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November 13, 2024 Elizabeth Motz, Authorized Agent HOPE, Inc 180 Sweetwater Dr Rollingstone, Minnesota 55969 License Number: 1072939 (245D – HCBS) Report Number: 202404417 CORRECTION ORDER Dear Elizabeth Motz: On August 27 and 28, 2024, a licensing review and licensing investigation of HOPE Inc, located at 503 East 2nd Street, Winona, 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 and licensing investigation, 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 2, paragraph (b). Violation: For two of three persons whose records were reviewed (P2 and P3), the license holder did not meet the requirements for an individual abuse prevention plan (IAPP) 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. a. The license holder failed to review P2’s IAPP annually in 2020. Additionally, the license holder failed to review and revise P2’s IAPP at least annually in 2022. P2’s IAPP was reviewed and revised on September 17, 2021 and on October 12, 2022. b. The license holder failed to develop an IAPP for P3 as part of the initial service plan. P3’s services were initiated on May 1, 2023, however, the license holder failed to develop an IAPP for P3 until June 14, 2023. Corrective Action Ordered: P3 no longer receives services from the license holder. On an ongoing basis, you must maintain compliance as required in this subdivision. 2. Citation: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (a), clause (4). Violation: For one person whose record was reviewed (P3), the license holder did not provide orientation to the license holder’s program abuse prevention plan (PAPP) within 24 hours of admission as required. P3’s admission date was May 1, 2023. The license holder failed to orientate P3 to the program’s PAPP within 24 hours of admission. P3 was orientated to the PAPP on June 14, 2023. Corrective Action Ordered: P3 no longer receives services from the license holder. On an ongoing basis, you must maintain compliance as required in this subdivision. 3. Citation: Minnesota Rules, part 9544.0030, subpart 1. Violation: For one person whose record was reviewed (P2), the license holder did not evaluate positive support strategies as required. For P2, the license holder failed to evaluate identified positive support strategies at least every six months. Corrective Action Ordered: Within 30 days of receiving this order, you must evaluate with P2 whether the identified positive support strategies currently meet the standards in subpart 2. Based on the results of the evaluation, you must determine whether changes are needed in the positive support strategies used, and if, so make appropriate changes. On an ongoing basis, you must maintain compliance as required in this subdivision. 4. Citation: Minnesota Statutes, section 245D.04, subdivision 1. Violation: For two persons whose records were reviewed (P2 and P3), the license holder did not provide a written notice that identified the service recipient rights and an explanation of those rights as required. a. The license holder failed to provide a written notice that identified the service recipient rights to P2 in 2020. b. P3’s services were initiated on May 1, 2023. The license holder failed to provide a written notice that identified the service recipient rights to P3 until June 14, 2023. Corrective Action Ordered: P3 no longer receives services from the license holder. On an ongoing basis, you must maintain compliance as required in this subdivision. 5. Citation: Minnesota Statutes, section 245D.05, subdivision 1a. Violation: For two persons whose records were reviewed (P2 and P3), the license holder did not meet the requirements of medication setup as required. a. The license holder failed to include the route of administration at time of setup in P2’s medication administration record. b. The license holder was assigned responsibility for medication setup in P3’s support plan addendum. The license holder failed to document the dates of setup in P3’s medication administration record. Corrective Action Ordered: Within 30 days of receiving this order, you must revise P2’s medication administration record to include the route of administration. P3 no longer receives services from the license holder. On an ongoing basis, you must maintain compliance as required in this subdivision. 6. Citation: Minnesota Statutes, section 245D.05, subdivision 2. Violation: For one person whose record was reviewed (P3), the license holder did not ensure information was documented in P3’s medication administration record as required. According to P3’s support plan addendum, the license holder was assigned responsibility for medication administration, medication setup, and medication assistance. The license holder failed to document instruction on when and to whom to report the following: · if a dose of medication is not administered or treatment is not performed as prescribed, whether by error by staff or the person or by refusal by the person; and · the occurrence of possible adverse reactions to the medication or treatment. Corrective Action Ordered: P3 no longer receives services from the license holder. On an ongoing basis, you must maintain compliance as required in this subdivision. 7. Citation: Minnesota Statutes, section 245D.05, subdivision 4. Violation: For two persons whose records were reviewed (P1 and P3), the license holder did not review the medication administration record as required. According to P1’s and P3’s support plan addendums, the license holder was assigned responsibility for medication administration. The license holder failed to review P1’s and P3’s medication records to identify medication administration errors at a minimum every three months. Corrective Action Ordered: Within 30 days of receiving this order, you must: · complete an audit of the medication administration records of all persons served by the program to ensure that the medication administration records are being reviewed at a minimum of every three months. Within 45 days of receiving this order, you must submit the following information to your licensor: · the results of the audit required above, and · based on the results of the audit, a detailed plan describing how you will come into compliance with these requirements and maintain compliance thereafter. P3 no longer receives services from the license holder. On an ongoing basis, you must maintain compliance as required in this subdivision. 8. Citation: Minnesota Statutes, section 245D.051, subdivision 1. Violation: For three persons whose records were reviewed (P1 through P3), the license holder did not develop, implement, and maintain documentation regarding psychotropic medications as required. a. P1 and P3 were prescribed multiple psychotropic medications. The license holder indicated on P1’s and P3’s “Psychotropic Medication Monitoring Data Report” form the diagnoses for which the medications were prescribed; however, the license holder failed to include a description of the target symptoms that each psychotropic medication was to alleviate. b. P1’s support plan addendum required that the license holder provide monitoring data to P1’s expanded support team semi-annually; however, the license holder failed to provide the monitoring data semi-annually as required. c. P2’s and P3’s support plan addendum required that the license holder provide monitoring data to P2’s and P3’s expanded support team quarterly; however, the license holder failed to provide the monitoring data quarterly as required. Corrective Action Ordered: Within 30 days of receiving this order, you must update the “Psychotropic Medication Monitoring Data Report” of all persons served in the program to include a description of the target symptoms that each psychotropic medication was to alleviate. P3 no longer receives services from the license holder. On an ongoing basis, you must maintain compliance as required in this subdivision. 9. Citation: Minnesota Statutes, section 245D.06, subdivision 4. Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not meet the requirements for safekeeping of funds and property as required. a. The license holder failed to obtain written authorization to assist P1 with safekeeping of funds or other property annually in 2023. Additionally, P1’s support plan addendum required the license holder to provide P1’s expanded support team with statements that itemized receipts and disbursements of funds or other property annually; however, the license holder failed to provide the statements annually as required. b. The license holder failed to obtain written authorization to assist P2 with safekeeping of funds or other property annually in 2020, 2021, and 2022. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 10. Citation: Minnesota Statutes, section 245D.07, subdivision 1a, paragraph (b), clause (3) item (iii). Violation: For one person whose record was reviewed (P3), the license holder did not provide services in response to the person’s identified needs, interests, preferences, and desired outcomes as specified in the support plan and support plan addendum, as required. Regarding complaint number 202404417, the license holder failed to provide the most integrated setting and inclusive service delivery that supports, promotes, and allows a balance between risk and opportunity when the license holder instructed P3’s staff to call law enforcement when P3 refused to smoke in a designated area. Furthermore, the license holder instructed staff to call law enforcement when P3 was smoking on a curb and standing too close to the road. Corrective Action Ordered: P3 no longer receives services from the license holder. Within 30 days of receiving this order, you must submit a detailed plan on how you will maintain compliance with this subdivision throughout your program to your licensor. On an ongoing basis, you must maintain compliance as required in this subdivision. 11. Citation: Minnesota Statutes, section 245D.07, subdivision 1. Violation: For one person whose record was reviewed (P3), the license holder did not provide services as assigned in the in the support plan as required in this subdivision. Regarding complaint number 202404417, an incident involving P3 occurred on May 16, 2024, that resulted in P3’s arrest. On May 17, 2024, P3’s support team requested that the license holder develop a safety plan prior to P3’s release from jail back to the program. P3 remained in jail until May 20, 2024, due to the license holder’s failure to develop a safety plan. The license holder failed to provide services as assigned. Corrective Action Ordered: P3 no longer receives services from the license holder. Within 30 days of receiving this order, you must submit the following to your licensor: · a written plan documenting that all staff persons have received training on each person’s support plan regarding the provision of services, as required in this subdivision; and · a detailed plan documenting how you will maintain compliance with this subdivision in the future. On an ongoing basis, you must maintain compliance as required in this subdivision. 12. Citation: Minnesota Statutes, section 245D.071, subdivision 3. Violation: For three persons whose records were reviewed (P1 through P3), the license holder did not meet the requirements for assessments and initial service planning as required for intensive services as required. a. Regarding P1, whose services were initiated on December 1, 2021, the license holder failed to: · complete assessments that produce information about the person that describes the person’s overall strengths, functional skills and abilities, and behaviors or symptoms; and · determine the following at P1’s initial planning meeting that occurred on January 19, 2022: o how the provider will support P1 to have control over P1’s schedule; o opportunities to develop and maintain essential and life-enriching skills, abilities, strengths, interests, and preferences; o opportunities for community access, participation, and inclusion in preferred community activities; o opportunities to develop and strengthen personal relationships with other persons of P1’s choice in the community; o opportunities to seek competitive employment and work at competitively paying jobs in the community; and o a discussion of how technology might be used to meet P1’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. b. Regarding P2, whose services were initiated on January 16, 2019, the license holder failed to: · complete assessments that produce information about the person that describes the person’s overall strengths, functional skills and abilities, and behaviors or symptoms; · meet with P2 and members of P2’s support team within 45 days of service initiation to determine: o how the provider will support P2 to have control over P2’s schedule; and o a discussion of how technology might be used to meet P3’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. c. Regarding P3, whose services were initiated on May 1, 2023, the license holder failed to: · complete a preliminary support plan addendum based on the support plan within 15 days of service initiation; · complete assessments that produce information about the person that describes the person’s overall strengths, functional skills, and abilities; · meet with P3 and members of P3’s support team within 45 days of service initiation to determine: o opportunities to develop and maintain essential and life-enriching skills, abilities, strengths, interests, and preferences; o opportunities for community access, participation, and inclusion in preferred community activities; o opportunities to develop and strengthen personal relationships with other persons of P3’s choice in the community; o opportunities to seek competitive employment and work at competitively paying jobs in the community; and o how services must be coordinated across other providers licensed under this chapter serving P3 and members of the support team to ensure continuity of care and coordination of services for the person; o a discussion of how technology might be used to meet P3’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: P3 no longer receives services from the license holder. Within 30 days of receiving this order, you must submit a detailed plan to your licensor that documents how you will maintain compliance throughout your program with this subdivision. On an ongoing basis, you must maintain compliance as required in this subdivision. 13. Citation: Minnesota Statutes, section 245D.071, subdivision 4. Violation: For one person whose record were reviewed (P3), the license holder did not develop a service plan that documents the service outcomes and supports based on the assessments completed under subdivision 3 and the requirements in section 245D.07, subdivision 1a, as required. The license holder failed to document the following information in P3’s current supports and methods for current outcomes: · the methods or actions that will be used to the support P3 and to accomplish the service outcomes, including information about any changes or modifications to the physical and social environments necessary when the service supports were provided; and · the measurable and observable criteria for identifying when the desired outcome had been achieved.
Corrective Action Ordered: P3 no longer receives services from the license holder. On an ongoing basis, you must maintain compliance as required in this subdivision. 14. Citation: Minnesota Statutes, section 245D.09, subdivision 4. Violation: For one of three staff persons whose records were reviewed (SP1), the license holder did not provide orientation training as required. Regarding SP1 who was hired on March 29, 2021, the license holder failed to provide the following orientation training within 60 days of hire: · the license holder’s current policies and procedures required under this chapter, including their location and access, and staff responsibilities related to implementation of those policies and procedures including: o grievance policy; o health service coordination and care; o safe transportation; o service admission; · the program abuse prevention plan according to the requirements in 245A.65, subdivision 3; · 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 · 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. 15. Citation: Minnesota Statutes, section 245D.09, subdivision 5. Violation: For two staff persons whose records were reviewed (SP1 and SP3), the license holder did not provide annual training as required. The license holder failed to provide SP1 with annual training for the annual year 2022. Additionally, the license holder failed to provide SP3 with one or more of the following trainings for 2023 and 2024: · data privacy requirements according to MN 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; · the service recipient rights and staff responsibilities related to ensuring the exercise and protection of those rights according to the requirements in 245D.04; · 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 · strategies to minimize the risk of sexual violence, including concepts of healthy relationships, consent, and bodily autonomy of people with disabilities. Furthermore, the training curriculum the license holder maintained did not meet the requirements in this subdivision. The curriculum was copyrighted in 2008 and was a nursing assistant training program. Corrective Action Ordered: Within 30 days of receiving this order, you must: · submit a training curriculum for the above mentioned topics that meets compliance with this subdivision for approval by your licensor. Within 60 days of receiving this order, you must: · training on the above mentioned topics. You must document this training in each staff person’s personnel record. On an ongoing basis, you must maintain compliance as required in this subdivision. 16. Citation: Minnesota Statutes, section 245D.09, subdivision 8. Violation: For two staff persons whose records were reviewed (SP1 and SP3), the license holder did not develop a staff orientation and training plan documenting as required. The license holder failed to develop a staff training plan documenting when and how compliance with section 245D.09, subdivisions 4, 4a, and 5 will be met. Additionally, the license holder failed to determine the 12-month period that will be used as the annual training calendar and implement it consistently. Corrective Action Ordered: Within 30 days of receiving this order, you must develop a staff training plan to determine the 12-month period that will be used for annual training for all staff persons. You must submit the plan to your licensor. 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 SP3) the license holder did not maintain personnel records as required. The license holder failed to maintain a personnel record for SP1 and SP3 to document and verify staff qualifications, orientation, and training. Corrective Action Ordered: Within 30 days of receiving this order, you must begin maintaining personnel records for all staff persons to include their qualifications, orientation training, and annual training. On an ongoing basis, you must maintain compliance as required in this subdivision. 18. Citation: Minnesota Statutes, section 245D.10, subdivision 3. Violation: For one person whose record was reviewed (P3), the license holder did not implement a temporary service suspension according to the requirements. Regarding complaint number 202404417, the license holder failed to implement a temporary service suspension when the license holder refused to pick P3 up from jail on May 17, 2024. See Citation 11 for evidence of this failure. Additionally, the license holder failed to: · document actions taken to minimize or eliminate the need for service suspension including at a minimum: o consultation with P3’s support team or expanded support team to identify and resolve issues leading to the issuance of the notice. · notify the person or the legal representative and case manager in writing of the intended temporary service suspension according to the requirements in section 245D.10, subdivision 3, paragraph (d); and · notify the commissioner in writing when the temporary service suspension was from residential supports and services as defined in section 245D.03, subdivision 1, paragraph (c), clause (3). Corrective Action Ordered: P3 no longer receives services from the license holder. Within 30 days of receiving this order, you must submit a detailed plan on how you will maintain compliance with this subdivision to your licensor. On an ongoing basis, you must maintain compliance as required in this subdivision. 19. Citation: Minnesota Statutes, section 245D.081. 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 (SP4), provided coordination of service delivery and evaluation for each person served by the program. See citations 1 through 13, and 18 for the designated coordinator’s failure to provide supervision, support, and evaluation of activities including: · oversight of the license holder’s responsibilities assigned in the person’s support plan and support plan addendum; · taking the action necessary to facilitate the accomplishment of the outcomes according to the requirements in section 245D.07 and 245D.071; · instruction and assistance to the direct support staff implementing the support plan and service outcomes, including direct observation of service delivery sufficient to assess staff competency; and · evaluation of the effectiveness of service delivery, methodologies, and progress on the person’s outcomes based on the measurable and observable criteria for identifying when the desired outcome has been achieved according to the requirements in section 245D.071. b. The license holder failed to ensure that the designated manager (SP4), provided program management and oversight of the services provided by the license holder. See citations 1 through 18 for the designated manager’s failure to: · maintain a current understanding of the licensing requirements sufficient to ensure compliance throughout the program as identified in section 245A.04, subdivision 1, paragraph (e); · ensure the duties of the designated coordinator are fulfilled according to the requirements in subdivision 2; and · ensuring staff competency requirements are met according to the requirements in section 245D.09, subdivision 3, and ensuring staff orientation and annual training is provided according to the requirements in 245D.09, subdivisions 4, 4a, and 5. Corrective Action Ordered: Within 30 days of receiving this order, you must submit a detailed written plan documenting how the license holder will ensure that the designated coordinator and designated manager perform the required duties as identified in these subdivisions to maintain compliance across the program. 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 Michael.Byrne@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: Michael Byrne Licensing Division PO Box 64242 St. Paul, MN 55164-0242 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. Michael Byrne, Human Services Licensor Licensing Division Office of Inspector General 651-431-3667
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