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December 22, 2022 Blake Elliott, Authorized Agent Bridges MN 1932 University Ave West Saint Paul, Minnesota 55104 RE: Request for Reconsideration of Correction Order License Number: 1102804/1079030 Report No.: 202204384 Dear Mr. Elliott: The Minnesota Department of Human Services (DHS), Division of Licensing, received your request for reconsideration of one of one citations in a Correction Order (Attachment A) issued to you by the Department of Human Services on August 19, 2022. After an independent review of the record, the Commissioner has determined that there is sufficient evidence to support the citation. Reconsideration Determination Citation. The citation was issued because the license holder failed to ensure services were provided in response to the person’s identified needs, interests, preferences, and desired outcomes as specified in the coordinated service and support plan (CSSP) and the coordinated service and support plan addendum, (CSSPA) and in compliance with the requirements of Chapter 245D. Specifically the consumers (C’s) CSSP and CSSPA included requirements that: 1) C have 2:1 staffing; 2) that if 2:1 staffing was unavailable, C’s guardians would be notified; and 3) that staff would accompany the C in the community at all times. On June 4, 2022, information was provided that the facility was unable to provide C’s 2:1 staffing; that no one from the facility contacted C’s guardians; and that the C was left unsupervised in the community for “over 20 minutes.” Applicable Law. The license holder must provide services in response to the persons’ identified needs, intersts, perferecnces, and desired outcomes as specified in the CSSP and CSSPA. Minnesota Statutes, section 245D.07, subdivision 1a, paragraph (a). Your Response. You state you did not violate Minnesota Statutes, section 245D.11, subdivision 2, because the staff person was trained to document the administration of a PRN, but failed to follow his/her training. Reconsideration Determination. You do not dispute that the staff person failed to document the administration of the medication at the time s/he administered it. As the license holder, you argue that you did not violate the law because you had a policy on administering medications at the time they are given and you trained the staff person on the policy. Section 245D.11, subdivision 2, states that you not only need to have policies and procedures regarding medication documentation and charting but that they must be established according to the requirements of section 245D.05, subdivisions 1a, 2, and 5. Section 245D.05, subdivision 2, clause 3, requires license holders to ensure the medication is administered according to the license holder’s medication administration policy and procedures and that the license holder document when a medication is administered. Here, the medication was not administered according to your policies because you did not ensure the medication administration was documented at the time it was administered. Because there was a violation of the law in your program, Minnesota Statutes, section 245A.06, provides that the Commissioner may issue a correction order to the license holder. As such, there is sufficient evidence to support the citation and it is affirmed. Disposition: The Commissioner has reviewed the relevant laws and all of the information you submitted in response to the Correction Order. The record supports the citation and it is affirmed. This is a final agency decision. Sincerely,
Kofi Montzka, Attorney Legal Counsel’s Office Office of Inspector General cc. Sam Orbovich
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