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December 16, 2022 CERTIFIED MAIL Cedric Key, Authorized Agent Key 360 Support Services, LLC 4124 Quebec Avenue North, Suite 101 Minneapolis, MN 55427 License Number: 1090600 (Home and Community-Based Services) License Number: 1096143 (Community Residential Setting) License Number: 1097300 (Community Residential Setting) ORDER OF CONDITIONAL LICENSES Dear Cedric Key: The Department of Human Services (DHS) is placing your licenses, Key 360 Support Services, LLC, to provide Home and Community-Based Services and Community Residential Setting services, on conditional status for two years, beginning December 16, 2022. This means you must meet certain conditions to maintain your license, detailed below. This order is based on your noncompliance with licensing requirements. Details of our findings are also provided below. Our next steps and your options are also detailed. REASON FOR THE CONDITIONAL LICENSE On September 14 through September 16, 2022, a DHS licensor conducted a licensing review of Key 360 Support Services, LLC located at 4124 Quebec Avenue North, Minneapolis. As a result of the licensing review, DHS determined that your program failed to comply with the laws and rules that apply to licensed services under Minnesota Statues, chapter 245D and related statutes and rules, citing 23 violations. DHS has considered the nature, chronicity, and severity of these violations, as well as the health, safety, and rights of persons served by the program. · Nature: Violations cited in this Order of Conditional License include violations of law or rule affecting the health, safety, or rights of individuals served by the program. The licensing violations include: o Failure to meet health service needs consistent with the person's health needs, including administering medications. o Failure to provide services in response to the person's identified needs, interests, preferences, and desired outcomes. o Failure to meet initial service planning requirements. o Failure to meet service plan review and evaluation requirements. o Failure to designate a qualified and competent staff person(s) to fulfill the responsibilities for coordination and evaluation of individual service delivery and program management and oversight. o Failure to provide required training to staff persons. · Chronicity: Your program received its license on October 31, 2017. The information below summarizes your history of noncompliance with licensing rules and statutes: o December XXX, 2022 – Conditional License (this order): 23 violations (6 repeat) o December 18, 2022 – Correction Order 7 violations · Severity: Many of the violations that led to the conditional status of your license relate to the health and safety of persons served within your program. Regarding the most recent licensing review conducted on September 14-16, 2022:
o Four violations were related to health services. o Fourteen violations were related to the manner in which services were not provided according to licensing standards. o Three violations were related to the program coordination, evaluation, and oversight of your program. o Two violations were related to inadequate staff training. Due to the serious and chronic nature of these violations, and the conditions in the program, which impact the health and safety of persons served in your care, your licenses to provide Home and Community-Based Services and Child Foster Residential Setting services are placed on conditional status. Licensing Violations DHS determined that your program failed to follow licensing rules and statutes, as described below. Program Coordination, Evaluation, and Oversight Violations 1. Violation: The license holder did not identify a designated manager (SP4) that met statute requirements and did not ensure that the identified designated manager provided program management and oversight of the services provided by the license holder as required. The license holder identified SP4 as the Designated Manager. See citations 2 through 23 regarding SP4’s failure to: · maintain 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; · ensure the program implements corrective action identified as necessary by the program following the review of incident and emergency reports; · conduct internal reviews of incident reports of alleged or suspected maltreatment as required; · 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; · ensure staff competency requirements are met according to the requirements in section 245D.09, subdivision 3, and ensure staff orientation and training is provided according to the requirements in section 245D.09, subdivisions 4, 4a, and 5; · evaluate the information identified in clauses (1) to (6) to develop, document, and implement ongoing program improvements. Statute Violated: Minnesota Statutes, section 245D.081. 2. Violation: The license holder did not ensure that the person identified as the Designated Coordinator (SP5) provided supervision, support, and evaluation of services as required. The license holder identified SP5 as the Designated Coordinator. See citations 4 through 23 regarding SP5’s failure to: · provide oversight of the license holder’s responsibilities assigned in the person’s coordinated service support plan (CSSP) and the CSSP addendum; · take the necessary action to facilitate the accomplishment of outcomes according to the requirements in 245D.07; · provide instruction and assistance to direct support staff implementing the CSSP and the support outcomes, including direct observation of service delivery sufficient to assess staff competency; and · evaluate 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. Statute Violated: Minnesota Statutes, section 245D.081. 3. Violation: For one person whose record was reviewed (P6), the license holder did not ensure that emergency use of manual restraint complied with the requirements of these subdivisions. P6 was involved in an incident that resulted in the emergency use of a manual restraint on February 15, 2022 and April 22, 2022 The license holder failed to: · verbally report the emergency use of manual restraint to P6’s legal representative and case manager within 24 hours of the occurrence. · complete and document an internal review within five working days that included an evaluation of: o if the person’s service and support strategies need to be revised; o if related policies and procedures were followed; o the policies and procedures were adequate; o there is a need for additional staff training; o the reported events is similar to past events with the person, staff, or services; and o there is a need for corrective action; · consult with the expanded support team within five working days after completion of the internal review to: o discuss the incident reported in subdivision 5, to define the antecedent or event that gave rise to the behavior resulting in the manual restraint and identify the perceived function the behavior served; and o determine whether the person's coordinated service and support plan addendum needs to be revised according to sections 245D.07 and 245D.071 to positively and effectively help the person maintain stability and to reduce or eliminate future occurrences requiring emergency use of manual restraint. · within five working days of the completed expanded support team review, submit the following to the Department of Human Services and the Office of the Ombudsman: o the incident report; o the internal review and corrective action plan; and o the summary of the expanded support team review. Statute Violated: Minnesota Statutes, section 245D.061, subdivisions 5 and 7. Health Related Violations 4. Violation: For two persons whose records were reviewed (P1 and P5), the license holder did not document health needs as required. a. P1’s support plan from the case manager stated that the license holder is responsible to assist the person to ensure they are taking medications as prescribed and ensure they are re-ordering medications. Staff were to be familiar with the medications and report side effects as necessary. The support plan also documented that P1 struggled frequently with anxiety. The license holder failed to maintain documentation that described how the person’s health needs would be met, including a description of how the license holder would: · provide medication administration, assistance or setup; · monitor health conditions; · assist with or coordinate appointments; and/or · use medical equipment or devices. b. The license holder was assigned the responsibility of medication administration and health needs for P5. P5’s support plan from the case manager stated that the license holder was responsible for assisting P5 with appointments. The license holder failed to maintain documentation that described how the license holder would meet these assigned health needs. The license holder was unable to provide a schedule or documentation to show what appointments P5 had attended. Statute Violated: Minnesota Statutes 245D.05, subdivision 1. 5. Violation: For two persons whose records were reviewed (P5 and P6), the license holder did not provide medication administration as required. The license holder failed to ensure that P5 and P6 received their medication as prescribed in the following ways: a. The license holder was assigned medication administration responsibility for P5. During a visit to the community residential setting where P5 resided and received services (license number 1097300), a DHS licensor observed that the current medication administration record (MAR) for P5 for the month of September 2022 reflected 14 doses of prescribed medication that had not been documented as administered between September 1 and September 14. During an interview with the Designated Manager (DM), the DM was asked by a DHS licensor how they were able to determine if the medications had actually been administered or not. The DM stated that the staff were to administer the medication from the bubble packs in a specific order and were to initial and date each bubble pack. However, based on the sporadic way the medication was popped out of the bubble pack and the absence of initials or dates on the bubble pack, the DM agreed that it would be impossible to know whether or not P5 received the 14 doses of medications as prescribed. A DHS licensor also reviewed numerous past MARs for P5 and observed the following: P5’s MARs for the month of July 2022 reflected 29 doses of medication that had not been documented and unable to determine if they were administered. Additionally, this MAR had a medication, Fexofanadine 180mg tablet to be given once daily, had no documentation of being administered from July 15 through July 31. The DM stated that they were pretty sure the medication had been discontinued; this had not been documented on the MAR and the license holder was unable to provide documentation from a medical professional that this medication had been discontinued. There was a second July 2022 MAR for P5 with completely different documentation on it. It was assumed by the license holder that this MAR was inaccurately dated; however, the license holder could not determine which month this MAR represented. This MAR documented: · Twenty-four doses of medications that had not been documented as administered. · A medication order of Fexofenadine 180mg to be given once daily. This medication was initialed as administered once on the sixth. · A medication order of Vitamin D3 to be given once daily. This medication was initialed as administered once on the sixth. · A medication order of Quetiapine 200mg to be given once daily at 2pm. In addition to this medication being documented as administered at 2pm, there were 12 days that contained an additional row of staff initials indicating that there was an extra dose of this medication given on those 12 days without a required prescription. P5’s MAR for the month of June 2022 reflected 51 doses of medications that were not documented and unable to determine if they were administered. P5’s MAR for the month of May 2022 reflected 35 doses of medications that were not documented and unable to determine if they were administered. P5’s MAR for the month of February 2022 reflected 36 doses of medications that were not documented and unable to determine if they were administered. P5’s MAR for the month of September 2021 reflected 6 doses of medications that were not documented and unable to determine if they were administered. P5’s MAR for the month of August 2021 reflected 11 doses of medications that were not documented and unable to determine if they were administered. P5’s MAR for the month of July 2021 reflected 24 doses of medications that were not documented and unable to determine if they were administered. b. The license holder was assigned medication administration responsibility for P6. During a visit to the community residential setting where P6 resided and received services (license number 1097300), a DHS licensor observed that the current medication administration record (MAR) for P6 for the month of September 2022 reflected 32 doses of prescribed medication that had not been documented as administered between September 1 and September 14. During an interview with the Designated Manager (DM), the DM was asked by a DHS licensor how they were able to determine if the medications had actually been administered. The DM stated that the staff were to administer the medication from the bubble packs in a specific order and were to initial and date each bubble pack. However, based on the sporadic way the medication was popped out of the bubble pack and the absence of initials or dates on the bubble pack, the DM agreed that it would be impossible to know whether or not P6 received the 32 doses of medications as prescribed. P6’s MAR for the month of June 2021 reflected 17 doses of medications that were not documented and unable to determine if they were administered. P6’s MAR for the month of June 2020 reflected 45 doses of medications that were not documented and unable to determine if they were administered. Of the 45 undocumented medications, 8 of them had notes written on the back giving the reason for the medication not administered. The notes documented four times when medications were not administered because the medication was not available at the home. The notes documented one time that medications were not administered at the proper time. The notes documented one time that there was no current order for the medication. There was one was illegible note. There was no explanation for the other 37 undocumented doses. P6’s MAR for the month of April 2020 reflected 12 doses of medications that were not documented and unable to determine if they were administered. There were two different sets of MARs for P6 that were labeled July 2022; however, both sets were different and it was unable to be determined which months they reflected. · The first set of P6’s MARs labeled July 2022 reflected 29 doses of medications that were not documented between July 5 and July 31 and unable to determine if they were administered. None of the medications between July 1 and July 5 were documented as administered. · The second set of P6’s MARs labeled July 2022 reflected 55 doses of medications that were not documented as administered. Additionally, there was a medication, Erythromycin that was to be administered six times a day for 5 days; however, this medication had no documentation of being administered or documentation of being discontinued. It was unable to be determined if this medication was administered as prescribed or if it had been discontinued but not removed from the MAR. P6’s MARs for the month of June 2022 reflected 12 doses of medications between June 11 and June 30 that were not documented and unable to determine if they were administered. June 1 through June 10 only had one day, June 5, that medication doses were documented as administered. P6’s MARs for the month of May 2022 reflected 12 doses of medications that were not documented and unable to determine if they were administered. P6’s MARs for the month of February 2022 reflected 34 doses of medications that were not documented and unable to determine if they were administered. Statute Violated: Minnesota Statutes, section 245D.05, subdivision 2. 6. Violation: For two persons whose records were reviewed (P5 and P6), the license holder did not meet the requirements for medication administration as required. The license holder was assigned the responsibility for medication administration for P5 and P6. The license holder failed to complete medication administration record reviews at a minimum of every three months to identify administration errors. Additionally, the license holder failed to report any dose of medication not administered as prescribed to the person’s legal representative and case manager. Statute Violated: Minnesota Statutes, section 245D.05, subdivision 4. 7. Violation: For two persons whose records were reviewed (P5 and P6), the license holder did not meet the requirements for psychotropic medication administration as required. Both P5 and P6 are prescribed psychotropic medications. The license holder failed to describe the target symptom that each psychotropic medication is to alleviate. For P5, the license holder identified “agitation” as a target symptom in the person’s record; however the license holder failed to identify which target symptom each psychotropic medication is to alleviate. Statute Violated: Minnesota Statutes, section 245D.051, subdivision 1, paragraph (b). Service Recipient Violations 8. Violation: For two of six persons whose records were reviewed (P5 and P6), the license holder did not meet the requirements for safekeeping of funds and property as required. The license holder was assigned the responsibility of safekeeping of funds and property for P5 and P6 by maintaining the person’s debit card and assisting with financial transactions. The license holder failed to immediately document the receipt and disbursements of funds at the time of receipt or disbursement. Statute Violated: Minnesota Statutes, section 245A.04, subdivision 13, paragraph (c). 9. Violation: For three persons whose records were reviewed (P1 through P3), the license holder did not provide an orientation to the internal and external reporting procedures related to suspected or alleged maltreatment as required. The license holder failed to provide P1 through P3 with an orientation to the internal and external reporting procedures related to suspected or alleged maltreatment within 24 hours of service initiation in the following ways: a. P1 was admitted to the program on January 3, 2022. The license holder failed to provide this orientation to the person and the person’s legal representative. b. P2 was admitted to the program on June 6, 2022. Although the license holder maintained a policy receipt form that stated that P2 and P2’s legal representative was provided with this orientation, the receipt form was not dated. Therefore, it was unable to be determined if this orientation was provided within 24 hours of service initiation as required. c. P3 was admitted to the program on March 9, 2022. The license holder maintained a policy receipt form that stated P3 was provided this orientation; however, the policy receipt form reflected that the orientation was provided on September 12, 2022, which was the day before the licensing compliance review. Therefore, the license holder failed to provide this orientation within 24 hours of service initiation as required. Statute Violated: Minnesota Statutes, section 245A.65, subdivision 1. 10. Violation: For four persons whose records were reviewed (P1 through P4) the license holder did not provide the service recipient rights as required. Minnesota Statues, section 245A.02, subdivision 2b defines “annual” or “annually” to mean prior to or within the same month of the subsequent calendar year. a. P1 was admitted to the program on January 3, 2022. The license holder failed to provide P1 and their legal representative with a copy of the service recipient rights and an explanation of those rights within five working days of service initiation, as required. b. P2 was admitted to the program on June 6, 2022. Although the license holder maintained a policy receipt form that stated that P2 and their legal representative were provided with a copy of the service recipient rights and an explanation of those rights, the receipt form was not dated. Therefore, it was unable to be determined if this orientation was provided within five working days of service initiation as required. c. P3 was admitted to the program on March 9, 2022. The license holder maintained a policy receipt form that stated P3 was provided with a copy of the service recipient rights and an explanation of those rights; however, the policy receipt form reflected that the rights were provided on September 12, 2022, which was the day before the licensing compliance review. Therefore, the license holder failed to provide P3 with the service recipient rights and an explanation of those rights within five days of service initiation as required. d. P4 was admitted to the program on June 27, 2019. The license holder failed to provide P4 and their legal representative with a copy of the service recipient rights and an explanation of those rights annually in 2021. Statute Violated: Minnesota Statutes, section 245D.04, subdivision 1. 11. Violation: For two persons whose records were reviewed (P5 and P6), the licensor did not ensure the protection of the individual’s protection related rights as required. The license holder installed multiple cameras throughout P5 and P6’s shared home that were used 24 hours per day. The license holder did not obtain participant consent for the use of monitoring technology from P5’s and P6’s legal representative. The license holder did maintain a participant consent document for P5 in P5’s record; however, the consent form was not valid as it was not signed by P5’s legal representative and was not dated or renewed annually. There was no such document in P6’s record. Therefore, the license holder failed to ensure that P5 and P6 maintained the right to personal privacy. Statute Violated: Minnesota Statutes, section 245D.04, subdivision 3, paragraph (14). 12. Violation: For six persons whose records were reviewed (P1 through P6), the license holder did not develop an individual abuse prevention plan (IAPP) as required in section 245A.65, subdivision 2. The license holder failed to meet the requirements for an IAPP in the following ways: a. P1’s service initiation date was January 3, 2022. The license holder developed an IAPP for P1 on February 14, 2022. Therefore, the license holder failed to develop an IAPP for P1 prior to or upon service initiation as required. Additionally, the license holder failed to identify specific measures to minimize the risk of abuse to P1. b. For P2 and P3, the license holder failed to develop an IAPP prior to or upon service initiation. At the time of the review, there were no IAPPs developed for P2 or P3. c. For P4, the license holder failed to review the person’s IAPP with the person’s support team annually in 2021 and 2022. d. For P5 an P6, the license holder failed to identify the person’s history of aggression and the person’s risk of retaliation, despite the person’s support plans and support plan addendums referencing long-standing histories of aggression and violence towards others. Statute Violated: Minnesota Statutes, section 245D.071, subdivision 2. 13. Violation: For two persons whose records were reviewed (P2 and P3), the license holder did not ensure person centered planning and service delivery as required. For P2 and P3, there was no documentation in their records that identified who they are as individuals, how they wanted services to be delivered, or what was important to them. Statute Violated: Minnesota Statutes, section 245D.07, subdivision 1. 14. Violation: For three persons whose records were reviewed (P2 through P4), the license holder did not complete assessments as required. a. For P2 and P3, the license holder failed to conduct the required assessments within 45 days of service initiation. b. For P4, the license holder failed to conduct the required assessments for the person annually in 2020, 2021, and 2022. The only assessments that were completed by the license holder for P4 were dated August 7, 2019 and August 15, 2019. Statute Violated: Minnesota Statutes, section 245D.071, subdivision 3, paragraph (b). 15. Violation: For three persons whose records were reviewed (P1 through P3), the license holder did not meet service initiation requirements for an intensive service as required. For P1 through P3, the license holder failed to meet with the person’s support team within 45 days of providing services or 60 calendar days to determine the following: · the scope of services to be provided to support the person’s daily needs and activities; · the person’s desired outcomes and the supports necessary to accomplish the person’s desired outcomes; · the person’s preferences for how services and supports are provided, including how the provider will support the person to have control of the person’s schedule; · whether the current service setting is the most integrated setting available and appropriate for the person; · opportunities to develop and strengthen personal relationships with other persons of the person’s choice in the community; · opportunity for community access, participation, and inclusion in preferred community activities; · opportunities to seek competitive employment and work at competitively paying jobs in the community, and · how services must be coordinated across other providers licensed under this chapter serving the person and members of the persons support team. Although the license holder did address the above mentioned areas in P1’s support plan addendum, there was no evidence that these areas were addressed with P1’s support team and no evidence of any meeting that took place. Statute Violated: Minnesota Statutes, section 245D.071, subdivision 3, paragraph (c). 16. Violation: For six persons whose records were reviewed (P1 through P6), the license holder did not meet the requirements for outcomes and supports as required. a. For P2 through P4, the license holder failed to use the assessments and person centered planning to develop outcomes and supports for the person.
b. For P1, P5, and P6 although the license holder developed outcomes and supports for the person, the license holder failed to ensure that the outcomes and supports were being implemented. · P1 had no data tracking sheets or documentation of the implementation of outcomes in their support plan addendum; · P5 and P6 had outcomes and supports in their support plan addendums that were kept in the main office; however, during a visit to the community residential settings where P5 and P6 resided and received services, there were no outcomes and supports present in the facility for the staff to implement and no documentation or data tracking sheets indicating that the outcomes were implemented. Statute Violated: Minnesota Statutes, section 245D.071, subdivision 4, paragraph (b). 17. Violation: For two persons whose records were reviewed (P1 and P4), the license holder did not meet the requirements for service planning and delivery as required. a. P1’s support plan from the person’s case manager required quarterly meetings with P1’s support team. The license holder failed to coordinate any meetings with P1’s support team in 2022. b. For P4, the license holder failed to meet with the person’s support team at a minimum of annually in 2021 and 2022. Statute Violated: Minnesota Statutes, section 245D.071, subdivision 5, paragraph (a). 18. Violation: For four persons whose records were reviewed (P1 and P4 through P6), the license holder did not meet the requirement for service planning and delivery as required. a. P1’s support plan from the person’s case manager required quarterly progress review reports. The progress review reports were to include the person’s status and progress on achieving the person’s outcomes. The license holder failed to provide quarterly progress review reports for 2022. b. The license holder failed to provide progress review reports at a minimum of annually in 2019 through 2022. c. P5’s support plan from the person’s case manager required quarterly progress review reports. The license holder failed to provide quarterly progress review reports in 2021 and 2022. The were two progress review reports in P5’s record dated January 20, 2021 and July 20, 2022 which provided information on the person’s progress on their outcomes; however, there was no documentation or tracking sheets to support the progress that was documented in the report. When the license holder was asked how the progress that was documented in these reports was determined with no tracking sheets, the license holder stated that they just asked the staff how the person was doing on the outcome. When a DHS licensor asked the license holder if they considered that to be accurate reporting to the support team, the license holder agreed that it was not. d. P6’s support plan from the person’s case manager required quarterly progress review reports. The license holder failed to provide quarterly progress review reports in 2019 through 2022. The last progress review report in P6’s record was dated October 2019. Statute Violated: Minnesota Statutes, section 245D.071, subdivision 5, paragraph (b). 19. Violation: For six persons whose records were reviewed (P1 through P6), the license holder did not maintain records as required. For P1 through P6, the license holder failed to ensure that daily progress notes or daily log notes were completed. Statute Violated: Minnesota Statutes, section 245D.095, subdivision 3, paragraph (b). 20. Violation: For five persons whose records were reviewed (P1 through P3, P5, and P6), the license holder did not ensure access to the person’s record as required. a. For P1 through P3, the license holder failed to provide staff access to the required information necessary to provide a person centered service and ensure health and safety by failing to include an individual abuse prevention plan (IAPP), self-management assessment (SMA), outcomes and supports, positive support strategies, or health needs information in the person’s record. b. For P5 and P6, the license holder failed to provide staff access to the required information necessary to implement the person’s outcomes and supports by not ensuring that the identified outcomes and supports were available at the community residential settings where P5 and P6 resided and received services. Statute Violated: Minnesota Statutes, section 245D.095, subdivision 4. 21. Violation: For four persons whose records were reviewed (P1 through P4), the license holder did not identify positive support strategies as required. a. For P1 through P3, the license holder failed to identify positive support strategies in the person’s plan and failed to evaluate them at a minimum of every six months. b. For P4, although the license holder identified positive support strategies in the person’s plan, the license holder failed to evaluate them with the person at a minimum of every six months. Rule Violated: Minnesota Rules, part 9544.0030. Staffing Standards Violations 22. Violation: For one staff person whose record was reviewed (SP1), the license holder did not provide orientation training as required. SP1, with a hire date of September 8, 2021, provided direct care to P5 and P6 who both require medication administration. The license holder failed to provide medication administration training to SP1 prior to SP1 administering medications. At the time of the review, there was no documentation to show that SP1 had received medication administration training. Statute Violated: Minnesota Statutes, section 245D.09, subdivision 4a, paragraph (d). 23. Violation: For one staff person whose record was reviewed (SP3), the license holder did not provide orientation training as required. SP3, with a hire date of July 18, 2022, provided direct care to P2. Although the license holder documented that SP3 received orientation to P2’s individual needs, which would include the person’s individual abuse prevention plan, self-management assessments, and outcomes and supports, SP3 would not have been able to receive this orientation because P2’s record did not include this information. Therefore, the license holder failed to provide SP3 with orientation to P2’s individual needs prior to having unsupervised direct contact with P2. Statute Violated: Minnesota Statutes, section 245D.09, subdivision 4a, paragraph (c). Immediate corrective action required You must immediately correct the violations cited above. Compliance with this order will be reviewed onsite on an ongoing basis. If you fail to demonstrate substantial compliance with HCBS and AFC requirements or with the terms of your conditional license as detailed below, DHS may take an additional licensing action, including revocation, against your license. CONDITIONAL LICENSE TERMS In addition to the Home and Community-Based Services and Adult Foster Care licensing rules and statutes, you are required to comply with the following terms: 1. Within 15 days of receiving this order, you must notify current persons receiving services, their legal representatives (if applicable), their case managers, all parties who refer persons to the program, and all payer sources of the conditional status of your license. The notification must be approved by DHS Licensing prior to being sent to persons receiving services and all other parties. Therefore, the draft notice must be submitted to DHS for approval within 10 days of receiving this order. The notification must specify the length of time of the conditional status of your license, the reasons your license was made conditional, and it must include a copy of the Order of Conditional License. While the license is on conditional status, you must notify new persons receiving services, referral sources, and payer sources that the license is on conditional status before they begin receiving services. The notification to new persons receiving services must specify the length of time of the conditional status of the license, the reasons the license was made conditional, and it must include either a copy of the Order of Conditional License or an offer to provide a copy of the order upon request. Within 30 days of receiving this order, you must submit to the DHS Licensing Division a list of the individuals and parties that received the notice. 2. Within 20 days of receiving this order, you must: · submit a written plan detailing how you will ensure the corrective action ordered in this order is completed; and · submit a written plan to your licensor detailing how you will audit all participant and staff records for compliance with all applicable rules and statutes. 3. Within 30 days of receiving this order, you must: · designate a staff person, other than SP5, who is responsible for delivery and evaluation of services provided by the license holder; · designate a managerial staff person, other than SP4, to provide program management and oversight of the services provided by the license holder; and · submit the staff person’s name and qualifications for designated coordinator and designated manager to your licensor for review and approval. · complete medication administration record reviews for all persons who you are assigned the responsibility for medication administration, from January 2022 through December 2022. Based on the results of these reviews: o identify any patterns of medications not being administered or documented as prescribed and develop a plan to correct these patterns; o retrain all staff who are responsible for administering medications with a training curriculum developed by a registered nurse that includes an observed skill assessment; o notify the legal representative and case manager of the persons receiving services of all incidents of a medication not being documented as administered or as administered as prescribed. 4. Within 45 days of receiving this order, you must: · ensure that you have developed outcomes and supports, using person centered planning tools and assessments, for all individuals receiving an intensive services in your program; · ensure that all staff have access to these outcomes and supports, have been trained on how to implement them, and have access to data sheets where the person’s progress should be documented; · develop and submit to your licensor, a plan for providing ongoing oversight to ensure that these outcomes are being implemented and evaluated. 5. Within 60 days of receiving this order, you must: · complete an audit of all participant and personnel records according to your written plan; · submit the results of the audit to your DHS licensor; and · submit the date to your DHS licensor that all participant and personnel records will be brought into compliance based on the results of your audit. 6. You may not admit new participants to your program from the date of this order until you have successfully demonstrated to DHS compliance with the terms of the conditional license and have maintained substantial compliance with all licensing standards. Program is defined by section 245D.02, subdivision 26 meaning either the nonresidential or residential programs as defined in 245A.02, subdivisions 10 and 14. At a minimum, you may not admit new participants to your program for a period of six months from the date of this conditional license. Admission of any new participant during the duration of the conditional license is only allowed with prior approval from DHS. 7. You may not apply for other DHS-issued licenses without prior approval from DHS for the duration of this conditional license. Submissions required as part of a corrective action ordered must be sent to your DHS licensor at: Commissioner, Department of Human Services ATTN: Tiffany Solano c/o Licensing Division PO Box 64242 St. Paul, MN 55164-0242 YOUR RECONSIDERATION RIGHTS You have the right to request reconsideration of the conditional license order and the cited violations. Your request must: · Be in writing · Clearly state that you are requesting reconsideration of the conditional license · List each citation you are challenging and identify what is inaccurate or incomplete about the information in the order · Supply information that is accurate or more complete · State why you believe your license should not be on a conditional status · Be made before the deadlines provided below If you are mailing your request, it must be sent by certified mail and postmarked within 10 calendar days from when you received this order. If you do not meet this deadline, you lose your right to request reconsideration. The timeline to appeal began when you received this order. Please send it to: Commissioner, Department of Human Services Office of Inspector General Licensing Division Attention: Legal Unit PO Box 64953 St. Paul, MN 55164-0953 If your request is being personally delivered, it must be received by DHS within 10 calendar days from when you received this order. Please bring it to: Commissioner, Department of Human Services Office of Inspector General Licensing Division Attention: Legal Unit 444 Lafayette Road North St. Paul, MN 55155 Conditional license stayed pending reconsideration If you request reconsideration within the timeframes described above, the terms of the conditional license will not take effect until a decision is issued by DHS. If the conditional license is affirmed on reconsideration, the terms would take effect on the date of the reconsideration decision, and run for two years from that date. You continue to be required to comply with all HCBS and AFC laws and rules. Legal authority for this licensing action · This action is taken under Minnesota Statutes, section 245A.07, subdivision 1, paragraph (a), which describes under which conditions DHS may impose a fine against a license. · The timeline to request reconsideration of the order of conditional license is provided in Minnesota Statutes, section 245A.06, subdivision 4. · If a license holder files a timely reconsideration request, the terms of the conditional license are stayed pending a decision by DHS under Minnesota Statutes, section 245A.06, subdivision 4. Questions If you have any further questions regarding this matter, you may contact Christala Culhane, HCBS Unit Supervisor, at 651-431-6541. Sincerely,
Jill Slaikeu, HCBS Unit Manager Licensing Division Office of Inspector General
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