|
December 22, 2022 Sheltonn Johnson, Authorized Agent Thrive Youth Services 1710 Douglas Drive N Golden Valley, Minnesota 55422 License Number: 1093608 (245D – HCBS) CORRECTION ORDER Dear Sheltonn Johnson: On September 14, 2022 and September 27, 2022 - September 29, 2022, a licensing review of Thrive Youth Services, located at 1710 Douglas Drive North, Golden Valley, 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 245A.65, subdivision 2, paragraph (b). Violation: For one of nine persons whose record was reviewed (P2), the license holder did not develop an individual abuse prevention plan (IAPP) as required. The license holder failed to include an individualized assessment of P2’s susceptibility of abuse. P2’s IAPP stated that P2 was susceptible to self-abuse. The IAPP specified that P2 dressed inappropriately and had an inability to care for self- help needs. During the licensing review on September 14, 2022, the license holder informed DHS licensors that P2 will binge and purge and will eat food out of the garbage. This information regarding P2’s risk of self-abuse was not included in the IAPP. Corrective Action Ordered: Within 30 days of receiving this order, you must review and revise the IAPP for P2 to meet the requirements of this subdivision. Compliance with this corrective action will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 2. Citation: Minnesota Statutes, section 245D.05, subdivision 1. Violation: For one person whose record was reviewed (P9), the license holder did not maintain documentation of how the person’s health needs would be met as required. The license holder was assigned the responsibility of meeting P9’s health needs, including medication administration. P9 was prescribed two psychotropic medications to be administered as needed (PRN). The license holder failed to maintain documentation of how P9’s health needs would be met, that included a description of the procedures the license holder would follow when administering the psychotropic PRN medication to P9.
Corrective Action Ordered: Within 30 days of receiving this order, you must document the above mentioned information for P9. Compliance with this corrective action will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 3. Citation: Minnesota Statutes, section 245D.05, subdivision 2, paragraphs (b) and (c). Violation: For two persons whose records were reviewed (P3 and P6), the license holder did not implement medication administration procedures as required. a. P3’s “Coordinated service and support plan (CSSP) addendum” documented that P3 administers their own insulin and staff assist in dialing the insulin pen to the correct dosage. The dosage is determined using a chart for current blood glucose level and a sliding scale based on carbohydrates. It is documented in P3’s blood glucose level log that P3 received incorrect doses of insulin on the following dates and times: · September 4, 2022 PM · September 7, 2022 PM · September 8, 2022 AM · September 16, 2022 AM and PM The license holder failed to ensure that the dosage was correct prior to P3 self-administering the insulin. b. The license holder was assigned responsibility for medication administration in P6’s CSSP addendum. On July 13, 2022, P6 was prescribed a new medication, Gabapentin 100mg to be taken daily at bedtime; however, the license holder did not start administering this medication to P6 until July 25, 2022. Additionally, P6 was prescribed Famotidine 10mg to be taken twice daily at 8:00 a.m. and 8:00 p.m. P6’s “Medication Administration Report” shows that this medication was not administered to P6 between February 15, 2022 and March 7, 2022, and notes that the medication was not available at the site and needed to be refilled. According to the license holder’s “Safe Medication Assistance and Administration Policy”, medication administration includes the coordination of medication refills and handling changes to prescriptions and implementation of those changes. The license holder failed to implement medication administration procedures to ensure P6 took medications as prescribed. The license holder failed to maintain documentation in P6’s medication administration record that included a notation of any occurrence of a dose of medication not being administered as prescribed, whether by error by the staff or the person or by refusal by the person, including the reason for not administering the medication; or, notation of when a medication was administered. On March 16, 2022, P6’s “Medication Administration Report” failed to document either the administration or refusal of Hydroxyzine to be taken at 12:00 p.m. On July 7, 2022, P6’s “Medication Administration Report” failed to document either the administration or refusal of Certavite, Clozapine, Desmophressin, Famotidine, Lamictal, Prazosi, and Ramelteon to be taken at 8:00pm. Corrective Action Ordered: Compliance with this corrective action will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 4. Citation: Minnesota Statutes, section 245D.05, subdivision 4, paragraphs (a) and (b). Violation: For one person whose record was reviewed (P6), the license holder did not review and report medication issues as required. The license holder completed a review of P6’s medication administration record on April 22, 2022 that identified a pattern of errors; however, the license holder failed to develop and implement a plan to correct this pattern of errors when identified. Additionally, the license holder failed to report that P6’s Famotidine was not administered between February 15, 2022 and March 7, 2022 to P6’s legal representative and case manager, as the errors occurred. Corrective Action Ordered: Compliance with this corrective action will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 5. Citation: Minnesota Statutes, section 245D.051, subdivision 1, paragraph (b). Violation: For one person whose record was reviewed (P2), the license holder did not develop, implement, and maintain documentation regarding psychotropic medications as required. The license holder was assigned responsibility for medication administration in P2’s CSSP addendum. P2 was prescribed several psychotropic medications; however, the license holder failed to maintain documentation that included a description of the target symptoms that each psychotropic medication was to alleviate. Corrective Action Ordered: Within 30 days of receiving this order, you must maintain documentation in P2’s CSSP addendum that includes a description of the target symptoms that each psychotropic medication is used to alleviate. Compliance with this corrective action will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 6. Citation: Minnesota Statutes, section 245D.071, subdivision 3, paragraph (b). Violation: For one person whose record was reviewed (P2), the license holder did not complete assessments as required.
The license holder completed assessments for P2; however, these assessments were inconsistent with other information provided by the license holder. During the licensing review on September 14, 2022, the license holder told DHS licensors that P2 will binge and purge and will eat food out of the garbage. The license holder stated that this seems to be correlated with times of stress for P2. The license holder also stated that P2 will vomit on the walls of the staff bathroom and that the license holder believed this to be somewhat of a behavioral issue, as P2 does not vomit on the walls of their own bathroom.
The license holder failed to document the above mentioned information in P2’s assessments regarding P2’s ability to self-manage health and medical needs or in the assessments of P2’s ability to self-manage symptoms or behaviors that may jeopardize the health and welfare of P2 or others. Corrective Action Ordered: Within 30 days of receiving this order, you must review and revise P2’s assessments to include the above mentioned information. Compliance with this corrective action will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 7. Citation: Minnesota Rules, part 9544.0110. Violation: For one person whose record was reviewed (P9), the license holder did not report incidents to the commissioner as required. There was a behavioral incident involving P9 that occurred on July 11, 2022. The license holder called 911 as a result of the behavioral incident. The license holder failed to use the behavior intervention report form to report the incident to the commissioner. The license holder later reported the incident to the commissioner on September 27, 2022. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required. 8. Citation: Minnesota Statute, section 245D.095, subdivision 5, paragraph (a). Violation: For seven staff persons whose records were reviewed (SP1, SP3, SP4, SP5, SP6, SP7, and SP12), the license holder did not maintain a personnel record as required. a. The license holder failed to maintain a personnel record for SP1, SP3, SP4, SP5, SP6 and SP7 that included: · documentation of orientation and training that included: o the date the training was completed; and o the name of the trainer or instructor. b. The license holder failed to maintain a personnel record for SP12 that included: · documentation of orientation and training that included: o the date the training was completed; and o the number of hours per subject area. Corrective Action Ordered: 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. 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 Legal Counsel’s Office Attention: 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
|
