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December 6, 2024 Michelle O’Toole, Authorized Agent Diversified Lifestyles, Inc. 1111 6th ST SE Willmar, MN 56201-4637 License Numbers: 1069582 (245D-Home and Community-Based Services) Investigation Report Number: 202404535 CORRECTION ORDER AND NONCOMPLIANCE WITH TERMS OF A CONDITIONAL LICENSE Dear Michelle O’Toole: On May 3, 2024, the Commissioner of the Department of Human Services (DHS) issued an Order of Conditional License to Diversified Lifestyles Inc., located at 1111 6th Street SE, Willmar, Minnesota. On September 10-12, 2024, a licensing review of Diversified Lifestyles, Inc., was conducted to determine compliance with state and federal laws and rules governing the provision of home and community-based services (HCBS) to persons with disabilities and age 65 and older under Minnesota Statutes, Chapter 245D and the terms of the Order of Conditional License issued on May 3, 2024. In addition, a licensing complaint investigation was completed regarding report number 202404535. As a result of this licensing review and the licensing complaint investigation, a Correction Order and Noncompliance with the Terms of a Conditional License is being issued. A. Reason for Correction Order and Noncompliance with the terms of Conditional 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 and maltreatment investigations. Corrective action for each violation is required by Minnesota Statutes, section 245A.06 and is hereby ordered by the Commissioner of Human Services. Program Coordination and Oversight 1. Citation: Minnesota Statutes, section 245D.081, subdivisions 2 and 3. Violation: The license holder did not meet the requirements for program coordination, evaluation, and oversight. a. The license holder failed to ensure that the staff person the license holder identified as the designated coordinator provided the supervision, support, and evaluation of activities that include: · 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; · instruction and assistance to direct support staff implementing the support plan 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 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 failure to provide program coordination and oversight of the services provided is evidenced in citations 1 through 21. b. The license holder failed to ensure that the staff person the license holder identified as the designated manager performed the required program management and oversight of the services provided by the license holder, including: · 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 1 through 21. Repeat Violation: In an Order of Conditional License dated May 3, 2024, you were previously found in violation of this same statute. Corrective Action Ordered: Within 30 days of receiving this order, you must complete all corrective action as ordered in this order. You must ensure that the program’s designated coordinator and designated manager provide program coordination, evaluation, and oversight as required. Compliance with this order will be monitored on site. On an ongoing basis, you must maintain compliance as required in this subdivision. Service Recipient Violations 2. Citation: Minnesota Statues, section 245A.65, subdivision 2, paragraph (b). Violation: For two of nine persons whose records were reviewed (P2 and P7), the license holder did not meet the requirements for an individual abuse prevention plan (IAPP) as required. a. P2 was assessed to be susceptible to sexual abuse; however, the license holder failed to include a statement of specific measures that would be taken to minimize the risk of abuse in this assessed area. b. The license holder failed to develop an IAPP for P7. Repeat Violation: In an Order of Conditional License dated May 3, 2024, you were previously found in violation of this same statute. Corrective Action Ordered: Within 30 days of receipt of this order, you must: · review and update P2’s IAPP to include the specific measures that would be taken to minimize the risk of abuse; and · develop an IAPP for P7. Compliance with this order will be monitored on site. On an ongoing basis, you must maintain compliance as required in this subdivision. 3. Citation: Minnesota Statutes, section 245D.04, subdivision 1. Violation: For four persons whose records were reviewed (P3, P4, P5 and P7), the license holder did not provide the person, or their legal representative, a written notice that identified the service recipient rights and an explanation of those rights as required. a. The license holder failed to provide P3’s legal representative with a written notice that identified the following rights: · access to the person’s personal possessions at any time, including financial resources; · have access to three nutritionally balanced meals and nutritious snacks between meals each day; · have freedom and support to access food and potable water at any time; · have the freedom to furnish and decorate the person’s bedroom or living unit; · a setting that is clean and free from accumulation of dirt, grease, garbage, peeling paint, mold, vermin, and insects; · a setting that is free from hazards that threaten the person’s health or safety; and · a setting that meets the definition of a dwelling unit within a residential occupancy as defined in the state fire code. b. The license holder failed to provide P4 and P5’s legal representative with a written notice that included the service recipient right to reside in a setting that is clean and free from accumulation of dirt, grease, garbage, peeling paint, mold, vermin, and insects. The written notice provided to P4 was also missing the right to a setting that is free from hazards that threaten the persons health or safety. c. The license holder failed to provide P7 with a written notice that identified the service recipient rights an explanation of those rights annually in 2023 and 2024. Repeat Violation: In a Correction Order dated April 13, 2017 and in an Order of Conditional License dated May 3, 2024, you were previously found in violation of this same statute. Corrective Action Ordered: Within 30 days of receiving this order, you must: · complete an audit of the written notice that was provided to persons or their legal representatives and ensure the written notice included the rights detailed above. You must maintain the results of the audit in your program’s records; and · for persons or legal representatives that were not provided a written notice that included the rights detailed above, you must provide those persons and legal representatives with a written notice that includes these rights. You must maintain documentation of the person’s or the person’s legal representative’s receipt of a copy and an explanation of the rights. Compliance with this order will be reviewed on site. On an ongoing basis, you must maintain compliance as required. 4. Citation: Minnesota Statutes, section 245D.04, subdivision 3, paragraphs (a) and (b). Violation: For three persons whose record was reviewed (P3, P8, P9), the license holder did not ensure the exercise and protection of the person’s rights as required. a. The license holder failed to ensure the exercise and protection of P3’s, P8’s, and P9’s right to have access to personal possessions at any time, including financial resources. The license holder assisted P3, P8, and P9 with the safekeeping of funds. A DHS licensor asked a staff person about how P3’s, P8’s, and P9’s finances were stored. The staff person stated that the P3’s, P8’s, and P9’s debit cards were not kept at their home and were instead kept with the staff person at all times, even when the staff person was not at work. b. P3 lived in a licensed residential site operated by the license holder. During a license visit on September 10, 2024, DHS licensors observed peeling paint on the bathroom walls at P3’s place of residence (Community Residential Setting, license number 1069583). The license holder failed to ensure the exercise of P3’s rights to receive services in setting that is clean and free from peeling paint. Repeat Violation: In an Order of Conditional License dated May 3, 2024, you were previously found in violation of this same statute. Corrective Action Ordered: Immediately, upon on receiving this correction order, you must: · ensure that all persons served by the program have access to their personal possessions, including financial resources at any time; and · ensure that all Community Residential Setting facilities operated by you are clean, and free of peeling paint. Compliance with this order will be monitored on site. On an ongoing basis, you must maintain compliance as required. 5. Citation: Minnesota Statutes, section 245D.06, subdivision 4, paragraph (a). Violation: For two persons whose records were reviewed (P3 and P6), the license holder did not meet the requirements for the safekeeping of funds as required. a. The license holder failed to implement the preferences of P3’s legal representative for receiving a statement that itemizes receipts and disbursements of funds on a semi-annual basis. b. The license holder assisted P6 with the safekeeping of funds on a periodic basis. The license holder did not maintain documentation of receipt and disbursements of P6’s funds. The license holder failed to immediately document receipt and disbursement of P6’s funds at the time of receipt or disbursement. Repeat Violation: In an Order of Conditional License dated May 3, 2024, you were previously found in violation of this same statute. Corrective Action Ordered: Immediately, upon receiving this order, you must begin documenting the receipt and disbursements of P6’s funds when you are assisting P6 with the safekeeping of funds. Compliance with this order will be monitored on site. On an ongoing basis, you must maintain compliance as required. 6. Citation: Minnesota Statutes, section 245D.061 Violation: For one person whose record was reviewed (P2), the license holder did not implement the emergency use of manual restraint policy and procedure as required. The license holder’s emergency use of manual restraint policy and procedures documented that the program does not allow the emergency use of manual restraints and that alternative measures must be used by staff to achieve safety when a person’s conduct poses imminent risk of physical harm to self or others. On January 19, 2024, the license holder failed to implement their emergency use of manual restraint policy and procedure when a staff person used a manual restraint during an incident involved P2. Repeat Violation: In an Order of Conditional License dated May 3, 2024, you were previously found in violation of this same statute. Corrective Action Ordered: Immediately, upon receiving this order, you must implement your program’s policies and procedures regarding the use of manual restraints. Within 15 days of receiving this order, you must: · for P2, submit the following information regarding the above-mentioned incident to DHS and the Office of the Ombudsman for Mental Health and Developmental Disabilities, as required under section 245.94, subdivision 2a: o the report required under subdivision 5; o the internal review and the corrective action plan required under subdivision 6; and o the summary of the expanded support team review required under subdivision 7; · provide training to all staff on the emergency use of manual restraint policy and procedure. You must maintain documentation of the training in all staff persons’ personnel records according to the requirements in 245D.095, subdivision 5. Compliance with this order will be monitored on site. On an ongoing basis, you must maintain compliance as required in this subdivision. 7. Citation: Minnesota Statutes, section 245D.07, subdivision 1a. Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not provide person centered planning and service delivery as required. a. The license holder failed to provide services in response to P1’s identified needs, interests, preferences, and desired outcomes as specified in the support plan. P1’s identified outcomes were to take medications 100% of the time, to not eat between meals 85% of the time, and to shower daily 75% of the time. P1’s support plan stated that P1 had interests and goals unrelated to the outcomes developed by the license holder including maintaining employment, learning how to drive, and saving money to buy a car. b. The license holder identified P2’s outcome as “[P2] will improve [his/her] mental health,” however this was not identified to be important to or important for P2. The license holder failed to provide person-centered service planning and delivery that identifies and supports what is important to the person as well as what is important for the person and use that information to identify outcomes the person desires. Additionally, P2’s outcome was reviewed and recommended to be continued on July 22, 2024. From this date through the time of the license review, the license holder failed to collect data on P2’s outcome. Corrective Action Ordered: Within 30 days of receiving this order, you must: · develop a person-centered outcome for P1. You must document the document the supports and methods to be implemented to support the person and to accomplish the outcome; · complete the corrective action ordered for P2 in citation number 9; and · begin collecting data on P1’s and P2’s outcomes. Compliance with this order will be monitored on site. On an ongoing basis, you must maintain compliance as required. 8. Citation: Minnesota Statutes, section 245D.071, subdivision 3, paragraph (b). Violation: For four persons whose records were reviewed (P2, P3, P5 and P7), the license holder did not complete assessments required for intensive service planning as required. a. The license holder competed assessments for P2; however, the license holder failed to document assessments that produce information about the P2 that describes their overall strengths, functional skills and abilities and behaviors or symptoms. b. The license holder failed to complete assessments for P3 and P5 in the following areas on an annual basis: · the person's ability to self-manage health and medical needs to maintain or improve physical, mental, and emotional well-being, including, when applicable, allergies, seizures, choking, special dietary needs, chronic medical conditions, self-administration of medication or treatment orders, preventative screening, and medical and dental appointments; · the person's ability to self-manage personal safety to avoid injury or accident in the service setting, including, when applicable, risk of falling, mobility, regulating water temperature, community survival skills, water safety skills, and sensory disabilities; and · the person's ability to self-manage symptoms or behavior that may otherwise result in an incident as defined in section 245D.02, subdivision 11, clauses (4) to (7), suspension or termination of services by the license holder, or other symptoms or behaviors that may jeopardize the health and welfare of the person or others, and · the assessments must produce information about the person that describes the person's overall strengths, functional skills and abilities, and behaviors or symptoms. c. The license holder failed to complete assessments for P7 in the following areas: · the person's ability to self-manage health and medical needs to maintain or improve physical, mental, and emotional well-being, including, when applicable, allergies, seizures, choking, special dietary needs, chronic medical conditions, self-administration of medication or treatment orders, preventative screening, and medical and dental appointments; · the person's ability to self-manage personal safety to avoid injury or accident in the service setting, including, when applicable, risk of falling, mobility, regulating water temperature, community survival skills, water safety skills, and sensory disabilities; and · the person's ability to self-manage symptoms or behavior that may otherwise result in an incident as defined in section 245D.02, subdivision 11, clauses (4) to (7), suspension or termination of services by the license holder, or other symptoms or behaviors that may jeopardize the health and welfare of the person or others, and · the assessments must produce information about the person that describes the person's overall strengths, functional skills and abilities, and behaviors or symptoms. Repeat Violation: In a Correction Order dated April 13, 2017 and in an Order of Conditional License dated May 3, 2024, you were previously found in violation of this same statute. Corrective Action Ordered: Within 30 days of receipt of this order, you must: · complete assessments in the above-mentioned areas for P3, P5, and P7; and · review and update P2’s assessments to ensure the assessment that produce information about the P2 that describes their overall strengths, functional skills and abilities and behaviors or symptoms. You must document the date P2’s assessment was reviewed and updated. Compliance with this order will be monitored on site. On an ongoing basis, you must maintain compliance as required. 9. Citation: Minnesota Statutes, section 245D.071, subdivision 4. Violation: For three persons whose records were reviewed (P2, P4 and P7), the license holder did not develop supports and outcomes as required. a. The license holder documented outcomes for P2; 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 material 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 names of the staff or position responsible for implementing the supports and methods. b. The license holder failed to develop an outcome for P4 after P4’s previous outcome was achieved on June 30, 2024. c. The license holder failed to develop service outcomes and supports for P7. The license holder failed to document the following supports and methods to accomplish outcomes: · the methods and actions that will be used to support the person and to accomplish the services outcomes, including information about; o any changes or modifications to the physical and social environments necessary when the service supports where 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 will be collected; · the projected starting date for implementing the supports and methods and the date by which progress towards accomplishing the outcomes would be reviewed and evaluated; and · the names of the staff person or position responsible for implementing the supports and methods. Repeat Violation: In an Order of Conditional License dated May 3, 2024, you were previously found in violation of this same statute. Corrective Action Ordered: Within 30 days of receiving this order, you must develop outcomes for P2, P4, and P7. The documentation for the outcome must include the following: · the methods and actions that will be used to support the person and to accomplish the services outcomes, including information about; o any changes or modifications to the physical and social environments necessary when the service supports where 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 will be collected; · the projected starting date for implementing the supports and methods and the date by which progress towards accomplishing the outcomes would be reviewed and evaluated; and · the names of the staff person or position responsible for implementing the supports and methods. Compliance with this order will be monitored on site. On an ongoing basis, you must maintain compliance as required in this subdivision. 10. Citation: Minnesota Statutes, section 245D.071, subdivision 5. Violation: For five persons whose records were reviewed (P1- P5), the license holder did not meet the requirements for service plan review and evaluation as required. a. The license holder failed to discuss the items below with P1, P1’s case manager and members of P1’s support team annually and document the discussions: · how technology might be used to meet P1’s desired outcomes, any decision made related to the use of technology, and a description of any further research that must be completed before a decision regarding technology can be made; and · options for P1 transitioning out of a community setting controlled by the provider and into a setting not controlled by a provider and a description of any further research or education that must be completed before a decision regarding transitioning out of a provider-controlled setting can be made. Additionally, the license holder failed to summarize P1’s status and progress toward achieving identified outcomes with recommendations and the rationale for changing, continuing, or discontinuing implementation of supports and methods. b. The license holder met with P2 and P2’s case manager annually in 2024, however the license holder failed to discuss the items below and document the discussions: · how technology might be used to meet the person’s desired outcomes, any decision made related to the use of technology, and a description of any further research that must be completed before a decision regarding technology can be made; and · options for P2 transitioning out of a community setting controlled by a provider and into a setting not controlled by a provider and a description of any further research or education that must be completed before a decision regarding transitioning out of a provider-controlled setting can be made. Additionally, license holder summarized P2’s statues and progress toward achieving the identified outcomes; however, the license holder failed to identify the rationale for changing, continuing, or discontinuing implementation of the supports and methods identified in subdivision 4. c. The license holder failed to identify the rationale for changing, continuing, or discontinuing P4’s outcomes in P4’s progress reports. d. P3’s support plan required semi-annual progress reports. The license holder failed to provide progress reports for P3 semi-annually. e. P5’s support plan addendum required semi-annual service plan review meetings. The license holder failed to hold service plan review meetings on a semi-annual basis. Repeat Violation: In a Correction Order dated April 13, 2017 and in an Order of Conditional License dated May 3, 2024, you were previously found in violation of this same statute. Corrective Action Ordered: Within 30 days of receiving this order, you must: · hold discussions with P1’s and P2’s support teams regarding the above mentioned items; and · document the discussions, the date of the discussions, and who participated in the discussions in P1’s and P2’s records. Compliance with this order will be monitored on site. On an ongoing basis, you must maintain compliance as required. 11. Citation: Minnesota Rule, section 9544.0030, subparts 1 and 2. Violation: For four persons whose records were reviewed (P1, P3, P5 and P7), the license holder did not meet the requirements for positive support strategies as required. a. The license holder failed to evaluate with P1, P3, and P5 whether the positive support strategies met standards at least every six months. b. The license holder failed to develop positive support strategies for P7.
Repeat Violation: In an Order of Conditional License that DHS issued on May 3, 2024, you were previously found in violation of this same statute. Corrective Action Ordered: Within 30 days of receiving this order, you must: · evaluate with P1, P3, P5 whether the positive support strategies met standards and document the review in their records; and · develop positive supports for P7 and incorporate in writing the positive support strategies to an existing treatment, service, or other individual plan for P7. Compliance with this order will be monitored on site. On an ongoing basis, you must maintain compliance as required. Health Service Needs Violations 12. Citation: Minnesota Statutes, section 245D.05, subdivision 1a. Violation: For two persons whose records were reviewed (P1 and P5), the license holder did not maintain documentation for medication setup as required. a. The license holder completed medication setup for P1 as part of medication administration. The license holder failed to document the following in P1’s record: · dates of setup; · name of medication; · quantity of dose; · times to be administered; and · route of administration at time of setup. b. The license holder completed medication setup for P5 as part of medication administration. The license holder failed to document the following in P5’s record: · dates of setup; · name of medication; · quantity of dose; · times to be administered; · and route of administration at time of setup; and · when P5 was away from home, to whom the medications were given. Repeat Violation: In an Order of Conditional License dated May 3, 2024, you were previously found in violation of this same statute. Corrective Action Ordered: Immediately upon receiving this order, you must begin documenting medication setup for P1 and P5. Compliance with this order will be monitored on site. On an ongoing basis, you must maintain compliance as required. 13. Citation: Minnesota Statutes, section 245D.05, subdivision 2, paragraph (b). Violation: For one person whose record was reviewed (P5), the license holder did not implement medication procedures as required. The license holder was responsible for administering medications for P5. P5’s MAR listed that P5’s was to take Senna, two 8.6 mg tablets by mouth daily. The prescription label for P2’s Senna stated that it was supposed to be taken as needed (PRN) for constipation. The license holder was administering this medication as a daily scheduled medication. The license holder stated that P5’s prescriber changed the order so that the medication was to be administered daily but did not have documentation from the prescriber of this change. The license holder failed to administer medications as prescribed. Repeat Violation: In an Order of Conditional License dated May 3, 2024, you were previously found in violation of this same statute. Corrective Action ordered: Immediately, upon receiving this order, you must ensure that P5 receives medications as prescribed. Within 30 days of receiving this order, you must complete the correction action ordered in citation number 15 for P5. Compliance with this order will be monitored on site. On an ongoing basis you must maintain compliance as required. 14. Citation: Minnesota Statutes, section 245D.05, subdivision 2, paragraph (c). Violation: For one person whose record was reviewed (P4) the license holder failed to document medication administration as required. The license holder failed to document a notation of when a medication or treatment administered for P4. P4 was prescribed a weekly treatment. Staff signed off on this weekly treatment daily, even though it was not being administered daily. Corrective Action Ordered: Compliance with this order will be monitored on site. On an ongoing basis, you must maintain compliance as required in this subdivision. 15. Citation: Minnesota Statutes, section 245D.05, subdivision 4. Violation: For five persons whose records were reviewed (P1-P3, P5 and P7), the license holder was assigned responsibility for administration of medication in their support plan addendums. The license holder did not ensure that the medication administration records were reviewed as required. The license holder failed to conduct a medication administration record (MAR) review at least every three months for P1- P3, P5, and P7. Repeat Violation: In an Order of Conditional License that DHS issued on May 3, 2024, you were previously found in violation of this same statute. Corrective Action Ordered: Within 30 days of receiving this correction order, you must: · review P1’s-P3’s, P5’s and P7’s MARs for the past six months to ensure that the information in the MARs is current and to identify medication errors. You must document the review and maintain the documentation in the person’s record; · based on the review, you must develop, document, and implement a plan to correct patterns of medication administration errors when identified. Within 60 days of receiving this order, you must: · review the MARs for the past six months for all other persons your program is assigned medication administration for to ensure that the information in the MARs is current and to identify medication errors; and · based on the review, you must develop and implement a plan to correct patterns of medication administration errors when identified. Compliance with this order will be monitored on site. On an ongoing basis, you must maintain compliance as required. 16. Citation: Minnesota Statutes, section 245D.05, subdivision 4, paragraph (b). Violation: For one person whose record was reviewed (P4), the license holder did not report medication errors or refusals as required. P4 did not receive their prescribed medication on February 22, 2024. The license holder failed to ensure P4’s case manager and legal representative were notified of the missed medication.
Repeat Violation: In an Order of Conditional License that DHS issued on May 3, 2024, you were previously found in violation of this same statute. Corrective Action Ordered: Within 30 days of receiving this order, you must notify P4’s legal representative and case manager of this missing medication. Compliance with this order will be monitored on site. On an ongoing basis, you must maintain compliance as required. 17. Citation: Minnesota Statutes, section 245D.051, subdivision 1, paragraph (b). Violation: For six persons whose records were reviewed (P1- P5, and P7), the license holder did not develop documentation regarding psychotropic medications as required. a. The license holder was assigned responsibility for monitoring and measuring the target symptoms to be alleviated by two psychotropic medications for P1. The license holder failed to document the monitoring and measuring of the target symptoms, any reports on medication or symptom related data, and any monitoring data provided to the expanded support team for review every three months. b. The license holder was assigned responsibility for medication administration for P3, P4, P5 and P7, who were prescribed psychotropic medications. The license holder failed to document a description of target symptoms that each psychotropic medication was prescribed to alleviate.
c. The license holder documented P2 and P4’s prescriber required the license holder to monitor and measure changes to the target symptoms that were to be alleviated by the psychotropic medications. The license holder failed to collect and report on medication and symptom related data as instructed by the prescriber for P2 and P4. d. The license holder failed to provide monitoring data to the expanded support team for review every six months as requested by the person’s legal representative. Repeat Violation: In an Order of Conditional License that DHS issued on May 3, 2024, you were previously found in violation of this same statute.
Corrective Action Ordered: Within 30 days of receiving this order, you must maintain documentation in P4, P5, and P7’s support plan addendum that includes a description of the target symptoms that each psychotropic medication was to alleviate, as required in this subdivision. Compliance with this order will be monitored on site. On an ongoing basis, you must maintain compliance as required. Staff Violations 18. Citation: Minnesota Statutes, section 245D.09, subdivision 4. Violation: For one of four staff persons whose record was reviewed (SP2), the license holder did not provide orientation training as required. The license holder failed to provide SP2 with basic first aid training within 60 days of hire. Corrective Action Ordered: Within 30 days of receiving this order, you must provide SP2 with basic first aid training. Compliance with this order will be monitored on site. On an ongoing basis, you must provide orientation training as required in this subdivision. 19. Violation: For two staff persons whose record was reviewed (SP3 and SP4), the license holder did not provide annual training as required. NOTE: “Annual” or “annually” is defined in section 245A.02, subdivision 2b as prior to or within the same month of the subsequent calendar year.
a. The license holder failed to provide SP3 and SP4 with training on the program abuse prevention plan (PAPP) on an annual basis. b. The license holder stated that they provided staff persons with certified basic first aid training. The license holder was unable to provide evidence of SP3 and SP4’s certified basic first aid training and DHS licensors were unable to verify if or when SP3 and SP4 had certified basic first aid training. The license holder failed to provide basic first aid training prior to the expiration of SP3 and SP4’s basic first aid certification. Repeat Violation: In an Order of Conditional License that DHS issued on May 3, 2024, you were previously found in violation of this same statute. Corrective Action Ordered: Within 30 days of receiving this order, you must: · provide SP3 and SP4 with training on the PAPP; · provide SP3 and SP4 with basic first aid training. Compliance with this order will be monitored on site. On an ongoing basis, you must maintain compliance as required. Record Keeping Violations 20. 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 a service recipient record as required. The license holder failed to maintain progress review reports and progress or daily log notes for P1 and P2. Corrective Action Ordered: Within 30 days of receiving this order, you must begin maintaining progress or daily log notes for P1 and P2. Compliance with this order will be monitored on site. On an ongoing basis you must maintain compliance as required with this subdivision. 21. Citation: Minnesota Statutes, section 245D.095, subdivision 5, paragraph (a).
Violation: For two staff persons whose records were reviewed (SP2 and SP4), the license holder did not maintain personnel records as required.
The license holder failed to maintain the hours of training per subject area in SP2 and SP4’s personnel record for each required training subject area. Corrective Action Ordered: Compliance with this order will be monitored on site. On an ongoing basis, you must maintain the following training information in each staff person’s personnel record as required in this subdivision: · the date the training was completed; · the number of hours per subject area; and · the name of the trainer or instructor. 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 Diana Arnzen at 651-431-6638 as soon as possible. Renae Dressel, Human Services Licensor Office of Inspector General
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