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January 30, 2024 Sheltonn Johnson, Authorized Agent Thrive Youth Services 4033 Hollyhock Cir N Brooklyn Park, Minnesota 55443 License Number: 1093608 (245D – HCBS) CORRECTION ORDER Dear Sheltonn Johnson: On January 17, 2024, a licensing review of Thrive Youth Services, located at 1710 Douglas Drive N, 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 245A.65, subdivision 2, paragraph (a). Violation: For two of four persons whose record was reviewed (P1 and P3), the license holder did not provide orientation to the program abuse prevention plan (PAPP) as required. P1’s services were initiated on September 14, 2023, and P3’s services were initiated on December 4, 2023. The license holder failed to provide orientation to P1 and P3 with orientation to the PAPP within 24 hours of admission. The license holder provided orientation to the PAPP to P1, and P3 on January 16, 2024. Repeat Violation: The license holder was cited for a similar violation in an Order of Conditional Order dated November 5, 2021. 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 one person whose record was reviewed (P1), the license holder did not review medication administration records and report medication and treatment issues as required. P1 refused to take all medications on September 30, 2023. Although, the license holder informed P1’s legal representative and case manager on January 16, 2024, the license holder failed to report this refusal as it occurred. The license holder reviewed medication and treatment issues every three months for P1; however, the license holder failed to 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; in a Correction Order dated December 22, 2022; and in a correction order dated October 12, 2023. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 3. Citation: Minnesota Statutes, section 245D.09, subdivision 4. Violation: For one of four staff persons whose records were reviewed (SP4), the license holder did not provide orientation training as required. SP4 was hired on March 6, 2023. The license holder failed to provide SP4 with an orientation on first aid within 60 days of hire. Repeat Violation: The license holder was cited for a similar violation in an Order of Conditional Order dated November 5, 2021; and in a Noncompliance of Conditional Order and Correction Order dated May 19, 2022. Corrective Action Ordered: Within 30 days of receiving this order, you must provide SP4 with first aid training and maintain documentation of this training as required in section 245D.095, subdivision 5. On an ongoing basis, you must maintain compliance as required in this subdivision. 4. Citation: Minnesota Statutes, section 245D.09, subdivision 4a. Violation: For one staff person whose records were reviewed (SP4), the license holder did not provide orientation training as required. SP4 was hired on March 6, 2023. Beginning on March 31, 2023, SP4 began providing medication administration to persons served during this time. The license holder failed to provide SP4 with the following prior to SP4 administering medications: · review and instruction on the medication administration procedures established for the person; and · medication administration training from a training curriculum developed by a registered nurse or appropriate licensed health professional. The training curriculum must incorporate an observed skill assessment conducted by the trainer to ensure unlicensed staff demonstrate the ability to safely and correctly follow medication procedures. SP4 received this training on April 28, 2024. Repeat Violation: The license holder was cited for a similar violation in an Order of Conditional Order dated November 5, 2021. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 5. Citation: Minnesota Statutes, section 245D.09, subdivision 5. Violation: For two staff persons whose records were reviewed (SP1 and SP3), 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. a. The license holder failed to provide SP1 with the following required annual training in 2023: · 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 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; and · basic first aid. b. The license holder failed to provide SP3 with annual training in 2023 on basic first aid. 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 October 12, 2023. Corrective Action Ordered: Within 30 days of receiving this order, you must provide the above-mentioned training for SP1 and SP3 and maintain documentation of the above-mentioned trainings in SP1 and SP3’s personnel files. 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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