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November 10, 2022 Blake Elliott, Authorized Agent Bridges MN 1932 University Avenue West Saint Paul, Minnesota 55104 License Number: 1079030 (Home and Community-Based Services) Community Residential Site: 1097762 License Complaint Report Number: 202206131, 202206297, 202208084 CORRECTION ORDER Dear Blake Elliott: A licensing complaint investigation of Bridges MN, located at 2181 Sunrise Drive, 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. 1. Citation: Minnesota Statutes, section 245D.081, subdivision 2 and 3. Violation: For three of three person whose record 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 and P2, see citation 3 for evidence of failures; · Regarding P3, see citation 2 and 3 for evidence of failures. b. Regarding P1, P2 and P3, the license holder failed to provide program management and oversight of the services provided by the license holder. See citations 2 through 4 for the failures to provide supervision, support and evaluation of activities, including: · 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); and · ensure the duties of the designated coordinator are fulfilled according to the requirements in subdivision 2. c. The license holder failed to ensure that the designated manager implemented corrective action identified by the program following review of incident reports according to the requirements in section 245D.11, subdivision 2, clause (7). During an onsite visit of P1, P2 and P3’s home, DHS licensors interviewed SP3, SP4 and SP5. Each were asked if SP2 had received any type of corrective action regarding an incident on July 28, 2022. SP5 informed DHS licensors that SP2 did receive corrective action specifically on reporting when a staff is sleeping on an awake shift. However, review of the corrective action provided to SP2 on July 28, 2022 did not document the corrective action that SP5 stated had occurred. . SP2’s corrective action only identified how SP2 was sleeping during an awake shift. SP2 was never identified in the initial licensing complaint report as also sleeping. Repeat Violation: The license holder was cited for a similar violation in an Order of Conditional Order March 10, 2020; and in correction orders dated June 14, 2019, March 12, 2020, May 20, 2021, June 3, 2022, October 14, 2022 and November 4, 2022. 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. 2. Citation: Minnesota Statutes, section 245D.05, subdivision 1 and subdivision 2. Violation: Regarding complaint 202206297, for one person served (P3), the license holder did not implement medication administration procedures as required. The license holder was assigned the responsibility for health needs and medication administration in P3’s coordinated service and support plan addendum. P3 had an appointment on July 20, 2022. During that appointment P3 had a medication discontinued and a new medication prescribed; both of the medication changes were ordered to change on July 21, 2022. During a medication administration record review conducted by the license holder on August 2, 2022, it was determined that the medication changes were not completed for P3. The license holder failed to implement and transcribe the prescriber’s new and discontinued medication orders for P3’s medications on July 21, 2022. The license holder reported to the prescriber this error upon discovery. Repeat Violation: The license holder was cited for similar violation in an Order of Conditional Order March 10, 2020; and in correction orders dated September 13, 2018, June 14, 2019, December 10, 2019, December 27, 2019, October 7, 2020, February 5, 2021, April 2, 2021, November 9, 2021 February 25, 2022, and September 21, 2022. 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. 3. Citation: Minnesota Statutes, section 245D.07, subdivision 1a. Violation: Regarding complaint reports 202206131 and 202208084 three persons whose records were reviewed (P1-P3), the license holder did not provide services 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 (CSSP) addendum. During an onsite visit of P1, P2 and P3’s home, DHS licensors interviewed SP3, SP4 and SP5. During this interview, SP3, SP4 and SP5 confirmed staffing at the home included two staff to be providing direct care, including the overnights. SP3 reported, during the afternoons, between 2p and 3p there can be one staff, as that was identified as “down time.” However, documented in P1, P2 and P3’s CSSP addendums it states staff will utilize two person lifts when transferring P1, P2 and P3, which would require two staff be available. a. In an internal review completed by the license holder regarding an incident on July 28, 2022, SP1 and SP2 were observed as either sleeping in a resident’s bed or nodding off on the couch. On July 28, 2022 P1, P2 and P3 were without supervision due to SP1 and SP2 sleeping. The license holder failed to provide services as required. b. In an internal review completed by the license holder regarding an incident on September 29, 2022, SP2 was observed sleeping while on a scheduled awake daytime shift. SP2 was the only staff working at this time. The license holder failed to provide services as required. Repeat Violation: The license holder was cited for a similar violation in correction orders dated June 30, 2019, March 22, 2019, May 20, 2021, October 15, 2021, December 6, 2021, February 25, 2022, June 8, 2022, August 19, 2022, September 29, 2022 and November 4, 2022. 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. 4. Citation: Minnesota Statutes, section 245D.11, subdivision 2 Violation: Regarding complaint report 202206297, one persons whose record was reviewed (P3), the license holder did not ensure the program and program staff enforced the program’s policy and procedures on safe medication assistance and administration as required. The license holder’s policy and procedure titled “Policy and Procedure on Safe Medication Assistance and Administration” required the following in regards to handling changes to prescriptions and implementation of the changes: · All written instructions regarding changes to medications and treatments are required to be documented through a prescription label or the prescriber’s written or electronically recorded order for the prescription. · Changes made to prescriptions will be immediately communicated to the manager and nurse, as applicable. · Staff will implement changes and document appropriately on the monthly medication sheet. · Discontinued medications or medications that the dosage is no longer accurate due to the changes will be discarded appropriately. Additionally, the policy and procedure required the following in regards to coordination and communication with prescribers: · All prescriber instructions will be implemented as directed within required timelines by staff and/or the person served and documented in related health documentation The license holder failed to enforce the above mentioned policy. Repeat Violation: The license holder was cited for similar violation in an Order of Conditional Order March 10, 2020; and in correction orders dated February 5, 2021, November 9, 2021 and February 25, 2022. 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. 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. Submissions required as part of a corrective action ordered must be sent to your Licensor at: 1. By secure email at Elizabeth.Schiefelbein@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: Liz Schiefelbein 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 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. Liz Schiefelbein, Human Services Licensor Licensing Division Office of Inspector General 651-431-2738
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