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May 16, 2023 Yasmin Farah, Authorized Agent Hope Housing Services 7800 Metro Parkway Suite 200-62 Bloomington, Minnesota 55425 License Number: 1108423 (245D – HCBS) CORRECTION ORDER Dear Yasmin Farah: On March 6, 2023, a licensing review of Hope Housing Services, located at 7800 Metro Parkway Suite 200-62, Bloomington, 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.071, subdivision 4, paragraph (b). Violation: For one of two persons whose records were reviewed (P1), the license holder did not develop a service plan that documents the service outcomes and supports based on the assessments completed under subdivision 3 and the requirements in section 245D.07, subdivision 1a, as required. One of P1’s service outcomes and supports was documented as, with support from staff, P1 will access recreational and leisure activity resources in their community once per week for 75% of all opportunities present within the review period. Although the license holder had outcomes listed for P1 and maintained documentation of data collection of P1’s service outcomes, the license holder failed to document the following information in P1’s current supports and methods for this outcome: · the methods or actions that will be used to support the person and to accomplish the service outcomes, including information about: o any changes or modifications to the physical and social environments necessary when the service supports are provided; o any equipment and materials required; and o techniques that are consistent with the person’s communication mode and learning style; · the measurable and observable criteria for identifying when the desired outcome has been achieved and how data will be collected; · the projected starting date for implementing the supports and methods and the date by which progress towards accomplishing the outcomes will be reviewed and evaluated; and · the names of the staff or position responsible for implementing the supports and methods. Corrective Action Ordered: Within 30 days of receiving this order, you must develop a service plan that documents the service outcomes and supports listed above for P1. On an ongoing basis, you must maintain compliance as required in this subdivision. 2. Citation: Minnesota Statutes, section 245D.095, subdivision 3 Violation: For two persons whose record was reviewed (P1 and P2) the license holder did not meet record requirements, as required The license holder failed to maintain progress or daily log notes for P1 and P2. Corrective Action Ordered: Immediately, you must begin maintaining daily progress or daily log notes for all persons served in your program. On an ongoing basis, you must maintain compliance as required in this subdivision. 3. Citation: Minnesota Statutes, section 245D.10, subdivision 4 paragraphs a and b Violation: The licensed holder did not review and update, as needed, the written policies and procedures as required. The license holder maintained documentation of required policies and procedures; however, they did not meet the requirements under section 245D.10, subdivision 1, 2, and 3a. The license holder failed to review and update, as needed, the following policies and procedures: · grievances; · service termination; · emergency use of manual restraint not allowed; and · safe medication assistance and administration policy Corrective Action Ordered: Within 30 days of receiving this order, you must review and update the above-mentioned policies to comply with statutory requirements. Additionally, you must provide a written notice to all persons or their legal representatives any procedural revisions to policies affecting a person’s service-related or protection-related rights under section 245D.04. You must also inform all employees of the revisions and provide training on implementation of the revised policies and procedures prior to implementing the revisions. 4. Citation: Minnesota Statutes, section 245D.11, subdivisions 2 and 3. Violation: The license holder did not establish and maintain policies and procedures as required in this section. a. The license holder failed to maintain an updated safe medication assistance and administration policy according to 245D.11, subdivision2, paragraph (3). b. The license holder failed to maintain an updated written policy related to the review of incidents and emergencies according to 245D.11, subdivision 2, paragraph (7); and c. The license holder failed to maintain updated policies and procedures related to admission criteria recipient rights by ensuring data privacy according to 245D.11, subdivision 3. d. Corrective Action Ordered: Within 30 days of receiving this order, you must review and update the above-mentioned policies to comply with statutory requirements. Additionally, you must provide a written notice to all persons or their legal representatives any procedural revisions to policies affecting a person’s service-related or protection-related rights under section 245D.04. You must also inform all employees of the revisions and provide training on implementation of the revised policies and procedures prior to implementing the revisions. Submissions required as part of a corrective action ordered must be sent to your Licensor at: 1. By secure email at nicole.m.riley@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: Nicole Riley 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 ATTN: Legal Unit Licensing Division PO Box 64953 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 Nicole Riley, Senior Licensor, at 651-431-3657, as soon as possible. Christala Culhane, Human Services Licensor Licensing Division Office of Inspector General
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