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October 1, 2024 Amanda Russell, Authorized Agent Hope Haven Inc. 719 7th Ave SW Pipestone, Minnesota, 56164 License Number: 1069279 (245D – HCBS) 1092172 (DSF) CORRECTION ORDER Dear Amanda Russell: On August 6-7, 2024, a licensing review of Hope Haven, Inc. dba The Achievement Center, located at 717 7th Ave SW, Pipestone, 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 Statues, section 245A.65, subdivision 2, paragraph (b). Violation: For two of five persons whose records were reviewed (P1 and P2) the license holder did not meet the requirements for an individual abuse prevention plan as required. The license holder failed to meet the requirements of an individual abuse prevention plan (IAPP) for P1 and P2 in the following ways: a. For P1, the license holder failed to complete an individualized assessment that included any reports of abuse related to the person. P1’s addendum identified a history of suicidal thoughts and suicide attempts; however, P1’s IAPP did not identify this risk for P1. b. For P1 and P2, the license holder failed to develop an IAPP that included measures with specific action the program would take to minimize the risk of abuse within the scope of the licensed services. Corrective Action Ordered: Within 30 days of receipt of this order, you must review and revise P1’s and P2’s IAPP to include the above-mentioned information. On an ongoing basis, you must maintain compliance as required in this subdivision. 2. Citation: Minnesota Statutes, section 245D.04, subdivision 1. Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not meet the service recipient rights requirements as required. The license holder failed to provide P1 and P2 with a copy of service recipient rights and an explanation of those rights annually in 2022 and 2023. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 3. Citation: Minnesota Statutes, section 245D.071, subdivision 3, paragraph (b). Violation: For one person whose record was reviewed (P1), the license holder did not meet service planning and delivery requirements for an intensive service as required. The license holder failed to complete the required assessments for P1 at a minimum of annually. Additionally, the assessments the license holder completed for P1 included 2021, 2022, 2023, and 2024 included outdated and irrelevant information that indicated that the assessments were not based on the person’s status within the last 12 months. Corrective Action Ordered: Within 30 days of receiving this order, you must: · complete the required assessments for P1 and ensure that the assessments are based on the person’s status within the last 12 months. Assessments based on older information must be documented and justified; and · provide P1’s support team with an opportunity to review the assessments completed for P1. You must document this review in P1’s service recipient record. On an ongoing basis, you must maintain compliance throughout your program, as required in this subdivision. 4. Citation: Minnesota Statutes, section 245D.071, subdivision 3, paragraph (d). Violation: For one person whose record was reviewed (P2), the license holder did not meet the requirements for intensive support services as required. The license holder failed to have a discussion with P2, P2’s case manager and other members of the support team of how technology might be used to meet P2's desired outcomes. The support plan or support plan addendum must include a summary of this discussion. The summary must include: · a statement regarding any decision that is made regarding the use of technology; and · a description of any further research that needs to be completed before a decision regarding the use of technology can be made. Corrective Action Ordered: Within 30 days of receipt of this order, you must have a discussion with P2, P2’s case manager, and other members of the support team about how technology might be used to meet P2’s desired outcomes. On an ongoing basis, you must maintain compliance as required in this subdivision. 5. Citation: Minnesota Statutes, section 245D.071, subdivision 4. Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not develop a service plan that documented the service outcomes and supports as required. The license holder failed to develop a service plan that documented the service outcomes and supports based on the assessments and person-centered planning for P1 and P2. Corrective Action Ordered: Within 30 days of receiving this order, you must develop a service plan for P1 and P2 that includes the following: · the methods or actions that will be used to support the person and to accomplish the service outcomes; o any changes or modifications to the physical and social environments necessary when the service supports are provided; o any 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 will be reviewed and evaluated; and · the names of the staff or position responsible for implementing the supports and methods. Within 45 days of receiving this order, you must: · train all staff persons who provide direct support services to P1 and P2 on the outcomes and supports and methods and how to implement the supports and methods for P1 and P2. You must document the training in the staff persons’ personnel records. On an ongoing basis, you must maintain compliance as required in this subdivision. 6. Citation: Minnesota Statutes, section 245D.071, subdivision 5, paragraph (g). Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not meet the requirements of service planning and review as required. For P1 and P2, the license holder failed to: · summarize the person’s status and progress toward achieving the identified outcome(s); · make recommendations; and · identify the rationale for changing, continuing, or discontinuing implementation of supports and methods identified in subdivision in a report available at the time of the progress review meeting. Corrective Action Ordered: Within 30 days of receipt of this order, you must provide P1’s and P2’s support teams with a progress review report that includes the above-mentioned information. On an ongoing basis, you must maintain compliance as required in this subdivision. 7. Citation: Minnesota Rules, 9544.0030, subpart 1. Violation: For one of two persons whose records were reviewed (P1 and P2), the license holder did not meet the requirements for positive support strategies and person-centered planning as required. The license holder failed to develop positive support strategies and incorporate the positive support strategies in writing to an existing treatment, service, or other individual plan for P1 and P2. Corrective Action Ordered: Within 30 days of receipt of this order, you must: · assess P1’s and P2’s strengths, needs, and preferences to identify and create positive support strategies for each person; · incorporate the positive support strategies for P1 and P2 in writing to an existing treatment, service, or other individual plan for each person. On an ongoing basis, you must evaluate with the person, at least every six months, whether the identified positive support strategies currently meet the standards in subpart 2 and determine whether changes are needed in the positive support strategies used based upon the results of the evaluation, and if so, make appropriate changes. 8. Citation: Minnesota Statutes, section 245D.095, subdivision 3. Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not maintain service recipient records as required. The license holder failed to maintain progress or daily log notes in P1’s and P2’s record. Corrective Action Ordered: Immediately upon receiving this order, you must maintain progress or daily log notes for P1, P2, and all other persons receiving services in your program. On an ongoing basis, you must maintain compliance as required in this subdivision. 9. Citation: Minnesota Statutes, section 245A.65, subdivision 3. Violation: For two staff persons whose records were reviewed (SP4 and SP5), the license holder did not provide orientation training and annual review of the license holder’s program abuse prevention plan (PAPP) 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 SP4 and SP5 with: · an orientation of the license holder’s program abuse prevention plan within 72 hours of first providing direct contact services; and · an annual review of the PAPP. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 10. Citation: Minnesota Statutes, section 245D.09, subdivision 4. Violation: For two staff persons whose records were reviewed (SP1 and SP2), the license holder did not provide orientation training as required. The license holder failed to provide SP1 and S2 with review of and instruction on basic first aid within 60 calendar days of hire. Corrective Action Ordered: Within 30 days of receiving this order, you must provide SP1 and SP2 with review and instruction on basic first aid. On an ongoing basis, you must maintain compliance as required in this subdivision. 11. Citation: Minnesota Statutes, section 245D.09, subdivision 5. Violation: For one staff person whose record was reviewed (SP4), the license holder did not provide annual training as required. The license holder failed to provide SP4 annual training on staff responsibilities related to protecting persons from maltreatment and reporting maltreatment. SP4 received this training in July 2022 and August 2023. Corrective Action Ordered: 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 64242 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. Kate Spenger, Senior Human Services Licensor Licensing Division Office of Inspector General 651-431-5757
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