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October 12, 2023 Sheltonn Johnson, Authorized Agent Thrive Youth Services 1710 Douglas Drive N, Suite 224D Golden Valley, Minnesota 55422 License Number: 1093608 (245D – HCBS) CORRECTION ORDER Dear Sheltonn Johnson: On September 6, 2023, a licensing review of Thrive Youth Services, located at 1710 Douglas Drive N, Suite 224D, Golden Valley, 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.05, subdivision 2. Violation: For two of five persons whose records were reviewed (P1 and P2), the license holder did not implement medication administration procedures as required. a. The license holder was assigned responsibility for medication administration in P1’s support plan and support plan addendum. P1 was prescribed glucophage 500 mg tablets, to be taken twice daily at 8 AM and 8 PM. On April 27, 2023, P1’s physician changed the orders for P1’s glucophage. The new prescription was glucophage 500mg tablets, take two tablets at 8 AM. The license holder continued to administer P1’s glucophage according to the previous order until June 14, 2023. Therefore, the license holder failed to implement medication administration procedures to ensure P1 took their medications as prescribed between April 28, 2023 and June 14, 2023. b. P1 was prescribed Lamictal 25 mg tablets, take one tablet at 8 AM and two tablets at 12 PM. Between July 2, 2023, and July 7, 2023, P1 was administered two tablets of Lamictal 25 mg at 8 AM and 12 PM. Therefore, the license holder failed to implement medication administration procedures to ensure P1 took their medication as prescribed between July 2, 2023, and July 7, 2023. c. The license holder maintained a medication administration record for P1 where the license holder documented when P1’s medications were started, administered, changed, discontinued, or any occurrence of a dose of medication not being administered as prescribed. However, the license holder failed to ensure notation of when a medication or treatment was administered or an occurrence of a dose of medication not being administered as prescribed to P1 on the following dates: · June 12, 2023; · July 22, 2023; · August 15, 2023; and · September 2, 2023. d. The license holder maintained a “Safe Medication Assistance and Administration Policy” that defined “medication administration” to include, but not limited to: · coordination of medication refills; · communicating with the pharmacy; and · coordination and communication with the prescriber. P2 was prescribed vitamin D3 1,000 unit capsules. P2’s medication administration record for August 2023 indicates that administration of one or more of these medications did not occur on August 10-12, 2023 due to the medication not being available. The license holder’s failed to ensure medications were administered according to the license holder’s medication administration policy and procedures as required in section 245D.11, subdivision 2, clause (3). e. The license holder was assigned responsibility for medication administration in P2’s support plan and support plan addendum. P2 was prescribed prazosin, 5mg, take two capsules once daily at 8 PM. On June 20, 2023, P2’s physician changed the orders for P2’s prazosin. The new prescription was prazosin, 5mg, take one capsule once daily at 8 PM. P2’s prazosin came packaged in a ‘bubble pack,’ separated by each day. The license holder did not remove the ‘bubble pack’ that included P2’s original prescription of prazosin that included two capsules in each day. The license holder conducted a medication record review on August 1, 2023, and discovered the ‘bubble pack’ with the original prescription and the ‘bubble pack’ with the new prescription were both being administered to P2 between July 11-31, 2023. Therefore, the license holder failed to ensure P2 took their medication as prescribed between July 11-31, 2023. Repeat Violation: The license holder was cited for a similar violation in an Order of Conditional Order dated November 5, 2021; in a Noncompliance of Conditional Order and Correction Order dated May 19, 2022; and in a Correction Order dated December 22, 2022. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision.
2. Citation: Minnesota Statutes, section 245D.05, subdivision 4. Violation: For three persons whose records were reviewed (P1-P3), the license holder did not review medication administration records and report medication and treatment issues as required. a. P2 did not receive a medication on July 28, 2023. Although the license holder informed P2’s legal representative of the medication error, the license holder failed to report this error to P2’s case manager. b. For P2 and P3, the license holder reviewed medication and treatment issues every three months for; however, the license holder did not develop and implement a plan to correct patterns of medication administration errors when identified in the reviews. Repeat Violation: The license holder was cited for a similar violation in an Order of Conditional Order dated November 5, 2021; in a Noncompliance of Conditional Order and Correction Order dated May 19, 2022; and in a Correction Order dated December 22, 2022. Corrective Action Ordered: Within 30 days of receiving this order, you must inform P2’s case manager of the above stated error. On an ongoing basis, you must maintain compliance as required in this subdivision. 3. Citation: Minnesota Statutes, section 245D.10, subdivision 3a. Violation: For two persons whose records were reviewed (P4 and P5), the license holder did not enforce their policy for service termination as required. For P4 and P5, the license holder issued a service termination on July 26, 2023, to P4, P5 and their case managers with a termination date of September 23, 2023. On August 22, 2023, P4, P5 and their case managers were notified of a termination date of August 31, 2023. The license holder failed to provide P4, P5 and their case managers a notice of the proposed service termination 60 days prior to the termination. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. Staff Standards 4. Citation: Minnesota Statutes, section 245D.09, subdivision 5. Violation: For one of three staff persons whose record was reviewed (SP1), the license holder did not provide annual training as required. 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 failed to provide SP1 with annual training on the following topics: · 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 section 245D.04; · sections 245A.65, 245A.66, 626.556, and 626.557, governing maltreatment reporting and service planning for children and vulnerable adults, and staff responsibilities related to protecting persons from maltreatment and reporting maltreatment. This orientation must be provided within 72 hours of first providing direct contact services and annually thereafter according to section 245A.65, subdivision 3; · 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. Repeat Violation: The license holder was cited for a similar violation in an Order of Conditional Order dated November 5, 2021. Corrective Action Ordered: Within 30 days of receiving this order, you must provide the above-mentioned training to SP1 and document the training in SP1’s personnel record according to the requirements in 245D.095, subd, 5. On an ongoing basis, you must maintain compliance as required in this subdivision. 5. Citation: Minnesota Statutes, section 245D.095, subdivision 5. 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 a personnel record for SP2 and SP3 that included documentation of orientation and training of one of the following: · the date the training was completed; · the number of hours per subject area; and · the name of the trainer or instructor. Repeat Violation: The license holder was cited for a similar violation in an Order of Conditional Order dated November 5, 2021; and in a Correction Order dated December 22, 2022. 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. 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. Liz Schiefelbein, Senior Human Services Licensor Licensing Division Office of Inspector General 651-431-2738
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