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November 20, 2023 Vannesa Thao, Authorized Agent Afton Home Care Inc. 1025 Manning Avenue South Afton, Minnesota 55001 License Number: 1106821 (245D – HCBS) CORRECTION ORDER Dear Vannesa Thao, On October 4, 2023, a licensing review of Afton Home Care Inc., located at 1025 Manning Avenue South, Afton 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, paragraph (b). Violation: For one of two persons whose record was reviewed (P1), the license holder did not develop an individual abuse prevention plan (IAPP) as required. The license holder failed to develop an IAPP for P1 that included an accurate individualized assessment of: · P1's susceptibility to abuse by other individuals, including other vulnerable adults; · P1's risk of abusing other vulnerable adults; and · statements of the specific measures to be taken to minimize the risk of abuse to P1 and other vulnerable adults. P1’s Coordinated Services and Supports Plan (CSSP) dated September 23, 2022 stated “[s/he] reports [s/he] would need assistance in case of emergency due to vision impairment and mobility issues. Without formal and informal support in place, [s/he] would be at risk of self-neglect and at risk for vulnerability.” The license holder failed to include this assessment in P1’s IAPP. Corrective Action Ordered: Immediately, you must update P1’s IAPP to include an individualized assessment of: · P1’s susceptibility to abuse by other individuals, including other vulnerable adults; · P1’s risk of abusing other vulnerable adults; and · statements of the specific measure to be taken to minimize the risk of abuse to P1 and other vulnerable adults. Within 30 days of receiving this order, you must submit P1’s updated IAPP to your licensor. On an ongoing basis, you must maintain compliance as required in this subdivision. 1. Citation: Minnesota Statutes, section 245D.04, subdivision 1, paragraph (1). Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not provide written notice of the service recipient rights as required. The license holder failed to provide P1 and P2 with a written notice that identified the service recipient rights, and an explanation of those rights within 5 working days of service initiation. Corrective Action Ordered: Immediately, you must provide all persons and their legal representatives, as applicable, a written notice of the service recipient rights. You must maintain documentation of the person’s or the person’s legal representative’s receipt of the copy and an explanation of the rights according to Minnesota Statutes, section 245D.095, subdivision 3. On an ongoing basis, you must maintain compliance as required in this subdivision. 2. Citation: Minnesota Statutes, section 245D.07, subdivision 2, paragraph (d). Violation: For one person whose record was reviewed (P2), the license holder did not meet service planning requirements for basic support services. The license holder was responsible for participating in semi-annual service planning and support team meetings with P2 and their support team. The license holder failed to participate in a meeting as required in P2’s support plan. Corrective Action Ordered: 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 complete service planning and delivery for intensive support services as required. P1’s service initiation was on February 8, 2023. The license holder failed to complete a preliminary support plan addendum for P1 within 15 days of service initiation. Corrective Action Ordered: Within 30 days of receiving this order, you must complete a preliminary support plan addendum based on the support plan for P1. 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 (P1), the license holder did not develop outcomes and supports as required. The license holder failed to develop a service plan that documented the supports and methods to be implemented for P1 to support the person and accomplish outcomes related to acquiring, retraining, or improving skills and physical, mental and emotional health and well-being, including: · the methods or actions that will be used to support the person 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 were provided; o any equipment and materials required; and o techniques that were consistent with the person’s communication mode and learning style; · the measurable and observable criteria for identifying when the desired outcome had been achieved and how data would be collected; · the projected starting date for implementing the supports and methods and the date by which progress towards accomplishing the outcomes would be reviewed and evaluated; and · the names of the staff persons or positions responsible for implementing the supports and methods. Corrective Action Ordered: Within 30 days of receiving this order, you must: · develop a service plan that documents the service outcomes and supports listed above for P1; and · submit documentation of the supports and methods detailed above to your licensor. On an ongoing basis, you must maintain compliance as required in this subdivision. 5. Citation: Minnesota Statutes, section 245D.10, subdivision 4, paragraph (b). Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not provide copies of policies and procedures as required. a. P1’s services were initiated on February 8, 2023. The license holder failed to inform P1’s case manager of the required policies and procedures and provide copies of those policies and procedures, within five working days of service initiation. The license holder informed P1’s case manager and provided copies of the required policies and procedures on September 26, 2023. b. P2’s services were initiated on March 20, 2023. The license holder failed to inform P2’s case manager of the following policies and procedures and provide copies of those policies and procedures within five working days of service initiation: · grievance policy; · service suspension policy; · service termination policy; and · emergency use of manual restraints policy. Corrective Action Ordered: Within 30 days of receiving this order, you must provide P2’s case manager with copies of the above mentioned policies and procedures. On an ongoing basis, you must maintain compliance as required in this subdivision. 6. Citation: Minnesota Rules, chapter 9544.0030, subpart 1. Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not evaluate positive support strategies as required. The license holder failed to evaluate P1 and P2’s positive support strategies with P1 and P2 at least every six months. Corrective Action Ordered: Within 30 days of receiving this order, you must evaluate the positive support strategies documented in P1 and P2’s support plan addendums with P1 and P2. Additionally, you must evaluate with the person whether the identified positive support strategies for P1 and P2 meet the standards in subpart 2. On an ongoing basis, you must maintain compliance as required in this subpart. 7. Citation: Minnesota Statutes, section 245D.095, subdivision 3, paragraph (b), clause (11). Violation: For one person whose record was reviewed (P1), the license holder did not maintain service recipient records as required. The license holder failed to maintain progress or daily log notes for P1 that were recorded by the program. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 9. Citation: Minnesota Statutes, section 245D.09, subdivisions 3, 4 and 4a. Violation: For one of three staff persons whose record was reviewed (SP2), the license holder did not provide orientation training as required. a. The license holder failed to provide and ensure completion of orientation sufficient to create staff competency for SP2 in the following areas: · job description and how to complete specific job functions including: o responding to and reporting incidents as required in Minnesota Statutes, section 245D.06, subdivision 2; and o following safety practices established by the license holder and as required in section 245D.06, subdivision 2; · the license holder's current policies and procedures, including their location and access, and staff responsibilities related to implementation of those policies and procedures; and · the person’s support plan or support plan addendum as it relates to the responsibilities assigned to the license holder, and the person’s individual abuse prevention plan, to achieve an understanding of the person as a unique individual and how to implement those plans. b. The license holder failed to provide SP3 orientation training on 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 training. On an ongoing basis, you must maintain compliance as required in this subdivision. 10. Citation: Minnesota Statutes, section 245A.65, subdivision 3. Violation: For one staff person whose record was reviewed (SP2), the license holder did not provide an orientation to vulnerable adult maltreatment prevention and reporting as required. 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. Corrective Action Ordered: Within 30 days of receiving this order, you must provide SP2 with the above mentioned required training. 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 Nichol.Ginther@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: Nichol Ginther 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 ATTN: Legal Unit Licensing Division PO Box 64242 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, you may contact Niki Ginther, Senior Human Services Licensor, at 651-431-4822. Brittany Raddatz, Supervisor Licensing Division Office of Inspector General
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