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February 12, 2025 Mark Nash, Authorized Agent Northland AFC, Inc 20 Kilner Bay Drive Superior, Wisconsin 54880 License Number: 1068585 (245D – HCBS) CORRECTION ORDER Dear Mark Nash: On November 12-14, 2024, a licensing review of Northland AFC, Inc located at 5103 Ramsey Street, Duluth, 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 245D.04, subdivision 1. Violation: For three of five persons whose records were reviewed (P1-P3), the license holder did not provide a written notice that identified the service recipient rights as required. The license holder failed to provide P1-P3 with a written notice that identified the following service recipient 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; · 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. Corrective Action Ordered: Within 30 days of receiving this order, you must provide P1-P3 with a written notice that identifies all of the service recipient rights identified in subdivisions 2 and 3, and an explanation of those rights. Additionally, you must maintain documentation of P1-P3’s legal representative’s receipt of a copy and an explanation of these rights in P1-P3’s record. On an ongoing basis, you must maintain compliance as required in this subdivision. 2. Citation: Minnesota Statutes, section 245D.04, subdivision 3, paragraph (a). Violation: For one person whose record was reviewed (P5), the license holder did not ensure the protection and exercise of the person’s rights when the person resides in a residential site licensed according to chapter 245A as required. The license holder failed to ensure the exercise and protection of P5’s rights to receive services in a clean and safe environment when the license holder is the owner, lessor, or tenant of the service site. During a site visit on November 13, 2024, DHS licensors observed the following at P5’s place of residence (CRS# 1070419): · ceiling missing from the bathroom in the basement of the home; · strong odor of urine in P5’s bedroom and urine stain on the floor; · window cranks missing from several windows in the main level of the home; · missing window cranks and no emergency escape option for P5; and · exposed wiring in the bathroom where the ceiling was missing Corrective Action Ordered: Within 30 days of receiving this order, you must ensure that P5’s services are provided in an environment that is clean, safe and free from hazards that threaten the person’s health and safety. On an ongoing basis, you must maintain compliance as required in this subdivision. 3. Citation: Minnesota Statutes, section 245D.04, subdivision 3, paragraph (c). Violation: For one person whose record was reviewed (P5), the license holder did not implement and document the restriction of a person’s rights as required. Through conversations with the license holder, it was determined P5 did not have access to personal possessions at any time. The license holder failed to document the rights restriction in P5’s support plan or support plan addendum including: · the justification for the restriction based on an assessment of the person’s vulnerability related to exercising the right without restriction; · the objective measures set as conditions for ending the restriction; · a schedule for reviewing the need for the restriction based on the conditions for ending the restriction to occur semiannually from the date of the initial approval, at a minimum, or more frequently if requested by P3, P3’s legal representative, if any and case manager; and · signed and dated approval for the restriction from P3’s legal representative. Corrective Action Ordered: Within 30 days of receiving this order, you must document the above information in P5’s support plan or support plan addendum. On an ongoing basis, you must maintain compliance as required in this subdivision. 4. Citation: Minnesota Statutes, section 245D.061, subdivisions 6 and 7. Violation: For one person whose record was reviewed (P4), the license holder did not complete an internal review of the emergency use of manual restraint or consult with the expanded support team as required. P4 was involved in an incident that resulted in an emergency use of manual restraint. The license holder failed to: · within five working days of the emergency use of manual restraint, complete an internal review of the emergency use of manual restraint that included an evaluation of whether: o the person's service and support strategies developed according to sections 245D.07 and 245D.071 needed to be revised; o related policies and procedures were followed; o the policies and procedures were adequate; o there was a need for additional staff training; o the reported event was similar to past events with the persons, staff, or the services involved; o was there a need for corrective action by the license holder to protect the health and welfare of persons; · consult with the expanded support team within five working days after the completion of the internal review to: o discuss the incident reported in subdivision 5, to define the antecedent or event that gave rise to the behavior resulting in the manual restraint and identified the perceived function the behavior served; and o determine whether the person's support plan addendum needs to be revised according to sections 245D.07 and 245D.071 to positively and effectively help the person maintain stability and to reduce or eliminate future occurrences requiring emergency use of manual restraint. Corrective Action Ordered: P4 is no longer receiving services. On an ongoing basis, you must maintain compliance as required in this subdivision. 5. Citation: Minnesota Statutes, section 245D.071, subdivision 5. Violation: For one person whose record was reviewed (P5), the license holder did not meet the requirements for service plan review and evaluation as required. Although the license holder met with the P5, P5's legal representative, the case manager, and other people as identified by the person or the person's legal representative to discuss how technology might be used to meet P5's desired outcomes, the license holder failed to include a summary of this discussion that included a statement regarding any decision made related to the use of technology and a description of any further research that must be completed before a decision regarding the use of technology can be made. Corrective Action Ordered: With 30 days of receive this order, you must include a summary of the above mentioned discussion in P5’s support plan addendum, including a statement regarding any decision 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. On an ongoing basis, you must maintain compliance as required in this subdivision. 6. Citation: Minnesota Statutes, section 245D.09, subdivision 5. Violation: For one of six staff persons whose records were reviewed (SP3), the license holder did not provide annual training as required. Minnesota Statutes, section 245A.02, subdivision 2b defines “annual” or “annually” to mean prior to or within the same month of the subsequent calendar year. The license holder failed to provide SP3 with annual training on the following topics in 2023: · data privacy requirements according to Minnesota 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 Minnesota Statutes, section 245D.04. The license holder provided this training on February 28, 2019 and March 24, 2020; · 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; · basic first aid; · strategies to minimize the risk of sexual violence, including concepts of healthy relationships, consent, and bodily autonomy of people with disabilities; and · annual review to the license holder’s program abuse prevention plan. Corrective Action Ordered: SP3 was provided the above mentioned training on November 28, 2023. On an ongoing basis, you must maintain compliance as required in this subdivision. 7. Citation: Minnesota Statutes, section 245D.095, subdivision 5. Violation: For six staff persons whose records were reviewed (SP1-SP6), the license holder did not maintain personnel records as required. The license holder failed to maintain documentation in SP1-SP6’s training that included documentation with the number of hours per subject area. Corrective Action Ordered: Within 30 days of receiving this order, you must document the above mentioned information in SP1-SP6’s personnel records. On an ongoing basis, you must maintain compliance as required in this subdivision. If you fail to correct the violations specified in the Correction Order within the prescribed time lines the Commissioner may issue an Order of Conditional License or may impose a fine and order other licensing sanctions pursuant to Minnesota Statutes, sections 245A.06 and 245A.07. B. Right to Request Reconsideration If you believe any of the citations are in error, you have the right to request that the Commissioner of Human Services reconsider the parts of the Correction Order that you believe to be in error. The request for reconsideration must be in writing and received by the Commissioner within 20 calendar days after receipt of this report. Your request for reconsideration must be sent to: Commissioner, Department of Human Services 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 651-431-3657 as soon as possible. Nicole Riley, Home and Community-Based Services Licensor Licensing Division Office of Inspector General
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