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October 24, 2022 Blake Elliott, Authorized Agent Bridges MN 1932 University Avenue West Saint Paul, Minnesota 55104 License Number: 1079030 (245D – Home and Community-Based Services) License Number: 1108950 (Community Residential Setting) Compliant Number (s): 202206199; 202206522; and 202207030 CORRECTION ORDER Dear Blake Elliott: On September 6, 2022, a licensing investigation of Bridges MN, located at 1411 Shakopee Avenue East, Shakopee, 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 investigation 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 245D.05, subdivision 1, paragraph (b). Violation: For one person whose record was reviewed (P1), the license holder did not document how health needs would be met as required. P1’s coordinated service support plan addendum dated January 11, 2022, stated that P1 required medication assistance. SP3 stated in June (specific date not provided) there was an incident and it was determined that the license holder would be responsible for medication administration going forward. The license holder failed to update P1’s coordinated service support plan addendum until September 3, 2022. In addition, the license holder failed to inform P1’s case manager of the changes to P1’s change in needs. Corrective Action Ordered: P1 no longer received services from the license holder. On an ongoing basis, you must maintain compliance as required with this subdivision. 2. Citation: Minnesota Statutes, section 245D.09, subdivision 3. Violation: For four of six staff person whose record was reviewed (SP1, SP2, SP4 and SP5), the license holder did not ensure staff competency as required. The license holder was responsible for administering P1’s medications. The license holder determined that SP1, SP2, SP4 and SP5 needed to be trained following medication documentation errors on P1’s medication administration record (MAR); however the license holder failed to provide that training. · SP1 did not document that P1’s Ketoconazole cream was administered on July 5, 2022. The Medication or Treatment Error or Refusal Report dated July 6, 2022, stated that SP1 was to attend a training with SP3. As of October 3, 2022, the license holder failed to provide this training to SP1. · SP2 did not document that P1’s Ketoconazole cream was administered on July 30, 2022. The Medication or Treatment Error or Refusal Report dated August 1, 2022, stated that SP2 would be re-trained on the importance of documenting the MAR. As of October 3, 2022, the license holder failed to provide this training to SP2. · SP4 did not document that P1’s Ketoconazole cream was administered on August 21, 2022. The Medication or Treatment Error or Refusal Report dated August 24, 2022 stated that SP4 was to receive an Identification/Resolutions Form (IRF) and retraining on the importance of documenting the medication administration record. SP4 did receive an IRF that was not signed or dated, but did state again that SP4 was to be retrained on the importance of documenting the MAR. On October 5, 2022, the license holder provided documentation that SP4 received a training on various topics; however, these trainings were a training for a site P1 did not live at and did not include the importance of documenting the MAR or anything regarding P1. · SP5 did not administer P1’s medication correctly on August 22 and 23, 2023. An incident report dated August 24, 2022 documented that SP5 would receive a retraining with SP5. SP5 received an IRF on September 2, 2022; however, there was no retraining documented. Corrective Action Ordered: P1 no longer receives services from the license holder. You must provide the training to SP1, SP2, SP4, and SP5 as stated in your Medication or Treatment Error or Refusal Report and/or incident reports and submit the training documentation to the licensor listed below according to the requirements in Minnesota Statutes, section 245D.095, subdivision 5. On an ongoing basis, you must ensure competency of staff according to the requirements in this subdivision. 3. Citation: Minnesota Statutes, section 245D.081, subdivisions 2 and 3. Violation: The license holder failed to provide program management and oversight as required. The license holder failed to ensure staff competency requirements are met according to the requirements in section 245D.09, subdivision 3. The license holder identified SP1, SP2, SP4 and SP5 needed additional training; however, the license holder failed to provide additional training to SP1, SP2, SP4 and SP5. Corrective Action Ordered: You must provide documentation to this licensor that corrective action ordered has been completed within the stated timelines. On an ongoing basis, you must provide the program management and oversight as required in this subdivision. Submissions required as part of a corrective action ordered must be sent to your Licensor at: 1. By secure email at diana.arnzen@state.mn.us ; or 2. If you are unable to submit corrective action ordered securely through email, you can mail or fax using the information below: Commissioner, Department of Human Services ATTN: Diana Arnzen Licensing Division PO Box 64242 St. Paul, MN 55164-0242 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
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