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February 18, 2025 Teresa Reeves Victory Care LLC 1736 84th Court North Brooklyn Park, Minnesota 55444 License Number: 1103082 (245D – HCBS) CORRECTION ORDER Dear Teresa Reeves, On January 9, 2025, a licensing review of Victory Care LLC, located at 151 Island Park Drive Northeast, Suite two, 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 1. Violation: For one of three persons whose record was reviewed (P3), the license holder did not provide an orientation to the internal and external reporting procedures of alleged or suspected maltreatment of vulnerable adults as required. The license holder failed to provide P3 or P3’s legal representative an orientation to the internal and external reporting procedures of alleged or suspected maltreatment of vulnerable adults within 24 hours of admission. P3’s services were initiated on September 27, 2022. The license holder later provided this orientation to P3 and P3’s legal representative on March 1, 2024. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 2. Citation: Minnesota Statutes, section 245A.65, subdivision 2. Violation: For three persons whose records were reviewed (P1, P2 and P3), the license holder did not maintain abuse prevention plans as required. a. For P1 and P3, the license holder failed to have a posted copy of the program abuse prevention plan (PAPP) in a prominent location in the program and be available upon request to mandated reporters, persons receiving services and legal representatives. b. For P1, P2 and P3, the license holder failed to: · develop an individualized abuse prevention plan (IAPP) as part of the initial individual program plan or service plan prior to or upon service initiation to P1’s integrated community supports, P2’s employment services and P3’s employment services. · contain an individualized assessment of P1, P2 and P3’s susceptibility to abuse by other individuals, including other vulnerable adults and P1, P2 and P3’s risk of abusing other vulnerable adults. · Include a statement of the specific measures that would be taken to minimize the risk of abuse to P1, P2 and P3, or other vulnerable adults in P1, P2 and P3’s IAPP. Corrective Action Ordered: Within 60 days of receiving this order, you must: · post a copy of the PAPP in a prominent location in the program and be available upon request to mandated reporters, persons receiving services and legal representatives; · revise P1, P2 and P3’s IAPP to contain an individualized assessment of P1, P2 and P3’s susceptibility to abuse and include a statement of the specific measures that would be taken to minimize the risk of abuse; and · review P1, P2 and P3’s revised IAPP with P1, P2 and P3, P1, P2 and P3’s legal representative, and P1, P2 and P3’s case managers. You must maintain documentation with the date the IAPP was reviewed in P1, P2 and P3’s service recipient record. Compliance with this order will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 3. Citation: Minnesota Statutes, section 245D.04, subdivision 1. Violation: For three persons whose records were reviewed (P1, P2 and P3), the license holder did not provide the service recipient rights as required. 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 provide 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 5 working days of service initiation. · P1’s employment support services were initiated on July 27, 2023. The license holder did not provide the service recipient rights to P1’s legal guardian until August 28, 2023. · Additionally, P1’s integrated community support services were initiated on March 1, 2024. The license holder did not provide service recipient rights, and an explanation of those rights within 5 working days of service initiation to P1’s legal representative. b. The license holder failed to provide P2 with a written notice that identified the service recipient rights in subdivision 2 and 3, and an explanation of those rights within 5 working days of service initiation · P2’s 24- hour emergency support services and in-home support with family training services were initiated on February 24, 2021. The license holder failed to provide P2 with the service recipient rights, and an explanation of those rights within 5 working days of service initiation. · P2’s individualized home supports with training services were initiated on July 14, 2021. The license holder failed to provide P2 with the service recipient rights, and an explanation of those rights within 5 working days of service initiation. · Additionally, the license holder failed to provide P2 with a written notice that identified the service recipient rights, and an explanation of those rights annually in 2022. c. The license holder failed to provide P3 and P3’s legal representative with a written notice that identified the service recipient rights in subdivision 2 and 3, and an explanation of those rights within 5 working days of service initiation. P3’s employment services were initiated on January 9, 2023. The license holder later provided this to P3 and P3’s legal representative on March 1, 2024.
Corrective Action Ordered: Within 60 days of receiving this order, you must: · audit all service recipient records to ensure you have provided an explanation and written notice that identifies the service recipient rights in subdivisions 2 and 3; and · if any service recipient has not received these rights, or has not received these rights in the last annual year, provide these rights to the person or their legal representative, if applicable; · maintain documentation of the person or their legal representative’s receipt of these rights as required in Minnesota Statutes, section 245D.095, subdivision 3, paragraph (b); and · maintain documentation of the audit results at your program for review by DHS licensors. Compliance with this order will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 4. Citation: Minnesota Statutes, section 245D.07, subdivision 2. Violation: For two persons whose records were reviewed (P2 and P3), the license holder did not meet service planning and delivery requirements for basic support services. a. The license holder failed to review and revise P2 and P3’s support plan addendum, as needed, within 60 days of service initiation to document the services that will be provided including how, when and by whom services will be provided, and the person responsible for overseeing the delivery and coordination of services. P3 no longer receives basic support services from the license holder. b. The license holder was assigned the responsibility of participating in annual service planning and support team meetings in P2’s support plan addendum. The license holder failed to participate in an annual service plan review meeting that was required in March 2022 with P2, and their support team. Corrective Action Ordered: Within 60 days of receiving 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, and by whom services will be provided, and the person responsible for overseeing the delivery and coordination of those services; · audit all service recipient records receiving basic support services to ensure a 60-day review was completed for each basic support service provided and the required information identified in this citation are documented in the person’s support plan addendum; · for any service in which a 60-day review was not completed and/or the information identified in this citation is not documented in the person’s support plan addendum, complete the review and document the requirements identified above; and · maintain documentation of the audit results at your program for review by DHS licensors. Compliance with this order will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 5. Citation: Minnesota Statutes, section 245D.07, subdivision 2, paragraph (d), and subdivision 3. Violation: For one person whose record was reviewed (P2), the license holder did not meet requirements for meetings and reports for basic support services as required. The license holder was assigned responsibility for providing written reports regarding P2’s progress or status in P2’s support plan addendum. The license holder failed to provide annual progress review reports in 2021, 2022, 2023 and 2024 to P2, and their support team. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. 6. Citation: Minnesota Statutes, section 245D.071, subdivision 3. Violation: For three persons whose record were reviewed (P1, P2 and P3), the license holder did not meet initial service planning requirements for intensive support services as required. a. P1's integrated community support services were initiated Feb 15, 2024. The license holder failed to complete a preliminary support plan addendum based on the support plan for P1 within 15 days of service initiation. b. P2’s employment services were initiated April 5, 2021. The license holder failed to complete a preliminary support plan addendum based on the support plan for P2 within 15 working days of service initiation. c. P3’s employment services were initiated on January 9, 2023. The license holder failed to complete a preliminary support plan addendum based on the support plan for P3 within 15 days of service initiation. d. For P1, P2 and P3, the license holder failed to meet with the person, the person’s legal representative, if applicable, the case manager and other members of the support team or expanded support team within 45 calendar days of service initiation to determine the following based on the information obtained from the assessments identified in section 245D.071, subdivision 3, paragraph (b), the person’s identified needs in the support plan, and the requirements in subdivision 4 and section 245D.07, subdivision 1a: · the scope of services to be provided to support the person’s daily needs and activities; · the person’s desired outcomes and the supports necessary to accomplish the desired outcomes; · the person’s preferences for how services and supports are provided, including how the provider will support the person to have control of their schedule; · whether the current service setting is the most integrated setting available and appropriate for the person; · opportunities to develop and maintain essential and life-enriching skills, abilities, strengths, interests, and preferences; · opportunities for community access, participation, and inclusion in preferred community activities; · opportunities to develop and strengthen personal relationships with other persons of the person's choice in the community; · opportunities to seek competitive employment and work at competitively paying jobs in the community; · 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 · how technology might be used to meet the person’s desired outcomes at this meeting and maintain a summary of this conversation in the person’s support plan or support plan addendum that included a statement in the summary 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. e. For P3, the license holder failed to complete assessments in the following areas before providing 45 days of service. The license holder later completed the assessments, however the assessments failed to produce information about P3 that described P3’s overall strengths, functional skills and abilities: · P3'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; · P3'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 · P3'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. Corrective Action Ordered: Within 60 days of receiving this order, you must: · audit all service recipient records receiving intensive support services to ensure: o the assessments identified in this citation have been completed; o an initial service planning meeting was held for each intensive support service provided; and o the information identified in part “d” of this violation were determined and documented in the person’s support plan addendum; · for any service recipient in which assessments and/or a 45 or 60-day review was not completed or the information identified in this citation is not documented in the person’s support plan addendum, complete the assessments and document the requirements identified above; · maintain documentation of the audit results at your program for review by DHS licensors; · revise P3’s assessments to produce information about P3’s overall strengths, functional skills, and abilities; and · review P3’s assessments with P3, P3’s legal representative, and P3’s case manager. You must maintain documentation in P3’s record that includes the date the assessments were reviewed. Compliance with this order will be monitored on site. On an ongoing basis, you must maintain compliance as required in this subdivision. Repeat Violation: The license holder was cited for a similar violation in a correction order dated April 15, 2021.
7. Citation: Minnesota Statutes, section 245D.071, subdivision 4. Violation: For three persons whose record were reviewed (P1, P2 and P3), the license holder did not develop supports and outcomes as required. The license holder failed to develop and document the following supports and methods to be implemented, to support the person and accomplish outcomes related to acquiring, retaining, or improving skills and physical, mental and emotional health and well-being for each intensive service the license holder was providing to P1, P2 and P3: · the methods or actions that will be used to support the person and accomplish the service outcomes, including information about: o any changes or modifications to the physical and social environments necessary when the service supports were provided; o any equipment and materials required; and 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 would 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 persons or positions responsible for implementing the supports and methods. Corrective Action Ordered: Within 60 days of receiving this order, you must: · develop a service plan for P1, P2 and P3, that documents the above mentioned supports and methods; · review the supports and methods with P1, P2 and P3’s case managers, legal representatives if applicable, and other members of the support team. You must maintain documentation in P1, P2, and P3’s record when the outcomes were reviewed; · audit all service recipient records receiving intensive support services to ensure the supports and methods identified above are documented in the person’s support plan addendum; · for any service recipient in which the supports and methods identified above are not documented in the person’s support plan addendum, develop a service plan that documents the supports and methods and maintain this service plan in the person’s support plan addendum; and · maintain documentation of the audit results at your program for review by DHS licensors. Compliance with this order will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. Repeat Violation: The license holder was cited for a similar violation in a correction order dated April 15, 2021. 8. Citation: Minnesota Statutes, section 245D.071, subdivision 5, paragraph (a) and (g). Violation: For two persons whose record were reviewed (P1 and P2), the license holder did not meet requirements for service plan review and evaluation for intensive support services as required. a. P1’s intake meeting was on August 1, 2023, and the following service plan review meeting was on November 1, 2024. The license holder failed to participate in service plan review meetings annually as outlined in the support plan addendum for P1. b. P2’s intake meeting was on March 2, 2021, and the following service plan review meeting was on September 1, 2022. The license holder failed to participate in service plan review meetings annually as outlined in the support plan addendum for P2. Corrective Action Ordered: Within 60 days of receiving this order, you must: · audit all service recipient records receiving intensive support services to ensure service plan review and evaluation was completed based on the timelines established in the persons support plan or support plan addendums; · for any service recipient in which the service planning meetings did not occur, conduct a service plan review and evaluation; and · maintain documentation of the audit results at your program for review by DHS licensors. Compliance with this order will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 9. Citation: Minnesota Statutes, section 245D.095, subdivision 2. Violation: For three persons whose record were reviewed (P1, P2 and P3), the license holder did not maintain an admission and discharge register as required. The license holder failed to keep an accurate written or electronic register, listing in chronological order the dates and names of all persons served by the program who have been admitted, discharged or transferred. The license holder provided DHS licensors with an admission and discharge record, however, the record provided failed to document all services the license holder provided to each person, including an accurate date of service initiation for each service. Corrective Action Ordered: Within 60 days of receiving this order, you must: · review and revise your admission and discharge register for all persons receiving services; · audit all service recipient records for accurate admission and discharge dates for all services provided; and · maintain documentation of the audit results at your program for review by DHS licensors. Compliance with this order will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 10. Citation: Minnesota Statutes, section 245D.095, subdivision 3. Violation: For three persons whose record were reviewed (P1, P2 and P3), the license holder did not maintain service recipient records as required. a. The license holder failed to maintain a record of current services provided to P1, P2 and P3 on the premises where services are provided and coordinated. b. The license holder failed to maintain an admission form signed by P1, P2 and P3, or their legal representative, that included the following: · identifying information, including the person’s name, date of birth, address, and telephone number; · the name, address, and telephone number of the persons legal representative, a primary emergency contact, the case manage, and family members or others identified by the person or case manager; · 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 · health information, including medical history, special dietary needs, and allergies. c. 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 could not be reached. Corrective Action Ordered: Within 60 days of receiving this order, you must: · ensure all records of current services are maintained for all persons on the premises where the services are provided and coordinated; · maintain an admission form with the above-mentioned information for P1, P2, and P3; · audit all service recipient records for admissions forms that include the above-mentioned information; · develop an admission form for all service recipient records; and · maintain documentation of the audit results at your program for review by DHS licensors. Compliance with this order will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 11. Citation: Minnesota Statutes, section 245D.10, subdivision 4. Violation: For three persons whose records were reviewed (P1, P2 and P3) the license holder did not provide written or electronic copies of policies and procedures as required. The license holder failed to inform and provide copies of the following policies and procedures affecting a person’s rights under section 245D.04 to P1’s legal representative, P1’s case manager, P2, P2’s case manager, P3’s legal representative and P3’s case manager within five working days of service initiation: · grievance policy and procedure; · service suspension and termination policy and procedure; and · data privacy policy. Corrective Action Ordered: Within 60 days of receiving this order, you must: · provide the policies and procedures identified above to P1, P1’s case manager, P2, P2’s case manager, P3’s legal representative and P3’s case manager; · audit all service recipient records to ensure the policies and procedures identified above were provided to each service recipient, their legal representatives if applicable, and case manager’s; · for any service recipient, their legal representatives if applicable, and case manager’s that did not receive these policies and procedures, provide them; and · maintain documentation of the audit results at your program for review by DHS licensors. Compliance with this order will be monitored on site. On an ongoing basis, you must maintain compliance as required in this subdivision. 12. Citation: Minnesota Rule 9544.0030, subpart 1. Violation: For three persons whose record were reviewed (P1, P2 and P3), the license holder did not incorporate and evaluate positive support strategies as required. a. The license holder failed to incorporate positive support strategies in writing to P3’s existing treatment, service, or other individual plans. b. The license holder failed to evaluate with P1 and P2 whether the identified positive support strategies currently met the standards in Minnesota Rules 9544.0030, subpart 2, as required at least every 6 months. Corrective Action Ordered: Within 60 days of receiving this order, you must: · incorporate positive support strategies into P3’s existing treatment service, or other individual plans; · evaluate P1 and P2’s positive support strategies; · audit all service recipient records to ensure positive support strategies are incorporated in writing to existing treatment, service, or other individual plans; · audit all service recipient records to evaluate whether the identified positive support strategies currently met the standards in Minnesota Rules 9544.0030, subpart 2, as required at least every 6 months; 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. Repeat Violation: The license holder was cited for a similar violation in a correction order dated April 15, 2021. 13. Citation: Minnesota Rule 9544.0080. Violation: For three persons whose records were reviewed (P1, P2 and P3) the license holder did not provide notice of the emergency use of manual restraint policy as required. The license holder failed to provide P1, P1’s legal representative, P2, P3 and P3’s legal representative with notice of the license holder’s policy on the emergency use of manual restraints at the time of each service initiation. Additionally, the license holder failed to obtain written acknowledgement from P1’s legal representative, P2, and P3’s legal representative with notice of the license holder’s policy on the emergency use of manual restraints. P3 later received this from the license holder on March 1, 2024. Corrective Action Ordered: Within 60 days of receiving this order, you must: · provide notice of the license holder’s policy on the emergency use of manual restraints to P1, P1’s legal representative and P2. · you must obtain written acknowledgement of receipt of the policy and procedure on the emergency use of manual restraints from P1’s legal representative and P2; · audit all service recipient records to ensure notice of the policy on emergency use of manual restraints was provided to each service recipient, their legal representatives if applicable. · for any service recipient, their legal representatives if applicable, that did not receive the emergency use of manual restraint policies, provide them; and · maintain documentation of the audit results at your program for review by DHS licensors. Compliance with this order will be monitored on site. On an ongoing basis, you must maintain compliance as required in this subdivision. 14. Citation: Minnesota Statutes, section 245A.65, subdivision 3. Violation: For two of two staff persons whose records were reviewed (SP1 and SP2) the license holder did not provide orientation and annual training to the license holder’s program abuse prevention plan (PAPP) as required. The license holder failed to provide SP2 with orientation to the license holder’s PAPP within 72 hours of first providing direct contact services. SP2 later received this orientation to this license holder. Additionally, the license holder failed to provide SP1 with annual training on the PAPP in 2022, 2023 and 2024. Corrective Action Ordered: Within 60 days of receiving this order, you must: · provide SP1 with training to the license holder’s PAPP; · audit the personnel records for all employees to ensure they have received orientation and annual training to the PAPP; · based on the audit, you must provide orientation training to any staff that has not received it; and · maintain documentation of the audit results at your program for review by DHS licensors 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.09, subdivision 4. Violation: For one staff person whose record was reviewed (SP2) the license holder did not provide orientation training as required. SP2 was hired on February 19, 2023. The license holder failed to provide orientation training in the following areas within 60 days of hire. The license holder later provided these orientation trainings to SP2 in 2024: · the job description and how to complete specific job functions including following safety practices established by the license holder as required in section 245D.06, subdivision 2; · 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; · data privacy requirements according to 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 section 245D.04; · 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. This orientation must be provided within 72 hours of first providing direct contact services. · 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; 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: · audit the personnel records for all employees to ensure they have received the required orientation trainings; · based on the audit, you must provide orientation training to any staff that has not received it; and · maintain documentation of the audit results at your program for review by DHS licensors Compliance with this order will be monitored on site. On an ongoing basis, you must maintain compliance as required in this subdivision. 16. Citation: Minnesota Statutes, section 245D.09, subdivision 4a. Violation: For one staff person whose record was reviewed (SP2) the license holder did not provide orientation to individual service recipient needs as required. The license holder failed to provide SP2 with instruction on the requirements in paragraphs (b) to (f) as they related to SP2’s job functions prior to having unsupervised direct contact with a person served by the program. The license holder was not able to provide documentation that this orientation occurred. Corrective Action Ordered: Within 60 days of receiving this order, you must: · provide SP2 with orientation to individual service recipient needs for all persons served that SP2 provides direct support to. You must document this orientation in SP2’s personnel record; · audit the personnel records for all employees to ensure they have received orientation to service recipient needs. Based on the audit, you must provide this orientation to any staff that has not received it; and · maintain documentation of the audit results at your program for review by DHS licensors Compliance with this order will be monitored on site. On an ongoing basis, you must maintain compliance as required in this subdivision. 17. Citation: Minnesota Statutes, section 245D.09, subdivision 5. Violation: For one staff person whose records was reviewed (SP1) the license holder did not provide annual training as required. The license holder failed to provide SP1 with annual training on the following topics in 2022 and 2023. The license holder did provide these annual trainings to SP1 in 2024: · data privacy requirements according to 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 section 245D.04; · 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 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: · audit the personnel records for all employees to ensure they have received the required annual trainings; · based on the audit, you must provide annual training to any staff that has not received it; and · maintain documentation of the audit results at your program for review by DHS licensors Compliance with this order will be monitored on site. 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 as soon as possible. Kelly Bosch, HCBS Licensor Licensing Division Office of Inspector General 651-431-6621
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