.
The licensee's policy, titled "Bill of Rights," dated
November 20, 2015, read, "(licensee's name)
shall provide the client or the client's
representative a written copy of the Minnesota
Home Care Bill of Rights (BOR) before the
initiation of services to that client." The policy also
read, "(licensee's name) shall obtain written
acknowledgement of the client's receipt of BOR
or shall document why an acknowledgement
cannot be obtained. The acknowledgement may
be obtained from the client or the client's
representative."
TIME
{0 835} 144A.4791, Subd. 3 Statement of Home Care
{0 835}
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
has a basic or comprehensive home care license,
Minnesota Department of Health
STATE FORM
6899
FHNW12
If continuation sheet 4 of 9
PRINTED: 01/06/2016
FORM APPROVED
Minnesota Department of Health
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING: ______________________
B. WING _____________________________
H26359
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
SIGNE AND OLIVIAS LLC
1545 HARBOR STREET
OGILVIE, MN 56358
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
{0 835} Continued From page 4
ID
PREFIX
TAG
(X3) DATE SURVEY
COMPLETED
R
12/22/2015
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
{0 835}
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 a statement of services
was provided to clients upon admission for two of
three clients (#2, #6) with records reviewed.
This practice resulted in a level one violation
(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 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
or in several locations, but is not found to be
pervasive.)
Client #2 and #6's record lacked
acknowledgement they had received a statement
of services from the licensee.
On December 23, 2015, employee A
(administrator) verified client's #2 and #6's
records lacked acknowledgement of receipt for
the licensees statement of home care services.
Employee A stated that she mailed every family a
copy of the statement of services around "the end
of November or early December," and was still
awaiting most of the signatures. Employee A
Minnesota Department of Health
STATE FORM
6899
FHNW12
If continuation sheet 5 of 9
PRINTED: 01/06/2016
FORM APPROVED
Minnesota Department of Health
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING: ______________________
B. WING _____________________________
H26359
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
SIGNE AND OLIVIAS LLC
1545 HARBOR STREET
OGILVIE, MN 56358
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
{0 835} Continued From page 5
ID
PREFIX
TAG
(X3) DATE SURVEY
COMPLETED
R
12/22/2015
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
{0 835}
verified she did not document when the
statement of home care services were mailed out
and did not document follow-up for the clients as
to where in the process of receiving the statement
of home care services acknowledgement was.
The licensee's policy, titled, "Statement of Home
Care Services," dated, November 20, 2015,
read, "(licensee's name) shall provide a
Statement of Home Care Services to client's and
client's representatives. This statement shall be
provided prior to the initiation of services." The
policy also read, "(licensee's name) shall obtain
written acknowledgement from the client that
(licensee's name) provided the statement, or
must document why the home care provider
could not obtain such acknowledgement."
{0 905} 144A.4792, Subd. 2 Provision of Medication Mgt
{0 905}
Services
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.
Minnesota Department of Health
STATE FORM
6899
FHNW12
If continuation sheet 6 of 9
PRINTED: 01/06/2016
FORM APPROVED
Minnesota Department of Health
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING: ______________________
B. WING _____________________________
H26359
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
SIGNE AND OLIVIAS LLC
1545 HARBOR STREET
OGILVIE, MN 56358
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
{0 905} Continued From page 6
ID
PREFIX
TAG
(X3) DATE SURVEY
COMPLETED
R
12/22/2015
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
{0 905}
(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
conducted a face to face assessment with the
client, identifying and reviewing all medications
the client is known to be taking, and review of
those medications as required for two of two
clients (#1, #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
is issued at a widespread 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). Findings include:
Client #1 was admitted for services with
diagnoses that included dementia and diabetes.
Client #1's service plan, dated December 30,
2014, identified that the client received
medication administration.
Client #1's physician's orders, dated June 24,
Minnesota Department of Health
STATE FORM
6899
FHNW12
If continuation sheet 7 of 9
PRINTED: 01/06/2016
FORM APPROVED
Minnesota Department of Health
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING: ______________________
B. WING _____________________________
H26359
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
SIGNE AND OLIVIAS LLC
1545 HARBOR STREET
OGILVIE, MN 56358
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
{0 905} Continued From page 7
ID
PREFIX
TAG
(X3) DATE SURVEY
COMPLETED
R
12/22/2015
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
{0 905}
2015, included: polyethylene glycol (laxative) 17
grams daily as needed (PRN), senna (laxative)
8.6 mg (milligrams) 2 tabs po (by mouth) BID
(twice a day), allopurinol (anti-gout) 100 mg PO
daily, amlodipine (anti-hypertension) 2.5 mg PO
daily, Atenolol (antihypertensive) 75 mg PO daily,
clopidogrel (blood thinner) 75 mg PO daily, fish oil
(supplement) 1000 mg PO daily, Lantus insulin
(treats high blood sugar levels) 12 units
subcutaneous at bedtime, linisopril
(anti-hypertensive) 40 mg PO daily, lovastatin
(treats high cholesterol) 20 mg PO daily,
metformin (anti-diabetic) 1000 mg PO twice daily,
multi-vitamin (supplement) 1 tab PO daily,
paroxetine (anti-depressant) 40 mg PO daily,
Tylenol Arthritis (pain reliever) 650 mg PO TID
(three times daily)
Client #2 was admitted for services with
diagnoses that included dementia and diabetes.
Client #2's service plan, dated July 19, 2013,
identified that the client received medication
administration.
Client #2's medication administration record for
October 2015, indicated the client received the
following medications: citalopram
(anti-depressant) 20 mg PO daily, aspirin 81 mg
PO daily, metformin 500 mg PO BID, ibuprofen
(pain reliever, fever reducer) 200 mg PO BID,
omeprazole (treats indigestion) 40 mg PO daily,
potassium chloride 10 meq (miliequivalents) PO
daily, triamterene-HCTZ (diuretic) 37.5-25 mg 1
tab PO daily, simvastatin (anti-cholesterol) 40 mg
PO daily, and Pulmacort 0.5 mg/2 ml (inhaled
corticosteroid) inhale one dose via nebulizer once
daily.
On December 23, 2015, employee C (registered
nurse) confirmed that clients #1 and #2's records
Minnesota Department of Health
STATE FORM
6899
FHNW12
If continuation sheet 8 of 9
PRINTED: 01/06/2016
FORM APPROVED
Minnesota Department of Health
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING: ______________________
B. WING _____________________________
H26359
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
SIGNE AND OLIVIAS LLC
1545 HARBOR STREET
OGILVIE, MN 56358
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
{0 905} Continued From page 8
ID
PREFIX
TAG
(X3) DATE SURVEY
COMPLETED
R
12/22/2015
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
{0 905}
lacked documentation of a face to face
comprehensive assessment with the client
including and identifying all medications the client
was known to be taking, including indication for
medications, side effects, contraindications,
allergic or adverse reactions, actions to address
these issues and identifying interventions needed
in management of medications to prevent
diversion of medication by the client or others
who may have access to the medications.
Employee C confirmed all client records lacked
this requirement. Employee C stated she
misunderstood the regulation.
The license's policy, titled, "Medication
Management Services Provided by Unlicensed
Personnel," read, "A RN must conduct a
face-to-face client assessment to determine what
medication management services will be provided
and how those services will be provided." The
policy also read, "Medication management
services provided by an unlicensed personnel to
home care client's of (licensee's name) will be
performed consistent with Minnesota
Comprehensive Home Care Rules."
Minnesota Department of Health
STATE FORM
6899
FHNW12
If continuation sheet 9 of 9
Protecting, Maintaining and Improving the Health of Minnesotans
Certified Mail # 7015 1520 0000 6771 2363
Email: [email protected]
October 28, 2015
Ms. Victoria Fore, Administrator
Signe and Olivias, LLC
1545 Harbor Street
Ogilvie, MN 56358
Re: Enclosed State Licensing Orders - Project Number SL26359006
Dear Ms. Fore:
A survey of the Home Care Provider named above was completed on October 15, 2015, for the purpose
of assessing compliance with State licensing regulations. At the time of survey staff from the
Minnesota Department of Health noted one or more violations of these regulations that are issued in
accordance with Minnesota Statutes, sections 144A.43 to 144A.482.
State licensing orders are delineated on the attached Minnesota Department of Health order form. The
Minnesota Department of Health is documenting the State Licensing Correction 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 that are in violation of the
state statute after the statement, "This MN Requirement is not met as evidenced by."
We urge you to review these orders carefully. If you have questions, please contact Alice Sanders at
(651) 201-3993.
DOCUMENTATION OF ACTION TO COMPLY
In accordance with Minnesota Statutes, section 144A.474, subd. 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.
______________________________________________________________________________________________________
Minnesota Department of Health • Health Regulation Division • Home Care & Assisted Living Program
General Information: 651-201-5000 • Toll-free: 888-345-0823
http://www.health.state.mn.us
An equal opportunity employer
Signe And Olivias, LLC
October 28, 2015
Page 2
CORRECTION ORDER RECONSIDERATION PROCESS
In accordance with Minnesota Statutes, 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 Correction Order Reconsideration Process
Minnesota Department of Health
Health Regulation Division
P.O. Box 64900
St. Paul, Minnesota 55164-0900
Failure to correct state licensing correction orders may result in enforcement actions in accordance
with the provisions of Minnesota Statutes, sections 144A.43 to 144A.482.
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,
Paula Bastian
Senior Health Program Representative
Health Regulation Division
Home Care & Assisted Living Program
cc:
Home Care & Assisted Living File
Kanabec County Social Services
Michael Budion, Minnesota Department of Human Services
Cheryl Hennen, Office of the Ombudsman
PRINTED: 10/28/2015
FORM APPROVED
Minnesota Department of Health
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING: ______________________
B. WING _____________________________
H26359
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
SIGNE AND OLIVIAS LLC
1545 HARBOR STREET
OGILVIE, MN 56358
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
(X4) ID
PREFIX
TAG
0 000 Initial Comments
ID
PREFIX
TAG
(X3) DATE SURVEY
COMPLETED
10/15/2015
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
0 000
*****ATTENTION******
Minnesota Department of Health is
documenting the State Licensing
Correction 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 Correction.
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:
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.
On October 13, 14 and 15, 2015, 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 09 clients that
were receiving services under the comprehensive
license.
THERE IS NO REQUIREMENT TO
SUBMIT A PLAN OF CORRECTION FOR
VIOLATIONS OF MINNESOTA STATE
STATUTES.
0 265 144A.44, Subd. 1(2) Up-To-Date Plan/Accepted
0 265
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
Minnesota Department of Health
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
STATE FORM
6899
TITLE
FHNW11
(X6) DATE
If continuation sheet 1 of 21
PRINTED: 10/28/2015
FORM APPROVED
Minnesota Department of Health
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING: ______________________
B. WING _____________________________
H26359
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
SIGNE AND OLIVIAS LLC
1545 HARBOR STREET
OGILVIE, MN 56358
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
0 265 Continued From page 1
ID
PREFIX
TAG
(X3) DATE SURVEY
COMPLETED
10/15/2015
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
0 265
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 follow standards of
practice in the areas of bed rails for one of two
clients (#1) 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) and is issued at an
isolated scope (one or a limited number of clients
affected). Findings include::
Client #1's record failed to include a functional
assessment completed by the registered nurse
assessing the need and appropriateness for bed
rails. The record also failed to include
documentation that risks versus benefits had
been discussed with the client and or their
responsible party.
Client #1 was admitted for services with
diagnoses that included dementia and diabetes.
On October 13, 2015, bilateral bed rails were
observed attached to the upper 1/2 of client #1's
beds. The side rails measured approximately 30
inches long by 20 inches wide with bar spacing
less than 4 3/4 inches. The bed rails were
securely attached to the bed. Client #1 was not
observed to use the bed rails at any time during
the survey.
On October 14, 2015, employee C (registered
Minnesota Department of Health
STATE FORM
6899
FHNW11
If continuation sheet 2 of 21
PRINTED: 10/28/2015
FORM APPROVED
Minnesota Department of Health
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING: ______________________
B. WING _____________________________
H26359
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
SIGNE AND OLIVIAS LLC
1545 HARBOR STREET
OGILVIE, MN 56358
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
0 265 Continued From page 2
ID
PREFIX
TAG
(X3) DATE SURVEY
COMPLETED
10/15/2015
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
0 265
nurse) verified that she did not complete a
functional assessment for client #1 to determine
the need and appropriateness of bed rails.
Employee C also verified education regarding
risks versus benefits had not been completed for
client #1.
No policy was provided related to this matter.
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
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."
TIME PERIOD FOR CORRECTION: Twenty-one
(21) days
0 825 144A.4791, Subd. 1 HBOR Notification to Client
0 825
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
Minnesota Department of Health
STATE FORM
6899
FHNW11
If continuation sheet 3 of 21
PRINTED: 10/28/2015
FORM APPROVED
Minnesota Department of Health
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING: ______________________
B. WING _____________________________
H26359
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
SIGNE AND OLIVIAS LLC
1545 HARBOR STREET
OGILVIE, MN 56358
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
0 825 Continued From page 3
ID
PREFIX
TAG
(X3) DATE SURVEY
COMPLETED
10/15/2015
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
0 825
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, 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."
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
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.
Minnesota Department of Health
STATE FORM
6899
FHNW11
If continuation sheet 4 of 21
PRINTED: 10/28/2015
FORM APPROVED
Minnesota Department of Health
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING: ______________________
B. WING _____________________________
H26359
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
SIGNE AND OLIVIAS LLC
1545 HARBOR STREET
OGILVIE, MN 56358
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
0 825 Continued From page 4
ID
PREFIX
TAG
(X3) DATE SURVEY
COMPLETED
10/15/2015
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
0 825
(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 ensure the most recent
up-to-date bill of rights was provided to two of two
clients (#1, #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 is issued at a widespread
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 #1 and #2's record failed to include
acknowledgement they received the most
up-to-date home care bill of rights.
Client #1 was admitted for services with
diagnoses that included dementia and diabetes.
Client #1's record included an acknowledgement
form dated December 30, 2014, which included
documentation he had received the home care
bill of rights.
Minnesota Department of Health
STATE FORM
6899
FHNW11
If continuation sheet 5 of 21
PRINTED: 10/28/2015
FORM APPROVED
Minnesota Department of Health
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING: ______________________
B. WING _____________________________
H26359
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
SIGNE AND OLIVIAS LLC
1545 HARBOR STREET
OGILVIE, MN 56358
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
0 825 Continued From page 5
ID
PREFIX
TAG
(X3) DATE SURVEY
COMPLETED
10/15/2015
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
0 825
Client #2 was admitted for services with
diagnoses that included diabetes.
Client #2's record included an acknowledgement
form dated December 30, 2014, which included
documentation she had received the home care
bill of rights.
On October 14, 2014, employee A (administrator)
provided a copy of the home care bill of rights
which was dated March 29, 2006. Employee A
stated she was unaware there was a more
current home care bill of rights in which the
licensee was required to give to all of its clients.
Employee A verified none of the licensee's clients
had received the most up-to-date home care bill
of rights.
No policy was provided related to this matter.
TIME PERIOD FOR CORRECTION: Twenty-one
(21) days
0 835 144A.4791, Subd. 3 Statement of Home Care
0 835
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
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
Minnesota Department of Health
STATE FORM
6899
FHNW11
If continuation sheet 6 of 21
PRINTED: 10/28/2015
FORM APPROVED
Minnesota Department of Health
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING: ______________________
B. WING _____________________________
H26359
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
SIGNE AND OLIVIAS LLC
1545 HARBOR STREET
OGILVIE, MN 56358
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
0 835 Continued From page 6
ID
PREFIX
TAG
(X3) DATE SURVEY
COMPLETED
10/15/2015
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
0 835
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 a statement of services
was provided to clients upon admission for two of
two (#1, #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 is issued at a widespread
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 #1 and #2's record lacked
acknowledgement they had received a statement
of services from the licensee.
On October 14, 2015, employee A (administrator)
stated the licensee did not provide any of its
clients with a statement of services as required.
Employee A stated she as unaware of this
requirement.
No policy was provided related to this matter.
TIME PERIOD FOR CORRECTION: Twenty-one
(21) days
0 900 144A.4792, Subd. 1 Medication Management;
0 900
Comprehensive
Minnesota Department of Health
STATE FORM
6899
FHNW11
If continuation sheet 7 of 21
PRINTED: 10/28/2015
FORM APPROVED
Minnesota Department of Health
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING: ______________________
B. WING _____________________________
H26359
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
SIGNE AND OLIVIAS LLC
1545 HARBOR STREET
OGILVIE, MN 56358
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
0 900 Continued From page 7
ID
PREFIX
TAG
(X3) DATE SURVEY
COMPLETED
10/15/2015
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
0 900
Subdivision 1. Medication management services;
comprehensive home care license. (a) This
subdivision applies only to home care providers
with a comprehensive home care license that
provide
medication management services to clients.
Medication management services may not be
provided by a
home care provider who has a basic home care
license.
(b) A comprehensive home care provider who
provides medication management services must
develop, implement, and maintain current written
medication management policies and
procedures. The
policies and procedures must be developed
under the supervision and direction of a
registered nurse,
licensed health professional, or pharmacist
consistent with current practice standards and
guidelines.
(c) The written policies and procedures must
address requesting and receiving prescriptions
for
medications; preparing and giving medications;
verifying that prescription drugs are administered
as
prescribed; documenting medication
management activities; controlling and storing
medications;
monitoring and evaluating medication use;
resolving medication errors; communicating with
the
prescriber, pharmacist, and client and client
representative, if any; disposing of unused
medications; and
educating clients and client representatives about
Minnesota Department of Health
STATE FORM
6899
FHNW11
If continuation sheet 8 of 21
PRINTED: 10/28/2015
FORM APPROVED
Minnesota Department of Health
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING: ______________________
B. WING _____________________________
H26359
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
SIGNE AND OLIVIAS LLC
1545 HARBOR STREET
OGILVIE, MN 56358
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
0 900 Continued From page 8
ID
PREFIX
TAG
(X3) DATE SURVEY
COMPLETED
10/15/2015
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
0 900
medications. When controlled substances are
being
managed, the policies and procedures must also
identify how the provider will ensure security and
accountability for the overall management,
control, and disposition of those substances in
compliance
with state and federal regulations and with
subdivision 22.
This MN Requirement is not met as evidenced
by:
Based on interview and record review, the
licensee failed to ensure it retained all of the
required medication policies.
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
is issued at a widespread 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). Findings include:
The licensee lacked the following medication
policies: requesting and receiving prescriptions
for medications; verifying that prescription drugs
are administered as prescribed; controlling and
storing medications; monitoring and evaluating
medication use; communicating with the
prescriber, pharmacist, and client and client
representative, if any; disposing of unused
medications; and educating clients and client
representatives about medications. When
controlled substances are being managed, the
policies and procedures must also identify how
the provider will ensure security and
Minnesota Department of Health
STATE FORM
6899
FHNW11
If continuation sheet 9 of 21
PRINTED: 10/28/2015
FORM APPROVED
Minnesota Department of Health
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING: ______________________
B. WING _____________________________
H26359
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
SIGNE AND OLIVIAS LLC
1545 HARBOR STREET
OGILVIE, MN 56358
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
0 900 Continued From page 9
ID
PREFIX
TAG
(X3) DATE SURVEY
COMPLETED
10/15/2015
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
0 900
accountability for the overall management,
control, and disposition of those substances in
compliance with state and federal regulations and
with subdivision 22.
On October 14, 2015, employee A (administrator)
verified these medication policies were lacking.
Employee A stated she was unaware the licensee
was required to retain such written policies and
procedures.
TIME PERIOD FOR CORRECTION: Twenty-one
(21) days
0 905 144A.4792, Subd. 2 Provision of Medication Mgt
0 905
Services
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
Minnesota Department of Health
STATE FORM
6899
FHNW11
If continuation sheet 10 of 21
PRINTED: 10/28/2015
FORM APPROVED
Minnesota Department of Health
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING: ______________________
B. WING _____________________________
H26359
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
SIGNE AND OLIVIAS LLC
1545 HARBOR STREET
OGILVIE, MN 56358
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
0 905 Continued From page 10
ID
PREFIX
TAG
(X3) DATE SURVEY
COMPLETED
10/15/2015
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
0 905
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
conducted a face to face assessment with the
client, identifying and reviewing all medications
the client is known to be taking, and review of
those medications as required for two of two
clients (#1, #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
is issued at a widespread 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). Findings include:
Client #1 was admitted for services with
diagnoses that included dementia and diabetes.
Client #1's service plan, dated December 30,
2014, identified that the client received
medication administration.
Client #1's physician's orders, dated June 24,
2015, included: polyethylene glycol (laxative) 17
grams daily as needed (PRN), senna (laxative)
8.6 mg (milligrams) 2 tabs po (by mouth) BID
(twice a day), allopurinol (anti-gout) 100 mg PO
Minnesota Department of Health
STATE FORM
6899
FHNW11
If continuation sheet 11 of 21
PRINTED: 10/28/2015
FORM APPROVED
Minnesota Department of Health
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING: ______________________
B. WING _____________________________
H26359
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
SIGNE AND OLIVIAS LLC
1545 HARBOR STREET
OGILVIE, MN 56358
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
0 905 Continued From page 11
ID
PREFIX
TAG
(X3) DATE SURVEY
COMPLETED
10/15/2015
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
0 905
daily, amlodipine (anti-hypertension) 2.5 mg PO
daily, atenolol (antihypertensive) 75 mg PO daily,
clopidogrel (blood thinner) 75 mg PO daily, fish oil
(supplement) 1000 mg PO daily, Lantus insulin
(treats high blood sugar levels) 12 units
subcutaneous at bedtime, linisopril
(anti-hypertensive) 40 mg PO daily, lovastatin
(treats high cholesterol) 20 mg PO daily,
metformin (anti-diabetic) 1000 mg PO twice daily,
multi-vitamin (supplement) 1 tab PO daily,
paroxetine (anti-depressant) 40 mg PO daily,
Tylenol Arthritis (pain reliever) 650 mg PO TID
(three times daily)
Client #2 was admitted for services with
diagnoses that included dementia and diabetes.
Client #2's service plan, dated July 19, 2013,
identified that the client received medication
administration.
Client #2's medication administration record for
October 2015, indicated the client received the
following medications: citalopram
(anti-depressant) 20 mg PO daily, aspirin 81 mg
PO daily, metformin 500 mg PO BID, ibuprofen
(pain reliever, fever reducer) 200 mg PO BID,
omeprazole (treats indigestion) 40 mg PO daily,
potassium chloride 10 meq (miliequivalents) PO
daily, triamterene-HCTZ (diuretic) 37.5-25 mg 1
tab PO daily, simvastatin (anti-cholesterol) 40 mg
PO daily, and Pulmacort 0.5 mg/2 ml (inhaled
corticosteroid) inhale one dose via nebulizer once
daily.
On October 14, 2015, employee C (registered
nurse) confirmed that clients #1 and #2's records
lacked documentation of a face to face
comprehensive assessment with the client
including and identifying all medications the client
was known to be taking, including indication for
Minnesota Department of Health
STATE FORM
6899
FHNW11
If continuation sheet 12 of 21
PRINTED: 10/28/2015
FORM APPROVED
Minnesota Department of Health
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING: ______________________
B. WING _____________________________
H26359
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
SIGNE AND OLIVIAS LLC
1545 HARBOR STREET
OGILVIE, MN 56358
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
0 905 Continued From page 12
ID
PREFIX
TAG
(X3) DATE SURVEY
COMPLETED
10/15/2015
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
0 905
medications, side effects, contraindications,
allergic or adverse reactions, actions to address
these issues and identifying interventions needed
in management of medications to prevent
diversion of medication by the client or others
who may have access to the medications.
Employee C confirmed all client records lacked
this requirement. Employee C stated she was
unaware of this requirement.
The licensee did not retain a policy related to this
matter.
TIME PERIOD FOR CORRECTION: Twenty-one
(21) days
01030 144A.4793, Subd. 2 Policies and Procedures
01030
Subd. 2. Policies and procedures. (a) A
comprehensive home care provider who provides
treatment and therapy management services
must develop, implement, and maintain
up-to-date written treatment or therapy
management policies and procedures. The
policies and procedures must be developed
under the supervision and direction of a
registered nurse or appropriate licensed health
professional consistent with current practice
standards and guidelines.
(b) The written policies and procedures must
address requesting and receiving orders or
prescriptions for treatments or therapies,
providing the treatment or therapy, documenting
of treatment or therapy activities, educating and
communicating with clients about treatments or
therapy they are receiving, monitoring and
evaluating the treatment and therapy, and
communicating with the prescriber.
Minnesota Department of Health
STATE FORM
6899
FHNW11
If continuation sheet 13 of 21
PRINTED: 10/28/2015
FORM APPROVED
Minnesota Department of Health
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING: ______________________
B. WING _____________________________
H26359
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
SIGNE AND OLIVIAS LLC
1545 HARBOR STREET
OGILVIE, MN 56358
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
01030 Continued From page 13
ID
PREFIX
TAG
(X3) DATE SURVEY
COMPLETED
10/15/2015
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
01030
This MN Requirement is not met as evidenced
by:
Based on interview and record review, the
licensee failed to retain written policies and
procedures related to treatments and therapies.
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
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:
The licensee held a comprehensive home care
license and provided treatment management
services to clients.
Client #1 was admitted for service with diagnoses
that included diabetes. Client #1 recieved the
treatment of blood glucose monitoring.
The licensee failed to develop all of the required
policies including: requesting and receiving
orders or prescriptions for treatments or
therapies, providing the treatment or therapy,
documenting of treatment or therapy activities,
educating and communicating with clients about
treatments or therapy they are receiving,
monitoring and evaluating the treatment and
therapy, and communicating with the prescriber.
On October 14, 2015, employee A (administrator)
verified the licensee lacked, in writing, the above
treatment and therapy policies and procedures.
TIME PERIOD FOR CORRECTION: Twenty-one
Minnesota Department of Health
STATE FORM
6899
FHNW11
If continuation sheet 14 of 21
PRINTED: 10/28/2015
FORM APPROVED
Minnesota Department of Health
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING: ______________________
B. WING _____________________________
H26359
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
SIGNE AND OLIVIAS LLC
1545 HARBOR STREET
OGILVIE, MN 56358
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
01030 Continued From page 14
ID
PREFIX
TAG
(X3) DATE SURVEY
COMPLETED
10/15/2015
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
01030
(21) days
01080 144A.4794, Subd. 3 Contents of Client Record
01080
Subd. 3. Contents of client record. Contents of a
client record include the following for each client:
(1) identifying information, including the client's
name, date of birth, address, and telephone
number;
(2) the name, address, and telephone number of
an emergency contact, family members, client's
representative, if any, or others as identified;
(3) names, addresses, and telephone numbers of
the client's health and medical service providers
and
other home care providers, if known;
(4) health information, including medical history,
allergies, and when the provider is managing
medications, treatments or therapies that require
documentation, and other relevant health
records;
(5) client's advance directives, if any;
(6) the home care provider's current and previous
assessments and service plans;
(7) all records of communications pertinent to the
client's home care services;
(8) documentation of significant changes in the
client's status and actions taken in response to
the
needs of the client including reporting to the
appropriate supervisor or health care
professional;
(9) documentation of incidents involving the client
and actions taken in response to the needs of the
client including reporting to the appropriate
supervisor or health care professional;
(10) documentation that services have been
provided as identified in the service plan;
Minnesota Department of Health
STATE FORM
6899
FHNW11
If continuation sheet 15 of 21
PRINTED: 10/28/2015
FORM APPROVED
Minnesota Department of Health
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING: ______________________
B. WING _____________________________
H26359
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
SIGNE AND OLIVIAS LLC
1545 HARBOR STREET
OGILVIE, MN 56358
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
01080 Continued From page 15
ID
PREFIX
TAG
(X3) DATE SURVEY
COMPLETED
10/15/2015
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
01080
(11) documentation that the client has received
and reviewed the home care bill of rights;
(12) documentation that the client has been
provided the statement of disclosure on
limitations of
services under section 144A.4791, subdivision 3;
(13) documentation of complaints received and
resolution;
(14) discharge summary, including service
termination notice and related documentation,
when
applicable; and
(15) other documentation required under this
chapter and relevant to the client's services or
status.
This MN Requirement is not met as evidenced
by:
Based on interview and record review, the
licensee failed to ensure a discharge summary
was completed as required, for one of two clients
(#5) 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 is issued at an isolated
scope (one or a limited number of clients
affected). Findings include:
Client #5's record failed to include a discharge
summary.
with diagnoses that included
Client #5 was admitted for services on
September 9, 2014 with diagnoses that included
dementia and was discharged on September 10,
2015.
On October 14, 2015, employee C (registered
Minnesota Department of Health
STATE FORM
6899
FHNW11
If continuation sheet 16 of 21
PRINTED: 10/28/2015
FORM APPROVED
Minnesota Department of Health
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING: ______________________
B. WING _____________________________
H26359
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
SIGNE AND OLIVIAS LLC
1545 HARBOR STREET
OGILVIE, MN 56358
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
01080 Continued From page 16
ID
PREFIX
TAG
(X3) DATE SURVEY
COMPLETED
10/15/2015
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
01080
nurse) verified that she had not completed the
discharge summary for client #5. Employee C
stated that she was aware a discharge summary
was required upon discharge of a client but had
not yet gotten around to it.
No Policy was provided related to this matter.
TIME PERIOD FOR CORRECTION: Seven (7)
days
01170 144A.4796, Subd. 2 Content of Orientation
01170
Subd. 2. Content. The orientation must contain
the following topics:
(1) an overview of sections 144A.43 to
144A.4798;
(2) introduction and review of all the provider's
policies and procedures related to the provision
of
home care services;
(3) handling of emergencies and use of
emergency services;
(4) compliance with and reporting of the
maltreatment of minors or vulnerable adults
under
sections626.556 and 626.557;
(5) home care bill of rights under section
144A.44;
(6) handling of clients' complaints, reporting of
complaints, and where to report complaints
including information on the Office of Health
Facility Complaints and the Common Entry Point;
(7) consumer advocacy services of the Office of
Ombudsman for Long-Term Care, Office of
Ombudsman for Mental Health and
Developmental Disabilities, Managed Care
Ombudsman at the
Minnesota Department of Health
STATE FORM
6899
FHNW11
If continuation sheet 17 of 21
PRINTED: 10/28/2015
FORM APPROVED
Minnesota Department of Health
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING: ______________________
B. WING _____________________________
H26359
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
SIGNE AND OLIVIAS LLC
1545 HARBOR STREET
OGILVIE, MN 56358
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
01170 Continued From page 17
ID
PREFIX
TAG
(X3) DATE SURVEY
COMPLETED
10/15/2015
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
01170
Department of Human Services, county managed
care advocates, or other relevant advocacy
services; and
(8) review of the types of home care services the
employee will be providing and the provider's
scope of licensure.
This MN Requirement is not met as evidenced
by:
Based on interview and record review, the
licensee failed to ensure the content of home
care orientation was completed as required for
one of one employees (B) 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
is issued at a widespread 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). Findings include:
Employee B (ULP) had a hire date of December
28, 2015.
Employee B's personnel record failed to include
documentation of completed orientation to home
care as required. Employee B's personnel record
lacked the required areas of training including:
home care bill of rights under section 144A.44
(most up-to-date version), consumer advocacy
services of the Office of Ombudsman for Mental
Health and Developmental Disabilities, Managed
Care Ombudsman at the Department of Human
Services, county managed care advocates, or
other relevant advocacy services; and review of
the types of home care services the employee will
be providing and the provider's
Minnesota Department of Health
STATE FORM
6899
FHNW11
If continuation sheet 18 of 21
PRINTED: 10/28/2015
FORM APPROVED
Minnesota Department of Health
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING: ______________________
B. WING _____________________________
H26359
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
SIGNE AND OLIVIAS LLC
1545 HARBOR STREET
OGILVIE, MN 56358
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
01170 Continued From page 18
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(X3) DATE SURVEY
COMPLETED
10/15/2015
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
01170
scope of licensure.
On October 14, 2015, employee A (administrator)
verified the personnel record lacked the above
identified areas of training. Employee A stated
that she was unaware of all the new training
requirements upon the licensee's conversion
from a class F license to a comprehensive
license. Employee A verbalized that the other
staff members also lacked the above identified
training.
No policy was provided related to this matter.
TIME PERIOD FOR CORRECTION: Twenty-one
(21) days
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
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.
Minnesota Department of Health
STATE FORM
6899
FHNW11
If continuation sheet 19 of 21
PRINTED: 10/28/2015
FORM APPROVED
Minnesota Department of Health
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING: ______________________
B. WING _____________________________
H26359
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
SIGNE AND OLIVIAS LLC
1545 HARBOR STREET
OGILVIE, MN 56358
(X4) ID
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SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
01245 Continued From page 19
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(X3) DATE SURVEY
COMPLETED
10/15/2015
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
01245
This MN Requirement is not met as evidenced
by:
Based on interview and record review, the
licensee failed to ensure TST (tuberculin skin
tests) and symptom screening had been
completed as required for two of two (B, D)
employees with records reviewed. Further, the
licensee did not have a written TB infection
control program that included: a TB infection
control team, and a provider TB facility risk
assessment.
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
is issued at a widespread 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). Findings include:
Both employee B and D's personnel records
lacked two step TST, IGRA or chest X-Ray as
well as a symptom screening as required.
Employee B (unlicensed personnel) had a hire
date of December 28, 2013. Included in
employee B's personnel record was a one step
TST dated February 25, 2014.
Employee D (licensed practical nurse) had a hire
date of March 19, 2015. Included in employee
B's personnel record was a one step TST dated
July 16, 2015.
On October 14, 2015, employee A (administrator)
verified the licensee's personnel records lacked a
two step TST and symptom screening. Employee
A stated the licensee's practice was to complete a
Minnesota Department of Health
STATE FORM
6899
FHNW11
If continuation sheet 20 of 21
PRINTED: 10/28/2015
FORM APPROVED
Minnesota Department of Health
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
A. BUILDING: ______________________
B. WING _____________________________
H26359
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
SIGNE AND OLIVIAS LLC
1545 HARBOR STREET
OGILVIE, MN 56358
(X4) ID
PREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
01245 Continued From page 20
ID
PREFIX
TAG
(X3) DATE SURVEY
COMPLETED
10/15/2015
PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)
(X5)
COMPLETE
DATE
01245
two step TST upon hire. However, employee A
was unable to locate the documentation.
Employee A stated she was unaware a symptoms
screen was required.
On October 15, 2015, employee A verified the
licensee did not complete a facility risk
assessment and did not have a written TB
infection control program. Employee A stated
she was unaware of this requirement.
The licensee did not retain any policies related to
this matter.
TIME PERIOD FOR CORRECTION: Twenty-one
(21) days
Minnesota Department of Health
STATE FORM
6899
FHNW11
If continuation sheet 21 of 21