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December 23, 2024 Ali Ahmed Sharif, Authorized Agent Bridge Caregiver LLC 1109 Moore Lake Drive East Fridley, Minnesota 55432 License Number: 1106063 (245D – HCBS) CORRECTION ORDER Dear Ali Ahmed Sharif: On October 16, 2024, and October 22, 2024, a licensing review of Bridge Caregiver LLC, located at 1109 Moore Lake Drive East, Fridley, 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 2. Violation: For one of three persons whose records were reviewed (P2), the license holder did not develop and review the individual abuse prevention plan (IAPP) as required. a. The license holder failed to develop an IAPP for P2 upon service initiation. P2’s services were initiated on December 1, 2022; however, the license holder developed an IAPP on December 22, 2022. b. The license holder developed an IAPP for P2 that identified areas where they were susceptible to abuse or at risk of abusing other vulnerable adults. The license holder failed to include statements of measures, including specific actions, that the program would take to minimize the risk of abuse to that person within the scope of the license services, when an individual assessment required in section 626.557, subdivision 14, paragraph (b), indicated the need for measures. c. The license holder failed to review P2’s IAPP annually in 2023. Corrective Action Ordered: Within 30 days of receiving this order, you must: · establish and enforce P2’s IAPP to ensure the IAPP meets the requirements of this section; · review P2’s IAPPs with the person, their legal representative, if applicable, and their case manager; and · maintain documentation of this review in P2’s record; 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 provide written notice that identified the service recipient rights as required. a. The license holder failed to provide P1 or P1's legal representative with a written notice that identified the service recipient rights in subdivisions 2 and 3, and an explanation of those rights within five working days of service initiation. P1 later received this on June 1, 2024. b. The license holder failed to provide P2 with a written notice that identified the service recipient rights in subdivisions 2 and 3, and an explanation of those rights within five working days of service initiation. P2’s services were initiated on December 1, 2022, and P2 received a written notice and explanation of the rights on December 14, 2022. Additionally, the license holder failed to provide P2 with a copy and explanation of the rights annually in 2023. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 3. Citation: Minnesota Statutes, section 245D.05, subdivision 1. Violation: For three persons whose records were reviewed (P1, P2 and P3), the license holder did not meet health service needs as required. The license holder was responsible for meeting P1, P2 and P3’s health service needs. The license holder failed to maintain documentation on how P1 and P3’s health needs would be met, including a description of the procedures the license holder would follow in order to: · provide medication administration; · monitor health conditions according to written instructions from a licensed health care professional; · use medical equipment, devices or adaptive aides or technology safely and correctly according to written instructions from a licensed health professional. Corrective Action Ordered: Within 30 days of receiving this order, you must document how P1, P2 and P3’s health needs will be met in their support plan addendums. On an ongoing basis, you must maintain compliance as required in this subdivision. 4. Citation: Minnesota Statutes, section 245D.05, subdivision 2. Violation: For two persons whose records were reviewed (P1 and P3), the license holder did not meet the requirements for medication administration as required. Through an interview with the license holder, it was determined that the license holder was responsible for administering medications to P1 and P3. The license holder failed to: · obtain written authorization from P1 and P3’s's legal representative to administer medication or treatment. · maintain a medication administration record (MAR) for P1 and P3; thus, the following information was not documented in the person's medication administration record: o information on any risks or other side effects that are reasonable to expect, and any contraindications to its use. This information (risks, side effects, and contraindications) was readily available to all staff administering the medication; o the possible consequences if the medication or treatment is not taken or administered as directed; o 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 the staff or the person or by refusal by the person; and · the occurrence of possible adverse reactions to the medication or treatment; and · notation of when a medication or treatment was started, administered, changed, or discontinued. Corrective Action Ordered: Within 30 days of receiving this order, you must: · obtain written authorization from P1 and P3’s's legal representative to administer medication or treatment. · maintain a medication administration record (MAR) for P1 and P3. The following information must be documented in the person's medication administration record: o information on any risks or other side effects that are reasonable to expect, and any contraindications to its use. This information (risks, side effects, and contraindications) was readily available to all staff administering the medication; o the possible consequences if the medication or treatment is not taken or administered as directed; o 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 the staff or the person or by refusal by the person; and · the occurrence of possible adverse reactions to the medication or treatment; and · notation of when a medication or treatment was started, administered, changed, or discontinued. On an ongoing basis, you must maintain compliance as required in this subdivision. 5. Citation: Minnesota Statutes, section 245D.051, subdivision 1. Violation: For one person whose record was reviewed (P1), the license holder did not develop, implement, and maintain documentation regarding psychotropic medications as required The license holder was responsible for administering P1’s psychotropic medication. The license holder failed to maintain documentation that included a description of the target symptoms that each of the psychotropic medications are to alleviate. For the purposes of this section, "target symptom" refers to any perceptible diagnostic criteria for a person's diagnosed mental disorder, as defined by the Diagnostic and Statistical Manual of Mental Disorders Fourth Edition Text Revision (DSM-IV-TR) or successive editions, that has been identified for alleviation. Corrective Action Ordered: Within 30 days of receiving this order, you must develop, implement, and maintain the following documentation in the person's support plan addendum: · a description of the target symptoms that the psychotropic medication is to alleviate; · determine if the prescriber requires data on P1’s target symptoms. If so, you must: o include documentation methods the license holder will use to monitor and measure changes in the target symptoms that are to be alleviated by the psychotropic medication in P1’s support plan addendum; o collect and report on P1’s medication and symptom related data as instructed by the prescriber. · determine if P1’s expanded support team requires medication and symptom-related data. If so, you must: o provide the monitoring data to the expanded support team for review every three months, or as otherwise requested by the person or the person's legal representative. On an ongoing basis, you must maintain compliance as required in this subdivision. 6. Citation: Minnesota Statutes, section 245D.07, subdivision 1. Violation: For two persons whose records were reviewed (P1 and P3), the license holder did not comply with the provision of services as required. According to the Community-Based Services Manual, individualized home supports with family training cannot be provided by a relative. a. P1 and P3 received individualized home supports with family training from the license holder. The license holder failed to comply with the federal waiver plan when P1 and P3’s relatives were hired by the license holder as staff persons to provide P1 and P3’s individualized home supports with family training service. b. DHS licensors determined that P1 had a rate exception. The license holder failed to provide services assigned in P1’s support plan when the license holder failed to pay staff the higher wages consistent with the rates in the rate exception form approved for P1. Corrective Action Ordered: Immediately, upon receiving this order, you must comply with the provision of services according to the requirements of this chapter and the federal waiver plans. On an ongoing basis, you must maintain compliance as required in this subdivision. 7. Citation: Minnesota Statutes, section 245D.07, subdivision 2. Violation: For one person whose record was reviewed (P2), the license holder did not meet service planning and delivery requirements for basic support services. For P2, the license holder failed to, within 15 days of service initiation, complete a preliminary support plan addendum based on the support plan. P2’s services were initiated on December 1, 2022. In addition, the license holder failed to review and revise within 60 days of service initiation as the preliminary support plan addendum to document the services that will be provided for P2 including how, when, and by whom services will be provided, and the person responsible for overseeing the delivery and coordination of services. P2 received multiple basic support services from the license holder, including night supervision, homemaker, and individualized home supports without training. The license holder failed to comply with the requirements of this subdivision for all services provided. Corrective Action Ordered: Within 30 days of receiving this this order, you must review and revise, as needed, P2’s support plan addendum to document the services that will be provided including how, when, by whom services will be provided, and the person responsible for overseeing the delivery and coordination of those services. On an ongoing basis, you must maintain compliance as required in this subdivision. 8. Citation: Minnesota Statutes, section 245D.071, subdivision 3. Violation: For one person whose record was reviewed (P1), the license holder did not meet assessments and initial service planning as required. a. The license holder failed to: · complete a preliminary support plan addendum based on the support plan within 15 days of P1’s service initiation; · participate in an initial service planning meeting; therefore, the license holder failed to complete assessments for P1 in the following areas before the 45-day planning meeting: o 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; o 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 o 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; · the license holder later completed the above mentioned assessments for P1 on June 1, 2024, however, the license holder failed to complete assessments on P1’s ability to self manage in the area of choking and sensory disabilities; · meet with P1, P1’s legal representative, P1’s case manager, and other members of the support team or expanded support team within 45 days of service initiation to determine the following. The license holder later completed this: o the scope of the services to be provided to support the person's daily needs and activities; o the person's desired outcomes and the supports necessary to accomplish the person's desired outcomes; o the person's preferences for how services and supports are provided, including how the provider will support the person to have control of the person's schedule; o whether the current service setting is the most integrated setting available and appropriate for the person; 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 the person's choice in the community; o opportunities to seek competitive employment and work at competitively paying jobs in the community; o how services must be coordinated across other providers licensed under this chapter serving the person and members of the support team or expanded support team to ensure continuity of care and coordination of services for the person; and o have a discussion of how technology might be used to meet the person's desired outcomes. Corrective Action Ordered: Within 30 days of receiving this order, you must complete assessments on P1’s ability to self manage in the area of choking and sensory disabilities. On an ongoing basis, you must maintain compliance as required in this subdivision. 9. Citation: Minnesota Statutes, section 245D.071, subdivision 4. Violation: For two persons whose records were reviewed (P1 and P3), the license holder did not develop a service plan that documented the service outcomes and supports as required. a. 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 within 10 days of the initial service planning meeting. The license holder later developed an outcome for P1 on June 1, 2024, however, the outcome failed to identify all of the following supports and methods to be implemented to support P1: · methods of 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 materials 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 outcomes had been achieved and; · the projected starting date for implementing the supports and methods; and · the names of the staff or position responsible for implementing the supports and methods. b. The license holder failed to identify the following supports and methods to be implemented to support P3: · the projected starting date for implementing the supports and methods; and · the names of the staff or position responsible for implementing the supports and methods. The license holder documented that “The Personal Care Assistants and case manager are responsible for implementing the support and methods” however, that information is not consistent with information reviewed elsewhere in P1’s record. Corrective Action Ordered: Within 60 days of receiving this order, you must: · develop a service plan P1 that documents the service outcomes and supports that includes the following: o the methods or actions that will be used to support P1 and to accomplish the service outcomes, including information about: · any changes or modifications to the physical and social environments necessary when the service supports are provided; · any equipment and materials required; and · techniques that are consistent with the person’s communication mode and learning style; o the measurable and observable criteria for identifying when the desired outcome has been achieved and how data will be collected; o the projected starting date for implementing the supports and methods and the date by which progress towards accomplishing the outcomes will be reviewed and evaluated; and o the names of the staff or position responsible for implementing the supports and methods. · revise P3’s service outcomes and supports to includes the following: o the projected starting date for implementing the supports and methods; and o the names of the staff or position responsible for implementing the supports and methods · submit copies P1 and P3’s service outcomes and supports to this licensor. On an ongoing basis, you must maintain compliance as required in this subdivision. 10. Citation: Minnesota Statutes, section 245D.95, subdivision 2. Violation: For three persons whose records were reviewed (P1 through P3), the license holder did not maintain admission and discharge register as required. The license holder failed to maintain a written or electronic register, listing in chronological order the dates and names of all persons served by the program who have been admitted or discharged by the license holder. Corrective Action Ordered: Within 30 days of receiving this order, you must maintain admission and discharge register with the above-mentioned requirements. On an ongoing basis, you must maintain compliance as required in this subdivision. 11. Citation: Minnesota Statutes, section 245D.95, subdivision 3. Violation: For three persons whose records were reviewed (P1 through P3), the license holder did not maintain service recipient record as required. · P1’s services were initiated on December 15, 2022. The license holder failed to develop an admission form signed by P1 or P1’s legal representative that maintained the following information for P1. The license holder did develop this for P1 on June 1, 2024: o identifying information, including the person’s name, date of birth, address, and telephone number, including the name, address, and telephone numbers of the persons legal representative, a primary emergency contact, and family members or others as identified by the person or case manager; o service information, including service initiation information, verification of the person’s eligibility for services, documentation verifying that services have been provided as identified in the support plan or support plan addendum according to paragraph (a), and date of admission or readmission; and o health information, including medical history, special dietary needs, and allergies. · The license holder failed to maintain documentation to show a signed statement authorizing the license holder to act in a medical emergency when P1 and P3’s legal representative and cannot be reached or is delayed in arriving. · The license holder failed to maintain copies of progress or daily log notes for P1-P3 that are recorded by the program. Corrective Action Ordered: Within 30 days of receiving this order, you must: · maintain documentation to show a signed statement authorizing the license holder to act in a medical emergency when P1 and P3’s legal representatives and cannot be reached or is delayed in arriving; and · maintain copies of progress or daily log notes for P1-P3 that are recorded by the program. On an ongoing basis, you must maintain compliance as required in this subdivision. 12. Citation: Minnesota Statutes, Minnesota Statutes, section 245D.10, subdivision 4. Violation: For three persons whose records were reviewed (P1 through P3), the license holder did not provide written or electronic copies of policies and procedures as required a. The license holder failed to inform P1, P1’s legal representative, and P1’s case manager of the policies and procedures affecting P1’s rights under section 245D.04, and provide copies of the following policies and procedures, within 5 working days of service initiation. P1’s services were initiated on December 15, 2022. The license holder later provided this to P1’s legal representative and P1’s case manager on May 10, 2023: • grievance policy; • temporary service suspension policy; • service termination policy; • emergency use of manual restraints policy; and • data privacy policy. Additionally, the license holder failed to obtain written acknowledgment from P1's legal representative that P1 had been notified of the policy and procedures on the emergency use of manual restraints as required in Minnesota Rules, part 9544.0080, subpart 1 at the time P1’s services were initiated. b. The license holder failed to inform P2 and P2’s case manager of the policies and procedures affecting P2’s rights under section 245D.04, and provide copies of the required policies and procedures, within 5 working days of service initiation. P2’s services were initiated on December 1, 2022. The license holder provided P2 copies of the required policies and procedures on December 14, 2022. c. The license holder failed to inform P3’s case manager of the policies and procedures affecting P3’s rights under section 245D.04, and provide copies of the following policies and procedures, within 5 working days of service initiation. The license holder later provided this to P3’s case manager on October 8, 2024: • grievance policy; • temporary service suspension policy; • service termination policy; • emergency use of manual restraints policy; and • data privacy policy. Corrective Action Ordered: Within 30 days of receiving this order, you must provide P2’s case manager with written or electronic copies of the above-mentioned policies and procedures. On an ongoing basis, you must maintain compliance as required in this subdivision. 13. Citation: Minnesota Rule, 9544.0030, subpart 1. Violation: For two persons whose records were reviewed (P1 and P2), the license holder did not incorporate and evaluate positive support strategies as required. a. For P2, the license holder failed to incorporate positive support strategies in writing to an existing treatment, service, or other individual plan. b. The license holder failed to evaluate with P1 and P2, at least every six months, whether any positive support strategies used, needed changes, and, if so, make appropriate changes. Corrective Action Ordered: Within 30 days of receiving this order, you must: · develop and implement positive support strategies for P2, and incorporate those positive support strategies into writing in P2’s existing treatment, service, or other individual plan; and · evaluate the identified positive support strategies with P1 and P2. Based upon the results of the evaluation, you must determine whether changes are needed in the positive support strategies used, and, if so, make appropriate changes. · maintain documentation of P1 and P2’s the evaluation in their files. 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. On an ongoing basis, you must maintain compliance as required in this subpart. 14. Citation: Minnesota Statutes, section 245D.09, subdivision 4. Violation: For four of six staff persons whose records were reviewed (SP1, SP2, SP3 and SP4), the license holder did not provide orientation training as required. The license holder failed to provide SP1, SP2, SP3 and SP4 with an orientation to the following within 60 calendar days of hire: · the job description and how to complete specific job functions, including: o responding to and reporting incidents as required under Minnesota Statutes, section 245D. 06, subdivision 1; and o following safety practices established by the license holder and as required in section 245D.06, subdivision 2; · the license holder’s current policies and procures required under Minnesota Statutes, chapter 245D, including their location, access, and staff responsibilities related to the implementation of those policies and procedures, including: o use of universal precautions and sanitary practices; o safe transportation; o service admission; o emergency response, reporting and reviewing; and o incident response, reporting and reviewing; · data privacy requirements according to Minnesota Statutes, section 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; · sections 245A.65, 245A.66, 626.556, and 626.557, governing maltreatment reporting and service planning for children and vulnerable adults, and staff responsibilities related to protecting persons from maltreatment and reporting maltreatment. This orientation must be provided within 72 hours of first providing direct contact services and annually thereafter according to section 245A.65, subdivision 3; · the principles of person-centered planning and delivery as identified in Minnesota Statutes, 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; and · strategies to minimize the risk of sexual violence, including concepts of healthy relationships, consent, and bodily autonomy or people with disabilities. Corrective Action Ordered: Within 60 days of receiving this order, you must provide SP3 and SP4 training on the above stated requirements. Regarding SP1 and SP2, you will need to complete the Corrective Action Ordered in citation 16 of this order. On an ongoing basis, you must maintain compliance as required in this subdivision. 15. Citation: Minnesota Statutes, section 245D.09, subdivision 4a. Violation: For four staff persons whose records were reviewed (SP1, SP2, SP3 and SP4), the license holder did not provide orientation to individual service recipient needs as required. The license holder failed to provide SP1, SP2, SP3 and SP4 with the following training before having unsupervised direct contact with a person served by the program: · orientation to the individual service recipient needs; · the person’s support plan or support plan addendum; and · the person’s individual abuse prevention plan (IAPP), to achieve and demonstrate an understanding of the person as a unique individual, and how to implement those plans. Corrective Action Ordered: Within 60 days of receiving this order, you must: · ensure SP1, SP2, SP3 and SP4 have reviewed and received instruction on the requirements identified above for each service recipient they are providing direct support services to; · complete an audit of all staff records providing direct support services licensed under this chapter to ensure the above stated training has been provided; · for staff persons who have not been provided this training, provide this training, and maintain documentation of completion as required in this chapter; and · maintain documentation of the audit results at your program for review by DHS licensors. On an ongoing basis, you must maintain compliance as required in this subdivision. Citation: Minnesota Statutes, section 245D.09, subdivision 5. 16. Violation: For two staff persons whose records were reviewed (SP1 and SP2), the license holder did not provide annual training as required. 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 SP1 and SP2 with annual training on the following topics: · data privacy requirements according to sections 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; · 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 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; · basic first aid; 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: Within 60 days of receiving this order, you must: · provide SP1 and SP2 training on the topics identified above; · complete an audit of all staff records to ensure all required training has been completed and is current per the requirements of this chapter; · provide any lapsed training identified in the audit to the staff persons and maintain documentation of this training as required in section 245D.095, subdivision 5; and · maintain documentation of the audit results at your program for review by DHS licensors. On an ongoing basis, you must maintain compliance as required in this subdivision. 17. Citation: Minnesota Statutes, section 245D.095, subdivision 5, paragraph (a). Violation: For four staff persons whose records were reviewed (SP1, SP2, SP3 and SP4), the license holder did not maintain service recipient records as required. The license holder failed to maintain documentation of the following in SP1, SP2, SP3 and SP4’s personnel record: · the date the training was completed; · the number of hours per subject area; and · the name of the trainer or instructor. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 18. Citation: Minnesota Statutes, section 245D.10, subdivision 1. Violation: The license holder did not establish and enforce policies and procedures as required in this chapter and chapter 245A. The license holder's “Drug and Alcohol Prohibition Policy” required employees to report criminal drug use or activity to a specific staff or title within the program; however, the license holder’s policy failed to identify the specific staff or title and stated “[insert a staff name and/or title]”. The license holder maintained two different copies of the policy that each included different staff persons to contact. The license holder failed to establish a policy that could be enforced as the policy was incomplete. Corrective Action Ordered: Within 30 days of receiving this order, you must establish, enforce, and maintain policies and procedures that meet the requirements identified above. On an ongoing basis, you must maintain compliance as required in this subdivision. 19. Citation: Minnesota Statutes, section 245D.10, subdivision 2. Violation: The license holder did not establish and maintain policies and procedures related to grievances as required. While the license holder maintained a policy and procedure titled “Grievance Policy,” the license holder failed to include the name, address, and telephone number of the current authorized agent. Corrective Action Ordered: Within 30 days of receiving this order, you must establish a grievance policy that meets the requirements of this section. On an ongoing basis, you must maintain compliance as required in this subdivision. 20. Citation: Minnesota Statutes, section 245D.11, subdivision 2, paragraph 5, 6 and 7. Violation: The license holder did not establish, enforce, and maintain written policies and procedures as required. a. The license holder established a policy titled “Emergency Response, Reporting and Review Policy,” however the license holder failed to establish a written plan for responding to the following emergencies: · Fires; · Severe weather and natural disasters; · Power failures. b. The license holder established a policy titled “Incident Response, Reporting and Review Policy,” however the license holder failed to establish a plan for responding to the following incidents as defined in section 245D.06, subdivision 11: · mental health crisis; · unauthorized or unexplained absence; Additionally, the license holder failed to establish a procedure for the review of incidents and emergencies. Corrective Action Ordered: Within 30 days of this order, you must include the above requirements in your Emergency Response, Reporting and Review Policy and Incident Response, Reporting and Review Policy. 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. Submissions required as part of a corrective action ordered must be sent to your Licensor at: 1. By secure email at amber.n.nielsen@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: Amber Nielsen 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 Office of Inspector General Legal Counsel’s Office Attention: Licensing Legal Unit PO Box 64953 St. Paul, MN 55164-0953 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 at 651-431-3661 as soon as possible. Amber Nielsen, Home and Community-Based Services Licensor Licensing Division Office of Inspector General
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