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April 18, 2025 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: 202500642 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 March 18- 20, 2025, 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 202500642. 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 outcomes according to the requirements in section 245D.07; · instructions 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 delegated the responsibility to directly observe the service delivery activities to assess staff competency; and · 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 provided program coordination and oversight of the services provided is evidenced in citations 2 – 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 understating of the licensing requirements sufficient to ensure compliance throughout the program as identified in section 245A.04, subdivision 1, paragraph (e), and when applicable, identified in 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 were met according to the requirements in section 245D.09, subdivision 3, including ensure periodic performance evaluations of direct support staff’s ability to perform the job functions based on direct observations 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 2 – 21. Repeat Violation: In an Order of Conditional License dated May 3, 2024, and a Correction Order that DHS issued on December 6, 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 Statutes, section 245A.65, subdivision 2, paragraph (a). Violation: For one of seven persons whose record was reviewed (P3), the license holder did not provide orientation to the program abuse prevention plan as required. The license holder failed to provide orientation to the program abuse prevention plan to P3 within 24 hours of admission. Corrective Action Ordered: Within 30 days of receiving this order, you must provide orientation to P3 of your program abuse prevention plan. Compliance with order will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 3. Citation: Minnesota Statutes, section 245A.65, subdivision 2, paragraph (b). Violation: For two persons whose records were reviewed (P4 and P5), the license holder did not develop an individual abuse prevention plan (IAPP) as required. a. The license holder assessed P4 as susceptible to physical abuse. The license holder failed to include a statement of the specific measures that would be taken to minimize the risk of abuse in this assessed area. b. The license holder assessed P5 as susceptible to sexual abuse. 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. Repeat Violation: In an Order of Conditional License that DHS issued on May 3, 2024, and a Correction Order that DHS issued on December 6, 2024, you were previously found in violation of this same statute. Corrective Action Ordered: Within 30 days of receiving this order, you must review and revise P4’s and P5’s IAPPs to include the above-mentioned information. Compliance with this order will be monitored on site. On an ongoing basis, you must maintain compliance as required in this subdivision. 4. Citation: Minnesota Statutes, section 245D.04, subdivisions 1 and 3. Violation: For three persons whose records were reviewed (P4 – P6), the license holder did not ensure the exercise and protection of the person’s rights when the person resided in a licensed residential site as required. The license holder failed to ensure the exercise and protection of P4’s – P6’s right to receive services in a clean and safe environment when the license holder was the owner lessor or tenant of the service site (CRS license number 1069582). During site visits that were completed on March 18 and 19, 2025, DHS licensors observed a strong smell of urine in the home. Repeat Violation: In an Order of Conditional License dated May 3, 2024, and a Correction Order that DHS issued on December 6, 2024, you were previously found in violation of this same statute. Corrective Action Ordered: Immediately upon receipt of this order, you must ensure all persons you provide services to in a licensed site or where the license holder is the owner, lessor or tenant site receive services in a clean and safe environment. 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.04, subdivision 3, paragraph (c). Violation: For one person whose record was reviewed (P2), the license holder did not document the restriction of rights in the person’s support plan addendum as required. The license holder maintained documentation in P2’s support plan addendum for a restriction of P2’s personal privacy, and the right to access their personal possessions at any time, including P2’s cell phone and laptop charging cords. The license holder failed to document the following: · the objective measure set as conditions for ending the restriction; and · a schedule for reviewing the need for the restriction based on the conditions for ending the restriction to occur semiannually from the date of initial approval, at a minimum or more frequently if requested by the person, the person’s legal representative, if any, and case manager. Additionally, the license holder failed to review P2’s rights restriction on a semi-annual basis. At the time of this licensing review, the license holder had not reviewed the need for the restriction based on the conditions for ending the restriction. Corrective Action Ordered: Within 30 days of this order, you must document the above-mentioned information for P2’s rights restriction and review the need for the restriction. Compliance with this subdivision will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 6. Citation: Minnesota Statutes, section 245D.06, subdivision 4. Violation: For one person whose record was reviewed (P3), the license holder did not document the safeguarding of funds and property as required. The license holder was assigned the responsibility of safeguarding funds for P3. P3’s financial authorization documented the license holder would provide statements to P3’s legal representative and case manager that itemized receipts and disbursements of funds every six months. The license holder failed to provide the itemized statements for P3 every six months. Corrective Action Ordered: Within 30 days of receiving this order, you must audit P3’s funds and provide an itemized statement to P3’s case manager and legal representative. Compliance with this subdivision will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. Repeat Violation: In an Order of Conditional License dated May 3, 2024, and a Correction Order that DHS issued on December 6, 2024, you were previously found in violation of this same statute. 7. Citation: Minnesota Statutes, section 245D.061, subdivision 8. Violation: For one person whose record was reviewed (P5), the license holder did not report the emergency use of manual restraint as required. During the licensing review conducted on September 10-12, 2024, DHS licensors observed documentation indicating P5 was involved in an incident that resulted in an emergency use of manual restraint on January 19, 2024. In the correction order dated December 6, 2024, the license holder was ordered to submit the following to the Department of Human Services, and the Office of the Ombudsman for Mental Health and Developmental Disabilities, as required under section 245.94, subdivision 2a: · the report required under subdivision 5; · the internal review and the corrective action plan required under subdivision 6; and · the summary of the expanded support team review required under subdivision 7. At the time of the licensing review conducted on March 18-20, 2025, DHS licensors determined the license holder failed to complete the corrective action ordered. Repeat Violation: In an Order of Conditional License that DHS issued on May 3, 2024, and a Correction Order that DHS issued on December 6, 2024, you were previously found in violation of this same statute. Corrective Action Ordered: Within 15 days of receiving this order, you must submit the above-mentioned information for P5 to Department of Human Services and the Office of the Ombudsman for Mental Health and Developmental Disabilities, as required under section 245.94, subdivision 2a. Compliance with this order will be monitored on site. On an ongoing basis, you must maintain compliance as required in this subdivision. 8. Citation: Minnesota Statutes, section 245D.07, subdivision 1a. Violation: For three persons whose records were reviewed (P2, P3, and P5), the license holder did not provide services in response to their identified needs, interests, preferences and desires as required. a. The license holder identified P2’s outcome as “[P2] is refreshing himself/herself on DBT and would like to educate staff one day one what it is and how it will help him/her.” This outcome was implemented on September 1, 2024. From this date through the time of the licensing review, the license holder failed to collect data on P2’s outcome. b. The license holder identified P3’s outcome as “[P3] will plan and participate in two community activities per month with a consecutive follow through of 75% of 12 months.” This outcome was implemented on August 1, 2024. From September 2024 to the date of the licensing review, the license holder failed to collect data on P3’s outcome. c. The license holder identified P5’s outcome as “[P5] will be encouraged once a month to plan and attend a community activity or event with 80% of follow-through for 12 consecutive months.” P5’s outcome was reviewed and recommended to be continued on December 4, 2024. From this date through the time of the licensing review, the license holder failed to collect data on P5’s outcome. Additionally, the license holder discontinued the community activity outcome for P5 on March 13, 2025, and identified a new goal as “tracking target behaviors.” The license holder maintained an assessment of P5’s ability to self-manage symptoms and behaviors that may otherwise result in an incident, suspension, or termination of service by the program, or other symptoms or behaviors that may jeopardize the health and safety of the person or others. The assessment indicated that P5 did not need or want to set an outcome related to acquiring, retaining, or improving skills in this area. 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. Repeat Violation: In a Correction Order that DHS issued on December 6, 2024, you were previously found in violation of this same statute. Corrective Action Ordered: Within 30 days of receiving this order, you must: · develop a person-centered outcome for P5. You must document the document the supports and methods to be implemented to support the person and to accomplish the outcome; and · begin collecting data on P2’s, P3’s, and P5’s outcomes. Compliance with this order will be monitored on site. On an ongoing basis, you must maintain compliance as required in this subdivision. 9. Citation: Minnesota Statutes, section 245D.071, subdivision 3. Violation: For three persons whose records were reviewed (P3, P4, and P5) the license holder did not complete assessments as required. a. The license holder failed to complete assessments that assessed P3’s ability to self-manage regulating water temperature and water safety skills. b. The license holder failed to complete assessments that assessed P4’s ability to self-manage the following areas: · self-administration of medication or treatment orders; · water safety skills; · sensory disabilities; and · P4’s ability to self-manage symptoms or behaviors that may otherwise result in an: o incident as defined in 245D.02, subdivision 11, clauses (4) to (7); o suspension or termination of services by the license holder; or o other symptoms or behaviors that may jeopardize the health and safety of P4 or others. Additionally, the assessments completed by the license holder for P4 failed to produce information that described P4’s overall strengths, functional skills, and abilities, and behaviors or symptoms. c. The license holder failed to complete assessments that produced information about the P5 that described their overall strengths, functional skills and abilities and behaviors or symptoms. Repeat Violation: In an Order of Conditional License that DHS issued on May 3, 2024, and a Correction Order that DHS issued on December 6, 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 assessment of P3 - P5 based on their status within the last 12 months that includes the areas outlined above; and · the assessments must include the person’s strengths, functional skills and abilities, and behaviors or symptoms. 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 4. Violation: For one person whose records was reviewed (P1), the license holder did not develop supports and outcomes as required. The license holder failed to document the following supports and methods to accomplish P1’s 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 that DHS issued on May 3, 2024, and a Correction Order that DHS issued on December 6, 2024, you were previously found in violation of this same statute. Corrective Action Ordered: Within 30 days of receiving this order, you must document the above-mentioned supports and methods in P1’s support plan addendum. Compliance with this order will be monitored on site. On an ongoing basis, you must maintain compliance as required in this subdivision. 11. Citation: Minnesota Statutes, section 245D.071, subdivision 5, paragraph (b). Violation: For five person whose records were reviewed (P1 – P5), the license holder did not review and evaluate service plans as required. a. The license holder failed to meet with P3’s support team within the timelines established in P3’s support plan addendum. P3’s support plan dated July 26, 2024, documented the team would meet semiannually. At the time of the licensing review the team had not met since July 26, 2024. b. The license holder failed to discuss with P2 and members of their support team options for 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. c. The license holder failed to discuss with P4, P4’s legal representative, P4’s case manager and other people as identified by P4 or P4’s legal representative how technology might be used to meet P4’s desired outcomes at least once per year. The license holder documented a discussion in P4’s support plan that was not related to how technology could be used to meet P4’s desired outcomes. d. The license holder failed to discuss with P1, P2, P5 and members of their support teams about how technology might be used to meet P1’s, P2’s, and P5’s desired outcomes at least once per year. Repeat Violation: In Order of Conditional License that DHS issued on May 3, 2024, and a Correction Order that DHS issued on December 6, 2024, you were previously found in violation of this same statute. Corrective Action Ordered: Within 30 days of receiving this order, you must: · participate in a service plan review meeting with P3 and P3’s support team; · discuss with P1’s, P2’s, P4’s, and P5’s support teams about how technology might be used to meet their desired outcomes. A summary of this discussion and a statement regarding any decision made related to the use of technology including a description of any further research that must be completed before a decision can be made must be included in the support plan addendum as required; and · discuss with P2 and members of their support team options for transitioning out of a community setting controlled by a provider and into a setting not controlled by a provider. 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 Rules Part 9544.003, subpart 1. Violation: For one person whose record was reviewed (P3), the license holder did not evaluate positive support strategies as required. The license holder failed to evaluate P3’s positive support strategies with P3 every six months. Repeat Violation: In an Order of Conditional License dated May 3, 2024, and a Correction Order that DHS issued on December 6, 2024, you were previously found in violation of this same statute. Corrective Action Ordered: Within 30 days of receiving this order, you must review and evaluate P3’s positive support strategies with P3. Compliance with this order with be reviewed onsite. On an ongoing basis, you must maintain compliance as required in this subpart. Health Service Needs Violations 13. Citation: Minnesota Statutes, section 245D.05, subdivision 1. Violation: For one person whose record was reviewed (P6), the license holder did not document how health needs would be met as required. P6 was prescribed an albuterol inhaler as an as needed medication in January 2025 according to P6’s medication administration record (MAR). The license holder failed to maintain documentation of a description of the procedures the license holder would follow to administer P6’s albuterol. In addition, P6 had a wound that required P6’s brief to be changed every two hours. The license holder failed to document how P6’s needs would be met, including a description of the procedures the license holder would follow in order to monitor health conditions according to written instructions from a licensed health care professional. Corrective Action Ordered: Immediately upon receipt of this order, you must document the procedures you will follow to meet P6’s health needs as stated above. P6’s albuterol Compliance with this order will be reviewed onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 14. Citation: Minnesota Statutes, section 245D.05, subdivision 1a. Violation: For four persons whose records were reviewed (P1 – P4), the license holder did not implement medication setup procedures as required. a. The license holder provided medication setup to P1, P2, and P3 as part of medication administration. The license holder failed to document medication setup in P1’s-P3’s medication administration record (MAR) of the following: · dates of medication setup; · name of the medications; · quantity of dose; · times to be administered; and · route of administration at time of setup. b. The license holder provided medication setup to P4 as part of medication administration. The license holder failed to maintain accurate documentation in P4’s MAR of the following: · dates of medication setup; · name of the medications; · quantity of dose; · times to be administered; and · route of administration at time of setup. The medications outlined on the medication setup record the license holder maintained did not match the prescription labels on P4’s medications or P4’s MAR. Repeat Violation: In an Order of Conditional License that DHS issued on May 3, 2024, and a Correction Order that DHS issued on December 6, 2024, you were previously found in violation of this same statute. Corrective Action: Immediately upon receiving this order, you must begin maintaining documentation of medication setup for P1 – P4, including the information outlined above that matches the MAR and the information on the medication prescription labels. 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 1b, paragraph (b). Violation: For one person whose record was reviewed (P2), the license holder did not maintain documentation of how the person’s health needs would be met as required. The license holder was assigned the responsibility of meeting P2’s health service needs, including medication assistance for an injectable medication and medication administration for the rest of P2’s medications. The license holder provided P2 reminders to take the injectable medication that P2 self-administered. The license holder failed to maintain a description of the procedures the license holder would follow in order to provide medication assistance according to this chapter. Corrective Action: Within 30 days of receiving this order, you must document the above-mentioned information for P2. Compliance with this order will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. 16. Citation: Minnesota Statutes, section 245D.05, subdivision 2 paragraph (b). Violation: For two persons whose records were reviewed (P3 and P7), the license holder did not implement medication administration procedures as required. a. The license holder was responsible for administering P3’s medications. The license holder failed to implement medication administration procedures to ensure P3 received medications as prescribed. P3 was prescribed Novolog 7 units to be administered before meals. The license holder documented this on P3’s MAR as Novolog 7 units to be administered before meals and at bedtime. This resulted in the license holder administering P3 an extra dose of Novolog daily. b. The license holder was responsible for administering P7’s medications. The license holder failed to implement medication administration procedures to ensure P7 received medications as prescribed for the following medications: · P7 was prescribed 300 mg Gabapentin capsules by mouth, one capsule in the morning, one capsule at noon, and one capsule before bedtime. The license holder documented this on P7’s MAR as Gabapentin tablet 300mg, take one tablet by mouth in the morning, one tablet at 2pm, and one tablet at bedtime. · P7 was prescribed Lithium Carbonate 300mg tablet, take one tablet in the morning, one tablet at noon, and one tablet before bedtime. The license holder documented this on P7’s MAR as Lithium Carbonate 300mg, take one tablet in the morning, one tablet at 2pm, and one tablet at bedtime. · P7 was prescribed Clozapine 100mg and Clozapine 50mg tablets, take three 100mg tablets in the morning with the 50mg dose for a total of 350mg. The license holder documented on P7’s MAR as Clozapine 100mg, and Clozapine 100mg take three 100mg tablets at every bedtime and take Clozaril 50mg tablet at every bedtime. Repeat Violation: In an Order of Conditional License dated May 3, 2024, and a Correction Order that DHS issued on December 6, 2024, you were previously found in violation of this same statute. Corrective Action Ordered: Immediately upon receipt of this order you must audit P3’s and P7’s MARs to ensure all medications are documented correctly and administered as prescribed. You must document the audit of P3’s and P7’s MARs, including who completed the audit, the date of the audit, and the results of the audit. Compliance with this order will be monitored onsite. On an ongoing basis, you must maintain compliance as required with this subdivision. 17. Citation: Minnesota Statutes, section 245D.05, subdivision 2, paragraph (c) clauses (1) through (4). Violation: For three persons whose record were reviewed (P1-P3), the license holder did not maintain documentation in the MAR as required. The license holder failed to maintain the following documentation in P1’s-P3’s MARs: · information on any risks or other side effects that are reasonable to expect, and any contraindications to its use. This information must be readily available to all staff administering the medication; · the possible consequences if the medication or treatment is not taken or administered as directed; · instruction on when and to whom to report the following: o 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 o the occurrence of possible adverse reactions to the medication or treatment. Corrective Action Ordered: Within 30 days of receiving this order, you must develop and maintain the documentation requirements listed above in P1’s-P3’s MARs. Compliance with this order will be monitored onsite. On an ongoing basis, you must maintain compliance as required with this subdivision. 18. Citation: Minnesota Statutes, section 245D.05, subdivision 2, paragraph (c), clause 6. Violation: For six persons whose records were reviewed (P1 – P6), the license holder did not document medication administration as required. a. The license holder was responsible for administering P1’s medications. DHS Licensors reviewed P1’s MARs from January 2025 to March 17, 2025. The license holder failed to document a notation of when a medication was administered in 9 instances from January 2025 to March 17, 2025. b. The license holder was responsible for administering P2’s medications. DHS Licensors reviewed P2’s MARs from January 2025 to March 17, 2025. The license holder failed to document a notation of when a medication was administered in 48 instances from January 2025 to March 17, 2025. c. The license holder responsible for administering P3’s medications. DHS licensors reviewed P3’s MARs from January and February 2025. The license holder failed to document a notation of when a medication was administered in 194 instances in January and February 2025. d. The license holder was responsible for administering P4’s medications. DHS Licensors reviewed P4’s MARs from December 2024 to February 2025. The license holder failed to document a notation of when a medication was administered in 235 instances from December 2024 to February 2025. e. The license holder was responsible for administering P5’s medications. DHS Licensors reviewed P5’s MARs from December 2024 to February 2025. The license holder failed to document a notation of when a medication was administered in 361 instances from December 2024 to February 2025. f. The license holder was responsible for administering P6’s medications. DHS Licensors reviewed P6’s MARs from January 2025 to March 17, 2025. The license holder failed to document a notation of when a medication was administered in 73 instances from January 2025 to March 17, 2025. In addition, the license holder documented in P6’s MAR that P6’s blood sugar was to be checked three times a daily before meals and to record the blood sugar reading on a separate reading sheet. There were 32 instances from January 2025 to March 17, 2025, where the license holder failed to document P6’s blood sugar reading. The license holder documented on P6’s MAR that P6’s blood sugar reading was completed. The license holder failed to document the blood sugar reading on the P6’s reading sheet. g. P6 was prescribed an albuterol inhaler to be used as needed in January 2025.In January 2025 it was prescribed as an as needed medication in P6’s MAR. The license holder’s February 2025 MAR for P6 did not list the albuterol inhaler and there was no documentation that this medication was discontinued. The license holder failed to document a notation of when P6’s albuterol was discontinued in P6’s MAR. Corrective Action Order: See citation 19 for further corrective action. Compliance with this subdivision will be monitored onsite. On an ongoing basis, you must maintain compliance as required in this subdivision. Repeat Violation: In a Correction Order that DHS issued on December 6, 2024, you were previously found in violation of this same statute. 19. Citation: Minnesota Statutes, section 245D.05, subdivision 4. Violation: For five persons whose records were reviewed (P1-P5), the license holder did not ensure medication and treatment issues were reviewed and reported as required. a. The license holder failed to review P1’s, P2’s, P3’s, and P5’s MARs every three months to ensure the records were current and to identify medication administration errors. The only MAR reviews the license holder maintained in P1’s -P3’s, and P5’s records were dated March 1, 2025. The MAR reviews the license holder completed on March 1, 2025, for P1-P3, and P5, were inaccurate. The MAR reviews indicated there were no medication errors when P1’s-P3’s, and P5’s MARs had multiple errors (see citation 18). b. The license holder failed to develop and implement a plan to correct patterns of medication administration errors to P4 when identified. The license holder documented reviews of P4’s MAR and indicated no errors were identified on November 15, 2024, January 8, 2025, and March 1, 2025. DHS licensors reviewed P4’s MAR from October 2024 through February 2025 and identified patterns of medication administration not being documented by staff responsible for administration of medication to P4. The license holder did not maintain documentation of follow up completed to ensure the medications were administered to P4, or any correction action that was completed to correct the medication administration documentation errors. c. P2 refused their medication on multiple dates. The license holder failed to report medication refusals to P2’s case manager as they occurred. At the time of this licensing review, the license holder had not notified P2’s case manager of medications refusals that happened from October 8, 2024, to February 7, 2025. Repeat Violation: In an Order of Conditional License that DHS issued on May 3, 2024, and a Correction order that DHS issued on December 6, 2024, you were previously found in violation of this same statute. Corrective Action Ordered: Immediately upon receiving this order you must: · report P2’s medication refusals to their case manager; and · maintain documentation of the notifications regarding medication errors in P2’s record. Within 30 days of receiving this order, you must: · review P1’s-P5’s MARs for the past six months to ensure that the information in the MARs is current and to identify medication errors, including medication administration documentation errors. You must document the review and maintain the documentation in the person’s record; and · based upon the review, you must develop, document, and implement a plan to correct the patterns of medication administration errors identified. Documentation of this review and the plan must be maintained in the medication administration record as required. 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 the responsibility for medication administration 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; and · maintain documentation of the MAR reviews you complete, including the date(s) of completion, and the name of the person(s) who completed the MAR reviews. Compliance with this order will be monitored on site. On an ongoing basis, you must maintain compliance as required. 20. Citation: Minnesota Statutes, section 245D.051, subdivision 1. Violation: For five persons whose records were reviewed (P1-P5), the license holder did not meet the condition of psychotropic medication administration as required. The license holder was assigned responsibility for monitoring and measuring the target symptoms to be alleviated by psychotropic medications for P1 – P5. The license holder failed to: · document the monitoring and measuring of the target symptoms; · collect and report on medication and symptom related data as instructed by the prescriber; and · provide monitoring data to the expanded support team for review semi-annually. Repeat Violation: In an Order of Conditional License that DHS issued on May 3, 2024, and a Correction Order that DHS issued on December 6, 2024, you were previously found in violation of this same statute. 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. Record Keeping Violations 21. Citation: Minnesota Statutes, section 245D.095 subdivision 3. Violation: For one person whose record was reviewed (P4), the license holder did not maintain service recipient records as required. The license holder failed to maintain progress or daily log notes in P4’s service recipient record. Corrective Action Ordered: Immediately upon receipt of this order, you must begin to maintain progress or daily log notes for P4. On an ongoing basis, you must maintain compliance as required in this subdivision. 22. Citation: Minnesota Statutes, section 245D.095, subdivision 5, paragraph (a). Violation: For two of four staff persons whose records were reviewed (SP1 and SP2), the license holder did not maintain personnel records as required. The license holder failed to document the number of hours per subject area for each training in SP1’s and SP2’s personnel records. Corrective Action Ordered: On an ongoing basis, you must maintain compliance as required in this subdivision. Repeat Violation: In a Correction Order that DHS issued on December 6, 2024, you were previously found in violation of this same statute. 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. Diana Arnzen, Human Services Licensor Office of Inspector General
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