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May 21, 2024 Stephanie Stevens, Authorized Agent Ultimate Sustainability 5240 12th Avenue E, Ste D Shakopee, Minnesota 55379 License Number: 1095137 (245D – HCBS) License Number: 1111440 (Day Service Facility) License Number: 1111441 (Day Service Facility) Report Number: 202306788 CORRECTION ORDER Dear Stephanie Stevens, On March 26, 2024, thru March 28, 2024, a licensing review and investigation of Ultimate Sustainability, located at 5240 12th Avenue East, Suite D, Shakopee, 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 245D.081 Violation: The license holder did not meet the requirements of program coordination, evaluation, and oversight. · The license holder failed to ensure the designated coordinator (SP3), provided supervision, support, and evaluation of activities that include: · oversight of the license holder’s responsibilities assigned in the persons 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 direct observation of service delivery sufficient to assess staff competency; and · 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 license holder failed to ensure that the designated managers (SP4) provided program management and oversight of the services provided by the license holder that include: · maintaining a current understanding of the licensing requirements sufficient to ensure compliance throughout the program as identified in section 245A.04, subdivision 1, paragraph €, 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; · evaluation of satisfaction of persons served by the program, the person’s legal representative, if any, and the case manager with the service delivery and progress towards accomplishing outcomes identified in section 245D.07 and 245D.071 and ensuring and protecting each person’s rights as identified in section 245D.04; · ensuring staff competency requirements are met according to the requirements in section 245D.09, subdivision 3, and ensuring staff orientation and training is provided according to the requirements in section 245D.09, subdivision 4, 4a and 5; and · evaluating the information identified in clauses (1) to (6) to develop, document, and implement ongoing program improvements. See citations 2 through 20 for the designated coordinator and designated managers failures to provide the above stated requirements. Corrective Action Ordered: Immediately upon receiving this order, you must review and complete all corrective action within the timeline stated for each violation in this order and maintain documentation of the corrective action completed at the program. Within 30 days of receiving this order, you must develop a written plan that details how the designated coordinator and designated manager will ensure timelines for initial service planning and ongoing service plan review and evaluation are met for persons served by the program Many citations in this order include violations related to the failure to meet timeline requirements. On an ongoing basis, you must maintain compliance with all applicable laws and rules of your license. Service Recipient Violations 2. Citation: Minnesota Statutes, section 245A.65, subdivision 1. Violation: For three of nine persons whose records were reviewed (P1-P3), the license holder did not provide an orientation to the internal and external reporting procedures related to suspected or alleged maltreatment as required. P1 began receiving day support services (DSS) from the license holder on November 1, 2022. P2 began receiving DSS from the license holder on June 20, 2023. P3 began receiving DSS from the license holder on May 1, 2022. The license holder failed to provide P1-P3, or their legal representatives, with an orientation to the internal and external reporting procedures of alleged or suspected maltreatment of vulnerable adults within 72 hours of admission. Corrective Action Ordered: Within 30 days of receiving this order, you must provide P1-P3 or their legal representatives with an orientation to the internal and external reporting procedures related to suspected or alleged maltreatment. Additionally, you must maintain documentation of this orientation as required in section 245D.095, subdivision 3, paragraph (b). On an ongoing basis, you must maintain compliance as required in this subdivision. 3. Citation: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (a), clause (4). Violation: For four persons whose records were reviewed (P1-P4), the license holder did not provide an orientation to the program abuse prevention plan (PAPP) as required. The license holder failed to provide P1-P4 with orientation to the program abuse prevention plan (PAPP) within 24 hours of admission. The license holder provided this orientation to P4’s legal representative on March 11, 2024. Corrective Action Ordered: Within 30 days of receiving this order, you must provide P1-P3 or their legal representatives with an orientation to your PAPP. On an ongoing basis, you must maintain compliance as required in this subdivision. 4. Citation: Minnesota Statutes, section 245D.04, subdivision 1, paragraph (1). Violation: For three persons whose records were reviewed (P1, P3 and P4), the license holder did not provide the service recipient rights 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. · The license holder failed to provide P1 and P3, or their legal representative, with a notice and explanation of the service recipient rights within five working days of service initiation. · The license holder failed to provide P1, P3, and P4, or their legal representative with a notice and explanation of the service recipient rights annually. · The license holder failed to provide these rights to P1 or their legal representative legal representative annually in 2022 and 2023. · The license holder failed to provide these rights to P3 or their legal representative legal representative annually in 2022 and 2023. · The license holder failed to provide P4’s legal representative with a notice and explanation of the service recipient rights annually in 2021, 2022, and 2023. The license holder provided P4’s legal representative with this notice on March 11, 2024. Corrective Action Ordered: Within 60 days of receiving this order, you must: · provide P1 and P3 or their legal representative, as applicable, with a notice and explanation of the service recipient rights; · complete an audit of all service recipient records; · based on the results of the audit, create a written plan that details the following: o how your program will provide the rights to any service recipients that has not received these rights, or has not received these rights annually, to the person or their legal representative, if applicable; o the date that all service recipient records will be brought into compliance with the requirements of this subdivision based on the results of your audit. This date must be prior to October 1, 2024; and o how your program will maintain ongoing compliance in this subdivision. · maintain documentation of the person or their legal representative’s receipt of these rights as required in Minnesota Statutes, section 245D.095, subdivision 3, paragraph (b); and · submit the results of the audit and your written plan to your licensor. On an ongoing basis, you must maintain compliance as required in this subdivision. 5. Citation: Minnesota Statutes, section 245D.05, subdivision 1. Violation: For one person whose record was reviewed (P8), the license holder did not document health needs as required. The license holder was assigned responsibility for meeting P8’s health need of medication administration. The license holder failed to maintain documentation of how P8’s health needs will be met, including a description of the procedures the license holder would follow in order to provide medication administration according to this chapter. Corrective Action Ordered: Within 30 days of receiving this order, you must: · develop and maintain documentation of the above stated requirements for P8; and · submit the documentation to your licensor. On an ongoing basis, you must maintain compliance as required in this subdivision. 6. Citation: Minnesota Statutes, section 245D.06, subdivision 4, paragraph (a), and Minnesota Statutes, section 245A.04, subdivision 13. Violation: For four persons whose record was reviewed (P1-P4), the license holder did not meet requirements for safekeeping of funds as required. · The license holder assisted P1-P4 with the safekeeping of funds. The license holder failed to obtain written authorization from P1-P4’s legal representative and/or case manager with five working days of service initiation. · The license holder failed to survey, document, and implement the preferences of P1-P4’s legal representative and case manager for the frequency of receiving a statement that itemizes receipts and disbursements of funds. · The license holder failed to obtain written authorization from P1, P3, and P4’s legal representative and case manager for the safekeeping of funds annually. · The license holder failed to immediately document receipt and disbursement of P1-P4’s funds at the time of receipt or disbursement. · The license holder received funds from P1-P4 every month that went into the same account. The license holder failed to ensure separation of P1-P4‘s funds. Corrective Action Ordered: Immediately upon receiving this order, you must ensure the separation of funds for P1-P4, and all other persons served you are safekeeping funds for. Within 30 days of receiving this order, you must: · complete an audit of all service recipient records to determine: · if you are safekeeping funds; and · if you have surveyed, documented, and implemented the preferences of the person or person’s legal representative and the case manager for frequency of receiving a statement that itemizes receipts and disbursements of funds. · based on the audit results, create a written plan that includes: o how your program will obtain written authorization to safekeep funds from the person or person’s legal representative and the case manager; o how your program, upon written authorization, will survey, document, and implement the preferences of the person or person’s legal representative and the case manager for frequency of receiving a statement that itemizes receipts and disbursements of funds or other property; o how the program will separate funds of persons served; o how the program will ensure the immediate documentation of the receipt and disbursement of the person’s funds; o how the designated coordinator will fulfill the duty of overseeing the license holder’s responsibilities safekeeping of funds and property; and o the date that all service recipient records will be brought into compliance with the requirements of this subdivision based on the results of your audit. The date must be prior to October 1, 2024. · submit the results of the audit, the written plan and the program’s playbook to your licensor to ensure compliance with the safekeeping of funds; and · maintain documentation of the written authorization and preferences of the person or person’s legal representative and the case manager. On an ongoing basis, you must maintain compliance as required in this subdivision. 7. Citation: Minnesota Statutes, section 245D.071, subdivision 2. Violation: For three persons whose records were reviewed (P1, P3, and P4), the license holder did not develop, document, implement and review an individual abuse prevention plan (IAPP) as required in section 245A.65, subdivision 2. · The license holder failed to develop an IAPP for P1, P3, and P4 prior to or upon service initiation. · P1’s services were initiated on November 1, 2022. The license holder developed an IAPP for P1 on October 27, 2023. · P3’s services were initiated on May 1, 2022. The license holder developed an IAPP for P3 on May 23, 2022. · The license holder provided multiple services to P4. The license holder was unable to provide a service initiation date for P4’s day support services (DSS); however, it was able to be determined that P4’s DSS were initiated prior to 2024. The license holder developed an IAPP for P4 on February 14, 2024. · The license holder failed to review P3 and P4’s IAPP with their interdisciplinary teams annually. · The license holder reviewed P3’s IAPP with their interdisciplinary team (IDT) on May 23, 2022, and December 15, 2023. · The license holder began providing employment services to P4 in 2019. P4’s IAPP was not reviewed with their IDT in 2021, 2022, and 2023. · P4’s IAPP indicated P4 was not susceptible to self-abuse and that P4 was not at risk of being verbally abusive to others; however, these assessments were not consistent with other information in P4’s record. Corrective Action Ordered: Within 30 days of receiving this order, you must: · establish an enforce an IAPP for P4 that meet the requirements of this section; · review P4’s IAPP with the person, their legal representative, if applicable, and their case manager; and · maintain documentation of this review in P4’s record. On an ongoing basis, you must maintain compliance as required. 8. Citation: Minnesota Statutes, section 245D.071, subdivision 3. Violation: For four persons whose records were reviewed (P1, P2, P3, and P4), the license holder did not meet requirements for initial service planning and assessments as required. a. The license holder failed to complete a preliminary support plan addendum for P1 and P3 within 15 calendar days of service initiation. b. The license holder failed to complete the assessments required in paragraph (b), clauses (1) through (3), for P1 and P4 prior to the 45-day planning meeting. The license holder completed these assessments on October 27, 2023, for P1, and February 14, 2024, for P4. c. The license holder failed to hold initial service planning meetings for P1, P2, and P4 within 45 days of first providing services. · P1 began receiving day support services from the license holder on November 1, 2022, and the license holder held a service planning meeting on October 27, 2023. · P2 began receiving day support services from the license holder on June 20, 2023, and the license holder held a service planning meeting on December 18, 2023. · The license holder provided multiple services to P4. The license holder was unable to provide a service initiation date for P4’s day support services (DSS); however, it was able to be determined that P4’s DSS were initiated prior to 2024. The license holder held a service planning meeting on February 14, 2024. d. The license holder maintained a document in P3’s record titled “Intensive Support Self-Management Assessment”. The license holder failed to ensure the assessments produced information about P3 that described their overall strengths, functional skills, and abilities. e. The license holder maintained a document in P4’s record titled “Intensive Support Self-Management Assessment”. The license holder failed to ensure the assessments produced information about P4 that described their overall strengths, functional skills, and abilities. Additionally, the license holder’s assessment of “choking” was documented as “not applicable”; however, this assessment was inconsistent with other information in P4’s record. f. The license holder failed to complete the assessments required in paragraph (b), clauses (1) through (3), annually for P1, P3, and P4. Corrective Action Ordered: Within 30 days of receiving this order, you must: · complete the assessments identified in part “f” of this citation for P1, P3 and P4; · meet with P1, P3 and P4, and their support teams to review the assessments completed. On an ongoing basis, you maintain compliance as required. 9. Citation: Minnesota Statutes, section 245D.071, subdivision 4, paragraph (b). Violation: For four persons whose records were reviewed (P1-P4), the license holder did not meet requirements for service outcomes and supports. The license holder identified outcomes for P1-P4; however, the license holder failed to document the following supports and methods to accomplish outcomes: · the methods or actions that will be used to support the person and to accomplish the service outcomes, including information about: o any changes or modifications to the physical and social environments necessary when the service supports are provided; o any equipment and materials required; and 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 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. Corrective Action Ordered: Within 60 days of receiving this order, you must: · meet with P1-P4, and their support teams to determine the supports and methods to be implemented to support the person and accomplish their outcomes; · within 10 working days of the meetings, develop service plans for P1-P4 that documents the supports and methods identified above and maintain the plan in P1-P4’s support plan addendums. · within 20 working days of the meetings, submit and obtain dated signatures from P1-P4 or their legal representative, if applicable, and case manager to document completion and approval of the support plan addendums; · submit the service outcomes, and supports and methods developed for P1-P4 to your licensor; · audit all service recipient records receiving intensive support services to ensure each person has service outcomes, including supports and methods documented in the person’s support plan addendum; · based on the audit results, create a written plan that includes: o how your program will develop service plans that documents the service outcomes, and supports and methods for any person identified in the audit who did not have service outcomes; o the date that all service recipient records will be brought into compliance with the requirements of this subdivision based on the results of your audit. The date must be prior to October 1, 2024; o how the designated coordinator and/or designated manager will meet the responsibilities assigned in the person’s support plan and the support plan addendum and taking the action necessary to facilitate and accomplishment of the outcomes according to the requirements in section 245D.07, and · submit the results of the audit and your written plan to your licensor. On an ongoing basis, you must maintain compliance as required in this subdivision. 10. Citation: Minnesota Statutes, section 245D.071, subdivision 5, paragraphs (a), (b) and (g). Violation: For four persons whose records were reviewed (P1, P3, P4 and P8), the license holder did not meet the requirements for service plan review and evaluation as required. · The license holder failed to participate in service plan review meetings with P1, P3, P4, and their support teams at least once per year. · The license holder failed to meet with P1 and their support team in 2021. · The license holder met with P3 and their support team on May 23, 2022, and December 15, 2023; therefore, the license holder failed to meet with P3 and their support team annually in 2023. · The license holder met with P4 and their support team on February 14, 2024. No other information was maintained in P4’s record regarding service plan review meetings; therefore, the license holder failed to meet with P4 and their support team annually in 2021, 2022, and 2023. · The license holder failed to, at least once per year, meet with P1, P3, and P4, and their support teams to discuss how technology might be used to meet the person’s desired outcomes and include a summary of this discussion in the person’s support plan addendum. · The license holder failed to summarize P1, P3, and P4’s status and progress toward achieving the identified outcomes and make recommendations and identify the rational for changing, continuing, or discontinuing implementation of supports and methods identified in subdivision 4 in a report available at the progress review meeting at least once per year. · The license holder failed to meet within 30 days of a written request from P8’s case manager. On August 2, 2023, P8’s case manager requested to schedule a meeting with the license holder, the Ombudsman and P8’s legal representative. On August 11, 2023, the license holder responded to the team declining to have a meeting with P8’s team. Corrective Action Ordered: Within 30 days of receiving this order, you must create a written plan that includes how the designated coordinator and/or designated manager is going to ensure the license holder is in compliance with the above requirements and submit the written plan to your licensor. On an ongoing basis, you must maintain compliance as required in this subdivision. 11. Citation: Minnesota Statutes, section 245D.095, subdivision 3. Violation: For four persons whose records were reviewed (P1-P4), the license holder did not maintain service recipient records as required. a. The license holder failed to maintain progress or daily log notes in P1-P4’s service recipient record. b. The license holder failed to maintain a signed admission form for P1 that included the address and telephone number of P1’s case manager. c. The license holder failed to maintain a signed admission form for P2 that included the name, address, and telephone number of P2’s case manager. d. P4 received multiple services from the license holder. The license holder failed to maintain service initiation information in P4’s record related to day support service (DSS). Corrective Action Ordered: Immediately, you must begin recording progress or daily notes for each person you are providing services to under this license and maintain them in the person’s service recipient record. Within 30 days of receiving this order, you must create a written plan that includes: · how your program will come into compliance and maintain compliance; and · how the progress or daily log notes will be maintained in each persons served record; and submit the written plan to your licensor. Within 30 days or receiving this order, you must maintain the information identified above for P1, P2 and P4’s service recipient records. On an ongoing basis, you must maintain compliance as required. 12. Citation: Minnesota Statutes, section 245D.10, subdivisions 3. Violation: For four person whose record was reviewed (P5, P6, P7 and P9), the license holder did not enforce policies and procedures related to service suspension as required. The license holder failed to limit the temporary service suspensions for P5, P6, P7 and P9 to the situations identified in subdivision 3, paragraph (b), clauses 1-3 and document the specific circumstances and the reasons. Additionally, the license holder failed to document the required actions taken to minimize or eliminate the need for service suspension for P5, P6, P7 and P9 prior to giving notice of temporary service suspension. · The license holder issued a temporary service suspension for P5 on November 16, 2022, with an effective date of November 16, 2022. The temporary service suspension stated that P5 could return to services on November 21, 2022. At the time the license holder issued the temporary service suspension the license holder documented a date P5 could return to receiving services. The license holder failed to determine with P5’s support team or expanded support team that P5 no longer posed an imminent risk of physical harm to self or others before P5 returned to receiving services. · The license holder issued a temporary service suspension for P6 on January 26, 2024, effective the same day. In an email, dated January 26, 2024, sent to P6’s support team, the license holder stated P6 was suspended for two weeks and could not return until P6 began therapy from an accredited behavioral therapist that the program could contact to determine if the program would still be a good fit. Additionally, the email stated P6 would only be able to return after two weeks with the mutual agreement from a therapist and upper management of the program. On February 14, 2024, P6 provided the license holder with a written statement from a therapist recommending P6’s return to the program. At the time of the licensing review P6 had not returned to the program. The license holder failed to allow P6 to return to the program after a recommendation to return was received from P6’s therapist. · The license holder issued a temporary service suspension for P7 on January 26, 2024, effective the same day. In an email, dated January 26, 2024, sent to P7’s support teams, the license holder stated P7 was suspended for two weeks and could not return until P7 began therapy from an accredited behavioral therapist that the program could contact to determine if the program would still be a good fit. Additionally, the email stated P7 would only be able to return after two weeks with the mutual agreement from a therapist and upper management of the program. The license holder failed to implement their policy and procedure related to service suspensions. · The license holder issued a temporary service suspension for P9 on July 19, 2023, effective the same day. Included in the suspension notice the license holder stated the suspension was due to inconsistent attendance and lack of payment for activity fees. The notice stated P9 could not return to the program unless P9 attended a minimum of 4 days per week beginning July 31, 2023, and P9’s activity fees were paid in full by August 4, 2023, for the months of March, April, May, June and July. The license holder failed to implement their policy and procedure related to service suspensions. Repeat Violation: In a correction that DHS issued on July 3, 2019, you were previously found in violation of this same statute. Corrective Action Ordered: Within 30 days of receiving this order, you must develop a detailed plan describing how you will come into compliance with these requirements. The plan must include how the designated manager will ensure the program maintains ongoing compliance with the requirements in this subdivision. You must submit the plan to your licensor. On an ongoing basis, you must implement temporary service suspensions according to the requirements in subdivision 3. 13. Citation: Minnesota Statutes, section 245D.10, subdivisions 3a. Violation: For one person whose record was reviewed (P5), the license holder did not enforce policies and procedures related to service termination as required. The license holder issued a service termination for P5 on October 5, 2023, with an effective date of October 5, 2023. The license holder failed to: · prior to giving notice of service termination document actions taken to minimize or eliminate the need for termination. Including at a minimum: o consultation with the persons support team or expanded support team to identify and resolve issues leading to issuance of the termination notice; and o a request to the case manager for intervention services identified in section 245D.03, subdivision 1, paragraph (c), clause (1), or other professional consultation or intervention services to support the person in the program; · notify the commissioner of the intended service termination in writing; and · include the following in the service termination notice: o a summary of actions taken to minimize or eliminate the need for service termination or temporary service suspensions required under paragraph (c), and why these measures failed to prevent the termination or suspension; o P1’s right to appeal the termination of services under section 256.045, subdivision 3, paragraph (a); and o P1’s right to seek a temporary order staying the termination of services according to the procedures in section 256.045, subdivision 4a or 6, paragraph (c). · notify the person or the legal representative and case manager in writing of the intended service termination at least 60 days prior to termination and according to the requirements in section 245D.010, subdivision 3a, paragraph (d). Repeat Violation: In a correction that DHS issued on July 3, 2019, you were previously found in violation of this same statute. Corrective Action Ordered: Within 30 days of receiving this order, you must develop a detailed plan describing how you will come into compliance with these requirements. The plan must include how the designated manager will ensure the program maintains ongoing compliance with the requirements in this subdivision. You must submit the plan to your licensor. On an ongoing basis, you must implement service terminations according to the requirements in subdivisions 3a. 14. Citation: Minnesota Statutes, section 245D.10, subdivision 4. Violation: For three persons whose records were reviewed (P1, P2, and P3), the license holder did not provide written or electronic copies of policies and procedures as required. The license holder failed to inform P1, P2, P3, and their case managers of the following policies and procedures affecting a person’s rights under section 245D.04 and provide copies of those policies and procedures within five working days of service initiation: · grievance policy and procedure; · service suspension policy and procedure; · service termination policy and procedure; · emergency use of manual restraints policy and procedure; and · data privacy policy and procedure. The license holder-maintained information in P2’s record that these policies and procedures were provided to P2 on March 14, 2024. Additionally, the license holder maintained a document in P3’s record that stated “245D policies and procedures have been sent” in 2024; however, this document did not indicate what policies and procedures were sent, a date the policies and procedures were sent, or who the policies and procedures were sent to. Repeat Violation: In a correction that DHS issued on July 3, 2019, you were previously found in violation of this same statute. Corrective Action Ordered: Within 30 days of receiving this order, you must: · provide the policies and procedures identified above to P1 and their case manager; · audit all service recipient records to ensure the policies and procedures identified above were provided to each service recipient’s case manager; · for any service recipient’s case manager that did not receive these policies and procedures, provide them; and · maintain documentation of the audit results at your program for review by your licensor. On an ongoing basis, you must maintain compliance as required in this subdivision. 15. Citation: Minnesota Rules, part 9544.0030, subpart 1. Violation: For three persons whose records were reviewed (P1, P3, and P4), the license holder did not incorporate and evaluate positive support strategies as required. The license holder failed to evaluate the identified positive support strategies with P1, P3, and P4 at least every six months. Corrective Action Ordered: Within 30 days of receiving this order, you must: · evaluate whether the identified positive support strategies meet the standards in subpart 2 with P1, P3, and P4 and based upon the evaluation, the license holder must determine whether changes are needed in the positive support strategies used, and, if so, make appropriate changes. · audit all service recipient records to ensure positive support strategies are incorporated, in writing, to an existing treatment, service, or other individual plans; · for any service recipient records in which positive support strategies have not been incorporated, in writing, develop and incorporate these and maintain this documentation in the person’s support plan addendum; and · submit documentation of the audit results to your licensor. Additionally, you must evaluate these strategies with each service recipient at least every six months. On an ongoing basis, you must maintain compliance as required in this subdivision. Staffing Standards Violations 16. Citation: Minnesota Statutes, section 245D.09, subdivisions 5. Violation: For one of four staff persons whose records were reviewed (SP1), the license holder did not provide annual training as required. 245A.02, subdivision defines “annual” or “annually” to mean prior to or within the same month of the subsequent calendar year. 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 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; and · the safe and correct use of manual restraint on an emergency basis according to the requirements in section 245D.061 or successor provisions, and what constitutes the use of restraints, time out, and seclusion, including chemical restraint. Corrective Action Ordered: Within 30 days of receiving this order, you must provide SP1 training on the topics identified above and maintain documentation of the completed trainings as required in 245D.096, subdivision 5, paragraph (a), clause 2. On an ongoing basis, you must maintain compliance as required in this subdivision. 17. Citation: Minnesota Statutes, section 245D.095, subdivision 5. Violation: For two staff persons whose records were reviewed (SP1 and SP2), the license holder did not maintain personnel records as required. The license holder failed to maintain personnel records for SP1 and SP2 that included documentation of orientation and training that included: · the date the training was completed; · the number of hours per subject area and · the name of the trainer or instructor. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. Day Service Facility Violations 18. Citation: Minnesota Statutes, section 245A.65, subdivision 1, paragraph (d). Violation: The license holder failed to post a copy of the vulnerable adult maltreatment reporting policies and procedures. Regarding day services facility 1111440 and 1111441 the license holder failed to post a copy of the internal and external reporting policies and procedures, including the telephone number of the common entry point as defined in section 626.5572, subdivision 5, in a prominent location in the program and have it available upon request to mandated reporters, persons receiving services, and the person’s legal representatives. Corrective Action Ordered: Immediately upon receiving this order you must post a copy of the internal and external reporting policies and procedures in a prominent location at day service facility 1111440 and 1111441 that meet the above-mentioned requirements. On an ongoing basis, you must maintain compliance as required in this subdivision. 19. Citation: Minnesota Statutes, section 245D.22, subdivision 5. Violation: The license holder did not meet the requirements for a written plan for emergencies as required. The license holder failed to maintain a log of quarterly fire drills on file in the day service facility 1111440 and 1111441. Corrective Action Ordered: Immediately upon receiving this order you must begin maintaining a log of quarterly fire drills on file at each licensed facility. On an ongoing basis you must maintain compliance as required. Policy and Procedures 20. Citation: Minnesota Statutes, section 245D.11, subdivision 4. Violation: The license holder did not establish policies and procedures related to admission criteria as required. The license holder maintained a policy and procedure titled “Admission Criteria Policy” and a supplemental document titled playbook that contained other admission criteria. The license holder failed to ensure this policy and procedure promoted continuity of care by ensuring that admission or service initiation criteria identified the criteria to be applied in determining whether the license holder can develop services to meet the needs specified in the person’s support plan. Corrective Action Ordered: Within 30 days of receiving this order, you must: · establish a policy and procedure related to admission criteria and the playbook that includes the requirements identified above; · submit to your DHS licensor to ensure compliance and approval; · upon approval from DHS provide copies of the updated policy and procedure to all persons served or their legal representative and their case managers; · maintain a list of all persons served, legal representatives and case managers the updated policy and procedures were provided to; and · submit the list to your licensor. 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. Submissions required as part of a corrective action ordered must be sent to your Licensor at: 1. By secure email at Elizabeth.Schiefelbein@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: Liz Schiefelbein 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 in writing. Your request must: 1. Specify the parts of the correction order that are alleged to be in error; 2. Explain why they are in error; and 3. Include documentation to support the allegation of error. 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 questions regarding this Correction Order, please contact me as soon as possible. Sincerely, Liz Schiefelbein, Senior Human Services Licensor Licensing Division Office of Inspector General 651-431-2738
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