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November 22, 2023 Trisha Zimmerman, Authorized Agent Good Neighbor + 400 River Road Suite 1 Grand Rapids, Minnesota 55744 License Number: 1075000 (245D – HCBS) CORRECTION ORDER Dear Renee Bymark: On July 17, 2023, a licensing review of Good Neighbor +, located at 400 River Road Suite 1, Grand Rapids, 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 1. Violation: For one of three persons whose records were reviewed (P3), the license holder did not provide an orientation to the internal and external reporting procedures of alleged or suspected maltreatment of vulnerable adults as required. P3’s basic services were initiated on March 1, 2022. The license holder failed to provide P3 an orientation to the internal and external reporting procedures of alleged or suspected maltreatment of vulnerable adults within 24 hours of admission. The license holder provided this orientation to P3 on May 18, 2022. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 2. Citation: Minnesota Statutes, section 245A.65, subdivision 2. Violation: For three persons whose records were reviewed (P1-P3), the license holder did not meet the requirements for an individual abuse prevention plan (IAPP) as required. a. Regarding P1, the license holder failed to develop P1’s IAPP as part of the initial individual program plan or service plan prior to or upon service initiation. b. Regarding P2, the license holder failed to review the IAPP annually in 2022. c. Regarding P3, the license holder failed to develop P3’s IAPP as part of the initial individual program plan or service plan prior to or upon service initiation. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 3. Citation: Minnesota Statutes, section 245D.04, subdivision 1. Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not provide a written notice that identified the service recipient rights annually 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. Although the license holder provided P1 with a written notice that identified the service recipient rights on October 29, 2021 and November 4, 2022, the license holder failed to provide the written notice annually. b. Although the license holder provided P2 with a written notice that identified the service recipient rights on March 10, 2021 and May 16, 2022, the license holder failed to provide the annual written notice annually. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 4. Citation: Minnesota Statutes, section 245D.07, subdivision 2. Violation: For three persons whose records were reviewed (P1-P3), the license holder did not meet service planning requirements for basic support services as required. a. P1’s services were initiated on August 1, 2021. The license holder failed to review and revise the preliminary support plan addendum to document the services that will be provided including how, when, and by whom services will be provided, and the person responsible for overseeing the delivery and coordination of services within 60 days of service initiation. b. P2 and P3 have similar failures within this subdivision. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 5. Citation: Minnesota Statutes, section 245D.09, subdivision 4. Violation: For one person whose record was reviewed (SP2), the license holder did not provide orientation training as required. Regarding SP2, who was hired on January 24, 2022, the license holder failed to provide the following orientation training within 60 days of hire: · 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. This was provided on July 24, 2023; · 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. This was provided on July 24, 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. This was provided on July 24, 2023; · 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. This was provided on July 26, 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. This was provided on July 26, 2023; and · strategies to minimize the risk of sexual violence, including concepts of healthy relationships, consent, and bodily autonomy of people with disabilities. This was provided on July 24, 2023. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 6. Citation: Minnesota Statutes, section 245D.09, subdivision 4a. Violation: For two of three staff persons whose records were reviewed (SP1 and SP2), the license holder did not provide an orientation to individual service recipient needs as required. a. On June 1, 2020, SP1 had unsupervised direct contact with a person served by the program. The license holder failed to provide an orientation to the individual service recipient needs to SP1 prior to that date. b. On February 1, 2022, SP2 had unsupervised direct contact with a person served by the program. The license holder failed to provide an orientation to the individual service recipient needs to SP2 prior to that date. Corrective Action Ordered: Within 30 days of receiving this order, you must provide SP1 and SP an orientation to individual service recipient needs as required. On an ongoing basis, you must maintain compliance as required in this subdivision. 7. Citation: Minnesota Statutes, section 245D.09, subdivision 5. Violation: For one person 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. Regarding SP1, the license holder failed to provide the following annual training on an annual basis for 2021: · 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; · 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; · 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; · 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: 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 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, please contact Lacey Walsvik at lacey.l.walsvik@state.mn.us as soon as possible. Christala Culhane, Supervisor Licensing Division Office of Inspector General
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