|
December 2, 2022 Rashad Gabose, Authorized Agent Peoples Development Social Services 475 University Avenue West Saint Paul, MN, 55103 License Number: 1098343 (245D – HCBS) CORRECTION ORDER Dear Rashad Gabose: On September 1, 2022, a licensing review of Peoples Development Social Services, located at 475 University Avenue West, 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 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, section 245D.071, subdivision 3, paragraph (d). Violation: For one of two persons whose record was reviewed (P2), the license holder did not meet requirements for initial service planning for intensive support services as required. The license holder reported that P2’s 45-day meeting was held on December 8, 2021, however the license holder failed to hold a discussion of how technology might be used to meet P2’s desired outcomes at P2’s 45-day meeting. Additionally, the license holder failed to include a summary of this discussion in P2’s coordinated service and support plan (CSSP) or support plan addendum (CSSP addendum), that included a statement regarding any decision that is made regarding the use of technology and a description of any further research that needs to be completed before a decision regarding the use of technology can be made. Corrective Action Ordered: Within 30 days of receiving this order, you must discuss with P2 and P2’s case manager, how technology might be used to meet P2’s desired outcomes. Additionally, you must include a summary of this discussion in P2’s CSSP or CSSP addendum including a statement regarding any decision that is made regarding the use of technology and a description of any further research that needs to be completed before a decision regarding the use of technology can made. On an ongoing basis, you must maintain compliance as required in this subdivision. 2. Citation: Minnesota Statutes, section 245D.095, subdivision 3. Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not maintain service recipient records as required. The license holder failed to maintain the date of admission and progress or daily log notes that are recorded by the program in P1 and P2’s service recipient record. Corrective Action Ordered: Within 30 of receiving this order, you must document and maintain the date of admission for P1 and P2 in their service recipient records. Additionally, you must begin recording progress or daily log notes for service recipients receiving services under this license. On an ongoing basis, you must maintain compliance as required in this subdivision. 3. Citation: Minnesota Rules, part 9544.0030, subpart 1. Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not evaluate the identified positive support strategies every six months as required. The license holder failed to evaluate with P1 and P2, at least every six months, if any positive support strategies used needed changes, and, if so make appropriate changes. Corrective Action Ordered: Within 30 days of receiving this order, you must evaluate with P1 and P2 whether the identified positive support strategies currently meet the standards in Minnesota Rules, part 9544.0030, subpart 2. Based upon the results of the evaluation, you must determine whether changes are needed in the positive support strategies used, and, if so, make appropriate changes. Additionally, you must maintain documentation of compliance with these requirements as required in Minnesota Rules, part 9544.0100. On an ongoing basis, you must maintain compliance as required in this subpart. 4. Citation: Minnesota Statutes, section 245D.09, Subdivision 4. Violation: For two of two staff persons whose records were reviewed (SP1 and SP2), the license holder did not provide orientation training as required. SP1 was hired on May 18, 2021. SP2 was hired on November 19, 2021. The license holder failed to provide SP1 and SP2 with an orientation to the safe and correct use of manual restraint on an emergency basis according to the requirements in section 245D.061 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, why such procedures are not effective for reducing or eliminating symptoms or undesired behavior, and why such procedures are not safe, within 60 days of hire. Corrective Action Ordered: Within 30 days of receiving this order, you must provide SP1 and SP2 with an orientation to the training topics identified above. Additionally, you must maintain documentation of this training in SP1 and SP2’s personnel record that includes the date the training was completed, the number of hours per subject area, and the name of the trainer or instructor as required in section 245D.095, subdivision 5. On an ongoing basis, you must maintain compliance as required in this subdivision. 5. Citation: Minnesota Statutes, section 245D.095, subdivision 5, paragraph (a), clause (2). Violation: For two staff persons whose records were reviewed (SP1 and SP2), the license holder did not maintain personnel records as required. The license holder failed to maintain a personnel record for SP1 and SP2 to document and verify orientation and training that included: · the date training was completed; · the number of hours per subject area; and · the name of the trainer or instructor. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 6. Citation: Minnesota Statutes, section 245C.13, subdivision 2. Violation: For one staff persons whose record was reviewed (SP2), the license holder did not complete a background study as required. The license holder initiated a background study for SP2 using the electronic system known as NETStudy on December 2, 2021. The commissioner issued a notice informing the license holder that the study for SP2 has been completed and cleared on January 5, 2022. However, SP2 first had unsupervised contact with a person served by the program on December 4, 2021. The license holder failed to ensure that SP2 was supervised when providing direct contact services to a person served by the program prior to receiving a notice from the commissioner stating that SP2 was not disqualified or more time was needed to complete the study and that SP2 was not required to be under continuous direct supervision prior to the completion of the background study. Under Minnesota Statutes, section 245A.07, subdivision 3, paragraph (d), except for background study violations involving the failure to comply with an order to immediately remove an individual or an order to provide continuous, direct supervision, the Commissioner shall not issue a fine to a license holder who self-corrects a background study violation before the Commissioner discovers the violation. Corrective Action Ordered: Immediately and ongoing, you must comply with the background study requirements in Minnesota Statutes, chapter 245C. 7. Citation: Minnesota Statutes, section 245D.10, subdivision 1 and 2. Violation: The license holder did not establish and maintain policies and procedures as required in this chapter and chapter 245A. a. Documented in the license holder’s “Maltreatment of Vulnerable Adult Mandated Reporting” policy, the license holder identified “office manager” as the secondary person or position to whom internal reports may be made and secondary person or position responsible for forwarding internal reports to the common entry point as defined in section 626.5572, subdivision 5. The position of “officer manager” was not identified on the organizational chart of the program. Additionally, when DHS licensors asked the license holder about this role during the licensing review the license holder reported that this was not a position title within the program. Therefore, the license holder failed to identify a secondary person or position to whom internal reports may be made and the secondary person or position responsible for forwarding internal reports to the common entry point as defined in section 626.5572, subdivision 5. b. The license holder’s “Grievance Policy” failed to identify the current address of the highest level of the authority in the program. Corrective Action Ordered: Within 30 days of receiving this order, you must: · establish, enforce, and maintain policies related to suspected or alleged maltreatment and grievances as required in this chapter and chapter 245A. · provide these policies to all persons receiving services under this license, their legal representatives, if applicable, their case managers; and · inform all employees of the revisions and provide training on the revised policies and procedures as required in subdivision 4, paragraph (d). 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 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. If you have any questions regarding this Correction Order, please contact me as soon as possible, Robert Romani, Robert.r.romani@state.mn.us, 651-431-3658. Christala Culhane, Supervisor Licensing Division Office of Inspector General
|
