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December 21, 2022 Marlene Smith, Authorized Agent Becker County DAC 900 Central Street East Detroit Lakes, Minnesota 56501 License Number: 1073127 (245D – HCBS) 1073128 (245D – DSF) CORRECTION ORDER Dear Marlene Smith: On September 21, 2022, a licensing review of Becker County DAC located at 900 Central Street East, Detroit Lakes, 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.04, subdivision 5, paragraph (a) Violation: For one of five persons whose record was reviewed (P1), the license holder did not provide the person a written notice that identified the service recipient rights as required. The license holder failed to provide P1 with a written notice that identified the service recipient rights and an explanation of those rights within five working days of service initiation. P1’s services were initiated on July 1, 2022. The license holder failed to provide P1 with a notice until August 17, 2022. Corrective Action Ordered: On an ongoing basis, you must maintain compliance throughout your program as required in this subdivision. 2. Citation: Minnesota Statutes, section 245D.07, subdivision 1a, paragraph (a). Violation: For one person whose record was reviewed (P4), the license holder did not provide a person centered service delivery. For P4, the license holder failed to provide services in response to the person’s needs and preferences. Throughout P4’s CSSP addendum, the license holder failed to address P4 with their preferred name and gender. Corrective Action Ordered: Immediately upon receiving this order, you must provide services to P4 that reflect P4’s preferred name and gender. On an ongoing basis, you must ensure that you are providing person centered services to all individuals receiving services in your program, as required in this subdivision. 3. Citation: Minnesota Statutes, section 245D.07, subdivision 1a, paragraph (b). Violation: For one persons whose records were reviewed (P5), the license holder did not provide services in response the person’s identified needs, interests, preferences and desired outcomes as specified in the coordinated service and support plan and support plan addendum as required. The license holder failed to use the information identified in P5’s coordinated service and support plan addendum (CSSPA), to identify outcomes in response to the persons identified interests and desired outcomes. P5’s identified needs and interests were, “Car rides”, “Helping me with my therapy and help me make toast”, doing stuff with me, “Coloring”, “being in room 4”, and “going for short walks with staff”; However, the license holder identified P5’s outcomes as: · P5 will increase their use of appropriate social interaction skills while at the DAC and in the community, 85% of opportunities charted by August 2022” Corrective Action Ordered: Within 30 days of receiving this order, you must: · retrain all program staff on the principals of person centered planning and how they apply to direct support services provided by the program; · audit all service recipient records to ensure the requirements found in 245D.07, subdivision 1a are being met; and · update as needed, the service recipient records to include person-centered service planning and delivery that: o identifies and supports what is important to the person as well as what is important for the person, including preferences for when, how, and by whom direct support service is provided; o uses that information to identify outcomes the person desires; and o respects each person's history, dignity, and cultural background. 4. Citation: Minnesota Statutes, section 245D.071, subdivision 5, paragraph (a). Violation: For one person whose record was reviewed (P2), the license holder did not meet the requirements for service planning and evaluation as required. P2’s 45-day meeting was held on February 12, 2020. P2’s coordinated service and support plan addendum required semi-annual service planning and support team meetings. Although P2 had a semi-annual meeting on October 22, 2020, the license holder failed to participate in service plan review meetings following the stated timelines established in P2’s support plan addendum. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 5. Citation: Minnesota Statutes, section 245D.071, subdivision 5, paragraph (g). Violation: For two persons whose records were reviewed (P4 and P5), the license holder did not identify the rationale for changing, continuing, or discontinuing implementation of supports and methods as required. In the most recent progress review reports dated June 13, 2022 for P4 and July 19, 2022 for P5, the license holder failed to document a rationale for continuing, discontinuing, or changing the person centered outcome and support methods. Corrective Action Ordered: Within 30 days of receiving this order, you must: · audit all service recipient records to ensure the requirements found in 245D.071, subdivision 5, paragraph (g) are being met; and · maintain compliance on an ongoing basis as required. 6. 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. Regarding SP1, who began a position as a direct support staff on March 29, 2021, the license holder failed to provide the following trainings within 60 days of hire: · strategies to minimize the risk of sexual violence, including concepts of healthy relationships, consent, and bodily autonomy of people with disabilities; · 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. Regarding SP2, who began a position as a direct support staff on May 18, 2022, the license holder failed to provide the following trainings within 60 days of hire: · the license holder's current policies and procedures required under this chapter, including their location and access, and staff responsibilities related to implementation of those policies and procedures including: o grievance policy o service suspension policy; and o service admission · Strategies to minimize the risk of sexual violence, including concepts of healthy relationships, consent, and bodily autonomy of people with disabilities Corrective Action Ordered: At the time of this review, SP1 was no longer employed. Within 30 days of receipt of this order, you must provide SP2 with the above mentioned trainings. On an ongoing basis, you must provide orientation training as required in this subdivision. 7. Citation: Minnesota statutes, section 245D.09, subdivision 5. Violation: For one staff person whose record was reviewed (SP1) the license holder did not provide annual training as required. Minnesota Statutes, section 245A.02, subdivision 2b defines “annual” or “annually” to mean prior to or within the same month of the subsequent calendar year. The license holder failed to provide SP1 annual training on the following topics: • data privacy requirements according of Minnesota Statutes, section 13.01 to 13.10 and 13.46, the federal Health Insurance Portability Accountability Act of 1996 (HIPPA) and staff responsibilities related to complying with data practices; • 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; • staff responsibilities related to the 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; • strategies to minimize the risk of sexual violence, including concepts of healthy relationships, consent, and bodily autonomy of people with disabilities; and • basic first aid. Corrective Action Ordered: Within 30 days of receiving this order, audit the most recent annual training records for all staff to ensure all staff have received annual training on all of the required topics. You must provide any annual training that is required. On an ongoing basis, you must provide all staff persons annual training as required in this subdivision. 8. Citation: Minnesota Statutes, section 245D.095, subdivision 5, paragraphs (a) and (b). Violation: For two staff persons whose record was reviewed (SP1 and SP2), the license holder did not maintain a personnel records as required. The license holder failed to maintain documentation in the personnel records, or elsewhere, sufficient to determine the dates of SP1 and SP2’s first supervised direct contact and unsupervised direct contact with a person served by the program. Corrective Action Ordered: On an ongoing basis, you must maintain personnel records for all staff as required in this subdivision. 9. Citation: Minnesota Statutes, section 245D.10, subdivision 2. Violation: The license holder did not establish and maintain policies and procedures related to grievances as required. While the license holder maintained a policy and procedure titled “Grievance Policy,” the license holder failed to include the current name of the highest level of authority in the policy. The grievance policy that was submitted to DHS on June 30, 2022 listed someone other than the authorized agent as the highest level of authority. Corrective Action Ordered: The license holder corrected the policy onsite. On an ongoing basis, you must maintain compliance throughout your program 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 Lacey Walsvik at 651-431-3667 as soon as possible. Christala Culhane, Supervisor Licensing Division Office of Inspector General
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