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July 31, 2024 Judith Ploeger, Authorized Agent AchieveCare LLC 745 140th Lane Northwest Andover, Minnesota 55304 License Number: 1105716 (245D – Home and Community-Based Services) CORRECTION ORDER Dear Judith Ploeger: On June 27, and 28, 2024, a licensing review of AchieveCare LLC, located at 2705 Bunker Lake Boulevard Northwest, Suite 200, Andover, Minnesota, was conducted to determine compliance with state and federal laws and rules governing the provision of home and community-based services to persons with disabilities and age 65 and older under Minnesota Statutes, Chapter 245D. As a result of this licensing review a Correction Order is being issued. A. Reason for Correction Order Pursuant to Minnesota Statutes, section 245A.06, if the Commissioner of the Department of Human Services (DHS) finds that the license holder has failed to comply with an applicable law or rule and this failure does not imminently endanger the health, safety, or rights of the persons served by the program, the Commissioner may issue a Correction Order to the license holder. The following violation(s) of state or federal laws and rules were determined as a result of the licensing review. Corrective action for each violation is required by Minnesota Statutes, section 245A.06 and is hereby ordered by the Commissioner of Human Services. 1. Citation: Minnesota Statutes, section 245A.65, subdivision 1. Violation: For one of four persons whose record was reviewed (P1), the license holder did not enforce their policy and procedures related to suspected or alleged maltreatment as required. The license holder received a report of suspected maltreatment on January 1, 2024, regarding P1. The license holder failed to provide the mandated reporter with a written notice stating whether the facility reported the incident to the common entry point within two working days. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 2. Citation: Minnesota Statutes, section 245C.04, subdivision 1, paragraph (g) and 245A.07, subdivision 3, paragraph (d). Violation: For one staff person whose record was reviewed (SP1), the license holder did not complete a background study as required. SP1 began a position providing direct contact on May 22, 2023. The license holder completed a background study for SP1 on May 4, 2023. The license holder separated SP1’s study on May 24, 2023. SP1’s study was affiliated on June 21, 2023. SP1 did not have a valid study to provide direct contact from May 24, 2023 – June 21, 2023. The license holder stated SP1 did have direct contact with persons served by the program during these dates. Under Minnesota Statutes, section 245A.07, subdivision 3, paragraph (d), the Commissioner shall not issue a fine to a license holder who self-corrects a background study violation before the Commissioner discovers the violation. A license holder how has previously exercised the provision of paragraph (d) to avoid a fine for a background study violation may not avoid fine for a subsequent background study violation unless at least 365 days have passed since the license holder self-corrected the earlier background study violation. Because the license holder self-corrected the background study violation involving SP1 before the Commissioner discovered the violation, the license holder is not being fined for the background study violation involving SP1. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required with this subdivision. 3. Citation: Minnesota Statutes, section 245D.05, subdivision 1, paragraph b, clause (3). Violation: For three persons whose records were reviewed (P1, P2 and P3), the license holder did not maintain documentation on how health services would be met as required. a. The license holder stated P1 needed assistance with coordinating medical, dental and other health service needs appointment. The license holder failed to document how the license holder would assist P1 with coordinating medical, dental and other health service needs appointments. b. The license holder failed to document how health service needs for P2 would be met. P2’s support plan dated June 8, 2023, documented that P2 needed assistance with coordinating medical, dental and other health service appointments. P2’s self-management assessment dated June 8, 2023, documented that P2 scheduled P2’s appointments. c. The license holder failed to document how health service needs for P3 would be met. P3’s 45-day meeting held on January 23, 2024, documented that the license holder would assist with medical appointments. P3’s self management assessment dated December 6, 2023, documented that P3 can self-manage medical appointments. Corrective Action Ordered: Within 30 days of receipt of this order, you must: · document how you are assistance P1 with medical, dental, and other health service appointments and review with P1’s support team; and · discuss with P2 and P3, and their support teams of how health needs will be met and update this information in their support plan addendums. On an ongoing basis, you must maintain compliance as required in this subdivision. 4. Citation: Minnesota Statutes, section 245D.071, subdivision 3. Violation: For three person whose records were reviewed (P1, P2 and P4), the license holder did not meet service planning and delivery requirements for an intensive service as required. a. The license holder initiated individualized homes supports with training for P1 on August 15, 2023. The license failed to meet with the P1 and P1’s support team before providing 45 days of service, or within 60 calendar says of service initiation. b. The license holder failed to review P2’s assessments annually in 2022. c. The license holder failed to include information about P4’s overall strengths, functional skills and abilities and behaviors or symptoms in P4’s assessments. Corrective Action Ordered: Within 30 days of receipt of this order, you must: · review assessments required at 45-day planning meeting with P1 and P1’s support team; and · review and revise P4’s self-management assessment to include the above-mentioned information. On an ongoing basis, you must maintain compliance as required in this subdivision. 5. Citation: Minnesota Statutes, section 245D.071, subdivision 4. Violation: For four persons whose records were reviewed (P1, P2, P3, and P4), the license holder did not develop outcomes as required. The license holder failed to maintain the following documentation for P1, P2, P3, and P4’s 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 were provided; o any equipment and materials required; o techniques that were consistent with the person’s communication mode and learning style · the measurable and observable criteria for identifying when the desired outcome had been achieved and how data would be collected; · the projected starting date for implementing the supports and methods and the date by which program towards accomplishing the outcomes would be reviewed and evaluated; and · the names of the staff or position responsible for implementing the supports and methods. Corrective Action Ordered: Within 30 days of receipt of this order, you must: · document the above-mentioned information for P1, P2, P3, and P4’s outcomes; and · review all of your person served records who receive an intensive service to ensure their outcomes have the above-mentioned information; On an ongoing basis, you must maintain compliance as required in this subdivision. 6. Citation: Minnesota Statutes, section 245D.09, subdivision 5 Violation: For two of four staff persons whose records were reviewed (SP3 and SP4), the license holder did not provide annual training as required. The license holder failed to provide the following trainings annually to SP3 and SP4 in 2022, 2023 and/or 2024: · data privacy requirements according to MN Statutes, section 13.01 to 13.10 and 13.46, the federal Health Insurance Portability and Accountability Act of 1996 (HIPPA), 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 245D.04; and · strategies to minimize the risk of sexual violence, including concepts of healthy relationships, consent, and bodily autonomy of people with disabilities. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 7. Citation: Minnesota Statutes, section 245D.095, subdivision 5 Violation: For four staff persons whose records were reviewed (SP1, SP2, SP3 and SP4) the license holder did not maintain personnel files as required. The license holder failed to maintain the number of hours per subject area and the name of the trainer or instructor for all of SP1, SP2, SP3 and SP4’s trainings in their training records. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 8. Citation: Minnesota Statutes, section 245D.10, subdivision 4. Violation: For three persons whose records were reviewed (P1, P3, and P4) they did not provide policies and procedures as required. The license holder failed to inform and provide copies of the policies and procedures affecting a person’s rights under section 245D.04 within five working days of service initiation to P1, P3, and P4’s case managers. Corrective Action Ordered: Within 30 days of receipt of this order, you must inform and provide copies of the policies and procedures that affect the person’s rights under section 245D.04 to P1, P3, and P4’s case managers. In addition, you must review all your person served records to ensure all service recipients’ case managers received the above-mentioned policies and procedures. On an ongoing basis, you must maintain compliance as required in this subdivision. If you fail to correct the violations specified in the Correction Order within the prescribed time lines the Commissioner may issue an Order of Conditional License or may impose a fine and order other licensing sanctions pursuant to Minnesota Statutes, sections 245A.06 and 245A.07. B. Right to Request Reconsideration If you believe any of the citations are in error, you have the right to request that the Commissioner of Human Services reconsider the parts of the Correction Order that you believe to be in error. The request for reconsideration must be in writing and received by the Commissioner within 20 calendar days after receipt of this report. Your request for reconsideration must be sent to: Commissioner, Department of Human Services ATTN: Legal Unit Licensing Division PO Box 64953 St. Paul, MN 55164-0242 Please note that a request for reconsideration does not stay any provisions or requirements of the Correction Order. The Commissioner’s disposition of a request for reconsideration is final and not subject to appeal under Minnesota Statutes, chapter 14. If you have any questions regarding this Correction Order, please contact me as soon as possible. Diana Arnzen, Human Services Licensor Licensing Division Office of Inspector General 651-431-6638
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