Minnesota

September 28, 2023

Yashmin Nagujja, Authorized Agent

Green Lakes LLC

277 Coon Rapids Blvd Northwest, suite 414

Coon Rapids, Minnesota 55433

License Number: 1108646 (245D – HCBS)

NOTICE OF NONCOMPLIANCE AND

CORRECTION ORDER

Dear Yashmin Nagujja:

On August 10, 2023, a Correction Order was issued to Green Lakes LLC, located at 277 Coon Rapids Boulevard Northwest, suite 414, Coon Rapids, Minnesota, as a result of a licensing review. You were ordered to submit evidence of corrective action taken for violations determined under citations number 2, 6, 9 and 10, within 60 days of receipt of the order. On September 27, 2023, a review of your submissions received on September 21, 2023, was concluded. For citations number 9 and 10, it has been determined that corrective action has not been achieved. As a result, this notice of noncompliance is being issued including an additional citation. Additional materials submitted but not ordered have not been reviewed and will not be addressed in this order.

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.

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 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;

· 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;

· 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.

License Holder Response: The license holder submitted a document titled, “Staff Orientation Record” for SP1 and SP2.

DHS Response:

a. Regarding SP1, the license holder submitted documentation that verified and maintained evidence of competency in the above-mentioned orientation training areas.

b. Regarding SP2, the license holder submitted documentation that verified and maintained evidence of competency in the following orientation training areas:

· 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; and

· 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;

c. The license holder failed to submit a copy of the training record for SP2 that documented orientation 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.

Corrective Action Ordered: Within 30 days of receiving this order, you must submit documentation of SP2’s orientation 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 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:

· 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;

· 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;

· 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.

License Holder Response: The license holder submitted a document titled, “Staff Annual Training Record 2022-2023” for SP1 and SP2. The license holder did not submit documentation of annual training for SP3 as ordered.

DHS Response:

a. Regarding SP1, the license holder submitted documentation that verified and maintained evidence of competency in the above-mentioned annual training areas.

b. Regarding SP3, the license holder failed to submit a copy of the annual training for the following required annual training topics:

· 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;

· basic first aid;

· 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 submit documentation of the above-mentioned annual training topics for SP3 to your licensor including the date the training was completed, the number of hours per subject area; and the name of the trainer or instructor. On an ongoing basis, you must maintain compliance as required in this subdivision.

Additional Citation

12. Citation: Minnesota Statutes, section 245D.095, subdivision 5.

Violation: For two staff persons whose records were reviewed (SP1-SP2), the license holder did not maintain personnel records as required.

The license holder failed to maintain a personnel record for SP1 and SP2 that included documentation of the following in their personnel records:

· the date of the training;

· the number of hours per subject area; and

· the name of the trainer or instructor.

Corrective Action Ordered: Within 30 days of receiving this order, you must:

· maintain a personnel record for SP1 and SP2 that includes documentation of the following int their personnel records:

o the dates of the training;

o the number of hours per subject area; and

o the name of the trainer or instructor;

· submit copies of SP1 and SP2’s training records that include the above-mentioned personnel record requirements to this licensor.

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 Amber Nielsen at amber.n.nielsen@state.mn.us or 651-431-3661 as soon as possible.

Christala Culhane, HCBS Licensing Supervisor

Licensing Division

Office of Inspector General

PO Box 64242 • Saint Paul, Minnesota • 55164-0242 • An Equal Opportunity and Veteran Friendly Employer
https://mn.gov/dhs/general-public/licensing/