|
December 28, 2023 Amanda Bucar-Annis, Authorized Agent Trillium Services, Inc. 4629 Airpark Blvd Duluth, MN 55811-5750 License Number: 1108879 (HCBS) CORRECTION ORDER Dear Amanda Bucar-Annis, On November 1-2, 2023, Department of Human Services (DHS) licensors conducted a licensing review at your program located at 4629 Airpark Blvd, Duluth, Minnesota. As a result of this visit, DHS determined that you are in violation of six of the 245D rules and statutes. As a result, DHS is issuing this order which requires you to take the correction action as described under each violation. Details of our findings are provided below. Our next steps and your options are also detailed. LICENSING VIOLATIONS DHS determined that your program failed to follow licensing rules and statutes, as described below. Service Recipient 1. Violation: For two of seven persons whose records were reviewed (P5 and P6), the license holder did not provide services in response to the person’s identified needs, interests and preferences as required for each service. The license holder provided multiple services to P5 and P6. The license holder failed to ensure that P5 and P6’s support plan addendums identified how services were provided for each service, including how, when and by whom. Statute Violated: section 245D.07, subdivision 1a. Corrective Action Required: Within 30 days of receiving this order, you must review and update P5 and P6’s support plan addendums to include the information listed above. On an ongoing basis, you must maintain compliance as required. 2. Violation: For three persons whose records were reviewed (P5—P7) the license holder did not meet the requirements for service plan review and evaluation as required. a. For P5—P7, The license holder failed to discuss with the person, the person’s legal representative, and members of the support team about how technology might be used to meet the person’s desired outcomes at least once per year and failed to maintain a summary of the discussion in the person’s support plan addendum. b. For P7, the license holder failed to discuss with the person, the persons legal representative, the case manager options for transitioning out of a community setting controlled by the provider and into a setting not controlled by the provider and maintain a summary of this discussion. Statute Violated: section 245D.071, subdivision 5, paragraphs (b), (c), and (d). Corrective Action Ordered: Within 30 days of receiving this order, you must: · discuss with each person, their legal representative, case manager and members of the support team about topics stated above as required; and · summarize this conversations and include it in P5—P7’s support plan addendums. On an ongoing basis, you must maintain compliance as required. 3. Violation: For one person whose record was reviewed (P7), the license holder did not complete service plan review and evaluation as required. For P7, the license holder failed to summarize the P7’s status and progress toward achieving the identified outcomes and make recommendations and identify the rationale for changing, continuing, or discontinuing implementation of supports and methods. Statute Violated: section 245D.071, subdivision 5, paragraph (g). Corrective Action Required: On an ongoing basis, you must maintain compliance as required. 4. Violation: For one person whose record was reviewed (P11), the license holder did not report an incident as required. P11 sustained an serious injury on November 1, 2023. The license holder failed to report the incident to DHS within 24 hours of the incident occurring. The license holder reported the incident to DHS on November 3, 2023. Statute Violated: section 245D.06, subdivision 1 pargraph (b). Corrective Action Required: On an ongoing basis, you must maintain compliance as required. RECORD REQUIREMENTS 5. Violation: For four persons whose records were reviewed (P5, P6, P7 and P9), the license holder failed to maintain service recipient records as required. The license holder failed to maintain progress or daily log notes in P5, P6, P7 and P9’s service recipient records. Statute Violated: section 245D.095, subdivision 3, paragraph (b), clause (11). Corrective Action Required: Within 30 days of receiving this order, you must begin maintaining progress or daily log notes for each person served by your program. You must maintain the progress or daily log notes in the person’s service recipient record. On an ongoing basis, you must maintain compliance as required. 6. For one person whose record was reviewed (P6), the license holder failed to ensure access to the person’s service recipient record as required. The license holder failed to ensure the staff providing services to P6 had access P6’s service recipient record. Rule/Statute Violated: Minnesota Statutes, section 245D.095, subdivision 4. Corrective Action Required: Within 30 days of receiving this order, you must ensure staff have access to the service recipient record for each person served by your program. On an ongoing basis, you must maintain compliance as required. YOUR RIGHT TO REQUEST RECONSIDERATION You have the right to request reconsideration of this order and the cited violations. Your request must: · Be in writing · List each violation you are challenging and identify what is inaccurate or incomplete about the information in the order · Supply information that is accurate or more complete · Be made before the deadlines provided below If you are mailing your request, it must be received by DHS within 20 calendar days from when you received this order. If you do not meet this deadline, you lose your right to request reconsideration. The timeline to appeal began when you received this order. Please send it to: Commissioner, Department of Human Services Office of Inspector General Legal Counsel’s Office Attn: Licensing Legal Unit PO Box 64953 St. Paul, MN 55164-0953 If your request is being personally delivered, it must be received by DHS within 20 calendar days from when you received this order. Please bring it to: Commissioner, Department of Human Services Office of Inspector General Legal Counsel’s Office Attn: Licensing Legal Unit 444 Lafayette Road North St. Paul, MN 55155 Legal authority for this licensing action · This action is taken under Minnesota Statutes, section 245A.06, subdivision 1. · The timeline to request reconsideration of the order is provided in Minnesota Statutes, section 245A.06, subdivision 2. Questions If you have any further questions regarding this matter, you may contact me at 651-431-6646. Sincerely, Nichole Dawson Licensing Division Office of Inspector General
|
