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September 29, 2023 Jessica Horn, Authorized Agent Clearwater Day Activity Center PO Box 29 Bagley, MN 56621-0029 License Number: 1073124 (245D – Home and Community-Based Services) CORRECTION ORDER Dear Jessica Horn: On May 9-10, 2023 a licensing review of Clearwater Day Activity Center located at 402 5th Street, Bagley, 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 2. Violation: For one of four persons whose records were reviewed (P2), the license holder did not meet the requirements for an individual abuse prevention plan (IAPP) as required. The license holder failed to include a statement of measures that would be taken to minimize the risk of abuse to P2 when the individual assessment indicated the need for measures in the following areas: · lack of understanding sexuality; · likely to seek or cooperate in an abusive situation; · inability to be assertive; · inability to identify potentially dangerous situations; · inability to deal with verbally/physically aggressive persons; · inability to care for self-help needs; · lack of self-preservation skills (ignores personal safety); and · inability to handle financial matters. Corrective Action Ordered: Within 30 days of receiving this order, you must include a statement of specific measures that will be taken to minimize the risk of abuse in P2’s IAPP when the individual assessment indicates the need for measures. On an ongoing basis, you must maintain compliance as required in this subdivision. 2. Citation: Minnesota Statutes, section 245D.04, subdivision 1. Violation: For three persons whose records were reviewed (P1-P3), the license holder did not provide a written notice that identified the service recipient rights as required. Minnesota Statutes, section 245A.02, subdivision 2b defines “annual” or “annually” to mean prior to or within the same month of the subsequent calendar year. a. The license holder failed to provide P1’s legal representative and P2’s legal representative a written notice and explanation of the service recipient rights in subdivisions 2 and 3 that included the right to access the person’s personal possessions at any time, including financial resources. b. The license holder failed to provide P3’s legal representative with a notice of the service recipient rights on an annual basis. The license holder did not provide P3’s legal representative with a notice of the service recipient rights in 2021. The license holder later provided the notice on February 24, 2022. Corrective Action Ordered: Within 30 days of receiving this order, you must provide P1’s legal representative, and P2’s legal representative a written notice that identifies the service recipient rights in subdivisions 2 and 3 and an explanation of those rights as required. On an ongoing basis, you must maintain compliance as required in this subdivision. 3. Citation: Minnesota Statutes, section 245D.071, subdivision 3. Violation: For one person whose record was reviewed (P1), the license holder did not meet the requirements for assessment and initial service planning as required for intensive support services. P1’s services were initiated on July 11, 2022. The license holder failed to include a discussion of how technology might be used to meet P1’s desired outcomes as part of the 45- day meeting. Corrective Action Ordered: Within 30 days of receiving this order, you must discuss with P1 and P1’s support team how technology might be used to meet P1’s desired outcomes. You must also include a summary of this discussion in P1’s support plan or support plan addendum. On an ongoing basis, you must maintain compliance as required in this subdivision. 4. Citation: Minnesota Statutes, section 245D.071, subdivision 4, paragraph (b). Violation: For one person whose record was reviewed (P4), the license holder did not meet the service planning requirements for an intensive service as required. P4 received multiple intensive services from the license holder. Although the license holder developed a service plan that documented a service outcome for P4, the license holder failed to develop and document a service outcome and supports for each intensive service P4 received from the license holder. Corrective Action Ordered: Within 30 days of receiving this order, you must develop a service plan that documents the service outcomes and supports for each intensive service P4 receives from your program. On an ongoing basis, you must maintain compliance as required in this subdivision. 5. Citation: Minnesota Statutes, section 245D.071, subdivision 5. Violation: For three persons whose records were reviewed (P1-P3), the license holder did not meet the requirements for service plan review and evaluation. a. P1’s support plan addendum required semi-annual meetings. P1’s semi-annual meeting was held on February 6, 2023; however, there was no documentation that indicated P1’s case manager was present at the meeting. The license holder failed to meet with P1’s case manager following the stated timelines in P1’s support plan addendum. b. P2’s support plan addendum required semi-annual meetings. P2’s semi-annual meeting was held on February 28, 2023; however, there was no documentation that indicated P2’s case manager was present at the meeting. The license holder failed to meet with P2’s case manager following the stated timelines in P2’s support plan addendum. c. P3’s support plan addendum required semi-annual meetings. The license holder stated that P3’s team met semi-annually in 2021; however, the license holder did not have documentation that showed these meetings occurred in 2021. d. The license holder failed to discuss with P2, P2’s legal representative, P2’s case manager, and members of the support to discuss how technology might be used to meet the person’s desired outcomes at least once per year. The license holder failed to document the following: · discussion of how technology might be used to meet P2’s desired outcomes; and · a summary of this discussion that included a statement regarding any decision made related to the use of technology and a description of any further research that must be completed before a decision regarding the use of technology can be made. Corrective Action Ordered: Within 30 days of receiving this order, you must discuss with P2 and P2’s support team how technology might be used to meet P2’s desired outcomes. You must document the above mentioned information in P2’s support plan addendum. On an ongoing basis, you must maintain compliance as required in this subdivision. 6. Citation: Minnesota Statutes, section 245D.10, subdivision 4. Violation: For one person whose record was reviewed (P1), the license holder did not inform the case manager of the policies and procedures affecting a person’s rights under section 245D.04 and provide copies of those policies and procedures within five working days of service initiation as required. P1’s services were initiated on July 11, 2022, the license holder failed to inform P1’s case manager of the policies and procedures affecting a person’s rights under section 245D.04 and provide copies of those policies and procedures within five working days of service initiation. Corrective Action Ordered: Within 30 days of receiving this order, you must inform P1’s case manager of the policies and procedures affecting a person’s rights under section 245D.04 and provide copies of those policies and procedures. On an ongoing basis, you must maintain compliance as required in this subdivision. 7. Citation: Minnesota Statutes, section 245D.09, subdivision 4 and 4a. Violation: For one of three staff persons whose records were reviewed (SP2), the license holder did not provide orientation training as required. The license holder failed to provide SP2 with orientation training on basic first aid within 60 calendar days of hire. SP2’s date of hire was February 1, 2021. The license holder provided basic first aid training on April 8, 2021. Corrective Action Ordered: On an ongoing basis you must maintain compliance as required. 8. Citation: Minnesota Statutes, section 245D.09, subdivision 5. Violation: For two staff persons whose records were reviewed (SP2 and SP3), the license holder did not provide annual training as required. Minnesota Statutes, section 245A.02, subdivision 2b defines “annual” or “annually” to mean prior to or within the same month of the subsequent calendar year. The license holder provided SP2 with training on the topics listed below in February and March 2022. The license holder provided SP3 with training on the topics listed below as part of orientation training in February and March 2022. At the time of the licensing review conducted on May 9-10, 2023, the license holder had not provided the training to SP2 and SP3 since February and March 2022. The license holder failed to provide training on the following topics on an annual basis to SP2 and SP3: · 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; · the service recipient rights and staff responsibilities related to ensuring the exercise and protection of those rights according to the requirements in Minnesota Statutes, section 245D.04; · sections 245A.65, 245A.66, and 626.557 and chapter 260E 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 Minnesota Statutes, section 245D.07, subdivision 1a, and how they applied to direct support services 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 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; · basic first aid; and · strategies to minimize the risk of sexual violence, including concepts of healthy relationships, consent, and bodily autonomy of people with disabilities. Corrective Action Ordered: Within 30 days of receiving this order, you must: · provide SP2 and SP3 with the above-mentioned required annual training; and · audit the most recent annual training records for all staff to ensure all staff have received training on all required topics within the past 12 months. Within 60 days of receiving this order, you must: · based on the results of the audit, provide annual training to all staff who have not received training on any of required annual training topics in the past 12 months. On an ongoing basis, you must maintain compliance as required in this subdivision. 9. Citation: Minnesota Statutes, section 245D.095, subdivision 5, paragraph (a). Violation: For two staff persons whose records were reviewed (SP2 and SP3), the license holder did not maintain personnel records as required. The license holder failed to maintain the hours of training per subject area and the name of the trainer or instructor in SP2 and SP3’s personnel records for each required training subject area. Corrective Action Ordered: On an ongoing basis, you must maintain the following training information in each staff person’s personnel record as required in this subdivision: · the date the training was completed; · the number of hours per subject area; and · the name of the trainer or instructor. 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. 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 ATTN: Legal Unit Licensing Division PO Box 64953 St. Paul, MN 55164-0242 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. Renae Dressel, Senior Human Services Licensor Licensing Division Office of Inspector General 651-431-2661
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