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May 3, 2024 CERTIFIED MAIL Michelle O’Toole, Authorized Agent Diversified Lifestyles Inc. 1111 6th Street Southeast Willmar, MN 56201-4637 License Number: 1069582 (Home and Community-Based Services) Licensing Complaint Numbers: 202306665, 202400503 ORDER OF CONDITIONAL LICENSE Dear Michelle O’Toole: The Department of Human Services (DHS) is placing your license to provide Home and Community-Based Services for Diversified Lifestyles Inc. at 1111 6th Street Southeast, Willmar, Minnesota on conditional status for two years, beginning May 3, 2024. This means you must meet certain conditions to maintain your license, detailed below. This order is based on your noncompliance with Home and Community-Based licensing requirements. Details of our findings are also provided below. Our next steps and your options are also detailed. REASON FOR THE CONDITIONAL LICENSE On January 16-18, 2024, DHS licensors conducted a licensing review and licensing complaint investigations at your facility located at 1111 6th Street Southeast, Willmar, Minnesota. As a result of this licensing visit and licensing complaint investigation, the DHS licensors determined that your program failed to comply with the laws and rules that apply to licensed Home and Community-Based Services, citing 25 violations. DHS has considered the nature, chronicity, and severity of these violations, as well as the health, safety, and rights of persons served by the program. · Nature: Many of the violations cited in the Order of Conditional License are violations of law or rule affecting the health, safety, or rights of persons served by the program. The licensing violations include: o Failure to provide program coordination, evaluation, and oversight by a designated coordinator and a designated manager o Failure to ensure the exercise and protection of a person’s service-related and protection-related rights o Failure to meet the requirements for the completion of individual abuse prevention plans for persons served o Failure to meet the requirements for the safekeeping funds and property for persons served o Failure to meet the requirements for the completion of the assessments for persons served o Failure to develop and incorporate positive support strategies and person-centered planning o Failure to meet the requirements for intensive service planning and delivery o Failure to develop service outcomes and supports o Failure to provide persons served with an orientation to and an explanation of the service recipient rights o Failure to meet health service needs requirements consistent with the person’s health needs o Failure to provide information on policies and procedures that affect a person’s rights o Failure to maintain service recipient and personnel records o Failure to provide required annual training to staff persons o Failure to enforce policies and procedures o Failure to notify DHS of all controlling individuals on the license · Chronicity: Your program received its license on January 1, 2014. Since that time, your program has demonstrated a history of noncompliance with licensing rules and statutes. The information below summarizes this history: o May 3, 2024 Conditional License (this order): 25 violations (3 repeat) o April 13, 2017 Correction Order: 4 violations · Severity: Many of the violations that led to the Order of Conditional License relate to the health and safety of persons served. Due to the serious and chronic nature of these violations, and the conditions in the program, which impact the health and safety of persons served in your care, your license to provide Home and Community-Based Services is placed on a conditional status. Licensing Violations DHS determined that your program failed to follow licensing rules and statutes, as described below. CONTROLLING INDIVIDUALS 1. Violation: The license holder did not notify the commissioner before making any changes to the license holder’s controlling individuals as required. At the time of the licensing review, the license holder stated that SP7 and SP8 were owners of the program. In addition, SP1 stated s/he acted in a managerial official role who directed the management of the program. SP7 was the only person listed as a controlling individual on the license. The license holder failed to notify the commissioner before making changes to the license holder’s controlling individuals. Statute Violated: Minnesota Statutes, section 245A.04, subdivision 7a, paragraph (a). PROGRAM COORDINATION AND OVERSIGHT VIOLATIONS 2. Violation: The license holder did not meet the requirements for program coordination, evaluation, and oversight. a. The license holder failed to ensure that the designated coordinator (SP1) was competent to perform the required duties, including the supervision, support, and evaluation of activities that included: · oversight of the license holder’s responsibilities assigned in the person’s support plan and support plan addendum; · taking the action necessary to facilitate the accomplishment of the outcomes according to the requirements in section 245D.07; · instruction and assistance to direct support staff implementing the support plan and the service outcomes, including the failure to have an established process in which the designated coordinator determines the competency of the person that has been has delegated the responsibility to directly observe the service delivery activities to assess staff competency; · evaluation of the effectiveness of services delivery, methodologies, and progress on the person’s outcomes based on the measurable and observable criteria for identifying when the desired outcomes based on the measurable and observable criteria for identifying when the desired outcome has been achieved according to the requirements in section 245D.07. The failure to provide program coordination and oversight of the services provided is evidenced in citations 2 through 25. b. The license holder failed to ensure that the designated manager (SP1) was competent to perform the required program management and oversight of the services provided by the license holder, included: · maintaining a current understanding of the licensing requirements sufficient to ensure compliance throughout the program as identified in section 245A.04, subdivision 1, paragraph (e), and when applicable, as identified in section 256B.04, subdivision 21, paragraph (g); · ensuring the duties of the designated coordinator are fulfilled according to the requirements in subdivision 2; · ensuring staff competency requirements are met according to the requirements in section 245D.09, subdivision 3, including ensuring periodic performance evaluations of the direct support staff’s ability to perform the job functions based on direct observation are completed by the license holder; and · evaluating the information identified in clauses (1) to (6) to develop, document, and implement ongoing program improvements. The failure to provide program management and oversight of the services provided is evidenced in citations 1 through 25. Statute Violated: Minnesota Statutes, section 245D.081, subdivisions 2 and 3. SERVICE RECIPIENT RIGHTS AND PROTECTION STANDARDS VIOLATIONS 3. Violation: The license holder did not meet the requirements for abuse prevention plans as required. The license holder maintained a program abuse prevention plan (PAPP) for the community residential setting (CRS, license number 1069584) that was dated as being last reviewed on May 7, 2021. The license holder failed to review the program abuse prevention plan (PAPP) on an annual basis. Statute Violated: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (a), clause (5). 4. Violation: For three of nine persons whose record was reviewed (P1- P4), The license holder did not provide service recipient rights as required. a. P2’s services were initiated on July 17, 2017. The license holder failed to provide P2 with a written notice that identifies the service recipient rights annually. At the time of the review, the license holder only maintained a written notice of rights dated May 11, 2023. b. P3's date of service initiation was December 15, 2018. The license holder failed to provide P3 with a written notice that identifies the service recipient rights annually. At the time of the review, the license holder only maintained a written notice of rights dated January 27, 2023. c. The written notice provided to P1’s legal representative, to P2, and to P4 failed to include the following rights: · have access to the person's personal possessions at any time, including financial resources; · have access to three nutritionally balanced meals and nutritious snacks between meals each day; · have freedom and support to access food and potable water at any time; · have the freedom to furnish and decorate the person’s bedroom or living unit; · a setting that is clean and free from accumulation of dirt, grease, garbage, peeling paint, mold, vermin, and insects; · a setting that is free from hazards that threaten the person’s health or safety; and · a setting that meets the definition of a dwelling unit within a residential occupancy as defined in the State Fire Code. Statute Violated: Minnesota Statutes, section 245D.04, subdivision 1, paragraph (1). Repeat Violation: In a Correction Order that DHS issued on April 13, 2017, you were previously found in violation of this same statute. 5. Violation: The license holder did not ensure the exercise and protection of the person’s rights in the service provided as required. The license holder failed to ensure persons served by program had their personal, financial, service and health information kept private. During the licensing review DHS licensors observed that the program used documents from persons records to print on the blank side of the paper. DHS licensors found persons documents in other persons records, in staff records, and in program records. Statute Violated: Minnesota Statutes, section 245D.04, subdivision 3. 6. Violation: For three persons whose record was reviewed (P7—P9), The license holder did not ensure protection related rights.
The license holder failed to ensure P7—P9, received services in a clean and safe environment when the license holder was the owner, lessor, or tenant of the services site and P7—P9 lived in a setting that was clean, and free from accumulation of dirt, garbage, vermin, and insects. During a site visit of the license holder’s CRS (license number 1069583) during the licensing review, a DHS licensor noted: · an accumulation of dirt, debris, and dead insects in the bathroom and bathroom cupboard that housed hygiene products used by persons living in the home; · a pile of dirty gloves, discarded on the floor in the basement; and · a box spring used by a person served that was stained with urine and feces. At the time of the licensing review, the license holder replaced the box spring. Statute Violated: Minnesota Statutes, section, 245D.04, subdivision 3, paragraphs (a), clause (5) and paragraph (b), clause (8). 7. Violation: For one person whose record was reviewed (P1), the license holder did not meet the requirements for safekeeping of funds as required. The license holder assisted P1 with the safekeeping of funds. P1’s services were initiated on December 27, 2022. The license holder obtained written authorization from P1’s legal representative on February 1, 2023. The license holder failed to obtain written authorization from P1’s legal representative and case manager within five working days of service initiation. At the time of the licensing review, the license holder had not obtained written authorization from P1’s case manager. Additionally, the license holder failed to survey, document, and implement the preferences of P1’s legal representative and case manager for frequency of receiving a statement that itemizes receipts and disbursements of funds. Statute Violated: Minnesota Statutes, section 245D.06, subdivision 4, paragraph (a). SERVICE RECIPIENT VIOLATIONS 8. Violation: For three persons whose records were reviewed (P2-P4), the license holder did not meet the requirements for an individual abuse prevention plan (IAPP) as required. a. At the time of the review, no IAPP was developed or maintained in P2 or P4’s records.
b. The license holder failed to review P3’s IAPP with members of the interdisciplinary team on an annual basis. The license holder failed to review P3’s IAPP in 2021 and 2022. Statute Violated: Minnesota Statutes, section, 245A.65, subdivision 2, paragraph (b). 9. Violation: For one person whose record was reviewed (P1), the license holder did not meet initial service planning requirements as required. The license holder held a 45-day service planning meeting with P1 and members of P1’s support team on February 1, 2023. The license holder failed to determine the following at P1’s 45-day service planning meeting: · whether the current service setting is the most integrated setting available and appropriate for the person; · opportunities to develop and strengthen personal relationships with other persons of the person’s choice in the community; · opportunities for community access, participation, and inclusion in preferred community activities; · opportunities to develop and strengthen personal relationships with other persons of the person’s choice in the community; · how services must be coordinated across other providers licensed under this chapter serving the person and members of the support team or expanded support team to ensure continuity of care and coordination of services for the person; · have a discussion of how technology might be used to meet the person's desired outcomes. The support plan addendum must include a summary of this discussion. The summary must include: o a statement regarding any decision that is made regarding the use of technology; and o a description of any further research that needs to be completed before a decision regarding the use of technology can be made. Statute Violated: Minnesota Statutes, section 245D.071, subdivision 3, paragraph (a).
10. Violation: For three persons whose records were reviewed (P1-P3), the license holder did not complete assessments required for intensive service planning as required. a. The license holder failed to complete assessments for P1 in the following areas prior to P1’s 45-day service planning meeting: · the person's ability to self-manage health and medical needs to maintain or improve physical, mental, and emotional well-being, including, when applicable, allergies, seizures, choking, special dietary needs, chronic medical conditions, self-administration of medication or treatment orders, preventative screening, and medical and dental appointments; · the person's ability to self-manage personal safety to avoid injury or accident in the service setting, including, when applicable, risk of falling, mobility, regulating water temperature, community survival skills, water safety skills, and sensory disabilities; and · the person's ability to self-manage symptoms or behavior that may otherwise result in an incident as defined in section 245D.02, subdivision 11, clauses (4) to (7), suspension or termination of services by the license holder, or other symptoms or behaviors that may jeopardize the health and welfare of the person or others, and · the assessments must produce information about the person that describes the person's overall strengths, functional skills and abilities, and behaviors or symptoms. At the time of the licensing review the license holder had not completed the assessments for P1. b. The license holder failed to complete assessments that produced information about P2 that described the person's overall strengths, functional skills, and abilities, and behaviors or symptoms in the assessments the license holder completed on May 11, 2023. c. The license holder failed to complete assessments for P2 and P3 on an annual basis. · P2’s record contained the assessments dated May 11, 2023. At the time of the licensing review, no other assessments were documented or maintained by the license holder. · P3’s record contained assessments dated January 27, 2023. At the time of the licensing review, no other assessments were documented or maintained by the license holder. Statute Violated: Minnesota Statutes, section 245D.071, subdivision 3, paragraph (b). Repeat Violation: In a Correction Order that DHS issued on April 13, 2017, you were previously found in violation of this same statute. 11. Violation: For three persons whose records were reviewed (P1-P3), the license holder did not develop a service plan that documents the service outcomes and supports based on the assessments completed under subdivision 3 and the requirements in 245D.07, subdivision 1a as required. The license holder failed to document the supports and methods to be implemented to support the person and accomplish outcomes related to acquiring, retaining, or improving skills and physical, mental, and emotional health and well-being. For P1, P2, and P3 the license holder failed to document the following: · the methods or actions that will be used to support the person and to accomplish the service outcomes including: o information about changes or modifications to the physical and social environments; o equipment and materials required; o techniques that are consistent with the person’s communication mode and learning style; · the measurable and observable criteria for identifying when the desired outcome has been achieved and how data will be collected; · the projected starting date for implementing the supports and methods and the date by which the progress towards accomplishing the outcomes will be reviewed and evaluated; and · the names of the staff or position responsible for implementing the supports and methods. Statute Violated: Minnesota Statutes, section 245D.071, subdivision 4, paragraph (b). 12. Violation: For three persons whose records were reviewed (P1- P3), the license holder did not meet the requirements for service plan review and evaluation as required. a. P1 and P3’s support plan addendum required semi-annual service plan review meetings. The license holder failed to meet with the persons and members of their support team on an annual and semi-annual basis. b. The license holder failed to meet with P2 and P2’s case manager and other members of the support team on an annual basis ad required. Additionally, the license holder failed to provide progress reports for P2 on an annual basis. Statute Violated: Minnesota Statutes, section 245D.071, subdivision 5. Repeat Violation: In a Correction Order that DHS issued on April 13, 2017, you were previously found in violation of this same statute. 13. Violation: For one person whose record was reviewed (P1), the license holder did not provide copies of the policies and procedures as required. The license holder failed to provide copies of the following policies and procedures within five working days of service initiation to P1’s case manager: · grievance policy; · temporary service suspension policy; · service termination policy; · emergency use of manual restraints policy; and · data privacy policy. Statute Violated: Minnesota Statutes, section 245D.10, subdivision 4, clause (b). 14. Violation: For three persons whose records were reviewed (P1-P3), the license holder did not meet the requirements for positive support strategies as required. a. For P1 and P3, the license holder failed to evaluate with the person whether the positive support strategies met standards at least every six months. b. For P2, the license holder failed to incorporate positive support strategies into an existing support plan. Furthermore, the license holder failed to evaluate with the person whether the positive support strategies met standards at least every six months. Rule Violated: Minnesota Rule, section 9544.0030, subparts 1 and 2. HEALTH SERVICES VIOLATIONS 15. Violation: For one person whose record was reviewed (P6), the license holder did not meet health service needs as required. The license holder was assigned the responsibility of meeting P6’s health needs. P6 had a seizure disorder, and the license holder maintained a seizure protocol that stated staff needed to document each seizure including specific details to be provided to P6’s neurologist at appointments. The license holder failed to document P6’s seizures. Statute Violated: Minnesota Statutes, section 245D.05, subdivision 1, paragraph (a). 16. Violation: For one person whose record was reviewed (P2), the license holder did not document health service needs in the support plan addendum as required. The license holder was assigned the responsibility of meeting P2’s health service needs in the support plan addendum. The license holder failed to maintain documentation, including a description of the procedures the license holder would follow in order to use P2’s medical equipment, devices, or adaptive aides. Statute Violated: Minnesota Statutes, section 245D.05, subdivision 1, paragraph (b). 17. Violation: For four persons whose records were reviewed (P1, P2, P3, and P6), the license holder did not meet the requirements for medication setup as required. The license holder was assigned the responsibility of meeting P1- P3, and P6’s health needs, including medication administration. During site visits at the program’s community residential settings (CRS) DHS licensors determined that the program set up persons medications in pill minders and administered the medications to persons from the pill minders. The license holder failed to document the following information in P1- P3, and P6’s medication administration records (MAR): · dates of setup; · name of medication; · quantity of dose; · times to be administered; · route of administration at time of setup; and · when the person will be away from home, to whom the medications were given. Statute Violated: Minnesota Statutes, section 245D.05, subdivision 1a. 18. Violation: For four persons whose records were reviewed (P1, P2, P5, and P6), the license holder did not implement medication administration procedures as required. a. The license holder failed to document a notation when one or more medications were administered on P1’s MAR. P1 was prescribed multiple medications. From June 1, 2023 through November 30, 2023 there were 255 instances where there was no documentation of the administration of a medication on P1’s MAR. b. The license holder failed to document a notation when one or more medications were administered on P2’s MAR. P2 was prescribed multiple medications. From December 1, 2023 through January 16, 2024, there were 85 instances where there was no documentation of the administration of medications on P2’s MAR. c. During a site visit to P2, P5, and P6’s CRS on January 18, 2024, DHS licensors found multiple different loose medications in the containers where each person’s medications were maintained. It could not be determined if these medications fell out of the medication setup boxes for the persons or if persons received the medications as prescribed. The license holder failed to implement medication administration procedures to ensure persons took medications as prescribed. Statute Violated: Minnesota Statutes, section 245D.05, subdivision 2, paragraph (b). Violation: For two persons whose record was reviewed (P1 and P2), the license holder did not implement medication administration procedures as required.
The license holder failed to ensure the following information was documented in P1 and P2’s MARs: · information on any risks or other side effects that are reasonable to expect, and any contraindications to its use. This information must be readily available to all staff administering the medication; · the possible consequences if the medication or treatment is not taken or administered as directed; and · instruction on when and to whom to report the following: o if a dose of medication is not administered or treatment is not performed as prescribed, whether by error by the staff or the person or by refusal by the person; o the occurrence of possible adverse reactions to the medication or treatment; and · notation of any occurrence of a dose of medication not being administered or treatment not performed as prescribed, whether by error by the staff or the person or by refusal by the person, or of adverse reactions, and when and to whom the report was made. Statute Violated: Minnesota Statutes, section 245D.05, subdivision 2, paragraph (c). 19. Violation: For three persons whose records were reviewed (P1-P3), the license holder did not review medication administration records as required. a. The license holder was responsible for medication administration for P1. During the licensing review DHS licensors requested P1’s MAR reviews completed by the program since P1’s service initiation in December 2022 to current. The license holder provided two MAR reviews for that time period. The license holder failed to conduct MAR reviews every three months as required. Additionally, the MAR review the license holder completed for P1 in November 2023 failed to identify medication errors. The MAR review stated that that there were no medication errors for the months reviewed. P1’s MAR for this same time period had many instances where there was no notation that P1’s medication was administered. Based on the information provided by the license holder, the license holder also failed to: o develop and implement a plan to correct patterns of medication administration errors; and o report as required to the support team, P1’s refusal or failure to take or receive medications or treatment as prescribed. b. The license holder was responsible for medication administration for P2. During the licensing review, DHS licensors requested P2’s MAR reviews for the year of 2023. The license holder produced a document titled, “Medication Administration Review Record” for P2. The document was dated with the following dates: o March 10, 2023; o June 10, 2023; o September 10, 2023; and o December 10, 2023. The license holder indicated that there were multiple MAR reviews documented on one page for P2. The license holder documented that there was not a pattern of medication administration errors identified during this same time period. The license holder failed to identify a pattern of medication administration errors. At the time of the review, DHS licensors noted P2’s MARS has having significant errors. For example, between December 1, 2023 and December 9, 2023, which would have been part of the license holder’s medication administration review, DHS licensors noted 11 instances where staff failed to note whether the medication was administered. Based on the information provided by the license holder, the license holder also failed to: o develop and implement a plan to correct patterns of medication administration errors; and o report as required to the support team, P2’s refusal or failure to take or receive medications or treatment as prescribed. c. For P3, the license holder was responsible for medication administration. During the licensing review DHS licensors requested P3’s MAR reviews completed by the program from December 2022 to current. The license holder provided one MAR review for that time period. The license holder failed to conduct MAR reviews every three months as required. Statute Violated: Minnesota Statutes, section 245D.05, subdivision 4. 20. Violation: For three persons whose records were reviewed (P1-P3), the license holder was assigned responsibility for medication administration in the support plan addendum. The license holder did not develop, implement, and maintain documentation regarding psychotropic medications as required. a. P1’s support plan addendum required the license holder to provide medication and symptom-related monitoring data to P1’s expanded support team on a semi-annual basis. The license holder failed to provide the monitoring data to P1’s expanded support team on a semi-annual basis. b. P2’s support plan addendum assigned responsibility to the license holder to administer psychotropic medications. The license holder failed to develop, implement, and maintain a description of the target symptoms that the psychotropic medication is to alleviate. c. P3’s support plan addendum required the license holder to provide medication and symptom-related monitoring data to P3’s expanded support team on a quarterly basis. The license holder failed to provide the monitoring data to P3’s expanded support team on a quarterly. Statute Violated: Minnesota Statutes, section 245D.051, subdivision 1, paragraph (b). STAFFING STANDARDS VIOLATIONS 21. Violation: For one of eight staff persons whose record was reviewed (SP3), the license holder did not provide annual training as required.
For SP3, the license holder failed to provide training on the following required topics on an annual basis: · 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 Minnesota Statutes, section 245D.04; · sections 245A.65, 245A.66, and 626.557 and chapter 260E governing maltreatment reporting and service planning for children and vulnerable adults, and staff responsibilities related to protecting persons from maltreatment and reporting maltreatment; · the program abuse prevention plan according to the requirements in 245A.65, subdivision 3; · the principles of person-centered service planning and delivery as identified in Minnesota Statutes, section 245D.07, subdivision 1a, and how they applied to direct support services 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 the 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. Statute Violated: Minnesota Statutes, section 245D.09, subdivision 5. RECORD REQUIREMENTS VIOLATIONS 22. Violation: The license holder did not ensure that the content and format of service recipient, personnel and program records were uniform and legible according to this chapter. During the licensing review, the license holder stored staff, service recipient and program records in paper records. The license holder’s offices had documents scattered on the floor, in boxes, in three ring binders and on shelves. The license holder had difficulty locating requested documents for the licensing review. The license holder failed to ensure the uniform organization of records. Statute Violated: Minnesota Statutes, section 245D.095, subdivision 1. 23. Violation: For three staff persons whose records were reviewed (SP3, SP5, and SP6) the license holder did not maintain personnel records as required. The license holder failed to maintain the hours of training per subject area in SP3, SP5 and SP6’s personnel records for each required training subject area. Statute Violated: Minnesota Statutes, section 245D.095, subdivision 5. POLICIES AND PROCEDURES VIOLATIONS 24. Violation: The license holder did not develop, document, and implement a policy and procedures related to the emergency use of manual restraints as required. The license holder established two contradictory policies related to the emergency use of manual restraints. The license holder established one policy that allowed for the emergency use of manual restraints and one policy that did not allow the emergency use of manual restraints. Statute Violated: Minnesota Statutes, section 245D.061, subdivision 9. 25. Violation: The license holder did not implement the program’s safe medication assistance and administration policy as written. During site visits on January 18, 2024, to the CRS facilities where P2, P6, and P10 lived licensors discovered that P2, P6, and P10 had expired medications maintained in the same locations where their current medications were maintained. The license holder’s policy on the safe assistance and administration of medication stated that medications would be disposed of according to the Environment Protection Agency (EPA) guidelines. EPA guidelines specifically state expired medications are to be disposed of. The license holder failed to follow the program’s policy on the safe assistance and administration of medication. Statute Violated: Minnesota Statutes, section 245D.11, subdivision 2, paragraph (3). Immediate corrective action required You must immediately correct the violations cited above. Compliance with this order will be reviewed onsite. you fail to demonstrate substantial compliance with home and community-based services requirements or with the terms of your conditional license that are provided below, DHS may take an additional licensing action, including revocation, against your license. CONDITIONAL LICENSE TERMS In addition to the Home and Community-Based licensing rules and statutes, you are required to comply with the following terms: 1. Within 15 days of receiving this order, you must notify current persons receiving services, their legal representatives (as applicable), case managers, all payer sources of the conditional status of your license. The notification must specify the length of time of the conditional status of your license, the reasons your license was made conditional, and it must include either a copy of the Order of Conditional License or an offer to provide a copy of the order upon request. The notification must be approved by DHS Licensing prior to being sent to persons receiving services and all other parties. Therefore, the draft notice must be submitted to DHS for approval within 10 days of receiving this order. While the license is on conditional status, you must notify new persons receiving services, case managers, and payer sources that the license is on conditional status before they begin receiving services. The notification to new persons receiving services must specify the length of time of the conditional status of the license, the reasons the license was made conditional, and it must include either a copy of the Order of Conditional License or an offer to provide a copy of the order upon request. Within 30 days of receiving this order, you must submit to the DHS Licensing Division a list of the individuals and parties that received the notice. 2. Within 30 days of receiving this order, you must: · designate a staff person, other than SP1, who is responsible for delivery and evaluation of services provided by the license holder; · designate a managerial staff person, other than SP1, to provide program management and oversight of the services provided by the license holder; and · submit this staff person’s name and qualifications to your licensor for approval. The same person may perform both functions if the work and education requirements outlined in section 245D.081, subdivisions 2 and 3 are met. 3. Within 60 days of receiving this order, you must: · submit a written plan detailing how you will ensure the corrective action ordered in this order is completed; and · submit a written plan to your licensor detailing how you will audit all participant and personnel records for compliance with all applicable rules and statutes. 4. Within 60 days of receiving this order, you must: · complete the audit of all participant and personnel records according to your written plan; · submit the results of the audit to your licensor; and · submit the date to your licensor that all participant and personnel records will be brought into compliance based on the results of your audit. This date must be prior to September 1, 2024. 5. You may not admit new participants to your program from the date of this order until you have successfully demonstrated to DHS compliance with the terms of the conditional license and have maintained substantial compliance with all licensing standards. Program is defined by section 245D.02, subdivision 26 meaning either the nonresidential or residential programs as defined in 245A.02, subdivisions 10 and 14. At a minimum, you may not admit new participants to your program for a period of six months from the date of this conditional license. Admission of any new participant during the duration of the conditional license is only allowed with prior approval from DHS. 6. You may not apply for other DHS-issued licenses without prior approval from DHS for the duration of this conditional license. 7. You may not add additional services to your HCBS license without prior approval from DHS for the duration of this conditional license. Submissions required as part of a corrective action ordered must be sent to your Licensor at: 1. By secure email at renae.s.dressel@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: Renae Dressel Licensing Division PO Box 64242 St. Paul, MN 55164-0242 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 · Clearly state that you are requesting reconsideration of the conditional license · List each citation you are challenging and identify what is inaccurate or incomplete about the information in the order · Supply information that is accurate or more complete · State why you believe your license should not be on a conditional status · Be made before the deadlines provided below If you are mailing your request, it must be sent by certified mail and postmarked within 10 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 10 calendar days from when you received this order. Please bring it to: Commissioner, Department of Human Services Office of Inspector General Licensing Division Attention: Legal Unit 444 Lafayette Road North St. Paul, MN 55155 Conditional license stayed pending reconsideration If you request reconsideration within the timeframes described above, the terms of the conditional license will not be imposed until a decision is issued by DHS. You continue to be required to comply with all Home and Community – Based Services laws and rules. Legal authority for this licensing action · This action is taken under Minnesota Statutes, section 245A.06, subdivision 1. · Home and Community – Based Services are required to follow Minnesota Statutes 245A, 245C, 245D, and Minnesota Rules, chapter 9544. · The timeline to request reconsideration of the order is provided in Minnesota Statutes, section 245A.06, subdivision 4. · If a license holder files a timely reconsideration request, the terms of the conditional license are stayed pending a decision by DHS under Minnesota Statutes, section 245A.06, subdivision 4. · Minnesota Statutes, section 245A.06, subdivision 3 states that DHS may impose additional licensing actions against a license holder that does not correct the violations cited in a conditional license order. Questions If you have any further questions regarding this matter, you may contact Renae Dressel, Supervisor, at 651-431-2661. Sincerely,
Jill Slaikeu, Unit Manager Licensing Division Office of Inspector General
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