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January 17, 2024 Debra Shriver 328 5th Street SW Suite 5 Willmar, MN 56201 RE: Report No. 202307645/202308621 Fourth Avenue Homes, Inc. License No. 1104516/1068742 Dear Debra Shriver: CORRECTION ORDER An investigation of Fourth Avenue Homes, Inc. was completed regarding report number 202307645/202308621 which alleged violation of Minnesota Statutes, section 626.557, and Minnesota Statutes, Chapter 245D. This maltreatment allegation concerned neglect. The disposition of one of the allegations of the investigation report is inconclusive and the disposition of one of the allegations of the investigation report is substantiated. Two violations were noted. VIOLATIONS AND CORRECTION ORDERS The following violations of state and (or) federal laws and rules were observed. Corrective action for the violations is required by Minnesota Statutes, section 245A.06, and is hereby ordered by the Commissioner of Human Services. Failure to correct the violations within the prescribed amount of time may result in fines and/or action against your license, as provided for in Minnesota Statutes, sections 245A.06 and 245A.07. 1. Citation: Minnesota Statute, section 245D.07, subdivision 1.
Violation: On September 6, 2023, a staff person left the facility and failed to provide supervision to a service recipient who required 24-hour supervision. On October 7, 2023, a staff person slept and failed to supervise a vulnerable adult that required 24-hour supervision. The license holder did not provide services in response to the person’s identified needs, interests, preferences, and desired outcomes as specified in the support plan and the support addendum. Corrective action ordered: Correct immediately and on an ongoing basis, you must maintain compliance as required in this subdivision. 2. Citation: Minnesota Statute, section 245D.09, subdivision 4, paragraph 5; and subdivision 4A.
Violation: For one (P) of four staff persons whose record were reviewed, the license holder did not maintain personnel records as required. The facility did not maintain records to show that SP2 was trained on: · The Reporting of Maltreatment of Vulnerable Adults Act within 72 hours of first providing direct contact. · The service recipient’s (R) needs before having unsupervised direct contact. Training on the R’s plan was not provided. The facility failed to maintain documentation in The P’s personnel records that included the date training was complete, the number of hours, and the name of the instructor or trainee. Corrective action ordered: Correct immediately and on an ongoing basis, you must maintain compliance as required in this subdivision. If you believe any of the citations are in error, you may ask the Commissioner of Human Services to reconsider the parts of the correction order that you believe to be in error. If you choose to exercise this right, your request for reconsideration must be in writing and received by the Commissioner within 20 calendar days after receipt of this letter. Your request for reconsideration must be sent to: Commissioner Minnesota Department of Human Services c/o Licensing Division PO Box 64242 St. Paul, MN 55164-0242 You must include any and all information, documentation, or other evidence you have to support your request for reconsideration. Please note that a request for reconsideration does not stay any provisions of the correction order. If you have any questions regarding the investigation, contact me immediately. If you have any questions regarding compliance with this Correction Order or applicable rules, contact your licensor, Nichol Ginther. Sincerely,
Judith Schwanke, Investigator Office of Inspector General Licensing Division judith.schwanke@state.mn.us 651-431-4033 Enclosure
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