|
June 8, 2023 Su-Fei Wong, Authorized Agent 7625 Metro Blvd Ste 200 Minneapolis, MN, 55439-3057 License Number: 1036848 (CRF) CORRECTION ORDER Dear Su-Fei Wong, On February 28, 2023, and March 1 through 3, 6 and 7, 2023, the Department of Human Services (DHS) conducted a modified licensing review at your facility, Bar None Residential Services, located at 22426 Saint Francis Blvd, Anoka, MN. As a result of this visit, DHS is issuing this order which requires you to take the correction action as described under each violation. Details of our findings are provided below. Our next steps and your options are also detailed. LICENSING VIOLATIONS DHS determined that your program failed to follow licensing rules and statutes, as described below. PRACTICES 1. Violation: The license holder did not maintain documentation demonstrating that a qualified staff person developed a therapeutic recreation plan. Therapeutic recreation activity calendars did not indicate they were developed by a qualified staff person. Rule Violated: Minnesota Rules, part 2960.0450, subpart 2, item D Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the provision of therapeutic recreation meets all applicable requirements. RESIDENT FILES 2. Violation: Two of two resident files reviewed for requirements governing the provision of medication education did not meet requirements (resident files numbered 1 and 2). Documentation did not identify who provided medication education provided during the informed consent process. Rule Violated: Minnesota Rules, part 2960.0590, item C. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure the provision of medication education meets all applicable requirements. 3. Violation: Two of two resident files reviewed for requirements governing individual treatment plans did not meet requirements (resident files numbered 1 and 3). The individual treatment plan did not include the frequency of interventions. Rule Violated: Minnesota Rules, part 2960.0490, subpart 3, item C. Corrective Action Required: Immediately and on an ongoing basis, the license holder must ensure individual treatment plans meet all applicable requirements. 4. Violation: Two of four resident files reviewed for requirements governing medication administration did not meet requirements in the following ways: a. The resident file included a document titled “Physician’s Standing Orders”, but the document was not signed by a physician (resident file numbered 3); and b. The resident file did not include a physician’s standing order allowing for the administration of over-the-counter medication (resident file numbered 4). Rule Violated: Minnesota Rules, part 2960.0080, subpart 11, item D. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure medication administration meet all applicable requirements. 5. Violation: Two of two resident files reviewed for requirements governing the informed consent of psychotropic medications did not meet requirements (resident files numbered 1 and 2). Informed consent documentation did not identify the expected benefits of the medication, including the level to which the medication is to change the symptoms and behavior. Rule Violated: Minnesota Rules, part 2960.0620, subpart 7, item B. Corrective Action Ordered: Immediately and on an ongoing basis, the license holder must ensure documentation of informed consent meet all applicable requirements. YOUR RIGHT TO REQUEST RECONSIDERATION You have the right to request reconsideration of this order and the cited violations. Your request must: · Be in writing · List each violation you are challenging and identify what is inaccurate or incomplete about the information in the order · Supply information that is accurate or more complete · Be made before the deadlines provided below If you are mailing your request, it must be received by DHS within 20 calendar days from when you received this order. If you do not meet this deadline, you lose your right to request reconsideration. The timeline to appeal began when you received this order. Please send it to: Commissioner, Department of Human Services Office of Inspector General Legal Counsel’s Office Attn: Licensing Legal Unit PO Box 64953 St. Paul, MN 55164-0953 If your request is being personally delivered, it must be received by DHS within 20 calendar days from when you received this order. Please bring it to: Commissioner, Department of Human Services Office of Inspector General Legal Counsel’s Office Attn: Licensing Legal Unit 444 Lafayette Road North St. Paul, MN 55155 Legal authority for this licensing action · This action is taken under Minnesota Statutes, section 245A.06, subdivision 1. · This Children’s Residential Facility must maintain compliance with the licensing statutes and rules, specifically Minnesota Rules, chapter 2960. · The timeline to request reconsideration of the order is provided in Minnesota Statutes, section 245A.06, subdivision 2. Questions If you have any further questions regarding this matter, you may contact me at 651-431-6259. Sincerely, Katie Leuer, Unit Supervisor Licensing Division Office of Inspector General
|
