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April 25, 2023 License Number: 1100408 Licensing Report Number: 202207016 Dana Nelson, Authorized Agent American Indian Community Development Corporation (AICDC) 1800 Chicago Avenue Minneapolis, MN 55404
Dear Dana Nelson: This matter arises from an Order of Conditional License, dated February 24, 2023, issued after a licensing review conducted November 15 – 17, 2022 (See attached Exhibit A). On March 6, 2023, the Minnesota Department of Human Services (DHS), Licensing Division, received your request for reconsideration of the Order of Conditional License. You included information in the reconsideration request for each of the twenty-three violations in the Order of Conditional License, and you described corrective measures that have been taken. However, you did not dispute the accuracy of the citations. The citations are therefore final and not included in the scope of this review. You also did not dispute the Order in general but requested a reduction in the length of time your license is placed on conditional status. A. CONDITIONAL LICENSE DISPUTED, DHS’ RESPONSE and DISPOSITION Under Minnesota Statutes, section 245A.06, subdivision 1, when issuing a conditional license, the Commissioner must consider the nature, chronicity, or severity of the violation of the law or rule and the effect of the violation on the health, safety, or rights of persons served by the program. In the request for reconsideration, you indicate the belief that the program should receive a shorter 6-month conditional license because the program has taken steps to mitigate risk, address concerns and ensure they are providing services in compliance with rules and statutes. You outlined in detail the responses the program has taken to address each of the twenty-three citations, and you indicate the program has a plan to ensure ongoing compliance. You also indicate the program recognizes the health and safety of persons served as the highest priority, and you indicate confidence that requirements will be met due to new leadership that began in 2022, changes in staffing, ongoing support from community partners, and support for program improvement from other withdrawal management providers. The Commissioner appreciates that the program has taken steps to ensure compliance. However, the Commissioner has considered the nature, chronicity, and severity of the licensing violations and determined that a conditional license is warranted. The Conditional Order cites twenty-three citations reflecting that the program has failed to comply with multiple requirements. You did not challenge the accuracy of any of the citations, and the citations support the need for a conditional license because they demonstrate serious licensing violations that indicate a failure to follow procedure and practice requirements which affect the health, safety, and rights of clients. The nature and severity of the cited violations is a basis for the conditional license. The citations involved a failure to follow requirements which affected the health and safety of the persons served, including the failure to ensure a licensed nurse was on duty on each shift while providing medically monitored services to patients, a failure to identify patients in need of stabilization service and implement stabilization plans, and a failure to monitor for patients’ safety. The program also failed to comply with background study requirements, which are in place to ensure the safety of the residents served by the program. Other violations related to a failure to complete individual abuse plans as required, a failure to comply with requirements for comprehensive assessments and multiple violations for failure to follow the discharge policy. The license holder also failed to meet requirements related to staff which resulted in violations that were severe in number and nature, including multiple violations for failure to meet standards related to documentation. Documentation in client files is necessary to demonstrate that services are being provided, that the services being provided are relevant, how the client is responding to services, and whether the services are effective. The program also had multiple violations for failure to provide staff orientation and training and one violation for the failure to ensure a Program Director knew and understood licensing requirements. Requirements regarding staff qualifications, training, and orientation are in place to ensure staff are familiar with policies and procedures related to resident safety and well-being and that staff are qualified and able to provide care to those residents. Due to the need to monitor the program for compliance with applicable licensing laws and rules, and to ensure the health and safety of persons served by the program, the Commissioner affirms the Order of Conditional License issued on February 24, 2023. However, when considering the significant changes made by the program since the conditional license was issued, the Commissioner has determined it is appropriate to reduce the length of the conditional license. The period of the conditional license is one year, beginning on the date of this reconsideration decision. Because the terms of the conditional license were stayed pending a decision on your request for reconsideration, the terms of the conditional license begin from the date of receipt of this letter. You must immediately correct the violations cited in the Order of Conditional license and submit documentation to your DHS licensor within 30 days from when you received this reconsideration decision explaining how you have corrected the violations. B. TERMS OF THE CONDITIONAL LICENSE In addition to the Withdrawal Management treatment licensing rules and statutes, you are required to comply with the following terms: 1. Within 14 days of receipt of this reconsideration decision, you must notify current patients and all parties who refer individuals to your program of the conditional status of your license. The notification must be approved by DHS Licensing prior to being sent to residents and all other parties. Therefore, the draft notice must be submitted to DHS for approval within 10 days of receipt of this reconsideration decision. The notification must specify the length of time of the conditional status of your license, the reasons your license was placed on conditional status, and include either a copy of the Order of Conditional License or an offer to provide a copy upon request. While the license is on conditional status, you must notify new patients and referral sources the license is on conditional status before they begin receiving services. The notification to new patients must specify the length of time of the conditional status of your 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. A copy of the notice with patient and/or legal representative(s) signature must be maintained in the patient file. Within 30 days of receipt of this reconsideration decision, you must submit to the DHS Licensing Division, a copy of the notice and a list of all referral sources that received the notice. 2. Within 30 days of receipt of this reconsideration decision, you must develop a self-monitoring tool and plan that ensures an ongoing approach for monitoring compliance with applicable rules and statute requirements. The self-monitoring tool and plan must include the following: a. Names and titles of those responsible to carry out duties within the plan; and b. Procedure that includes a sample review of patient records requirements, personnel files, medication administration records, grievances, and monitoring of the implementation of policies and procedures on a monthly basis. The plan must be submitted to and approved by DHS Licensing. Documentation of the results of the monthly reviews, discrepancies found within the reviews and corrective actions taken, must be submitted to your licensor on July 15, 2023, October 15, 2023, and January 15, 2024, April 15, 2024, July 15, 2024, October, 15, 2024, January 15, 2025 or until otherwise determined by DHS Licensing. 3. Within 30 days from when you received this reconsideration decision, you must develop and submit a plan for managing personnel files. The personnel plan must be approved by the DHS Licensor and must include: a. A description of how you will ensure that background study requirements are met on an ongoing basis, including identifying who will be responsible for managing staff background studies, and documentation that the responsible person has received training on these duties; b. A description of how you will ensure that all applicable qualifications are met for current staff and on an ongoing basis, including identifying who will be responsible for knowing and verifying staff qualifications, and documentation that the responsible person has received training on these duties; and c. A description of how you will ensure that staff orientation and training requirements are met on an ongoing basis, including identifying who will be responsible for monitoring staff orientation and training on an ongoing basis, and documentation the person has received training on these duties. 4. Within 60 days from when you received this reconsideration decision, you must submit revised policies and procedures to your DHS Licensor for violations numbered 3 and 4 in the Order of Conditional License, specifically outlining the program’s procedure for determining a patient’s level of care. The revised policies and procedures must correct the violations identified and meet all applicable requirements and must be approved by DHS Licensing. Within 30 days following approval of the revised policies and procedures, you must provide training to all staff, and submit documentation of the training to the DHS Licensor. Your licensor will monitor your compliance with all applicable laws and rules. Verification of compliance may include unannounced visits. Failure to comply with the requirements in Minnesota Statutes, chapter 245A (Human Services Licensing Act), Minnesota Statutes, chapter 245C (Human Services Background Study Act), Minnesota Statutes, chapter 245F (Withdrawal Management), Minnesota Statutes, section 626.557, and with the terms of your conditional license may result in further negative action, including revocation of your license. This is a final agency decision and is subject to further review only by the Minnesota Court of Appeals. Please note that there are time limits for seeking review by the Minnesota Court of Appeals. See Minnesota Statutes, Chapter 606 and Minnesota Rules of Civil Appellate Procedure, Rule 115. If you have any questions regarding the Order of Conditional License, please contact Kristi Strang, Unit Supervisor, at (651) 431-6611. Sincerely,
Frances Simon Standing, Attorney Legal Counsel’s Office Office of Inspector General
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