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June 6, 2023 Walter Still, Authorized Agent Strive Home & Community Services 2000 Whitewater Trail Brooklyn Park, Minnesota 55444 License Number: 1096972 (245D - HCBS) CORRECTION ORDER Dear Walter Still: On May 12, 2023, a licensing review of Strive Home & Community Services, located at 331 Second Avenue South Suite 414, Minneapolis, 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 Rules, part 9544.0030, subparts 1 and 2. Violation: For two of two persons whose records were reviewed (P1 and P2), the license holder did not meet the requirements of positive support strategies and person-centered planning as required. The license holder failed to develop and implement positive support strategies for P1 and P2 according to the standards in subpart 2, and failed to incorportate principles of person-centeredness into the services provided to P1 and P2. Additionally, the license holder failed to evaluate with P1 and P2 identified positive support strategies at least every six months. Corrective Action Ordered: Within 45 days of receiving this order, you must document the positive support strategies and person centered planning for P1 and P2 as required in these subparts. This corrective action will be reviewed on site. On an ongoing basis, you must evaluate with the person, at least every six months, whether the identified positive support strategies currently meet the standards in subpart 2 and determine whether changes are needed in the positive support strategies used based upon the results of the evaluation, and if so, make appropriate changes. 2. Citation: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (b). Violation: For one person whose record was reviewed (P2), the license holder did not develop and review the individual abuse prevention plan as required. P2’s service initiation date was February 3, 2021. The license holder failed to develop an individual abuse prevention plan for P2 as part of the initial individual abuse prevention plan and annually in 2022. However, an individual abuse prevention plan was later developed in February 2023. Repeat Violation: The license holder was cited for a similar violation in a correction order dated August 17, 2021. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 3. Citation: Minnesota Statutes, section 245D.04, subdivision 1, paragraph (1). Violation: For two people whose records were reviewed (P1 and P2), the license holder did not provide the person or their legal representative with a written notice that identified the service recipient rights as required. a. The license holder failed to provide P1 with a notice that identified the service recipient rights and an explanation of those rights annually in 2022. b. The license holder failed to provide P2 with a notice that identified the service recipient rights and an explanation of those rights within five working days of service initiation and annually in 2022. However, rights were later provided in February 2023. Repeat Violation: The license holder was cited for a similar violation in a correction order dated August 17, 2021. Corrective Action Ordered: Within 45 days of receiving this order, you must provide P1 with service recipient rights and an explanation of those rights. This corrective action will be reviewed on site. On an ongoing basis, you must maintain compliance throughout your program as required in this subdivision. 4. Citation: Minnesota Statutes, section 245D.071, subdivision 4. Violation: For one person whose record was reviewed (P2), the license holder did not develop support and outcomes as required. The license holder failed to develop and document the supports and methods to be implemented for P2 to support the person and accomplish outcomes related to acquiring, retaining, or improving skills and physical, mental, and emotional health and well-being, including: · the methods or actions that will be used to support the person and accomplish the service outcomes, including information about: o any changes or modifications to the physical and social environments necessary when the service supports were provided; o any equipment and materials required; and o techniques that were consistent with the person’s communication mode and learning style; · the measurable and observable criteria for identifying when the desired outcome had been achieved and how data would be collected; · the projected starting date for implementing the supports and methods and the date by which progress towards accomplishing the outcomes would be reviewed and evaluated; and · the names of the staff persons or positions responsible for implementing the supports and methods. Repeat Violation: The license holder was cited for a similar violation in a correction order dated August 17, 2021. Corrective Action Ordered: Within 45 days of receipt of this order, you must develop the above mentioned information for P2. This corrective action will be reviewed on site. On an ongoing basis, you must maintain develop supports and as required in this subdivision. 5. Citation: Minnesota Statutes, section 245D.071, subdivision 3, paragraph (b). Violation: For one person whose record was reviewed (P2), the license holder did not, within the scope of services, complete assessments as required. The license holder failed to complete assessments for P2 that included information about the person that described the person's overall strengths, functional skills and abilities, and behaviors or symptoms within 45 days of service initiation and annually in 2022. However, a self-management assessment plan was later developed in February 2023. Repeat Violation: The license holder was cited for a similar violation in a correction order dated August 17, 2021. Corrective Action Ordered: On an ongoing basis, you must maintain compliance throughout your program as required in this subdivision. 6. 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 service plan review and evaluation requirements. The license holder failed to meet with P2’s team annually in 2022 and 2023 as required. Repeat Violation: The license holder was cited for a similar violation in a correction order dated August 17, 2021. Corrective Action Ordered: Within 45 days of receiving this order, you must meet with P2, P2’s legal guardian if applicable and P2’s case manager. This corrective action will be reviewed on site. On an ongoing basis, you must maintain compliance as required in this subdivision. 7. Citation: Minnesota Statutes, section 245D.09, subdivision 4. Violation: For one of two staff persons whose record was reviewed (SP2), the license holder did not provide orientation training as required. SP2 was hired on January 1, 2023. The license holder failed to provide orientation training in the following areas within 60 days of hire: · the job description and how to complete specific job functions including: o responding to and reporting incidents as required under section 245D.06, subdivision 1; and o following safety practices established by the license holder as required in section 245D.06, subdivision 2; · 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 o use of universal precautions and sanitary practices o health service coordination and care o safe medication assistance and administration o safe transportation o service admission o emergency response, reporting, and reviewing o incident response, reporting, and reviewing o service termination policy; and o prohibition on drug and alcohol use policy; · the service recipient rights and staff responsibilities related to ensuring the exercise and protection of those rights according to the requirements in section 245D.04; · the principles of person-centered service planning and delivery as identified in section 245D.07, subdivision 1a, and how they apply to direct support service provided by the staff person; · 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 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; · basic first aid; and · training to the person including the coordinated service and support plan, coordinated service and support plan addendum as it relates to the responsibilities assigned to the license holder, the person’s individual abuse prevention plan to achieve and demonstrate an understanding of the person as a unique individual and how to implement those plans. Corrective Action Ordered: Within 45 days of receiving this order, you must provide SP2 with the above mentioned training. This corrective action will be reviewed on site. On an ongoing basis, you must provide orientation training as required in this subdivision. 8. 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. The license holder failed to provide SP1 with the following annual training in 2022 and 2023: · data privacy requirements according to sections 13.01 to 13.10 and 13.46, the federal Health Insurance Portability and Accountability Act of 1996 (HIPPA), and staff responsibilities related to complying with data privacy practices; · the service recipient rights and staff responsibilities related to ensuring the exercise and protection of those rights according to the requirements in section 245D.04; · sections 245A.65, 245A.66, 626.556, and 626.557, governing maltreatment reporting and service planning for children and vulnerable adults, and staff responsibilities related to protecting persons from maltreatment and reporting maltreatment; · the principles of person-centered service planning and delivery as identified in section 245D.07, subdivision 1a, and how they apply to direct support service provided by the staff; · 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. Repeat Violation: The license holder was cited for a similar violation in a correction order dated August 17, 2021. Corrective Action Ordered: Within 45 days of receiving this order, you must provide SP1 with the above annual training. This corrective action will be reviewed on site. On an ongoing basis, you must provide annual training as required in this subdivision. 9. Citation: Minnesota Statutes, section 245D.095, subdivision 2. Violation: The license holder failed to keep a written or electronic register listing in chronological order the dates and names of all persons served by the program who have been admitted, discharged, or transferred, including service terminations initiated by the license holder and deaths. The license holder included 5 individuals on the notice of reinspection during the licensing review. The license holder was actually providing 245D licensed services to 11 individuals. Corrective Action Ordered: Immediately, you must maintain the above mentioned information. This corrective action will be reviewed on site. On an ongoing basis, you must maintain service recipient records as required in this subdivision. 10. Citation: Minnesota Statutes, section 245D.095, subdivision 3. Violation: For one person whose record was reviewed (P1), the license holder did not maintain a service recipient record as required. The license holder failed to maintain daily log notes in P1 and P2’s coordinated service and support plan addendum. Corrective Action Ordered: Immediately, you must maintain the above mentioned information in P1 and P2’s service recipient record. This corrective action will be reviewed on site. On an ongoing basis, you must maintain service recipient records as required in this subdivision. 11. Citation: Minnesota Statutes, section 245D.095, subdivision 5, paragraph (a). Violation: For one staff person whose record was reviewed (SP1), the license holder did not maintain a personnel record as required. The license holder failed to document the following information in SP1’s personnel record: · the date the training was completed; · the number of hours per subject area; and · the name of the trainer or instructor. Corrective Action Ordered: This corrective action will be reviewed on site. On an ongoing basis, you must maintain personnel records for all staff as required in this subdivision. 12. Citation: Minnesota Statutes, section 245D.095, subdivision 5, paragraph (b). Violation: For one staff person whose record was reviewed (SP2), the license holder did not maintain a personnel record as required. The license holder failed to maintain documentation in the personnel records or elsewhere, sufficient to determine the date of SP2’s first supervised and unsupervised direct contact with a person served by the program. Corrective action ordered: Within 45 days of receipt of this order, you must maintain the documentation listed above in SP2 personnel record and submit written documentation that the above mentioned requirement is documented in SP2 personnel record. This corrective action will be reviewed on site. On an ongoing basis, you must maintain compliance as required in this subdivision. 13. Citation: Minnesota Statutes, section 245D.10, subdivision 4, paragraph (b). Violation: For one person whose record was reviewed (P2), the license holder did not provide written or electronic copies of policies and procedures as required. The license holder failed to inform P2 or their legal representative, and their case manager of the following policies and procedures that affect a person’s rights and provide copies of those policies and procedures, within five working days of service initiation; · grievance policy; · temporary service suspension policy; · service termination policy; · emergency use of manual restraints policy; and · data privacy policy. Corrective action ordered: Within 45 days of receipt of this order, you must inform P2, or their legal representative and their case manager of the policies and procedures that affect a person’s rights under section 245D.04, and provide copies of those policies and procedures as required in this subdivision. This corrective action will be reviewed on site. On an ongoing basis, you must maintain compliance as required in this subdivision. 14. Citation: Minnesota Statutes, section 245D.081, subdivision 2. Violation: The license holder did not ensure the delivery and evaluation of services provided were coordinated by the designated staff persons as required. The designated coordinator identified by the license holder (SP4) failed to provide supervision, support, and evaluation of activities that include: · oversight of the license holder's responsibilities assigned in the person's coordinated service and support plan and the coordinated service and support plan addendum; · taking the action necessary to facilitate the accomplishment of the outcomes according to the requirements in section 245D.07; · instruction and assistance to direct support staff implementing the coordinated service and support plan and the service outcomes, including direct observation of service delivery sufficient to assess staff competency; and · evaluation of the effectiveness of service delivery, methodologies, and progress on the person's outcomes based on the measurable and observable criteria for identifying when the desired outcome has been achieved according to the requirements in section 245D.07. Repeat Violation: The license holder was cited for a similar violation in a correction order dated August 17, 2021. Corrective Action: Within 20 days of receiving this order, you must: · hire or contract a person, other than SP1, SP3, and SP4 to be appointed as the designated coordinator, who is responsible for delivery and evaluation of services provided by the license holder; and · submit the name, contact information and qualifications of the person(s) you have hired or contracted and have ensured is competent to perform the duties of the designated manager as required in this section. 15. Citation: Minnesota Statutes, section 245D.081, subdivision 3. Violation: The license holder did not ensure that the designated managerial staff persons provided program management and oversight of the services provided as required. The designated managers identified by the license holder (SP3) failed to provide program management and oversight of the services provided by being responsible for the following: · maintaining a current understanding of the licensing requirements sufficient to ensure compliance throughout the program; · ensuring the duties of the designated coordinator are fulfilled; · ensuring staff competency requirements are met. The failure to provide program management and oversight of the services provided is evidenced in citation 1 through 14. Repeat Violation: The license holder was cited for a similar violation in a correction order dated August 17, 2021. Corrective Action Ordered: Within 20 days of receiving this order, you must: · hire or contract a person, other than SP1, SP3, and SP4 to be appointed as the designated manager, who is responsible for delivery and evaluation of services provided by the license holder; and · submit the name, contact information and qualifications of the person(s) you have hired or contracted and have ensured is competent to perform the duties of the designated manager as required in this section. On an ongoing basis, you must maintain compliance as required in this subdivision. Submissions required as part of a corrective action ordered must be sent to your Licensor at: Commissioner, Department of Human Services ATTN: Lindsay Norris 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 Office of Inspector General 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 Lindsay Norris at 651-431-5752 as soon as possible. Lindsay Norris, Senior Licensor-Home and Community Based Services Licensing Division Office of Inspector General
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