Minnesota

September 28, 2022

Stephanie Kalbach, Authorized Agent

REM Minnesota Community Services, Inc.

6600 France Avenue South Suite 500

Edina, Minnesota 55435

License Number: 1071801 (245D – Home and Community-Based Services)

CORRECTION ORDER

Dear Stephanie Kalbach:

On August 15 – 17, 2022, a licensing review of REM Minnesota Community Services, located at 15025 Glazier Avenue, Suite 246, Apple Valley, Minnesota, and 199 Coon Rapids Boulevard, Suite 210, Coon Rapids, 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, 245A.65, subdivision 1.

Violation: For two of fourteen persons whose records were reviewed (P6 and P9), the license holder did not provide orientation to the license holders internal and external reporting procedures of alleged or suspected maltreatment of vulnerable adults as required.

The license holder failed to provide P6 and P9 with orientation to the license holder’s internal and external reporting procedures of alleged or suspected maltreatment of vulnerable adults within 24 hours of admission.

· P6’s admission date was July 18, 2022; however, this orientation did not take place until July 20, 2022.

· P9’s admission date was November 18, 2021; however, the license holder failed to provide this orientation to P9.

Corrective Action Ordered: Within 30 days of receipt of this order, you must provide P9 with the above-mentioned orientation and maintain documentation of the orientation as required in Minnesota Statutes, section 245D.095, subdivision 3, paragraph (b), clause (7). On an ongoing basis, you must maintain compliance as required in this subdivision.

2. Citation: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (a).

Violation: For one person whose record was reviewed (P9), the license holder did not provide orientation to the license holder’s program abuse prevention plan as required.

The license holder failed to provide P9 with orientation to the license holder’s program abuse prevention plan within 24 hours of admission. This orientation did not occur until January 14, 2022.

Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required with this subdivision.

3. Citation: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (b).

Violation: For six persons whose records were reviewed (P3, P5, P6, P8, P9 and P11), the license holder did not develop and review individual abuse prevention plans (IAPP) 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. Regarding P3, P5, P6, P8, P9, and P11, the license holder failed to include a statement of specific measures that would be taken to minimize the risk of abuse for each assessed area of risk of abuse for the person.

b. Regarding P5, and P8, the license holder failed to review the individual abuse prevention plan annually with the person’s interdisciplinary team.

· P5’s IAPP was review on July 20, 2021; however, it was not reviewed again until August 2, 2022.

· P8’s IAPP was reviewed on January 14, 2019; however, it was not reviewed again until January 31, 2022.

c. P11 received 24-hour emergency assistance and individual home supports with training from the license holder. The license holder failed to develop an individual abuse prevent plan to document the statement of measures that would be taken to minimize the risk of abuse within the scope of each service P11 received.

Corrective Action Ordered: Within 30 days of receiving this order, you must:

· review and revise P3, P5, P6, P8, and P9’s individual abuse prevention plans 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 P11’s individual abuse prevention plan to include the specific measures the program will take to minimize the risk of abuse within the scope of each licensed service P11 receives.

On an ongoing basis, you must develop and review individual abuse prevention plans as required in this subdivision.

4. Citation: Minnesota Statutes, section 245D.04, subdivision 1.

Violation: For five persons whose records were reviewed (P2, P4, P5, P8 and P9), the license holder did not provide service recipient rights as required.

a. The written notice provided to P2’s legal representative on November 23, 2021, failed to include the following rights:

· access to the person's personal possessions at any time, including financial resources;

· have access to three nutritionally balanced meals and nutritious snacks between meals each day;

· have freedom and support to access food and potable water at any time;

· have the freedom to furnish and decorate the person’s bedroom or living unit;

· a setting that is clean and free from accumulation of dirt, grease, garbage, peeling paint, mold, vermin, and insects;

· a setting that is free from hazards that threaten the person’s health or safety; and

· a setting that meets the definition of a dwelling unit within a residential occupancy as defined in the State Fire Code.

b. The license holder failed to provide P4, P5 and P8 with a written notice that identified the service recipient’s rights in subdivision 2 and 3 and an explanation of those rights on an annual basis.

· P4’s legal representative was provided a written notice of the service recipient rights on February 9, 2021 and August 16, 2022.

· P5’s legal representative was provided a written notice of the service recipient rights on July 20, 2021 and August 2, 2022.

· P8 has not been provided a written notice of the service recipient rights since January 14, 2019.

c. The license holder failed to provide P9 with a written notice that identified the service recipient’s rights in subdivision 2 and 3 and an explanation of those rights within five working days of service initiation.

Corrective Action Ordered: Within 30 days of receipt of this order, you must provide P2’s legal representative, P8 and P9 with the above mentioned rights and maintain documentation they received these rights. On an ongoing basis, you must provide service recipient rights as required in this subdivision.

5. Citation: Minnesota Statutes, section 245D.05, subdivision 1.

Violation: For one person whose record was reviewed (P4), the license holder did not maintain documentation of how the person’s health needs would be met as required when the license holder was assigned responsibility in the CSSP (coordinated services and support plan) and CSSP addendum.

P4 was prescribed Diazepam 2mg tab to be taken once daily as needed (PRN) for anxiety and Olapatadine Sol 0.2% eye drops to be administered in both eyes once daily as needed (PRN) (reason undocumented). The license holder failed to include a description of the procedures the license holder would follow when administering these PRNs to P4.

Corrective Action Ordered: Within 30 days of receipt of this order, you must document the procedures you will follow when administering the above-mentioned PRN medications to P4. On an ongoing basis, you must provide service recipient rights as required in this subdivision.

6. Citation: Minnesota Statutes, section 245D.05, subdivisions 1 and 2.

Violation: For one person whose record was reviewed (P14), the license holder did not meet health services needs assigned in the coordinated service and support plan and coordinated service and support plan addendum.

a. The license holder maintained a Self-Management Assessment for P14 that was completed in July of 2021. According to the assessment, the license holder was responsible for utilizing a seizure watch at all times and a floor mat at night for P14, however, the license holder was not using either at the time of the review. SP16 reported that the mat was no longer needed and the watch was only needed at night, but the documentation just had not been updated yet. There was nothing in P14’s record that indicated that the procedures related to monitoring seizures for P14 had changed.

b. P14’s medications included Debrox ear drops that expired on April 12, 2022. There was nothing on P14’s Medication Administration Record regarding administration of the drops. SP16 reported that the drops were for general PRN use that everyone in the residence would have. A General Medical Referral dated 3/23/21 indicated that the drops were prescribed specifically for P14 and were to be used for five days prior to office visits.

Corrective Action Ordered: Within 15 days of receiving this order, you must submit a plan detailing how you will obtain and maintain compliance with this subdivision for SP14. On an ongoing basis, you must maintain compliance as required with this subdivision.

7. Citation: Minnesota Statutes, section 245D.05, subdivision 2.

Violation: For two persons whose records were reviewed (P4 and P9), the license holder did not implement medication administration procedures to ensure a person takes medications and treatments as prescribed.

a. The license holder was responsible for administering P9’s medications. The license holder failed to obtain a written authorization from P9’s legal representative prior to administering medication or treatment.

b. The license holder was responsible for administering P4’s medications. The license holder failed to make a notation when a medication is administered. On July 29, 2022, the license holder did not make a notation in P4’s medication administration record (MAR) when the following HS (hour of sleep) medications were administered:

· Advair 100/50 Diskus 60 inhaler

· Keppra 250 mg tab

· Systane Gel Drop 0.4-0.3%

· Vitafusion Womens Gummy

· Melatonin 10mg tab

Corrective Action Ordered: Immediately upon receipt of this order, you must obtain a written authorization to administer P9’s medication from P9’s legal representative. On an ongoing basis, you must maintain compliance with this subdivision as required.

8. Citation: Minnesota Statutes, section 245D.05, subdivision 4.

Violation: For two persons whose records were reviewed (P2 and P4), the license holder was assigned responsibility for administration of medication in the person’s coordinated services and support plan addendum (CSSPA). The license holder did not ensure that the medication administration records were reviewed as required.

At a minimum, the license holder is required to conduct a medication administration record review for medication errors every three months. For P2 and P4, the license holder did not ensure that the medication administration records were reviewed every three months as required.

Corrective Action Ordered: Within 30 days of receipt of this order, you must review P2 and P4’s medication administration records for the past three months and maintain documentation of the review. On an ongoing basis, you must provide service recipient rights as required in this subdivision.

9. Citation: Minnesota Statutes, section 245D.05, subdivision 5.

Violation: For one person whose record was reviewed (P8), the license holder did not maintain documentation for an injectable medication as required.

P8 was prescribed an injectable PRN medication. There was an agreement signed by the license holder and the prescriber; however, the license holder failed to get the agreement signed by P8’s legal representative. In addition, there was no information specifying what injections maybe given, when and how. There was a note to administer per protocol, but there was no protocol in P8’s file.

Corrective Action Ordered: Immediately upon receipt of this order, you must obtain an agreement with the above-mentioned requirements. On an ongoing basis, you must maintain compliance as required with this subdivision.

10. Citation: Minnesota Statutes, section 245D.051, subdivision 1, paragraph (b).

Violation: For three persons whose records were reviewed (P2, P4, and P9), the license holder did not meet the requirements for psychotropic medications as required.

Target symptoms refer 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.

· P9 was prescribed Risperidone, Olanzapine, Lorazepam and Sertraline. The license holder maintain a document in P9’s record titled “Psychotropic Medication Initiation Notification,” dated February 15, 2022, that stated the target symptoms for Risperidone and Olanzapine; but failed to maintain this information for the Lorazepam and Sertraline.

· P4 was prescribed Halipoderal, Diazepam and Melatonin. The license holder maintained a document in P4’s record titled “PRN Psychotropic Administration Protocol & Documentation,” dated May 15, 2019, which listed the target symptoms for Haloperidal; however, the license holder failed to maintain target symptoms for Diazepam and Melatonin.

· P2 was prescribed Clonidine, Risperidone and Quetiapine. The license holder did not list the target symptoms each psychotropic medication was to alleviate for P2.

Corrective Action Ordered: Within 30 days of receipt of this order, you must maintain the above mentioned information for P2, P4 and P9. On an ongoing basis, you must maintain compliance as required with this subdivision.

11. Citation: Minnesota Statutes, section 245D.06, subdivision 1, paragraph (e).

Violation: For one person whose record was reviewed (P13), the license holder did not report a serious injury as required.

P13 was involved in an incident that resulted in a serious injury on January 21, 2022. The license holder failed to report the serious injury to the Department of Human Services (DHS) within 24 hours. The report was not made to DHS until February 1, 2022.

Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required with this subdivision.

12. Citation: Minnesota Statutes, section 245D.06, subdivision 4.

Violation: For two person whose record was reviewed (P1 and P9), the license holder did not obtain an authorization for the safekeeping of funds and other property as required.

a. The license holder stated they were not responsible for safekeeping of P1’s funds; however, there was a consent form dated January 12, 2016, in P1’s file that documented the license holder was holding $20.00 in cash for P1. P1’s individual abuse prevention plan dated January 4, 2022, stated the license holder kept $20.00 in a lock box for P1. The license holder failed to obtain an authorization for the safekeeping of P1’s funds annually. In addition, the license holder did not maintain a documentation of the receipt and disbursement of P1’s funds.

b. The license stated they were responsible for safekeeping P9’s funds; however, the license holder failed to obtain an authorization to do so within five working days of service initiation.

Corrective Action Ordered: Within 30 days of receipt of this order, you must obtain an authorization for safekeeping P9’s funds and document safekeeping of P1’s funds. On an ongoing basis, you must maintain compliance as required with this subdivision.

13. Citation: Minnesota Statutes, section 245D.07, subdivision 1a.

Violation: For one person whose record was reviewed (P11), the license holder did not provide services in response to the person’s identified needs, interests and preferences for each service as required.

The license holder provided multiple services to P11. The license holder failed to ensure that P11’s coordinated services support plan addendum identified how services were to be provided for each service, including how, when and by whom.

Corrective Action Ordered: Within 30 days of receipt of this order, you must review and update P11’s coordinated service support plan addendum to include the information listed above. On an ongoing basis, you must maintain compliance as required with this subdivision.

14. Citation: Minnesota Statutes, section 245D.071, subdivision 3.

Violation: For three persons whose records were reviewed (P3, P4, and P9), the license holder did not meet initial service planning and delivery requirements for an intensive service as required.

a. Regarding P3, the license holder met with P3, P3’s case manager and members of the support team within 45 days of service initiation; however, the license holder failed to determine opportunities to seek competitive employment and work at competitively paying jobs in the community.

b. Regarding P4 and P9, the license holder failed to conduct a 45-day planning meeting with the person and their support team within 45 days of service initiation.

· P4’s date of service initiation was March 29, 2019; however, the license holder did not conduct the 45-day meeting until May 23, 2019.

· P9’s date of service initiation was November 18, 2021; however, the license holder did not conduct the 45-day meeting until January 14, 2022.

Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required with this subdivision.

15. Citation: Minnesota Statutes, section 245D.071, subdivision 3.

Violation: For four persons whose records were reviewed (P1, P5, P7 and P8), the license holder did not meet service planning and delivery requirements for an intensive service as required.

a. P1’s assessments did not document the services being provided by the license holder. P1’s assessments documented contradictory information that P1 was not able to self-administer their own medications; however, during the review, other assessments documented that P1 was able to self-administer their own medications. In addition, the license holder failed to complete assessments for P1 that included information about the person that described the person's overall strengths, functional skills and abilities, and behaviors or symptoms.

b. P7’s assessments did not document the services being provided by the license holder. P7’s assessments documented that P7 was able to self-administer their own medications; however, during the review, the license holder stated they are responsible for administering P7’s medications.

c. Regarding P5 and P8, the license holder failed to review the person’s assessments annually with the person and their support team annually.

· P5’s assessments were reviewed on July 20, 2021; however, the assessments were not reviewed again until August 2, 2022.

· P8’s assessments were reviewed on January 14, 2019; however, the assessments were not reviewed again until January 31, 2022.

Corrective Action Ordered: Within 30 days of receipt of this order, you must review and revise P1 and P7’s assessments to include the above-mentioned information. On an ongoing basis, you must maintain compliance as required with this subdivision.

16. Citation: Minnesota Statutes, section 245D.071, subdivision 4.

Violation: For five persons whose record were reviewed (P2, P3, P4, P5 and P8), the license holder did not maintain documentation of support and outcomes as required.

a. The license holder failed to document, for P2, P3, P4 and P5’s supports and outcomes, 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.

b. The license holder failed to document the following information for P8’s supports and outcomes:

· The methods or actions that will be used to support the person and to accomplish the service outcomes, including information about:

o any changes or modifications to the physical and social environments necessary when the service supports were provided;

o any equipment and materials required;

o techniques that were consistent with the person’s communication mode and learning style;

o the measureable and observable criteria for identifying when the desired outcome had been achieved; and

o the names of the staff persons or positions responsible for implementing the supports and methods.

Corrective Action Ordered: Within 30 days of receipt of this order, you must document the above-mentioned information for P2, P3, P4, P5 and P8’s supports and outcomes. On an ongoing basis, you must document supports and outcomes as required in this subdivision.

17. Citation: Minnesota Statutes, section 245D.071, subdivision 5.

Violation: For four persons whose records were reviewed (P4, P5, P7 and P8), the license holder did not review and evaluate the service plan as required.

a. Regarding P7 and P8, the license holder failed to include the rationale for changing, continuing, or discontinuing the person’s supports and outcomes in P7’s progress report dated April 14, 2022 and P8’s progress report dated January 31, 2022.

b. Regarding P5 and P8, the license holder failed to conduct service-planning meetings with the person and their support team annually.

· P5 required annual service planning meetings. The license holder conducted a meeting on July 20, 201; however, the license holder did not conduct another service planning meeting until August 2, 2022.

· P8 required annual service planning meetings. The license holder conducted a service planning meeting on January 14, 2019; however, the license holder did not conduct another service planning meeting until January 31, 2022.

c. Regarding P4, P5 and P8, the license holder failed to provide progress reports as required to the support team.

· P4 required semi-annual progress reports. The license holder provided P4’s team with a progress report on February 1, 2020. The license holder did not provide another report in 2020. In addition, a semi-annual progress report was due to be completed for P4 in February 2022. At the time of the licensing review, a progress report has not been completed for P4 yet in 2022.

· P5 required annual progress reports. The license holder provided a progress report on July 15, 2021. The license holder did not provide another progress report until August 2, 2022.

· P8 required annual progress reports. The license holder provided a progress report on January 14, 2019. The license holder did not provide another progress report for P8 until January 31, 2022.

Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required with this subdivision.

18. Citation: Minnesota Statutes, section 245D.095, subdivision 3.

Violation: For one person whose record was reviewed (P9), the license holder did not maintain documentation in the service recipient record as required.

The license holder did not maintain documentation in P9’s service recipient record to show a signed statement authorizing the license holder to act in a medical emergency when the P9’s legal representative cannot be reached or is delayed in arriving.

Corrective Action Ordered: Within 30 days of receipt this order, you must maintain the above-mentioned documentation in P9’s service recipient record. On an ongoing basis, you must maintain documentation as required in subdivision.

19. Citation: Minnesota Statutes, section 245D.10, subdivision 4.

Violation: For one person whose record was reviewed (P9), the license holder did not provide policies and procedures as required.

The license holder failed to inform and provide copies of the following policies and procedures to P9 and P9’s case manager:

· grievance policy and procedures;

· service suspension policy and procedure;

· service termination policy and procedure;

· emergency of manual restraint policy and procedure; and

· data privacy requirements.

Corrective Action Ordered: Within 30 days of receipt of this order, you must inform and provide copies of the above-mentioned policies and procedures. On an ongoing basis, you must maintain compliance as required with this subdivision.

20. Citation: Minnesota Rules, Part 9455.0080, subpart 1.

Violation: For two persons whose records were reviewed (P6 and P9), the license holder did not provide a notice of the license holder’s policy on the emergency use of manual restraint as required.

The license holder failed to obtain a written acknowledgement from P6 and P9, or their legal representative, that a copy of the license holder’s emergency use of manual restraint policy was received.

Corrective Action Ordered: Within 30 days of receipt of this order, you must obtain the above-mentioned acknowledgement from P6 and P9, or their legal representative. On an ongoing basis, you must maintain compliance as required with this subpart.

21. Citation: Minnesota Statutes, section 245D.09, subdivision 4.

Violation: For four of sixteen staff persons whose records were reviewed (SP1, SP2, SP5 and SP6), the license holder did not complete orientation as required.

The license holder failed to provide and ensure completion of orientation sufficient to create staff competency for direct support staff that combines supervised on-the-job training with review of and instruction in the following required areas within 60 days of each staff person’s date of hire.

a. For SP1, 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 Minnesota Statutes, section 245D.04;

· 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.

b. For SP2, the principles of person-centered service planning and delivery as identified in Minnesota Statutes, 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 or successor provisions, and what constitutes the use of restraints, time out, and seclusion, including chemical restraint; and

· staff responsibilities related to prohibited procedures under section 245D.06, subdivision 5, or successor provisions, why such procedures are not effective for reducing or eliminating symptoms or undesired behavior, and why such procedures are not safe.

c. For SP5, 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; and

· strategies to minimize the risk of sexual violence, including concepts of healthy relationships, consent, and bodily autonomy of people with disabilities.

d. For SP6, the service recipient rights and staff responsibilities related to ensuring the exercise and protection of those rights according to the requirements in Minnesota Statutes, section 245D.04.

Corrective Action Ordered: Within 30 days of receiving this order, you must provide SP1, SP2, SP5, and SP6 with the orientation trainings above. On an ongoing basis, you must ensure completion of orientation to new staff persons as required in subdivision.

22. Violation: For eight staff persons whose records were reviewed (SP2 – SP4, SP8 – SP11 and SP13), the license holder did not complete annual training as required.

Minnesota Statutes, section 245D.02 defines “annual” as prior to or within the same month of the subsequent calendar year. The license holder failed to provide the following annual trainings to staff persons:

a. For SP2, the service recipient rights and staff responsibilities related to ensuring the exercise and protection of those rights according to the requirements in Minnesota Statutes, section 245D.04 was provided in July of 2021 but had not been provided again by the time of the review.

b. For SP3, 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 was provided in March of 2021 but had not been provided again by the time of the review;

· the service recipient rights and staff responsibilities related to ensuring the exercise and protection of those rights according to the requirements in Minnesota Statutes, section 245D.04 was provided in February of 2021 but had not been provided again by the time of the review;

· Minnesota Statutes, sections 245A.65, 245A.66, and 626.557 and chapter 260E governing maltreatment reporting and service planning for children and vulnerable adults, and staff responsibilities related to protecting persons from maltreatment and reporting maltreatment. This orientation must be provided within 72 hours of first providing direct contact services and annually thereafter according to section 245A.65, subdivision 3 was provided in January of 2021 but not again until April of 2022;

· the principles of person-centered service planning and delivery as identified in Minnesota Statutes, section 245D.07, subdivision 1a, and how they apply to direct support service provided by the staff person had not been provided during the timeframe that was reviewed;

· strategies to minimize the risk of sexual violence, including concepts of healthy relationships, consent, and bodily autonomy of people with disabilities was provided in April of 2022, but had not been provided previously during the timeframe that was reviewed.

c. For SP4, 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 was provided in March of 2021 but had not been provided again by the time of the review;

· the service recipient rights and staff responsibilities related to ensuring the exercise and protection of those rights according to the requirements in Minnesota Statutes, section 245D.04;

· strategies to minimize the risk of sexual violence, including concepts of healthy relationships, consent, and bodily autonomy of people with disabilities had been provided in February of 2021 but had not been provided again at the time of the review.

d. For SP8, 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 was provided in October of 2021, but had not been provided previously within the timeframe that was reviewed;

· the service recipient rights and staff responsibilities related to ensuring the exercise and protection of those rights according to the requirements in Minnesota Statutes, section 245D.04 was provided in July of 2021 but had not been provided previously within the timeframe that was reviewed and had not been provided again at the time of the review;

· the principles of person-centered service planning and delivery as identified in Minnesota Statutes, section 245D.07, subdivision 1a, and how they apply to direct support service provided by the staff person was provided in September of 2019 but had not been provided again at the time of the review; and

e. For SP9, the service recipient rights and staff responsibilities related to ensuring the exercise and protection of those rights according to the requirements in Minnesota Statutes, section 245D.04 was not provided during the timeframe reviewed;

· the principles of person-centered service planning and delivery as identified in Minnesota Statutes, section 245D.07, subdivision 1a, and how they apply to direct support service provided by the staff person was provided in July of 2019 but had not been provided again at the time of the review;

f. For SP10, 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 was provided in May of 2019 but not again until July of 2022;

· strategies to minimize the risk of sexual violence, including concepts of healthy relationships, consent, and bodily autonomy of people with disabilities was provided in August of 2022 but had not been provided previously during the timeframe that was reviewed.

g. For SP11, 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 was provided in January of 2021 but had not been provided again at the time of the review;

· the service recipient rights and staff responsibilities related to ensuring the exercise and protection of those rights according to the requirements in Minnesota Statutes, section 245D.04 was provided in January of 2020 but had not been provided again the time of the review;

· Minnesota Statutes, sections 245A.65, 245A.66, and 626.557 and chapter 260E governing maltreatment reporting and service planning for children and vulnerable adults, and staff responsibilities related to protecting persons from maltreatment and reporting maltreatment was provided in January of 2021 but have not been provided again at the time of the review;

· strategies to minimize the risk of sexual violence, including concepts of healthy relationships, consent, and bodily autonomy of people with disabilities had not been provided during the timeframe reviewed;.

h. For S13, 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 was provided in October of 2019 but not again until February of 2022;

· the service recipient rights and staff responsibilities related to ensuring the exercise and protection of those rights according to the requirements in Minnesota Statutes, section 245D.04 was provided in July of 2019 but had not been provided again at the time of the review;

· basic first aid was provided in October of 2019 but was not provided again until July of 2022.

Corrective Action Ordered: Within 30 days of receipt this order, you must submit a plan detailing how you will obtain and maintain compliance with annual training for all staff persons within your program. On an ongoing basis, you must maintain compliance with annual training as required in subdivision.

23. Citation: Minnesota Statutes, section 245D.09, subdivision 4a.

Violation: For one staff person whose record was reviewed (SP6), the license holder did not complete orientation to individual service recipient needs as required.

SP6 was hired on February 18, 2022 and began having unsupervised contact with persons receiving services on March 19, 2022, however, the license holder did not ensure that SP6 reviewed and received instruction on the each person’s coordinated service and support plan or coordinated service and support plan addendum as it relates to the responsibilities assigned to the license holder and each person’s individual abuse prevention plan, to achieve and demonstrate an understanding of the person as an individual.

Corrective Action Ordered: On an ongoing basis, you must complete orientation for new staff as required in this subdivision.

24. Citation: Minnesota Statutes, section 245D.095, subdivision 5.

Violation: For three staff persons whose records were reviewed (SP6, SP7, and SP10), the license holder did not maintain a personnel record as required.

The license holder failed to maintain documentation of training as required under Minnesota Statutes, section 2459.09, subdivisions 3 to 5, including the date the training was completed, the number of hours per subject area, and the name of the trainer or instructor. Specifically:

a. For SP6, training on data privacy and basic first aid were reportedly provided, but the dates of the trainings were not documented.

b. For SP7, training on emergency use of manual restraints and prohibited procedures were reportedly provided, but the dates of the trainings were not documented.

c. For SP10, training on service recipient rights and vulnerable adult maltreatment reporting was reportedly provided but the dates of the trainings were not documented.

Corrective Action Ordered: Within 30 days of receipt this order, you must maintain the above mentioned documentation in SP6, SP7 and SP10’s personnel record. On an ongoing basis, you must maintain documentation as required in this subdivision.

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.

C. Posting the Correction Order

Pursuant to Minnesota Statutes, section 245A.06 subdivision 8, you must post this Correction Order for two years in a place that is conspicuous to the people receiving services and all visitors to the facility, even if you request reconsideration.

If you have any questions regarding this Correction Order, please contact me as soon as possible.

Diana Arnzen, Senior Human Services Licensor

Licensing Division

Office of Inspector General

651-431-6638

PO Box 64242 • Saint Paul, Minnesota • 55164-0242 • An Equal Opportunity and Veteran Friendly Employer
https://mn.gov/dhs/general-public/licensing/