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August 22, 2022 Lisa Thelen, Authorized Agent REM South Central Services, Inc. 6600 France Ave S STE 500 Minneapolis, Minnesota 55435-1878 License Number: 1071617 (245D - HCBS) CORRECTION ORDER Dear Lisa: On July 19 and 20, 2022, a licensing review of REM South Central Services, Inc., located at 307 12th Avenue South, Suite 102, Buffalo, Minnesota, was conducted to determine compliance with state and federal laws and rules governing the provision of home and community-based services to persons with disabilities and age 65 and older under Minnesota Statutes, Chapter 245D. As a result of this licensing review a Correction Order is being issued. A. Reason for Correction Order Pursuant to Minnesota Statutes, section 245A.06, if the Commissioner of the Department of Human Services (DHS) finds that the license holder has failed to comply with an applicable law or rule and this failure does not imminently endanger the health, safety, or rights of the persons served by the program, the Commissioner may issue a Correction Order to the license holder. The following violation(s) of state or federal laws and rules were determined as a result of the licensing review. Corrective action for each violation is required by Minnesota Statutes, section 245A.06 and is hereby ordered by the Commissioner of Human Services. 1. Citation: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (a). Violation: For two of sixteen persons whose records were reviewed (P12 and P13), the license holder did not provide orientation to the program abuse prevention plan (PAPP) as required. The license holder failed to provide P12 and P13 with orientation to the PAPP within 24 hours of admission as required. P12 was admitted to the program on August 8, 2021, and P13 was admitted to the program on November 8, 2021. P12 received orientation to the PAPP on September 23, 2021, and P13 received orientation to the PAPP on December 29, 2021. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required with this subdivision. 2. Citation: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (b), clause (1) and (2). Violation: For ten persons whose records were reviewed (P1, P2, P3, P4, P5, P7, P8, P9, P11 and P12), the license holder did not meet the requirements for an individual abuse prevention plan (IAPP) as required. a. The license holder failed to develop an IAPP as part of the initial program plan or service plan prior to or upon service initiation for P5. P5’s services were initiated on May 1, 2019. The license holder did not develop an IAPP for P5 until March 30, 2021. b. The license holder failed to include a statement of the specific measures that would be taken to minimize the risk of abuse in P1, P2, P3, P4, P5, P11 and P12’s IAPPs. The license holder listed similar measures in P1-P5, and P12’s IAPP. c. P4 and P5 both received respite and individual home supports services with training from the license holder. The license holder developed IAPPs for P4 and P5; however, the license holder failed to document the statement of measures that would be taken to minimize the risk of abuse within the scope of each service P4 and P5 received. d. The license holder failed to develop an IAPP as a part of the initial program or service plan for P7 when the license holder initiated community residential services for P7 on March 17, 2021. e. P8’s and P9’s individual abuse prevention plans documented that P8 and P9 were susceptible to physical, sexual and verbal/emotional abuse; however, the license holder failed to include a statement of specific measures to be taken to minimize the risk of abuse. Corrective Action Ordered: Within 30 days of receiving this order, you must: · review and revise P1, P2, P3, P4, P5, P8, P9, P11 and P12’s IAPPs to include statements of the specific measures that would be taken to minimize the risk of abuse for each assessed area of risk of abuse; · review and revise P4 and P5 IAPPs to include the specific measures the program will take to minimize the risk of abuse within the scope of each licensed service the person receives; and · You must review and revise P7’s IAPP for the community residential service. On an ongoing basis, you must maintain compliance as required. 3. Citation: Minnesota Statutes, section 245D.04, subdivision 1. Violation: For three persons whose records were reviewed (P5, P10 and P14), the license holder did not provide service recipient rights as required. Minnesota Statutes, section 245A.02, subdivision 2b defines “annual” or “annually” to mean prior to or within the same month of the subsequent calendar year. a. The license holder failed to provide P5’s legal representative with a written notice and explanation of the service recipient rights within five days of service initiation. These rights were not provided to P5 until March 30, 2021. b. The license holder failed to provide P5 and P10’s legal representatives, and P14 with the written notice and explanation of the service recipient rights annually. · For P5, the license holder did not provide a written notice of the service recipient rights in 2020. The license holder later provided the written notice on March 30, 2021. · For P10, the license holder did not provide a written notice of the service recipient rights annually since September 3, 2019. · For P14, the license holder provided service recipient rights on May 21, 2021 and on June 22, 2022. Corrective Action Ordered: Within 30 days of receipt of this order, you must provide P10’s legal representative with a copy of the above-mentioned rights and maintain documentation of the receipt of these rights. On an ongoing basis, you must maintain compliance as required. 4. Citation: Minnesota Statues, section 245D.05, subdivision 2, paragraph (b), clause (1). Violation: For one person whose records was reviewed (P7), the license holder did not meet the requirements for medication administration as required. The license holder was assigned the responsibility for medication administration for P7. The license holder failed to implement medication administration procedures to ensure a person was administered treatments as prescribed. P7’s medication administration record (MAR) for March 2022 documented the license holder was to administer Miralax (polyethylene) powder daily at 8:00 am. The MAR documented P7 received this medication daily from March 19 through March 25. The documentation for the remainder of the month indicated the medication was held. The MAR for April 2022 documented that the medication order was changed from daily at 8:00 am to a “PRN”. During an interview, the license holder stated that the medication was added on the MAR by mistake, without having been ordered by a prescriber and that it had been documented and administered in error March 19 through the March 25. Corrective Action Ordered: Within 30 days or receipt of this order, you must report the medication error to P7’s case manager if it has not already been reported. On an ongoing basis, you must ensure that you implement medication administration procedures to ensure that all persons receiving services in your program take medications and receive treatments as prescribed, as required in this subdivision. 5. Citation: Minnesota Statutes, section 245D.05, subdivision 4. Violation: For two persons whose records were reviewed (P7 and P10), the license holder did not conduct the medication administration record reviews as required. a. For P7, the license holder failed to conduct a review, at a minimum of every three months, of the person’s medication administration record (MAR) to ensure that the information maintained in the MAR is current and identify medication errors. b. For P10, the license holder failed to conduct medication administration record reviews for every three months prior to November 2021. Corrective Action Ordered: Within 30 days of receiving this order, you must conduct medication administration record reviews from March 2022 through July 2022 for P7. On an ongoing basis, you must maintain compliance as required in this subdivision. 6. Citation: Minnesota Statutes, section 245D.051, subdivision 1, paragraph (b). Violation: For six persons whose records were reviewed (P7, P10, P11, P12, P13 and P14), the license holder did not meet the requirements for psychotropic medication use and monitoring as required. Target symptoms refers to any perceptible diagnostic criteria for a person’s diagnosed mental disorder, as defined by the Diagnostic and Statistical Manual of Mental disorders Fourth Edition Text Revision (DSM-IV-TR) or successive editions, that has been identified for alleviation. a. P7 was prescribed Prozac. The license holder failed to document the description of the target symptoms that the psychotropic medication was prescribed to alleviate and the license holder failed to obtain documentation methods used to monitor and measure. b. P10 was prescribed Risperidone. The license holder maintained a document in P10’s record titled “Psychotropic Medication Initiation Notification,” dated July 14, 2022, that the target symptom for Risperidone was behaviors. Although the license holder provided documentation of target symptoms, the license holder failed to provide a description of the target symptoms in accordance with the DSM-IV-TR. c. P11 was prescribed Citalopram and Clozapine. The license holder maintained a document in P11’s record titled “Psychotropic Medication Initiation Notification,” dated December 13, 2021, that the target symptom for Citalopram and Clozapine was anxiety. Although the license holder provided documentation of target symptoms, the license holder failed to provide a description of the target symptom in accordance with the DSM-IV-TR. d. P12 was prescribed Citalopram. The license holder maintained a document in P12’s record titled “Psychotropic Medication Initiation Notification,” dated July 15, 2022, that the target symptom for Citalopram was depression. Although the license holder provided documentation of target symptoms, the license holder failed to provide a description of the target symptom in accordance with the DSM-IV-TR. e. P13 was prescribed Olanzapine and Hydroxyzine. The license holder maintained a document in P13’s record titled “Medication/Treatment Record,” for every month that included the target symptoms for the prescribed psychotropic medications. The target symptoms for Olanzapine and Hydroxyzine were documented as either anxiety or mood stabilizer. Although the license holder provided documentation of target symptoms, the license holder failed to provide a description of the target symptoms in accordance with the DSM-IV-TR. f. P14 was prescribed Venlafaxine, Buspirone and Ziprasidnoe. The license holder maintained a document in P14’s record titled “Progress Review Report,” dated December 6, 2021 that included the target symptoms of the prescribed psychotropic medications. The target symptoms for Venlafaxine, Buspirone and Ziprasidone were either mood and behavior or mood. Although the license holder provided documentation of target symptoms, the license holder failed to provide a description of the target symptoms in accordance with the DSM-IV-TR. Corrective Action Ordered: Within 30 days of received this order, you must develop, implement, and maintain documentation that includes a description of the target symptoms that each psychotropic medication is to alleviate for P7, P10, P11, P12, P13, and P14 is prescribed. On an ongoing basis, you must maintain compliance as required in this subdivision. 7. Citation: Minnesota Statutes, section 245D.06, subdivision 1, paragraph (e). Violation: For one person whose record was reviewed (P15), the license holder did not report serious injury as required. P15 was involved in an incident that resulted in a serious injury on July 16, 2021. The license holder failed to report this serious injury to the Department of Human Services (DHS) within 24 hours of serious injury. They did not report this to DHS until July 19, 2021. Corrective Action Ordered: On an ongoing basis, you must report serious injuries as required in this subdivision. 8. Citation: Minnesota Statutes, section 245D.06, subdivision 4. Violation: For one person whose record was reviewed (P10), the license holder did not safe keep funds as required. The license holder failed to obtain an authorization for the safekeeping of P10’s funds and other property annually in 2020, 2021 and 2022. The last authorized that was obtained was on September 30, 2019. In addition, the license holder failed to document the preferences of P10’s case manager for the frequency of receiving statements that itemized receipts and disbursements of funds or other property. Corrective Action Ordered: Within 30 days of receipt of this order, you must obtain an authorization for the safekeeping of P10’s funds and other property that meets compliance with this subdivision. On an ongoing basis, you must maintain compliance as required with this subdivision. 9. Citation: Minnesota Statutes, section 245D.07, subdivision 1a. Violation: For two persons whose records were reviewed (P4 and P5), the license holder did not provide services in response to the person’s identified needs, interests and preferences as required for each service. The license holder provided multiple services to P4 and P5. The license holder failed to ensure that P4 and P5’s coordinated service and support plan addendums (CSSPA) identified how services are provided for each service, including how, when and by whom. Corrective Action Required: Within 30 days of receiving this order, you must review and update P4 and P5’s CSSPAs to include the information listed above. On an ongoing basis, you must maintain compliance as required. 10. Citation: Minnesota Statutes, section 245D.071, subdivision 3 and 4. Violation: For one person whose records was reviewed (P5), the license holder did not meet service planning delivery requirements for an intensive service as required. a. The license holder failed to complete assessments on P5’s ability to self-manage health and medical needs, self-manage personal safety to avoid injury or accident in the service setting, and self-manage symptoms or behavior that may otherwise result in an incident prior to the 45 day service planning meeting. P5’s services were initiated on May 1, 2019 and the licensed holder did not complete assessments until March 30, 2021. a. The license holder failed to meet with P5, P5’s legal representative, the case manager, and other members of the support team or expanded support team within 45 days of service initiation. P5’s services were initiated on May 1, 2019 and the first documented service planning meeting for P5 was held on March 30, 2021. Corrective Action Ordered: On an ongoing basis, you must meet service planning and delivery requirements for an intensive service as required in this subdivision. 11. Citation: Minnesota Statutes, section 245D.071, subdivision 4, paragraph (a). Violation: For one person whose record was reviewed (P5), the license holder did not meet the requirements for service outcomes and supports.
a. P5 initiated services on May 1, 2019. The license holder failed to develop a service plan for P5 that documents the service outcomes and supports in 2019. b. The license holder initiated services for P5 on May 1, 2019. As stated in citation (10), the license holder did not conduct a 45 day planning meeting for P5. In addition, the license holder failed to develop a service plan that documents the service outcomes and supports based on the assessments completed in subdivision 3. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 12. Citation: Minnesota Statutes, section 245D.071, subdivision 4, paragraph (b). Violation: For five persons whose records were reviewed (P1, P2, P3, P4 and P5), the license holder did not document support and methods as required. For P1, P2, P3, P4 and P5, the license holder failed to document information about any changes or modifications to the physical and social environment necessary when the service supports are provided to support the person and accomplish the service outcomes. Corrective action ordered: Within 30 days of receiving this order, you must update P1, P2, P3, P4 and P5’s service outcome and supports with the above mentioned information. On an ongoing basis, you must maintain compliance as required. 13. Citation: Minnesota Statutes, section 245D.071, subdivision 5, paragraphs (a), (b) and (g). Violation: For eight persons whose records were reviewed (P4, P5, P8, P9, P10, P12, P13, and P14), the license holder did not meet the requirements for service plan review and evaluation as required. a. The license holder failed to discuss with P4, P4’s legal representative and members of the support team about how technology might be used to meet P4’s outcomes at least once per year. b. The license holder failed to provide progress reports for P5 annually. The license holder failed to provide a progress report in 2020. The license holder later provided a progress report on March 30, 2021. c. The license holder failed to make recommendations based off the summary of P12 and P13’s status and progress toward achieving the identified outcome. d. For P8, P9, P10, P12 and P13, the license holder failed to identify the rationale for changing, continuing, or discontinuing implementation of supports and methods identified in subdivision 4. e. For P5 and P14, the license holder failed to, at least once per year, in coordination with the person’s support team or expanded support team, meet with the person, the person’s case manager, and other people as identified by the person to participate in progress review meetings. · The license holder did not meet with P5’s support team in 2020. The license holder later met with P5’s support team on March 30, 2021. · The license holder met with P14’s support team on May 21, 2021 and not again until June 22, 2022. Corrective Action Ordered: Within 30 days of receiving this order, you must: · For P4, discuss with each person, their legal representative, case manager and members of the support team about how technology might be used to meet their desired outcomes; · summarize this conversation and include it in P4’s CSSPA; and · include a statement in the summary regarding any decision that is made regarding the use of technology and a description of any further research that needs to be completed before a decision regarding the use of technology can be made. On an ongoing basis, you must maintain compliance as required in this subdivision. 14. Citation: Minnesota statutes, section 245D.09, subdivision 5. Violation: For one of sixteen staff person whose record was reviewed (SP16), the license holder did not provide annual training as required. SP16 was a contracted staff person for the license holder that has provided direct care services for the license holder since 2012. The license holder failed to provide SP16 with annual training as required in the following areas: · data privacy requirements according to sections 13.01 to 13.10 and 13.46, the federal Health Insurance Portability and Accountability Act of 1996 (HIPAA), and staff responsibilities related to complying with data privacy practices; · the service recipient rights and staff responsibilities related to ensuring the exercise and protection of those rights according to the requirements in section 245D.04; · the principles of person-centered service planning and delivery as identified in section 245D.07, subdivision 1a, and how they apply to direct support service provided by the staff person; · the safe and correct use of manual restraint on an emergency basis according to the requirements in section 245D.061 and what constitutes the use of restraints, time out, and seclusion, including chemical restraint; · staff responsibilities related to prohibited procedures under section 245D.06, subdivision 5, why such procedures are not effective for reducing or eliminating symptoms or undesired behavior, and why such procedures are not safe; · basic first aid; and · strategies to minimize the risk of sexual violence, including concepts of healthy relationships, consent, and bodily autonomy of people with disabilities; and Corrective Action Ordered: Within 30 days of receiving this order, you must: · provide SP16 with the above-mentioned required annual training; and · audit the most recent annual training records for all contracted staff persons to ensure all contracted staff persons have received annual training on all of the required topics within the past 12 calendar months. Within 60 days of receiving this order, you must: · based on the results of the audit, provide annual training to all contracted staff persons who have not received training on any of required annual training topics. On an ongoing basis, you must maintain compliance as required in this subdivision. 15. Citation: Minnesota Statutes, section 245D.095, subdivision 3, paragraph (b). Violation: For one person whose records were reviewed (P5), the license holder did not maintain records as required. At the time of the licensing review, the license holder stated that they were unable to locate any of P5’s service recipient record for 2019 and 2020. The license holder failed to protect P5’s service recipient record against loss. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required. 16. Citation: Minnesota Statutes, section 245D.095, subdivision 5. Violation: For fourteen staff persons whose records were reviewed (SP1-SP13 and SP16), the license holder did not maintain personnel records as required. a. The license holder failed to maintain a personnel record for SP16. b. The license holder failed to document the number of training hours per subject area in SP1-SP13’s personnel records. Corrective Action Ordered: On an ongoing basis, you must maintain personnel records as required in this subdivision. 17. Citation: Minnesota Statutes, section 245D.10, subdivision 4, clause (b). Violation: For two persons whose records were reviewed (P5 and P7), the license holder did not provide policies and procedures as required.
a. The license holder failed to inform P5 and P5’s case manager of the following policies and procedures and provide copies within five working days of service initiation: · grievance policy; · temporary service suspension policy; · service termination policy; · emergency use of manual restraints policy; and · data privacy policy. b. The license holder failed to inform P7’s case manager of the following policies and procedures and provide copies within five working days of service initiation: · grievance policy; · temporary service suspension policy; · service termination policy; · emergency use of manual restraints policy; and · data privacy policy. P7’s service initiated on March 17, 2020; however, these policies were not provided to the case manager until July 13, 2022.
Corrective Action Ordered: Within 30 days of receiving this order, you must: · inform and provide copies of the above mentioned policies and procedures to P5, and P5’s case manager; and · obtain written acknowledgement from P5’s legal representative that P5 has been notified of your emergency use of manual restraints policy as required in Minnesota Rules, part 9544.0080. On an ongoing basis, you must maintain compliance as required in this subdivision. 18. Citation: Minnesota Statutes, section 245C.04, subdivision 1, paragraph (f).
Violation: For one staff person whose records were reviewed (SP13), the license holder did not submit a completed background study request to DHS using the electronic system known as NETStudy before SP13 began a position allowing direct contact in a licensed program.
SP13 was hired on December 12, 2016, and was allowed direct contact with persons served by the program. The license holder failed to submit a background study to DHS for SP13 until July 15, 2022.
Corrective Action Ordered: On an ongoing basis, you must submit a completed background study request to DHS before an individual specified in section 245C.03, subdivision 1, begins a position allowing direct contact in your program. If you fail to correct the violations specified in the Correction Order within the prescribed time lines the Commissioner may issue an Order of Conditional License or may impose a fine and order other licensing sanctions pursuant to Minnesota Statutes, sections 245A.06 and 245A.07. B. Right to Request Reconsideration If you believe any of the citations are in error, you have the right to request that the Commissioner of Human Services reconsider the parts of the Correction Order that you believe to be in error. The request for reconsideration must be in writing and received by the Commissioner within 20 calendar days after receipt of this report. Your request for reconsideration must be sent to: Commissioner, Department of Human Services ATTN: Legal Unit Licensing Division PO Box 64242 St. Paul, MN 55164-0242 Please note that a request for reconsideration does not stay any provisions or requirements of the Correction Order. The Commissioner’s disposition of a request for reconsideration is final and not subject to appeal under Minnesota Statutes, chapter 14. If you have any questions regarding this Correction Order, please contact me as soon as possible. Diana Arnzen, Human Services Licensor Licensing Division Office of Inspector General 651-431-6638
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