|
November 4, 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: 1080199 (Community Residential Setting) Licensing Complaint Number(s): 202205100; 202205171; 202205188; 202205331; 202205978; 202206082 CORRECTION ORDER Dear Blake Elliott: A licensing complaint investigation of Bridges MN, located at 373 Skillman Avenue East, Saint Paul, 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 the licensing complaint investigation(s) 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. Licensing Violations Program Coordination, Evaluation, and Oversight 1. Citation: Minnesota Statutes 245D.081, subdivisions 2 and 3. Violation: For three of three persons whose records were reviewed (P1, P2 and P3), the license holder did not provide program management and oversight of the services provided by the license holder as required. a. The license holder failed to provide oversight of the license holder’s responsibility assigned in P1, P2 and P3’s coordinated service and support plan (CSSP) and the coordinated service and support plan (CSSP) addendum: · Regarding P1, see citations 3, 4 letters a and d and citation 5 for additional evidence of failures; · Regarding P2, see citation 4 letters a, b and c and citation 6 for additional evidence of failures; and · Regarding P3, see citation 4 letters d, e, f and g for additional evidence of failures. b. Regarding P1, P2 and P3, the license holder failed to provide coordination of service delivery and evaluation for each person served by the program. See citations 2 through 8 for the failures to provide supervision, support and evaluation of the activities including: · ensuring the effectiveness of service delivery, methodologies, and progress on the person's outcomes based on the measurable and observable criteria for identifying when the desired outcome has been achieved according to the requirements in section 245D.07; and · instruction and assistance to direct support staff implementing the coordinated service and support plan and the service outcomes, including direct observation of service delivery sufficient to assess staff competency. c. The license holder failed to provide program management and oversight of the services provided by the license holder. See citations 2 through 8 for the license holder’s failures to: · maintain a current understanding of the licensing requirements sufficient to ensure compliance throughout the program as identified in section 245A.04, subdivision 1, paragraph (e), and when applicable, as identified in section 256B.04, subdivision 21, paragraph (b); · ensure the duties of the designated coordinator are fulfilled according to the requirements in subdivision 2; d. The license holder failed to ensure the program implemented corrective action identified by the program following review of incident reports according to the requirements in section 245D.11, subdivision 2, clause (7). · Regarding P3, the license holder documented in an incident report dated June 28, 2022 that SP4 would receive a performance improvement plan (PIP) based off of an incident involving P3. The license holder provided SP4 PIP, dated July 7, 2022 does not reflect any corrective action specific to the concerns identified in the incident report dated June 28, 2022. · Regarding P2, the license holder completed a review on July 1, 2022 of an incident report specific to an incident that occurred on June 29, 2022. While the license holder fully reviewed the incident report and internal report completed by SP2, the license holder did not complete the review accurately. The license holder documented the CSSP addendum for P2 was followed by the staff, however P2’s alone time in the community was not followed as documented in P2’s CSSP addendum, see citation 3, letter b for additional evidence of this failure. On July 1, 2022, the license holder reviewed the incident report and internal review completed and approved the document, although there was inconsistent information. · P2 had an incident on July 21, 2022 and the license holder completed an internal review on July 22, 2022. The internal review included a section asking if the applicable CSSP addendum was implemented for the person involved. Documented in that section is “yes,” however, at the time of the incident the “four stage crisis plan” was not implemented by SP1 at the time of the behavior and SP1 immediately went to calling 911 as an intervention. e. Regarding P1, P2 and P3 the license holder failed to evaluate satisfaction of persons served by the program, the person's legal representative, if any, and the case manager, with the service delivery and progress towards accomplishing outcomes identified in sections 245D.07 and 245D.071, and ensuring and protecting each person's rights as identified in section 245D.04. See citations 2, 4 and 5 for additional evidence of failures. f. The license holder failed to ensure staff competency requirements were met according to the requirements in section 245D.09, subdivision 3, and ensuring staff orientation and training is provided according to the requirements in section 245D.09, subdivisions 4, 4a, and 5: · Regarding SP1, see citation 7 for additional evidence of failures; and · Regarding SP4, see citation 8 for additional evidence of failures. Repeat Violation: Corrective Action Ordered: Because the license is currently revoked, operating under appeal, you must: · share this correction order with the person, the person’s legal representative, and the person’s case manager; and · inform each of how you will maintain compliance with this licensing requirement on a continuing basis; and · submit, to the licensor identified in this correction order, evidence showing that the above mentioned requirements has been completed. Service Recipient Violations 2. Citation: Minnesota Statutes, section 245D.04, subdivision Violation: Regarding complaint reports 202205188 and 202206082 for one person served (P2), the license holder did not ensure the protection of the person’s rights in the services provided. During the course of the above listed licensing complaint investigations an allegation found evidence that P2’s rights were violated. SP2 was witnessed antagonizing P2 and P2 is often triggered verbally with antagonization. The license holder failed to ensure P2 was treated with courtesy and respect. Repeat Violation: Corrective Action Ordered: Because the license is currently revoked, operating under appeal, you must: · immediately ensure the protection of P2’s rights; · re-train SP2 on individual service recipient rights within 30 days of receipt of this order; · share this correction order with the person, the person’s legal representative, and the person’s case manager; and · inform each of how you will maintain compliance with this licensing requirement on a continuing basis; and · submit, to the licensor identified in this correction order, evidence showing that the above mentioned requirements has been completed. 3. Citation: Minnesota Statutes, section 245D.06, subdivision 4. Violation: Regarding complaint report 202205100 for one persons served (P1), the license holder did not meet requirements for safekeeping a person’s funds. The license holder maintained documentation assigning responsibility for assisting P1 with the safekeeping of funds. The license holder obtained written authorization to do so on March 29, 2022 at service initiation. Additionally, on March 29, 2022 the license holder surveyed and documented the preferences of P1’s legal representative and case manager for frequency of receiving a statement that itemizes receipts and disbursements of funds. P1’s legal representative and case manager requested monthly itemized ledgers showing the disbursements of P1’s funds. The license holder failed to implement the safekeeping of P1’s funds and provide monthly itemized ledgers to P1’s legal representative and case manager. Repeat Violation: The license holder was cited for a similar violation in an Order of License Revocation, Determinations of Maltreatment, and Failure to Report Maltreatment dated June 27, 2022; and in correction orders dated December 29, 2017, June 14, 2019, August 19, 2020, and May 20, 2021. Corrective Action Ordered: Because the license is currently revoked, operating under appeal, you must: · share this correction order with the person, the person’s legal representative, and the person’s case manager; and · inform each of how you will maintain compliance with this licensing requirement on a continuing basis; and · submit, to the licensor identified in this correction order, evidence showing that the above mentioned requirements has been completed. On an ongoing basis, you must maintain compliance as required in this subdivision. 4. Citation: Minnesota Statutes, section 245D.07, subdivision 1a. Violation: Regarding complaint reports 202205188, 202205978, 202206082, 202205331 and 202205171 three persons whose records were reviewed (P1-P3), the license holder did not provide service in response to the person’s identified needs, interests, preferences and desired outcomes as specified in the coordinated services and support plan (CSSP) and coordinated service and support plan addendum (CSSPA). a. On July 25, 2022 SP1 was scheduled to work until 8:00am. At 8:09am SP2 arrived for their shift and SP1 had already left leaving P1 and P2 unsupervised. It was determined SP1 left their shift at 5:00am. SP1 left their shift without notifying the designated on-call staff or the residential supervisor. Through interviews and review of P1 and P2’s record, it was identified that P1 and P2 have some alone time, however, P1 and P2 are never to be left unsupervised while in the home with another housemate present. P1 and P3 require supervision while in their home when home with each other. The license holder failed to provide services in response to P1 and P3’s identified needs in the CSSP. b. P2’s CSSP addendum stated P2 accesses the community with the assistance from staff and P2 has 4 hours of alone time in the community each day if P2 chooses. When out, if P2 does not reach out to staff by the end of the 4th hour staff will call P2 to find out where P2 needs to be picked up. If P2 does not respond or call back, staff will notify one of P2’s family members within the next 30 minutes to see if they can reach P2. Once the time is at 5 hours and no one has communication with P2 the non-emergency police should be notified of P2’s absence. On June 28, 2022, P2 was to be picked up by SP1 at 8:30pm, however, SP1 failed to pick up P2. Additionally, P2 was not picked up until the following morning. The license holder failed to follow P2’s CSSP addendum as written. c. P2’s CSSP addendum contained a document titled “Four Stage Crisis Plan,” with a date of July 6, 2022. The “Four Stage Crisis Plan” identifies specific intervention strategies to support P2 through several stages of a behavior. On the following dates staff did not follow P2’s four stage crisis plan and immediately called 911: · July 15, 2022; · July 21, 2022 Additionally, documented in the corrective action of the incident report was all staff will be trained on P2’s new behavior support plan, however, the created date of the “four stage crisis plan” was documented as July 6, 2022 and the training of P2’s new plan was not going to be trained on until July 19, 2022 at a staff meeting. Regarding the July 21, 2022 incident, SP1 did not follow the plan, and immediately called 911 prior to trying any intervention strategies identified in P2’s plan. d. On July 24, 2022 SP1 was scheduled to work until 8:00am. At 6:00am, it was discovered by P3 that SP1 had left their shift. P3 called a person in management to report the staff left and P1 and P3 were at the home with no staff present. SP1 did not call the designated on-call staff or the house supervisor prior to leaving [his/her] shift. P1 and P3 were left alone until 11:00am. Through interviews and review of P1 and P3’s record, it was identified that P1 and P3 have some alone time, however, 6:00am to 11:00am was longer than their alone time identified in their coordinated service and support plan (CSSP) addendums. Additionally, P1 and P3 are not to be left unsupervised while in the home with each other present. P1 and P3 require supervision while in their home when home with each other. The license holder failed to provide services in response to P1 and P3’s identified needs in the CSSP addendum. e. On July 4, 2022, P3 had verbalized a plan to house staff and her family regarding [his/her] plans for that night. The license holder did not have available staffing specific to P3’s home to take P3 to a firework show that night. Because of the lack of staffing, P3 planned to go with another person served by the license holder and their staff. The plan was for P3’s staff to provide the drop off of P3 to the firework show and to meet up with the person served and staff. The additional plan was after the show the persons served staff would drive P3 back to [his/her] home. However, the person served and their staff left without informing P3 and left P3 at the park alone with no additional plan for P3 to get home. The license holder failed to provide services in response to P3’s identified needs and preferences as written in the CSSP addendum. f. Through interviews with P3 and through review of their record, P3 enjoyed their independence, dreamed of attending college and wanted to work at a daycare center specifically with infants. P3 also enjoyed crafts, going out with friends, keeping in touch with family, caring for their pet hamster and collecting Squishmallows. P3’s support and outcomes were written as: · P3 will tidy up his/her room 1 time a day to organize and declutter their room with a success rate of 75% within 6 month review period. Through an interview with SP2, P3 has trauma surrounding the cleanliness of their room and has a hard time throwing items away. According to SP2, this goal was important for P3’s family. g. P3’s “P3 Outcome 1-Organizing” dated July 1, 2022, describes the methods and actions staff will use to support P3 as: · P3 will create a visual schedule to work with staff in organizing their room; · Staff and P3 will use the schedule to serve as a guide to remind P3 of what they are working on; · Staff will offer prompts and encourage P3 daily to pick up and organize their bedroom while allowing them time to process; · if P3 is not ready when prompted, staff should ask what time they would like to do it and prompt them again at that time; · Staff will ensure there are cleaning supplies available; · at the end of the week, P3 will discuss an pick an activity with the supervisor for staff to complete following a successful week. During an onsite visit of P3’s home, DHS licensors interviewed P3, SP2 and SP3. During this interview, P3 was asked if they could show the licensor their visual schedule. P3 stated that the schedule had been lost for some time, and they were unable to find it. When SP2 and SP3 was asked if they could show the licensor where the visual schedule was, they were also unable to provide evidence or documentation of this visual schedule. Repeat Violation: Corrective Action Ordered: Because the license is currently revoked, operating under appeal, you must: · share this correction order with the person, the person’s legal representative, and the person’s case manager; and · inform each of how you will maintain compliance with this licensing requirement on a continuing basis; and · submit, to the licensor identified in this correction order, evidence showing that the above mentioned requirements has been completed. 5. Citation: Minnesota Statutes, section 245D.071, subdivision 2 and section 245A.65, subdivision 2. Violation: Regarding complaint 20220510, one person served (P1), the license holder did not develop and enforce an individual abuse prevention plan (IAPP) as required in section 626.557, subdivision 14. The license holder failed to develop an IAPP for P1 that included an accurate individualized assessment of P1’s susceptibility to abuse. At the time of the licensing complaint, the license holder stated P1 was susceptible to financial exploitation, including being unable to read and identify the amount of money being presented and cannot understand the value of money or the concept of exchanging money for a good or service. P1’s IAPP contained documentation that staff were responsible for assisting P1 with budgeting for needed items, keeping P1’s receipts, keeping track of P1’s money on a ledger and sending the ledger to P1’s representative payee monthly. During the licensing complaint review, the license holder failed to enforce and follow the IAPP as written for P1, when P1 was safekeeping [his/her] own funds, and staff were not keeping receipts, helping P1 budget or tracking P1’s money on a ledger. At the time of the licensing complaint review no monthly ledgers had been documented on or sent to the representative payee. Repeat Violation: Corrective Action Ordered: Because the license is currently revoked, operating under appeal, you must: · share this correction order with the person, the person’s legal representative, and the person’s case manager; and · inform each of how you will maintain compliance with this licensing requirement on a continuing basis; and · submit, to the licensor identified in this correction order, evidence showing that the above mentioned requirements has been completed. On an ongoing basis, you must maintain compliance as required in this subdivision. 6. Citation: Minnesota Statutes, section 245D.11, subdivision 2. Violation: Regarding complaint report 202205188 and 202205100 for one person served (P2), the license holder did not enforce policies and procedures promoting health and welfare as required. The license holder failed to follow enforce the policy titled “Policy and Procedure on Reviewing Incidents and Emergencies.” a. P1 had an incident on June 26, 2022 and the license holder completed an internal review on July 27, 2022. The license holder documented on the internal review that the company policies and procedures were not followed, however did not specify what the license holder would do to correct current lapses and prevent future lapses in performance by staff or the license holder. b. P2 had an incident on June 28, 2022 and the license holder completed an additional internal review on July 29, 2022. The license holder documented on the internal review that the company policies and procedures were not followed, however did not specify what would be done to correct current lapses and prevent future lapses in performance by staff or the license holder. Repeat Violation: Corrective Action Ordered: Because the license is currently revoked, operating under appeal, you must: · share this correction order with the person, the person’s legal representative, and the person’s case manager; and · inform each of how you will maintain compliance with this licensing requirement on a continuing basis; and · submit, to the licensor identified in this correction order, evidence showing that the above mentioned requirements has been completed. On an ongoing basis, you must maintain compliance as required in this subdivision. Staffing Standards 7. Citation: Minnesota Statutes, section 245D.09, subdivision 4a. Violation: Regarding complaint report 202205188, for one staff person whose record was reviewed (SP1), the license holder did not provide orientation to individual service recipient needs as required. The license holder failed to provide SP1 with orientation to P2’s individual service recipient needs, including instruction to achieve and demonstrate an understanding of the person as a unique individual, and how to implement P2’s coordinated service and support plan or coordinated service and support plan addendum as it relates to the responsibilities assigned to the license holder. On June 8, 2022 SP1 completed a training document specific to P2 titled “Annual Ramsey Familiarization to the Worksite.” SP1 answered and documented on the training document regarding P2 inconsistently with documentation found in P2’s CSSP and CSSP addendum. The following inconsistencies were documented: · SP1 documented “N/A” when being requested to document any specialized diets P2 may be on. Documented in P2’s CSSP addendum, dated March 21, 2022 it states P2 has diabetes and staff are to make diabetic friendly food available and verbally encourage P2 to make healthy food choices and portion control. · SP1 documented “N/A” when being requested to documented areas of support that P2 requires under the health needs section of the CSSP Addendum. Documented in P2’s CSSP addendum under health needs stated details and procedures about the responsibilities assigned to the license holder and staff responsibilities related to health services and medication administration. Repeat Violation: Corrective Action Ordered: Because the license is currently revoked, operating under appeal, you must: · share this correction order with the person, the person’s legal representative, and the person’s case manager; and · inform each of how you will maintain compliance with this licensing requirement on a continuing basis; and · submit, to the licensor identified in this correction order, evidence showing that the above mentioned requirements has been completed. 8. Citation: Minnesota Statutes, section 245D.09, subdivision 5. Violation: Regarding complaint report 202205171, for one staff persons whose record was reviewed (SP4), the license holder did not provide annual training as required. The license holder failed to provide SP4 with annual training on 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. SP4 received training on individual rights on June 16, 2021 and not again until July 31, 2022. Repeat Violation: Corrective Action Ordered: Because the license is currently revoked, operating under appeal, you must: · submit, to the licensor identified in this correction order, a written plan how you will maintain compliance with this licensing requirement on a continuing basis. If you fail to correct the violations specified in the Correction Order within the prescribed time lines the Commissioner may impose a fine and order other licensing sanctions pursuant to Minnesota Statutes, sections 245A.06 and 245A.07. A. 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 Office of Inspector General Legal Counsel’s Office ATTN: Licensing Legal Unit PO Box 64953 St. Paul, MN 55164-0953 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.
Sincerely, Liz Schiefelbein, Senior HCBS Licensor Licensing Division Office of Inspector General 651-431-2738
|
