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September 19, 2023 Suad Sherif, Authorized Agent Aldrich Health Services 3650 Vermilion Court North Eagan, Minnesota 55122 License Number: 1104311 (245D – HCBS) CORRECTION ORDER Dear Suad Sherif: On August 23, 2023, a licensing review of Aldrich Health Services, located at 3650 Vermilion Court North, Eagan, 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, subdivisions 3 and 4. Violation: For one person whose record was reviewed (P1), the license holder did not meet service planning and delivery requirements for intensive support services. a. The license holder failed to complete assessments before providing 45 days of service or within 60 calendar days of service initiation for P1 in the following areas: · P1’s ability to self-manage health and medical needs to maintain or improve physical, mental and emotional well-being, including, when applicable, allergies, seizures, choking, special dietary needs, chronic medical conditions, self-administration of medication or treatment orders, preventative screening, and medical and dental appointments; · P1's ability to self-manage personal safety to avoid injury or accident in the service setting, including, when applicable, risk of falling, mobility, regulating water temperature, community survival skills, water safety skills, and sensory disabilities; and · P1's ability to self-manage symptoms or behavior that may otherwise result in an incident as defined in section 245D.02, subdivision 11, clauses (4) to (7), suspension or termination of services by the license holder, or other symptoms or behaviors that may jeopardize the health and welfare of the person or others. b. The license holder failed to meet with P1, P1’s case manager, and other members of the support team before providing 45 days of service or within 60 calendar days of service initiation to determine the following requirements: · the scope of services to be provided to support P1’s daily needs and activities; · P1’s desired outcomes and the supports necessary to accomplish the desired outcomes; · P1’s preferences for how services and supports are provided, including how the provider will support P1 to have control of P1’s schedule; · whether the current service setting is the most integrated setting available and appropriate for P1; and · how services must be coordinated across other providers licensed under this chapter serving P1 and member of the support team or expanded support team to ensure continuity of care and coordination of services for P1. Additionally, the license holder failed to have a discussion of how technology might be used to meet P1’s desired outcomes at the 45-day planning meeting and maintain a summary of the conversation in P1’s support plan or support plan addendum that included a statement regarding any decision that was made regarding the use of technology and a description of any further research that needed to be completed before a decision regarding the use of technology could be made. c. The license holder failed to, within ten working days of the 45-day planning meeting, develop a service plan for P1 that documents the following supports and methods to be implemented to support P1 and accomplish outcomes related to acquiring, retaining, or improving skills and physical, mental, and emotional health and well-being: · the methods or actions that will be used to support P1 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 P1’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: · complete the assessments required in part “a” of this citation; · meet with P1, P1’s legal representative and P1’s case manager, and other members of the support team to: o review the assessments required in part “a” of this citation; o document the information required in part “b” of this citation; and o have a discussion with P1 and P1’s case manager and other members of the support team of how technology might be used to meet P1’s desired outcomes and maintain a summary of this discussion in P1’s support plan addendum; · within 10 working days of meeting with P1, P1’s legal representative and P1’s case manager, develop a service plan that documents the requirements in part “c” of this citation; and · within 20 working days of this meeting, submit to and obtain dated signatures from P1, P1’s legal representative and P1’s and case manager to document completion and approval of the assessments and support plan addendum. Within 60 days of receiving this order, you must submit the following to your licensor: · the assessments required in part “a” of this citation; · the information required in part “b” of this citation; and · dated signatures from P1, P1’s legal representative and P1’s case manager documenting the completion and approval of P1’s support plan addendum. On an ongoing basis, you must maintain compliance as required in this subdivision. 2. Citation: Minnesota Statutes, section 245D.095, subdivision 3, paragraph (b). Violation: For one person whose record was reviewed (P1), the license holder did not maintain the service recipient record as required. The license holder failed to maintain progress or daily log notes that were recorded by the program in P1’s record. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 3. Citation: Minnesota Statutes, section 245D.095, subdivision 5. Violation: For two of two staff persons whose records were reviewed (SP1 and SP2), the license holder did not maintain personnel records as required. The license holder provided SP1 and SP2 review and instruction on individual service recipient needs; however, the license holder failed to maintain documentation of this orientation in SP1 and SP2’s personnel records, including: · the date the training was completed; · the number of hours per subject area; and · the name of the trainer or instructor. Corrective Action Ordered: 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 kristopher.oberg@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: Kristopher Oberg 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 Kris Oberg at 651-431-6589 as soon as possible. Brittany Raddatz, Supervisor Licensing Division Office of Inspector General
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