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November 21, 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: 1099274 License Complaint Report Number: 202206888 CORRECTION ORDER Dear Blake Elliott: A licensing complaint investigation of Bridges MN, located at 738 Magnolia 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 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. Program Coordination, Evaluation and Oversight 1. Citation: Minnesota Statutes, section 245D.081. Violation: For one of one person whose records were reviewed (P1), the license holder did not provide program management and oversight of the services provided by the license holder as required. The license holder failed to provide oversight of the license holder’s responsibility assigned in P1’s coordinated service and support plan (CSSP) and the coordinated service and support plan (CSSP) addendum. See citation 2 for evidence of failures. 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, November 4, 2022 and November 10, 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. On an ongoing basis, you must maintain compliance as required in this subdivision. Service Recipient Violations 2. Citation: Minnesota Statutes, section 245D.07, subdivision 1a. Violation: For one of one person whose record was reviewed (P1), the license holder did not provide program 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 addendum (CSSPA) On August 21, 2022, SP1 was scheduled to work the awake overnight shift. During the awake overnight shift, SP1 was observed to be sleeping, leaving P1 unsupervised. In an internal review completed by the license holder regarding this incident, documentation includes SP1 was sleeping during the awake shift. Through interviews and review of P1’s record, it was identified that P1 did not have alone time and required supervision 24 hours, including awake overnights. The license holder failed to provide services in response to P1’s identified needs in the CSSP. Repeat Violation: The license holder was cited for a similar violation 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, November 4, 2022 and November 10, 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. On an ongoing basis, you must maintain compliance as required in this subdivision. 3. Citation: Minnesota Statutes, section 245D.11, subdivision 2. Violation: For one person served (P1), the license holder did not enforce policies and procedures promoting health and welfare as required. On September 14, 2022, the license holder completed a review of an incident report that occurred on August 21, 2022. While the license holder reviewed the incident report and completed an internal review, the license holder did not complete the review accurately. The license holder documented policies and procedures were not followed, however failed to document what would be done to correct this. Additionally, the license holder failed to develop, document and implement a corrective action plan. The license holder failed to enforce the policy titled “Policy and Procedure on Reviewing Incidents and Emergencies.” Repeat Violation: The license holder was cited for a similar violation correction orders dated 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. On an ongoing basis, you must maintain compliance 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 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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