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August 10, 2023 Yashmin Nagujja, Authorized Agent Green Lakes LLC 277 Coon Rapids Blvd Northwest, suite 414 Coon Rapids, Minnesota 55433 License Number: 1108646 (245D – HCBS) CORRECTION ORDER Dear Yashmin Nagujja: On July 31, 2023, a licensing review of Green Lakes LLC, located at 277 Coon Rapids Boulevard Northwest, suite 414, Coon Rapids, 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 245A.65, subdivision 1. Violation: For two of two persons whose records were reviewed (P1 and P2), the license holder did not provide orientation to the internal and external reporting procedures of alleged or suspected maltreatment of vulnerable adults as required. a. P1’s services were initiated on June 11, 2022. The license holder failed to provide P1 with an orientation to the internal and external reporting procedures of alleged or suspected maltreatment of vulnerable adults within 24 hours of admission. b. P2’s services were initiated on November 8, 2022. The license holder failed to provide P2 with orientation to the internal and external reporting procedures of alleged or suspected maltreatment of vulnerable adults within 24 hours of admission. Corrective Action Ordered: Within 30 days of receiving this order, you must: · provide P1 with orientation to the internal and external reporting procedures of alleged or suspected maltreatment of vulnerable adults; · maintain documentation of this orientation to maltreatment reporting policies and procedures; and · audit all of your person served records to ensure theses policies and procedures have been provides. P2 is no longer receiving services from the license holder. On an ongoing basis, you must maintain compliance as required in this subdivision. 2. Citation: Minnesota Statutes, section 245D.04, subdivision 1. Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not provide written notice that identified the service recipient rights as required. The license holder failed to provide P1 and P2 with a written notice that identified the service recipient’s rights in subdivisions 2 and 3 and explanation of those rights within five working days of service initiation. Corrective Action Ordered: Within 30 days of receiving this order, you must: · provide P1 with a copy of the written notice that identifies the service recipient rights and an explanation of those rights; · maintain documentation of the receipt and an explanation of the rights; · submit documentation of the receipt and explanation of the service recipient rights to this licensor; and · audit all of your person served records to ensure the service recipient rights have been provided. P2 is no longer receiving services from the license holder. On an ongoing basis, you must maintain compliance as required in this subdivision. 3. Citation: Minnesota Statutes, section 245D.05, subdivision 2. Violation: For one person whose record was reviewed (P2), the license holder did not implement medication administration procedures as required. The license holder was assigned responsibility for the administration of P2’s medications in P2’s support plan. The license holder failed to obtain a written authorization from P2 to administer medication or treatment before administering medication or treatment. Corrective Action Ordered: P2 is no longer receiving services from the license holder. On an ongoing basis, you must maintain compliance as required in this subdivision. 4. Citation: Minnesota Statutes, section 245D.051, subdivision 1, paragraph (b). Violation: For one person whose records was reviewed (P2), the license holder did not develop, implement, and maintain documentation regarding psychotropic medications as required. P2 was prescribed several psychotropic medications. The license holder failed to maintain documentation that included a description of the target symptoms that each individual psychotropic medication was to alleviate. Corrective Action Ordered: P2 is no longer receiving services from the license holder. On an ongoing basis, you must maintain compliance as required in this subdivision. 5. Citation: Minnesota Statutes, section 245D.07, subdivision 1. Violation: For one person whose record was reviewed (P1), the license holder did not provide services in compliance with the federal waiver plans. NOTE: According to the Community-Based Services Manual, out-of-home crisis respite services must be provided in one of the following settings: · Adult foster care licensed under Minn. R. 9555.5150 to 9555.6265; · Child foster care licensed under Minn. R. 2960.3000 to 2960.3340; · CRS licensed under Minn. Stat. Chapter 245D; or · Licensed hotel The license holder failed to comply with the federal waiver plan while providing crisis respite services to P2. Crisis respite services were provided in a setting that did not meet the definition of an out-of-home placement. The license holder was providing crisis respite services for P2 in an assisted living facility. Corrective Action Ordered: P2 is no longer receiving services from the license holder. On an ongoing basis, you must maintain compliance as required in this subdivision. 6. Citation: Minnesota Statutes, section 245D.07, subdivision 2. Violation: For one person whose record was reviewed (P1), the license holder did not meet service planning for basic support services as required. The license holder failed to develop a support plan for P1 that documented the services that would be provided including how, when and by whom services would be provided, and the person responsible for overseeing the delivery and coordination of services. Additionally, the license holder failed to establish a timeline for when the license holder would participate in service planning and support team meetings for P1. At the time of the review, the license holder did not have a support plan developed for P1. Corrective Action Ordered: Within 30 days of receiving this order you must: · develop a support plan for P1 that documents the services that would be provided including how, when and by whom services will be provided, and the person responsible for overseeing the delivery and coordination of services; · establish a timeline for when the license holder would participate in service planning and support team meetings for P1; · review P1’s support plan with P1, P1’s case manager and other members of P1’s support team; · maintain documentation of when the service plan was developed and reviewed with P1, P1’s case manager and other members of P1’s support team; · audit all person served records to ensure a support plan has been developed that includes the above mentioned requirements; · submit the findings of your audit to this licensor; and · submit a copy of P1’s support plan to this licensor. On an ongoing basis, you must maintain compliance as required in this subdivision. 7. Citation: Minnesota Statutes, section 245D.10, subdivision 4. Violation: For two persons whose record were reviewed (P1 and P2), the license holder did not provide written or electronic copies of policies and procedures as required. a. Regarding P1 whose services were initiated on June 11, 2022. · The license holder failed to inform and provide copies of the following policies and procedures to P1 within 5 working days of service initiation: o temporary service suspension policy; o service termination policy; and o emergency use of manual restraints policy. · The license holder failed to inform P1’s case manager of the policies and procedures affecting P1’s rights under section 245D.04, and provide copies of the following policies and procedures, within 5 working days of service initiation: o grievance policy; o temporary service suspension policy; o service termination policy; and o emergency use of manual restraints policy. b. Regarding P2 whose services were initiated on November 8, 2022. · The license holder failed to inform and provide copies of the following policies and procedures to P2 within 5 working days of service initiation: o temporary service suspension policy; o service termination policy; and o emergency use of manual restraints policy. · The license holder failed to inform P2’s case manager of the policies and procedures affecting P2’s rights under section 245D.04, and provide copies of the following policies and procedures, within 5 working days of service initiation: o grievance policy; o temporary service suspension policy; o service termination policy; o emergency use of manual restraints policy; and o data privacy policy. Corrective Action Ordered: Within 30 days of receiving this order, you must: · inform and provide copies of the above mentioned policies and procedures to P1 and P1’s case manager; and · audit all persons served records to ensure the above mentioned policies and procedures have been provided. P2 is no longer receiving services from the license holder. On an ongoing basis, you must maintain compliance as required in this subdivision. 8. Citation: Minnesota Statutes, section 245A.65, subdivision 3. Violation: For one of three staff persons whose records were reviewed (SP2), the license holder did not provide an orientation to vulnerable adult maltreatment prevention and reporting as required. SP2’s date of hire was July 13, 2022. SP2 began providing direct contact services on November 25, 2022. The license holder failed to provide an orientation to SP2 on vulnerable adult maltreatment reporting and review of the license holder’s internal policies and procedures related to prevention and reporting of maltreatment of individuals receiving services within 72 hours of SP2 first providing direct contact services. SP2 received this training on February 15, 2023. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 9. Citation: Minnesota Statutes, Section 245D.09, subdivision 4. Violation: For three staff persons whose records were reviewed (SP1-SP3), the license holder did not provide orientation training as required. a. SP1 was hired on May 11, 2022. The license holder failed to provide the following orientation training within 60 days of hire: · the job description and how to complete specific job functions including 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, including the location and access, and staff responsibilities related to implementation of the license holder’s policies and procedures; · 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. SP1 received this training on January 2, 2023; · 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. SP1 received this training on January 2, 2023; · basic first aid. P1 received this training on January 2, 2023. b. SP2 was hired on July 13, 2022. The license holder failed to provide the following orientation training within 60 days of hire: · the job description and how to complete specific job functions including 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, including the location and access, and staff responsibilities related to implementation of the license holder’s policies and procedures; · 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. SP2 received this training on February 15, 2023; · 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. SP2 received this training on February 15, 2023; · 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. SP1 received this training on February 15, 2023; · strategies to minimize the risk of sexual violence, including concepts of healthy relationships, consent, and bodily autonomy od people with disabilities. SP2 received this training on February 15, 2023; and · basic first aid. c. SP3 was hired on March 11, 2021. The license holder failed to provide the following orientation training within 60 days of hire: · data privacy requirements according to Minnesota Statues, 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. SP3 received this training on March 23, 2022; · the service recipient rights and staff responsibilities related to ensuring the exercise and protection of those rights according to the requirements in Minnesota Statues, section 245D.04. SP3 received this training on February 18, 2022; · 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. SP3 received this training on January 12, 2023; · 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. SP3 received this training on January 5, 2022; · 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. SP3 received this training on January 5, 2022; · basic first aid. SP3 received this training on February 1, 2022; and · strategies to minimize the risk of sexual violence, including concepts of healthy relationships, consent, and bodily autonomy od people with disabilities. SP3 received this training on February 19, 2022. Corrective Action Ordered: Within 30 days of receiving this order, you must: · provide SP1 and SP2 with training on the job description and how to complete specific job functions including following safety practices established by the license holder as required in section 245D.06, subdivision 2; · provide SP1 and SP2 with training on the license holder’s current policies and procedures required, including the location and access, and staff responsibilities related to implementation of the license holder’s policies and procedures; · provide SP1 and SP2 with training on 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; · provide SP2 with basic first aid training; · audit all staff records to ensure they receive orientation training as required; · submit the findings of your audit to this licensor; and · submit copies of the above mentioned trainings for SP1 and SP2 to your licensor On an ongoing basis, you must maintain compliance as required in this subdivision. 10. Citation: Minnesota Statutes, Section 245D.09, subdivision 5. Violation: For two staff persons whose records were reviewed (SP1 and SP3), the license holder did not provide annual training as required. a. The license holder failed to provide SP1 with the following annual training: · data privacy requirements according to Minnesota Statues, 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 Minnesota Statues, section 245D.04; and · strategies to minimize the risk of sexual violence, including concepts of healthy relationships, consent, and bodily autonomy od people with disabilities. b. The license holder failed to provide SP3 with the following annual training: · the service recipient rights and staff responsibilities related to ensuring the exercise and protection of those rights according to the requirements in Minnesota Statues, section 245D.04; · 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; · data privacy requirements according to sections 13.01 to 13.10 and 13.46, the federal Health Insurance Portability and Accountability Act of 1996 (HIPAA), and staff responsibilities related to complying with data privacy practices; · basic first aid; · 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; and · strategies to minimize the risk of sexual violence, including concepts of healthy relationships, consent, and bodily autonomy od people with disabilities. Corrective Action Ordered: Within 30 days of receiving this order, you must: · provide SP1 and SP3 with the above mentioned trainings; · audit all staff records to ensure they receive annual training as required; · submit the findings of your audit to this licensor; and · submit copies of the above mentioned trainings for SP1 and SP3 to your licensor On an ongoing basis, you must maintain compliance as required in this subdivision. 11. Citation: Minnesota Statutes, section 245D.095, subdivision 5. Violation: For three staff persons whose records were reviewed (SP1-SP3), the license holder did not maintain personnel records as required. The license holder failed to maintain a personnel record for SP1-SP3 that included documentation of the following in their personnel records: · the date of SP1-SP3’s first supervised contact with a person served by the program; · the date of SP1-SP3’s first unsupervised contact with a person served by the program; and · SP1-SP3’s orientation and training, that included: o the number of hours per subject area; and o the name of the trainer or instructor. Corrective Action Ordered: Within 30 days of receiving this order, you must: · document the date of first supervised and unsupervised contact with a person served by the program for SP1-SP3; and · audit all staff records to ensure the above mentioned items are maintained in the personnel record. On an ongoing basis, you must maintain compliance as required in this subdivision. If you fail to correct the violations specified in the Correction Order within the prescribed time lines the Commissioner may issue an Order of Conditional License or may impose a fine and order other licensing sanctions pursuant to Minnesota Statutes, sections 245A.06 and 245A.07. Submissions required as part of a corrective action ordered must be sent to your Licensor at: 1. By secure email at amber.n.nielsen@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: Amber Nielsen 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 me as soon as possible. Christala Culhane, HCBS Licensing Supervisor Licensing Division Office of Inspector General
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