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June 3, 2024 CERTIFIED MAIL Kejyana Clark, Authorized Agent 9234 Upland Lane North Maple Grove, Minnesota 55369 License Number: 1110667 (Home and Community-Based Services) ORDER OF CONDITIONAL LICENSE Dear Kejyana Clark: The Department of Human Services (DHS) is placing your license to provide Home and Community-Based Services for Enriching Home Care Services, located at 9234 Upland Lane North, Maple Grove, Minnesota, on conditional status for two years, beginning June 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 Services 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 February 13, 2024 and February 16, 2024, DHS licensors conducted a licensing review at your facility located at 6045 Vicksburg Lane North, Plymouth, Minnesota. As a result of this licensing visit, 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 23 violations. DHS has considered the nature, chronicity, and severity of these violations, as well as the health, safety, and rights of persons 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 provide orientation to the internal and external reporting procedures of alleged or suspected maltreatment of minors o Failure to develop individual abuse prevention plans o Failure to ensure the protection of rights o Failure to develop and incorporate positive support strategies and person-centered planning o Failure to meet health service needs consistent with the person’s health needs, including administering medications o Failure to provide persons served with an orientation to and an explanation of the service recipient rights o Failure to maintain service recipient records o Failure to provide required orientation and annual training to staff persons · Chronicity: Your program received its license on June 15, 2022. The licensing review completed on February 13, 2024 and February 16, 2024 demonstrated that your program has noncompliance with licensing rules and statutes. · June 3, 2024 Conditional License (this order): 23 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. Program Coordination and Oversight Violations 1. 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 coordinated service and support plan (CSSP) and CSSP 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 CSSP 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 measureable and observable criteria for identifying when the desired outcomes based on the measureable 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 23. 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 2 through 23. Statute Violated: Minnesota Statutes, section 245D.081, subdivisions 2 and 3. Service Recipient Violations 2. Violation: For three of six persons whose records were reviewed (P1, P2, and P4), the license holder did not provide an orientation to the internal and external reporting procedures of alleged or suspected maltreatment of minors as required. a. P1’s services were initiated on December 16, 2022. The license holder failed to provide P1’s legal representative an orientation to the internal and external reporting procedures of alleged or suspected maltreatment of minors within 24 hours of admission. This was not provided until August 17, 2023. b. P2’s services were initiated on August 17, 2023. The license holder failed to provide an orientation to the internal and external reporting procedures of alleged or suspected maltreatment of minors within 24 hours of admission. P2 was discharged from the program, then had a second service initiation on September 29, 2023. The license holder failed to provide an orientation to the internal and external reporting procedures of alleged or suspected maltreatment of minros within 24 hours of admission. c. P4’s services were initiated on May 25, 2023. The license holder failed to provide P4’s legal representative an orientation to the internal and external reporting procedures of alleged or suspected maltreatment of minors within 24 hours of admission. Statute Violated: Minnesota Statutes, section 245A.65, subdivision 1, paragraph (c). 3. Violation: For three persons whose records were reviewed (P1,P2, and P4), the license holder did not provide orientation to the license holder’s program abuse prevention plan (PAPP) within 24 hours of admission as required. a. The license holder failed to provide P1 an orientation to the program’s PAPP within 24 hours of admission. b. For P2’s service admission on August 17, 2023, the license holder failed to provide an orientation to the program’s PAPP within 24 hours of admission. For P2’s service admission on September 29, 2023, the license holder failed to provide an orientation to the program’s PAPP within 24 hours of admission. c. For P4’s service admission on May 25, 2023, the license holder failed to provide an orientation to the program’s PAPP within 24 hours of admission. Statute Violated: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (a), clause (4). 4. Violation: For one persons whose record were reviewed (P3), the license holder did not meet the requirements for individual abuse prevention plans (IAPP) as required. P3 received intensive services from the license holder as a minor. During the course of service delivery, P3 turned 18 years old and required an IAPP. The license holder failed to develop an IAPP for P3 at the time P3 turned 18 years old. Statute Violated: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (b). 5. Violation: For three persons whose records were reviewed (P1, P2 and P4), the license holder did not provide the person a written notice that identified the service recipient rights and an explanation of those rights as required. a. The license holder failed to provide P1’s legal representative with a written notice that identified the service recipient rights and an explanation of those rights within five working days of service intitiation. b. For P2’s service initiation on September 29, 2023, the license holder failed to provide P2’s legal representative with a written notice that identified the service recipient rights and an explanation of those rights within five working days of service initiation. c. P4 was discharged from the program in July 2023. When P4’s services were initiated again and P4 returned to the program on December 19, 2023, the license holder failed to provide P4’s legal representative with a written notice that identified the service recipient rights and an explanation of those rights within five working days of service initiation. Statute Violated: Minnesota Statutes, section 245D.04, subdivision 1. 6. Violation: For one person whose record was reviewed (P2), the license holder did not ensure the exercise and protection of the service recipient rights as required. A document titled, “Quiet/Bed Time Hours” was maintained in P2’s room. Implementation of rules in this document restricted or limited the right for P2 to engage in chosen activities and have use and free access to common areas in the residence. The license holder failed to ensure the exercise and protection of the service recipient rights. Rule/Statute Violated: Minnesota Statutes, section 245D.04. 7. Violation: For one person whose record was reviewed (P1), the license holder did not ensure the provision of services in response to the person’s identified needs, interests, preferences, and desired outcomes as specified in the support plan and the support plan addendum as required. P1’s coordinated services and support plan dated November 21, 2023 identified P1’s needs and interests as music, learning to play guitar, learning to play piano, video games, swimming, shopping, going to the movies and fishing. However, the license holder identified P1’s outcomes as: · at least once per day, with staff support, [P1] will request his/her medication, identify which medications are his/hers and receive the medications from staff, 75% of days per month; · [P2] will complete a continuous 30-minute exerices that focuses on strength-building, 30% of trials each month, for 3 consective months; and · [P2] wil use 4 coping skills, given 2 verbal prompts for 2 consecutive quarters. The license holder failed to use information consistent with the principles of person centered service planning and delivery to identify outcomes P1 desired. Statute Violated: Minnesota Statutes, section 245D.07, subdivision 1a. 8. Violation: For two persons whose records were reviewed (P1 and P4), the license holder did not provide written or electronic copies of policies and procedures affecting a person’s rights as required. a. The license holder failed to inform P1’s legal representative and case manager of and provide copies of the following policies and procedures within five days of service initiation: · grievance policy; · temporary service suspension policy; · service termination policy; · emergency use of manual restraints policy; and · data privacy policy. b. P4 was discharged from the program in July 2023. P4’s services were initiated again on December 19, 2023. The license holder failed to inform P4’s case manager of and provide copies of the above policies and procedures within five days of service initiation in December 2023. Statute Violated: Minnesota Statutes, section 245D.10, subdivision 3. 9. Violation: For two persons whose records were reviewed (P5 and P6), the license holder did not enforce policies and procedures related to a temporary service suspension and service termination as required. a. The license holder provided a notice of service termination to P5 on March 6, 2023. Prior to giving notice of service termination, the license holder failed to: · document actions taken to minimize or eliminate the need for termination including at a minimum: o a request to P5’s 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 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). b. Regarding P5, the license holder failed to implement a temporary service suspension according to the requirements. The license holder stated to DHS licensors that a service suspension was provided to P5 at the same time as the service termination; however, there was no documentation of this in P5’s record. c. Regarding P6, the license holder failed to implement a temporary service suspension and service termination according to the requirements. The license holder stated to DHS licensors that a service suspension was provided to P6 at the same time as the service termination; however, there was no documentation of this in P6’s record. Statute Violated: Minnesota Statutes, section 245D.10, subdivisons 3 and 3a. 10. Violation: For four persons whose records were reviewed (P1-P4), the license holder did not meet the requirements of the positive support strategies rule as required. The license holder failed to develop and incorporate positive support strategies in writing to an existing treatment, service or other individual plan for P1-P4. Rule Violated: Minnesota Rules, part 9544.0030, subpart 1. Health Needs Violations 11. Violation: For four persons whose records were reviewed (P1-P4), the license holder did not maintain documentation of how the person’s health needs would be met as required. a. The license holder was assigned responsibility for P1’s health needs. The license holder failed to maintain documentation on how P1’s health needs would be met, including a description of the procedures the license holder will follow in order to administer psychotropic PRN (as needed) medications. b. The license holder failed to maintain documentation on how P2, P3 and P4’s health needs would be met, including as applicable, a description of the procedures the license holder would follow in order to: · provide medication setup, assistance, or administration according to this chapter. Unlicensed staff responsible for medication setup or medication administration under this section must complete training according to section 245D.09, subdivision 4a, paragraph (d); · monitor health conditions according to written instructions from a licensed health professional; · assist with or coordinate medical, dental, and other health service appointments; and · use medical equipment, devices, or adaptive aides or technology safely and correctly according to written instructions from a licensed health professional. P2 was prescribed Flovent HFA 44 MCG oral inhaler with instructions to “inhale 2 puffs by mouth twice daily. Increase per asthma action plan when in yellow or red zone.” There was no documentation of an action plan in P2’s record. The license holder failed to maintain documentation of the action plan for the identified health need for P2. Statute Violated: Minnesota Statutes, section 245D.05, subdivision 1 paragraph (b). 12. Violation: For four persons whose records were reviewed (P1- P4), the license holder did not implement medication administration procedures as required. a. The license holder failed to obtain written authorization from the P1, P2, and P4’s legal representative to administer medications prior to administering medications or treatments. · The license holder began administering medications to P1 on December 16, 2022. P1’s legal representative signed the written authorization on August 17, 2023. · The license holder began administering medications to P2 on August 17, 2023. P2’s legal representative signed the written authorization on August 21, 2023. For P2’s service initaiton on September 29, 2023, the license holder began administering meds to P2 on September 29, 2023. At the time of the the license review, a signed authorization had not been obtained. · The license holder began administering medications to P4 on December 19, 2023. At the time of the the license review, a signed authorization had not been obtained. b. P1 was prescribed Omeprazole 20mg 1 capsule daily in December 2023. P1’s medication administration record (MAR) for January 2024 documented that this medication was not administered. The license holder failed to ensure P1 took medications as prescribed. Additionally, P1’s MAR documented that P1 received a PRN dose of melatonin; however, there is no documentation in P1’s record that P1 was prescribed melatonin. The license holder failed to ensure P1 took medications as prescribed. c. P2 was prescribed a Flovent HFA 44 MCG oral inhaler with instructions to “inhale 2 puffs by mouth twice daily. Increase per asthma action plan when in yellow or red zone.” The was no documentation of this medication P2’s MAR. The license holder failed to ensure P2 took medications as prescribed. P2 was prescribed the following medications: · Tramadol HCL 150 mg 1 tab by mouth as needed. This was documented on P2’s MAR in October 2023. · Ibuprofen 600mg tab by mouth as needed, which was documented in October 2023, November 2023 and December 2023. · Acetaminophen 600mg tab by mouth as needed. This was documented on P2’s MAR in October 2023 and December 2023. · Ventolin HFA inhaler with instructions to inhale 2 puffs by mouth every 4 hours as needed. This was not documented on P2’s MARs. The license holder failed to ensure P2 took medications as prescribed. d. P3 was prescribed Lamotrigine 150mg and 25mg tablet daily in January 2024. The pharmacy provided 14 tablets in each bottle with the directions for use. P3’s MAR for January and February 2024 documents that this medication was administered daily; however, the medication was filled on January 30, 2024 and at the time of the licensing review on February 13, 2024, there were 6-150mg tablets in the bottle and 5-25mg tablets in the bottle. The license holder failed to ensure P3 took medications as prescribed. e. P4 was prescribed Fluticasone nasal spray to be sprayed into each nostril daily. P4’s MAR documents the nasal spray as a PRN (as needed) medication. The license holder failed to ensure P4 took medication as prescribed. f. The license holder failed to maintained one or more the following information for P1-P4 in the MAR, as required. · the information on the current prescription label or the prescriber's current written or electronically recorded order or prescription that includes the person's name, description of the medication or treatment to be provided, and the frequency and other information needed to safely and correctly administer the medication or treatment to ensure effectiveness; · 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; · 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; and o the occurrence of possible adverse reactions to the medication or treatment; · notation of when a medication or treatment is started, administered, changed or discontinued. Statute Violated: Minnesota Statutes, section 245D.05, subdivision 2. 13. Violation: For four persons whose records were reviewed (P1-P4), the license holder did not ensure that the medication administration records were reviewed as required. The license holder was assigned responsibility for medication administration for P1-P4. The license holder failed to review P1-P4’s medication administration records to identify medication administration errors at a minimum of every three months. Statute Violated: Minnesota Statutes, section 245D.05, subdivision 4, paragraph (a). 14. Violation: For two persons whose records were reviewed (P1 and P4), the license holder did not report medication errors or refusals as required.
a. P1’s MAR documented a medication refusal in November 2023. The license holder failed to report the medication refusal to P1’s legal representative and case manager. b. P4’s MAR documented multiple errors or refusals between December 2023 and February 2024. The license holder failed to report the medication errors or refusals to P4’s legal representative and case manager. Statute Violated: Minnesota Statutes, section 245D.05, subdivision 4, paragraph (b). 15. Violation: For four persons whose records were reviewed (P1-P4), the license holder did not develop, implement, and maintain documentation regarding psychotropic medications as required. P1-P4 were prescribed psychotropic medications. The license holder failed to maintain documentation that included a description of the target symptoms that each psychotropic medication was to alleviate. Statute Violated: Minnesota Statutes, section 245D.051. Staff Violations 16. Violation: For two of five staff persons whose records were reviewed (SP2 and SP4), the license holder did not provide and ensure completion of orientation training sufficient to create staff competency for direct support staff, within 60 calendar days of hire.
a. SP2 was hired December 19, 2022. The license holder failed to provide orientation and training to SP2 in the following areas: · 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; and · basic first aid. b. SP4 was hired on May 23, 2023. The license holder failed to provide orientation and training to SP4 within 60 days of hire, including: · the license holder’s current policies and procedures required under this chapter, including their location and access, and staff responsibilities related to implementation of these policies; · 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; · 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; · 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; · staff responsibilities related to prohibited procedures under section 245D.06, subdivision 5, or successor provisions, why such procedures are not effective for reducing or eliminating symptoms or undesired behavior, and why such procedures are not safe; and · basic first aid. Statute Violated: Minnesota Statutes, section 245D.09, subdivision 4. 17. Violation: For two staff persons whose records were reviewed (SP2 and SP4), the license holder did not provide orientation to individual service recipient needs as required. The license holder failed to ensure that SP2 and SP4’s medication administration training incorporated an observed skill assessment conducted by the trainer to ensure unlicensed staff demonstrate the ability to safely and correctly follow medication procedures. Statute Violated: Minnesota Statute, section 245D.09, subdivision 4a. 18. Violation: For one staff persons whose records were reviewed (SP2), the license holder did not ensure that staff providing direct services received annual training 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 annual training to SP2 in 2023 on the following topics: · data privacy requirements according to Minnesota Statutes, 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; · 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 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 service 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 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; and · basic first aid. Statute Violated: Minnesota Statutes, section 245D.09, subdivision 5. Record Requirement Violations 19. Violation: The license holder did not notify the commissioner, in a manner prescribed by the commissioner, and obtain the commissioner’s approval before making any change that would alter the license information as required. The license holder failed to notify the commissioner and obtain approval before changing the location of the program licensed under this chapter. Statute Violated: Minnesota Statutes, section 245A.04, subdivision 7a, paragraph (b). 20. Violation: The license holder did not maintain an admission record as required. The license holder failed to keep a written or electronic register, listing in chronological order the dates and names of all persons served by the program who have been admitted, discharged, or transferred, including service termination initiated by the license or deaths. Statute Violated: Minnesota Statutes, section 245D.095, subdivision 2. 21. Violation: For two persons whose records were reviewed (P1 and P2), the license holder failed to maintain service recipient records as required. a. The license holder failed to maintain the following information for P1: · an admission form that includes: o the person’s date of birth address, and telephone number; o address and telephone number of legal representative; and o name, address, and telephone number of a primary emergency contact and the case manager; · a signed statement authorizing the license holder to act in a medical emergency when the person’s legal representative, if any, cannot be reached or is delayed in arriving; and · a medical appointment schedule. b. The license holder failed to maintain the following information for P2: · an admission form signed by the person’s legal representative that includes: o the person’s telephone number; and o name, address, and telephone number of the case manager; · a signed statement authorizing the license holder to act in a medical emergency when the person’s legal representative, if any, cannot be reached or is delayed in arriving; · a medical appointment schedule. Statute Violated: Minnesota Statutes, section 245D.095, subdivision 3, paragraph (b), clause (1). Policy and Procedures Violations 22. Violation: For four persons whose records were reviewed (P1-P4), the license holder did not implement the programs safe medication assistance and administration policy as written. a. The license holder’s policy and procedure on safe medication assistance and administration established that the license holder would document on a person’s medication administration record information on the current labels or prescribers current written or electronically record order or prescription that included frequency of administration. The license holder failed to document this information on P2-P4’s medication administration records (MAR). The license holder’s policy and procedure on safe medication assistance and administration established that staff would transcribe a prescriber’s new, changed, and discontinued medication/treatmenet orders to the monthly medication sheet by: · drawing an arrow to the start date for each assigned time for new medication’sand · writing the date the medication is to start, the name of prescriber who order the medication, and the intials of the person making the entry , on the line just below the arrows or under the order on a separate line. P2 was prescribed multiple new medications between October 2023 and December 2023; however, the license holder failed to document this information on P2’s MAR. b. The license holder’s policy and procedure on safe medication assistance and administration established that the license holder would ensure that clear and accurate documentation of prescription orders had been obtained by the prescriber in written format. For P1, P2, and P4, the license holder failed to obtain prescription orders by the prescriber in written format for all medications. Statute Violated: Minnesota Statutes, section 245D.10, subdivision 2. 23. Violation: The license holder failed to enforce the program’s policy and procedures on data privacy according to the requirements in the Health Insurance Portability and Accountable Act of 1996 (HIPAA) as required. The program used a group messaging application named “GroupMe.” The license holder used GroupMe to communicate daily operations information and to communicate information regarding service recipients. The license holder failed to enforce the program’s policy on data privacy when the license holder used GroupMe to communicate health related information of persons they provided services to. GroupMe messages were not encrypted, and GroupMe was not a HIPAA compliant application. Statute Violated: Minnesota Statutes, section 245D.11, subdivision 3. Corrective action required You must immediately correct the violations cited above. Compliance with this order will be reviewed onsite on an ongoing basis. If 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 Services licensing rules and statutes, you are required to comply with the following terms: 1. Within 15 days from receipt of this Order, you must: · provide written notification of the conditional status of your license to all service recipients currently receiving home and community-based services from your program; · a copy of the notification must also be provided to legal representatives, as applicable, and case managers of all persons receiving service; · 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; and · 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. While the license is on conditional status, you must notify new persons receiving services, referral sources, 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 from receipt of this Order, you must submit a copy of the notice and a list of all persons that received the notice. 2. Within 30 days of receiving this order, you must: · ensure that all designated coordinators and designated managers in your program receive training and instruction on the Home and Community-Based Services licensing requirements sufficient to maintain compliance with all applicable rules and statutes throughout your program; and · maintain documentation that this training has been completed that includes: o who received the training; o the date of the training; o the name of the trainer or instructor; and o subject areas covered during the training. 3. Within 60 days of receiving this order, you must: · review this order with the identified designated managers; · correct all areas of non-compliance in the timeline stated for each violation in this order; and · maintain documentation of the corrective action completed at the program for review by DHS licensors. Compliance with this term will be monitored onsite at subsequent licensing reviews. 4. 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. 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. Submissions required as part of a corrective action ordered must be sent to your DHS licensor at: 1. By secure email at lacey.l.walsvik@state.mn.us; or 2. If you are unable to submit submissions ordered securely through email, please mail of fax using the information below: Commissioner, Department of Human Services ATTN: Lacey Walsvik c/o Licensing Division PO Box 64242 St. Paul, MN 55164-0242 Fax: 651-431-7673 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 Licensing Division Attention: Legal Unit PO Box 64242 St. Paul, MN 55164-0242 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 Legal authority for this licensing action · This action is taken under Minnesota Statutes, section 245A.06, subdivision 1. · Home and Community-Based Services license holders are required to follow Minnesota Statutes, Chapters 245A, 245C, and 245D and Minnesota Rules, Chapter 9555. · 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 Christala Culhane, HCBS Unit Supervisor, at 651-431-6541.  Sincerely,
Jill Slaikeu, HCBS Unit Manager Licensing Division Office of Inspector General
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